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Surg Clin N Am 88 (2008) 343–359

Complications of Gynecologic Surgery
Michael P. Stany, MDa, John H. Farley, MDb,*
Division of Gynecologic Oncology, Walter Reed Army Medical Center, 6900 Georgia Avenue, NW, Washington, DC 20307, USA b Department of Obstetrics and Gynecology, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, USA
a

Within thelast several decades, many advances have been made in the field of gynecologic surgery. Specifically, both laparoscopy and hysteroscopy have provided patients with minimally invasive procedures for treatment of conditions previously thought to require laparotomy. Regardless of the nature of the procedure, the proximity of the female reproductive tract to the urinary tract, bowel, nerves, and pelvicvasculature places these structures at risk for injury during surgery. This article presents the intraoperative and postoperative complications most commonly encountered during gynecologic surgery and reviews strategies for both prevention and management. Intraoperative complications Urinary tract injury The urinary tract is at risk for injury during gynecologic surgery because of its proximityto the blood supply of the uterus and ovaries. The overall incidence of urinary tract injury during pelvic surgery is between 0.33% and 4.8% [1,2]. Bladder injury is more common than ureteral injury, representing 80% of urinary tract injuries [1]. Risk factors for urinary tract injury include pelvic adhesions, malignant tumor, and history of previous irradiation [1,3]. In a prospective study byVakili and colleagues [2] that employed universal cystoscopy after hysterectomy, the incidence of urinary tract injury was found to be 4.8%. Bladder injury (3.6%) occurred more frequently than ureteral injury (1.7%). Interestingly, only 12.5% of ureteral injuries and 35.3%
The opinion or assertions contained herein are the private views of the authors and are not to be construed as official or asreflecting the views of the Department of the Army or the Department of Defense. * Corresponding author. E-mail address: jfarley@usuhs.mil (J.H. Farley). 0039-6109/08/$ - see front matter. Published by Elsevier Inc. doi:10.1016/j.suc.2007.12.004

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of bladder injuries were detected before cystoscopy. Early recognition of urinary tract injurylowers the risk of patients needing re-operation for these complications [1]. Any time a surgeon suspects urinary tract injury, he or she is obligated to investigate and prove the suspicion to be unwarranted. Ureteral injury Ureteral injury most commonly occurs proximally at the pelvic brim during ligation of the infundibulopelvic ligament and distally during ligation of the uterine artery duringhysterectomy [1,4,5]. A review of total laparoscopic hysterectomies found a 0.3% incidence of ureteral injury, with all injuries occurring at the distal ureter at the level of the uterine artery/uterosacral ligament [6]. Up to 50% of cases of unilateral ureteral injury are asymptomatic postoperatively [7]. The best way to prevent ureteral injury is to identify the ureter before clamping criticalpedicles. If injury occurs, however, management depends on the location and mechanism of injury. If the ureter is ligated with suture, the suture should be removed and the ureter assessed for viability. If it is deemed viable, a stent should be placed. This procedure can be performed by cystoscopy or by performing a cystotomy and then placing a stent [5]. If there is a partial transection injury, aureteral stent should be placed in the ureterotomy, and the defect closed with 5-0 polyglycolic acid suture [5]. Repair of a complete transection ureteral injury depends on the location. If the injury occurs in the upper or middle third of the ureter, a ureteroureterostomy can be performed [5]. This method, however, is successful only if there is adequate length to allow a tension-free repair and...