Intraoperative Complications of Vaginal Surgery

General considerations

Vaginal surgery considerations

Health and ability to tolerate anaesthetic

Enemas to clear the rectum

Jehovah’s Witness with refusal of blood and blood products

Antibiotic douches to decrease vaginal bacterial count

Preoperative antibiotics

Deep vein thrombosis prophylaxis

Discontinuation of anti-platelet agents and/or anticoagulants

Positioning in dorsal lithotomy position with proper padding

Perineal retractor

Labial retraction sutures or Lonestar retractor

Headlight

Trendelenburg position

Continuous bladder drainage

Vaginal packing

The general medical condition of the patient must be taken into account when planning any elective surgical procedure. Consultation and clearance should be sought from anaesthetic and medical services whenever the patient has a condition which may decrease her ability to tolerate an anaesthetic or may adversely affect the surgical outcome. In some situations, the patient’s general health may influence the type of anaesthetic administered (spinal vs. general), or in the case of a Jehovah’s Witness, may dictate the nature of the resuscitation which can be employed in the intraoperative and postoperative periods. Some have reported on the use of preoperative EPO administration in Jehovah’s Witnesses or postoperatively in those with acute blood loss anemia [6, 7].

Antibiotic prophylaxis with a 1st or 2nd generation cephalosporin, aminoglycoside plus metronidazole, or clindamycin should be administered to decrease the likelihood of postoperative infection [8, 9]. Surgical Care Improvement Project (SCIP) protocols have been implemented in many institutions. In our institution, hysterectomy/vaginal surgery patients should receive cefoxitin, cefazolin, or Unasyn as prophylactic antibiotics, or, in the case of concomitant bowel surgery, cefoxitin, Unasyn, or ertapenem. Several studies have demonstrated that perioperative cleansing of the vagina with saline can increase the risk for infection, and no studies have demonstrated the effectiveness of douches or other method of vaginal cleansing for prevention of infection [10, 11]. There is no consensus regarding method of prophylaxis for deep-vein thromboembolism (DVT). Some advocate for prophylaxis in the form of low-dose subcutaneous heparin given before and every 12 hours after surgery [12] until the patient is ambulatory, as well as intermittent pneumatic calf compression devices (SCDs) employed in the same manner [2, 12–14]. Multiple studies have shown the rate of DVT after pelvic reconstructive surgery to be low, between 0.3 and 2.2 % [15, 16]. In a prospective randomized trial assessing SCDs versus heparin, the rate of DVT was equivalent in both groups [17].

Every effort should be made to minimize the risk of bleeding. Antiplatelet agents such as aspirin should be discontinued at least 7–10 days before surgery. Patients on long-acting anticoagulants should cease taking these medications until their coagulation parameters return to the normal range. If the risk of a thromboembolic event is too high to allow discontinuing anticoagulation, they should be switched to a short-acting agent such as low-molecular weight heparin which can be stopped 18 to 24 hours before surgery and resumed fairly promptly afterwards. In patients for whom a heparin drip is required, the drip can be stopped 6 hours prior to surgery.

Candy-cane or Allen stirrups can be used to place the patient in the dorsal lithotomy position. Potential nerve injuries include the femoral, lateral femoral cutaneous, obturator, sciatic, and common peroneal nerves. Femoral and obturator nerves can be injured from prolonged lithotomy position. Lateral femoral cutaneous injury arises from compression beneath the inguinal ligament. Common peroneal injury occurs with direct compression of the lateral aspect of the proximal fibula, most commonly secondary to direct contact of the leg with the pole of a candy cane stirrup. Sciatic nerve injury is especially uncommon but arises with abduction, external rotation and over-flexion of the hip joint. Care should be taken to avoid over-flexion or overextension of the lower extremities, and all pressure points should be padded to avoid peripheral nerve injury secondary to positioning. The use of an egg crate mattress should be considered in patients with neurologic problems, particularly if the procedure will take several hours. Prepping and draping for vaginal surgery should encompass not only the perineum but the lower abdomen up to the level of the umbilicus as well in case an abdominal incision has to be made to repair an unexpectedly large bladder laceration or a ureteral injury. Vaginal exposure can be facilitated by the use of a weighted speculum in conjunction with a Lone Star, Scott, or Turner Warwick retractor [18]. A headlight improves visualization in patients with a narrow and/or deep vagina and/or a hyper-elevated urethra and bladder neck. Placing the patient in Trendelenburg position serves to better expose the anterior vaginal wall and allows the abdominal contents to fall backwards, thereby making suture carrier or trocar passage less likely to cause bowel injury.

The bladder should be decompressed by placing a urethral catheter to straight drainage at the beginning of the procedure. In and out catheterization should be discouraged since the bladder can refill quickly with intraoperative intravenous fluid administration. The injection of sterile water, diluted epinephrine or lidocaine beneath the anterior vaginal wall in patients who have had previous vaginal surgery causing scarring, may help define the plane of dissection, thereby decreasing the risk of urethral, bladder or rectal injury during the initial phases of vaginal wall dissection.

