Type of surgical access

One of the most important elements that determines the type of complications and risks associated with surgery is the type of surgical access used by the obstetrician-gynaecologist.

There are three types of access when planning pelvic surgery*:

• vaginal access - as the name suggests the procedure is performed by inserting surgical instruments into the vagina,
• abdominal access (laparotomy) - the so-called classic access. The oldest and most common method, used extensively in general surgery. It involves opening the abdominal integuments,
• laparoscopic access - the laparoscopic method is one of the most modern and rapidly developing surgical methods. It involves inserting an optical instrument (camera) through the abdominal shells and performing procedures by producing only a few (usually three) holes through which instruments are inserted.

Each of these methods has a number of advantages and disadvantages. One of the most important factors in deciding on the type of access is precisely the assessment of the risk of postoperative complications.

Types of postoperative complications

There are two main divisions in the classification of post-operative complications. The first according to the time of their diagnosis:

• early complications - i.e. those that occurred while the operation was still in progress,
• late complications - those diagnosed after the operation has been completed,

The second classification is based on a division according to the type of organ or system damaged. These include complications such as:

• bleeding and thromboembolic complications,
• urinary complications,
• complications concerning the digestive system,
• wound healing complications, including infections.

Bleeding and thromboembolic disorders

These are so-called homeostatic disorders. They mainly involve a disruption of the blood clotting process. In the case of bleeding, the extent of the procedure, its complexity and sometimes a doctor's error can just as often be the reason for the profuse haemorrhage. This type of complication often occurs, for example, in the case of a hysterectomy. The removal of the uterus involves the creation of a surgical wound and the ligation of two large uterine arteries. This creates a high risk of heavy bleeding. If this occurs, doctors place the patient under close observation. If the blood loss is high and accompanied by severe general symptoms (drop in blood pressure, tachycardia**, drop in diuresis***), treatment involving fluid supplementation and coagulation drugs is implemented.

In the case of thromboembolic disorders, the most important thing is their prevention. These are extremely dangerous complications that often threaten not only the health but also the life of the patient. It is therefore extremely important to identify women with an increased risk of this type of complication. These are patients who are obese, have a cardiovascular disease, take contraceptive pills, smoke or are over 70 years of age.

photo: panthermedia

Complications involving the urinary tract

Due to its organ proximity, the urinary system is extremely vulnerable to damage in gynaecological and obstetric procedures. The risk of damage is mainly to the bladder, ureters and urethra. Bladder damage is the most common complication in this group. The doctor may unknowingly damage the continuity of the bladder and cause the release of urine into the peritoneal cavity. This type of complication is always treated by performing repeat surgery and suturing the damaged bladder.

Complications involving the digestive system

Also as with the urinary system, it is the proximity of the organs that is the greatest risk factor for bowel damage. Depending on the surgical access, the type of damage varies. The most common occurrence is:

• bowel perforation - i.e. damage to the continuity of the bowel and spillage of faecal contents into the abdominal cavity,
• obstruction - usually the so-called 'functional' obstruction. This means that intestinal peristalsis stops, i.e. food does not move,
• the formation of a fistula.

In the case of laparotomy, damage to the bowel can occur when opening the peritoneum, when releasing adhesions or when closing the abdominal wall. Laparoscopy poses a risk of organ damage with a trocar, Verresa**** needle or when using electric current to coagulate tissue.

When such complications are suspected, the doctors' management is initially limited to observing the patient, ensuring an adequate fluid balance, introducing a fluid diet and auscultating gastrointestinal peristalsis. If it turns out that one of the complications has occurred, reoperation is often the only treatment option.

Infections and wound healing complications

This is the type of complication that occurs most frequently. It is mainly related to the quality of aseptics maintained during the operation and the state of the patient's immune system. In the case of infections, the most common infection of the surgical wound is by strains of staphylococci and streptococci. This is associated with severe pain, high fever and the risk of the infection becoming generalised! Therefore, every patient after gynaecological and obstetric surgery is observed for the risk of developing an infection. If necessary, antibiotic therapy with broad-spectrum drugs or targeted antibiotic therapy is introduced, i.e. only after assessing the antibiotic sensitivity of the specific bacterium that caused the infection. The risk of infection is also increased by immunodeficiency states, usually caused by chronic diseases such as diabetes or liver failure.

In the case of wound healing complications, factors that delay the process are of greatest importance. These include, for example, as in the case of infection risk, chronic diseases (diabetes) and, in addition, high blood loss, including plasma proteins, or medication used by the patient (e.g. glucocorticosteroids).

* Lesser pelvis - anatomical region containing the female reproductive organs

** Tachycardia - acceleration of the heart rate above 100 beats per minute.

*** diuresis - the process of making and expelling urine

**** trocar, Verres needle - names of surgical instruments used in laparoscopic methods.