Complications of gynecologic surgery

New Insights into the Assessment of Peri-Operative Risk in Women Undergoing Surgery for Gynecological Neoplasms: A Call for a New Tool

Existing tools for predicting postoperative complications in women undergoing surgery for gynecological neoplasms are evaluated in this narrative review. Although surgery is a very efficient therapy for gynecological tumors, it is not devoid of the possibility of negative postoperative outcomes. Widely used tools at present, such as the Surgical Apgar Score and the Modified Frailty Index, fail to consider the complex characteristics of gynecological malignancies and their related risk factors. A thorough search of the PubMed database was conducted for our review, specifically targeting studies that investigate several aspects impacting postoperative outcomes, including nutritional status, obesity, albumin levels, sodium levels, fluid management, and psychological well-being. Research has shown that both malnutrition and obesity have a substantial impact on postoperative mortality and morbidity. Diminished sodium and albumin levels together with compromised psychological well-being can serve as reliable indicators of negative consequences. The role of appropriate fluid management in enhancing patient recovery was also investigated. The evidence indicates that although current mechanisms are useful, they have limitations in terms of their range and do not thoroughly address these recently identified risk factors. Therefore, there is a need for a new, more comprehensive tool that combines these developing elements to more accurately forecast postoperative problems and enhance patient results in gynecological oncology. This paper highlights the need to create such a tool to improve clinical practice and the treatment of patients.

Abdominal Gynecologic Procedures in Pancreas Transplant Recipients

INTRODUCTION

With the growing population of pancreas transplant recipients followed long-term, some female recipients are going to require surgical intervention for gynecologic symptoms and pathologies. Currently, there is a lack of literature describing how to approach this population and whether pelvic gynecologic procedures (GYN) can be performed safely given the proximity of the pancreatic (and possibly renal) allograft. In this single-center retrospective analysis, all pancreas transplant recipients that subsequently underwent GYN were reviewed.

METHODS

Subjects were identified by cross-referencing all pancreas transplants performed between January 2003 and December 2022 for any subsequent GYN. Demographics at transplant and GYN, indications and procedure performed, operative time, presence and involvement of a transplant surgeon, complications length of stay, and readmissions were reviewed.

RESULTS

Seventeen patients who underwent a total of 19 GYN after pancreas transplantation were identified. Operations performed included tubal ligation (n = 2), total abdominal hysterectomy with (n = 6) or without bilateral salpingectomy (n = 2), oophorectomy versus cyst drainage (n = 2), bilateral oophorectomy (n = 1), and unilateral (n = 4) versus bilateral (n = 2) salpingectomy. Four were performed through an open laparotomy and 15 were performed laparoscopically. In 11 cases, a transplant surgeon was involved intra-operatively. Eight of the 17 patients developed post-operative complications including post-operative fevers, fluid overload, neutropenia, elevated creatinine (n = 2), nephrolithiasis, urinary tract infection, and incisional hernia. Five required readmission.

CONCLUSION

GYN can be performed safely following pancreas transplantation, but careful planning and the involvement of the transplant surgery team are advised.

PROJECT PREVENT: a randomized controlled trial of preoperative vaginal metronidazole to decrease patient issues and infections after hysterectomy

Objectives

To evaluate if vaginal metronidazole for 5 days before hysterectomy decreases postoperative infections and patient issues.

Design

This randomized trial compared vaginal metronidazole for 5 days before a scheduled hysterectomy to no intervention. Sample size calculation was based on a 20% difference in issues and infection (30% incidence and 10% in the intervention arm) with 80% power and an alpha error of 0.05 and indicated 62 subjects needed in each arm.

Setting

Outpatient gynecology clinics at a single academic institution.

Participants

154 subjects were screened for eligibility between July 2020 and September 2022. 133 underwent hysterectomy including 68 subjects (51.1%) randomized to the metronidazole and 65 (48.9%) controls. Overall, the population was racially and ethnically diverse. There was no significant difference in characteristics between the two groups.

Interventions

Vaginal metronidazole for 5 days before hysterectomy.

