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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_999_Библиотеки_им_академика_М_И_Перельмана
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Chapter 24
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Post-Operative Complications After
Emergency Laparotomy
ZiQinNg andDieterWeber
Introduction
Emergency laparotomy (EL) has an important role in modern surgical practice. This
role remains relevant, even though minimally invasive surgery and advances in nonoperative care have fundamentally changed the care of these patients in recent years.
EL forms a signicant part of acute general surgery for various pathologies such as
incarcerated hernia, perforated viscus, intestinal obstruction, haemorrhage
and sepsis.
Historically, considerable mortality and morbidity are associated with EL.A
recent systematic review found that the one-year mortality following EL is up to
20% [1]. Since the initiative of National Emergency Laparotomy (NELA) in the UK
in 2012, there have been signicant efforts in reducing the mortality rates following
EL.The concept of risk stratication pre-operatively has been adopted across continents [2–4].
In Australia, the introduction of ANZELA-QI has been modelled upon the NELA
concept [5, 6]. The hospitals across Australia and New Zealand are encouraged to
participate in prospective data collection on the emergency laparotomy on indices
Consent: The authors have obtained consent from the individual patients for the use of clinical
photographs or cross-sectional imaging for submission and publication.
Z. Q. Ng (*)
Department of General Surgery, Royal Perth Hospital, Perth, WA, Australia
e-mail: ziqin.ng@health.wa.gov.au
D. Weber
Department of General Surgery, Royal Perth Hospital, Perth, WA, Australia
School of Surgery, University of Western Australia, Nedlands, WA, Australia
e-mail: dieter.weber@health.wa.gov.au
Switzerland AG 2024
J. Faintuch, S. Faintuch (eds.), Recent Strategies in High Risk Surgery,
https://doi.org/10.1007/978-3-031-56270-9_24
395© The Author(s), under exclusive license to Springer Nature
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that could impact on outcomes such as: time seen by the consultant, sub-specialty
of the surgical team, the lactate level on arrival, time to access computed tomography (CT) scan and theatre, the most senior surgical and anasthesiology staff members, admission to critical care unit, unplanned return to theatre or intensive care
unit, post-operative complications and mortality and discharge destination. Each
individual hospital will receive an annual report on its performance against national
standards.
Apart from NELA, other scoring systems such as P-POSSUM and ACS-NSQIP
have been studied with varying sensitivity and specicity [2, 7, 8]. Some studies
have combined these clinical scores with CT-derived parameters such as psoas density to predict the post-operative complications following EL [7, 9]. In association
with these developments, signicant shifts in clinical management have also
occurred: implementation of sepsis bundles, early theatre access, involvement of
consultant surgeon and anaesthetist in decision-making and post-operative admission to intensive care unit [10], are strategies, which among others, continue to push
for the better care of the emergency general surgery patient.
Despite the efforts to better patient selection and early discussion of ceiling of
care, clinicians are expected to face patients with more complex comorbidities and
poorer physiological reserves. This chapter focuses on the common post-operative
complications following EL and strategies to manage and prevent them. The authors
also illustrate some examples of the management of complications and potential
pitfalls post-EL.
Z. Q. Ng and D. Weber
Post-operative Complications
Haemorrhage
Post-operative haemorrhage refers to excessive bleeding that occurs after a surgical
procedure. It is a potentially serious complication that can range from minor bleeding to severe and life-threatening blood loss. Haemorrhage can occur at the surgical
site, or at sites distant to the surgery in situations of coagulopathy.
Post-operative haemorrhage is usually accompanied by pain, deranged physiology by the hypovolaemia and reduced urine output. The haemoglobin level drop
may lag time. In younger patients, the initial response may be just compensatory
tachycardia due to the physiological reserves. If there is any suggestion of postoperative haemorrhage, it is imperative to take the patient back to theatre to control
the bleed. In certain cases, where there has been a drain placed, the clinician should
not be reassured by the lack of blood in the drain as it can easily be clogged. Often,
during the takeback, there is no active bleeding but rather generalized ooze.
