Surgical Complications

Key Points

Rochester, N.Y. - Even the most adept surgeon can - and most likely will - run into postsurgical complications, regardless of the painstaking precautions he or she routinely takes.

"If you perform surgery, no matter how talented you are, complications will occur. This is why an informed consent is crucial, and that the surgeon speaks to the patient in great detail concerning unwanted surgical complications, because though they are not com-mon, they are a very real possibility," says Marc D. Brown, M.D., professor of dermatology and oncology at the University of Rochester School of Medicine, Rochester, N.Y.

However, when complications do occur, they're likely to fall within a few specific categories. Dr. Brown says the "terrible tetrad" of surgical complications are bleeding, infection, dehiscence and necrosis.

Bleeding

Bleeding may be caused by inadequate hemostasis intraoperatively; it may be drug related; or it may be due to a pre-existing coagulopathy in the patient.

"Recent studies have shown that anticoagulants do not result in significant bleeding-related complications. Furthermore, there is an increased risk of serious thrombotic events in those patients taken off anticoagulants, which is a rather sobering fact. It is probably safe, though, to stop aspirin in patients who take it prophylactically and do not have a cardiac or cerebral history," Dr. Brown says.

He tells Dermatology Times that the standard methods of intraoperative hemostasis include electrocautery, suture ligation, closure of dead space and the use of drains. He advises surgeons to approach acute bleeding by opening and decompressing the wound, insuring hemostasis, resuturing (if necessary), securing a drain and administering antibiotics. Bleeding may be prevented with the help of a pressure dressing, ice, rest, elevation and minimizing the patient's alcohol intake.

Infection

A wound infection is usually the result of a combination of bacterial contamination and compromised host defenses.

If a wound is infected, some or all of the following symptoms may be present: erythema, warmth, swelling, purulent drainage, tenderness, pain, chills, fever and adenopathy. Dr. Brown says it is crucial to immediately culture the wound in order to be able to administer the most appropriate antibiotic, pending sensitivity results. Staphylococcus aureus is a common offender; Pseudomonas can be suspected for infections in the ear and Candida in granulating wounds. Methicillin-resistant Staphylococcus aureus (MRSA) is be-coming more common, even in the outpatient setting.

Dr. Brown says there is a general lack of scientific evidence to support antibiotic prophylaxis. Yet, at least one-third of plastic surgeons prescribe antibiotics for graft and flap surgery, and many Mohs surgeons place all patients on antibiotics. According to Dr. Brown, antibiotics could be considered in the following instances: long operative procedures, complex reconstructions, significant wound tension, specific operative sites (nose, ear, perineum), poor tissue quality, alcohol or cigarette abuse in patients, immunosuppression, malnutrition and diabetes.

"Antibiotics work best to prevent infection if given before the surgical procedure begins. However, surgeons should only give them when necessary, because of possible allergic reactions, side effects, resistance and cost," Dr. Brown says.

He says physicians should be careful not to confuse an allergic contact dermatitis with an infection of a wound. An allergic contact dermatitis can be characterized by itching and a vesicular eruption with a lack of purulent exudate. The usual reason for such a reaction is an antibiotic ointment.