Advancements in minimally invasive gynecologic surgical techniques, such as laparoscopy and hysteroscopy, have allowed more outpatient procedures for patients. Postoperative complications among inpatients are now seen out of the hospital. The prevalence of all postoperative complications after gynecologic procedures is reported to be 9%, whereas 3.7% are considered major complications.¹ The most common reasons for ED visits during the postoperative period after gynecologic procedures are pain, fever, and vaginal bleeding.

HISTORY

Patient risk factors for postoperative complications include age >80 years, medical comorbidities, dependent functional status, and obesity or unintentional weight loss.¹ Key historical questions are listed in Table 105-1. The interval between surgery and the onset of symptoms is very important in determining the cause of symptoms. For example, most cases of early postoperative fevers (<24 hours) are not infectious but rather result from pulmonary atelectasis, hypersensitivity reactions to antibiotics, pyogenic reactions to tissue trauma, or hematoma formation. Fever occurring on postoperative days 3 to 5 may be due to a urinary tract infection. On postoperative days 4 to 6, consider venous thromboembolism, and ≥7 days after surgery, consider a surgical site infection.²

PHYSICAL EXAMINATION

Examine all appropriate body systems. Do not assume that complaint is gynecologic, and investigate other potential explanations of symptom. Postoperative pain and tenderness can be difficult to assess. After laparoscopy, patients may have shoulder or upper abdominal pain because of carbon dioxide bubbles trapped between the liver and diaphragm after insufflation for the procedure, with 50% to 70% of patients still being affected 48 hours after surgery.³ Postoperative pain and tenderness are concerning if associated with fever, nausea and vomiting, and a change in bowel sounds.

Examine the surgical wound and perform a pelvic examination, including both a sterile speculum and a bimanual examination. In patients undergoing fertility treatment, defer the pelvic examination until consulting with the gynecologist, due to the possibility of rupturing enlarged ovarian follicles. During sterile speculum examination, the cervix or vaginal cuff must be visualized. After vaginal hysterectomy, no special precautions are needed for a speculum examination. Note any evidence of bleeding, discharge, erythema, and cuff or labial cellulitis. After a vaginal or abdominal hysterectomy, record the presence of tenderness, masses, and an intact cuff. After hysteroscopy or dilatation and curettage, evaluate cervical motion, uterine, and adnexal tenderness. Perform a rectal examination to assess for tenderness, masses, or fecal impaction.

LABORATORY TESTING

Laboratory studies should be directed toward the patient’s complaints. A CBC with a manual differential count is almost always indicated. Obtain a serum β-human chorionic gonadotropin level for all women with childbearing potential. A clean-catch or catheterized urine specimen along with urine, blood, wound, and cervical (if present) cultures should be obtained if the patient is febrile. A complete chemistry panel may be necessary to evaluate hepatic and renal function.

Imaging is often necessary. A chest radiograph can confirm pneumonia or inappropriate air under the diaphragm. Air or insufflated carbon dioxide should be completely absorbed by the third postoperative day. Supine and erect abdominal series help confirm bowel obstruction. Although pelvic sonogram is helpful for visualizing the pelvic structures, CT is the gold standard for diagnosing most postoperative abdominal complications, with a sensitivity and specificity of >90%.⁴ MRI may be indicated in the evaluation of septic pelvic thrombophlebitis.

LAPAROSCOPY

Gynecologic laparoscopy is used for diagnosis and treatment. Indications for laparoscopy are listed in Table 105-2. Laparoscopy is almost always an ambulatory surgical procedure and is performed under general anesthesia with endotracheal intubation.

After cesarean sections, abortion, cholecystectomy, and coronary angioplasty, tubal sterilization is the next most common operation in the United States, with a rate of 12.2 procedures per 1000 unsterilized women.^5,6,7 When not performed postpartum with cesarean sections, the procedure is almost always performed laparoscopically.⁶ Laparoscopic hysterectomy is another common procedure.

