7Other Post-op. Complications Post.op. pancreatitis ( 10% of all cases of acute pancreatitis) Operations in vicinity of pancreas e.g. 1% after cholecystectomy and 8% after CBD exploration.Post-op. Parotitis.C.V.A. ( 1-3% after carotid endarterectomy)Post-op. cholecystitis.Complications of I.V. Therapy ( air embolism, phlebitis.)
8Post-op. jaundice. I. Pre-hepatic jaundice (bilirubin overload) Haemolysis (drugs, Transfusion, sickle cell crisis)Reabsorption of haematomas.II. Hepatocellular insufficiencyViral hepatitis.Drug-induced (anesthesia, others)Ischemia (shock, hypoxemia, low-output states)SepsisLiver resection (loss of parenchyma)III. Post-hepatic obstruction to bile flowRetained stonesInjury to ductsTumour (unrecognized or untreated)CholecystitisPancreatitis
9Wound Infection After After open surgery laparoscopic surgery 10% <2%● large wound size ● small● open to atmosphere ● not● more manipulation ● less● poor blood supply ● better
10AetiologyPre-operative Operative Post-operative(exist before surgery) (during operation) (after patient’s return to ward)● perforated organ. ● inadequate sterilization ● cross● compound of instruments, surgeon’s infectionfracture hands or dressings between● skin infection patients(boils) ● nasal carriers of ● contaminationStaphylococci among during dressingnurses and surgeons.● operations on alimentary,biliary or urinary tracts
11Clinical Picture Occurs a few days or even weeks after surgery. Pain and swelling of site of operation.General manifestations e.g. malaise, vomiting or anorexia.Swinging temperature (hic tic).Wound is also red and tender.Pus may be expressed out on pressure.
12Treatment Prophylactic Therapeutic dressing techniques. associated ● good sterilization. ● drainage of pus● scrupulous O.R. and ● antibiotics ifdressing techniques associated● isolation of infected cases with spreading● elimination of carriers with cellulitiscold or septic lesions amongnurses and surgical teams
13Burst Abdomen Total (early) Partial (late) ● all layers gape ● Skin is intact which leads toincluding skin, so weak scar leading toviscera comes out incisional hernia
14Clinical Picture Usually occurs on the 10th post-operative day. Pinkish discharge (pink fluid sign).Viscera may come out after a strain e.g. coughing or sneezing.
15Treatment Sedation to alleviate fear. Cover contents with sterile saline packsRe-suturing of wound using strong nylon through all layers of abdominal wall (tension sutures).Usually heals rapidly and soundly.
16Post-operative sinus or fistula Gastrointestinal Biliary Pancreatic
17Causes Poor surgical technique. Poor blood supply at anastomotic site. Sepsis leading to suture line break-down.Poor patient’s condition e.g. uraemia, anaemia, protein deficiency or cachexia.Distal obstruction e.g. missed CBD stone.
18Clinical PictureUsually obvious due to escape of bowel contents or bile.Oral methylene blue test.Testing fistula fluid for bile or pancreatic enzymes e.g. amylase.Injection of contrast to delineate the tract.Sinogram / Fistulogram
19● vitamins and drainage of nutrients pus ● antibiotic therapy Management● protect skin ● replace fluid and ● reduce sepsis byfrom ulceration electrolytes judicious● vitamins and drainage ofnutrients pus● antibiotictherapy
20Post-operative Pyrexia (high temperature for more than 48 hours) Causes :Wound haematoma.Pelvic abscess.D. V. T.Chest infection (collapse, pneumonia, infarction or sub-phrenic abscess).U. T. I.Enterocolitis.Possible drug sensitivity.
21Pulmonary CollapseIt is a common post-operative complication after abdominal or thoracic surgery.Due to mucous retention blocking fine bronchi.Usually involves basal lung segments.May become secondarily infected by inhaled organisms or blood born.
22Aetiology acute or anaesthetic ● immobilization chronic lung agents Pre-operative Operative Post-operative● pre-existing ● irritant ● painacute or anaesthetic ● immobilizationchronic lung agentsinfection. ● atropine which● emphysema Makes secretions viscid● heavy Smoking
23Clinical Picture Occurs within first 48 hours post-operative Dyspnea, tachycardia and fever.May be cyanosis.Fruity cough.Impaired chest movement particularly on the affected side.Basal dullness and crepitations with diminished air entry.CxR opacity of involved segments.
24Treatment Pre-operative Post-operative ● breathing ● breathing exercisesexercises. ● encourage coughing.● stop smoking. ● small doses of● antibiotics for sedatives for paininfection. ● antibiotics ifsputum is infected
25Deep Vein Thrombosis (D. V. T.) Usually occurs at time of operation. Manifest itself during the second post-operative week.Involves the deep veins of lower limbs and pelvis.Pain and swelling of the leg and calf muscles.Skin temperature is increased with dilated superficial veins.May be mild pyrexia.Homan’s sign may be positive.
26Investigations Venogram I125 labeled Doppler fibrinogen ultrasound ● very valuable ● very sensitive ● simpleand sensitive. ● can be repeated at ● non-invasive● can not be short intervals ● can detect lossrepeated frequently ● only useful for of doppler detection of veins effect on thebelow knee occluded (excreted in urine veinsand held inbladder).
27Treatment Prophylactic active and early mobilization post-operatively. elevation of legs.elastic graded compressionstocking.use of inflatable bags.electrical stimulation of legmuscles.prophylactic S.C. doses ofheparin.Therapeuticheparinization.oral anticoagulants.ligation of I.V.C.I.V.C. umbrella.
28Pulmonary EmbolismDue to dislodgement of a clot from deep veins of lower limbs or pelvis.A massive embolus can obstruct the right heart out put and causes death.Less severe cases give rise to shock, breathlessness and cyanosis with severe retro-sternal pain and discomfort.Mild cases present with pleural pain, dyspnea and haemoptesis in 50% of cases.Might lead to lung infarction if patient has cardiac failure due to lung congestion.
29Clinical Picture Difficult to diagnose clinically. Helpful signs are : pleural rubcrepitationsdiminished air entryMay be silent.
30InvestigationsCxR → normal in early stage, but shows patchy shadowing later-on.E.C.G. → Changes of right heart strain.Perfusion lung scan → uneven circulation through the lungs with multiple perfusion defects.Ventilation scan → normal in absence of pre-existing pulmonary diseases.Arteriogram (diagnostic) → shows filling defect due to embolus in pulmonary artery.
31Treatment Morphia for pain. Oxygen. Lysis of embolus with streptokinase if seen early.Heparinization.Embolectomy in critically ill patients using the cardio-pulmonary by-pass machine