Presentation given by Mr Graham Williams, Royal Wolverhampton Hospitals, at the Dukes' Club AGM 2012. Why do complications occur, identification and management of complications, management of the situation.

1. Dukes Club Annual Meeting
2012

2. When Things go Wrong
How to Deal with Complications in Surgery
Mr J Graham Williams BSc, FRCS, MCh
Royal Wolverhampton Hospitals
“When things go wrong, boy can they go wrong”

3. SURGICAL DISASTERS
Scope of Talk
• Why do complications
occur?
• Identification of
complications
• Management of
complications
• Management of the
situation

4. Complications in Abdominal
Surgery
Reasons Complications Develop
• The patient
• The surgeon
• The operation

5. Reasons Complications Develop
The Patient
• Shape and size (a growing problem)
• Co-morbidity
• Previous surgery
• Motivation
• Immune state and nutritional state

6. Decision Making in Surgery
Rarely One Right Answer

7. Reasons Complications Develop
The Operation
• Type of Procedure
–Right hemi colectomy vs Low anterior
resection
–Subtotal colectomy and ileostomy vs
restorative proctocolectomy
• Nature and incidence of complication

8. Reasons Complications Develop
The Operation
• Complex surgery
–Multiple steps, all of which must be right
• Procedure performed
–Colostomy vs anastomosis
–Resection vs bypass
–Laproscopic vs open surgery

9. Reasons Complications Develop
The Operation
• Unexpected findings
• Abnormal anatomy
• Intraoperative problems
• Inadequate help

11. Complications in Surgery
The Cascade Effect - 1
Post operative bleeding
Hypotension
Poor blood supply to gut
Ischaemia at anastomosis
Anastomotic leak
Peritonitis
Death

12. Complications in Surgery
The Cascade Effect - 2
Inadequate analgesia
Poor mobility
Pulmonary atelectasis
Post operative chest infection
Hypoxia and confusion
Anastomotic leak

13. COMPLICATIONS IN SURGERY
Identification of complications
• Be aware that complications can
and will occur

14. COMPLICATIONS IN SURGERY
Identification of complications
• Be aware that complications will
occur
• Complications present in many
guises

15. COMPLICATIONS IN SURGERY
Identification of complications
• 379 patients, colorectal resection for
cancer, with anastomosis
• 22 (6%) clinical leak rate
• 7 (1/3) classical presentation
• 15 (2/3) initially misdiagnosed
– 13 – cardiac symptoms
– 1 – post operative obstruction
– 1 - ascites
Leicester UK Sutton et al 2004, Colorectal Diseases

16. COMPLICATIONS IN SURGERY
Identification of complications
• 379 patients, colorectal resection for
cancer, with anastomosis
• 30 post operative cardiac symptoms
• 3 – myocardial infarction
Leicester UK Sutton et al 2004, Colorectal Diseases

17. COMPLICATIONS IN SURGERY
Identification of complications
• Be aware that complications will
occur
• Complications present in many
guises
• “If the patient is not right, the
operation is not right”

18. COMPLICATIONS IN SURGERY
Identification of complications
• Be aware that complications will
occur
• Complications present in many
guises
• “If the patient is not right, the
operation is not right”
• Find out why!

19. COMPLICATIONS IN SURGERY
Identification of complications
• Go and see the patient!
• History and examination
• Review bed charts
• Simple investigations
• Reassess and consider further
investigation
• Decision - action / observation

20. Abdominal Surgery Complications
• Bleeding; primary and secondary
• Wound infection
• Incisional hernia
• Intra-abdominal infection (abscess)
• Intestinal obstruction
• Anastomotic leak
• Thromboembolic complications
• Cardiac / respiratory complications

21. COMPLICATIONS IN COLORECTAL SURGERY
Intraoperative bleeding
• Torn vein – right hemicolectomy
• Splenic capsular tear – left colon
mobilisation
• Pelvic bleeding – Rectal resection

23. COMPLICATIONS IN COLORECTAL SURGERY
Torn Vein (gastro-epiploic – SMV)
• Access, light, assistance 
• Clamping
• Blind suture ligation or ligaclips
• Gentle, direct pressure 
• Direct suture ligation 

24. Control of Mesenteric Venous Bleeding

25. COMPLICATIONS IN COLORECTAL SURGERY
Splenic Capsular Tear
• Avoid!
• Access, light, assistance 
• Direct Pressure
• Haemostatic swab (Surgicel )
®
• Diathermy (spray, set high)
• Suture repair
• Splenectomy

26. COMPLICATIONS IN COLORECTAL SURGERY
Pelvic bleeding
• Site
–Pelvic side wall
–Back of Prostate
–Vagina
–Pre-sacral veins

27. COMPLICATIONS IN COLORECTAL SURGERY
Pelvic bleeding
• Access, light, assistance 
– “Fisting”
• Direct Pressure (pelvic packing)
• Haemostatic swab (Surgicel ) ®
• Diathermy
• Suture ligation
• Drawing pin
• Tight pack and return

28. Control of Pre-sacral Venous Bleeding

29. COMPLICATIONS IN COLORECTAL SURGERY
Post operative bleeding
• Recognition of the problem
– Epidural analgesia
– Drains
• Decision making
• Intraoperative strategy
–Usual suspects
–Sites of most clot
• Haemostatic pause
–Packing

31. COMPLICATIONS IN COLORECTAL SURGERY
Post operative obstruction
• Adynamic
–Ileus
• Mechanical
–Adhesions
–Internal hernia
–Infection / leak

