Post operative Complications

Incisional Hernia& Burst Abdomen

By

Dr. Magdy Basheer

Assistant Professor of General Surgery
Faculty of Medicine –Mansoura University
 Post operative Complications
Classification
I. General complications

II. Specific to operation

III. Wound complications

 Post operative Complications
General Complications:
1. Pain
2. Nausea & vomiting
3. Fluid and Electrolyte imbalance
4. Bleeding (Primary, Reactionary, Secondary)
5. Shock (Hypovolemic, Cardiogenic, Neurogenic, Septic)
6. Deep vein thrombosis (DVT)
7. Hypothermia / shivering
8. Fever
9. Respiratory (Atelectasis, Pneumonia)
10. Confusional states
11. Acute Urine Retention
12. Paralytic ileus
13. Complications of Blood transfusion
 1-Post operative Pain
Types of Pain:
➢ Somatic pain from inflammation and ischemia
➢ Neuropathic pain arises from a dysfunction in CNS
➢ Psychogenic pain is modified by the mental state.

Treatment of Pain:
Effective analgesia is an essential part
• NSAIDS such: Diclofenac (Voltaren, Cataflam)

Ibuprofen (Brufen)

Paracetamol (Cetal, Abimol, Panadol)

• Opiates (pethidine, morphine, Nalufin)

• Epidural analgesia.

• Psychological support to relieve fear, to give support.

 2-Post operative Nausea & Vomiting(PONV)

➢ Nausea and vomiting: occur when a

stimulation of vomiting centre by multiple
factors like(pain, anxiety, shock).
➢ Prevention: Adequate treatment of pain,
anxiety, hypotension and dehydration will
minimize PONV.

➢ Treatment: Administer antiemetics:

i. HT3 receptor antagonists (Ondansetron)
ii. Steroids (e.g. Dexamethasone)
iii. Phenothiazines (e.g. Prochlorperazine)
iv. Metaclopramide(e.g. Primperan)
v. Antihistamines (e.g. Cyclizine)
 3-Fluid and Electrolyte Imbalance
- Fluid overload / Dehydration

- Hypokalaemia / Hyperkalaemia (K+)

- HypoNatremia / HyperNatremia (Na+)

- Hypoglycemia / Hyperglycemia (Glucose)

- Acid Base imbalance (Acidosis- Alkalosis)

Fluid Chart (Input and Output)
 4-Post operative Bleeding
CLASSIFICATION ACCORDING TO TIME OF OCCURRENCE:
1.Primary haemorrhage: Occurs due surgical trauma.

2. Reactionary Haemorrhage: Occurs within 24 hours after the operation due to

slipping of ligatures or a clot is going to dislodge as a result of restlessness &
restoration of B.P

3. Secondary hemorrhage: Occurs within 7-14 days after trauma or operation due
to sepsis which dissolves the clot & erodes the vessel wall.

Early Diagnosis:
The patient’s pulse, blood pressure, urine output, dressings and
drains should be checked regularly in the first 24 h after surgery.
 4-Post operative Bleeding
Rapid Investigations:
➢ Blood samples should be sent for complete blood count,
coagulation profile and crossmatch.

➢ Ultrasound or CT scan may need to the size and extent of

the hematoma.

Immediate control of bleeding:

➢ If bleeding is expected: First pressure applied to the site.

➢ Fluid resuscitation should also be started.

➢ May be need for blood transfusion.

➢ The patient taken back to the operating theatre (OR).

➢ If surgical hemostasis is not successful using conventional

methods, hemostatic dressings or surgical glue or Packing .

➢ The radiological embolization of bleeding vessels.

 5-Postoperative Shock
Types of shock may be:
Hypovolemic
Cardiogenic
Obstructive (Pulmonary Embolism)
Neurogenic: Sympathetic (Spinal shock)
Parasympathetic (vasovagal attack)
Anaphylactic
Septic

Any postoperative shock should be

assumed to be hypovolemic until proved
otherwise.
Any hypovolemic shock should be assumed
to be due to hemorrhage until this has been
excluded (must search for bleeding)
 6-Deep Venous Thrombosis(DVT)
Diagnosis:
➢ Postoperative (DVT) may present with calf
pain, swelling, warmth, redness and
engorged veins.

➢ However, most will show no physical signs.

