🚨 Emergency Surgery in O&G — Key Points Guidance

Definition & Scope

• Emergency surgery includes unplanned operative interventions in obstetrics/gynaecology (e.g. ruptured ectopic, torsion, ovarian rupture, acute abdomen in pregnancy, postpartum hemorrhage needing laparotomy).

• Requires timely decision-making, senior input, multidisciplinary support, and adequate staffing out-of-hours.

System & Organizational Issues (TOG)

• Adequate on-call consultant rosters with defined roles (first/second on-call) ensure emergencies are handled promptly. 

• Units may use regional networks, shared rotas, or consultant “flying squads” for high-risk surgeries. 

• Quality assurance and audit of emergency surgical outcomes are encouraged.

• Focus on communication, transfer protocols, and escalation pathways.

Markers of surgical site infection

Pre-operative Management

• IV access × 2 large-bore cannulas

• Baseline labs: FBC, U&E, cross-match, coagulation profile.

• IV fluids and blood products as indicated.

• Antibiotic prophylaxis (broad-spectrum if contamination or ruptured viscus).

• Thromboprophylaxis — mechanical if bleeding risk.

• Informed consent for possible hysterectomy in obstetric cases.

Intra-operative Key Points

• Vertical midline incision preferred in unstable patients.

• Assess for concealed bleeding (retroperitoneal, broad ligament).

• Minimise delay: rapid suction, pack, identify source, control bleeding.

• Blood conservation: cell salvage if available.

• Record estimated blood loss.

Clinical Challenges & Risks

• High stakes: limited time, unstable patients, less preparation.

• Greater risk of complications, bleeding, anesthetic problems, infection.

• Surgeons must be prepared for unexpected findings and to convert minimally invasive to open.

• Importance of senior involvement in decision-making and operative leadership in emergencies.

MRCOG Exam Tips for Emergency Surgery

• In scenarios with unstable patients, illustrate ABCDE, resuscitation, timely decision for surgery, senior involvement.

• Mention protocols for safe transfer, surgical safety checklists, pre-op optimization (as far as possible).

• For obstetric surgical emergencies, include hemorrhage control measures, damage control surgery, multidisciplinary back-up (e.g. interventional radiology).

• Always mention audit, morbidity & mortality review, and learning from complications.

⚠️ Surgical Complications in Gynaecology TOG Highlights

Incidence & Context

• Complications in gynaecologic surgery are “considerable,” even in expert hands.

• In benign gynaecologic surgery, “major complications” (requiring medical or surgical intervention) may occur in ~ 5 % of cases. 

• Emergency procedures carry higher odds of complications compared to elective ones.

Types of Surgical Complications

Common categories involve:

• Example: Laparoscopic entry complications (e.g. bowel, vascular, urologic) are more likely in the phase of blind insertion of trocars. 

• In RCOG Green-top Guideline No. 49 (on preventing laparoscopic entry-related injuries), serious complications estimated at ~1 per 1,000 procedures; bowel injuries ~0.6/1,000, urological ~0.3/1,000. 

Risk Factors for Complications

• Emergency surgery

• Previous abdominal surgery / adhesions

• Obesity / difficult anatomy

• Surgeon inexperience / low volume

• Complex / advanced disease

• Prolonged operative time

• Poor preoperative preparation

Recognition & Management Principles

• Early recognition is key — unrecognized injuries lead to higher morbidity.

• Intraoperative vigilance (inspecting operative field before closure).

• Low threshold for intraoperative repair or conversion.

• Postoperative monitoring — be alert to signs of leakage, peritonitis, bleeding.

• Timely re-operation or intervention if complications suspected.

• Multidisciplinary support: urology, general surgery, interventional radiology.

Psychological & Professional Impact

• Surgeons often feel distress, guilt, and psychological burden (“second victim”) when complications occur. 

• Effects include impact on sleep, mental health, relationships. 

• Younger or less experienced surgeons more likely to suffer greater psychological impact. 

Prevention & Risk Mitigation

• Good surgical technique, anatomical knowledge, and training.

• Use safety checklists, time-outs, and “pause” before critical steps.

• Adequate staff, appropriate instruments, and senior supervision.

• Preoperative planning: imaging, planning for adhesions or difficult anatomy.

• In laparoscopy: adopt entry techniques with lowest risk (optical trocars, open entry where needed).

• Audit complications, morbidity & mortality meetings, learning systems.

Exam Tips for Surgical Complication Writing

• When asked: list types of complications, risk factors, and how to minimize them.

• Use sample vignettes: e.g. post-hysterectomy leaking urine → suspect ureteric injury.

• Emphasize prevention, but also early recognition & management.

• If asked about surgeon “well-being”, mention psychological distress, support systems, learning from errors.

🧩 Mnemonic — “RAPID” for Emergency Surgery

Resuscitate
Assess (ABCDE)
Prepare for theatre (blood, antibiotics)
Involve senior team
Definitive surgery

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