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

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

3. 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

4. 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?

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

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

8. 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)

9. 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?

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

11. U/S Pelvic abscess CT

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

13. 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?

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

15. 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

16. 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?

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

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

19. US & CT

20. Types of biliary tract injuries

21. 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

22. Cystic duct leak post-cholecystectomy

23. CBD stent

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

25. CBD injury

26. 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 ?

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

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

29. 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

30. 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?

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

32. 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

33. Thank you!