Perioperative and Postoperative Care
What you must know
Preoperative assessment: risk stratification, medical optimization, anemia, glycemic control, VTE risk (Caprini), and informed consent including mesh and recurrence discussion. Antibiotic prophylaxis for clean-contaminated and implant procedures; timing within 60 minutes of incision. Bowel prep, positioning, and DVT prophylaxis.
Intraoperative principles: hemostasis, ureteral identification, cystoscopy when indicated, and recognition of bladder/ureteral/bowel injury. Postoperative care: early ambulation, multimodal analgesia (opioid-sparing), catheter management, and recognition of complications - hemorrhage, infection, VTE, urinary retention, ileus, and mesh erosion.
Specific complications: ureteral obstruction after prolapse surgery (flank pain, rising creatinine), bladder injury (hematuria, leakage), and voiding dysfunction after sling (PVR, retention). Understand enhanced recovery pathways and discharge counseling.
Traps
Missing a ureteral injury because symptoms are delayed. Assuming postoperative fever is always infection - consider atelectasis, VTE, and drug fever. Forgetting that constipation and urinary retention are common after pelvic surgery. Don't skip VTE prophylaxis in pelvic surgery patients.
Rule of thumb
"Fever on POD 1–2: atelectasis; POD 3–5: UTI; POD 5–10: wound or pelvic abscess; anytime: VTE."
Worked example: A patient after sacrocolpopexy has flank pain and rising creatinine on POD 2. Think ureteral obstruction/kink; obtain imaging and urology consultation urgently.