➢ On palpation, the muscle may be tender

and there is a positive Homans’ sign (calf
pain on dorsiflexion of the foot).

➢ Duplex or Doppler ultrasound is used to

assess flow and the presence of
thromboses.
 6-Deep Venous Thrombosis(DVT)
Treatment:
➢ Intravenous heparin followed by longer-
term warfarin.
➢ In large DVT, a IVC filter may be
required to decrease the possibility of
pulmonary embolism.
Prophylaxis:
i. Use of compression stockings
ii. Calf pumps
iii. Drugs, such as low molecular weight
heparin.
 7-Hypothermia & Shivering
Causes:
Anaesthesia induces loss of thermoregulatory control.
Hypothermia is due to exposure of skin and organs to:
i. A cold operating environment
ii. Volatile skin preparation (cool by evaporation)
iii. The infusion of cold IV Fluids.
This, in turn, leads to increased :
i. Cardiac morbidity
ii. Hypo coagulable state
iii. Shivering with imbalance of oxygen supply and
demand
iv. Immune function impairment with wound
infection
Treatment: (avoid Lethal Triad)
◼ Active warming devices should be used to treat
hypothermia
◼ Use warmer(Bair Hugger) blankets
◼ Use warm lights
◼ Use Warm IV Fluids
8-Post operative Fever
 9-Confusional State
Postoperative Delirium(POD)
Acute Confusional states can occur on recovery from anaesthesia or a few days after surgery.

The overall incidence of POD is 5–15 %, but is higher in the elderly and is associated with
increased morbidity and mortality.

Confusion may present as:

i. Anxiety
ii. Incoherent speech
iii. Clouding of consciousness or destructive behavior, e.g. Pulling out of cannula.
Risk factors for POD:
i. Pre-existing cognitive impairment (dementia)
ii. Use of narcotics
iii. Benzodiazepines
iv. Alcohol (and withdrawal from it)
v. Severe illness
vi. Renal impairment
vii. Depression
10-Complications of blood transfusion
1. Pyrogenic (Febrile) reactions
2. Allergic (Anaphylactic) reactions
3. Congestive cardiac failure
4. Hemolytic reactions: rare but serious
5. Transmission of infection (HIV, HCV)
6. Hyperkalaemia
7. Citrate intoxication
8. Air embolism
9. Thrombophlibitis
10. Complication of massive blood transfusion
 II- Complications Specific to Abd Operations
1- Anastomotic leak: first sign is ?????
- Between days 4 – 14 postoperatively manifested
a) Peritonitis
b) Intra – abdominal abscess
c) Enteric fistula. (through wound or drain site)

2- Intestinal obstruction
a) Mechanical – uncommon as early complication – late due to adhesion.
b) Paralytic ileus

3- Adhesions:
a) Fibrnonos – usually resolve 6-9 weeks
b) Can become fibrosed dense fibrotic adhesion. In abdomen these bands of
tissue may form between or over loops of small bowel in particular.
may lead to “kinking” or compression of small bowel loops, causing
obstruction and even infarction of the blood supply (Strangulation).
Such complication may occur shortly after the adhesions form. Within
months of surgery, or many years after.
 III- Wound Complications
• Wound Infections (SSI)
• Bleeding
• Hematoma
• Seroma
• Dehiscence(Burst)
• Incisional hernia
• Hypertrophic scar→→→
• Keloid Scar.
 Wound Infections
Surgical Site Infections(SSIs)
Risk Factors:
• Patient-specific factors:
–Local
–Systemic

• Surgical factors:
 Factors influencing SSIs
Patient Risk Factors:
⚫ Local: ⚫ Systemic:
⚫ High bacterial load ⚫ Advanced age
⚫ Wound hematoma ⚫ Shock

⚫ Wound seroma ⚫ Diabetes

⚫ Closure under tension ⚫ Malnutrition

⚫ Necrotic tissue ⚫ Alcoholism

⚫ Foreign body ⚫ Steroids

⚫ Obesity ⚫ Chemotherapy
⚫ Immuno-compromised
 Factors influencing SSIs
Surgical Risk Factors:
➢ Bad tissues handling.
➢ Excessive cautery
➢ Presence of devitalized tissues
➢ Seroma, Hematoma
➢ Closure under tension affect blood supply
➢ Type of procedure, Degree of contamination
➢ Duration of operation, Urgency of operation
➢ Skin preparation, Operating room environment