32. COMPLICATIONS IN COLORECTAL SURGERY
Post operative obstruction
• Clinical assessment paramount
–Onset
–Pain
–Observations & Inflammatory markers
–Examination
–Bowel sounds?
–Investigations

33. COMPLICATIONS IN COLORECTAL SURGERY
Post operative obstruction - management
• Establish cause
• Nasogastric suction
• Careful Fluid & electrolyte balance
• TPN
• Investigation
• Patience
• Re-operation

34. COMPLICATIONS IN COLORECTAL SURGERY
Operating on Post operative obstruction
• Clear indication
• 5-10 days 
• >10 days – misery
• Dealing with serosal tears
• Adhesion preventing strategies

35. COMPLICATIONS IN COLORECTAL SURGERY
Anastomotic leak – factors important in healing
• Blood supply, blood supply, blood supply
– Tension on anastomosis
– Mobility of bowel
– Site of anastomosis
• Surgical technique
• Patient factors
– Arterial disease
– Steroids
– Radiotherapy

36. COMPLICATIONS IN COLORECTAL SURGERY
Anastomotic leak – consequences
• None
• Poor function
• Contained abscess
• Faecal fistula
• Peritonitis
–Multiorgan failure
–Death
• Increased rate of local recurrence

37. COMPLICATIONS IN COLORECTAL SURGERY
Anastomotic Leak
Leak rate by operation performed
Operation Number Leak Rate
Right Hemicolectomy 329 2%
Left Hemicolectomy 210 2%
Anterior resection 329 5%
Ileo-anal pouch 102 2%
Colostomy closure 40 5%
Ileostomy closure 217 2%
Oxford UK, Colorectal Diseases 2007

38. COMPLICATIONS IN COLORECTAL SURGERY
Anastomotic Leak
Reported Leak Rates
Author Number Operation Leak Rate
Vignali 1997 1014 Ant resect 2.9%
Isbister 2001 803 Colorectal 4.2%
Killingback 2002 1392 Colorectal –cancer 2.1%
Walker 2004 1722 Colorectal –cancer 5.1%
Yeh 2005 978 Ant resect 2.8%
Peeters 2005 924 TME – cancer 11.6%

39. COMPLICATIONS IN COLORECTAL SURGERY
Anastomotic leak – identification
• High index of suspicion
• Abdominal presentations
– Increasing pain
– Obstruction
– Wound discharge
– Rectal discharge
• Non abdominal presentations
– Cardiac
– Respiratory
– Neurological

40. COMPLICATIONS IN COLORECTAL SURGERY
Anastomotic leak – identification
•Examination
– Abdominal
– Gentle PR
• Plain radiology
– Free gas
– Retroperitoneal gas
• Contrast radiology
• CT scanning

44. Pseudoleak

46. COMPLICATIONS IN COLORECTAL SURGERY
Anastomotic leak – choice of imaging modality
• 36 patients with large bowel anastomotic leak
• 28/36 (78%) decision to operate based on
imaging
• 27 patients CT scan
– 4 +ve (extravasation of contrast)
– 9 more +ve on review
• 18 patients H O soluble enema
2
– 15 (83%) +ve
• 10 patients initial scan –ve
• 8 +ve on subsequent H O enema
2
Nicksa, Connecticut, DCR 2006

47. COMPLICATIONS IN COLORECTAL SURGERY
Anastomotic leak – choice of imaging modality
• Question to be answered
• Available technology
• Available radiological skills
• Clinical state of the patient
• Awareness of limitation of investigations

48. COMPLICATIONS IN COLORECTAL SURGERY
Anastomotic leak – Management (1)
• State of the patient
• Nature of the anastomosis
• Nature of the leak
• Presentation of the leak
• Adequate existing drainage
• Defunctioning stoma
–Pre-operative bowel prep

49. COMPLICATIONS IN COLORECTAL SURGERY
Anastomotic leak – Management (2)
• Optimise the patient
–Fluid resuscitation
–Antibiotics
–Oxygen
• HDU / ITU
–Ventilation
–Inotropic support
–Renal support
– Wonder drugs

50. COMPLICATIONS IN COLORECTAL SURGERY
Anastomotic leak – Management (3)
• Sepsis control
–Percutaneous drainage
–Per-rectal drainage
–Open drainage
–Open drainage and defunctioning
–Removal of source of sepsis

51. COMPLICATIONS IN COLORECTAL SURGERY
Anastomotic leak – Operative strategy
• Senior staff both ends
• Finger dissection
• Isolation and lavage
• Control sepsis
• Never, ever attempt re-anastomosis!
• Fuss with the stoma
• Laparostomy

55. Dealing with Complications
Common Techniques

56. Dealing with Complications
You - The Surgeon:
• Accept there is a problem
• Understand the nature of the
problem
• Make an appropriate plan
• Have a plan b, c & d
• Review the situation frequently
• Learn from the complication
• Work with a supportive team

58. Dealing with Complications
The Patient:
• Pay particular attention to the
patient as a whole
• Listen to their concerns
• Spend time discussing the nature of
the problem
• Keep them informed at all times

59. Dealing with Complications
The Relatives: (the hard part!)
• Do not hide!
• Recognise their emotions, including
anger
• Be open and honest and spend
time
• Be realistic, manage expectation

60. COMPLICATIONS IN SURGERY
Concluding Remarks
• Complications will occur
• Leave the operating table as happy
as you can be
• Assume the worst and hope for the
best
• Keep on top of the situation
• Discuss complications with
colleagues