Risk factors, clinical outcome and complications of Common Gynecological Surgeries at Zagazig University Hospital, Egypt

In present era, with the availability of better health care facilities and understanding of health issues, women are experiencing longer life expectancy and using more gynecological services, so obviously there is increase in gynecological surgeries. Any surgical procedure carries risks of complications. The risk of postoperative complications depends on individual characteristics, including age, medical comorbidities, and functional status. The aim of study was to reduce rates of mortality/morbidity among women who undergo surgical gynecological intervention at Zagazig University Hospital. This study included 212 cases were retrived prospectively in a cross sectional study. They underwent gynecological interventions. Our study group was 212 cases 24 cases ended with morbidity with percentage of 11.3% and 2 cases ended by death with percentage of 0.9% . This study shows that the most frequent complications among the studied group were septic wound infection (2.4%), bladder injury (2.4%), respiratory tract infection (1.9%),Venous thromboembolism(VTE) (1.9%) and GIT injury (1.4%). This study explains that there were two mortality cases the rst case died on table due to primary hemorrhage during hysterectomy operation as a result of great vessel injury and the other case died during hysterectomy operation due to venous thromboembolic catastrophe (Pulmonary embolism). During post-operative period, she developed hypoxia; therefore, she was referred to ICU. Unfortunately, the patient was diagnosed as pulmonary embolism; thus, she was admitted at ICU for 3 days, but she nally died. Conclusion With the availability of highly skilled personnel with improved surgical expertise, safe anesthesia and collaboration of other specialized medical personnel, the major complications and mortality rate will decrease, but the postoperative complications like, fever, respiratory tract infection, septic wound and DVT still frequent in a signicant number of patients in our community, which brings about much distress to the patients.


Introduction
At present, with better health facilities and an understanding of health issues, women have longer lives expectancy and are using more gyneecological services, so it goes without saying that gynaecological operations are increasing (1).
Any operation carries the risk of complications. The risk of postoperative complications depends on the characteristics of age, medical comorbidity and function (2).
It is important that potential known risk factors are identi ed in the examination of patients for surgical operations and this should be part of good clinical practise. Any complication, for example the presence of intra-abdominal adhesion, visceral injuries and postoperative infections, should be discussed with prior abdominal surgeries, including indication and route. Conditions that make operations complicated, including endometriosis, cancer, disturbed coagulation and obesity should also be noted as these increase the chances of injury (3).
During gynaecological operation, complications result from the proximity of the uterus and ovaries to other critical pelvic structures. These include the urinary tract, intestine, nerves and blood vessels. In performing these procedures, knowledge of pelvic anatomy is essential and critical for altered anatomy due to adhesive disease and during intraoperative haemorrhage. Unintended injury recognition and repair offers the best possibility to minimise sequelae of these complications (4).
For safe surgery, high-risk areas should be identi ed and the way to minimise them. Every surgeon may experience complications at some point but it is necessary to detect when these occur and the most suitable initial management to prevent or minimise immediate and long-term complications. Injury should be detected during surgery; the steps necessary to repair the injury will prolong the anaesthetic and recovery of the patient. We therefore decide to investigate the complications of major gynaecological operations (5).

Aim of the work
To reduce rates of mortality/morbidity among women who undergo surgical gynecological intervention at Zagazig University Hospital.

Patients And Methods
To reduce rates of mortality/morbidity among women who undergo surgical gynecological intervention at Zagazig University Hospital.

Patients and Methods
This cross-sectional observational study was conducted at the Department of Obstetrics and Gynecology at Zagazig University Hospital from January 2019 to January 2020.

Patients:
The sample size was calculated according to the total number of cases coming before to Zagazig University Hospital, for gynecological surgery in 1 year, which was 500 cases and the frequency of complications in gynecological surgery was 3.7%. So at a power of study 80%, and a CI 95%, the sample size was calculated to be 212 cases with no drops in patients. 5. Reporting of post-operative complications.
6. The management of complications either conservatively or by surgical intervention.
All data was collected from the patients´ follow up cards.

Statistical analysis:
The collected data were computerized and statistically analyzed using SPSS program (Statistical Package for Social Science) version 18.0.

Results
This cross-sectional observational study was conducted at the Department of Obstetrics and Gynecology at Zagazig University Hospital from January 2019 to January 2020 included 212 patients. respectively). Table 4 shows that the most prevalent medical disorder in complicated and noncomplicated group is diabetes 37.5% and 10.6% respectively followed by hypertension 25% and 9% respectively. Table 5 shows that mortality rate among the studied group was 0.9%. One case died from primary hemorrhage and the second from pulmonary embolism. table 6 shows that there was no relation between complication and level of doctors but there was statistical signi cance increase in frequency of complication in old age group ≥ 45 years, in female had children and in Wertheim operation cases.