Intraoperative check of the rotational thromboelastometry or thromboelastometry
can guide product replacement to aid haemostasis. In patients with an underlying
coagulation deciency, a consultation with the haematologist can assist in the management with replacement of specic factors, fresh frozen plasma and/or
24 Post-Operative Complications After Emergency Laparotomy
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a
Fig. 24.1 This patient has a history of chronic kidney failure on haemodialysis presented with
large bowel obstruction secondary to perforated sigmoid diverticulitis. The patient underwent
emergency Hartmann’s procedure. Two weeks post-surgery, the patient presented with per rectal
bleeding and lower abdominal pain. CT scan (a, b) showed a rim-enhancing collection at the pelvis
adjacent to the staple-line of the rectal stump likely an infected haematoma. The interventional
radiology placed a percutaneous drain into the collection (c)
b
c
cryoglobulin. Certain groups of patients may be at a higher risk of bleeding due to
the underlying use of antiplatelets or anticoagulants for various cardiovascular indications or underlying chronic kidney disease with dysfunctional platelets. Often,
due to the urgency of the intra-abdominal sepsis, the EL has to proceed without the
wearing off of medication therapeutic effect with time. Energy device such as ultrasonic shears and bipolar can be used with good effect. Careful suture ligation of the
vessels should be performed. Various adjunct topical haemostatic agents such as
oxidized regenerated cellulose (Surgicel™), haemostatic matrix containing thrombin
(SURGIFLO™), haemostatic matrix containing both thrombin and brinogen
(Tisseel) can be applied in cases with generalized ooze.
In cases of delayed presentation a few days post-EL and patient remaining haemodynamically stable, a CT angiogram can be performed to locate the source of the
haemorrhage. Depending on the location, the interventional radiologist may be able
to access with view of performing embolization of the targeted bleeding vessel.
In certain cases, it may manifest as an infected haematoma when a cross- sectional
imaging is performed a few days post-EL for investigation of a septic source.
Depending on the clinical status of the patient, size and location of the infected
haematoma, percutaneous drainage by the interventional radiologist can be considered (Fig.24.1).
Surgical Site Infection
EL and some risk factors such as obesity, immunocompromised, diabetes mellitus,
smoking and perforated viscus with gross contamination increase the risk of wound
infections. It will be difcult to optimize these risk factors in an emergency setting.
Nevertheless, a few approaches can be employed to mitigate the risk of wound
infections: using a wound protector and ensuring the wounds are protected by packs
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Z. Q. Ng and D. Weber
when performing intestinal resections with potential spillage of enteric contents and
use saline and/or betadine wash of the wound.
Most cases are supercial wound infections and are characterized by the presence of erythema around the incision site, tenderness and a bulge (from the underlying pus). They occur around day 5–7 post-EL. Occasionally, it is detected on
cross-sectional imaging with the presence of uid collection and air at the incision
site. It should be corresponded with the clinical ndings. The infected wound site
can be opened and drained at bedside with simple daily dressing change. If there is
a suggestion of a deeper infective collection, it is advisable to perform in theatre
under a general anaesthetic for proper washout of the wound and ensure the fascia
closure remains intact. A vacuum assisted closure can be applied.
There is recent evidence to show that prophylactic use of negative pressure
wound dressings can reduce the incidence of wound infections in contaminated
wounds [11, 12]. Different commercial products such as Prevena, PICO dressings
can be applied. These negative pressure dressings are applied for a period of
5–7days and removed. It is important to inspect the underlying wound site of the
negative pressure wound dressing if there is suggestion of an undiagnosed infective source.
Certain surgical site infections may be deep and manifest as intra-abdominal
abscess. The causes of it need to be investigated to ensure it is not secondary to an
anastomotic leak. The management of anastomotic leak is discussed later. Most
cases can be managed non-operatively with intravenous antibiotics and/or percutaneous drainage by the interventional radiologist (Fig.24.2).
b
a
Fig. 24.2 This was an elderly man that underwent an emergency ultralow Hartmann’s procedure
for perforated stercoral colitis at the rectosigmoid junction with an underlying mid rectal tumour.
