Surgery and Healing in the Developing World - Dartmouth-Hitchcock

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116 Surgery and Healing in the Developing World
Figure 4. Dilatation and curettage. Uterine perforation.
Regular aseptic techniques are the key in the prevention of infection. There are
no substitutes for simple handwashing, careful preparation of the surgical field, draping
and sterilization of equipment, no matter how modified the technique employed.
Broad spectrum antibiotics are a most useful adjunct but should be reserved especially
if limited supplies exist. These are, of course, imperative in the patient already
septic.
Long-term complications from perforated uterus that was managed conservatively
are rare. If further surgical intervention was necessary then the nature of the
specific situation determines the outcome. Secondary infection can have devastating
long-term effects, especially infertility. The cultural and local connotations may
vary but it is often a social stigma for the individual, which may prove to be a
lifetime burden. The surgeon should remember this and take whatever precautions
can be taken to minimize this late sequelae.
Asherman’s syndrome, although uncommon in everyday gynecologic practice,
results from an overzealous evacuation and sharp curettage of the suterus. This results
in excessive denudation of the endometrium with scarring, scanty menstrual
flow and infertility. It is more commonly seen in curettage for diagnostic purposes
but can also be the consequence in any instance where excessive sharp curetting is
performed.
Urinary tract infections can best be avoided by minimizing the need for catheterization
and encouraging voluntary voiding preoperatively.
Dilatation and curettage is a very simple operation that can restore the patient to
normal functioning in a relatively short time. It can easily be one of the most rewarding
procedures the surgeon will perform. Bleeding in the pregnant patient is
oftentimes frightening for them, the risk of miscarriage and the sequelae that follows,
oftentimes a great burden on the individual. The complication of bleeding in
pregnancy with or without surgical intervention can be fatal. The successful outpatient
management approach is useful knowledge for the surgeon in an isolated area.