Clinical case A 45-year-old woman presents to the emergency department with the chief complaint of vaginal and abdominal pain. She has been in post-hysterectomy status (s/p) for 2 weeks. She had been feeling well until yesterday when she had a follow-up with her surgeon, at which time she reported that they performed an internal exam and inserted a ’medication disk’ into her vagina. Since then, she has had severe and worsening pain in her abdomen and vagina. It is observed that the patient has mild tachycardia and also fever. He has a diffusely tender abdomen with guarding. A pelvic speculum examination to locate the "medication disk" is notable because there is no foreign body, but intestine is seen in the upper part of the vaginal vault . |
Hysterectomies are one of the most common gynecologic surgeries performed in the United States. More than 600,000 procedures are performed annually and it is estimated that 1/3 of women will have undergone a hysterectomy by the time they turn 60 (1,2). Surgical approaches to the procedure include open abdominal, transvaginal and laparoscopic. The route chosen depends on the patient’s age, uterine volume, body mass index (BMI), previous surgeries and parity (1).
Total abdominal hysterectomy ( TAH) is associated with a slightly higher complication rate than laparoscopic hysterectomy (LH) or vaginal hysterectomy (VH) (3,4). Operative complications requiring surgical intervention or hospitalization occur in approximately 3-6% of all hysterectomies (5).
During a hysterectomy, the uterus and cervix (partial hysterectomy) or the uterus, cervix, and ovaries (complete hysterectomy) are removed. The vagina is left as a blind pouch and the vaginal cuff (the area at the top of the vagina) is closed with sutures. There should be no erythema, purulent drainage, bleeding, or opening in that incision on pelvic examination. If there are abnormal findings on clinical examination, further testing may be necessary.
Common complications
Complications can be classified by type of injury and timing of the procedure. Temporal categorization includes perioperative complications that occur (<7 days after surgery) or late complications , which can occur between 1 and 6 weeks after surgery.
- Perioperative complications include fever, ileus, pulmonary embolism, C. difficile infection, and postoperative hemorrhage.
- Late complications include wound infection, seroma, hematoma, intestinal injury, and vaginal cuff dehiscence (1).
Complications will be discussed here by category .
Infectious complications : The risk of postoperative infection can reach 20% without adequate antibiotic prophylaxis and is reduced to approximately 7% with adequate prophylaxis (6). Fever occurs in the immediate postoperative period in up to 50% of patients (6). The degree of testing performed in response to fever should be dictated by the patient’s clinical symptoms. Routine examinations such as complete blood count (CBC), chest x-ray, blood or urine cultures have been found to rarely yield positive results in the absence of clinical symptoms (6). The following are common infectious etiologies of fever with hysterectomy:
Vaginal cuff cellulitis – This condition occurs in approximately 2% of patients and is one of the most common infectious complications. It usually occurs in the first days after the operation (2,6). The presence of bacterial vaginosis or trichomonas vaginitis preoperatively is associated with an increased risk of cuff cellulitis in the postoperative period. Patients may present with fever, back pain, lower abdominal pain, pelvic pain, or vaginal discharge (2). On pelvic examination, the vaginal cuff may appear indurated or erythematous, may present purulent discharge, and will be painful on palpation (2,6). Treatment should include a second or third generation cephalosporin (with the addition of metronidazole for associated trichomoniasis or doxycycline for chlamydia) and should be continued for 48 hours after cessation of fever (2).
Abscess and infected hematoma : This condition is usually delayed and occurs most frequently between 10 and 14 days after the operation. Patients may present with fever, pelvic pain, or rectal pressure. On pelvic examination, there may be a fluctuating mass in the vaginal cuff or purulent discharge from the cuff (6). Laboratory tests may demonstrate anemia in the setting of an infected hematoma. An elevated white blood cell count may also be seen (2). Patients should be started on empiric broad-spectrum intravenous (IV) antibiotics until the patient is afebrile for 48 hours (6). Antibiotics should cover gram-negative bacilli, enterococci, streptococci and anaerobes and infections are usually polymicrobial (10). If the fluid collection is more than 5 cm in diameter, it should be referred for surgical drainage (2).
