James D. Perkins, MD

The authors report no financial relationships relevant to this article.

Despite advances in medicine and surgery over the past century, postoperative wound complication remains a serious challenge. When a complication occurs, it translates into prolonged hospitalization, lost time from work, and greater cost to the patient and the health-care system.

Prevention of wound complication begins well before surgery. Requirements include:

• understanding of wound healing (see below) and the classification of wounds (TABLE 1)
• thorough assessment of the patient for risk factors for impaired wound healing, such as diabetes or use of corticosteroid medication (TABLE 2)
• antibiotic prophylaxis, if indicated (TABLE 3)
• good surgical technique, gentle tissue handling, and meticulous hemostasis
• placement of a drain, when appropriate
• awareness of technology that can enhance healing
• close monitoring in the postoperative period
• intervention at the first hint of abnormality.

In this article, we describe predisposing factors and preventive techniques and measures, and outline the most common wound complications, from seroma to dehiscence, including effective management strategies.

Biologic phases of wound healing—overlapping and interdependent

It was pioneering Scottish surgeon John Hunter who noted that “injury alone has in all cases the tendency to produce the disposition and means of a cure.”¹⁵

Unlike the tissue regeneration that occurs primarily in lower animals, human wound healing is mediated by collagen deposition, or scarring, which provides structural support to the wound. This scarring process may itself cause a variety of clinical problems.

Wound healing is characterized by overlapping, largely interdependent phases, with no clear demarcation between them. Failure in one phase may have a negative impact on the overall outcome.

In general, wound healing involves two phases: inflammation and proliferation. Within these phases, the following processes occur: scar maturation, wound contraction, and epithelialization. These repair mechanisms are activated in response to tissue injury even when it is surgically induced.

Inflammatory phase

The initial response to tissue injury is inflammation, which is mediated by various amines, enzymes, and other substances. This inflammation can be further broken down into vascular and cellular responses.

Inflammation triggers increased blood flow and migration of neutrophils, monocytes, macrophages, and other cells into the wound.

The first burst of blood acts to cleanse the wound of foreign debris. It is followed by vasoconstriction, which is mediated by thromboxane 2, to decrease blood loss. Vasodilation then occurs once histamine and serotonin are released, permitting increased blood flow to the wound. The surge in blood flow accounts for the increased warmth and redness of the wound. Vasodilation also increases capillary permeability, allowing the migration of red blood cells, platelets, leukocytes, plasma, and other tissue fluids into the interstitium of the wound. This migration accounts for wound edema.

In the cellular response, which is facilitated by increased blood flow, cell migration occurs as part of an immune response. Neutrophils, the first cells to enter the wound, engage in phagocytosis of bacteria and debris. Subsequently, there is migration of monocytes, macrophages, and other cells. This nonspecific immune response is sustained by prostaglandins, aided by complement factors and cytokines. A specific immune response follows, aimed at destroying specific antigens, and involves both B- and T-lymphocytes.

Proliferative phase

Proliferation is characterized by the infiltration of endothelial cells and fibroblasts and subsequent collagen deposition along a previously formed fibrin network. This new, highly vascularized tissue assumes a granular appearance—hence, the term “granulation tissue.”

Collagen that is deposited in the wound undergoes maturation and remodeling, increasing the tensile strength of the wound. The process continues for months after the initial insult.

All wounds undergo some degree of contraction, but the process is more relevant in wounds that remain open or involve significant tissue loss.

Last, the external covering of the wound is restored by epithelialization.

TABLE 1

Classification of surgical wounds

TABLE 2

Risk factors for poor wound healing and dehiscence

Conditions and drugs that impair healing

Preexisting medical conditions may limit healing, especially conditions associated with diminished delivery of oxygen and nutrients to healing tissues.

Diabetes can damage the vasculature and may impair healing if the blood glucose level is markedly elevated in the perioperative period. Such an elevation impedes transport of vitamin C, a key component of collagen synthesis.

Malignancy and immunosuppressive disorders may prevent optimal healing by compromising the immune response.

Bacterial vaginosis, a common polymicrobial infection involving aerobic and anaerobic bacteria, appears to be associated with postoperative febrile morbidity and surgical-site infection, particularly after hysterectomy.¹ Current guidelines recommend that medical therapy for bacterial vaginosis be instituted at least 4 days before surgery and continued postoperatively.

Because steroids, NSAIDs, and chemotherapy agents impede wound healing, and anticoagulants may interfere with granulation, it is crucial to review the patient’s medications well in advance of surgery.

Nutrition plays a critical role

The importance of nutrition cannot be overstated. A significant percentage of patients are thought to have some degree of nutritional deficiency preoperatively. This deficiency may alter the inflammatory response, impair collagen synthesis, and reduce the tensile strength of the wound.

Because healing requires energy, deficits in carbohydrates may limit protein utilization, and deficiencies of vitamins and micronutrients can also interfere with healing.²

Obesity, too, increases the risk of postoperative wound complication. Markedly obese patients have a thick, avascular, subcutaneous layer of fat that compromises healing.³

Meticulous technique required

Good surgical technique and appropriate use of antibiotics are critical components of successful wound healing.

When placing the incision, avoid the moist, bacteria-laden subpannicular crease in the markedly obese.

During a procedure, handle tissue gently, keep it moist, and make minimal use of electrocautery to reduce tissue injury and promote healing. Keep operating time and blood loss to a minimum, and debride the wound of any foreign material and devitalized tissue.

Multiple studies have demonstrated that judicious use of prophylactic antibiotics significantly decreases the incidence of wound infection, particularly in relation to hysterectomy and vaginal procedures and when entry into bowel is anticipated.^4,5 A number of prophylactic regimens are given in TABLE 3.

Meticulous hemostasis at the time of closure is imperative. When complete hemostasis cannot be confirmed, place a small drain in the subcutaneous space (or subfascial space, if there is oozing on the muscle bed) and apply a pressure dressing to help prevent hematoma. Although a drain is not a substitute for precise hemostasis or careful surgical technique, it may be helpful when there is concern about oozing or a “wet” surface, or when the patient is markedly obese.

Some practitioners have expressed concern over the risk of bacterial migration and infection with placement of a drain, but others, including us, advocate use of a drain in the subcutaneous space to help remove residual blood, fluid, and other debris to prevent the formation of dead space and infection and promote wound closure and healing. In a small study, Gallup and associates demonstrated a decreased incidence of wound breakdown when a drain was placed.⁶

A closed-suction drain, such as a Jackson-Pratt or Hemovac model, helps minimize wound complication when it is placed in the subcutaneous layer. (Avoid a rubber Penrose drain because it may allow bacteria to enter the wound.) It is imperative that the drain exit the body via a separate site and not through the incision itself. We advocate removal when less than 30 mL of fluid accumulates in the reservoir over 24 hours.

TABLE 3

3 prophylactic antibiotic regimens

Fluid within the wound does not always indicate infection

Wound collections are not necessarily indicative of infection; collections of fluid within the wound may represent a serous transudate, blood, pus, or a combination of these. If the fluid is not addressed, however, fulminant infection may be the result.

Seroma is usually painless

A seroma is a collection of wound exudates within the dead space. Seroma typically involves thin, pink, watery discharge and minimal edge separation. In some cases, there may be surrounding edema but generally little to no tenderness.

When a seroma is detected, remove the staples or stitches in the area of concern and explore the wound. It is essential to ensure fascial integrity, as serous wound drainage may be a sign of impending evisceration. After these measures are taken, cleanse and lightly pack the wound to permit drainage.

Hematoma requires identification of the source of bleeding

Hematoma represents blood or a blood clot within the tissues beneath the skin. It may be caused by persistent bleeding of a vessel, although the pressure within the wound and the pressure produced by the dressing often provide tamponade on the bleeding source, in which case the hematoma forms with no active bleeding.

Hematoma is usually caused by small bleeding vessels that were not apparent at the time of surgery or were not cauterized or ligated at the time of closure. For this reason, it is important to achieve good hemostasis and a “dry” wound before closing the skin.

When hematoma is suspected, open the wound enough to permit adequate exposure and identify the source of bleeding. Evacuate as much blood and clot as possible because blood is an ideal medium for bacterial growth. If active bleeding is found, use a silver nitrate applicator or handheld cautery pen to accomplish hemostasis at bedside. If bleeding is more severe, or the source cannot be visualized, consider returning to the operating room for more extensive exploration.

Once hemostasis is achieved, irrigate the wound copiously and institute local wound care.

How common is infection?

Before it is possible to address this question, it is necessary to clarify the terminology of infection. Contamination and colonization are different entities. The first refers to the presence of bacteria without multiplication. The latter describes the multiplication of bacteria in the absence of a host response. When infection is present, bacterial proliferation produces clinical signs and symptoms.

Postoperative abdominal wound infection occurs in about 5% of cases but may be more common in procedures that involve a greater level of contamination.⁷ One study found a 12% incidence of wound infection, but the rate declined to 8% when antibiotic prophylaxis was instituted.⁴

Several other studies have examined determinants of infection. For example, a large Cochrane review found no real differences in infection rate by preoperative skin preparation technique or agent, but it did observe that one study had demonstrated the superiority of chlorhexidine to other cleansing agents.⁸

Cruse and Foord also noted the slight superiority of chlorhexidine, as well as the efficacy of clipping abdominal hair immediately before surgery.⁷

When identifying organisms, look for the usual suspects

The offending pathogens in infection are usually endogenous flora found on the patient’s skin and within hollow organs (vagina, bowel). The organisms most commonly responsible for infection are Staphylococcus (aureus, epidermidis), enterococci, and Escherichia coli. However, the bacteria identified in the wound may not be the causative organism.

Most infections typically become clinically apparent between the fifth and 10th postoperative days, often after the patient has been discharged, although they may appear much earlier or much later. One of us (Dr. Perkins) had a patient who presented with a suppurative infection after undergoing hysterectomy for endometrial carcinoma 5 months earlier.

Cellulitis is common

Wound cellulitis, a common, nonsuppurative infection of skin and underlying connective tissue, is generally not severe. The wound assumes a brawny, reddish brown appearance associated with edema, warmth, and erythema. Fever is not always present.

It is important to remember that cellulitis may surround a deeper infection. Although needle aspiration of the leading edge has been advocated, it yields a positive culture in only 20% to 40% of cases.

In the absence of purulent drainage, treat cellulitis with antibiotics, utilizing sulfamethoxazole-trimethroprim, a cephalosporin, or augmented penicillin, and apply warm packs to the wound.

If purulent drainage is seen, or the patient fails to improve significantly within 24 hours, suspect an abscess or resistant organism.

Most wound infections are superficial

Approximately 75% of all wound infections involve the skin and subcutaneous tissue layers. Superficial infection is more likely to occur when there is an undrained hematoma, excessively tight sutures, tissue trauma, or a retained foreign material. Edema, erythema, and pain and tenderness may be more pronounced than with cellulitis. A low-grade fever may be present, and incisional discharge typically occurs.

Drainage is the cornerstone of management and requires the removal of staples or sutures from the area. Local exploration is mandatory, and fascial integrity must be confirmed. If a pocket of pus is found, open the wound liberally to determine the extent of the pocket and permit as much evacuation as possible. Wound culture is optional. Institute local wound care and consider adjuvant antibiotics in selected cases.

Ensure fascial integrity

Any infection that arises immediately adjacent to the fascia may have an intra-abdominal component, although that is unlikely. Extensive exploration is warranted to assess fascial integrity.

If intra-abdominal infection is suspected, order appropriate imaging.

Patients who have deep infection usually exhibit frank, purulent discharge; fever; and severe pain. Marked separation of wound edges is often present as well, as is an elevated white blood cell count.

As with superficial infection, the key to therapy is liberal exploration, drainage of the abscess cavity, and mechanical wound debridement. Irrigate the wound copiously using a dilute mixture of saline and hydrogen peroxide to remove any remaining debris. Avoid povidone-iodine solution because it inhibits normal tissue granulation.

The wound may be left open to heal by secondary intention, or it may be closed secondarily after 3 to 6 days, provided there is no evidence of infection and a healthy granulating bed is present.

Consider adjuvant antibiotics, especially when the patient is immunocompromised.

If the wound has pronounced edema and unusual discoloration, consider a serious infection such as necrotizing fasciitis.

Wound dehiscence raises risk of evisceration

Dehiscence of the abdominal incision occurs when the various layers separate. Dehiscence may be extrafascial (superficial disruption of the skin and subcutaneous tissue only) or may involve all layers, including peritoneum (complete fascial dehiscence or burst abdomen).

When bowel or omentum extrudes, the term evisceration is appropriate.

In several reviews of the literature, the incidence of dehiscence ranged from 0.4% in earlier studies to 1% to 3% in later reviews.^9-12 Despite advances in preoperative and postoperative care, suture materials, surgical technique, and antibiotics, fascial dehiscence remains a serious problem in abdominal surgery.

What causes wound disruption?

To a great extent, abdominal wound breakdown is a function of surgical technique and method of closure. Although the conventional wisdom is that dehiscence occurs less frequently with a transverse incision than with a vertical one, this assumption is being challenged. A small study by Hendrix and associates found no differences in the rate of dehiscence by type of incision.¹³ That finding suggests that the incidence of dehiscence is inversely related to the strength of closure.

Selection of the appropriate suture material also is important. In addition, use of electrocautery in the “cutting current” mode when the abdomen is opened causes less tissue injury than “coagulation current.” The latter has a greater thermal effect, thereby weakening the fascial layer.

Patient characteristics that influence wound integrity include comorbidities such as diabetes and malignancy, recent corticosteroid administration, and malnutrition.

Although infection may accompany superficial wound separation, its role in complete dehiscence is unclear.

Conditions that cause abdominal distention, such as severe coughing, vomiting, ileus, and ascites, may contribute to dehiscence, particularly when the closure method is less than satisfactory.

Some authors have found a greater incidence of wound disruption when multiple risk factors are present. In patients who had eight or more risk factors, wound disruption was universal.^11,12

Management entails debridement, irrigation, and closure

When extrafascial dehiscence occurs, mechanical debridement and irrigation are usually the only measures necessary before deciding how to close the wound—even if infection is present. Remove all foreign material and excise any devitalized tissue.

As for the method of closure, the choice is usually between secondary closure and leaving the wound open to heal by secondary intention. An alternative to the latter is wound closure after several days, once a healthy granulating bed develops.

Dodson and colleagues described a technique of superficial wound closure that can be performed at the bedside using local anesthesia, with little discomfort to the patient.¹⁴ Wound separation caused by a small hematoma or sterile seroma especially lends itself to this type of immediate closure.

Complete fascial dehiscence is a “catastrophic” complication

Complete dehiscence of the fascia and extrusion of intra-abdominal contents is a serious catastrophic complication that is associated with a mortality rate of about 20%. It typically occurs between the third and seventh postoperative days, although later occurrences have been reported.

Warning signs of impending evisceration include serous drainage in the absence of obvious infection, and a “popping” sensation on the part of the patient—a feeling that something is “giving way.”

If evisceration occurs, cover exposed bowel with packs soaked in saline or povidone-iodine and prepare the patient for emergency surgery. Institute both hydration and broad-spectrum antibiotics.

Before replacing the abdominal contents, thoroughly irrigate the peritoneal cavity and inspect the bowel carefully, excising any necrotic tissue.

Reapproximate the fascia using interrupted #1 or #2 monofilament suture. Also consider placing retention sutures, particularly when the patient has multiple risk factors for wound complications (FIGURE). Leave the wound open, prepared for later closure.

If the abdomen cannot be closed because of peritonitis or bowel edema, or there is an insufficient amount of fascia remaining, approximate the abdominal wall using bridging sutures over a gauze pack as a temporizing measure until reconstruction can be performed. Consultation with a plastic surgeon or trauma specialist is recommended.

FIGURE Consider retention sutures for high-risk patients

Retention sutures are placed in interrupted fashion to support the primary suture line and are carried through the full thickness of the tissue, from the abdominal wall skin through the fascia and, if possible, the peritoneum. A rubber bolster placed across each suture keeps the suture from cutting into the skin (inset).

Necrotizing fasciitis: Worst of the worst

Necrotizing fasciitis is a dangerous, synergistic, bacterial infection involving the fascia, subcutaneous tissue, and skin. The culprits are multiple bacterial pathogens that include Streptococcus pyogenes, staphylococcal species, gram-negative aerobes, and anaerobes. The infection typically originates at a localized area, spreads along the fascial planes, and ultimately causes septic thrombosis of the vessels penetrating the skin and deeper layers. The result is necrosis. The associated mortality rate is approximately 20%.

The patient who has necrotizing fasciitis typically displays severe pain; anesthetic, edematous skin; purple, necrotic wound edges; hemorrhagic bullae; and crepitus.

Frank necrosis subsequently develops, with surrounding inflammation and edema, and leads to systemic toxicity, with fever, hemodynamic abnormality, and shock. In advanced stages, gangrene is present.

Laboratory evaluation includes a white blood cell count. Biopsy also is recommended. If necrotizing fasciitis is present, biopsy will reveal necrosis and thrombi of vessels passing through the fascia.

Treatment of necrotizing fasciitis requires intravenous, broad-spectrum antibiotics, including penicillin, that are adjusted according to the findings of the wound culture and sensitivity test. Cardiovascular and fluid-volume support is critical, as is wide surgical debridement of all necrosed skin and fascia. The latter, in fact, is the cornerstone of therapy.

The authors report no financial relationships relevant to this article.

Despite advances in medicine and surgery over the past century, postoperative wound complication remains a serious challenge. When a complication occurs, it translates into prolonged hospitalization, lost time from work, and greater cost to the patient and the health-care system.

Prevention of wound complication begins well before surgery. Requirements include:

• understanding of wound healing (see below) and the classification of wounds (TABLE 1)
• thorough assessment of the patient for risk factors for impaired wound healing, such as diabetes or use of corticosteroid medication (TABLE 2)
• antibiotic prophylaxis, if indicated (TABLE 3)
• good surgical technique, gentle tissue handling, and meticulous hemostasis
• placement of a drain, when appropriate
• awareness of technology that can enhance healing
• close monitoring in the postoperative period
• intervention at the first hint of abnormality.

In this article, we describe predisposing factors and preventive techniques and measures, and outline the most common wound complications, from seroma to dehiscence, including effective management strategies.

Biologic phases of wound healing—overlapping and interdependent

It was pioneering Scottish surgeon John Hunter who noted that “injury alone has in all cases the tendency to produce the disposition and means of a cure.”¹⁵

Unlike the tissue regeneration that occurs primarily in lower animals, human wound healing is mediated by collagen deposition, or scarring, which provides structural support to the wound. This scarring process may itself cause a variety of clinical problems.

Wound healing is characterized by overlapping, largely interdependent phases, with no clear demarcation between them. Failure in one phase may have a negative impact on the overall outcome.

In general, wound healing involves two phases: inflammation and proliferation. Within these phases, the following processes occur: scar maturation, wound contraction, and epithelialization. These repair mechanisms are activated in response to tissue injury even when it is surgically induced.

Inflammatory phase

The initial response to tissue injury is inflammation, which is mediated by various amines, enzymes, and other substances. This inflammation can be further broken down into vascular and cellular responses.

Inflammation triggers increased blood flow and migration of neutrophils, monocytes, macrophages, and other cells into the wound.

The first burst of blood acts to cleanse the wound of foreign debris. It is followed by vasoconstriction, which is mediated by thromboxane 2, to decrease blood loss. Vasodilation then occurs once histamine and serotonin are released, permitting increased blood flow to the wound. The surge in blood flow accounts for the increased warmth and redness of the wound. Vasodilation also increases capillary permeability, allowing the migration of red blood cells, platelets, leukocytes, plasma, and other tissue fluids into the interstitium of the wound. This migration accounts for wound edema.

In the cellular response, which is facilitated by increased blood flow, cell migration occurs as part of an immune response. Neutrophils, the first cells to enter the wound, engage in phagocytosis of bacteria and debris. Subsequently, there is migration of monocytes, macrophages, and other cells. This nonspecific immune response is sustained by prostaglandins, aided by complement factors and cytokines. A specific immune response follows, aimed at destroying specific antigens, and involves both B- and T-lymphocytes.

