Thursday, October 19, 2006

Post Operative Complications

Prior to any scheduled surgery, I usually have a pre-op appointment with the patient to review the surgery, do a quick exam to check for any brewing acute illness, and cover the risks of the surgery. I can do this spiel in my sleep. "With any surgery there are risks: bleeding, infection, damage to internal organs such as bowel or bladder, risk of hemorrhage requiring transfusion, risk of anesthesia, or even risk of death." I also will cover additional risks specific to the surgery the patient is having. There is an adage in medicine that the surgeon that has never had any complications has not done enough surgery. While frightening, it is true. Eventually, if you operate enough, you are going to have surgical and post operative complications. Like it or not. Last night, between every 3 hour pages (all night long) for normal blood sugars (!) and worrying about my post-operative patients, I got very little sleep.

I've sailed through several weeks without any surgical complications, and that lucky streak came to an end yesterday. It started off as a diagnostic laparoscopy for pelvic pain. The patient was taking narcotic pain meds like tic tacs, without relief. She was convinced that it was her uterus, so we took her to surgery to find a cause of her pain. Her uterus, tubes, and ovaries looked as normal as they could be, but she had pelvic adhesions from her intestines, criss-crossing her abdomen from top to bottom. I was able to dissect the majority of the bowel adhesions without complication, but one area, upon inspection, appeared as though I may have dissected too close to the bowel mucosa. I called a general surgeon in to take a peek, and he blustered and cursed, and finally agreed that he thought it was a little too close, too. I extended her umbilical incision by just a couple of cm, and we were able to bring the bowel up to the incision and oversew the questionable defect. I kept her overnight, just in case, but she did well and went home this morning.

My next worry was a patient with pelvic prolapse and urinary incontinence. Every Ob/Gyn has an area of surgery they love to do, and, more often than not, an area of surgery that they dislike. I. Hate. Urogynecology. I don't like anterior repairs ( I don't think they work). I hate vault suspensions. I hate mesh. I'm not particularly fond of Burches. TVTs are pretty cool, but the urologists in this hospital have domain over that procedure and get a little pissy (heh) if you step on their toes. No skin off my nose, since I really would rather not mess with Urogyn. Since there are no urogynecologists in my hospital, I had to co-schedule her surgery with a urologist so that he could do a sling. She had quite a bit of prolapse, and she really wanted a vaginal hysterectomy. No problem, right? She is also post-menopausal, so she wanted her ovaries out, no matter what (risk of cancer and all). Vaginal hysterectomies, as a general rule, are really cool surgeries, but the flow of the surgery is completely dependent upon the skill of your assistants. The name of the game is visualization, so your assistants need to know what you need to see. Skilled assistants are difficult to come by, and between my med student (that had never even scrubbed a case before this rotation) and the scrub tech that never does GYN, I was screwed in the assistant department. The uterus came down and out without too much of a struggle, but the ovaries were plastered to the pelvic sidewall. This means, for my non-medical readers, it is more difficult to completely remove the ovary and tubes, and more risky for not completely securing the big bad blood vessel leading to the ovary, thereby increasing risk for post op hemorrhage. I struggled with the stubborn ovaries for a solid hour, and finally coaxed them from their happy homes, there was a little oozing on both sides from the dissection, but I was fairly certain there was no active arterial bleeding at the end of the case. I did the obligatory anterior repair, and then the urologist did the sling. We had very little blood loss, and even though the entire surgery ended up taking over 2.5 hours, I felt satisfied that it had been successful. There is always that niggling doubt in the back of my mind about post-op complications, and for her, I knew, it would be bleeding.

After the surgery, I spoke with her family, and they were so happy that we were able to do the entire surgery vaginally. Fast forward to this morning, when I found that her hematocrit had dropped 10 points. That's a lot of blood, folks. Her vitals were stable and she had good urine output overnight, and her abdominal exam was normal for post-op day #1. She had very little vaginal bleeding, but I know that she bled somewhere. I didn't go rushing back to the OR, like my panicked little brain wanted to do. Instead, I checked another blood level, 6 hours after the morning level, and held her diet in anticipation in heading back for re-exploration. Then I prayed. God must love me, or, more pointedly, this woman, because her level at 12 noon was exactly the same as it was at 6 am. So, she bled somewhere overnight, but she is no longer bleeding. Yee haw. Most of the time, a source of the bleed is never found. It is usually venous oozing, and it could have been from my ovary dissection, but suburethral slings can cause some serious hematomas, too, so we may never know. For now, she is doing well, and maybe I can get some decent sleep tonight. Here's hoping!


Fat Doctor said...

Holy begoly. Just reading that made my heart beat faster. A drop of 10? What did she end up at...4?
One more reason I'm glad to not do surgery. And, having been the bladder-holder-upper on several vag hysts during school, I'm even more glad to not be the assistant!

dr. whoo? said...

Her hematocrit went from around 40-ish to 30-ish, her hemoglobin dropped about 4 points. She still has a few blood cells to rub together! :)

One of my worst memories from residency is being post call at 5 pm, ready to go home, and getting called down to hold the bladder blade for a 3 hour vaginal hysterectomy for the chief resident. I cried (silently, tears soaking into the mask)through most of the case. Holding stick for vag hysts can be freaking brutal.

Anonymous said...

Man, Dr. Whoo, I constantly marvel at how amazing and grown-up you are! xoxoxo Sleep well, kiddo.

DoctorMama said...

Like FD, I thought at first her hemoglobin dropped by 10! 4 is still a pretty big number.

God did I hate retracting for the vag hysts. I remember getting stuck by the surgeon while doing one of those, and she swore and said "Now I need a fresh needle, god dammit!" Like it was MY fault. Which maybe it was, being as I was a clueless med student and all, but boy was I tempted to just let go at that point and leave her with the half-dissected out uterus.

dr. whoo? said...

GG~ Grown up? Me? Nah. :)

doctormama~ Where I did residency, it must have been some weird anomaly, but everyone spoke of blood levels in terms of hematocrit instead of hemogobin. I'm still getting used to thinking the opposite way.

Wow, how dare you get in the way of her needle? Geez. :) When I was a resident, your upper levels would give you a real hard time if you weren't psyched to go hold for a vag hyst. They were mean.

Anonymous said...

WOW adhesions crisscrossing all the way up. Now wonder she was eating narcotic pain meds like Tic Tacs. I had some on the left side and it was excruciating so I can't imagine all over.

keep blogging, I like to read!

dr. whoo? said...

anon~ Yes, she really did have a terrible source for pain! Her colon was stuck up against her abdominal wall, so I'm sure that the pain was just awful. The bad thing about adhesions is that the more surgeries you have, the more likely you are to form additional scar tissue. It's a vicious cycle. Glad you like reading! :)