Classification Of Surgical Wounds According to Risk of Infection

1. CLEAN WOUND : 2 – 5%
2. CLEAN – CONTAMINATED WOUND: 5 – 10%
3. CONTAMINATED WOUND: 15 – 20%
4. DIRTY AND INFECTED WOUND: 28 – 40%
 Incisional Hernia
• Incisional Hernia
External abdominal hernia at site
of scar of previous abdominal
incision other than for hernia

• Recurrent Hernia
External abdominal hernia at site
of scar of previous hernial repair
 Etiology of incisional hernia
(A) Pre-operative (bad patient)

(B) Operative (bad technique)

(C) Post-operative (bad post operative care)

➢ Incidence of incisional hernia is an 10%, after midline

laparotomy increasing up to 40% in specific risk groups.

➢ SSI would increase the risk of incisional hernia occurrence by at

least threefold.
 (A) Pre-operative Causes (bad patient)
1. Old age due to decrease protein with very weak musculature

2. Patient with chronic straining conditions e.g. chronic Cough,

chronic Constipation and bladder neck Constriction (BPH)

3. Drugs: cytotoxic drugs, and radiation (death of cells).

4. Obesity due to weak muscles and decrease wound healing.

5. Diseases:
➢ Malnutrition: hypoproteinemia, hypovitaminosis A, C.
➢ Anemia and vascular diseases: due to decrease oxygen to tissues
➢ Uremia: urea →due to decrease growth of fibroblasts
➢ Jaundice: due to
* Decrease granulation tissue formation,
* Decrease collagen maturation
➢ Malignancy and diabetes: due to decrease growth of fibroblasts.
 (B) Operative causes (bad technique)

1. Factors related to operation:

➢ Emergency operations: peritonitis, appendicitis, intestinal obstruction.

➢ Operation on the pancreas with leakage of enzymes →disruption.

2. Factors related to incision:
1- Length of incision: too long incision more than short incisions.

2- Site of incision: midline incision more than paramedian incisions.

3- Type of incisions:

- Vertical abdominal incisions than transverse incisions.

- Muscle cutting than muscle splitting or muscle retracting incisions.

- Incisions which cause damage to muscles, their nerve supply or

their blood supply are prone to be weak.

 (B) Operative causes (bad technique)
3. Factors related to closure:
➢ Suture material: closure with absorbable more than non-absorbable.

➢ Too tight sutures (devitalization of tissues) or too loose sutures.

➢ Method of closure:

- Continuous sutures more than interrupted sutures.

- Thru and thru more than closure in more than closure in layers.

- Bad technique of repair: suturing muscles with each others.

➢ Imperfect homeostasis leads to haematoma and infection.

➢ Dead space from inefficient closure leads to seroma and infection.

4. Factors related to the drain:

➢ Drain coming out the wound more than drain coming out through separate stab wound.

➢ Prolonged use of the drain.

 (C) Post-operative Causes
Bad post operative care
1. Infection of the wound.
- Increase tissue tension.
- Increase collagen breakdown by proteolytic enzymes.
- Decrease collagen synthesis.
2. Lifting heavy weights before 3 months after operation.
3. Persistent cough, urethral obstruction, constipation.
4. Post-operative chest complications.
5. Post-Operative distension (acute gastric dilatation or paralytic ileus).
6. Abdominal Compartmental Syndrome (ACS)
7. Poor healing power & Dehiscence (burst) of the wound.
 Risk factors of incisional hernia
I-Patient related factors:
➢ Age: More than 60 years.
➢ Gender: Male.
➢ Obesity: BMI >35 kg/m2.
➢ Co-morbidities: Diabetes mellitus, chronic lung diseases (COPD),
obstructive jaundice.
➢ Immuno suppression in organ transplant patients, chemotherapy
and steroid therapy
➢ Biological factors: Defect in Collagen and metalloproteinase
synthesis
➢ Smoking .
➢ Nutritional deficiencies
 Risk factors of incisional hernia
II-Surgery related factors:
➢ Emergency operations, bowel surgery, stoma
closure, operations for peritonitis, re-laparotomy .

➢ Technique and suture material used for closure of

the abdominal incisions.