Discussion
Every operation has complications and is one of the main elements of surgical practice. In order to avoid or minimize immediate and long-term complications, recognition of those complications and proper management is essential. Furthermore, because some complications involve areas where the surgeon has comparatively little expertise, it is important to recognize that limitation and assistance from a suitable specialist is very important to patients at an early stage. (6).
Factors that predispose to complications during or after surgery and pre-operative strategies for determining such factors with recommendations for reducing their incidence will be taken into account. .
Large gynaecological operations often involve meticulous dissection near the pelvis' bladder, rectum, ureters and large pelvic vessels. Hemorrhage, infection, thromboembolism and visceral damage are complications of gynaecological surgery. The risk of complications depends on the extent and approach of the operation and the patient's features. The more common complications of this surgery can understandably be associated with these viscera wounds and occur during extensive cancer treatment resections or when anatomy is distorted due to infection or endometriosis. (8).
Pre-operative assessment should identify intraoperative or post-operative areas of concern. This information can be used by the surgeon to prepare the woman for operation and to plan for any preoperational measures necessary to avoid or manage complications. (9).
This study gave us an idea about the rate of morbidity and mortality following common surgical gynaecology and this study was never done at the University of Zagazig before. This is a cross-sectional observatory study on important intraoperative and postoperative surgical events such as surgery type, surgeon status, complication type and mortality. The main factors that lead to mortality are identi ed in 212 women.
This study showed that the age of the studied group varied from 12 to 80 years, with average 45.86 ± 12.41 years.We found that 44.3% of the study group were under 45 years of age with 55.7% over the age of 45 years, and that the incidence of complications increased in patients with a signi cant P value of more than 45 years (0.01). This is consistent with a study done by Erekson and his colleagues, which showed that complications have increased incidence of increasing patient age (10).
With regard to the relation between parity and the incidence of complications, the incidence of complications with increased parity is increasing, our results showed that multiparas have more than virgin complications, and that the results may be due to the increase in the number of multiparas women in the study than others.
This study shows that most patients were subject to simple hysterectomy with 44.3% of patients, 10.8% had Wertheim operation and similar% also received adenexectomy, 9.9% were classical repair and 5.7% were vaginal hysterectomy.
In order to report on overall complications following gynaecological surgery, we have decided to examine most of our gynaecological procedures (including laparotomies, vaginal procedure and procedure for gynaecological cancer). Both laparotomies and gynaecological cancer procedures were more complicated than vaginal treatments.
We have reported variable complications in this study (septic wound, bladder injury, respiratory tract infection, VTEs, GIT injury, primary haemorrhage in OR and pulmonary edema).
Wound infection is one of the most common postoperative complications in the case of septic wound and is responsible for signi cant morbidity. In our study there are only 5 cases in 212 patients with a percentage of septic injury (2.4 percent). According to the data published by (Dicker et al., 1982), the incidence of wound infection was 5% and current gures (Siddiqua et al., 2016) showed that the same low percentage of wound infected cases occurred. The current use of preoperative prophylactic antibiotics can be responsible for this low incidence of infection. (11,12).
The sexual and urinary tracts of women are anatomically closely related, so the potential for injury to one person should always be taken into consideration when acting on the other. Urinary tract injury is one of the most common complications after gynaecological surgery.
This study revealed that urinary tract injury was 2.4% among ve cases, and the results of a retrospective study (Wallis et al., 2016) show 242 patients (2.4%), with 101 1021 patients having hysterectomy, urinary tract injury, and the urological intervention required (13) Infection of the respiratory tract is a very common post-operative complication, which may be associated with anaesethia and poor post-operative ambulance, and prolonged hospital hospital stay associated with nosocomial chest infection. In our study 4 RTI cases with a percentage of 1.9 percent were developed. These results are consistent with a study by (Siddiqua et al., 2017) that showed three RTI cases from 100 cases with a percentage of 3%. (12) .
As There were only two cases of primary haemorrhage in this study (0.9 percent). One of them required reexploration, the other case died on the table after massive blood loss.
On other complications there is only one case in which pulmonary edoema has developed and this is not a surgery complication (12).
In this study, 24 cases developed complications after surgery. We found 21 of them have chronic medical conditions during our analysis of these complicated cases, and 3 cases have been medically free. Diabetes mellitus and hypertension were the most common medical conditions (9 cases 37.5%) ( There are 212 patients in this study, only 24 of whom have intraoperative and postoperative complications (11.3 percent) developed, while only 2 mortality cases are in the study group (0.94 percent ).
We found a similar frequency of major post-operational complications compared to others after gynaecological operations. In a 1991-1997 hysterectomy analysis at the Veterans Affairs Medical Centers (Weaver et al., 2001), the overall prevalence of all postoperative complications was reported to be (9.0%). (18) On the other hand, the overall mortality rate was (0.06%) which is different from our (0.94%) mortality rate. This difference can be related in comparison to this study to the limited number of cases in our study; no preoperative predictors were analysed in this study. Our results of 11.3 per cent lower composite morbidity are no surprise, because we excluded minor complications (urinary tract infections and surface injuries) and were concentrated on major postoperative events.
Obesity is usually regarded as a surgical risk factor but the risk level has been quanti ed inaccurately.
There is little evidence that excess body weight alone should contraindicate general operation. Obesity is frequently associated with abnormal cardiorespiratory function, metabolism and haemostasis, which can predispose after surgery to morbidity and mortality. This study shows that the rst case of death died on Table due to primary haemorrhage in hysterectomy, as mentioned above, was caused by a severe vessel injury; the rst case died from venous thromboembolic disaster (pulmonary embolism); the second case, 78, was previous medical history for diabetes mellitus, hypertension. She developed hypoxia during the post-operative period; therefore, she was referred to ICU. The patient was unfortunately diagnosed with lung embolism; she was therefore admitted to ICU for 3 days, but nally died.

Conclusion
With the availability of highly skilled personnel with improved surgical expertise, safe anesthesia and collaboration of other specialized medical personnel, the major complications and mortality rate will decrease, but the postoperative complications like, fever, respiratory tract infection, septic wound and DVT still frequent in a signi cant number of patients in our community, which brings about much distress of the patients.
The reasons behind it are: Low socioeconomic status.
Poor knowledge about hygiene.
People cannot afford costly antibiotics, and other necessary medications.
Again, hospital facilities were also at its minimum, too many patients needed to be accommodated in small place, many patients had to be operated in a same date, true post-operative isolation would not be possible and nally, visitor restriction in the post-operative ward also could not be strictly maintained.