Main outcome measures

Postoperative patient issues and documented postoperative infections at 4-8 weeks after surgery.

Results

There was no difference in the composite rate of patient-reported issues and/or documented postoperative infection (53/133 (39.8%) with no difference between groups (29/68 (42.6%) vs 24/65 (36.9%), p=0.50). There was no difference in patient-reported issues which was 51/133 (38.3%) with no difference between groups (28/68 (41.2%) vs 23/65 (33.8%), p=0.49) or in documented infections with a rate of 25/133 (18.8%) with no significant difference between groups (15/68 (22.0%) vs 10/65 (15.4%), p=0.33). In the intervention arm, the compliance rate was 73.5% for all 5 days of vaginal metronidazole, and a per-protocol analysis was performed which resulted in no significant difference between groups.

Conclusions

There is insufficient evidence to suggest a significant benefit of preoperative vaginal metronidazole to prevent surgical site infections and postoperative patient issues in patients undergoing hysterectomy.

Trial registration number

ClinicalTrials.gov, NCT04478617.

Complications in gynecological surgeries in Ukraine: results a multicenter study

OBJECTIVE

. Aim: To analyze the complications during gynecologic surgery procedures and identify possible risk factors associated with this type of surgery in Ukraine.

PATIENTS AND METHODS

Materials and Methods: We conducted a multicenter, retrospective cohort study in tertiary care hospitals from 12 regions of Ukraine from January, 2021, to December, 2023. The study included women who underwent gynecologic surgery at these hospitals. Postoperative complications are defined by Clavien-Dindo classification.

RESULTS

Results: A total of 13,937 women were included in our study. The overall prevalence of 30-day complications was 13.9%. The most frequently postoperative complication types were surgical site infections, hemorrhage, urinary tract infection, bowel injury, urinary tract injury, and bladder injury. Age 60 years or older (adjusted odds ratio (aOR 1.81), BMI ≥30 kg/m2 (aOR 1.78), diabetes mellitus (aOR 1.45), procedures for gynecologic cancer (aOR 2.58), prior pelvic surgery (aOR 1.61), emergency procedure (aOR 1.83), ASA-physical status class 5 vs. 1 or 2 (aOR 4.31), operative time greater than 3 hours vs. less than 1 hour (aOR 2.92), wound class 4 vs. 1 (aOR 4.28), and open abdominal approach for surgery vs. laparoscopic procedure (aOR 2.65) were significantly associated with postoperative complications.

CONCLUSION

Conclusions: This study found a high prevalence of complications rate in gynecological surgery varied widely depending on the approach and type of procedure. Risk factors for complications are age, obesity, diabetes, procedures for gynecologic cancer, prior pelvic surgery, emergency procedure, open abdominal surgery, ASA-physical status, duration of surgery, and wound class.

FIGO best practice guidance in surgical consent

Obtaining medical consent preoperatively is one of the key steps in preparing for surgery, and is an important step in informed decision making with the patient. According to good medical practice guidelines, doctors are required to have the knowledge and skills to treat patients as well as inform them, respect their wishes, and establish trust between themselves and their patients. Valid consent includes elements of competence, disclosure, understanding, and voluntariness. Documentation of these elements is also very important. The International Federation of Gynecology and Obstetrics (FIGO) Education Communication and Advocacy Consortium (ECAC) has realized that the quality of consent varies considerably across the world and has developed simple guidelines regarding consent and procedure-specific checklists for the most common obstetric and gynecological procedures.

Care Delivery for Patients with Leiomyomas: Failures, Real-Life Experiences, Analysis of Barriers, and Proposed Restorative Remedies

In this narrative review, we describe historical and contemporary influences that prevent patients with fibroids from getting appropriate medical care. Using patient stories as examples, we highlight how misogyny on all levels hurts patients and prevents medical teams from doing their best. Importantly, inequity and disparities result in massive gaps in care delivery. We suggest that we, as gynecologists and surgeons, must join public discourse on this topic to highlight the inadequacies of care delivery and the reasons behind it, suggest potential solutions, and join patients and communities in formulating and implementing remedies.

