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INTRODUCTION AND EPIDEMIOLOGY

Advancements in minimally invasive gynecologic surgical techniques, such as laparoscopy and hysteroscopy, have allowed more outpatient procedures for patients. Postoperative complications among inpatients are now commonly seen out of the hospital. The prevalence of all postoperative complications after gynecologic procedures is reported to be 9%, whereas 3.7% are considered major complications.1 Hysterectomy is the most common gynecologic surgical procedure performed in the United States, and although considered a safe operation, it results in complications in one of every two to six patients.2 The most common reasons for ED visits during the postoperative period after gynecologic procedures are pain, fever, and vaginal bleeding.

CLINICAL FEATURES

HISTORY

Patient risk factors for postoperative complications include age >80 years, medical comorbidities, dependent functional status, and obesity or unintentional weight loss.1 Key historical questions are listed in Table 105-1. The interval between surgery and the onset of symptoms is very important in determining the cause of symptoms. For example, postoperative fever is very common, occurring in about 40% of hysterectomy patients.2 Most cases of early postoperative fevers (<24 hours) are not infectious but rather result from pulmonary atelectasis, hypersensitivity reactions to antibiotics, pyogenic reactions to tissue trauma, or hematoma formation. Fever occurring on postoperative days 3 to 5 may be due to a urinary tract infection. On postoperative days 4 to 6, consider venous thromboembolism, and ≥7 days after surgery, consider a surgical site infection.2

TABLE 105-1Key Historical Questions to Assess Postoperative Complications

PHYSICAL EXAMINATION

Examine all appropriate body systems. Do not assume that the complaint is gynecologic, and investigate other potential explanations of symptom. Postoperative pain and tenderness can be difficult to assess. After laparoscopy, patients may have shoulder or upper abdominal pain because of carbon dioxide bubbles trapped between the liver and diaphragm after insufflation for the procedure, with 50% to 70% of patients still being affected 48 hours after surgery.3 Postoperative pain and tenderness are concerning if associated with fever, nausea and vomiting, and a change in bowel sounds.

Examine the surgical wound and perform a pelvic examination, including both a sterile speculum and a bimanual examination. In patients undergoing fertility treatment, defer the pelvic examination until consulting with the gynecologist, due to the possibility of rupturing enlarged ovarian follicles. During sterile speculum examination, the cervix or vaginal cuff must be visualized. After vaginal hysterectomy, no special precautions are needed for a speculum examination. Note any evidence of bleeding, discharge, erythema, and cuff or labial cellulitis. After a vaginal or abdominal hysterectomy, record the presence of tenderness, masses, and an intact cuff. After hysteroscopy or dilatation and curettage, evaluate cervical motion, uterine, and adnexal tenderness. Perform a rectal examination to assess for tenderness, masses, or fecal impaction.

LABORATORY TESTING

Laboratory studies should be directed toward the patient’s complaints. A CBC ...

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