Vaginal packing and absorbable suture should be opened and included on the surgical set-up from the start of the procedure in case the vaginal incision has to be closed and packed quickly to control excessive bleeding. A fine absorbable suture should be readily available to stop any bleeding from periurethral or vaginal vessels that cannot be controlled with electrocoagulation. Surgicel® should also be on hand for temporary packing, if needed, for hemostasis.

Excessive Bleeding

The proportion of patients who require transfusion as a consequence of excessive bleeding from a vaginal procedure is less than 2 % in most contemporary series [19–22], but the potential for massive blood loss should always be acknowledged preoperatively and reinforced at the time of the consent. Sources of blood loss include periurethral vessels as well as vaginal and retropubic venous plexuses. Discrete arterial bleeders can be electrocoagulated or ligated with fine absorbable suture. Profuse bleeding from the urethra when separating the perivesical or periurethral fascia from the anterior vaginal wall is often an indication that one is not dissecting in the correct plane. The area of dissection should be re-evaluated once blood loss is controlled to exclude an injury to the urethral wall (spongy tissues) or bladder, and to redirect the course of the surgery.

Injury to the cavernosal veins, dorsolateral to the urethra can occur as the retropubic space is being cleared to pass a ligature carrier during the performance of a needle suspension procedure, or during urethrolysis. Bleeding from the ischiorectal fossa during rectocele repair may also be difficult to control. A good strategy to minimize blood loss during vaginal surgery is to perform those steps of the procedure which are at low risk for bleeding first, leaving those steps which are potentially associated with more bleeding until the end. For instance, when performing a urethrolysis with a Martius labial flap placement, harvest the flap first before entering the retropubic space to perform the urethrolysis. In the case of a combined cystocele repair and sling procedure, fix the cystocele first, harvest and/or ready the sling material, then enter the retropubic space to transfer the sling sutures or material.

Since profuse venous bleeding from the retropubic space is unlikely to respond to attempts at ligation or electrocoagulation, in the case of bleeding the best course of action is to complete any transfer of sutures or material that must occur, then close the vaginal incision with a running absorbable stitch and pack the vagina. Blood will collect within the confines of the retropubic space and compress the injured venous plexuses. Should further work need to be done through the vaginal incision, the packing and sutures can be removed later on once the bleeding is under better control and the patient is stabilized. The anesthetist should be kept informed of excessive blood loss through the vaginal incision to manage resuscitative efforts accordingly. The vagina should remain packed at the end of surgery for 24–48 h to help tamponade bleeding. Compression of venous bleeders can also be achieved by temporarily inflating a Foley catheter within the vaginal space [23]. Aungst and Wagner reported control of excessive retropubic bleeding from retropubic sling insertion by placing a Foley catheter along the trocar insertion path and inflating the balloon within the space of Retzius [23]. A nationwide analysis of retropubic sling complications in Finland reported rates of blood loss over 200 ml and retropubic hematoma of 19 per 1000 cases [24]. The majority of these complications can be managed conservatively with intensive hemodynamic monitoring, and in some cases, transfusion. Open drainage of a retropubic hematoma caused by venous plexus bleeding should be avoided, since such a maneuver may promote more hemorrhage. Major vessel injury, a rare complication of retropubic sling insertion, should be treated with open ligation or embolization performed by an interventional radiologist via percutaneous approach [19, 25]. Patients with delayed bleeding after a vaginal procedure should be managed with vaginal packing, and, failing this, with embolization of the offending vessels by interventional radiology. Reoperative management via the vagina, depending on the initial procedure performed, is often very difficult due to the elusive nature of the bleeding vessels and should be attempted only in extreme cases where more conservative management has failed.

Bladder Injury

Case Presentation (Refer to Video 19.1 Vaginal Repair of Bladder Injury During Vaginal Hysterectomy (Zimmern P))

A 57-year-old woman underwent an uneventful laparoscopic assisted vaginal hysterectomy. The uterus was large with an anterior fibroid mass. The patient had a history of 2 prior C-sections. The dissection was difficult in the plane between cervix and bladder base. Blood was noted in the urine drainage bag thus prompting a cystoscopy. A bladder laceration had occurred fairly high up over the back wall of the bladder and away from the ureteric orifices as shown in the movie provided in the attachment (Refer to Video 19.1 Vaginal Repair of bladder injury during vaginal hysterectomy (Zimmern P)). The movie describes the steps of repair, which follow the guidelines for vesicovaginal fistula repair when performed transvaginally.

Bladder injury can occur during transvaginal surgery while dissecting in the plane between the anterior vaginal wall and the perivesical fascia, but more commonly occurs when attempting to clear the retropubic space or pass a suture carrier or trocar during incontinence surgery. Bladder laceration can also occur when entering the vesicovaginal space during vaginal hysterectomy [4].