Applying graph theory to improve the quality of scientific evidence from textual information: Neural injuries after gynaecologic pelvic surgery for genital prolapse and urinary incontinence

AIMS

To provide the overall rate for all types of neurologic iatrogenic injuries during urogynaecologic surgery from textual data.

METHODS

Systematic research focused on complications of gynaecologic surgery and neurologic injuries in abstracts. Keywords concerning complications (cluster A), unspecific; neurologic issues (cluster B); surgery (generic words) (cluster C); specific gynaecologic operations (cluster D); and specific gynaecologic operations for pelvic organ prolapse and urinary incontinence (cluster E) were extracted. Associations among clusters of keywords were assessed by using multiple runs of text-mining software Semantic Brand Score (SBS, https://semanticbrandscore.com/#primary). Association scores were converted into probabilities. The rate of neurologic complications in urogynaecologic surgery was calculated ("a priori" probability) by applying Bayes' theorem. Textual estimates of neurological injuries in urogynaecologic surgery are 0.035554 (95% confidence intervals 0.019607-0.0515001; no quantitative data were found). To test if the probability calculated on textual information was the same as quantitative data reports ("a posteriori" probability), the rate of neurologic complication of all gynaecologic surgery was calculated using a meta-analytics approach and was compared with the textual analysis value.

RESULTS

The rate of neurologic complications in gynaecologic surgery after meta-analytic data synthesis has been 0.016489 (95% confidence intervals 0.012163-0.022320), which is equal to the textual estimate (0.016889, 95% confidence intervals 0.019607-0.051501). Therefore, 0.035554 is a reliable likelihood to observe a neurologic complication in urogynaecologic surgery.

CONCLUSION

Iatrogenic nerve injuries in urogynaecologic surgery are higher than whole gynaecologic surgery. Text-mining software SBS and probability conversion can provide reliable answers from overall scholars' opinions on unsolved clinical questions when better evidence is lacking.

Exploring Adverse Events and Utilization of Topical Hemostatic Agents in Surgery

Background and Objectives:

This retrospective study provides preliminary qualitative assessment of the adverse events (AEs), focusing on pelvic and abdominal AEs and patient outcomes reported for three hemostatic agents used in gynecologic surgery.

Methods:

Utilization rates for oxidized regenerated cellulose powder (ORC), polysaccharide powder (PSP), and fibrin sealant solution (FSS) were obtained from hospitals via the Premier Healthcare databases for all surgical procedures from January 1, 2018 to September 30, 2020. All reported cases were extracted from the Food and Drug Administration (FDA) Manufacturer and User Facility Device Experience (MAUDE) database for ORC and PSP and from the FDA Adverse Event Reporting System (FAERS) database for FSS. Distributions of AEs by anatomical site (MAUDE/FAERS) and surgical procedures by specialty (Premier) were evaluated for each product. Number of cases and number and types of AEs were compared to the total utilization for each product.

Results:

PSP was the most used product during the period analyzed (n = 126,509 uses), followed by FSS (n = 80,628 uses), and ORC (n = 41,583 uses). Distribution of surgical procedures by anatomical site varied significantly between hemostatic agents (p < 0.001). ORC was associated with more patient cases with AEs and numbers of reported AEs compared with PSP and FSS (p < 0.001). ORC was associated with higher number of infections than PSP (p < 0.001) and FSS (p < 0.001).

Conclusion:

These findings suggest that ORC use in abdominal and pelvic surgery may result in more postoperative complications compared with non-ORC hemostatic agents. Further prospective randomized studies are needed to compare efficacy and safety of these products.

A Comparative Study of Braided versus Barbed Suture for Cystotomy Repair

Background

In this study, we aim to compare outcomes after cystotomy repair between standard sutures (910 polyglactin, poliglecaprone) versus barbed (V-Loc^TM 90) suture. As a secondary outcome, we analyzed factors for suture preference between the two groups.