Proliferative phase

Proliferation is characterized by the infiltration of endothelial cells and fibroblasts and subsequent collagen deposition along a previously formed fibrin network. This new, highly vascularized tissue assumes a granular appearance—hence, the term “granulation tissue.”

Collagen that is deposited in the wound undergoes maturation and remodeling, increasing the tensile strength of the wound. The process continues for months after the initial insult.

All wounds undergo some degree of contraction, but the process is more relevant in wounds that remain open or involve significant tissue loss.

Last, the external covering of the wound is restored by epithelialization.

TABLE 1

Classification of surgical wounds

TABLE 2

Risk factors for poor wound healing and dehiscence

Conditions and drugs that impair healing

Preexisting medical conditions may limit healing, especially conditions associated with diminished delivery of oxygen and nutrients to healing tissues.

Diabetes can damage the vasculature and may impair healing if the blood glucose level is markedly elevated in the perioperative period. Such an elevation impedes transport of vitamin C, a key component of collagen synthesis.

Malignancy and immunosuppressive disorders may prevent optimal healing by compromising the immune response.

Bacterial vaginosis, a common polymicrobial infection involving aerobic and anaerobic bacteria, appears to be associated with postoperative febrile morbidity and surgical-site infection, particularly after hysterectomy.¹ Current guidelines recommend that medical therapy for bacterial vaginosis be instituted at least 4 days before surgery and continued postoperatively.

Because steroids, NSAIDs, and chemotherapy agents impede wound healing, and anticoagulants may interfere with granulation, it is crucial to review the patient’s medications well in advance of surgery.

Nutrition plays a critical role

The importance of nutrition cannot be overstated. A significant percentage of patients are thought to have some degree of nutritional deficiency preoperatively. This deficiency may alter the inflammatory response, impair collagen synthesis, and reduce the tensile strength of the wound.

Because healing requires energy, deficits in carbohydrates may limit protein utilization, and deficiencies of vitamins and micronutrients can also interfere with healing.²

Obesity, too, increases the risk of postoperative wound complication. Markedly obese patients have a thick, avascular, subcutaneous layer of fat that compromises healing.³

Meticulous technique required

Good surgical technique and appropriate use of antibiotics are critical components of successful wound healing.

When placing the incision, avoid the moist, bacteria-laden subpannicular crease in the markedly obese.

During a procedure, handle tissue gently, keep it moist, and make minimal use of electrocautery to reduce tissue injury and promote healing. Keep operating time and blood loss to a minimum, and debride the wound of any foreign material and devitalized tissue.

Multiple studies have demonstrated that judicious use of prophylactic antibiotics significantly decreases the incidence of wound infection, particularly in relation to hysterectomy and vaginal procedures and when entry into bowel is anticipated.^4,5 A number of prophylactic regimens are given in TABLE 3.

Meticulous hemostasis at the time of closure is imperative. When complete hemostasis cannot be confirmed, place a small drain in the subcutaneous space (or subfascial space, if there is oozing on the muscle bed) and apply a pressure dressing to help prevent hematoma. Although a drain is not a substitute for precise hemostasis or careful surgical technique, it may be helpful when there is concern about oozing or a “wet” surface, or when the patient is markedly obese.

Some practitioners have expressed concern over the risk of bacterial migration and infection with placement of a drain, but others, including us, advocate use of a drain in the subcutaneous space to help remove residual blood, fluid, and other debris to prevent the formation of dead space and infection and promote wound closure and healing. In a small study, Gallup and associates demonstrated a decreased incidence of wound breakdown when a drain was placed.⁶

A closed-suction drain, such as a Jackson-Pratt or Hemovac model, helps minimize wound complication when it is placed in the subcutaneous layer. (Avoid a rubber Penrose drain because it may allow bacteria to enter the wound.) It is imperative that the drain exit the body via a separate site and not through the incision itself. We advocate removal when less than 30 mL of fluid accumulates in the reservoir over 24 hours.

TABLE 3

3 prophylactic antibiotic regimens

Fluid within the wound does not always indicate infection

Wound collections are not necessarily indicative of infection; collections of fluid within the wound may represent a serous transudate, blood, pus, or a combination of these. If the fluid is not addressed, however, fulminant infection may be the result.

Seroma is usually painless

A seroma is a collection of wound exudates within the dead space. Seroma typically involves thin, pink, watery discharge and minimal edge separation. In some cases, there may be surrounding edema but generally little to no tenderness.

When a seroma is detected, remove the staples or stitches in the area of concern and explore the wound. It is essential to ensure fascial integrity, as serous wound drainage may be a sign of impending evisceration. After these measures are taken, cleanse and lightly pack the wound to permit drainage.

Hematoma requires identification of the source of bleeding

Hematoma represents blood or a blood clot within the tissues beneath the skin. It may be caused by persistent bleeding of a vessel, although the pressure within the wound and the pressure produced by the dressing often provide tamponade on the bleeding source, in which case the hematoma forms with no active bleeding.

Hematoma is usually caused by small bleeding vessels that were not apparent at the time of surgery or were not cauterized or ligated at the time of closure. For this reason, it is important to achieve good hemostasis and a “dry” wound before closing the skin.

When hematoma is suspected, open the wound enough to permit adequate exposure and identify the source of bleeding. Evacuate as much blood and clot as possible because blood is an ideal medium for bacterial growth. If active bleeding is found, use a silver nitrate applicator or handheld cautery pen to accomplish hemostasis at bedside. If bleeding is more severe, or the source cannot be visualized, consider returning to the operating room for more extensive exploration.

Once hemostasis is achieved, irrigate the wound copiously and institute local wound care.

How common is infection?

Before it is possible to address this question, it is necessary to clarify the terminology of infection. Contamination and colonization are different entities. The first refers to the presence of bacteria without multiplication. The latter describes the multiplication of bacteria in the absence of a host response. When infection is present, bacterial proliferation produces clinical signs and symptoms.

Postoperative abdominal wound infection occurs in about 5% of cases but may be more common in procedures that involve a greater level of contamination.⁷ One study found a 12% incidence of wound infection, but the rate declined to 8% when antibiotic prophylaxis was instituted.⁴

Several other studies have examined determinants of infection. For example, a large Cochrane review found no real differences in infection rate by preoperative skin preparation technique or agent, but it did observe that one study had demonstrated the superiority of chlorhexidine to other cleansing agents.⁸

Cruse and Foord also noted the slight superiority of chlorhexidine, as well as the efficacy of clipping abdominal hair immediately before surgery.⁷

When identifying organisms, look for the usual suspects

The offending pathogens in infection are usually endogenous flora found on the patient’s skin and within hollow organs (vagina, bowel). The organisms most commonly responsible for infection are Staphylococcus (aureus, epidermidis), enterococci, and Escherichia coli. However, the bacteria identified in the wound may not be the causative organism.

Most infections typically become clinically apparent between the fifth and 10th postoperative days, often after the patient has been discharged, although they may appear much earlier or much later. One of us (Dr. Perkins) had a patient who presented with a suppurative infection after undergoing hysterectomy for endometrial carcinoma 5 months earlier.

Cellulitis is common

Wound cellulitis, a common, nonsuppurative infection of skin and underlying connective tissue, is generally not severe. The wound assumes a brawny, reddish brown appearance associated with edema, warmth, and erythema. Fever is not always present.

It is important to remember that cellulitis may surround a deeper infection. Although needle aspiration of the leading edge has been advocated, it yields a positive culture in only 20% to 40% of cases.

In the absence of purulent drainage, treat cellulitis with antibiotics, utilizing sulfamethoxazole-trimethroprim, a cephalosporin, or augmented penicillin, and apply warm packs to the wound.

If purulent drainage is seen, or the patient fails to improve significantly within 24 hours, suspect an abscess or resistant organism.

Most wound infections are superficial

Approximately 75% of all wound infections involve the skin and subcutaneous tissue layers. Superficial infection is more likely to occur when there is an undrained hematoma, excessively tight sutures, tissue trauma, or a retained foreign material. Edema, erythema, and pain and tenderness may be more pronounced than with cellulitis. A low-grade fever may be present, and incisional discharge typically occurs.

Drainage is the cornerstone of management and requires the removal of staples or sutures from the area. Local exploration is mandatory, and fascial integrity must be confirmed. If a pocket of pus is found, open the wound liberally to determine the extent of the pocket and permit as much evacuation as possible. Wound culture is optional. Institute local wound care and consider adjuvant antibiotics in selected cases.

Ensure fascial integrity

Any infection that arises immediately adjacent to the fascia may have an intra-abdominal component, although that is unlikely. Extensive exploration is warranted to assess fascial integrity.

If intra-abdominal infection is suspected, order appropriate imaging.

Patients who have deep infection usually exhibit frank, purulent discharge; fever; and severe pain. Marked separation of wound edges is often present as well, as is an elevated white blood cell count.

As with superficial infection, the key to therapy is liberal exploration, drainage of the abscess cavity, and mechanical wound debridement. Irrigate the wound copiously using a dilute mixture of saline and hydrogen peroxide to remove any remaining debris. Avoid povidone-iodine solution because it inhibits normal tissue granulation.

The wound may be left open to heal by secondary intention, or it may be closed secondarily after 3 to 6 days, provided there is no evidence of infection and a healthy granulating bed is present.

Consider adjuvant antibiotics, especially when the patient is immunocompromised.

If the wound has pronounced edema and unusual discoloration, consider a serious infection such as necrotizing fasciitis.

Wound dehiscence raises risk of evisceration

Dehiscence of the abdominal incision occurs when the various layers separate. Dehiscence may be extrafascial (superficial disruption of the skin and subcutaneous tissue only) or may involve all layers, including peritoneum (complete fascial dehiscence or burst abdomen).

When bowel or omentum extrudes, the term evisceration is appropriate.

In several reviews of the literature, the incidence of dehiscence ranged from 0.4% in earlier studies to 1% to 3% in later reviews.^9-12 Despite advances in preoperative and postoperative care, suture materials, surgical technique, and antibiotics, fascial dehiscence remains a serious problem in abdominal surgery.

What causes wound disruption?

To a great extent, abdominal wound breakdown is a function of surgical technique and method of closure. Although the conventional wisdom is that dehiscence occurs less frequently with a transverse incision than with a vertical one, this assumption is being challenged. A small study by Hendrix and associates found no differences in the rate of dehiscence by type of incision.¹³ That finding suggests that the incidence of dehiscence is inversely related to the strength of closure.

Selection of the appropriate suture material also is important. In addition, use of electrocautery in the “cutting current” mode when the abdomen is opened causes less tissue injury than “coagulation current.” The latter has a greater thermal effect, thereby weakening the fascial layer.

Patient characteristics that influence wound integrity include comorbidities such as diabetes and malignancy, recent corticosteroid administration, and malnutrition.

Although infection may accompany superficial wound separation, its role in complete dehiscence is unclear.

Conditions that cause abdominal distention, such as severe coughing, vomiting, ileus, and ascites, may contribute to dehiscence, particularly when the closure method is less than satisfactory.

Some authors have found a greater incidence of wound disruption when multiple risk factors are present. In patients who had eight or more risk factors, wound disruption was universal.^11,12

Management entails debridement, irrigation, and closure

When extrafascial dehiscence occurs, mechanical debridement and irrigation are usually the only measures necessary before deciding how to close the wound—even if infection is present. Remove all foreign material and excise any devitalized tissue.

As for the method of closure, the choice is usually between secondary closure and leaving the wound open to heal by secondary intention. An alternative to the latter is wound closure after several days, once a healthy granulating bed develops.

Dodson and colleagues described a technique of superficial wound closure that can be performed at the bedside using local anesthesia, with little discomfort to the patient.¹⁴ Wound separation caused by a small hematoma or sterile seroma especially lends itself to this type of immediate closure.

Complete fascial dehiscence is a “catastrophic” complication

Complete dehiscence of the fascia and extrusion of intra-abdominal contents is a serious catastrophic complication that is associated with a mortality rate of about 20%. It typically occurs between the third and seventh postoperative days, although later occurrences have been reported.

Warning signs of impending evisceration include serous drainage in the absence of obvious infection, and a “popping” sensation on the part of the patient—a feeling that something is “giving way.”

If evisceration occurs, cover exposed bowel with packs soaked in saline or povidone-iodine and prepare the patient for emergency surgery. Institute both hydration and broad-spectrum antibiotics.

Before replacing the abdominal contents, thoroughly irrigate the peritoneal cavity and inspect the bowel carefully, excising any necrotic tissue.

Reapproximate the fascia using interrupted #1 or #2 monofilament suture. Also consider placing retention sutures, particularly when the patient has multiple risk factors for wound complications (FIGURE). Leave the wound open, prepared for later closure.

If the abdomen cannot be closed because of peritonitis or bowel edema, or there is an insufficient amount of fascia remaining, approximate the abdominal wall using bridging sutures over a gauze pack as a temporizing measure until reconstruction can be performed. Consultation with a plastic surgeon or trauma specialist is recommended.

FIGURE Consider retention sutures for high-risk patients

Retention sutures are placed in interrupted fashion to support the primary suture line and are carried through the full thickness of the tissue, from the abdominal wall skin through the fascia and, if possible, the peritoneum. A rubber bolster placed across each suture keeps the suture from cutting into the skin (inset).

Necrotizing fasciitis: Worst of the worst

Necrotizing fasciitis is a dangerous, synergistic, bacterial infection involving the fascia, subcutaneous tissue, and skin. The culprits are multiple bacterial pathogens that include Streptococcus pyogenes, staphylococcal species, gram-negative aerobes, and anaerobes. The infection typically originates at a localized area, spreads along the fascial planes, and ultimately causes septic thrombosis of the vessels penetrating the skin and deeper layers. The result is necrosis. The associated mortality rate is approximately 20%.

The patient who has necrotizing fasciitis typically displays severe pain; anesthetic, edematous skin; purple, necrotic wound edges; hemorrhagic bullae; and crepitus.

Frank necrosis subsequently develops, with surrounding inflammation and edema, and leads to systemic toxicity, with fever, hemodynamic abnormality, and shock. In advanced stages, gangrene is present.

Laboratory evaluation includes a white blood cell count. Biopsy also is recommended. If necrotizing fasciitis is present, biopsy will reveal necrosis and thrombi of vessels passing through the fascia.

Treatment of necrotizing fasciitis requires intravenous, broad-spectrum antibiotics, including penicillin, that are adjusted according to the findings of the wound culture and sensitivity test. Cardiovascular and fluid-volume support is critical, as is wide surgical debridement of all necrosed skin and fascia. The latter, in fact, is the cornerstone of therapy.

The authors report no financial relationships relevant to this article.

Despite advances in medicine and surgery over the past century, postoperative wound complication remains a serious challenge. When a complication occurs, it translates into prolonged hospitalization, lost time from work, and greater cost to the patient and the health-care system.

Prevention of wound complication begins well before surgery. Requirements include:

• understanding of wound healing (see below) and the classification of wounds (TABLE 1)
• thorough assessment of the patient for risk factors for impaired wound healing, such as diabetes or use of corticosteroid medication (TABLE 2)
• antibiotic prophylaxis, if indicated (TABLE 3)
• good surgical technique, gentle tissue handling, and meticulous hemostasis
• placement of a drain, when appropriate
• awareness of technology that can enhance healing
• close monitoring in the postoperative period
• intervention at the first hint of abnormality.

In this article, we describe predisposing factors and preventive techniques and measures, and outline the most common wound complications, from seroma to dehiscence, including effective management strategies.

Biologic phases of wound healing—overlapping and interdependent

It was pioneering Scottish surgeon John Hunter who noted that “injury alone has in all cases the tendency to produce the disposition and means of a cure.”¹⁵

Unlike the tissue regeneration that occurs primarily in lower animals, human wound healing is mediated by collagen deposition, or scarring, which provides structural support to the wound. This scarring process may itself cause a variety of clinical problems.

Wound healing is characterized by overlapping, largely interdependent phases, with no clear demarcation between them. Failure in one phase may have a negative impact on the overall outcome.

In general, wound healing involves two phases: inflammation and proliferation. Within these phases, the following processes occur: scar maturation, wound contraction, and epithelialization. These repair mechanisms are activated in response to tissue injury even when it is surgically induced.

Inflammatory phase

The initial response to tissue injury is inflammation, which is mediated by various amines, enzymes, and other substances. This inflammation can be further broken down into vascular and cellular responses.

Inflammation triggers increased blood flow and migration of neutrophils, monocytes, macrophages, and other cells into the wound.

The first burst of blood acts to cleanse the wound of foreign debris. It is followed by vasoconstriction, which is mediated by thromboxane 2, to decrease blood loss. Vasodilation then occurs once histamine and serotonin are released, permitting increased blood flow to the wound. The surge in blood flow accounts for the increased warmth and redness of the wound. Vasodilation also increases capillary permeability, allowing the migration of red blood cells, platelets, leukocytes, plasma, and other tissue fluids into the interstitium of the wound. This migration accounts for wound edema.

In the cellular response, which is facilitated by increased blood flow, cell migration occurs as part of an immune response. Neutrophils, the first cells to enter the wound, engage in phagocytosis of bacteria and debris. Subsequently, there is migration of monocytes, macrophages, and other cells. This nonspecific immune response is sustained by prostaglandins, aided by complement factors and cytokines. A specific immune response follows, aimed at destroying specific antigens, and involves both B- and T-lymphocytes.

Proliferative phase

Proliferation is characterized by the infiltration of endothelial cells and fibroblasts and subsequent collagen deposition along a previously formed fibrin network. This new, highly vascularized tissue assumes a granular appearance—hence, the term “granulation tissue.”

Collagen that is deposited in the wound undergoes maturation and remodeling, increasing the tensile strength of the wound. The process continues for months after the initial insult.

All wounds undergo some degree of contraction, but the process is more relevant in wounds that remain open or involve significant tissue loss.

Last, the external covering of the wound is restored by epithelialization.

TABLE 1

Classification of surgical wounds

TABLE 2

Risk factors for poor wound healing and dehiscence

Conditions and drugs that impair healing

Preexisting medical conditions may limit healing, especially conditions associated with diminished delivery of oxygen and nutrients to healing tissues.

Diabetes can damage the vasculature and may impair healing if the blood glucose level is markedly elevated in the perioperative period. Such an elevation impedes transport of vitamin C, a key component of collagen synthesis.

Malignancy and immunosuppressive disorders may prevent optimal healing by compromising the immune response.

Bacterial vaginosis, a common polymicrobial infection involving aerobic and anaerobic bacteria, appears to be associated with postoperative febrile morbidity and surgical-site infection, particularly after hysterectomy.¹ Current guidelines recommend that medical therapy for bacterial vaginosis be instituted at least 4 days before surgery and continued postoperatively.

Because steroids, NSAIDs, and chemotherapy agents impede wound healing, and anticoagulants may interfere with granulation, it is crucial to review the patient’s medications well in advance of surgery.

Nutrition plays a critical role

The importance of nutrition cannot be overstated. A significant percentage of patients are thought to have some degree of nutritional deficiency preoperatively. This deficiency may alter the inflammatory response, impair collagen synthesis, and reduce the tensile strength of the wound.

Because healing requires energy, deficits in carbohydrates may limit protein utilization, and deficiencies of vitamins and micronutrients can also interfere with healing.²

Obesity, too, increases the risk of postoperative wound complication. Markedly obese patients have a thick, avascular, subcutaneous layer of fat that compromises healing.³

Meticulous technique required

Good surgical technique and appropriate use of antibiotics are critical components of successful wound healing.

When placing the incision, avoid the moist, bacteria-laden subpannicular crease in the markedly obese.

During a procedure, handle tissue gently, keep it moist, and make minimal use of electrocautery to reduce tissue injury and promote healing. Keep operating time and blood loss to a minimum, and debride the wound of any foreign material and devitalized tissue.

Multiple studies have demonstrated that judicious use of prophylactic antibiotics significantly decreases the incidence of wound infection, particularly in relation to hysterectomy and vaginal procedures and when entry into bowel is anticipated.^4,5 A number of prophylactic regimens are given in TABLE 3.

