Small bowel injuries are the most common intestinal injuries in gynecologic surgery. Small defects of the serosa or muscularis may be repaired using a single layer of continuous or interrupted 3-0 braided absorbable suture. Although single-layer closure of the small bowel has proved adequate, it is safer to close defects involving the lumen in two layers using a 3-0 braided absorbable suture. The defect should be closed in a direction perpendicular to the intestinal lumen. If a large area is injured, resection with reanastomosis may be necessary. Because the bacterial ﬂora of the ascending colon is similar to that of the small bowel, injuries can be repaired in a similar manner. The transverse colon rarely is injured in normal gynecologic procedures because it is well outside the operative field. However, the descending colon and the rectosigmoid colon are intimately involved with the pelvic structures and are at significant risk for injury during gynecologic surgery. Injuries not involving the mucosa may be repaired with a single running layer of 2-0 or 3-0 braided absorbable suture. If the laceration involves the mucosa, it may be closed as with small bowel injuries.
Significant arterial bleeding usually arises from the uterine arteries or the ovarian vessels near the insertion of the infundibulopelvic ligaments. Blind clamping of these vessels presents a risk for ureteral injury; therefore, the ureters should be identified in the retroperitoneal space and traced to the area of bleeding to avoid inadvertent ligation. It is best to apply a pressure pack to tamponade the bleeding and slowly remove the pack in an effort to visualize, isolate, and individually clamp the bleeding vessels. Mass ligatures should be avoided. The use of surgical clips may be helpful. Venous bleeding is less dramatic but often is more difficult to manage, particularly in the presence of extensive adhesions and fibroids. This type of bleeding can be controlled with pressure alone or with suture ligation. Bleeding from peritoneal edges or denuded surfaces may be controlled with pressure, application of topical agents such as thrombin or collagen, or Bovie cautery. A variety of laser techniques are used to control bleeding, such as the use of the Argon beam laser.
Management Bladder Drainage Overdistention of the bladder resulting from bladder trauma or the patient’s reluctance to initiate the voluntary phase of voiding is one of the most common complications after abdominal hysterectomy. An indwelling bladder catheter should be used for the first few postoperative hours until the patient is able to ambulate and urinate.
If retropubic urethropexy was performed, a suprapubic catheter, which allows postvoid residual levels to be checked without repetitive catheterizations, can be considered. This catheter may be removed when satisfactory postvoid residual levels of less than 100 mL are obtained.
Diet As soon as the patient is alert, diet is resumed, offering solid foods as tolerated with return of appetite. This dietary regimen assumes minimal intraoperative bowel manipulation and dissection. Early postoperative feeding was shown to be safe and to speed return of bowel function and recovery. In patients who had pelvic and para-aortic lymphadenectomy, bowel surgery, or other extensive dissections, a slower return to normal bowel function may occur, so the diet is administered as tolerated when the patient’s appetite returns.
Activity Early ambulation decreases the incidence of thrombophlebitis and pneumonia.