Methods

A retrospective chart review was undertaken for surgeries complicated by cystotomy, identified by ICD-9/10 codes from 2016 to 2019 at West Virginia University (WVU) Hospital. Comparisons were made between cystotomy repair using barbed suture versus standard braided suture. Injuries were categorized by procedure, surgical route, type of suture used in repair, and subsequent complications related to repair. Primary endpoints were examined by Pearson's Chi-square test and interval data by t-test. A p < 0.05 was significant.

Results

Sixty-eight patients were identified with iatrogenic cystotomy at WVU. Barbed suture was used for cystotomy repair in 11/68 (16.2%) patients. No significant difference was seen in postoperative outcomes between patients repaired with barbed suture versus standard braided suture. Barbed suture was significantly more likely to be used for cystotomy repair in minimally invasive surgery (p = 0.001). It was most often utilized in a robotic approach 7/11 (63.6%) followed by laparoscopic 3/11 (27.3%). Body mass index (BMI) was significantly higher in patients receiving a barbed suture repair (p = 0.005).

Conclusion

Barbed suture may be comparable to standard braided suture for cystotomy repair. Barbed suture may offer a practical alternative to facilitate cystotomy repair in minimally invasive surgery, especially in patients with a high BMI.

Incidence of bowel injury during gynecologic surgery for benign indications: A nationwide cross-sectional study of cases from 2009 to 2018

OBJECTIVE

To investigate the incidence and risk factors of intestinal injury during gynecologic surgery for benign diseases, based on a national database.

METHOD

The study cohort was generated by extracting patients with operation codes for benign gynecologic diseases from the Health Insurance Review & Assessment Service National Inpatient Sample from 2009 to 2018. After analyzing the incidence of bowel injury during gynecologic surgery, a multivariate analysis was performed to identify the associated risk factors for bowel injury.

RESULTS

Among 81 451 patients who underwent gynecologic surgery for benign diseases, the incidence of bowel injury was 6.14 per 1000 women. The risk of bowel injury decreased with laparoscopy (odds ratio [OR] 0.54; 95% confidence interval [CI] 0.41-0.69; P < 0.001) and increased with subtotal hysterectomy (OR 2.83; 95% CI 1.79-4.46; P < 0.001) and adnexectomy (OR 2.83; 95% CI 1.93-4.16; P < 0.001). Old age, higher Charlson comorbidity index, low socioeconomic status, and a higher clinic grade were associated with a higher risk of bowel injury.

CONCLUSION

This study revealed the incidence of bowel injury during benign gynecologic surgery in a Korean national population-based cohort. The risk of bowel injury increased with open surgery, subtotal hysterectomy, and adnexectomy.

Determining trainees' knowledge of surgical anatomy: A specialist's perspective

OBJECTIVES

Intraoperative identification of anatomical structures can potentially reduce the risk of surgical complications. This study aims to report specialists' perspectives about the anatomical structures that third-year residents should be able to identify during surgical operations. In addition, the factors which may influence specialists' opinions are discussed.

MATERIALS AND METHODS

This qualitative cross-sectional study was conducted on obstetricians and gynaecologists between 1/2/2019 and 30/10/2019. The specialists practising in a hospital with a residency programme were included, and were asked to rate the importance of structures that a third-year resident should be able to identify during operations. We performed a comparison of responses based on specialists' age, gender, practice type, years of experience, and surgical workload.

RESULTS

One hundred and sixty-five specialists were recruited with a response rate of 69.3%. The mean age of respondents was 46.1 years, and they had a mean experience of 13.4 years. Furthermore, 86.6% of specialists rated all the anatomical structures as "more important". The importance of surgical structures, as rated by specialists, was not related to gender, years of experience, or surgical workload. The importance of 63% of the anatomical structures was rated higher by junior specialists than senior specialists.

CONCLUSION

Knowledge of anatomical structures is vital for gynaecologic residency training. Specialist's perceptions of the importance of various anatomical structures reflect their understanding of the training requirements. Our results highlighted the important anatomical structures that third-year residents are expected to identify during surgical operations. Future research may establish a reference for the core anatomy knowledge essential for each training year.