Meticulous hemostasis at the time of closure is imperative. When complete hemostasis cannot be confirmed, place a small drain in the subcutaneous space (or subfascial space, if there is oozing on the muscle bed) and apply a pressure dressing to help prevent hematoma. Although a drain is not a substitute for precise hemostasis or careful surgical technique, it may be helpful when there is concern about oozing or a “wet” surface, or when the patient is markedly obese.

Some practitioners have expressed concern over the risk of bacterial migration and infection with placement of a drain, but others, including us, advocate use of a drain in the subcutaneous space to help remove residual blood, fluid, and other debris to prevent the formation of dead space and infection and promote wound closure and healing. In a small study, Gallup and associates demonstrated a decreased incidence of wound breakdown when a drain was placed.⁶

A closed-suction drain, such as a Jackson-Pratt or Hemovac model, helps minimize wound complication when it is placed in the subcutaneous layer. (Avoid a rubber Penrose drain because it may allow bacteria to enter the wound.) It is imperative that the drain exit the body via a separate site and not through the incision itself. We advocate removal when less than 30 mL of fluid accumulates in the reservoir over 24 hours.

TABLE 3

3 prophylactic antibiotic regimens

Fluid within the wound does not always indicate infection

Wound collections are not necessarily indicative of infection; collections of fluid within the wound may represent a serous transudate, blood, pus, or a combination of these. If the fluid is not addressed, however, fulminant infection may be the result.

Seroma is usually painless

A seroma is a collection of wound exudates within the dead space. Seroma typically involves thin, pink, watery discharge and minimal edge separation. In some cases, there may be surrounding edema but generally little to no tenderness.

When a seroma is detected, remove the staples or stitches in the area of concern and explore the wound. It is essential to ensure fascial integrity, as serous wound drainage may be a sign of impending evisceration. After these measures are taken, cleanse and lightly pack the wound to permit drainage.

Hematoma requires identification of the source of bleeding

Hematoma represents blood or a blood clot within the tissues beneath the skin. It may be caused by persistent bleeding of a vessel, although the pressure within the wound and the pressure produced by the dressing often provide tamponade on the bleeding source, in which case the hematoma forms with no active bleeding.

Hematoma is usually caused by small bleeding vessels that were not apparent at the time of surgery or were not cauterized or ligated at the time of closure. For this reason, it is important to achieve good hemostasis and a “dry” wound before closing the skin.

When hematoma is suspected, open the wound enough to permit adequate exposure and identify the source of bleeding. Evacuate as much blood and clot as possible because blood is an ideal medium for bacterial growth. If active bleeding is found, use a silver nitrate applicator or handheld cautery pen to accomplish hemostasis at bedside. If bleeding is more severe, or the source cannot be visualized, consider returning to the operating room for more extensive exploration.

Once hemostasis is achieved, irrigate the wound copiously and institute local wound care.

How common is infection?

Before it is possible to address this question, it is necessary to clarify the terminology of infection. Contamination and colonization are different entities. The first refers to the presence of bacteria without multiplication. The latter describes the multiplication of bacteria in the absence of a host response. When infection is present, bacterial proliferation produces clinical signs and symptoms.

Postoperative abdominal wound infection occurs in about 5% of cases but may be more common in procedures that involve a greater level of contamination.⁷ One study found a 12% incidence of wound infection, but the rate declined to 8% when antibiotic prophylaxis was instituted.⁴

Several other studies have examined determinants of infection. For example, a large Cochrane review found no real differences in infection rate by preoperative skin preparation technique or agent, but it did observe that one study had demonstrated the superiority of chlorhexidine to other cleansing agents.⁸

Cruse and Foord also noted the slight superiority of chlorhexidine, as well as the efficacy of clipping abdominal hair immediately before surgery.⁷

When identifying organisms, look for the usual suspects

The offending pathogens in infection are usually endogenous flora found on the patient’s skin and within hollow organs (vagina, bowel). The organisms most commonly responsible for infection are Staphylococcus (aureus, epidermidis), enterococci, and Escherichia coli. However, the bacteria identified in the wound may not be the causative organism.

Most infections typically become clinically apparent between the fifth and 10th postoperative days, often after the patient has been discharged, although they may appear much earlier or much later. One of us (Dr. Perkins) had a patient who presented with a suppurative infection after undergoing hysterectomy for endometrial carcinoma 5 months earlier.

Cellulitis is common

Wound cellulitis, a common, nonsuppurative infection of skin and underlying connective tissue, is generally not severe. The wound assumes a brawny, reddish brown appearance associated with edema, warmth, and erythema. Fever is not always present.

It is important to remember that cellulitis may surround a deeper infection. Although needle aspiration of the leading edge has been advocated, it yields a positive culture in only 20% to 40% of cases.

In the absence of purulent drainage, treat cellulitis with antibiotics, utilizing sulfamethoxazole-trimethroprim, a cephalosporin, or augmented penicillin, and apply warm packs to the wound.

If purulent drainage is seen, or the patient fails to improve significantly within 24 hours, suspect an abscess or resistant organism.

Most wound infections are superficial

Approximately 75% of all wound infections involve the skin and subcutaneous tissue layers. Superficial infection is more likely to occur when there is an undrained hematoma, excessively tight sutures, tissue trauma, or a retained foreign material. Edema, erythema, and pain and tenderness may be more pronounced than with cellulitis. A low-grade fever may be present, and incisional discharge typically occurs.

Drainage is the cornerstone of management and requires the removal of staples or sutures from the area. Local exploration is mandatory, and fascial integrity must be confirmed. If a pocket of pus is found, open the wound liberally to determine the extent of the pocket and permit as much evacuation as possible. Wound culture is optional. Institute local wound care and consider adjuvant antibiotics in selected cases.

Ensure fascial integrity

Any infection that arises immediately adjacent to the fascia may have an intra-abdominal component, although that is unlikely. Extensive exploration is warranted to assess fascial integrity.

If intra-abdominal infection is suspected, order appropriate imaging.

Patients who have deep infection usually exhibit frank, purulent discharge; fever; and severe pain. Marked separation of wound edges is often present as well, as is an elevated white blood cell count.

As with superficial infection, the key to therapy is liberal exploration, drainage of the abscess cavity, and mechanical wound debridement. Irrigate the wound copiously using a dilute mixture of saline and hydrogen peroxide to remove any remaining debris. Avoid povidone-iodine solution because it inhibits normal tissue granulation.

The wound may be left open to heal by secondary intention, or it may be closed secondarily after 3 to 6 days, provided there is no evidence of infection and a healthy granulating bed is present.

Consider adjuvant antibiotics, especially when the patient is immunocompromised.

If the wound has pronounced edema and unusual discoloration, consider a serious infection such as necrotizing fasciitis.

Wound dehiscence raises risk of evisceration

Dehiscence of the abdominal incision occurs when the various layers separate. Dehiscence may be extrafascial (superficial disruption of the skin and subcutaneous tissue only) or may involve all layers, including peritoneum (complete fascial dehiscence or burst abdomen).

When bowel or omentum extrudes, the term evisceration is appropriate.

In several reviews of the literature, the incidence of dehiscence ranged from 0.4% in earlier studies to 1% to 3% in later reviews.^9-12 Despite advances in preoperative and postoperative care, suture materials, surgical technique, and antibiotics, fascial dehiscence remains a serious problem in abdominal surgery.

What causes wound disruption?

To a great extent, abdominal wound breakdown is a function of surgical technique and method of closure. Although the conventional wisdom is that dehiscence occurs less frequently with a transverse incision than with a vertical one, this assumption is being challenged. A small study by Hendrix and associates found no differences in the rate of dehiscence by type of incision.¹³ That finding suggests that the incidence of dehiscence is inversely related to the strength of closure.

Selection of the appropriate suture material also is important. In addition, use of electrocautery in the “cutting current” mode when the abdomen is opened causes less tissue injury than “coagulation current.” The latter has a greater thermal effect, thereby weakening the fascial layer.

Patient characteristics that influence wound integrity include comorbidities such as diabetes and malignancy, recent corticosteroid administration, and malnutrition.

Although infection may accompany superficial wound separation, its role in complete dehiscence is unclear.

Conditions that cause abdominal distention, such as severe coughing, vomiting, ileus, and ascites, may contribute to dehiscence, particularly when the closure method is less than satisfactory.

Some authors have found a greater incidence of wound disruption when multiple risk factors are present. In patients who had eight or more risk factors, wound disruption was universal.^11,12

Management entails debridement, irrigation, and closure

When extrafascial dehiscence occurs, mechanical debridement and irrigation are usually the only measures necessary before deciding how to close the wound—even if infection is present. Remove all foreign material and excise any devitalized tissue.

As for the method of closure, the choice is usually between secondary closure and leaving the wound open to heal by secondary intention. An alternative to the latter is wound closure after several days, once a healthy granulating bed develops.

Dodson and colleagues described a technique of superficial wound closure that can be performed at the bedside using local anesthesia, with little discomfort to the patient.¹⁴ Wound separation caused by a small hematoma or sterile seroma especially lends itself to this type of immediate closure.

Complete fascial dehiscence is a “catastrophic” complication

Complete dehiscence of the fascia and extrusion of intra-abdominal contents is a serious catastrophic complication that is associated with a mortality rate of about 20%. It typically occurs between the third and seventh postoperative days, although later occurrences have been reported.

Warning signs of impending evisceration include serous drainage in the absence of obvious infection, and a “popping” sensation on the part of the patient—a feeling that something is “giving way.”

If evisceration occurs, cover exposed bowel with packs soaked in saline or povidone-iodine and prepare the patient for emergency surgery. Institute both hydration and broad-spectrum antibiotics.

Before replacing the abdominal contents, thoroughly irrigate the peritoneal cavity and inspect the bowel carefully, excising any necrotic tissue.

Reapproximate the fascia using interrupted #1 or #2 monofilament suture. Also consider placing retention sutures, particularly when the patient has multiple risk factors for wound complications (FIGURE). Leave the wound open, prepared for later closure.

If the abdomen cannot be closed because of peritonitis or bowel edema, or there is an insufficient amount of fascia remaining, approximate the abdominal wall using bridging sutures over a gauze pack as a temporizing measure until reconstruction can be performed. Consultation with a plastic surgeon or trauma specialist is recommended.

FIGURE Consider retention sutures for high-risk patients

Retention sutures are placed in interrupted fashion to support the primary suture line and are carried through the full thickness of the tissue, from the abdominal wall skin through the fascia and, if possible, the peritoneum. A rubber bolster placed across each suture keeps the suture from cutting into the skin (inset).

Necrotizing fasciitis: Worst of the worst

Necrotizing fasciitis is a dangerous, synergistic, bacterial infection involving the fascia, subcutaneous tissue, and skin. The culprits are multiple bacterial pathogens that include Streptococcus pyogenes, staphylococcal species, gram-negative aerobes, and anaerobes. The infection typically originates at a localized area, spreads along the fascial planes, and ultimately causes septic thrombosis of the vessels penetrating the skin and deeper layers. The result is necrosis. The associated mortality rate is approximately 20%.

The patient who has necrotizing fasciitis typically displays severe pain; anesthetic, edematous skin; purple, necrotic wound edges; hemorrhagic bullae; and crepitus.

Frank necrosis subsequently develops, with surrounding inflammation and edema, and leads to systemic toxicity, with fever, hemodynamic abnormality, and shock. In advanced stages, gangrene is present.

Laboratory evaluation includes a white blood cell count. Biopsy also is recommended. If necrotizing fasciitis is present, biopsy will reveal necrosis and thrombi of vessels passing through the fascia.

Treatment of necrotizing fasciitis requires intravenous, broad-spectrum antibiotics, including penicillin, that are adjusted according to the findings of the wound culture and sensitivity test. Cardiovascular and fluid-volume support is critical, as is wide surgical debridement of all necrosed skin and fascia. The latter, in fact, is the cornerstone of therapy.

The authors report no financial relationships relevant to this article.

The adverse consequences of obesity go far beyond aesthetic and psychosocial concerns. Patients who are markedly overweight face a real risk of developing severe health conditions—not just cardiac disease, diabetes mellitus, and hypertension, but also sleep apnea, venous thromboembolism, certain cancers (particularly breast and uterine), and biliary tract disease. Obesity also contributes to menstrual abnormalities and infertility and may complicate pregnancy.

Surgery in these patients poses a number of challenges. Not only does obesity frequently compromise the technical aspects of a procedure, it requires the surgeon to use certain measures in the preoperative and postoperative phases of management, such as counseling the patient extensively about the risks and potential complications she faces, initiating antibiotic prophylaxis, and ensuring early ambulation. These and other measures are especially important when uncontrolled, coexisting disease is present.

Not every obese patient is a significant surgical risk, so care should be individualized and use a team approach involving the gynecologist, anesthesiologist, primary care physician, and other appropriate subspecialists.

This article outlines the parameters of good surgical care in the obese patient, defined here as having a body mass index (BMI) of 30 kg/m² or above, or 35 kg/m² or above for morbid obesity. Whenever possible, we draw our recommendations from the published literature. In the absence of data, we base them on our surgical experience in the obese population.

Risks of surgery

It is imperative for the gynecologic surgeon to discuss the special risks of surgery with the obese patient well in advance of the operation and to formulate a systematic plan for evaluation, utilizing other members of the team when necessary. If the surgeon keeps the following risks in mind and is proactive, complications can be kept to a minimum.

Poor wound healing

Wound healing is a complex process involving several concurrent phases; an abnormality in any phase may impair healing. Those phases are:

• inflammatory phase, in which fluid and cells are released to clean the wound and prepare for the next phase of healing
• fibroplastic (proliferative) phase, in which fibroblasts accumulate and form collagen, the building block of connective tissue. This stage is marked by neovascularization and increased formation of granulation tissue
• wound contraction
• remodeling/maturation, in which new collagen is laid down as old collagen is broken down, resulting in scar formation.

Obese patients possess a thick layer of adipose tissue, which by its nature and location is minimally vascularized. This tissue essentially becomes dead space, an ideal medium for bacterial growth. Many obese patients also have diabetes mellitus, malignancy, or other comorbidity that further impairs healing.

As a result, obese patients are at increased risk of wound complications, breakdown, and subsequent dehiscence and evisceration. This translates into increased febrile morbidity, prolonged hospitalization, and higher cost.

What the data show. A number of studies have documented a higher incidence of wound complications in obese patients. In one retrospective review, Gallup¹ observed an increased risk of wound complications in obese patients, but the incidence diminished after implementation of a protocol of meticulous cleansing, subcutaneous heparin, and modified incision and closure techniques. In a similar retrospective study of 300 obese patients, Pitkin² reported wound complications among approximately one third of patients and postoperative fever among more than three quarters. Surgical-site infections are thought to occur in as many as 5% of patients.

Prophylaxis may be effective in some patients, but can be challenging. It entails meticulous skin cleansing and careful consideration of where the incision is placed, type of closure, use of a drain, and antibiotic administration.

Antibiotic prophylaxis is based on the theory that its presence in host tissues will alter natural defense mechanisms and kill bacteria that inoculate the wound. Because the window of efficacy is narrow, antibiotics should be administered shortly before the time of inoculation (ie, shortly before the time of incision, vaginal entry, etc.). Current guidelines suggest the use of broad-spectrum agents, including a cephalosporin, approximately 60 minutes before the incision. Redosing is recommended for procedures that last longer than 3 hours, as well as for those that involve significant blood loss (>1,500 mL).

For surgical procedures other than hysterectomy and laparotomy, prophylaxis may not be warranted.³ However, when the patient is markedly obese, many surgeons, including me (Dr. Perkins), sometimes opt to give antibiotics anyway—except for laparoscopic procedures—primarily for wound healing.

Compromised operative exposure

One of the main challenges of surgery in the obese is achieving adequate exposure; when it is inadequate, inadvertent injury may occur.

In addition to a thick abdominal wall composed largely of adipose tissue, these patients frequently have significant accumulations of fat in the mesenteries of the bowel, omentum, and pelvic peritoneum. These accumulations make it difficult to navigate around what becomes a narrow operative field.

Exposure can also be limited in vaginal surgery, because many obese women have very large thighs, buttocks, and accumulations of perineal fat.

Because exposure is a key element of successful surgery, modification of the procedure often becomes necessary—eg, focusing on a single area of the operative field at a time.

Use of a special retractor may help. A self-retaining retractor can be extremely useful. The Bookwalter retractor, first described in 1980, is a commonly used, table-fixed system that attaches to the side rail and can be assembled in minutes (FIGURE 1).⁴ The variety of rings and blades allows for excellent exposure. Although several complications have been associated with use of the Bookwalter retractor (primarily colon perforation and neuropathy⁵), they are infrequent and can be minimized by selecting the appropriate blade size and periodically repositioning the blades.

When this or other table-fixed retractors are unavailable, two Balfour retractors, placed at opposite poles of the field to obtain satisfactory exposure, may suffice. With a morbidly obese patient, multiple assistants may still be required to facilitate optimal exposure.

FIGURE 1 A tool to increase exposure

This self-retaining Bookwalter retractor is fixed to the surgical table and features a variety of rings and blades to facilitate exposure.

Thromboembolism

Venous thromboembolism is a major cause of mortality and morbidity in hospitalized patients, causing approximately 60,000 deaths every year.⁶ Obesity increases the risk of deep venous thrombosis in patients undergoing pelvic surgery. Because of their weight—and, often, coexisting conditions such as cardiorespiratory disease—many obese women are inactive or minimally active postoperatively, increasing the risk of thromboembolism, which remains heightened as long as 3 weeks after discharge. Older women are also at high risk, as are those with a malignancy.

Current guidelines call for the application of a pneumatic calf-compression device in the operating room, with removal after the patient is fully ambulatory. I (Dr. Perkins) also advocate simultaneous use of low-dose heparin, which should be given before surgery and continued until discharge.

Although the use of unfractionated heparin in conjunction with spinal or epidural anesthesia is not a major concern, the use of low-molecular-weight heparin warrants consultation with the anesthesiologist. Unfractionated heparin is preferred because it is metabolized much more rapidly than low-molecular weight heparin.⁷ The main concern with use of heparin in this setting (regardless of the patient’s weight) is spinal hematoma formation.

Inadvertent injury

Because exposure tends to be limited in obese patients, there is an ever-present risk of injury to bowel, bladder, ureter, and vascular structures. In obese women with a history of abdominal surgery, adhesions are likely, and the risk of bowel injury is increased. Similarly, in obese patients undergoing a laparoscopic procedure, many surface landmarks and vessels may be hard to discern.

Consider preoperative bowel preparation when there is a high risk of intestinal injury.⁸

Panniculectomy: Old technique with a new surgical purpose

Use a scalpel to incise the skin and delineate the area to be excised. That area typically consists of a large wedge of abdominal skin and subcutaneous fat.

Although the addition of panniculectomy to gynecologic surgery in the morbidly obese patient is a fairly recent strategy to increase exposure, the procedure itself has roots in the 19th century. In 1910, Howard Kelly of The Johns Hopkins Hospital reported a lipectomy that involved excision of a large wedge of abdominal skin and fat,²¹ although indications for that lipectomy appear to have been grounded in cosmesis and personal comfort for the patient.

Technique

Panniculectomy involves excision of a large portion of abdominal skin and subcutaneous fat down to, but not including, the rectus fascia, to gain much greater exposure to the lower abdominal cavity and pelvis.

Once the segment to be excised is delineated, it is mobilized using electrocautery to achieve meticulous hemostasis. After all surgical procedures are completed, the abdominal wall is closed in multiple layers, and drains are placed in the subcutaneous layer. Surgeons who have performed this procedure report significantly increased exposure and access to pelvic structures.

Once the skin is incised, the wedge is mobilized using electrocautery, down to, but not including, the rectus fascia.

Risks

The most important risk is impaired healing of the abdominal wound. One study of this procedure in patients on a gynecologic oncology service noted wound complications in 35% of patients, as well as significant blood loss (up to 1,800 mL in one case).²² Another study by Hopkins and associates,²³ however, reported minimal blood loss and wound complications.

Caveats

The procedure requires an experienced surgeon, particularly if no plastic surgeon is readily available. Also, when counseling the patient about this procedure, it is important to emphasize that its primary indication is to maximize exposure; cosmetic benefits are secondary.

