Abdominal hysterectomy is a major surgical procedure associated with a significant risk of infectious morbidity in upto 20% of cases. Post operative infection increases the length of hospital stay, increased medication/dressing costs and results in increased pain for the patient. Meticulous pre-operative assessment along with some simple measures can prevent post-operative infection to some extent.
The pre-operative assessment should include a detailed history including symptoms suggestive of anemia and past medical history of chronic illnesses like DM, Connective tissue disorders, renal failure, hepatic disorders, TB and any underlying malignancies. Drug history should be taken to check for prolonged use of corticosteroids, antibiotics, anticancerous drugs and immunosuppressants.
Examination should focus on the built, BMI, pallor, lymphadenopathy and for previous operative scars on the abdominal wall. It is essential to have the results of FBC, U&E, LFT, CRP along with a mid stream urine specimen sent for microscopy and C/S to rule out UTI and to know the fitness for surgery. CRP is optional as a serial measurement is of increased importance than a single measurement. High vaginal swab may be taken to rule out colonization of upper vagina with Bacterial vaginosis.
Alteration in the medications may be considered pre-operatively in close liasion with a physician/medical specialist if the woman was taking any medications.
A cleansing bath and skin preparation(shaving) should be undertaken preferably a few hours before the surgery rather than on the previous day.
General anaesthesia is associated with increased chance of post operative chest infection when compared to regional anaesthesia. But, the choice should be ideally left to the anaesthetist.
Prophylactic use of antibiotics is stongly recommended as they reduce the incidence of infection by 50%. If the woman is not allergic to penicillin then Augmentin with metronidazole or cefuroxime with metronidazole comibination is recommended. A single dose at the time of induction gives optimum tissue levels during surgery to prevent bacteraemia. If surgery takes more than 1 hour, then 2 further doses of antibiotics are recommended.
Ideally the surgeons should scrub for atleast 3-5 minutes, covering all the areas of both the hands and forearms and follow the \"closed gloving technique\".Surgical instruments and linen should be thoroughly autoclaved before use. A longitudinal incision may be easier and may give a better access especially when there is a larger fibroid, but is can increase the chances of post operative chest infection by increasing the risk of atelectasis and increased pain.
Experience of the surgeons may influence the time taken for the surgery and as a result on the postoperative infection. Longer the surgery takes, more is the chance for infection.
Meticulous hemostasis and swab/instrument count check are essential before closure of the abdomen.
Prolonged urinary catheterization and abdominal drains are to be avoided unless very much indicated.
Post operative increase in the pulse rate, temperature and CRP may suggest the possibility of infection. It may be reasonable to transfuse blood if the post operative Hb is 9g%.
The risk of post operative infection can be reduced by early ambulation, chest physiotherapy and adequate pain control. Good glycaemic control is required if the woman is a diabetic.
Post operative management should include the physiotherapist, dietician and medical specialists if required.
All medical personnel taking care of the woman post operatively should follow sterile precautions such as washing hands or using the alcohol gel between nursing patients to reduce the risk of spreading the super bug, MRSA. It should always be remembered that \"safe practice takes seconds\"
Posted by maria A.
Various measures to minimize the risk of post operative infection in a woman who is listed for abdominal hysterectomy for menorrhagia can be divided into preoperative, operative and postoperative measures.
Preoperative steps include optimizing the general health of the woman, correcting any anemia if present and treating any preexisting infection. Taking history regarding any predisposing factors for infection like asthma or preexisting respiratory infection is important. Past medical history should also be asked and whether she is taking any medication or not. Various preoperative investigations include full blood count, midstream specimen of urine for culture and sensitivity and CRP. If any infection is present, appropriate course of antibiotic should be given. Anemia can be corrected by giving injectable iron or by transfusing blood.
It should be recognized that infection, especially by Chlamydia, is the most important cause of acute and long-term physical morbidity. Various options for treating preoperative infection include screening and treating the positive cases, universal prophylactic treatment and universal screening and prophylaxis. Screening for Chlamydia infection and treating positive cases is effective in reducing risk of postoperative infection and allows contact tracing. However, the ELISA test has variable sensitivity and results may not be available at the time of surgery. PCR based testing has better sensitivity.
Regarding Universal prophylactic treatment it allows prompt treatment of all women. However, some women will be treated unnecessarily. Contact tracing is not possible and re-infection is likely to occur.
Ideal method with highest cost effectiveness is screening with universal prophylaxis. However there is a need to cover other microbes especially anaerobes and N. gonorrhoea. Recommended regimens include metronidazole perrectally plus doxycycline or azithromycin.
Operative measures include use of properly disinfected instruments and following hospital policy for infection prevention. Proper scrubbing technique is important as it is proven that hand washing reduces 40 % postoperative infection. It is recommended that abdominal skin should be shaved just before the procedure as this reduces subsequent risk of infection. Urinary catheterization should be done under strict aseptic techniques. Adequate hemostasis during surgery also reduces the risk of small hematomas and subsequent abcess formation.
Postoperatively chest infection can be prevented by physiotherapy to drain lung secretions and early mobilisation. If there had been a large amount of blood loss during surgery, blood should be transfused as anemia is a significant factor in causing infection.
Care should be taken regarding duration of urinary catheterization keeping it for as minimum duration as possible.
Posted by jyoti D.
In this case the preoperative assesment in particular the medical illness like diabetes , hypertension any local skin infections should be taken.any history of pelvic infection .
assess her bodymassindex ,smoking as it can impact on the wound healing and other surgical morbidity.accordingly a multidisciplinary approach for preoperative checkup involving the physician, dietician ,anaesthetist must be involved.ascertion any previous history of multiple surgeries over the abdomen as these may delay healing so incision should be appropriate along with excision of scar tissue.
investigations for fullblood count as anaemia can lead to delayed healing.
during the surgery the universal precautions should be taken care while insertion of catheter to avoid urinary infection.
as means of anaesthesia regional better because less chance of respiratory infections.prophylactic antibiotics given.proper tissue handlling ,time of surgery should be taken into account.
postoperatively assess the risk of thromboembolism and advice early mobilisation.
