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Chapter 87: Complications of General Surgical Procedures

Edmond A. Hooker

Content Update: Post-operative Pneumoperitoneum April 2020

Patients undergoing laparoscopic and open abdominal surgery have residual intra-abdominal pneumoperitoneum for varying amounts of time after surgery. Post-operative patients presenting to the ED with abdominal or chest pain may have pneumoperitoneum discovered on CT scanning or upright chest radiographs.  Differentiating normal,  from pathologic pneumoperitoneum related to perforation or anastomotic failure,  can be difficult.  Free air may be pathologic if the patient is more than 3-5 days post-op, if there is a large amount of air, or if the patient has evidence of peritoneal irritation, fever, or leukocytosis (1,2,3). For such patients consult surgery to help determine the next steps.

(1) Malgras, B  et al 'Natural History of Pneumoperitoneum after Laparotomy: findings on multidetector-row computed tomography' World Journal of Surgery 41.1 (2017):56-63  PMID 27456496(2) Gayer, G et al 'Post-operative Pneumoperitoneum as Detected by CT: Prevalence, duration, and relevant factors affecting its possible significance' AbdomImaging (2000) 25:301-305  doi:10.1007/s002610000036(3) Bernstein L et al 'Postoperative Pneumoperitoneum: Clearing the Air' J Surg (Jan, 2014):2 (1), 4.

INTRODUCTION

Outpatient surgical procedures are common, and with increasing pressure for cost containment, admitted patients are being discharged earlier in their postoperative course. As a result, more patients are coming to the ED with postoperative fever, respiratory complications, GU complaints, wound infections, vascular problems, and complications of drug therapy (Table 87-1). This chapter reviews the complications common to all surgical procedures and those specific to a specific procedure.

TABLE 87-1Complications of General Surgical Procedures
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TABLE 87-1 Complications of General Surgical Procedures
Complication Important Points
Fever “Five Ws” (wind, water, wound, walking, wonder drugs) are common causes
Pulmonary complications
 Atelectasis <24 h, treat with pulmonary toilet, discharge unless ill or hypoxemic
 Pneumonia 2–7 d, polymicrobial, most require admission
 Pneumothorax Multiple causes, consider expiratory views, consider needle aspiration
 Pulmonary embolism Dyspnea is main symptom, high index of suspicion
GI complications
 Intestinal obstruction Obtain radiographs, search for causes
 Intra-abdominal abscess CT diagnosis, early administration of broad-spectrum antibiotics
 Pancreatitis Always consider in postoperative patients with abdominal pain
 Cholecystitis Usually in older patients, can be acalculous
 Fistulas Can be high output, admit if concerns over output
GU complications
 Urinary tract infection 2–5 d, oral antibiotics, most discharged
 Urinary retention Rapid catheter drainage, most discharged
 Acute renal failure Prerenal, renal, and postrenal causes, most admitted
Wound complications
 Hematoma Caused by poor hemostasis, can drain most, but be careful with neck hematomas and hematomas after vascular surgery
 Seroma Painless swelling, clear fluid, drain and discharge
 Infection Open, drain, and culture specimens; be careful with wounds associated with respiratory tract, GI tract, or GU tract, or secondary to trauma
 Necrotizing fasciitis Pain out of proportion to physical findings
 Dehiscence Be careful with abdominal incisions (potential for evisceration)
Vascular complications
 Superficial thrombophlebitis Usually aseptic, provide local therapy and discharge
 Deep venous thrombosis Upper and lower extremity, perform Doppler studies
Complications of drug therapy
 Diarrhea Consider ...

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