Reported overall laparoscopic complication rates range from 0.2% to 10.3%.⁸ Major laparoscopic procedures are associated with a higher rate of complications compared with minor procedures (0.6% to 18% vs 0.06% to 7.0%, respectively).⁸

Both diagnostic and therapeutic gynecologic laparoscopy are accomplished by passing a rigid endoscope through a trocar that is inserted bluntly through a small infraumbilical incision into the abdominal cavity after a Veress needle has been used to insufflate the abdomen with carbon dioxide. The pneumoperitoneum must be sufficient to displace the bowel and is maintained throughout the surgery. Additional trocars may be placed so that other accessories can be used during the surgery. The majority of complications occur during entry of these instruments.

All laparoscopic procedures entail the same potential complications (Table 105-3), but more complex surgeries carry considerably more risk.

Bowel injury is uncommon, but may not be noted at the time of surgery. Patients with greater than expected pain after laparoscopy should be considered to have a bowel injury until proven otherwise. Signs and symptoms include abdominal pain and distention, fever, nausea, vomiting, and an elevated WBC count. Plain radiographs may show an ileus or free air under the diaphragm. Complications include peritonitis, abscess, enterocutaneous fistula, and septic shock. There are three major types of bowel injury: traumatic, thermal, and vascular.

Although many significant complications of laparoscopy are recognized in the operating room under direct visualization, thermal injury can easily be missed. Patients may not develop symptoms for several days or weeks postoperatively.^9,10,11 Early gynecologic consult is critical if a thermal injury is suspected, because damage is usually more extensive than may be apparent.

Vascular injury is uncommon^9,10,11 and is usually recognized during the operation. Patients may later present with a postoperative hematoma, which requires wound exploration by the gynecologist.

The rate of urinary tract injuries is about 4%.¹² Injuries can occur from mechanical or thermal trauma. Trocar or dissection injuries to the bladder are typically recognized intraoperatively. Thermal injuries, however, may not be initially apparent and may present later as peritonitis or fistula. The diagnosis of a ureteral injury is usually delayed. Thermal injury may present up to 14 days postoperatively with abdominal or flank pain, fever, and peritonitis. An abdominopelvic CT with IV contrast shows extravasation of urine or a urinoma. Mechanical obstruction of the ureter from sutures or staples may be recognized intraoperatively by direct visualization but may also present up to 1 week postoperatively with fever and flank pain. An IV pyelogram or CT helps define the site and degree of obstruction.

Incisional hernias and dehiscence are rare complications after laparoscopy. Incisional hernias are more common when defects >10 mm are made and can develop within the first postoperative week. Patients may be asymptomatic or may note pain, mass, evisceration, or signs and symptoms of a mechanical bowel obstruction. Fever may present if the bowel is incarcerated, and peritonitis may develop after bowel perforation. Dehiscence usually involves protrusion of the omentum and, in rare cases, the small bowel. Immediate incisional repair by a gynecologist is usually sufficient; however, a laparotomy is needed for bowel incarceration or perforation.

Wound infection after laparoscopy is uncommon and rarely a serious complication. Most infections are minor skin infections that can be managed with oral antibiotics and possible drainage. Antibiotics should cover against staphylococci, including methicillin-resistant Staphylococcus aureus and streptococci. Excluding minor skin infections, pelvic infection is quite rare and includes pelvic cellulitis, abscess, and necrotizing fasciitis.

HYSTEROSCOPY

Hysteroscopy is the direct visualization of the cervical canal and endometrial cavity using a rigid or flexible fiberoptic instrument. Hysteroscopy can be done as an office procedure under IV sedation or in an operating room. Complications (Table 105-4) are uncommon and occur more frequently as a result of operative hysteroscopy than diagnostic hysteroscopy.¹³

The most common indication for hysteroscopy is abnormal vaginal bleeding. Other indications include uterine leiomyomata, intrauterine adhesions, proximal tubal obstruction, removal of intrauterine devices, müllerian anomalies, and infertility evaluation. Therapeutic applications include directed biopsies, removal of small myomata or polyps, and endometrial ablation for menorrhagia. Also, hysteroscopic sterilization is growing in popularity. The Essure^® microinsert system is currently the only method available in the United States. The device is deployed in the fallopian tube and stimulates surrounding tissue growth, resulting in fallopian tube occlusion and permanent sterilization.