Wound infection : Infections of abdominal incisions are usually seen approximately 7 days after surgery (6). Up to 20% of women may experience a skin or soft tissue infection, but these are less common in laparoscopic hysterectomy (LH) than in total abdominal hysterectomy (TAH) (2,6). Patients may present with fever, pain, purulent drainage, bad odor or wound dehiscence (2,6). Wound infections should be treated with antibiotics targeting staphylococcal and streptococcal infections, and incision and debridement may be necessary to resolve the infection (2,6). A vacuum-assisted wound dressing can also be applied to aid in healing (2).
Urinary tract infection (UTI): When a patient presents with postoperative fever on days 3 to 5 and dysuria, a urinalysis should be obtained , especially if the patient was catheterized during the procedure or if she has localized signs of urinary tract infection. (6). UTIs account for 40% of nosocomial infections and E. Coli remains the most frequently identified organism (2). Symptoms may include fever, increased urinary frequency, urgency, hematuria, or dysuria. The diagnosis is confirmed by urine analysis and treated with antibiotics such as nitrofurantoin or trimethoprim-sulfamethoxazole .
Pneumonia: Pneumonia occurs in the first few days after surgery and is more common in patients with underlying lung disease. Patients may experience difficulty breathing, fever, chills, cough, chest pain, and increased sputum production. Physical examination may show rales, crackles, hypoxia, tachypnea, tachycardia, or fever. Patients can be treated with third-generation cephalosporin, fluoroquinolone, doxycycline or amoxicillin-clavulanate (2). With the changes in the IDSA guidelines and the elimination of HCAP, most people should be treated with antibiotics that treat community-acquired pneumonia (CAP) organisms, as the majority of these patients still have a very high incidence. loss of multiresistant organisms. However, if a patient is septic, has severe illness, a history of multidrug-resistant organisms, or other worrisome features, a broad-spectrum antibiotic should be initiated to cover organisms from nosocomial pneumonia or hospital-acquired pneumonia (HAP). ).
Non-infectious pathological complications
Venous thromboembolism (VTE): When a patient presents with fever on postoperative days 4 to 6, the provider should consider venous thromboembolism (VTE) as the cause (6). Half of all embolisms occur within the first 24 hours and 75% will occur on the third postoperative day. VTE is one of the most common complications of gynecological surgery (2). The diagnosis can be confirmed with ultrasound (for deep vein thrombosis) or computed tomography angiography (CTA) of the chest (for pulmonary embolism) and in patients treated with anticoagulants.
Blood loss – This can be a relatively common complication of hysterectomy. Twice as many women undergoing laparoscopic hysterectomy (LH) require transfusion than vaginal hysterectomy (VH) (6). Care must be taken during surgery to ensure that good hemostasis is achieved . If there is concern for significant bleeding based on clinical findings of conjunctival pallor, tachycardia, hypotension, or heavy bleeding, a complete blood count, type and screening, and coagulation studies should be obtained, keeping in mind that there may be a delayed fall in hemoglobin. during the acute phase of blood loss. Bleeding may or may not be seen on physical examination. On pelvic examination, bleeding can be localized to the vaginal cuff and easily visualized. If no external bleeding is seen, the patient may still be bleeding internally (especially if she has increased abdominal pain or distension), and a FAST exam or pelvic ultrasound may locate pelvic hematomas or other free fluid in the abdomen.
Anatomical injuries
Gastrointestinal (GI) injuries : Injuries to the gastrointestinal tract occur in approximately 1% of hysterectomies (1). There are three types of injuries to the intestine: thermal injury, direct mechanical injury, and indirect injury from interruption of blood supply (1).
Thermal injuries can occur when cautery is used where there is no clear visualization, such as in the deep pelvis, cuff, or cul-de-sac. These lesions may go unnoticed at the time of surgery and, if not repaired, often present with a delayed onset of infection and symptoms (1).
