Complications of abdominal surgery M K Alam Professor of Surgery AlMaarefa College

Patient No.1 A 35-year old male: 3 days of abdominal pain. Examination: features of generalized peritonitis. ?

He was prepared for surgery He was prepared for surgery. At laparotomy – features of generalized peritonitis. Perforated appendix was found. Appendectomy, & peritoneal lavage was done. Abdomen was closed with a drain in situ. Postoperatively: NPO, IV fluid & broad spectrum antibiotics

Post-operative period Day 1-4: Steady improvement. Afebrile, drain removed. Progressed from fluid to normal diet. Day 5: Temp. 38°C, loose motion- twice. Why ? Possible causes of fever. Why loose motion?

Postoperative fever- causes SSI - Superficial - Deep - Deep space infection DVT UTI Pulmonary atelectasis (day 1-2) Chest infection

Post-operative diarrhea- causes Pelvic collection: passage of mucous with diarrhoea is pathognomonic. Pseudomembranous colitis Food poisoning / gastro-enteritis

Postoperative fever- management History: chest symptoms, urinary symptoms, abdominal pain, wound site pain, leg pain, nature & number of loose motion. Examination: General, IV sites, chest, abdomen (wound, abdomen), P/R, Lower limb(DVT)

This patient E: normal Chest clear Lower limb: no swelling or tenderness Abdomen: wound looks OK, P/R- bulging anteriorly, tenderness. Significance of the finding? What to do?

Investigations CBC CXR, ?AXR U/S abdomen & pelvis CT scan

U/S Pelvic abscess CT

Management Conservative- very small collection may resolve Trans-rectal drainage CT guided drainage: Trans-rectal, Percutaneous suprapubic

Patient no. 2 40- year old female admitted with features of acute cholecystitis. Diagnosis confirmed by ultrasound. CBC & LFT- normal. Responded well to conservative management. Q: What is her further management?

Further management plan Cholecystectomy on next operation list ? ?Preconditions: Interval cholecystectomy after 6-12 weeks? ?Disadvantages:

Management of patient 2 Cholecystectomy on next list- 2 days after admission. Difficult laparoscopic cholecystectomy. Left a drain in subhepatic area. 1st postoperative day: Temp 38°C, pulse 100/ min. Abdomen mildly distended, sluggish bowel sounds. Drain 90 ml darkish fluid. Sips of water+ IV fluid

Management 2nd postoperative day: Temp 37.8°C, pulse 90/ min. Vomited twice in last 24 hours. Abdomen mildly distended, non-tender, sluggish bowel sound. Drain 175 ml dark green. IV fluid + NPO What next?

Post-cholecystectomy bile leak Biliary tract injury. Proximal bowel injury- ? Duodenum Bowe injury unlikely in this patient. Why?

Management- suspected bile leak ? CXR, AXR U/S CT

US & CT

Types of biliary tract injuries

Management of bile leak Establish and maintain adequate drainage. Drain was left in situ at the initial procedure- draining bile. If not- ultrasound scan guided percutaneous guided drain. Antibiotics and a daily assessment of drain output. Drainage: <200 ml/day & reducing daily- likely to stop on its own. Persistent drainage > 200 ml/day – ERCP indicated ERCP: cystic duct leak- internal stent (5-7 cm) Abdominal drain removed once it stops drainage Stent removed in 6-8 weeks Other CBD injury- surgical intervention

Cystic duct leak post-cholecystectomy

CBD stent

Causes of cystic duct leak Clips not properly applied Pressure necrosis from too tight application Distal obstruction- stone in CBD

CBD injury

Patient No. 3 C- hemodynamically unstable RTA victim, Conscious AB –stable C- hemodynamically unstable Rapid crystalloid infusion CBC, U/E, cross match FAST- splenic injury, free fluid in peritoneum Management ?

Management Consent for surgery. Urgent laparotomy- midline incision. Splenic injury with massive hemoperitoneum. Perisplenic packing. Blood sucked out.

Management Splenectomy. No other injury Abdomen closed with a tube drain

Post-operative management Day 1-3 Hemodynamically stable Initially- NPO+ IV fluid, Later allowed oral feeding 2 units of PCV to raise Hb above 10g/dl Pneumococcal vaccination Antibiotic

Post-operative management Drain: Day 1 - bloody, 150 cc. Day 2- serous 120 cc Day 3- turbid fluid 150 cc, Day 4- turbid fluid 230 cc Drainage fluid contained very high level of amylase Cause?

Pancreatic fistula Causes: Operative trauma, Complication of acute/ chronic pancreatitis

Pancreatic fistula- management Skin care Electrolyte & nutrition- NPO+TPN ERCP & pancreatic duct stenting Octreotide Repeated CT scan to rule any other collection PCD- for other collections

Thank you!