Post-operative complications in gynaecological surgery

It is 02:30 on the gynaecology ward. The post-op hysterectomy you have just taken over is day 5, the patient has been afebrile and "stable" for the morning round, and the nurse hands you the observation chart with a quiet word: "she's not quite right." Pulse 108, RR 22, blood pressure 104/68, temperature 37.9. NEWS2 is 6. The wound looks pink, the abdomen is soft, but the drain fluid that was serous yesterday is now muddy, and the patient has not opened her bowels since day 2. The diagnosis is already in the room — anastomotic leak, day 5, the classic presentation. The next ten minutes decide whether she goes to CT and survives, or to HDU and does not. This topic is that rehearsal.^[1][4][19]

Overview and definition

Complications are the second half of the surgical episode. The first half is the operation; the second half is the recovery; both belong to the surgeon. The post-operative period partitions naturally by time, and the differential changes with the clock. ^[1]

• Immediate (0–24 h): primary haemorrhage, reactional haemorrhage (24–48 h), emergence agitation, opioid-induced respiratory depression, anaphylaxis, hypothermia, vasovagal collapse.
• Early (24 h to 7 days): ileus, urinary retention, ileus vs early small-bowel obstruction, wound haematoma, seroma, urinary tract infection, Clostridium difficile, pneumonia, retained swab/instrument.
• Intermediate (5–14 days): the classic window for wound infection, fascial dehiscence, anastomotic leak (peak day 5–8), intra-abdominal collection, secondary haemorrhage, VTE.
• Late (after 14 days): late wound complications, port-site hernia, adhesive obstruction, chronic pain, lymphoedema, anastomotic stricture, recurrence in oncology.

The Clavien-Dindo classification is the modern common language. Reproduce it cold when the examiner asks for an example. ^[19]