Return to the Operation Theatre: An Analysis of Repeat Surgeries in Operative Obstetrics

Abstract

About the Author AbstractPurpose To determine the risk factors and associated comorbidities with a relaparotomy after primary surgery in pregnant mothers and to identify preventable causes.Methods A retrospective observational study was done at a tertiary care centre from January 2009 till August 2014. All records of exploratory laparotomy following primary surgery in the obstetric population during this period were retrieved from the hospital database and analysed. Results The incidence of relaparotomy was 0.22 %. In 94 % cases, the primary surgery was caesarean section. The commonest indication for relaparotomy was due to haemorrhagic complications like bleeding and haematoma (66.8 %). Sepsis was seen in 36.1 % cases with the predominant organism isolated being E coli (54 %). Most common comorbidity was hypertensive disorders (58 %) followed by liver disorders (19 %). 33.3 % needed ventilatory support, 30.5 % needed massive blood transfusion, 16.6 % were on total parenteral nutrition and 2.7 % needed renal replacement therapy. Maternal mortality was 2.8 %. Conclusion Relaparotomy following caesarean section is considered a near-miss mortality. Care must be taken in primary surgery with meticulous attention to haemostasis.

An analysis of relaparotomy in operative obstetrics

“…7 Another study from tertiary care urban hospital has shown incidence of relap to be 0.22%. 4 In this study, obstructed labour was the commonest indication for primary cesarean similar to study by Seal SL et al 6 Second stage cesarean is technically difficult with increased chances of extension of uterine incision of fragile and edematous lower uterine segment. Second stage cesarean section when done by less skilled obstetricians thus have more chances of bleeding from extension of uterine incision, hematoma formation or intraperitoneal hemorrhage requiring relaparotomy.…”

“…Third case was found to have massive ascites on relap, who finally succumbed to death. Mortality rate in other studies vary from as low as 2.8% in study by Ahmed et al to high rate of 12.1% and 15.78% 4,6,12.…”

“…Similar observations were found in other studies. 4,6 This reinforces the need for strict postoperative monitoring of vitals, documentation and to have high index of suspicion at the earliest to detect complications requiring relaparotomy. One case of intraperitoneal hemorrhage in…”

“…In study by Ahmed et al, reoperation was needed for hemoperitoneum in 62%, rectus sheath hematoma in 28.6% and for PPH in 9.5%. 4 Study by Srivastava et al also has intraperitoneal hemorrhage (31.5%), PPH (15.7%) and rectus sheath hematoma (15.7%) as main indications for relaparotomy. 9 However, in study by Seal et al, PPH was the commonest reason for relaparotomy in 42% followed by rectus sheath hematoma in 27.3% and hemoperitoneum in 7.58% only.…”

“…3 This has also translated into increased risk of rare but serious complication-need for relaparotomy with high maternal mortality and morbidity, so much so that it is considered as maternal near miss (MNM). 4 Therefore, selection of cases for the same is also important. Common indications for reoperations are to manage complications of previous surgery such as intra-abdominal hemorrhage, postpartum hemorrhage, rectus sheath hematoma, sepsis etc.…”