Impaired cardiorespiratory function

Pulmonary function typically is compromised in the markedly obese, with restrictive lung disease and reduced functional residual capacity. If the patient smokes or has chronic obstructive lung disease, her pulmonary function is compromised even further, and her condition should be relayed to the anesthesiologist.

In addition, many obese patients have preexisting heart disease or conditions such as hyperlipidemia that put them at risk for heart disease. When evaluating an obese surgical patient, also ask about less apparent disorders, such as sleep apnea, which, if not addressed, may have grave postoperative consequences.

Preoperative evaluation and preparation

Goal: Assess and minimize risks

This process begins in the office or clinic with a discussion with the patient of any concerns and risks. The importance of early mobilization and ambulation after surgery should be emphasized. Any patient with uncontrolled diabetes or hypertension should continue to be monitored by her primary care physician. A patient who has not seen a physician recently should be assessed by an internist to ensure that no conditions go undetected before surgery.

Routine testing to start, but additional assessment may be justified. An obese patient should undergo the same routine testing as a woman of normal weight, but further testing may be warranted for any coexisting disorder. Because the obese patient may have a restrictive lung pattern by virtue of her body habitus, pulmonary-function testing is unlikely to yield new information and is probably not indicated—unless she smokes or has a history of chronic obstructive pulmonary disease. In that case, tests will clarify the obstructive component and bronchodilator response and are useful in postoperative management. Measurement of arterial blood gases is useful, however, because levels reflect respiratory function on a day-to-day basis.

Additional tests of cardiac status probably are not indicated on the basis of obesity alone. However, if initial tests (eg, the electrocardiogram) and the history suggest compromised cardiac function, two-dimensional echocardiography should be performed to determine the ejection fraction. Any concerns regarding cardiac function should be discussed with the anesthesiologist and cardiologist.

Because compromised pulmonary function is likely, I (Dr. Perkins) instruct each patient on the use of incentive spirometry before she undergoes anesthesia so that she has realistic expectations about the postoperative course. I also administer heparin at least 2 hours before induction (8 hours before induction if unfractionated heparin is used).⁶

If a hysterectomy or prolonged laparotomy is planned, prophylactic antibiotics are recommended.³ Thigh-high compression stockings or a pneumatic calf-compression device should be applied upon arrival in the operating room.

Anesthesia-related issues

Anticipate challenges involving the airway

The anesthesiologist’s primary concern in regard to the obese patient is establishment and maintenance of an airway to promote oxygenation. In morbidly and extremely morbidly obese patients, anatomic factors such as large breasts; a short, thick neck; large tongue; decreased mobility of the cervical spine; limited mouth opening; and greater amount of adipose tissue in the face and cheeks can render mask ventilation and intubation extremely difficult or impossible. Decreased functional residual capacity and tidal volume in the range of closing capacity may lead to extremely rapid oxygen desaturation when the patient is apneic.⁹

If the patient is pregnant, factors such as excess adipose tissue in the face become even more pronounced and increase the potential for catastrophe.

Appreciate mechanical concerns

The morbidly obese patient may exceed the weight limit of the operating table. In addition, placing her in a steep Trendelenburg position or rotating her laterally may compromise the integrity of the bed.

Coexisting disease, such as sleep apnea and acid reflux disease, should also be kept in mind. Compromised respiratory mechanics (eg, restrictive lung pattern) may cause further deterioration and make mechanical ventilation more difficult.

It also may be hard to establish vascular access, necessitating central venous line placement and introducing its associated risks.

Keep the anesthesiologist in the loop

In the postoperative period, obese patients face a heightened risk of complications related to diminished pulmonary function, such as oxygen desaturation, hypoventilation, and airway obstruction, which may lead to atelectasis, pneumonia, and pulmonary edema.^10,11 For these reasons, early consultation with the anesthesiologist is recommended, especially if the initial evaluation suggests potential difficulties in securing the airway. In turn, the anesthesiologist should understand that, in some obese patients, even establishing a surgical airway may be difficult. Regional anesthesia should be considered when feasible.

Antacids and drugs that increase gastric motility have proved to be useful in minimizing aspiration-related risks.^12,13

Surgical technique

Begin abdominal procedures by carefully choosing an incision

Do not base the decision solely on the degree of obesity, but also consider any additional procedures that are planned, such as lymph-node sampling. A vertical incision does permit greater exposure than is afforded by a transverse incision, but in some cases the latter may be more appropriate—even if the patient is morbidly obese.

Do not place the incision below the panniculus, in the crease just above the suprapubic mound, though it may be tempting to do so when the panniculus is large and thick. This area is a warm, moist, anaerobic environment that promotes the proliferation of numerous micro-organisms, creating a bacterial cesspool. It is the worst place to make an incision.

If a transverse incision is selected, place caudal traction on the panniculus (which may be facilitated by applying two towel clips to the tissue fold), and incise through the fold at a point approximately three to four fingerbreadths above the symphysis (FIGURE 2).

If a midline incision is selected, a similar technique is appropriate, with downward traction applied to the panniculus and the incision begun at the lower pole of this fold up to the umbilicus—or through it and above, should more room be required.¹⁴

After incising the superficial fascia, greater exposure may be gained by incising the rectus sheath beneath the pannicular fold and extending it down to the symphysis. After entering the abdominal cavity, the surgeon may encounter a redundant, fat-laden layer of peritoneum. The edges of this tissue may be temporarily sutured to the edges of the skin incision to remove it from the operative field and obtain better visualization.

FIGURE 2 Incision placement can be counterintuitive

Avoid placing the skin incision beneath the panniculus, an anaerobic area ripe for infection. Instead, retract the panniculus caudally and incise the skin above the fold, as shown.

A few remedies can help when exposure is limited

Exposure is one of the most important elements of successful surgery, but it is often restricted when marked obesity is present. Fortunately, numerous adjuncts are available to address this problem, such as the table-fixed retractor systems described earlier in this article, or one or more of the following tactics:

• Do not try to expose the entire pelvic basin. One technique to ease exploration—especially when more than one procedure is planned—is to refrain from exposing the entire pelvic basin at one time. Instead, focus on obtaining adequate visualization in the immediate area and, once work in that area is finished, concentrate on the next.
• Use extra-long instruments in an extremely large patient, especially if she has a “deep” pelvis.
• Abbreviate the procedure, if possible. Because these cases are technically more difficult and frequently involve excessive blood loss, it may be wiser to perform an “incomplete” procedure, such as supracervical hysterectomy instead of total hysterectomy, depending on the indication.¹⁴
• Use a cell-saver blood-collection system if significant blood loss is anticipated. Also remember to give a second dose of prophylactic antibiotic.

Strategies for effective wound closure

The best method of abdominal wound closure has been a subject of debate among both gynecologic and general surgeons. In the obese patient, the key variables are the rather thick subcutaneous fat layer within the abdominal wall and the impact of intra-abdominal pressure on the incision.

What the data show. A number of studies, including one by Montz and colleagues,¹⁵ have demonstrated that the running mass-closure technique using delayed-absorbable or permanent suture is just as effective as interrupted suture placement (eg, Smead-Jones closure) but is faster, with less suture deposited in the wound.

The following considerations may also be helpful:

• Approximate the subcutaneous fascia? There has been some debate about whether the subcutaneous fascia must be approximated. My (Dr. Perkins) personal preference in morbidly obese patients is to place several interrupted sutures to obliterate much of the dead space, facilitate skin closure, and minimize tension on the wound; I have noted no significant increase in wound complications using this technique. Placement of a closed-suction drain (eg, Jackson Pratt, Hemovac) is a good alternative.
• Is a drain useful? Some have questioned whether use of a drain increases the likelihood of wound complications,¹⁶ but this concern is irrelevant because, in most—if not all—cases, the drainage tubing is exteriorized via a separate stab wound remote from the incision.
• Consider retention sutures. A morbidly obese patient may benefit from through-and-through retention sutures using 0 or #1 permanent material along with rubber bolsters to minimize cutting of the suture into the skin, especially if increased intra-abdominal pressure is likely (FIGURE 3).¹⁷ These sutures can be removed on the 10th to 12th postoperative day.

FIGURE 3 Minimize tension on the wound

A morbidly obese patient may benefit from through-and-through retention sutures along with rubber bolsters to minimize cutting of the suture into the skin.

Vaginal surgery does not increase complication rate in the obese

The vaginal approach can be extremely challenging in the morbidly obese patient, especially when hysterectomy is performed. Exposure is often compromised by the large folds about the thighs and buttocks, limiting access to the perineum and vaginal vault. If the patient also has a narrow, contracted pelvis, the difficulty is compounded. Because of these and other concerns about morbidity, many gynecologists hesitate to perform hysterectomy via the vaginal route when the patient is obese.

What the data show. Several studies have addressed these issues, including one by Pratt and Daikoku¹⁸ and another by Rafii and colleagues,¹⁹ both of which demonstrated that obese patients have a complication rate roughly equivalent to that observed in patients of normal weight, although obese patients have a greater decrease in hemoglobin level and a slightly higher incidence of postoperative fever.

Similarly, in a retrospective study, Pitkin²⁰ found no significant difference between the complication rates of obese and nonobese patients.

Another argument for the self-retaining retractor. From a technical standpoint, achieving good exposure is the primary challenge of vaginal surgery and usually requires two or more assistants—who themselves have limited or no direct view of the field—who must stand for long periods. Again, a viable alternative is use of a self-retaining retractor. One in particular, the MiniOmni retractor, is a small, uncumbersome, table-fixed system that can be maneuvered so that vaginal and perineal structures are readily accessible.

Choice of stirrups is also relevant. Exposure can be affected by the type of stirrups used. “Candy cane” stirrups facilitate exposure more than fixed stirrups (eg, Allen stirrups) do. Regardless of the stirrups selected, however, it is important to avoid excessive or prolonged hip flexion, or nerve injury may result.

How to minimize postoperative complications

After surgery, an obese patient requires close and continuous monitoring to avert complications and detect any that occur. Consider the following measures:

• A stint in the intensive care unit. In the morbidly obese patient, massive fluid shift (eg, extensive blood loss, prolonged surgery with losses from the peritoneum, etc.) or concern about sleep apnea may justify close monitoring in an intensive care unit or similar setting—at least briefly. Later, as the patient recovers, sleep studies may indicate whether apnea is present.
• Document fluid intake and output, especially in the elderly and in women with cardiorespiratory disease.
• Give analgesics in an amount sufficient to control pain and minimize activity that might place excessive tension on the abdominal incision, but also allows the patient to remain alert enough to ambulate effectively and perform pulmonary toileting.
• Begin ambulation on the first postoperative day—or on the evening after surgery, if circumstances permit. This helps clear secretions from the respiratory tract, reduces the risk of thromboembolism, and speeds the return of normal bowel function. Hourly incentive spirometry is also recommended for the first few days after surgery.
• Continue heparin. In patients at moderate or high risk of thromboembolism, continue low-dose heparin until discharge or for 7 days, whichever comes first.
• Keep other physicians involved. If the patient has a significant comorbidity, such as cardiorespiratory disease or uncontrolled diabetes, she should remain under the care of her internist or other primary care provider.
• Closely monitor the surgical wound for early signs of infection, which include inflammation and collections of serous fluid, blood, pus, or a mixture of these. If retention sutures were placed, check them frequently to ensure that they are not cutting into the skin of the abdomen.
• Strongly recommend weight loss. At the time of the last postoperative visit, tell the patient in clear language that obesity is extremely bad for her health and strongly encourage her to lose weight under the supervision of her primary care provider. If she has no such provider, make the appropriate referral.

The authors report no financial relationships relevant to this article.

The adverse consequences of obesity go far beyond aesthetic and psychosocial concerns. Patients who are markedly overweight face a real risk of developing severe health conditions—not just cardiac disease, diabetes mellitus, and hypertension, but also sleep apnea, venous thromboembolism, certain cancers (particularly breast and uterine), and biliary tract disease. Obesity also contributes to menstrual abnormalities and infertility and may complicate pregnancy.

Surgery in these patients poses a number of challenges. Not only does obesity frequently compromise the technical aspects of a procedure, it requires the surgeon to use certain measures in the preoperative and postoperative phases of management, such as counseling the patient extensively about the risks and potential complications she faces, initiating antibiotic prophylaxis, and ensuring early ambulation. These and other measures are especially important when uncontrolled, coexisting disease is present.

Not every obese patient is a significant surgical risk, so care should be individualized and use a team approach involving the gynecologist, anesthesiologist, primary care physician, and other appropriate subspecialists.

This article outlines the parameters of good surgical care in the obese patient, defined here as having a body mass index (BMI) of 30 kg/m² or above, or 35 kg/m² or above for morbid obesity. Whenever possible, we draw our recommendations from the published literature. In the absence of data, we base them on our surgical experience in the obese population.

Risks of surgery

It is imperative for the gynecologic surgeon to discuss the special risks of surgery with the obese patient well in advance of the operation and to formulate a systematic plan for evaluation, utilizing other members of the team when necessary. If the surgeon keeps the following risks in mind and is proactive, complications can be kept to a minimum.

Poor wound healing

Wound healing is a complex process involving several concurrent phases; an abnormality in any phase may impair healing. Those phases are:

• inflammatory phase, in which fluid and cells are released to clean the wound and prepare for the next phase of healing
• fibroplastic (proliferative) phase, in which fibroblasts accumulate and form collagen, the building block of connective tissue. This stage is marked by neovascularization and increased formation of granulation tissue
• wound contraction
• remodeling/maturation, in which new collagen is laid down as old collagen is broken down, resulting in scar formation.

Obese patients possess a thick layer of adipose tissue, which by its nature and location is minimally vascularized. This tissue essentially becomes dead space, an ideal medium for bacterial growth. Many obese patients also have diabetes mellitus, malignancy, or other comorbidity that further impairs healing.

As a result, obese patients are at increased risk of wound complications, breakdown, and subsequent dehiscence and evisceration. This translates into increased febrile morbidity, prolonged hospitalization, and higher cost.

What the data show. A number of studies have documented a higher incidence of wound complications in obese patients. In one retrospective review, Gallup¹ observed an increased risk of wound complications in obese patients, but the incidence diminished after implementation of a protocol of meticulous cleansing, subcutaneous heparin, and modified incision and closure techniques. In a similar retrospective study of 300 obese patients, Pitkin² reported wound complications among approximately one third of patients and postoperative fever among more than three quarters. Surgical-site infections are thought to occur in as many as 5% of patients.

Prophylaxis may be effective in some patients, but can be challenging. It entails meticulous skin cleansing and careful consideration of where the incision is placed, type of closure, use of a drain, and antibiotic administration.

Antibiotic prophylaxis is based on the theory that its presence in host tissues will alter natural defense mechanisms and kill bacteria that inoculate the wound. Because the window of efficacy is narrow, antibiotics should be administered shortly before the time of inoculation (ie, shortly before the time of incision, vaginal entry, etc.). Current guidelines suggest the use of broad-spectrum agents, including a cephalosporin, approximately 60 minutes before the incision. Redosing is recommended for procedures that last longer than 3 hours, as well as for those that involve significant blood loss (>1,500 mL).

For surgical procedures other than hysterectomy and laparotomy, prophylaxis may not be warranted.³ However, when the patient is markedly obese, many surgeons, including me (Dr. Perkins), sometimes opt to give antibiotics anyway—except for laparoscopic procedures—primarily for wound healing.

Compromised operative exposure

One of the main challenges of surgery in the obese is achieving adequate exposure; when it is inadequate, inadvertent injury may occur.

In addition to a thick abdominal wall composed largely of adipose tissue, these patients frequently have significant accumulations of fat in the mesenteries of the bowel, omentum, and pelvic peritoneum. These accumulations make it difficult to navigate around what becomes a narrow operative field.

Exposure can also be limited in vaginal surgery, because many obese women have very large thighs, buttocks, and accumulations of perineal fat.

Because exposure is a key element of successful surgery, modification of the procedure often becomes necessary—eg, focusing on a single area of the operative field at a time.

Use of a special retractor may help. A self-retaining retractor can be extremely useful. The Bookwalter retractor, first described in 1980, is a commonly used, table-fixed system that attaches to the side rail and can be assembled in minutes (FIGURE 1).⁴ The variety of rings and blades allows for excellent exposure. Although several complications have been associated with use of the Bookwalter retractor (primarily colon perforation and neuropathy⁵), they are infrequent and can be minimized by selecting the appropriate blade size and periodically repositioning the blades.

When this or other table-fixed retractors are unavailable, two Balfour retractors, placed at opposite poles of the field to obtain satisfactory exposure, may suffice. With a morbidly obese patient, multiple assistants may still be required to facilitate optimal exposure.

FIGURE 1 A tool to increase exposure

This self-retaining Bookwalter retractor is fixed to the surgical table and features a variety of rings and blades to facilitate exposure.

Thromboembolism

Venous thromboembolism is a major cause of mortality and morbidity in hospitalized patients, causing approximately 60,000 deaths every year.⁶ Obesity increases the risk of deep venous thrombosis in patients undergoing pelvic surgery. Because of their weight—and, often, coexisting conditions such as cardiorespiratory disease—many obese women are inactive or minimally active postoperatively, increasing the risk of thromboembolism, which remains heightened as long as 3 weeks after discharge. Older women are also at high risk, as are those with a malignancy.

Current guidelines call for the application of a pneumatic calf-compression device in the operating room, with removal after the patient is fully ambulatory. I (Dr. Perkins) also advocate simultaneous use of low-dose heparin, which should be given before surgery and continued until discharge.

Although the use of unfractionated heparin in conjunction with spinal or epidural anesthesia is not a major concern, the use of low-molecular-weight heparin warrants consultation with the anesthesiologist. Unfractionated heparin is preferred because it is metabolized much more rapidly than low-molecular weight heparin.⁷ The main concern with use of heparin in this setting (regardless of the patient’s weight) is spinal hematoma formation.

Inadvertent injury

Because exposure tends to be limited in obese patients, there is an ever-present risk of injury to bowel, bladder, ureter, and vascular structures. In obese women with a history of abdominal surgery, adhesions are likely, and the risk of bowel injury is increased. Similarly, in obese patients undergoing a laparoscopic procedure, many surface landmarks and vessels may be hard to discern.

Consider preoperative bowel preparation when there is a high risk of intestinal injury.⁸

Panniculectomy: Old technique with a new surgical purpose

Use a scalpel to incise the skin and delineate the area to be excised. That area typically consists of a large wedge of abdominal skin and subcutaneous fat.

Although the addition of panniculectomy to gynecologic surgery in the morbidly obese patient is a fairly recent strategy to increase exposure, the procedure itself has roots in the 19th century. In 1910, Howard Kelly of The Johns Hopkins Hospital reported a lipectomy that involved excision of a large wedge of abdominal skin and fat,²¹ although indications for that lipectomy appear to have been grounded in cosmesis and personal comfort for the patient.

Technique

Panniculectomy involves excision of a large portion of abdominal skin and subcutaneous fat down to, but not including, the rectus fascia, to gain much greater exposure to the lower abdominal cavity and pelvis.

Once the segment to be excised is delineated, it is mobilized using electrocautery to achieve meticulous hemostasis. After all surgical procedures are completed, the abdominal wall is closed in multiple layers, and drains are placed in the subcutaneous layer. Surgeons who have performed this procedure report significantly increased exposure and access to pelvic structures.

Once the skin is incised, the wedge is mobilized using electrocautery, down to, but not including, the rectus fascia.

Risks

The most important risk is impaired healing of the abdominal wound. One study of this procedure in patients on a gynecologic oncology service noted wound complications in 35% of patients, as well as significant blood loss (up to 1,800 mL in one case).²² Another study by Hopkins and associates,²³ however, reported minimal blood loss and wound complications.

Caveats

The procedure requires an experienced surgeon, particularly if no plastic surgeon is readily available. Also, when counseling the patient about this procedure, it is important to emphasize that its primary indication is to maximize exposure; cosmetic benefits are secondary.

Impaired cardiorespiratory function

Pulmonary function typically is compromised in the markedly obese, with restrictive lung disease and reduced functional residual capacity. If the patient smokes or has chronic obstructive lung disease, her pulmonary function is compromised even further, and her condition should be relayed to the anesthesiologist.

