Surgical Complications


 Surgical complications

Prof. Altaf Hussain Rathore FRCS
Chief oF Surgery
Foundation Hospital Rajana
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When I was a third year Medical Student, I was a great flatterer. I did not flatter my professors or the examiners. I used to flatter the house surgeons or the registrars of the surgical units so that they would allow me to assist them in the surgical operations or allow me to conduct minor operations like circumcision or sebaceous cyst. I was very much paranoid about surgery from the very beginning. I did my first surgical operation in 1957 that was circumcision, when I was in third year MBBS. After almost 60 years I still do off and on the same operation. And believe me I hate this operation the most. Still I am afraid of its complications.

Prof. Altaf H. Rathore

Surgeons job is very edgy how much learned he may be, how much experienced he may be still he cannot claim with absolute surety that no complications will occur after his surgery. Though his skill and experience will make him more cautious or may be in some cases over confident. I remember a case of Shapi Island, Kent, UK when a senior most surgeon removed a right diseased kidney. When he examined the specimen he realized that he had removed the shrunken liver of the patient instead of kidney. Next day the surgeon retired from his services. In other words I wants to emphasize that you can’t eliminate the complications altogether, no matter how much experienced you are. So don’t get upset if you get one . It is not always your fault. It may be due to some abnormal anatomy or unusual pathology. Sometime judgment is wrong due to poor investigational results. At other times it is anesthetist’s fault which is labeled on you. It may not be a technical fault; you may have not done preoperative work up. Patient has some serious concomitant medical illness like diabetes, COPD or heart disease or kidney failure, bleeding disorder or anemia or uncontrolled hypertension, etc. You may not be experienced enough for that particular surgery. You may not be able to stop the bleeding specially in cases of trauma surgery. Let us take the example of the commonest operation done by the surgeons that is appendectomy. Look what you may expect.

A long subserosal retrocaecal sub hepatic appendix which is not uncommon. Sometimes it runs out to be gangrenous caecum, ileocaecal tuberculosis, Crohn’s disease, Meckle’s diverticulum, non rotated gut, volvulus of caecum, tubo ovarian mass, even ureteric stone . Here you may commit gross mistake if you are not experienced

Ruptured ectopic  pregnancy usually is to be dealt by a general surgeon when we opens a case with alleged to be appendix. Have a good sucker and immediately put a clamp on the sac which usually includes one sided tube and ovary.After transfixing suck out and mop as much blood you can. Toilet the peritoneal cavity with two or three liters of saline and close the abdomen with a tube drain in and ask for at least 4-6 units of blood. In case of unexpected bleeding anywhere during the operation packing of the area tightly for few minutes is the best policy. When blood is area, with a good sucker and good light and control the bleeding. Always leave a drain even a pack inside which could be removed after 48 days.

It is not uncommon for a surgeon to come across with a lump with full of plastic adhesions or abscess or gangrenous perforated appendix. Old policy is to leave a drain in specially if there is an abscess and close the abdomen. Alternately enlarge the incision and be ready for right hemicolectomy. One can try to remove the appendix but its base should always be ligated otherwise you may get faecal fistula. Make sure you may not divide the right ureter (once I did so) and if you have done so anastomose both ends with Number 4/0 absorbable sutures, it unites well.

During laparotomy if you come across difficult perforations or obstruction or patient condition is not good or you are not happy with the anesthesia, perform a proximal ileostomy or colostomy . And if you are not sure specially in small intestine which is the proximal or distal loop do the loop ileostomy . The site on the abdomen is nearest to the loop without any tension forget the classical spot i.e RIF LIF right or left hypochondrium. For DU perforation close it with an absorbable interrupted sutures preferably no 2/0 vicryl. Put a piece of omentum on it. Suck out and toilet the whole peritoneum properly and leave one or two drains inside; if it is a big perforation and fragile as well then be ready for gastrojejunostomy. But this heroic operations should never be tried on simple perforations. For intestinal injury perform the proximal ileostomy or colostomy even exteriorize the perforated Gut.

In urology operation if there is too much bleeding from a kidney put a soft clamp on renal pedicle and suture the kidney incision with Number 2 CG or vicryl on atraumic big curved needle. Sometimes you have to do the nephrectomy when other kidney is functioning well. If you have divided the ureter by accident unite both end with fine suture it heals well. Retain a D.J Stent or baby feeding tube Number 4 bringing out one  end from the kidney or bladder . If the injury is near the bladder it is better to re-implant the proximal end into the bladder. Boaris operation is very useful for such occasions. In case of bladder injury repair it immediately and leave a catheter in for two weeks. You can get uncontrollable bleeding after open prostatectomy. I will advise you to use old Wilson-Heys technique of leaving a pack in prostate bed and a supra pubic No. 26 Nelton tube in the bladder. Pack can be removed after two days.