Disease trajectories and mortality among women diagnosed with breast cancer

Purpose

Breast cancer is a common disease with a relatively good prognosis. Therefore, understanding the spectrum of diseases and mortality among breast cancer patients is important, though currently incomplete. We systematically examined the incidence and mortality of all diseases following a breast cancer diagnosis, as well as the sequential association of disease occurrences (trajectories).

Methods

In this national cohort study, 57,501 breast cancer patients (2001–2011) were compared to 564,703 matched women from the general Swedish population and followed until 2012. The matching criteria included year of birth, county of residence, and socioeconomic status. Based on information from the Swedish Patient and Cause of Death Registries, hazard ratios (HR) were estimated for disease incidence and mortality. Conditional logistic regression models were used to identify disease trajectories among breast cancer patients.

Results

Among 225 diseases, 45 had HRs > 1.5 and p < 0.0002 when comparing breast cancer patients with the general population. Diseases with highest HRs included lymphedema, radiodermatitis, and neutropenia, which are side effects of surgery, radiotherapy, and chemotherapy. Other than breast cancer, the only significantly increased cause of death was other solid cancers (HR = 1.16, 95% CI = 1.08–1.24). Two main groups of disease trajectories were identified, which suggest menopausal disorders as indicators for other solid cancers, and both neutropenia and dorsalgia as diseases and symptoms preceding death due to breast cancer.

Conclusions

While an increased incidence of other diseases was found among breast cancer patients, increased mortality was only due to other solid cancers. Preventing death due to breast cancer should be a priority to prolong life in breast cancer patients, but closer surveillance of other solid cancers is also needed.

Electronic supplementary material

The online version of this article (10.1186/s13058-019-1181-5) contains supplementary material, which is available to authorized users.

Gastrointestinal injuries during gynaecologic operations at a university teaching hospital in Thailand: a 10-year review

The objective of this study was to investigate the incidence of gastrointestinal injuries during gynaecologic operations, the management of such injuries and associated risk factors. This case-control study (1:4) examined patients who received gynaecologic operations from 2007 to 2016 in Ramathibodi Hospital. The study cases comprised patients who had gastrointestinal injuries, while the control cases comprised patients who had gynaecologic surgeries in the same period with matching the types of procedures. The 10-year incidence was 0.38% (104 cases of gastrointestinal injuries among a total of 27,520 cases). The most common injury site was the small bowel (43.3%). There were 102 cases (98%) of gastrointestinal injuries which were diagnosed intraoperatively and which were immediately repaired with successful outcomes. Logistic regression indicated that a pelvic adhesion, previous pelvic surgery and previous abdominal surgery were predictive risk factors associated with the injuries (odds ratios: 9.45, 3.20 and 11.84, respectively). An immediate consultation with a surgeon and surgical repair of the injury resulted in excellent outcomes. Impact statement What is already known about this subject? Gastrointestinal injury is a rare, but fatal complication of gynaecologic operations. The previous small study identified some risk factors such as surgical approach and pelvic surgery associated with the injury. What do the results of this study contribute? Our study identified the associated risk factors for gastrointestinal injury, including previous abdominal injury, pelvic adhesion and previous pelvic surgery. A previous abdominal surgery was the most associated risk factor. Patients with the history of abdominal surgery had an almost 4-fold higher odds ratio than the ones with previous pelvic surgery. Other factors, including endometriosis, ovarian cancer and subsequent oncological procedures, and surgical staging were less related to the gastrointestinal injury. What are the implications of these findings for clinical practice and/or further research? The knowledge is useful for pre-operative evaluation and preparation. Bowel preparation and consultation with surgeon are necessary for patients with these risk factors prior to their surgeries. Moreover, an immediate intra-operative surgical correction of the injury results in excellent outcomes.