➢ Wound infection, long operating time, increased

blood loss, Seroma, Hematoma.
➢ Surgeon experience.
 Clinical Picture of Incisional Hernia
1. A swelling over scar of any operation except
hernia which is reducible (unless complicated)..
2. It increase in size on straining & decrease on
lying down.
3. With an expansile impulse on cough (unless
strangulated).
4. It may contain omentum or intestine.
5. The skin over hernia is stretched and may
become atrophic
6. Peristalsis of underlying coils of intestine may
be seen.
 Complications of Incisional Hernia
I. Irreducible hernia.
II. Obstructed hernia.
III. Inflamed hernia.
IV.Strangulated hernia.

* In general hernia complications

are those of the contents.
 Treatment of Incisional Hernia
(I) Prophylaxis: (avoid risk factors)
(II) Palliative abdominal belt: (If surgery is contraindicated)
(III) Operative treatment: (Surgery)

• Surgery always advised to avoid complications and prevent its

progressive enlargement

➢ Open Repair

➢ Laparoscopic Repair
 Open Repair of Incisional Hernia
Operative procedures:
1. Anatomical repair: Indicated in small defect.

2. The keel operation: Without opening the sac, it is pushed back in the
abdomen & by a series of inverting & continuous sutures into the abdomen thus the sac will
finally project into the abdomen like keel of a boat.

3. Hernioplasty:
 Open Repair of Incisional Hernia
Hernioplasty:
Strength defect by synthetic mesh (proline)
Methods of mesh fixation:
• Premuscular: after closure of defect (On-lay).
• Retromuscular (Sub-lay) between the rectus abdominis and posterior rectus sheath
• Preperitoneal: between posterior rectus sheath and peritoneum.
• Intraperitoneal to fill the defect (In-lay).
 Proline Mesh
Criteria of ideal mesh:
1- Inert
2- Non-absorbable
3- Non-infective
4- Non-oncogenic
5- Durable
6- Narrow pores
7- Monofilament
8- Irritant → to induce fibrosis
9- Available in different sizes.
 Laparoscopic repair steps (IPOM)
1. Creation of Pneumoperitoneum
(co2).

2. Port placement (3 or 4 port).

3. Adhesolysis.

4. Measuring defect size.

5. Mesh fixation.

6. Skin closure.
 Laparoscopic or Open ????
Laparoscopic hernia repair is better than open repair
as regard:
• Less postoperative pain.
• Shorter hospital stay.
• Faster return to normal daily activity.
• Lower rate of postoperative complications.
• Better cosmetic appearance.
Burst Abdomen (Abdominal Dehiscence)
Definition:
Dehiscence of abdominal wound with prolapse
of viscera extraperitoneal.

Etiology:
The same causes of incisional hernia.
➢ Bad patient
➢ Bad Technique
➢ Bad Post-Operative care
 Pathology of Burst Abdomen
A- Complete burst:
When all layers of the wound (including skin) give way →
the bowels prolapse through the skin to exterior.

B- Incomplete (partial) burst:

When the deeper layers of the wound only give way with
intact skin → the loops of intestine prolapse under skin
 Clinical Picture of Burst Abdomen
1- Serosanguinous discharge from the wound is a
warning sign in 50%.

2- Usually between 6th to 8th day

Complete burst → the wound gives way and coils of

intestine and omentum prolapse through the skin

Incomplete burst → the skin is intact over the intestine

 Complications of Burst Abdomen

1. Shock (Hypovolemic, Septic)

2. Dehydration and electrolyte imbalance.

3. Paralytic ileus and intestinal obstruction.

4. Devitalization of intestinal wall leads to

intestinal fistula.

5. Partial burst ends in incisional hernia.

 Treatment of Burst Abdomen
(A) Complete Burst:
Emergency operation to replace the bowel & to re-suture the wound

Pre-operative measures: While awaiting operation:

a. Cover the wound with a sterile towel.
b. Ryle’s tube + I.V. fluid. + Antibiotics.
Operation:
- Each protruding coil of intestine is washed gently with saline solution, and
returned to the abdominal cavity.
- All layers of the abdominal wall are approximated by through - and –
through sutures (Mass closure)
Post-operative measures: As incisional hernia.

(B) Partial Burst:

Treated by abdominal corset (binder), delayed removal of sutures then treat
as incisional hernia