Do not take orchidectomy so easily because nobody how old is he likes to get his testis removed. Once I operated an old man of eighty years senile for strangulated right inguinal hernia. I had to resect his gangrenous intestine along his right testis. He made such a hue and cry for it, feeling his scrotum again and again after operation. Another case, 15 years back, whom  I operated for prostatic enlargement turned out to be cancer. So, I did bilateral castration. He took me to the court but fortunate for me that he died of metastasis before court called me.

Injury to CBD or biliary duct during gallbladder operation specially in   acute state or with some anomaly, is not uncommon. If it is a partial injury, try to repair and always leave a T-tube in the CBD. If you have damaged the whole duct, try to find out the proximal end and perform choledocho-jejunostomy, If you are not experienced, retain a Nelton catheter in the proximal end then leave one or two No. 24 or 26 tube drains near porta hepatis and come out. Other more experienced surgeon will deal with it latter.

Never be afraid of suturing liver or spleen. Temporarily bleeding from liver can be controlled by application of soft clamp, even a rubber tube or with right thumb and index finger on biliary traid in foramen Wilmsolw. Spleen can easily be removed if bleeding from it is uncontrollable

Injury to abdominal aorta and inferior vena cava is not common during abdominal operation. Once one of my registrars was so rough that he injured inferior vena cava during right nephrectomy which had to be repaired. I am glad that he took orthopaedic later on as a specialty.

Thyroidectomy is a tricky surgery specially if its size is huge or it is toxic or malignant. Always get all the preoperative investigations including indirect laryngoscopy, T3, T4, TSH. Thyroid scan and X-ray neck. Make the patient euthyroid and have plenty of blood cross-matched before operation. Do not underestimate thyroid veins especially middle thyroid vein. Get a good exposure and do not drift from classical techniques. If you have uncontrollable bleeding or expect it, bilateral ligation of external carotid arteries is advisable. If you are not sure about the patency of upper respiratory passage, do not hesitate to do tracheostomy straightaway.

As far as bone trauma is concerned, if you are alone remember beside packing of the wound good antibiotic and analgesic, application of external fixator is a great breakthrough in orthopedic surgery  like Thomas splint in the past. As regards cardiothoracic and neurosurgery, they are highly specialized subjects so I will not touch these systems.

This is the era of research and advancement. Many gadgets and lab tests are now available to know the exact diagnosis, pathology anatomy and fitness before operation like endoscopy, X-ray CT Scan, MRI, Scintiscan etc., With the advent of safe anesthesia, most efficient blood transfusion services, the surgical complications  have come to minimum, still complications do occur even with the experienced surgeons. But they recognized them and try to deal with them. So to my younger colleagues if they want to avoid serious complications during the surgery,  I will suggest the following:

  1. Try to be absolutely sure of your diagnosis
  2. Get proper preoperative investigations and medical work up. If patient has any medical condition, treat it properly before operation: if emergency, use extra precautions explain it to the patient, warn the anesthetist and take a special written informed consent.
  3. If patient is anemic or you expect excessive bleeding get enough blood ready for transfusion.
  4. Always conduct the operation under proper anesthesia.
  5. Give proper prophylactic antibiotics specially if the disease is due to some infection or patient has septicemia or infection somewhere in the body.
  6. Make sure that proper surgical instruments, disposables and sutures are available in OT. There should always be a good light even spot light in the theater.
  7. Never compromise on aseptic techniques.
  8. Give proper incision of enough length it is not wise to try to do the button hole surgery.
  9. Don’t be rough with the tissues; be gentle in handling them during operation.
  10. Don’t be in hurry, take your time. Time is no factor in the modern surgery
  11. Make absolute homeostasis during surgery before closure. If you are not sure leave a drain inside and get some blood for the patient.
  12. Opening of the abdomen:  if you are unable to deal with the situation pack the wound and ask for the help.
  13. Always use the classical incision and techniques unless you are very much experienced. Don’t try experimental surgery on human unless you are working in ideal circumstances.
  14. Always keep an authoritative book of operative’s surgery ready at hand and go through if you come across a rare operation. Don’t be shy in consulting other colleagues if you are not absolutely sure of the technique. By taking all these precautions you can decrease the complications to a minimum. Remember everything is in the hand of almighty, surgeon can only do his best. Your eyes should be on the disease of the patient, rather on his pocket. Remember that ALLAH is watching you all the time. Always ask for his guidance.