In addition, many obese patients have preexisting heart disease or conditions such as hyperlipidemia that put them at risk for heart disease. When evaluating an obese surgical patient, also ask about less apparent disorders, such as sleep apnea, which, if not addressed, may have grave postoperative consequences.

Preoperative evaluation and preparation

Goal: Assess and minimize risks

This process begins in the office or clinic with a discussion with the patient of any concerns and risks. The importance of early mobilization and ambulation after surgery should be emphasized. Any patient with uncontrolled diabetes or hypertension should continue to be monitored by her primary care physician. A patient who has not seen a physician recently should be assessed by an internist to ensure that no conditions go undetected before surgery.

Routine testing to start, but additional assessment may be justified. An obese patient should undergo the same routine testing as a woman of normal weight, but further testing may be warranted for any coexisting disorder. Because the obese patient may have a restrictive lung pattern by virtue of her body habitus, pulmonary-function testing is unlikely to yield new information and is probably not indicated—unless she smokes or has a history of chronic obstructive pulmonary disease. In that case, tests will clarify the obstructive component and bronchodilator response and are useful in postoperative management. Measurement of arterial blood gases is useful, however, because levels reflect respiratory function on a day-to-day basis.

Additional tests of cardiac status probably are not indicated on the basis of obesity alone. However, if initial tests (eg, the electrocardiogram) and the history suggest compromised cardiac function, two-dimensional echocardiography should be performed to determine the ejection fraction. Any concerns regarding cardiac function should be discussed with the anesthesiologist and cardiologist.

Because compromised pulmonary function is likely, I (Dr. Perkins) instruct each patient on the use of incentive spirometry before she undergoes anesthesia so that she has realistic expectations about the postoperative course. I also administer heparin at least 2 hours before induction (8 hours before induction if unfractionated heparin is used).⁶

If a hysterectomy or prolonged laparotomy is planned, prophylactic antibiotics are recommended.³ Thigh-high compression stockings or a pneumatic calf-compression device should be applied upon arrival in the operating room.

Anesthesia-related issues

Anticipate challenges involving the airway

The anesthesiologist’s primary concern in regard to the obese patient is establishment and maintenance of an airway to promote oxygenation. In morbidly and extremely morbidly obese patients, anatomic factors such as large breasts; a short, thick neck; large tongue; decreased mobility of the cervical spine; limited mouth opening; and greater amount of adipose tissue in the face and cheeks can render mask ventilation and intubation extremely difficult or impossible. Decreased functional residual capacity and tidal volume in the range of closing capacity may lead to extremely rapid oxygen desaturation when the patient is apneic.⁹

If the patient is pregnant, factors such as excess adipose tissue in the face become even more pronounced and increase the potential for catastrophe.

Appreciate mechanical concerns

The morbidly obese patient may exceed the weight limit of the operating table. In addition, placing her in a steep Trendelenburg position or rotating her laterally may compromise the integrity of the bed.

Coexisting disease, such as sleep apnea and acid reflux disease, should also be kept in mind. Compromised respiratory mechanics (eg, restrictive lung pattern) may cause further deterioration and make mechanical ventilation more difficult.

It also may be hard to establish vascular access, necessitating central venous line placement and introducing its associated risks.

Keep the anesthesiologist in the loop

In the postoperative period, obese patients face a heightened risk of complications related to diminished pulmonary function, such as oxygen desaturation, hypoventilation, and airway obstruction, which may lead to atelectasis, pneumonia, and pulmonary edema.^10,11 For these reasons, early consultation with the anesthesiologist is recommended, especially if the initial evaluation suggests potential difficulties in securing the airway. In turn, the anesthesiologist should understand that, in some obese patients, even establishing a surgical airway may be difficult. Regional anesthesia should be considered when feasible.

Antacids and drugs that increase gastric motility have proved to be useful in minimizing aspiration-related risks.^12,13

Surgical technique

Begin abdominal procedures by carefully choosing an incision

Do not base the decision solely on the degree of obesity, but also consider any additional procedures that are planned, such as lymph-node sampling. A vertical incision does permit greater exposure than is afforded by a transverse incision, but in some cases the latter may be more appropriate—even if the patient is morbidly obese.

Do not place the incision below the panniculus, in the crease just above the suprapubic mound, though it may be tempting to do so when the panniculus is large and thick. This area is a warm, moist, anaerobic environment that promotes the proliferation of numerous micro-organisms, creating a bacterial cesspool. It is the worst place to make an incision.

If a transverse incision is selected, place caudal traction on the panniculus (which may be facilitated by applying two towel clips to the tissue fold), and incise through the fold at a point approximately three to four fingerbreadths above the symphysis (FIGURE 2).

If a midline incision is selected, a similar technique is appropriate, with downward traction applied to the panniculus and the incision begun at the lower pole of this fold up to the umbilicus—or through it and above, should more room be required.¹⁴

After incising the superficial fascia, greater exposure may be gained by incising the rectus sheath beneath the pannicular fold and extending it down to the symphysis. After entering the abdominal cavity, the surgeon may encounter a redundant, fat-laden layer of peritoneum. The edges of this tissue may be temporarily sutured to the edges of the skin incision to remove it from the operative field and obtain better visualization.

FIGURE 2 Incision placement can be counterintuitive

Avoid placing the skin incision beneath the panniculus, an anaerobic area ripe for infection. Instead, retract the panniculus caudally and incise the skin above the fold, as shown.

A few remedies can help when exposure is limited

Exposure is one of the most important elements of successful surgery, but it is often restricted when marked obesity is present. Fortunately, numerous adjuncts are available to address this problem, such as the table-fixed retractor systems described earlier in this article, or one or more of the following tactics:

• Do not try to expose the entire pelvic basin. One technique to ease exploration—especially when more than one procedure is planned—is to refrain from exposing the entire pelvic basin at one time. Instead, focus on obtaining adequate visualization in the immediate area and, once work in that area is finished, concentrate on the next.
• Use extra-long instruments in an extremely large patient, especially if she has a “deep” pelvis.
• Abbreviate the procedure, if possible. Because these cases are technically more difficult and frequently involve excessive blood loss, it may be wiser to perform an “incomplete” procedure, such as supracervical hysterectomy instead of total hysterectomy, depending on the indication.¹⁴
• Use a cell-saver blood-collection system if significant blood loss is anticipated. Also remember to give a second dose of prophylactic antibiotic.

Strategies for effective wound closure

The best method of abdominal wound closure has been a subject of debate among both gynecologic and general surgeons. In the obese patient, the key variables are the rather thick subcutaneous fat layer within the abdominal wall and the impact of intra-abdominal pressure on the incision.

What the data show. A number of studies, including one by Montz and colleagues,¹⁵ have demonstrated that the running mass-closure technique using delayed-absorbable or permanent suture is just as effective as interrupted suture placement (eg, Smead-Jones closure) but is faster, with less suture deposited in the wound.

The following considerations may also be helpful:

• Approximate the subcutaneous fascia? There has been some debate about whether the subcutaneous fascia must be approximated. My (Dr. Perkins) personal preference in morbidly obese patients is to place several interrupted sutures to obliterate much of the dead space, facilitate skin closure, and minimize tension on the wound; I have noted no significant increase in wound complications using this technique. Placement of a closed-suction drain (eg, Jackson Pratt, Hemovac) is a good alternative.
• Is a drain useful? Some have questioned whether use of a drain increases the likelihood of wound complications,¹⁶ but this concern is irrelevant because, in most—if not all—cases, the drainage tubing is exteriorized via a separate stab wound remote from the incision.
• Consider retention sutures. A morbidly obese patient may benefit from through-and-through retention sutures using 0 or #1 permanent material along with rubber bolsters to minimize cutting of the suture into the skin, especially if increased intra-abdominal pressure is likely (FIGURE 3).¹⁷ These sutures can be removed on the 10th to 12th postoperative day.

FIGURE 3 Minimize tension on the wound

A morbidly obese patient may benefit from through-and-through retention sutures along with rubber bolsters to minimize cutting of the suture into the skin.

Vaginal surgery does not increase complication rate in the obese

The vaginal approach can be extremely challenging in the morbidly obese patient, especially when hysterectomy is performed. Exposure is often compromised by the large folds about the thighs and buttocks, limiting access to the perineum and vaginal vault. If the patient also has a narrow, contracted pelvis, the difficulty is compounded. Because of these and other concerns about morbidity, many gynecologists hesitate to perform hysterectomy via the vaginal route when the patient is obese.

What the data show. Several studies have addressed these issues, including one by Pratt and Daikoku¹⁸ and another by Rafii and colleagues,¹⁹ both of which demonstrated that obese patients have a complication rate roughly equivalent to that observed in patients of normal weight, although obese patients have a greater decrease in hemoglobin level and a slightly higher incidence of postoperative fever.

Similarly, in a retrospective study, Pitkin²⁰ found no significant difference between the complication rates of obese and nonobese patients.

Another argument for the self-retaining retractor. From a technical standpoint, achieving good exposure is the primary challenge of vaginal surgery and usually requires two or more assistants—who themselves have limited or no direct view of the field—who must stand for long periods. Again, a viable alternative is use of a self-retaining retractor. One in particular, the MiniOmni retractor, is a small, uncumbersome, table-fixed system that can be maneuvered so that vaginal and perineal structures are readily accessible.

Choice of stirrups is also relevant. Exposure can be affected by the type of stirrups used. “Candy cane” stirrups facilitate exposure more than fixed stirrups (eg, Allen stirrups) do. Regardless of the stirrups selected, however, it is important to avoid excessive or prolonged hip flexion, or nerve injury may result.

How to minimize postoperative complications

After surgery, an obese patient requires close and continuous monitoring to avert complications and detect any that occur. Consider the following measures:

• A stint in the intensive care unit. In the morbidly obese patient, massive fluid shift (eg, extensive blood loss, prolonged surgery with losses from the peritoneum, etc.) or concern about sleep apnea may justify close monitoring in an intensive care unit or similar setting—at least briefly. Later, as the patient recovers, sleep studies may indicate whether apnea is present.
• Document fluid intake and output, especially in the elderly and in women with cardiorespiratory disease.
• Give analgesics in an amount sufficient to control pain and minimize activity that might place excessive tension on the abdominal incision, but also allows the patient to remain alert enough to ambulate effectively and perform pulmonary toileting.
• Begin ambulation on the first postoperative day—or on the evening after surgery, if circumstances permit. This helps clear secretions from the respiratory tract, reduces the risk of thromboembolism, and speeds the return of normal bowel function. Hourly incentive spirometry is also recommended for the first few days after surgery.
• Continue heparin. In patients at moderate or high risk of thromboembolism, continue low-dose heparin until discharge or for 7 days, whichever comes first.
• Keep other physicians involved. If the patient has a significant comorbidity, such as cardiorespiratory disease or uncontrolled diabetes, she should remain under the care of her internist or other primary care provider.
• Closely monitor the surgical wound for early signs of infection, which include inflammation and collections of serous fluid, blood, pus, or a mixture of these. If retention sutures were placed, check them frequently to ensure that they are not cutting into the skin of the abdomen.
• Strongly recommend weight loss. At the time of the last postoperative visit, tell the patient in clear language that obesity is extremely bad for her health and strongly encourage her to lose weight under the supervision of her primary care provider. If she has no such provider, make the appropriate referral.

The authors report no financial relationships relevant to this article.

The adverse consequences of obesity go far beyond aesthetic and psychosocial concerns. Patients who are markedly overweight face a real risk of developing severe health conditions—not just cardiac disease, diabetes mellitus, and hypertension, but also sleep apnea, venous thromboembolism, certain cancers (particularly breast and uterine), and biliary tract disease. Obesity also contributes to menstrual abnormalities and infertility and may complicate pregnancy.

Surgery in these patients poses a number of challenges. Not only does obesity frequently compromise the technical aspects of a procedure, it requires the surgeon to use certain measures in the preoperative and postoperative phases of management, such as counseling the patient extensively about the risks and potential complications she faces, initiating antibiotic prophylaxis, and ensuring early ambulation. These and other measures are especially important when uncontrolled, coexisting disease is present.

Not every obese patient is a significant surgical risk, so care should be individualized and use a team approach involving the gynecologist, anesthesiologist, primary care physician, and other appropriate subspecialists.

This article outlines the parameters of good surgical care in the obese patient, defined here as having a body mass index (BMI) of 30 kg/m² or above, or 35 kg/m² or above for morbid obesity. Whenever possible, we draw our recommendations from the published literature. In the absence of data, we base them on our surgical experience in the obese population.

Risks of surgery

It is imperative for the gynecologic surgeon to discuss the special risks of surgery with the obese patient well in advance of the operation and to formulate a systematic plan for evaluation, utilizing other members of the team when necessary. If the surgeon keeps the following risks in mind and is proactive, complications can be kept to a minimum.

Poor wound healing

Wound healing is a complex process involving several concurrent phases; an abnormality in any phase may impair healing. Those phases are:

• inflammatory phase, in which fluid and cells are released to clean the wound and prepare for the next phase of healing
• fibroplastic (proliferative) phase, in which fibroblasts accumulate and form collagen, the building block of connective tissue. This stage is marked by neovascularization and increased formation of granulation tissue
• wound contraction
• remodeling/maturation, in which new collagen is laid down as old collagen is broken down, resulting in scar formation.

Obese patients possess a thick layer of adipose tissue, which by its nature and location is minimally vascularized. This tissue essentially becomes dead space, an ideal medium for bacterial growth. Many obese patients also have diabetes mellitus, malignancy, or other comorbidity that further impairs healing.

As a result, obese patients are at increased risk of wound complications, breakdown, and subsequent dehiscence and evisceration. This translates into increased febrile morbidity, prolonged hospitalization, and higher cost.

What the data show. A number of studies have documented a higher incidence of wound complications in obese patients. In one retrospective review, Gallup¹ observed an increased risk of wound complications in obese patients, but the incidence diminished after implementation of a protocol of meticulous cleansing, subcutaneous heparin, and modified incision and closure techniques. In a similar retrospective study of 300 obese patients, Pitkin² reported wound complications among approximately one third of patients and postoperative fever among more than three quarters. Surgical-site infections are thought to occur in as many as 5% of patients.

Prophylaxis may be effective in some patients, but can be challenging. It entails meticulous skin cleansing and careful consideration of where the incision is placed, type of closure, use of a drain, and antibiotic administration.

Antibiotic prophylaxis is based on the theory that its presence in host tissues will alter natural defense mechanisms and kill bacteria that inoculate the wound. Because the window of efficacy is narrow, antibiotics should be administered shortly before the time of inoculation (ie, shortly before the time of incision, vaginal entry, etc.). Current guidelines suggest the use of broad-spectrum agents, including a cephalosporin, approximately 60 minutes before the incision. Redosing is recommended for procedures that last longer than 3 hours, as well as for those that involve significant blood loss (>1,500 mL).

For surgical procedures other than hysterectomy and laparotomy, prophylaxis may not be warranted.³ However, when the patient is markedly obese, many surgeons, including me (Dr. Perkins), sometimes opt to give antibiotics anyway—except for laparoscopic procedures—primarily for wound healing.

Compromised operative exposure

One of the main challenges of surgery in the obese is achieving adequate exposure; when it is inadequate, inadvertent injury may occur.

In addition to a thick abdominal wall composed largely of adipose tissue, these patients frequently have significant accumulations of fat in the mesenteries of the bowel, omentum, and pelvic peritoneum. These accumulations make it difficult to navigate around what becomes a narrow operative field.

Exposure can also be limited in vaginal surgery, because many obese women have very large thighs, buttocks, and accumulations of perineal fat.

Because exposure is a key element of successful surgery, modification of the procedure often becomes necessary—eg, focusing on a single area of the operative field at a time.

Use of a special retractor may help. A self-retaining retractor can be extremely useful. The Bookwalter retractor, first described in 1980, is a commonly used, table-fixed system that attaches to the side rail and can be assembled in minutes (FIGURE 1).⁴ The variety of rings and blades allows for excellent exposure. Although several complications have been associated with use of the Bookwalter retractor (primarily colon perforation and neuropathy⁵), they are infrequent and can be minimized by selecting the appropriate blade size and periodically repositioning the blades.

When this or other table-fixed retractors are unavailable, two Balfour retractors, placed at opposite poles of the field to obtain satisfactory exposure, may suffice. With a morbidly obese patient, multiple assistants may still be required to facilitate optimal exposure.

FIGURE 1 A tool to increase exposure

This self-retaining Bookwalter retractor is fixed to the surgical table and features a variety of rings and blades to facilitate exposure.

Thromboembolism

Venous thromboembolism is a major cause of mortality and morbidity in hospitalized patients, causing approximately 60,000 deaths every year.⁶ Obesity increases the risk of deep venous thrombosis in patients undergoing pelvic surgery. Because of their weight—and, often, coexisting conditions such as cardiorespiratory disease—many obese women are inactive or minimally active postoperatively, increasing the risk of thromboembolism, which remains heightened as long as 3 weeks after discharge. Older women are also at high risk, as are those with a malignancy.

Current guidelines call for the application of a pneumatic calf-compression device in the operating room, with removal after the patient is fully ambulatory. I (Dr. Perkins) also advocate simultaneous use of low-dose heparin, which should be given before surgery and continued until discharge.

Although the use of unfractionated heparin in conjunction with spinal or epidural anesthesia is not a major concern, the use of low-molecular-weight heparin warrants consultation with the anesthesiologist. Unfractionated heparin is preferred because it is metabolized much more rapidly than low-molecular weight heparin.⁷ The main concern with use of heparin in this setting (regardless of the patient’s weight) is spinal hematoma formation.

Inadvertent injury

Because exposure tends to be limited in obese patients, there is an ever-present risk of injury to bowel, bladder, ureter, and vascular structures. In obese women with a history of abdominal surgery, adhesions are likely, and the risk of bowel injury is increased. Similarly, in obese patients undergoing a laparoscopic procedure, many surface landmarks and vessels may be hard to discern.

Consider preoperative bowel preparation when there is a high risk of intestinal injury.⁸

Panniculectomy: Old technique with a new surgical purpose

Use a scalpel to incise the skin and delineate the area to be excised. That area typically consists of a large wedge of abdominal skin and subcutaneous fat.

Although the addition of panniculectomy to gynecologic surgery in the morbidly obese patient is a fairly recent strategy to increase exposure, the procedure itself has roots in the 19th century. In 1910, Howard Kelly of The Johns Hopkins Hospital reported a lipectomy that involved excision of a large wedge of abdominal skin and fat,²¹ although indications for that lipectomy appear to have been grounded in cosmesis and personal comfort for the patient.

Technique

Panniculectomy involves excision of a large portion of abdominal skin and subcutaneous fat down to, but not including, the rectus fascia, to gain much greater exposure to the lower abdominal cavity and pelvis.

Once the segment to be excised is delineated, it is mobilized using electrocautery to achieve meticulous hemostasis. After all surgical procedures are completed, the abdominal wall is closed in multiple layers, and drains are placed in the subcutaneous layer. Surgeons who have performed this procedure report significantly increased exposure and access to pelvic structures.

Once the skin is incised, the wedge is mobilized using electrocautery, down to, but not including, the rectus fascia.

Risks

The most important risk is impaired healing of the abdominal wound. One study of this procedure in patients on a gynecologic oncology service noted wound complications in 35% of patients, as well as significant blood loss (up to 1,800 mL in one case).²² Another study by Hopkins and associates,²³ however, reported minimal blood loss and wound complications.

Caveats

The procedure requires an experienced surgeon, particularly if no plastic surgeon is readily available. Also, when counseling the patient about this procedure, it is important to emphasize that its primary indication is to maximize exposure; cosmetic benefits are secondary.

Impaired cardiorespiratory function

Pulmonary function typically is compromised in the markedly obese, with restrictive lung disease and reduced functional residual capacity. If the patient smokes or has chronic obstructive lung disease, her pulmonary function is compromised even further, and her condition should be relayed to the anesthesiologist.

