Abhay Rané, Burak Turna, Riccardo Autorino and Jens J. Rassweiler (eds.)Practical Tips in Urology10.1007/978-1-4471-4348-2_32

32. How and When Do I Need to Perform an Exploratory Laparotomy After Major Urological Surgery?

Peter Alken¹ and Tarık Esen¹

(1)

Department Urology, Kıc University Medical School, Mannheim, D-68167, Germany

Peter Alken (Corresponding author)

Email: peter.alken@medma.uni-heidelberg.de

Tarık Esen

Email: tesen@ku.edu.tr

Abstract

Bleeding, anastomotic insufficiencies, ileus and wound dehiscence are the rare complications that may require surgical revisions. Timing and type of re-intervention have to be balanced against the patient’s individual conditions. Good cooperation with intensive care colleagues and experienced surgeons may be advisable.

Keywords

DrainageHemorrhageAnastomosisLeakIleusFascial DehiscenceLaparotomyRelaparotomy

Introduction

In a nationwide USA sample of 229,743 prostatectomies, 111,683 nephrectomies and 31,213 cystectomies performed between 2009 and 2011 a rare complication was hemorrhage with 1.2, 3.2 and 3.4 %. More frequent were genitourinary complications with 0.8 %, 2.5 % and 15.4 % and gastrointestinal complications with 4.0 %, 10.7 % and 28 %, respectively [10]. No data were given on the frequency of re-intervention which fortunately are rare events.

Blood, urine or feces are what you would not like to have in the previous operative field after any kind of urological surgery. Prolonged postoperative ileus (PPOI) is a frequent problem after major urological surgery; fascial dehiscence and burst abdomen is a rare but dangerous complication of laparotomy. The proper diagnostic work up of the patient’s condition, the “search part” should be “exploratory” but the surgical procedure based on the diagnostic finding, the “destroy part” should be targeted.

In these cases the need to, the timing and type and the risk of re-intervention are embedded in strategical thinking that considers the details and problems of the first surgical procedure, the patients conditions and the imagined details of the secondary intervention.

Drainage

Intraoperative drainage of the relevant anastomoses will not always but frequently help to reliably reveal such postoperative complications. The need to place drains near anastomotic sites is questioned in colorectal surgery [6], but it is still an unsettled question in major urological surgeries [1].

Blood

In case of bleeding after a laparotomy blood is diffusely dispersed in the peritoneal cavity; abdominal palpation or repetitive measurements of the abdominal circumference are usually not rewarding to establish the need for revision just as the rare cases in which we tried to find out about the site and extend of bleeding by CT or angiography in any form. Rapid or continuous blood accumulation in the drainage bag and/or equivalent circulatory signs may advise a revision at any postoperative time period even though an active bleeding is sometimes no more met during the reintervention.

Feces or Urine

If the primary surgical procedure was “uncomplicated”, if the patient is in a well-balanced condition and if the complication is met within the first 3–4 days it is an early manifestation of either incorrect suture lines or necrotic tissue secondary to mistakes of coagulation or dissection. The operative site is still without major secondary changes. Consequently an early operative revision targeted to the site of the complication might then be useful to perform a definitive correction in the sense of a restoration of the primary surgical goal and prevention of a secondary peritonitis [4].

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