On post-operative day 7, he developed some febrile episodes. A CT scan performed showed a
pelvic rim-enhancing collection as the most likely source of infection (a). Percutaneous drainage
under CT guidance was done with success (b)
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Pain Control
Following EL, post-operative pain control is crucial to prevent the development of
complications [13]. The techniques have advanced over the last decade. The planning of pain control commences prior to the EL.Spinal or epidural anaesthesia can
be considered but may not always be feasible in the unwell or haemodynamically
unstable patient. Bilateral transabdominis plane blocks with catheters for continuous infusion post-operatively function well [14]. The placement of the catheters in
the correct anatomical plane is important [15]. Its use can help to reduce opioid
requirements. Other strategies should be based on the WHO analgesia ladder:
paracetamol, non-steroidal anti-inammatory, slow-release opioids. In cases where
oral intake or return of gastrointestinal tract function is expected to be delayed, the
use of patient-controlled analgesia with opioids or ketamine can be used. Dedicated
Acute Pain Service (APS) is valuable to assist the clinicians in adjustment of the
different regimes based on the assessment of daily visual analogue scores.
Atelectasis
It is a common post-operative complication post-EL. It is usually addressed by
encouraging patients to sit out of bed and mobilize early. Adequate analgesia is vital
to allow early mobilization. Routine physiotherapist assessment post-EL should be
part of the daily practice [16, 17].
Post-operative Ileus
Post-operative ileus is dened based on clinical and/or radiological ndings [18,
19]: when patient develops two or more symptoms of the following ve criteria on
post-operative day 4 onwards:
• Nausea or vomiting over the preceding 12h
• Inability to tolerate an oral diet over the prior 24h
• Absence of atus over the prior 24h
• Abdominal distension (increased abdominal girth with tympany on percussion)
• Radiological ndings: gastric distention, presence of air-uid levels, dilated
small or large bowel loops without a transition point.
Its incidence has been reported ranging from 10–30% following abdominal surgery [20]. In the elective setting, various perioperative measures can be optimized
to prevent its occurrence. It is usually multifactorial [18]. In the emergency setting,
certain measures such as the amount of uids administered can be difcult due to
the initial sepsis [13]. The goal-directed uid resuscitation via the measurement of
the urine output perhaps is most realistic.
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Management of post-operative ileus is supportive [19] with nasogastric decompression, replacement and maintenance of uid and electrolytes losses, reduction in
the use of opioid analgesia, use of prokinetic agents such as metoclopramide and
mobilization. In certain cases where there was gross peritonitis in the index operation, a CT scan should be organized to ensure there is no underlying infective collection or an anastomotic leak that has contributed to the post-operative ileus. It is
also useful to differentiate with small bowel obstruction which may require surgical
intervention.
The duration of post-operative ileus can be unpredictable which range from days
to weeks. It is important to support the nutritional requirements with parenteral
nutrition.
Z. Q. Ng and D. Weber
Small Bowel Obstruction
Its presentation can be similar to post-operative ileus. In patients who have been
treated as ileus initially but are not progressing clinically, a CT abdomen should be
performed. Most cases are adhesive in nature [21] which will resolve with nonoperative management. A water-soluble oral contrast can be administered which has
both diagnostic and therapeutic values. A follow-up abdominal X-ray 6-h post
administration is performed to appreciate if the contrast has reached the large intestine. Very rarely, it could be due to small bowel incarceration from an internal hernia
resulting from the unclosed mesentery from bowel resection which will require a
return to theatre. It is usually more common in laparoscopic cases but certainly can
occur in open bowel resections [22]. A high index of suspicion is needed to diagnose on the CT scan.