In addition, many obese patients have preexisting heart disease or conditions such as hyperlipidemia that put them at risk for heart disease. When evaluating an obese surgical patient, also ask about less apparent disorders, such as sleep apnea, which, if not addressed, may have grave postoperative consequences.

Preoperative evaluation and preparation

Goal: Assess and minimize risks

This process begins in the office or clinic with a discussion with the patient of any concerns and risks. The importance of early mobilization and ambulation after surgery should be emphasized. Any patient with uncontrolled diabetes or hypertension should continue to be monitored by her primary care physician. A patient who has not seen a physician recently should be assessed by an internist to ensure that no conditions go undetected before surgery.

Routine testing to start, but additional assessment may be justified. An obese patient should undergo the same routine testing as a woman of normal weight, but further testing may be warranted for any coexisting disorder. Because the obese patient may have a restrictive lung pattern by virtue of her body habitus, pulmonary-function testing is unlikely to yield new information and is probably not indicated—unless she smokes or has a history of chronic obstructive pulmonary disease. In that case, tests will clarify the obstructive component and bronchodilator response and are useful in postoperative management. Measurement of arterial blood gases is useful, however, because levels reflect respiratory function on a day-to-day basis.

Additional tests of cardiac status probably are not indicated on the basis of obesity alone. However, if initial tests (eg, the electrocardiogram) and the history suggest compromised cardiac function, two-dimensional echocardiography should be performed to determine the ejection fraction. Any concerns regarding cardiac function should be discussed with the anesthesiologist and cardiologist.

Because compromised pulmonary function is likely, I (Dr. Perkins) instruct each patient on the use of incentive spirometry before she undergoes anesthesia so that she has realistic expectations about the postoperative course. I also administer heparin at least 2 hours before induction (8 hours before induction if unfractionated heparin is used).⁶

If a hysterectomy or prolonged laparotomy is planned, prophylactic antibiotics are recommended.³ Thigh-high compression stockings or a pneumatic calf-compression device should be applied upon arrival in the operating room.

Anesthesia-related issues

Anticipate challenges involving the airway

The anesthesiologist’s primary concern in regard to the obese patient is establishment and maintenance of an airway to promote oxygenation. In morbidly and extremely morbidly obese patients, anatomic factors such as large breasts; a short, thick neck; large tongue; decreased mobility of the cervical spine; limited mouth opening; and greater amount of adipose tissue in the face and cheeks can render mask ventilation and intubation extremely difficult or impossible. Decreased functional residual capacity and tidal volume in the range of closing capacity may lead to extremely rapid oxygen desaturation when the patient is apneic.⁹

If the patient is pregnant, factors such as excess adipose tissue in the face become even more pronounced and increase the potential for catastrophe.

Appreciate mechanical concerns

The morbidly obese patient may exceed the weight limit of the operating table. In addition, placing her in a steep Trendelenburg position or rotating her laterally may compromise the integrity of the bed.

Coexisting disease, such as sleep apnea and acid reflux disease, should also be kept in mind. Compromised respiratory mechanics (eg, restrictive lung pattern) may cause further deterioration and make mechanical ventilation more difficult.

It also may be hard to establish vascular access, necessitating central venous line placement and introducing its associated risks.

Keep the anesthesiologist in the loop

In the postoperative period, obese patients face a heightened risk of complications related to diminished pulmonary function, such as oxygen desaturation, hypoventilation, and airway obstruction, which may lead to atelectasis, pneumonia, and pulmonary edema.^10,11 For these reasons, early consultation with the anesthesiologist is recommended, especially if the initial evaluation suggests potential difficulties in securing the airway. In turn, the anesthesiologist should understand that, in some obese patients, even establishing a surgical airway may be difficult. Regional anesthesia should be considered when feasible.

Antacids and drugs that increase gastric motility have proved to be useful in minimizing aspiration-related risks.^12,13

Surgical technique

Begin abdominal procedures by carefully choosing an incision

Do not base the decision solely on the degree of obesity, but also consider any additional procedures that are planned, such as lymph-node sampling. A vertical incision does permit greater exposure than is afforded by a transverse incision, but in some cases the latter may be more appropriate—even if the patient is morbidly obese.

Do not place the incision below the panniculus, in the crease just above the suprapubic mound, though it may be tempting to do so when the panniculus is large and thick. This area is a warm, moist, anaerobic environment that promotes the proliferation of numerous micro-organisms, creating a bacterial cesspool. It is the worst place to make an incision.

If a transverse incision is selected, place caudal traction on the panniculus (which may be facilitated by applying two towel clips to the tissue fold), and incise through the fold at a point approximately three to four fingerbreadths above the symphysis (FIGURE 2).

If a midline incision is selected, a similar technique is appropriate, with downward traction applied to the panniculus and the incision begun at the lower pole of this fold up to the umbilicus—or through it and above, should more room be required.¹⁴

After incising the superficial fascia, greater exposure may be gained by incising the rectus sheath beneath the pannicular fold and extending it down to the symphysis. After entering the abdominal cavity, the surgeon may encounter a redundant, fat-laden layer of peritoneum. The edges of this tissue may be temporarily sutured to the edges of the skin incision to remove it from the operative field and obtain better visualization.

FIGURE 2 Incision placement can be counterintuitive

Avoid placing the skin incision beneath the panniculus, an anaerobic area ripe for infection. Instead, retract the panniculus caudally and incise the skin above the fold, as shown.

A few remedies can help when exposure is limited

Exposure is one of the most important elements of successful surgery, but it is often restricted when marked obesity is present. Fortunately, numerous adjuncts are available to address this problem, such as the table-fixed retractor systems described earlier in this article, or one or more of the following tactics:

• Do not try to expose the entire pelvic basin. One technique to ease exploration—especially when more than one procedure is planned—is to refrain from exposing the entire pelvic basin at one time. Instead, focus on obtaining adequate visualization in the immediate area and, once work in that area is finished, concentrate on the next.
• Use extra-long instruments in an extremely large patient, especially if she has a “deep” pelvis.
• Abbreviate the procedure, if possible. Because these cases are technically more difficult and frequently involve excessive blood loss, it may be wiser to perform an “incomplete” procedure, such as supracervical hysterectomy instead of total hysterectomy, depending on the indication.¹⁴
• Use a cell-saver blood-collection system if significant blood loss is anticipated. Also remember to give a second dose of prophylactic antibiotic.

Strategies for effective wound closure

The best method of abdominal wound closure has been a subject of debate among both gynecologic and general surgeons. In the obese patient, the key variables are the rather thick subcutaneous fat layer within the abdominal wall and the impact of intra-abdominal pressure on the incision.

What the data show. A number of studies, including one by Montz and colleagues,¹⁵ have demonstrated that the running mass-closure technique using delayed-absorbable or permanent suture is just as effective as interrupted suture placement (eg, Smead-Jones closure) but is faster, with less suture deposited in the wound.

The following considerations may also be helpful:

• Approximate the subcutaneous fascia? There has been some debate about whether the subcutaneous fascia must be approximated. My (Dr. Perkins) personal preference in morbidly obese patients is to place several interrupted sutures to obliterate much of the dead space, facilitate skin closure, and minimize tension on the wound; I have noted no significant increase in wound complications using this technique. Placement of a closed-suction drain (eg, Jackson Pratt, Hemovac) is a good alternative.
• Is a drain useful? Some have questioned whether use of a drain increases the likelihood of wound complications,¹⁶ but this concern is irrelevant because, in most—if not all—cases, the drainage tubing is exteriorized via a separate stab wound remote from the incision.
• Consider retention sutures. A morbidly obese patient may benefit from through-and-through retention sutures using 0 or #1 permanent material along with rubber bolsters to minimize cutting of the suture into the skin, especially if increased intra-abdominal pressure is likely (FIGURE 3).¹⁷ These sutures can be removed on the 10th to 12th postoperative day.

FIGURE 3 Minimize tension on the wound

A morbidly obese patient may benefit from through-and-through retention sutures along with rubber bolsters to minimize cutting of the suture into the skin.

Vaginal surgery does not increase complication rate in the obese

The vaginal approach can be extremely challenging in the morbidly obese patient, especially when hysterectomy is performed. Exposure is often compromised by the large folds about the thighs and buttocks, limiting access to the perineum and vaginal vault. If the patient also has a narrow, contracted pelvis, the difficulty is compounded. Because of these and other concerns about morbidity, many gynecologists hesitate to perform hysterectomy via the vaginal route when the patient is obese.

What the data show. Several studies have addressed these issues, including one by Pratt and Daikoku¹⁸ and another by Rafii and colleagues,¹⁹ both of which demonstrated that obese patients have a complication rate roughly equivalent to that observed in patients of normal weight, although obese patients have a greater decrease in hemoglobin level and a slightly higher incidence of postoperative fever.

Similarly, in a retrospective study, Pitkin²⁰ found no significant difference between the complication rates of obese and nonobese patients.

Another argument for the self-retaining retractor. From a technical standpoint, achieving good exposure is the primary challenge of vaginal surgery and usually requires two or more assistants—who themselves have limited or no direct view of the field—who must stand for long periods. Again, a viable alternative is use of a self-retaining retractor. One in particular, the MiniOmni retractor, is a small, uncumbersome, table-fixed system that can be maneuvered so that vaginal and perineal structures are readily accessible.

Choice of stirrups is also relevant. Exposure can be affected by the type of stirrups used. “Candy cane” stirrups facilitate exposure more than fixed stirrups (eg, Allen stirrups) do. Regardless of the stirrups selected, however, it is important to avoid excessive or prolonged hip flexion, or nerve injury may result.

How to minimize postoperative complications

After surgery, an obese patient requires close and continuous monitoring to avert complications and detect any that occur. Consider the following measures:

• A stint in the intensive care unit. In the morbidly obese patient, massive fluid shift (eg, extensive blood loss, prolonged surgery with losses from the peritoneum, etc.) or concern about sleep apnea may justify close monitoring in an intensive care unit or similar setting—at least briefly. Later, as the patient recovers, sleep studies may indicate whether apnea is present.
• Document fluid intake and output, especially in the elderly and in women with cardiorespiratory disease.
• Give analgesics in an amount sufficient to control pain and minimize activity that might place excessive tension on the abdominal incision, but also allows the patient to remain alert enough to ambulate effectively and perform pulmonary toileting.
• Begin ambulation on the first postoperative day—or on the evening after surgery, if circumstances permit. This helps clear secretions from the respiratory tract, reduces the risk of thromboembolism, and speeds the return of normal bowel function. Hourly incentive spirometry is also recommended for the first few days after surgery.
• Continue heparin. In patients at moderate or high risk of thromboembolism, continue low-dose heparin until discharge or for 7 days, whichever comes first.
• Keep other physicians involved. If the patient has a significant comorbidity, such as cardiorespiratory disease or uncontrolled diabetes, she should remain under the care of her internist or other primary care provider.
• Closely monitor the surgical wound for early signs of infection, which include inflammation and collections of serous fluid, blood, pus, or a mixture of these. If retention sutures were placed, check them frequently to ensure that they are not cutting into the skin of the abdomen.
• Strongly recommend weight loss. At the time of the last postoperative visit, tell the patient in clear language that obesity is extremely bad for her health and strongly encourage her to lose weight under the supervision of her primary care provider. If she has no such provider, make the appropriate referral.

This dreaded complication requires vigilance and skill to avoid, and adequate training and experience to manage and repair. In a perfect world, every gynecologist would be trained in techniques to prevent and repair inadvertent bowel injuries. Unfortunately, residency programs often do not provide such training.

Gynecologists routinely operate on patients with risk factors for bowel injury—obesity, endometriosis, multiple abdominal procedures, pelvic inflammatory disease, history of malignancy, and advanced age. A general surgeon is often called, however, for bowel repairs that can be performed by a gynecologist with sufficient training and experience. (There are instances, however, in which a general surgical consultation may not be readily available—another reason to master repair of bowel injuries encountered during gynecologic surgery.)

This article describes techniques to avert and manage intestinal injury. Topics include adhesiolysis, repair of bowel perforations, segmental bowel resection, and pre- and postoperative management. Vascular anatomy of the bowel is illustrated.

We emphasize the need for direct supervision by an experienced surgeon while mastering these techniques.

Bowel preparation: A useful tool to reduce infection, leakage

Isolated reports have questioned the need for mechanical bowel preparation,^1,2 and some experts point to the recent success of primary repairs of gunshot and stab wounds to the colon as evidence that bowel preparation and preoperative oral antibiotics are unnecessary.

Other studies indicate potential benefits, namely reducing infectious complications and anastomotic leakage following repair of inadvertent enterotomy. Indeed, the vast majority of North American surgeons continue to use some form of bowel preparation,^3,4 and it is the standard of care for elective intestinal surgery. For these reasons, bowel preparation is strongly encouraged for the gynecologic surgeon operating on a pelvic mass, endometriosis, or malignancy, or when difficult dissection is anticipated with the potential for inadvertent enterotomy and spillage of intestinal contents.

Bowel preparation consists of 2 phases: mechanical cleansing and antibiotic administration (TABLE). The postoperative infection rate can be reduced to well below 10% when these are properly performed.

Mechanical cleansing reduces the bulk of stool content within the lumen of the bowel, which also decreases the absolute amount of bacteria.⁵ Anaerobes are the predominant flora in the colon, with an estimated density of 10¹⁰ organisms per gram of stool. Perforation and spillage of colon contents contaminates the peritoneal cavity with more than 400 species of bacteria.

Perforation and spillage of colon contents contaminates the peritoneal cavity with more than 400 species of bacteria.

In the past, stool bulk was reduced via a low-residue or liquid diet combined with cathartics, enemas, or other agents given over 2 to 3 days. This regimen was time-consuming, patient compliance was poor, and nutritional intake was severely restricted prior to major surgery.

Today, polyethylene glycol and sodium phosphate are the 2 most popular methods of bowel preparation.

• Polyethylene glycol (Golytely, Braintree Labs, Braintree, Mass) is a balanced electrolyte solution dispensed in a 4-L quantity that must be taken over 4 hours. Some patients find this volume difficult to consume; one option is administering the solution via a small nasogastric tube. Complications may include nausea/vomiting, abdominal cramping, and, rarely, fluid overload and electrolyte disturbances.
  
• Sodium phosphate (Fleet Phosphosoda, C.B. Fleet Co, Lynchburg, Va) is administered in two 45-mL increments several hours apart. There is no consensus on which bowel-prep method is superior^3,4; most surgeons prefer one or the other. Due to potential electrolyte abnormalities with the use of sodium phosphate, polyethylene glycol is favored for patients with significant renal, cardiac, or hepatic disease.
  
• We recommend minimally absorbed oral antibiotics (1 g each of neomycin and erythromycin, given at 1 PM, 2 PM, and 11 PM the day before surgery) in combination with an intravenous second-generation cephalosporin (1 g if using cefotetan, 2 g if using cefoxitin; given immediately before surgery and continued postoperatively for 3 doses).
  
• Timing of antibiotic administration is important, since postoperative antibiotics alone do not appear to be effective. If significant spillage occurs intraoperatively, parenteral antibiotics should be continued for 5 days.
  

Bowel prep regimen

When injuries are most likely

Intestinal injuries during gynecologic surgery usually involve the small bowel and can be minor, such as a serosal tear or a small, full-thickness laceration—or major, involving a devitalized bowel loop or its mesentery.

Bowel injury may occur during a variety of surgical procedures. One study showed that most injuries occur during adhesiolysis or entry into the peritoneal cavity. A smaller but substantial number of cases occur during “less extensive” procedures such as uterine curettage and laparoscopy.⁶

Upon entering the peritoneal cavity, keep in mind the possibility of injuring an adherent loop of bowel. Because of its anatomical relationships to the pelvic viscera, portions of the bowel may become involved in adhesions, which can lead to extremely challenging pelvic dissections in conditions such as endometriosis or severe pelvic infection. Dissection of pelvic adhesions is a common cause of bowel injury, because bowel loops are retracted deeply downward by adhesive bands, and the limited pelvic space hampers visualization and gentle adhesiolysis.

At special risk for bowel injury are women who have undergone prior abdominal operations or who are obese. In a series of 270 general surgery patients undergoing reoperation,⁷ 52 (19%) sustained inadvertent enterotomy. These patients had undergone a mean of 3.3 previous laparotomies and had a higher body mass index (mean of 25.5 versus 21.9).

Age may be another risk factor, since patients with enterotomies were 60 years or older.⁷

Injury during laparoscopy. Inadvertent bowel injuries may occur during laparoscopic procedures, especially at the time of trocar insertion or manipulation of pelvic structures.⁵ One device that helps prevent these injuries is the optical trocar (Visiport, US Surgical, Norwalk, Conn), which allows physicians to visualize the layers of the abdominal wall as penetration occurs.

We also routinely direct anesthesia personnel to insert a nasogastric tube at the beginning of laparoscopic procedures to facilitate decompression of the stomach and small bowel.

The risks of electrosurgery. Electrocautery used for tubal ligation, pelvic dissection, or hemostasis may injure the bowel if the surgeon is not careful. Thermal injury due to unipolar cautery is particularly ominous because the extent of injury is greater than what can be grossly observed. The incidence of this type of injury can be reduced using bipolar cautery devices, as well as clips or bands for tubal ligation.

Injury as a result of uterine perforation is unlikely, but can occur. If perforation occurs during dilation and curettage, bowel laceration may result, particularly adhesions are present between the uterus and bowel loops. In extremely rare instances, a loop of bowel may be pulled through a perforation into the uterine cavity or vagina, requiring laparotomy for reduction and repair. Caution is advised during curettage, especially in a gravid uterus, to prevent this potentially catastrophic event.

Avoid the temptation to lyse opaque adhesions using blunt dissection, as serosal tears and enterotomies may occur.

Adhesiolysis: Plan on a lengthy, meticulous procedure

Adhesions are a common cause of pelvic pain, infertility, and bowel obstruction, and their presence may make it difficult to carry out the intended surgical procedure. Adhesiolysis may be necessary to mobilize loops of bowel tightly adherent to pelvic structures, to provide sufficient exposure of the surgical field and prevent subsequent bowel obstruction.

The extent of adhesions does not necessarily correlate with clinical symptoms.

Adhesions may be of the thin, filmy, “friendly” variety or dense, thick bands.

How adhesions occur. When tissue is injured, fibrin is deposited on the peritoneal and serosal surfaces. The extent to which this fibrin is infiltrated with fibroblasts and the degree of subsequent fibrosis determine adhesion density. Any process that impairs fibrinolysis tends to delay resolution of adhesions.

Contributing factors. Adhesions are commonly encountered in pelvic surgery and may be observed in 50% to 90% of patients who have undergone previous surgery.⁸

Obese patients also are more susceptible to adhesions. Other contributing factors include pelvic infection, bleeding, irradiation, chemical irritants, and conditions such as endometriosis.

Lysis technique. Apply gentle, controlled traction—as well as countertraction—on the bowel loops to facilitate isolation and dissection with sharp Metzenbaum scissors or a scalpel. (Forceful traction or rough handling of bowel loops may cause a breach in the bowel wall with subsequent spillage of intestinal contents.)

Avoid the temptation to lyse adhesions using blunt dissection (serosal tears and enterotomies may occur)—except in the case of translucent adhesions. These may be lysed via gentle, blunt dissection by rubbing the index finger and thumb back and forth over tissue. They also may be sharply cut using the tip of the scissors to form a “window” in a portion of the adhesion and cutting the adhesive segments in increments.

A characteristic line of demarcation often appears between adhesions and their peritoneal attachment, denoting a safe dissection plane.

Technique for special challenges: Chronic pelvic disease, prior laparotomies. When operating on these patients, be prepared for a long, meticulous procedure. A hasty approach in such cases is perilous and increases the likelihood of postoperative complications.

First, dissect the anterior abdominal wall from the adherent bowel on either side of the incision. Then extend the dissection laterally on both sides until the ascending and descending colon are identified. Next, dissect the small bowel free and mobilize it out of the pelvis.

It often is helpful to move to another area when dissection becomes too difficult; dissection through easier planes often will clarify the relationship of pelvic structures and adherent bowel loops.