Direct injury occurs from instruments during surgery and occurs most frequently during removal of adhesions. Vascular injuries can occur due to interruption of blood supply to the mesentery and very rarely occur during a routine hysterectomy (1). They are often recognized at the time of surgery, but if small lesions go unnoticed, patients may develop signs of postoperative peritonitis and infection after surgery. Patients may present with fever, elevated white blood cells, nausea, vomiting, abdominal distension, or peritonitis, and this may not be seen for days or weeks after surgery (2).
Thermal and direct injuries can be diagnosed by CT with oral contrast. These lesions tend to present with peritonitis when intestinal contents leak into the abdomen. Concern for vascular injury should be evaluated with CT and tends to present with severe pain out of proportion to the physical examination. Injuries to the gastrointestinal tract require surgical repair for definitive treatment and may require intravenous antibiotics (2).
Genitourinary (GU) injuries: Genitourinary tract injuries occur in approximately 2% of major gynecologic surgeries and 75% of them occur during a hysterectomy (2). A GU injury is twice as likely to occur if surgery is performed laparoscopically (2% vs. 1%) (1).
The urinary bladder may be injured during dissection of the surgical planes, but this is usually noted at the time of surgery. Serous lesions may go unnoticed since they are not full thickness lesions. This can cause a delay in cystotomy and the formation of a vesicovaginal fistula. Patients are at increased risk of bladder injury if they have had a cesarean delivery, endometriosis, pelvic adhesions, or cancer (1). Patients may present with fever, hematuria, abdominal pain, ascites, or peritonitis. Laboratory tests may demonstrate hyponatremia, hyperkalemia, and elevated creatinine. If an injury to the GU system is suspected, cystography or CT with intravenous contrast can help identify the injury (2).
Neuropathy : occurs rarely (about 2% of gynecological cases) (6). The femoral nerve is the nerve most commonly affected by pelvic surgeries and injury occurs when pelvic retractors are placed where the nerve runs along the anterior aspect of the psoas muscle or when a patient is hyperflexed at the hip in the lithotomy position. , the nerve can become pinched in the inguinal canal (2). Patients may experience sensory changes in the front of the thigh to the foot or weakness in the quadriceps muscle. The other nerves that can be affected during hysterectomy are the iliohypogastric and ilioinguinal nerves which can be injured during a wide abdominal incision. Spontaneous resolution of nerve injuries can occur in days or months depending on the severity of the original injury (2).
Vaginal cuff dehiscence – This is a relatively rare complication that occurs in approximately 0.3% of cases and occurs on average 11 weeks after the operation, but can even be observed several years after surgery (1,2,6 ,7). This is also seen more frequently after laparoscopic hysterectomy (LH) (1.5%) compared to vaginal hysterectomy (VH) or total abdominal hysterectomy (TAH) (0.1%) (1,2,7,8) . Vaginal cuff closure also has the lowest rate of dehiscence (1).
It may present with vaginal bleeding (the most common presenting symptom) (3) or watery vaginal discharge (2,6). A patient may experience pelvic pressure or a lump in the vagina if intestinal evisceration occurs (1,7). This may also predispose the patient to sepsis, peritonitis, or intestinal infarction, which must be recognized promptly. The greatest risk factor for dehiscence is direct trauma caused by sexual intercourse, generally during the first postoperative intercourse (1,6). Diagnosis is made by speculum examination (Figure 1). When you open the speculum and look at the top of the vaginal pouch you should not see any defects in the incision. If the top of the bag opens at any point, dehiscence is possible. Once diagnosed, the patient should be treated with broad-spectrum antibiotics and referred to an obstetrician/gynecologist for surgical repair (6).
Figure 1 : Dehiscence of the vaginal cuff with loops of intestine visible at the incision site.
Conclusion
Hysterectomy is a common gynecologic surgery and the emergency physician must be prepared to diagnose and treat associated postoperative complications. Complications can be infectious, non-infectious, and anatomic/surgical , and laboratory tests/imaging should be obtained based on symptoms obtained from the patient’s history. Many conditions will require imaging and the clinician should maintain a low threshold for initiating intravenous broad-spectrum antibiotics if there is a high suspicion of intra-abdominal infection. Consideration should be given to contacting the operating surgeon as soon as possible, as the patient may need to be readmitted or taken to the operating room for definitive care.
Pearls and traps
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Bibliographic references
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