Aspiration Pneumonia
It could happen on presentation or on anaesthetic induction in patients presenting
with bowel obstruction. It is important to have nasogastric tube decompression early
on to prevent repeated vomiting. When dealing with the intra-abdominal pathology
intraoperatively, communication with anaesthetics team is vital before milking the
small bowel content proximally to prevent the content entering the lungs. Suction
should be connected to the nasogastric tube.
It is also common in the post-operative period when the patient goes into postoperative ileus. It is manifested with reduced oxygen saturation with increasing
oxygen needs and tachypnea clinically. Blood tests might show rising inammatory
markers and a plain chest X-ray lm will typically show haziness in the right lower
lobe. Other information on the chest X-ray might show atelectasis, dilated stomach
and small bowel loops indicating ileus (Fig.24.3).
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401
a
Fig. 24.3 This elderly patient underwent an emergency laparotomy with small bowel resection for
ischemic bowel secondary from band adhesion. The surgery was uneventful. Post-operatively, the
patient suffered from delirium and was given anti-psychotic medication and led to drowsiness. As
a result, the patient aspirated and developed signicant aspiration pneumonia (a and b—chest
X-ray and CT chest showing signicant bilateral upper lobes aspiration pneumonia). This led a
vicious cycle of sepsis and further delirious episodes. The patient later succumbed to increasing
need of respiratory support
b
Management is mainly supportive with nasogastric decompression, uid resuscitation and electrolytes optimization to resolve the post-operative ileus. Broad spectrum intravenous antibiotics to cover the anaerobic microorganism should be given.
Aggressive chest physiotherapy should be encouraged [16, 17]. In severe cases, the
patient may require respiratory support in the critical care unit.
Anastomotic Leak
A signicant proportion of EL is performed for pathologies associated with the
small and large bowels [23]. Anastomotic leak is the most feared complication as its
impact can have a devastating effect on the quality of life of patients.
The decision to perform an anastomosis depends on a few factors [23–25]:
patient’s comorbidities, nutritional state, location of the bowel resection, degree of
peritoneal contamination, intraoperative haemodynamic status, and presence of
vasopressor/inotropic support. In the presence of these factors, the clinician should
consider the safest option that is construction of a stoma upfront.
The options of the type of stoma are summarized below:
• Distal small bowel resection/right hemicolectomy/extended right hemicolec-
tomy/subtotal colectomy—end ileostomy alone, Abcarian end ileostomy, end
ileostomy with venting distal colostomy
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• Left sided segmental colectomy—end colostomy with a short distal stump,
double- barrel colostomy, end colostomy with a long distal stump sutured below
the fascia or as a mucous stula
A practical way of management is based on the International Study Group of
Rectal Cancer grading system. Most of the anastomotic leaks present during the rst
few days post-EL.It can be subtle with rising inammatory markers of white cell
count and c-reactive protein. Clinically, the patient may have febrile episodes,
increasing abdominal pain and distention. With that, it prompts an urgent CT abdomen/pelvis with intravenous and oral contrast or rectal contrast (for left sided
colonic anastomosis) (Fig. 24.4). The considerations for the management of the
anastomotic leak are [26]:
(a) The location and degree of the anastomotic leak (contained vs free)
(b) The haemodynamic status of the patient
In cases with a contained anastomotic leak and clinically patient remains well, a
period of intravenous antibiotics and nil by mouth may be adequate. In cases with a
local abscess adjacent to the anastomosis, percutaneous drainage via interventional
radiology should be considered. In cases where patients are unwell, they should be
taken back to the theatre for re-exploration and washout. Depending on the integrity
of the anastomosis, a few options can be explored:
1. pinhole anastomotic leak without signicant contamination—oversew the defect
and perform a proximal defunctioning loop ileostomy.
a
Fig. 24.4 This patient presented with perforated proximal transverse colon cancer. He underwent
an emergency laparotomy and extended right hemicolectomy. On post-operative day 9, his inammatory markers of white cell count and c-reactive protein were rising despite relatively asymptomatic clinically
A CT scan showed free gas locules adjacent to the anastomosis, representing anastomotic leak (a,
b). The patient was taken back to theatre. The ileocolic anastomosis was resected, and an end ileostomy was performed
b
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2. a large defect or disintegration of the anastomosis—
(a) Ileocolic anastomosis: resection of the anastomosis and perform an end ile-
ostomy. Alternatively, an Abcarian end ileostomy or double-barrel stoma
can be performed depending on the distal colonic conduit.