Once the small bowel has been mobilized from the pelvis, lyse adhesions between loops of bowel that are causing kinking or narrowing of the lumen, to reduce the risk of postoperative bowel obstruction. Next, carefully dissect pelvic structures from the sigmoid colon and rectum.

How and when to repair serosal injury

Serosal injury is a breach of integrity of the visceral peritoneum, the outermost covering of the bowel wall. This may occur when the serosa is cut during entry into the abdomen or when it is torn during blunt dissection of dense adhesions.

If the underlying muscular and mucosal layers remain intact, these small areas of “denuded” serosa need not be repaired, since most experts believe that suture placement increases the likelihood of future adhesions. The serosal and muscular layers should be repaired if the mucosa is exposed, however. Otherwise the bowel wall will weaken at the site, making it vulnerable to perforation. The seromuscular layers can be approximated easily using interrupted 4-0 silk on a small tapered needle. Be careful to avoid placing the stitch through the mucosa, which would violate the bowel lumen.

When the defect of the seromuscular layer is large (when a more extensive area is denuded during dissection of densely adherent bowel away from a tumor or endometriotic lesion), repair becomes more involved. This may require resection of the injured area with primary anastomosis.

Intestinal perforations: Early recognition is essential

This critical serious complication can become disastrous if not immediately recognized and repaired. Perforation of the small intestine (enterotomy) or large bowel (colotomy) often occurs upon entry into the peritoneal cavity or during a difficult dissection, particularly when extensive adhesions are present.

Exercise special caution when operating on patients who have undergone prior surgery, who are advanced in age, or both.

Reoperation technique. When entering the abdomen through an old scar, reduce the likelihood of bowel injury by extending the new incision to either side of the old scar. Then enter the peritoneal cavity in a virgin area of the abdominal wall, where adherent loops of bowel are less likely.

Carefully open the fascia and dissect the preperitoneal fat down to the peritoneum. Before entering the abdominal cavity, retract the peritoneum upward with smooth forceps and palpate it between the thumb and index finger to ensure that a bowel loop is not in harm’s way.

If the underlying muscular and mucosal layers remain intact, small areas of “denuded” serosa need not be repaired.

Examine the entire small and large bowel carefully after surgery, to rule out injury. It is not uncommon for more than 1 perforation to occur in a bowel segment during a difficult dissection.

Begin at the ligament of Treitz and continue to the ileocecal junction. This is “running” the bowel—ie, inspecting in hand-over-hand fashion.

In the small bowel, the division between the jejunum and ileum is arbitrary, with no sharply defined line of demarcation. However, the diameter of the lumen decreases as one moves from jejunum to ileum, the number of vascular arcades increases, and the number of windows of Deaver diminishes. Also, the wall of the jejunum is generally thicker than that of the ileum.

In addition, inspect the colon in its entirety, with special emphasis on the sigmoid and rectum. Besides its larger lumen, the large bowel is distinguished by 3 longitudinal muscular bands called taenia coli, out-pouching of the wall (sacculations), and epiploic appendages.

Also examine the mesentery to exclude vascular compromise to the bowel wall.

Repair perforations immediately to limit contamination of the peritoneal cavity. Prior to closure, inspect wound edges for devitalized tissue and, if found, promptly debride it.

If colotomy occurs in the setting of an unprepared bowel with significant spillage, follow closure with copious irrigation.

Small perforations can usually be closed in 2 layers, with an inner layer of 3-0 delayed synthetic absorbable suture (Dexon, Vicryl) through the full thickness of the bowel wall, ensuring mucosal approximation. It is vital that this layer be “waterproof,” allowing no leakage of intestinal contents. Then place a second row of suture in the seromuscular layer using 4-0 silk to imbricate the first suture line.

General surgical consultation is needed whenever the gynecologist is inexperienced with bowel resection and anastomosis.

It also is essential that the suture line be perpendicular to the long axis of the bowel, rather than parallel; otherwise, the bowel lumen would narrow. Even perforations extending along the longitudinal axis for several centimeters should be repaired in transverse fashion to provide a lumen of adequate diameter.

Resecting the small bowel: If inexperienced, obtain general surgery consultation

Bowel resection and anastomosis require a greater degree of skill than is attained in a typical gynecologic training program. For that reason, resection is addressed here only superficially. Our primary caveat: A general surgical consultation should be obtained whenever the gynecologist is inexperienced with bowel resection and anastomosis.

Indications for resection. Strongly consider resection and anastomosis if the perforation involves more than 50% of the circumference of the bowel wall, if multiple perforations occur in a short segment of bowel, or if there is vascular compromise to a segment of bowel. Adequate perfusion to the bowel usually is indicated by a pink serosal surface. If the serosa remains dark or dusky and fails to become pink after several minutes of observation, vascular compromise is likely and resection is preferred.

If there is doubt about the blood supply to the bowel, give 1 g fluorescein intravenously and inspect the bowel under ultraviolet light (Wood’s lamp). Normal vascularized bowel will have a homogenous yellow-green appearance. Patchy fluorescence or areas without any fluorescence are evidence of ischemia.

To drain or not to drain

Because perforation and resection both involve entry into the bowel lumen, some degree of spillage is inevitable. This is of greater concern when the large bowel is involved, because of the increased likelihood of bacterial contamination. Immediate copious irrigation of the peritoneal cavity is indicated. Also consider a pelvic drain, especially when dissection has been extensive or raw surfaces are oozing.

The combination of bacterial contamination and free peritoneal blood in the pelvis increases the risk for infection. A strategically placed, half-inch Jackson Pratt drain (or a similar device) may help prevent abscess. In the event of anastomotic leakage, a drain often allows for a controlled enterocutaneous fistula to be managed without reoperation.

Some surgeons have satisfactory results without these drainage techniques.

When to begin postop feeding: Depends on type of repair

Opinion varies about the appropriate time to commence feeding after major abdominal surgery, particularly bowel surgery. Over the past decade, with the pressure to discharge patients earlier, many physicians have opted for earlier timing.

Traditionally, feeding was withheld until bowel sounds were auscultated; then it progressed slowly. Today many surgeons advance the diet much more quickly, with little or no delay in recovery. Fanning and Andrews⁹ demonstrated that early feeding does not increase the incidence of anastomotic leakage, dehiscence, or aspiration pneumonia—although it is associated with increased emesis.

Patients undergoing surgery for relatively minor injuries can have their diet advanced as if there were no intestinal involvement.

Feeding after minor repairs. When the surgery has involved relatively minor injuries, such as isolated serosal tears and adhesiolysis, nasogastric tube placement is not required. These patients can have their diet advanced as if there were no intestinal involvement. Give clear liquids when bowel sounds are heard and, if tolerated, advance to solids. It is probably not necessary to await a bowel movement before discharging the patient; she can be released once flatus is passed.

Substantial repairs. When major injuries have been repaired, such as with a large perforation repair or bowel resection, it is prudent to proceed more slowly.

Place a nasogastric tube to minimize bowel distention and subsequent leakage from the repair site. Give the patient nothing by mouth until bowel sounds are clearly present and flatus is passed. Then clamp the nasogastric tube for 24 hours, remove it, and institute clear liquids, provided there is no nausea, vomiting, or distension. Advance to full liquids and then solids, tailoring this process to the patient. When she can tolerate a regular diet, with substantial passage of flatus or bowel movement, recovery is signaled.

Need for additional training

The techniques necessary to manage simple bowel injury are not difficult to master. However, Ob/Gyn residency programs need to extend training in this area. Additional rotations on the general surgery or trauma services as second- or third-year residents would be ideal, but the use of animal laboratories is a good alternative.

The authors report no financial relationships relevant to this article.

This dreaded complication requires vigilance and skill to avoid, and adequate training and experience to manage and repair. In a perfect world, every gynecologist would be trained in techniques to prevent and repair inadvertent bowel injuries. Unfortunately, residency programs often do not provide such training.

Gynecologists routinely operate on patients with risk factors for bowel injury—obesity, endometriosis, multiple abdominal procedures, pelvic inflammatory disease, history of malignancy, and advanced age. A general surgeon is often called, however, for bowel repairs that can be performed by a gynecologist with sufficient training and experience. (There are instances, however, in which a general surgical consultation may not be readily available—another reason to master repair of bowel injuries encountered during gynecologic surgery.)

This article describes techniques to avert and manage intestinal injury. Topics include adhesiolysis, repair of bowel perforations, segmental bowel resection, and pre- and postoperative management. Vascular anatomy of the bowel is illustrated.

We emphasize the need for direct supervision by an experienced surgeon while mastering these techniques.

Bowel preparation: A useful tool to reduce infection, leakage

Isolated reports have questioned the need for mechanical bowel preparation,^1,2 and some experts point to the recent success of primary repairs of gunshot and stab wounds to the colon as evidence that bowel preparation and preoperative oral antibiotics are unnecessary.

Other studies indicate potential benefits, namely reducing infectious complications and anastomotic leakage following repair of inadvertent enterotomy. Indeed, the vast majority of North American surgeons continue to use some form of bowel preparation,^3,4 and it is the standard of care for elective intestinal surgery. For these reasons, bowel preparation is strongly encouraged for the gynecologic surgeon operating on a pelvic mass, endometriosis, or malignancy, or when difficult dissection is anticipated with the potential for inadvertent enterotomy and spillage of intestinal contents.

Bowel preparation consists of 2 phases: mechanical cleansing and antibiotic administration (TABLE). The postoperative infection rate can be reduced to well below 10% when these are properly performed.

Mechanical cleansing reduces the bulk of stool content within the lumen of the bowel, which also decreases the absolute amount of bacteria.⁵ Anaerobes are the predominant flora in the colon, with an estimated density of 10¹⁰ organisms per gram of stool. Perforation and spillage of colon contents contaminates the peritoneal cavity with more than 400 species of bacteria.

Perforation and spillage of colon contents contaminates the peritoneal cavity with more than 400 species of bacteria.

In the past, stool bulk was reduced via a low-residue or liquid diet combined with cathartics, enemas, or other agents given over 2 to 3 days. This regimen was time-consuming, patient compliance was poor, and nutritional intake was severely restricted prior to major surgery.

Today, polyethylene glycol and sodium phosphate are the 2 most popular methods of bowel preparation.

• Polyethylene glycol (Golytely, Braintree Labs, Braintree, Mass) is a balanced electrolyte solution dispensed in a 4-L quantity that must be taken over 4 hours. Some patients find this volume difficult to consume; one option is administering the solution via a small nasogastric tube. Complications may include nausea/vomiting, abdominal cramping, and, rarely, fluid overload and electrolyte disturbances.
  
• Sodium phosphate (Fleet Phosphosoda, C.B. Fleet Co, Lynchburg, Va) is administered in two 45-mL increments several hours apart. There is no consensus on which bowel-prep method is superior^3,4; most surgeons prefer one or the other. Due to potential electrolyte abnormalities with the use of sodium phosphate, polyethylene glycol is favored for patients with significant renal, cardiac, or hepatic disease.
  
• We recommend minimally absorbed oral antibiotics (1 g each of neomycin and erythromycin, given at 1 PM, 2 PM, and 11 PM the day before surgery) in combination with an intravenous second-generation cephalosporin (1 g if using cefotetan, 2 g if using cefoxitin; given immediately before surgery and continued postoperatively for 3 doses).
  
• Timing of antibiotic administration is important, since postoperative antibiotics alone do not appear to be effective. If significant spillage occurs intraoperatively, parenteral antibiotics should be continued for 5 days.
  

Bowel prep regimen

When injuries are most likely

Intestinal injuries during gynecologic surgery usually involve the small bowel and can be minor, such as a serosal tear or a small, full-thickness laceration—or major, involving a devitalized bowel loop or its mesentery.

Bowel injury may occur during a variety of surgical procedures. One study showed that most injuries occur during adhesiolysis or entry into the peritoneal cavity. A smaller but substantial number of cases occur during “less extensive” procedures such as uterine curettage and laparoscopy.⁶

Upon entering the peritoneal cavity, keep in mind the possibility of injuring an adherent loop of bowel. Because of its anatomical relationships to the pelvic viscera, portions of the bowel may become involved in adhesions, which can lead to extremely challenging pelvic dissections in conditions such as endometriosis or severe pelvic infection. Dissection of pelvic adhesions is a common cause of bowel injury, because bowel loops are retracted deeply downward by adhesive bands, and the limited pelvic space hampers visualization and gentle adhesiolysis.

At special risk for bowel injury are women who have undergone prior abdominal operations or who are obese. In a series of 270 general surgery patients undergoing reoperation,⁷ 52 (19%) sustained inadvertent enterotomy. These patients had undergone a mean of 3.3 previous laparotomies and had a higher body mass index (mean of 25.5 versus 21.9).

Age may be another risk factor, since patients with enterotomies were 60 years or older.⁷

Injury during laparoscopy. Inadvertent bowel injuries may occur during laparoscopic procedures, especially at the time of trocar insertion or manipulation of pelvic structures.⁵ One device that helps prevent these injuries is the optical trocar (Visiport, US Surgical, Norwalk, Conn), which allows physicians to visualize the layers of the abdominal wall as penetration occurs.

We also routinely direct anesthesia personnel to insert a nasogastric tube at the beginning of laparoscopic procedures to facilitate decompression of the stomach and small bowel.

The risks of electrosurgery. Electrocautery used for tubal ligation, pelvic dissection, or hemostasis may injure the bowel if the surgeon is not careful. Thermal injury due to unipolar cautery is particularly ominous because the extent of injury is greater than what can be grossly observed. The incidence of this type of injury can be reduced using bipolar cautery devices, as well as clips or bands for tubal ligation.

Injury as a result of uterine perforation is unlikely, but can occur. If perforation occurs during dilation and curettage, bowel laceration may result, particularly adhesions are present between the uterus and bowel loops. In extremely rare instances, a loop of bowel may be pulled through a perforation into the uterine cavity or vagina, requiring laparotomy for reduction and repair. Caution is advised during curettage, especially in a gravid uterus, to prevent this potentially catastrophic event.

Avoid the temptation to lyse opaque adhesions using blunt dissection, as serosal tears and enterotomies may occur.

Adhesiolysis: Plan on a lengthy, meticulous procedure

Adhesions are a common cause of pelvic pain, infertility, and bowel obstruction, and their presence may make it difficult to carry out the intended surgical procedure. Adhesiolysis may be necessary to mobilize loops of bowel tightly adherent to pelvic structures, to provide sufficient exposure of the surgical field and prevent subsequent bowel obstruction.

The extent of adhesions does not necessarily correlate with clinical symptoms.

Adhesions may be of the thin, filmy, “friendly” variety or dense, thick bands.

How adhesions occur. When tissue is injured, fibrin is deposited on the peritoneal and serosal surfaces. The extent to which this fibrin is infiltrated with fibroblasts and the degree of subsequent fibrosis determine adhesion density. Any process that impairs fibrinolysis tends to delay resolution of adhesions.

Contributing factors. Adhesions are commonly encountered in pelvic surgery and may be observed in 50% to 90% of patients who have undergone previous surgery.⁸

Obese patients also are more susceptible to adhesions. Other contributing factors include pelvic infection, bleeding, irradiation, chemical irritants, and conditions such as endometriosis.

Lysis technique. Apply gentle, controlled traction—as well as countertraction—on the bowel loops to facilitate isolation and dissection with sharp Metzenbaum scissors or a scalpel. (Forceful traction or rough handling of bowel loops may cause a breach in the bowel wall with subsequent spillage of intestinal contents.)

Avoid the temptation to lyse adhesions using blunt dissection (serosal tears and enterotomies may occur)—except in the case of translucent adhesions. These may be lysed via gentle, blunt dissection by rubbing the index finger and thumb back and forth over tissue. They also may be sharply cut using the tip of the scissors to form a “window” in a portion of the adhesion and cutting the adhesive segments in increments.

A characteristic line of demarcation often appears between adhesions and their peritoneal attachment, denoting a safe dissection plane.

Technique for special challenges: Chronic pelvic disease, prior laparotomies. When operating on these patients, be prepared for a long, meticulous procedure. A hasty approach in such cases is perilous and increases the likelihood of postoperative complications.

First, dissect the anterior abdominal wall from the adherent bowel on either side of the incision. Then extend the dissection laterally on both sides until the ascending and descending colon are identified. Next, dissect the small bowel free and mobilize it out of the pelvis.

It often is helpful to move to another area when dissection becomes too difficult; dissection through easier planes often will clarify the relationship of pelvic structures and adherent bowel loops.

Once the small bowel has been mobilized from the pelvis, lyse adhesions between loops of bowel that are causing kinking or narrowing of the lumen, to reduce the risk of postoperative bowel obstruction. Next, carefully dissect pelvic structures from the sigmoid colon and rectum.

How and when to repair serosal injury

Serosal injury is a breach of integrity of the visceral peritoneum, the outermost covering of the bowel wall. This may occur when the serosa is cut during entry into the abdomen or when it is torn during blunt dissection of dense adhesions.

If the underlying muscular and mucosal layers remain intact, these small areas of “denuded” serosa need not be repaired, since most experts believe that suture placement increases the likelihood of future adhesions. The serosal and muscular layers should be repaired if the mucosa is exposed, however. Otherwise the bowel wall will weaken at the site, making it vulnerable to perforation. The seromuscular layers can be approximated easily using interrupted 4-0 silk on a small tapered needle. Be careful to avoid placing the stitch through the mucosa, which would violate the bowel lumen.

When the defect of the seromuscular layer is large (when a more extensive area is denuded during dissection of densely adherent bowel away from a tumor or endometriotic lesion), repair becomes more involved. This may require resection of the injured area with primary anastomosis.

Intestinal perforations: Early recognition is essential

This critical serious complication can become disastrous if not immediately recognized and repaired. Perforation of the small intestine (enterotomy) or large bowel (colotomy) often occurs upon entry into the peritoneal cavity or during a difficult dissection, particularly when extensive adhesions are present.

Exercise special caution when operating on patients who have undergone prior surgery, who are advanced in age, or both.

Reoperation technique. When entering the abdomen through an old scar, reduce the likelihood of bowel injury by extending the new incision to either side of the old scar. Then enter the peritoneal cavity in a virgin area of the abdominal wall, where adherent loops of bowel are less likely.

Carefully open the fascia and dissect the preperitoneal fat down to the peritoneum. Before entering the abdominal cavity, retract the peritoneum upward with smooth forceps and palpate it between the thumb and index finger to ensure that a bowel loop is not in harm’s way.

If the underlying muscular and mucosal layers remain intact, small areas of “denuded” serosa need not be repaired.

Examine the entire small and large bowel carefully after surgery, to rule out injury. It is not uncommon for more than 1 perforation to occur in a bowel segment during a difficult dissection.

Begin at the ligament of Treitz and continue to the ileocecal junction. This is “running” the bowel—ie, inspecting in hand-over-hand fashion.

In the small bowel, the division between the jejunum and ileum is arbitrary, with no sharply defined line of demarcation. However, the diameter of the lumen decreases as one moves from jejunum to ileum, the number of vascular arcades increases, and the number of windows of Deaver diminishes. Also, the wall of the jejunum is generally thicker than that of the ileum.

In addition, inspect the colon in its entirety, with special emphasis on the sigmoid and rectum. Besides its larger lumen, the large bowel is distinguished by 3 longitudinal muscular bands called taenia coli, out-pouching of the wall (sacculations), and epiploic appendages.

Also examine the mesentery to exclude vascular compromise to the bowel wall.

Repair perforations immediately to limit contamination of the peritoneal cavity. Prior to closure, inspect wound edges for devitalized tissue and, if found, promptly debride it.

If colotomy occurs in the setting of an unprepared bowel with significant spillage, follow closure with copious irrigation.

Small perforations can usually be closed in 2 layers, with an inner layer of 3-0 delayed synthetic absorbable suture (Dexon, Vicryl) through the full thickness of the bowel wall, ensuring mucosal approximation. It is vital that this layer be “waterproof,” allowing no leakage of intestinal contents. Then place a second row of suture in the seromuscular layer using 4-0 silk to imbricate the first suture line.

General surgical consultation is needed whenever the gynecologist is inexperienced with bowel resection and anastomosis.