Prevalence of surgical complications in gynecological surgery at the Hospital Universitario San José in Popayán, Colombia. 2015

Introduction: Every surgery has risk of complications; prognosis depends on prompt diagnosis and timely management.Objective: To determine the prevalence of surgical complications in gynecological surgery in a tertiary care hospital and to explore associated factors.Materials and methods: Prevalence study with secondary analysis of medical records of patients who underwent scheduled gynecological surgery. The outcome variable was complications reported during a period of less than 30 days. The universe was established, and clinical, biological and sociodemographic variables were collected. To determine prevalence, the total number of complications was taken as the numerator and the total number of records was used as the denominator. To explore associated factors, odds ratio (OR) was used as a measure of association with a 95% CI.Results: 591 records were reviewed, finding a surgical management of ectopic pregnancy prevalence of 3.8% (OR=3.73, CI95%: 2.41-92.52). Obesity (OR 12.47, CI95%: 4.48-33.19) and gynecological surgery for malignancy (OR 3.73, CI95%: 1.14- 10.48) were associated with complications.Conclusion: The prevalence found in our institution was similar to what most studies have reported.

Use of computed tomography in the diagnosis of bowel complications after gynecologic surgery

OBJECTIVE

To determine factors predictive of bowel complications after gynecologic surgery and establish the added utility of computed tomography (CT) in the diagnostic process.

METHODS

Patients who underwent gynecologic surgery between January 2, 2008, and December 30, 2010, who had CT scans of the abdomen, pelvis, or abdomen and pelvis within 42 days for a suspected bowel complication were identified. Logistic regression analysis was used to identify factors predictive of bowel-related complications. The diagnostic accuracy of CT was compared among patient risk groups based on clinical suspicion (pretest probability) of bowel complications.

RESULTS

Among 205 eligible patients, 38 (18.5%) patients had a bowel-related complication. Mean time from surgery to CT was 12.4 (10.1) days. Clinical characteristics were used to develop a clinical model that included unexpected drainage from the drain, wound, or stoma (adjusted odds ratio [OR] 26.3, 95% confidence interval [CI] 3.1-224.4, P=.003), coronary artery disease (OR 10.7, CI 1.4-80.9, P=.022), laparotomy (compared with minimally invasive surgery) (OR 4.4, CI 1.1-17.2, P=.032), and age older than 45 years (OR 2.4, CI 0.7-8.8, P=.18). Addition of CT to clinical evaluation increased the predictive ability of the model (area under the curve) from 0.73 to 0.99. Among 57 low-risk patients, three with confirmed bowel-related complications would have been missed if CT was not performed. Among 13 high-risk patients, CT sensitivity was 70%, and it was negative for bowel complications in three patients subsequently confirmed to have serious complications (one anastomotic leak, two bowel perforations).

CONCLUSIONS

In patients who have undergone gynecologic surgery and have a high clinical probability of a postoperative bowel-related complication, CT alone may fail to accurately identify patients with serious complications.

LEVEL OF EVIDENCE

: II.

Iatrogenic gastrointestinal injuries during obstetrical and gynecological operation

Background

Gastrointestinal Injuries (GI) during gynecological operation are uncommon but proper management of these injuries is very important.

Objectives

The aim of this study was to review the causes and management of gastrointestinal injuries during gynecological and obstetrical operations.

Patients and Methods

In this descriptive retrospective study, 25 patients with gastrointestinal injuries during gynecological and obstetrical operation at Shabihkhani Maternity Hospital in Kashan city were reviewed. Demographic data such as age, gravid, parity, type of surgery or procedure, history of laparotomy, the surgical operation, injury site, time of diagnosis and method of treatment were extracted from medical records.

Results

The mean age of women was 33.2 ± 7.57 years. Fourty-four percent of the patients had a history of abdominal scar. Thirty-two percent of all GI injuries occurred during total abdominal hysterectomy (TAH). The small bowel was injured in 36% of cases. Fifty-two percent of injuries were diagnosed during the operation and the mean time of injury diagnosis was 2.8 ± 0.9 days.

Conclusions

All of the gynecologic surgeons must be aware of gastrointestinal injuries and should anticipate injury to these organs especially in high-risk patients for decreasing patient morbidity.