Patient risk factors for bladder injury include previous retropubic surgery such as paravaginal repair or Marshal-Marchetti-Krantz/Burch colposuspension, previous caesarian-section, prior history of myomectomy, and bladder overhanging pubic symphysis (Fig. 19.1). According to Mathevet et al., the incidence of bladder injury as a consequence of vaginal hysterectomy is approximately 1.7 % [4]. The risk of bladder perforation during transvaginal sling procedures ranges from 5 to 24 % for the retropubic synthetic sling to less than 5 % for a conventional pubovaginal sling [26–29]. A Cochrane Review of Mid Urethral Sling Placement found a significantly higher bladder perforation rate for retropubic versus transobturator slings (4.5 % vs. 0.6 %) [22]. The relatively high risk of bladder injury is not necessarily due to previous surgery in the case of the retropubic sling, but is secondary to blind passage of the trocar through the retropubic space. Surgical experience has also been noted to be a factor for both bladder injury and recognition of said injury [26, 30]. Cystotomy during anterior repair for anterior compartment POP is rare, and in a Cochrane review has been noted to be more likely when mesh is used than not (2.4 % vs 0.3 %) [31]. Anterior vaginal wall needle suspension procedures for the treatment of incontinence and anterior compartment prolapse are also associated with low rates of bladder injury (1.9 %) [32].

Fig. 19.1

Lateral view of voiding cystourethrogram showing anterior wall of bladder overhanging pubic symphysis. Such anatomy suggests adherence of the bladder to the back surface of the pubic bone, with the potential for accidental cystotomy when entering the retropubic space during sling or suspension surgery

An intraoperative bladder injury is usually detected by the presence of bloody urine draining from the Foley catheter or urine leaking into the operative field, although neither of these signs may be present. On other occasions, the Foley bulb may be seen within the vaginal incision [33]. Cystotomy during vaginal hysterectomy usually occurs at or above the trigone. If an injury is suspected, especially if it is small, its presence, extent and location may have to be confirmed with the bladder filled with irrigation fluid mixed with indigo carmine or methylene blue. Intraoperative cystoscopy should be performed routinely when performing retropubic sling placement [26]. Cystoscopy should be performed with a 70° lens or a flexible scope to inspect the anterior bladder wall (Fig. 19.2). This angle may detect unsuspected cases of sling arm or suture perforation since such an event is not always accompanied by hematuria. The non-absorbable sutures employed in pubovaginal sling or bladder neck suspension should be removed and repositioned more laterally. When overlooked, this iatrogenic bladder injury will result in stone formation over the exposed foreign body that perforated the bladder, as well as recurrent urinary tract infections, pain, and irritative voiding symptoms (Table 19.2). It is important to fully distend the bladder during cystoscopy lest the bladder wall fold over the perforation and obscure the injury.

Fig. 19.2

Perforation of the lateral bladder wall detected on cystoscopy after passage of sutures through the retropubic space. Note the blue prolene suture within the cystotomy site

Table 19.2

Principles of transvaginal cystotomy repair

Determine size, extent, location and number of bladder perforations

Rule out ureteral and trigonal involvement

Suprapubic tube placement

Adequate exposure of the perforation margins

2-layer tension-free watertight bladder closure with interposition of well vascularized tissue

Antibiotic prophylaxis and anticholinergics

Uninterrupted, prolonged postoperative bladder drainage

Extraperitoneal injuries such as perforation with a suture carrier or a trocar usually heal spontaneously without any further treatment, although some surgeons leave a Foley catheter in the bladder for a few more days postoperatively. Again, these injuries are dealt with by removing the offending suture, redirecting the suture carrier more laterally away from the margin of the bladder wall, and draining the bladder transurethrally or suprapubically. More extensive cystotomies should be closed transvaginally in order to prevent vesicovaginal fistula formation (Fig. 19.5), whereas bladder injuries involving the trigone and ureters should be repaired via an open approach rather than through the vagina [34] because of the frequent need for ureteral reimplantation.

The main principles to follow when repairing a cystotomy transvaginally include: (1) evaluation of the extent of bladder injury by determining the size, location and number of perforation(s) and determination of trigonal and/or ureteral involvement (retrograde pyelogram can be performed and if the ureters are involved, open repair is indicated); (2) identification and exposure of the margins of the perforation (3) a 2-layer, tension-free water-tight bladder closure with a consideration for an interposition flap of well-vascularized tissue (Martius labial fat pad, perivesical fat pad, omentum); (4) the use of postoperative antibiotic prophylaxis and anticholinergics to decrease the risk of infection and bladder spasms [33, 35]; and (5) prolonged uninterrupted postoperative bladder drainage for 2–4 weeks, facilitated by the intraoperative placement of a large bore suprapubic catheter in addition to the urethral Foley catheter (Table 19.2). The use of two catheters for bladder drainage is not always mandatory but is often recommended to maximize bladder drainage and avoid bladder distension should one catheter get kinked or not drain well, and to allow monitoring of bladder function via the suprapubic tube once the urethral Foley catheter has been removed. Adherence to these tenets should help prevent the occurrence of a secondary vesicovaginal fistula.

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