It also is essential that the suture line be perpendicular to the long axis of the bowel, rather than parallel; otherwise, the bowel lumen would narrow. Even perforations extending along the longitudinal axis for several centimeters should be repaired in transverse fashion to provide a lumen of adequate diameter.

Resecting the small bowel: If inexperienced, obtain general surgery consultation

Bowel resection and anastomosis require a greater degree of skill than is attained in a typical gynecologic training program. For that reason, resection is addressed here only superficially. Our primary caveat: A general surgical consultation should be obtained whenever the gynecologist is inexperienced with bowel resection and anastomosis.

Indications for resection. Strongly consider resection and anastomosis if the perforation involves more than 50% of the circumference of the bowel wall, if multiple perforations occur in a short segment of bowel, or if there is vascular compromise to a segment of bowel. Adequate perfusion to the bowel usually is indicated by a pink serosal surface. If the serosa remains dark or dusky and fails to become pink after several minutes of observation, vascular compromise is likely and resection is preferred.

If there is doubt about the blood supply to the bowel, give 1 g fluorescein intravenously and inspect the bowel under ultraviolet light (Wood’s lamp). Normal vascularized bowel will have a homogenous yellow-green appearance. Patchy fluorescence or areas without any fluorescence are evidence of ischemia.

To drain or not to drain

Because perforation and resection both involve entry into the bowel lumen, some degree of spillage is inevitable. This is of greater concern when the large bowel is involved, because of the increased likelihood of bacterial contamination. Immediate copious irrigation of the peritoneal cavity is indicated. Also consider a pelvic drain, especially when dissection has been extensive or raw surfaces are oozing.

The combination of bacterial contamination and free peritoneal blood in the pelvis increases the risk for infection. A strategically placed, half-inch Jackson Pratt drain (or a similar device) may help prevent abscess. In the event of anastomotic leakage, a drain often allows for a controlled enterocutaneous fistula to be managed without reoperation.

Some surgeons have satisfactory results without these drainage techniques.

When to begin postop feeding: Depends on type of repair

Opinion varies about the appropriate time to commence feeding after major abdominal surgery, particularly bowel surgery. Over the past decade, with the pressure to discharge patients earlier, many physicians have opted for earlier timing.

Traditionally, feeding was withheld until bowel sounds were auscultated; then it progressed slowly. Today many surgeons advance the diet much more quickly, with little or no delay in recovery. Fanning and Andrews⁹ demonstrated that early feeding does not increase the incidence of anastomotic leakage, dehiscence, or aspiration pneumonia—although it is associated with increased emesis.

Patients undergoing surgery for relatively minor injuries can have their diet advanced as if there were no intestinal involvement.

Feeding after minor repairs. When the surgery has involved relatively minor injuries, such as isolated serosal tears and adhesiolysis, nasogastric tube placement is not required. These patients can have their diet advanced as if there were no intestinal involvement. Give clear liquids when bowel sounds are heard and, if tolerated, advance to solids. It is probably not necessary to await a bowel movement before discharging the patient; she can be released once flatus is passed.

Substantial repairs. When major injuries have been repaired, such as with a large perforation repair or bowel resection, it is prudent to proceed more slowly.

Place a nasogastric tube to minimize bowel distention and subsequent leakage from the repair site. Give the patient nothing by mouth until bowel sounds are clearly present and flatus is passed. Then clamp the nasogastric tube for 24 hours, remove it, and institute clear liquids, provided there is no nausea, vomiting, or distension. Advance to full liquids and then solids, tailoring this process to the patient. When she can tolerate a regular diet, with substantial passage of flatus or bowel movement, recovery is signaled.

Need for additional training

The techniques necessary to manage simple bowel injury are not difficult to master. However, Ob/Gyn residency programs need to extend training in this area. Additional rotations on the general surgery or trauma services as second- or third-year residents would be ideal, but the use of animal laboratories is a good alternative.

The authors report no financial relationships relevant to this article.

This dreaded complication requires vigilance and skill to avoid, and adequate training and experience to manage and repair. In a perfect world, every gynecologist would be trained in techniques to prevent and repair inadvertent bowel injuries. Unfortunately, residency programs often do not provide such training.

Gynecologists routinely operate on patients with risk factors for bowel injury—obesity, endometriosis, multiple abdominal procedures, pelvic inflammatory disease, history of malignancy, and advanced age. A general surgeon is often called, however, for bowel repairs that can be performed by a gynecologist with sufficient training and experience. (There are instances, however, in which a general surgical consultation may not be readily available—another reason to master repair of bowel injuries encountered during gynecologic surgery.)

This article describes techniques to avert and manage intestinal injury. Topics include adhesiolysis, repair of bowel perforations, segmental bowel resection, and pre- and postoperative management. Vascular anatomy of the bowel is illustrated.

We emphasize the need for direct supervision by an experienced surgeon while mastering these techniques.

Bowel preparation: A useful tool to reduce infection, leakage

Isolated reports have questioned the need for mechanical bowel preparation,^1,2 and some experts point to the recent success of primary repairs of gunshot and stab wounds to the colon as evidence that bowel preparation and preoperative oral antibiotics are unnecessary.

Other studies indicate potential benefits, namely reducing infectious complications and anastomotic leakage following repair of inadvertent enterotomy. Indeed, the vast majority of North American surgeons continue to use some form of bowel preparation,^3,4 and it is the standard of care for elective intestinal surgery. For these reasons, bowel preparation is strongly encouraged for the gynecologic surgeon operating on a pelvic mass, endometriosis, or malignancy, or when difficult dissection is anticipated with the potential for inadvertent enterotomy and spillage of intestinal contents.

Bowel preparation consists of 2 phases: mechanical cleansing and antibiotic administration (TABLE). The postoperative infection rate can be reduced to well below 10% when these are properly performed.

Mechanical cleansing reduces the bulk of stool content within the lumen of the bowel, which also decreases the absolute amount of bacteria.⁵ Anaerobes are the predominant flora in the colon, with an estimated density of 10¹⁰ organisms per gram of stool. Perforation and spillage of colon contents contaminates the peritoneal cavity with more than 400 species of bacteria.

Perforation and spillage of colon contents contaminates the peritoneal cavity with more than 400 species of bacteria.

In the past, stool bulk was reduced via a low-residue or liquid diet combined with cathartics, enemas, or other agents given over 2 to 3 days. This regimen was time-consuming, patient compliance was poor, and nutritional intake was severely restricted prior to major surgery.

Today, polyethylene glycol and sodium phosphate are the 2 most popular methods of bowel preparation.

• Polyethylene glycol (Golytely, Braintree Labs, Braintree, Mass) is a balanced electrolyte solution dispensed in a 4-L quantity that must be taken over 4 hours. Some patients find this volume difficult to consume; one option is administering the solution via a small nasogastric tube. Complications may include nausea/vomiting, abdominal cramping, and, rarely, fluid overload and electrolyte disturbances.
  
• Sodium phosphate (Fleet Phosphosoda, C.B. Fleet Co, Lynchburg, Va) is administered in two 45-mL increments several hours apart. There is no consensus on which bowel-prep method is superior^3,4; most surgeons prefer one or the other. Due to potential electrolyte abnormalities with the use of sodium phosphate, polyethylene glycol is favored for patients with significant renal, cardiac, or hepatic disease.
  
• We recommend minimally absorbed oral antibiotics (1 g each of neomycin and erythromycin, given at 1 PM, 2 PM, and 11 PM the day before surgery) in combination with an intravenous second-generation cephalosporin (1 g if using cefotetan, 2 g if using cefoxitin; given immediately before surgery and continued postoperatively for 3 doses).
  
• Timing of antibiotic administration is important, since postoperative antibiotics alone do not appear to be effective. If significant spillage occurs intraoperatively, parenteral antibiotics should be continued for 5 days.
  

Bowel prep regimen

When injuries are most likely

Intestinal injuries during gynecologic surgery usually involve the small bowel and can be minor, such as a serosal tear or a small, full-thickness laceration—or major, involving a devitalized bowel loop or its mesentery.

Bowel injury may occur during a variety of surgical procedures. One study showed that most injuries occur during adhesiolysis or entry into the peritoneal cavity. A smaller but substantial number of cases occur during “less extensive” procedures such as uterine curettage and laparoscopy.⁶

Upon entering the peritoneal cavity, keep in mind the possibility of injuring an adherent loop of bowel. Because of its anatomical relationships to the pelvic viscera, portions of the bowel may become involved in adhesions, which can lead to extremely challenging pelvic dissections in conditions such as endometriosis or severe pelvic infection. Dissection of pelvic adhesions is a common cause of bowel injury, because bowel loops are retracted deeply downward by adhesive bands, and the limited pelvic space hampers visualization and gentle adhesiolysis.

At special risk for bowel injury are women who have undergone prior abdominal operations or who are obese. In a series of 270 general surgery patients undergoing reoperation,⁷ 52 (19%) sustained inadvertent enterotomy. These patients had undergone a mean of 3.3 previous laparotomies and had a higher body mass index (mean of 25.5 versus 21.9).

Age may be another risk factor, since patients with enterotomies were 60 years or older.⁷

Injury during laparoscopy. Inadvertent bowel injuries may occur during laparoscopic procedures, especially at the time of trocar insertion or manipulation of pelvic structures.⁵ One device that helps prevent these injuries is the optical trocar (Visiport, US Surgical, Norwalk, Conn), which allows physicians to visualize the layers of the abdominal wall as penetration occurs.

We also routinely direct anesthesia personnel to insert a nasogastric tube at the beginning of laparoscopic procedures to facilitate decompression of the stomach and small bowel.

The risks of electrosurgery. Electrocautery used for tubal ligation, pelvic dissection, or hemostasis may injure the bowel if the surgeon is not careful. Thermal injury due to unipolar cautery is particularly ominous because the extent of injury is greater than what can be grossly observed. The incidence of this type of injury can be reduced using bipolar cautery devices, as well as clips or bands for tubal ligation.

Injury as a result of uterine perforation is unlikely, but can occur. If perforation occurs during dilation and curettage, bowel laceration may result, particularly adhesions are present between the uterus and bowel loops. In extremely rare instances, a loop of bowel may be pulled through a perforation into the uterine cavity or vagina, requiring laparotomy for reduction and repair. Caution is advised during curettage, especially in a gravid uterus, to prevent this potentially catastrophic event.

Avoid the temptation to lyse opaque adhesions using blunt dissection, as serosal tears and enterotomies may occur.

Adhesiolysis: Plan on a lengthy, meticulous procedure

Adhesions are a common cause of pelvic pain, infertility, and bowel obstruction, and their presence may make it difficult to carry out the intended surgical procedure. Adhesiolysis may be necessary to mobilize loops of bowel tightly adherent to pelvic structures, to provide sufficient exposure of the surgical field and prevent subsequent bowel obstruction.

The extent of adhesions does not necessarily correlate with clinical symptoms.

Adhesions may be of the thin, filmy, “friendly” variety or dense, thick bands.

How adhesions occur. When tissue is injured, fibrin is deposited on the peritoneal and serosal surfaces. The extent to which this fibrin is infiltrated with fibroblasts and the degree of subsequent fibrosis determine adhesion density. Any process that impairs fibrinolysis tends to delay resolution of adhesions.

Contributing factors. Adhesions are commonly encountered in pelvic surgery and may be observed in 50% to 90% of patients who have undergone previous surgery.⁸

Obese patients also are more susceptible to adhesions. Other contributing factors include pelvic infection, bleeding, irradiation, chemical irritants, and conditions such as endometriosis.

Lysis technique. Apply gentle, controlled traction—as well as countertraction—on the bowel loops to facilitate isolation and dissection with sharp Metzenbaum scissors or a scalpel. (Forceful traction or rough handling of bowel loops may cause a breach in the bowel wall with subsequent spillage of intestinal contents.)

Avoid the temptation to lyse adhesions using blunt dissection (serosal tears and enterotomies may occur)—except in the case of translucent adhesions. These may be lysed via gentle, blunt dissection by rubbing the index finger and thumb back and forth over tissue. They also may be sharply cut using the tip of the scissors to form a “window” in a portion of the adhesion and cutting the adhesive segments in increments.

A characteristic line of demarcation often appears between adhesions and their peritoneal attachment, denoting a safe dissection plane.

Technique for special challenges: Chronic pelvic disease, prior laparotomies. When operating on these patients, be prepared for a long, meticulous procedure. A hasty approach in such cases is perilous and increases the likelihood of postoperative complications.

First, dissect the anterior abdominal wall from the adherent bowel on either side of the incision. Then extend the dissection laterally on both sides until the ascending and descending colon are identified. Next, dissect the small bowel free and mobilize it out of the pelvis.

It often is helpful to move to another area when dissection becomes too difficult; dissection through easier planes often will clarify the relationship of pelvic structures and adherent bowel loops.

Once the small bowel has been mobilized from the pelvis, lyse adhesions between loops of bowel that are causing kinking or narrowing of the lumen, to reduce the risk of postoperative bowel obstruction. Next, carefully dissect pelvic structures from the sigmoid colon and rectum.

How and when to repair serosal injury

Serosal injury is a breach of integrity of the visceral peritoneum, the outermost covering of the bowel wall. This may occur when the serosa is cut during entry into the abdomen or when it is torn during blunt dissection of dense adhesions.

If the underlying muscular and mucosal layers remain intact, these small areas of “denuded” serosa need not be repaired, since most experts believe that suture placement increases the likelihood of future adhesions. The serosal and muscular layers should be repaired if the mucosa is exposed, however. Otherwise the bowel wall will weaken at the site, making it vulnerable to perforation. The seromuscular layers can be approximated easily using interrupted 4-0 silk on a small tapered needle. Be careful to avoid placing the stitch through the mucosa, which would violate the bowel lumen.

When the defect of the seromuscular layer is large (when a more extensive area is denuded during dissection of densely adherent bowel away from a tumor or endometriotic lesion), repair becomes more involved. This may require resection of the injured area with primary anastomosis.

Intestinal perforations: Early recognition is essential

This critical serious complication can become disastrous if not immediately recognized and repaired. Perforation of the small intestine (enterotomy) or large bowel (colotomy) often occurs upon entry into the peritoneal cavity or during a difficult dissection, particularly when extensive adhesions are present.

Exercise special caution when operating on patients who have undergone prior surgery, who are advanced in age, or both.

Reoperation technique. When entering the abdomen through an old scar, reduce the likelihood of bowel injury by extending the new incision to either side of the old scar. Then enter the peritoneal cavity in a virgin area of the abdominal wall, where adherent loops of bowel are less likely.

Carefully open the fascia and dissect the preperitoneal fat down to the peritoneum. Before entering the abdominal cavity, retract the peritoneum upward with smooth forceps and palpate it between the thumb and index finger to ensure that a bowel loop is not in harm’s way.

If the underlying muscular and mucosal layers remain intact, small areas of “denuded” serosa need not be repaired.

Examine the entire small and large bowel carefully after surgery, to rule out injury. It is not uncommon for more than 1 perforation to occur in a bowel segment during a difficult dissection.

Begin at the ligament of Treitz and continue to the ileocecal junction. This is “running” the bowel—ie, inspecting in hand-over-hand fashion.

In the small bowel, the division between the jejunum and ileum is arbitrary, with no sharply defined line of demarcation. However, the diameter of the lumen decreases as one moves from jejunum to ileum, the number of vascular arcades increases, and the number of windows of Deaver diminishes. Also, the wall of the jejunum is generally thicker than that of the ileum.

In addition, inspect the colon in its entirety, with special emphasis on the sigmoid and rectum. Besides its larger lumen, the large bowel is distinguished by 3 longitudinal muscular bands called taenia coli, out-pouching of the wall (sacculations), and epiploic appendages.

Also examine the mesentery to exclude vascular compromise to the bowel wall.

Repair perforations immediately to limit contamination of the peritoneal cavity. Prior to closure, inspect wound edges for devitalized tissue and, if found, promptly debride it.

If colotomy occurs in the setting of an unprepared bowel with significant spillage, follow closure with copious irrigation.

Small perforations can usually be closed in 2 layers, with an inner layer of 3-0 delayed synthetic absorbable suture (Dexon, Vicryl) through the full thickness of the bowel wall, ensuring mucosal approximation. It is vital that this layer be “waterproof,” allowing no leakage of intestinal contents. Then place a second row of suture in the seromuscular layer using 4-0 silk to imbricate the first suture line.

General surgical consultation is needed whenever the gynecologist is inexperienced with bowel resection and anastomosis.

It also is essential that the suture line be perpendicular to the long axis of the bowel, rather than parallel; otherwise, the bowel lumen would narrow. Even perforations extending along the longitudinal axis for several centimeters should be repaired in transverse fashion to provide a lumen of adequate diameter.

Resecting the small bowel: If inexperienced, obtain general surgery consultation

Bowel resection and anastomosis require a greater degree of skill than is attained in a typical gynecologic training program. For that reason, resection is addressed here only superficially. Our primary caveat: A general surgical consultation should be obtained whenever the gynecologist is inexperienced with bowel resection and anastomosis.

Indications for resection. Strongly consider resection and anastomosis if the perforation involves more than 50% of the circumference of the bowel wall, if multiple perforations occur in a short segment of bowel, or if there is vascular compromise to a segment of bowel. Adequate perfusion to the bowel usually is indicated by a pink serosal surface. If the serosa remains dark or dusky and fails to become pink after several minutes of observation, vascular compromise is likely and resection is preferred.

If there is doubt about the blood supply to the bowel, give 1 g fluorescein intravenously and inspect the bowel under ultraviolet light (Wood’s lamp). Normal vascularized bowel will have a homogenous yellow-green appearance. Patchy fluorescence or areas without any fluorescence are evidence of ischemia.

To drain or not to drain

Because perforation and resection both involve entry into the bowel lumen, some degree of spillage is inevitable. This is of greater concern when the large bowel is involved, because of the increased likelihood of bacterial contamination. Immediate copious irrigation of the peritoneal cavity is indicated. Also consider a pelvic drain, especially when dissection has been extensive or raw surfaces are oozing.

The combination of bacterial contamination and free peritoneal blood in the pelvis increases the risk for infection. A strategically placed, half-inch Jackson Pratt drain (or a similar device) may help prevent abscess. In the event of anastomotic leakage, a drain often allows for a controlled enterocutaneous fistula to be managed without reoperation.

Some surgeons have satisfactory results without these drainage techniques.

When to begin postop feeding: Depends on type of repair

Opinion varies about the appropriate time to commence feeding after major abdominal surgery, particularly bowel surgery. Over the past decade, with the pressure to discharge patients earlier, many physicians have opted for earlier timing.

Traditionally, feeding was withheld until bowel sounds were auscultated; then it progressed slowly. Today many surgeons advance the diet much more quickly, with little or no delay in recovery. Fanning and Andrews⁹ demonstrated that early feeding does not increase the incidence of anastomotic leakage, dehiscence, or aspiration pneumonia—although it is associated with increased emesis.

Patients undergoing surgery for relatively minor injuries can have their diet advanced as if there were no intestinal involvement.

Feeding after minor repairs. When the surgery has involved relatively minor injuries, such as isolated serosal tears and adhesiolysis, nasogastric tube placement is not required. These patients can have their diet advanced as if there were no intestinal involvement. Give clear liquids when bowel sounds are heard and, if tolerated, advance to solids. It is probably not necessary to await a bowel movement before discharging the patient; she can be released once flatus is passed.

Substantial repairs. When major injuries have been repaired, such as with a large perforation repair or bowel resection, it is prudent to proceed more slowly.

Place a nasogastric tube to minimize bowel distention and subsequent leakage from the repair site. Give the patient nothing by mouth until bowel sounds are clearly present and flatus is passed. Then clamp the nasogastric tube for 24 hours, remove it, and institute clear liquids, provided there is no nausea, vomiting, or distension. Advance to full liquids and then solids, tailoring this process to the patient. When she can tolerate a regular diet, with substantial passage of flatus or bowel movement, recovery is signaled.

Need for additional training

The techniques necessary to manage simple bowel injury are not difficult to master. However, Ob/Gyn residency programs need to extend training in this area. Additional rotations on the general surgery or trauma services as second- or third-year residents would be ideal, but the use of animal laboratories is a good alternative.

The authors report no financial relationships relevant to this article.