İntraoperatif Cerrahi Komplikasyonlar ve Yönetimi
Özet
Jinekolojik cerrahide intraoperatif komplikasyonlar kanama, üriner sistem ve bağırsak yaralanmaları olarak üç ana başlıkta değerlendirilir. Jinekolojik organların mesane, üreter ve büyük damarlarla yakın komşuluğu nedeniyle titiz diseksiyon ve anatomi hakimiyeti şarttır. Kanser cerrahileri, endometriozis ve geçirilmiş pelvik operasyonlar yapışıklık oluşturarak hasar riskini artırır. Kanama yönetiminde ilk basamak bası uygulamaktır; durmayan kanamalarda vasküler ligasyon, topikal hemostatik ajanlar, uterin veya internal iliak arter ligasyonu ve son çare olarak histerektomi ile pelvik packing tercih edilir. Üriner sistem hasarları en sık elektrocerrahi ve yapışıklık diseksiyonu nedeniyle mesane ve üreterlerde gerçekleşir. Bu hasarların intraoperatif dönemde sistoskopi veya kontrast maddelerle saptanıp anında tamir edilmesi, postoperatif fistül, sepsis ve akut böbrek hasarı gibi ciddi morbidite ve mortalite risklerinin önüne geçer. Gastrointestinal sistem yaralanmaları genellikle diseksiyon veya termal travma kaynaklıdır; serozal sıyrıklar dışında muskularis ve mukozayı ilgilendiren hasarlar stapler veya elle primer olarak dikilmeli, yüksek evreli hasarlarda ise rezeksiyon ve anastomoz uygulanmalıdır. Fark edilmeyen bağırsak hasarları yüksek hayati risk taşır.
Intraoperative complications in gynecologic surgery are evaluated under three main headings: hemorrhage, urinary tract injury, and bowel damage. Due to the close proximity of gynecologic organs to the bladder, ureters, and major vessels, meticulous dissection and a profound command of pelvic anatomy are essential. Cancer surgeries, endometriosis, and history of pelvic operations increase the risk of injury by causing adhesions. The first step in hemorrhage management is applying pressure; for persistent bleeding, vascular ligation, topical hemostatic agents, uterine or internal iliac artery ligation, and as a last resort, hysterectomy or pelvic packing are preferred. Urinary tract injuries most frequently occur in the bladder and ureters due to electrosurgery and adhesion dissection. Identifying these injuries intraoperatively via cystoscopy or contrast agents and repairing them immediately prevents severe postoperative morbidity and mortality risks such as fistulas, sepsis, and acute kidney injury. Gastrointestinal tract injuries are generally caused by dissection or thermal trauma; except for serosal abrasions, damage involving the muscularis and mucosa must be repaired primarily with staplers or manual suturing, while high-grade injuries require resection and anastomosis. Unrecognized bowel damage carries a high risk of mortality.
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