(b) Colorectal anastomosis: resection of the anastomosis and perform and end
colostomy.
3. small bowel anastomotic leak—the principles are similar to the above.
Nevertheless, the location of the proximity of the stoma should be considered as
it is certain that high output stoma which will subject the patient being reliant on
parenteral nutrition till its reversal.
In the presence of intra-abdominal sepsis, the bowel is generally dilated and
oedematous. To create the stomal trephine, it is important to ensure it is wide enough
to allow the construct of the stoma without tension. The use of a wound protector
such as Alexis allows smooth delivery of the stoma. Another option would be to
perform an end loop stoma.
In cases where there is insufcient space to accommodate the distal efferent
limb, it can be sutured to the midline fascia as a mucus stula if blowout occurs.
403
Enterocutaneous Fistula (ECF)
It is often a sequela of anastomotic leak or iatrogenic injury to the intestine. Often,
it presents in the early post-operative period. Depending on the location of the intestinal injury, the content could be biliary-type (small intestine) or faeculent-type
(large intestine) through the drain or the wounds (Fig.24.5).
In early detection (<7days), the patient should be taken back to the theatre for a
relook. The bowel should be handled gently to avoid further serosal injury or enterotomies/colotomies. The identied enterotomy can be either primarily repaired or
resected depending on the size of the defect.
There are situations where a takeback is not feasible due to delayed presentation,
signicant malnutrition, and risk of further injuries due to hostile abdomen.
The principles of management are [27]:
(a) Controlling the sepsis—percutaneous drainage of any collection or a controlled
stula. The output of the ECF can be high (>500mL/24h) and irritating to the
surrounding skin. Appropriate wound care with appliances is important.
(b) The patients are in a catabolic state and nutritionally depleted. To control the
ECF output, the patient is kept nil orally initially. Total parenteral nutrition is
administered with careful replacement of electrolyte losses.
With these fundamental approaches, certain ECFs will likely resolve with nonoperative management, provided there is no distal obstruction or discontinuity of
the intestine (Fig.24.6).
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Fig. 24.5 This was a case of small bowel ischemia secondary to superior mesenteric thrombosis.
The patient underwent an exploratory laparotomy and small bowel resection of the gangrenous
small bowel at a peripheral hospital prior to transfer. The patient was left with 80cm of small
bowel from the duodenal-jejunal exure and 10cm of distal terminal ileum from the ileocecal
valve. On the arrival at the tertiary centre, the patient was taken back to theatre for a relook laparotomy. A thrombectomy was performed at the superior mesenteric artery and the abdomen was
left open with view of return the following day. The subsequent relook laparotomy found viable
remaining small intestine albeit mild degree of ischemia at the distal terminal ileum. A handsewn
end-to-end small bowel anastomosis was performed. At post-operative day 7, the midline laparotomy wound looked erythematous with signs of infection. The staples were removed, and enteric
content discharged. A CT scan performed showed anastomotic leak leading to ECF. The patient
was managed with non-operative strategies (kept nil orally, intravenous proton pump inhibitor,
subcutaneous octreotide, wound care with dressing changes and total parenteral nutrition). The
ECF output reduced in the following days and resolved. This is a case to demonstrate the difculty
of returning to theatre in the setting of ECF as it would have not been survivable with the length of
jejunum left as a jejunostomy
In cases with continuous high output ECF, multiple ECFs, discontinuity of intestine, patience in the management is key. This group of patients will require multidisciplinary care: wound care, outpatient administration and monitoring of the total
parenteral nutrition and physiotherapy due to deconditioning.
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