Preventing and Managing Surgical Complications: Perspectives from Surgeons: 2nd Edition

Background: Implant-based reconstruction (IBR) is the most common method of breast reconstruction after mastectomy. Prior studies have demonstrated that complications rates vary with incision type. We evaluated whether incision type affected culture positivity in IBR complications. Methods: A retrospective cohort study was performed of all patients undergoing mastectomy for cancer or cancer prophylaxis with IBR from 2012 to 2023. Abstracted data included patient characteristics, oncologic treatment history, mastectomy and reconstruction characteristics, culture positivity, infectious organism, and antibiotic treatment history. Results: A total of 6901 patients underwent post-mastectomy implant-based reconstruction, 183 (2.7%) patients had unplanned operative intervention for IBR complications, and 80/183 (43.7%) had culture-positive IBR infections. Culture-negative and culture-positive groups were similar in patient characteristics and oncologic treatment history. There was no difference in mastectomy incision types. The most common organisms were methicillin-sensitive Staphylococcus aureus, Pseudomonas aeruginosa, and coagulase-negative Staphylococcus. More patients in the culture-positive group were treated with antibiotics (81.2% vs. 51.5%, p = 0.0005). Antibiotic therapy duration was longer in the culture-negative group (8.52 vs. 5.78 days, p = 0.039). Among different incision types, there was no significant difference in duration of antibiotic therapy. Conclusions: No association between mastectomy incision type and culture-positive infections was observed among IBR complications in this study. Antibiotics may sterilize cultures, but operative intervention is still often required for IBR infections. Full article

Introduction: Chordomas are rare, locally aggressive tumors of the spine and skull base typically managed with maximal surgical resection followed by adjuvant radiotherapy. Although postoperative radiotherapy improves local control, the optimal interval for initiation remains uncertain, as early delivery may exacerbate wound-related complications while delayed initiation may allow tumor progression. Methods: We performed a retrospective cohort analysis using the multi-center, national TriNetX Research Network. Adults with histologically confirmed skull base and/or spinal chordoma who underwent surgical resection followed by radiotherapy were stratified into ultraearly (≤2 weeks), standard (4–6 weeks), or delayed (≥10 weeks) radiotherapy initiation groups. Propensity score matching was used to adjust for demographic and clinical covariates. The primary outcome was all-cause mortality at 1, 3, and 5-years. Secondary outcomes included wound dehiscence, surgical site infection, and neurologic complications. Results: A total of 378 patients met the inclusion criteria. Ultraearly radiotherapy was not associated with significant differences in mortality at 1 year (RR 1.338; 95% CI 0.833–2.15; p = 0.22), 3 years (RR 1.233; 95% CI 0.858–1.772; p = 0.25), or 5 years (RR 1.196; 95% CI 0.876–1.633; p = 0.25) compared with standard timing. Delayed radiotherapy, however, demonstrated significantly reduced mortality at 1 year (RR: 0.53; 95% CI: 0.331–0.851; p = 0.01), 3 years (RR 0.641; 95% CI 0.449–0.914; p = 0.01), and 5 years (RR 0.654; 95% CI 0.473–0.905; p = 0.01) compared with standard timing. Event counts for secondary outcomes were insufficient for robust statistical comparison. Conclusions: Radiotherapy timing following surgical resection of chordoma did not impact short-term survival, but delayed radiotherapy significantly decreased 1, 3 and 5-year mortality. Rare secondary complications were seen. These findings suggest that the delayed initiation of radiotherapy may be helpful for patients with chordoma, supporting the need for prospective, long-term studies to clarify the balance between oncologic efficacy and perioperative morbidity. Full article

Background: Posterior cruciate ligament reconstruction (PCLR) remains one of the most technically demanding procedures in knee ligament surgery, with complication rates considerably higher than those observed for other arthroscopic procedures. Residual laxity, arthrofibrosis, neurovascular injury, tunnel-related complications, and heterotopic ossification (HO) represent the most frequent adverse events. With increasing surgical volumes and complexity—particularly in multiligament knee injuries (MLKIs)—structured, evidence-based strategies for complication avoidance are essential. The objective of this review is to provide a comprehensive, evidence-based overview of the main complications associated with PCLR and to propose a structured, reproducible protocol for complication prevention integrating current literature and high-volume institutional experience. Methods: A narrative review of the literature was conducted using PubMed and Google Scholar to identify clinical, biomechanical, and systematic studies on PCLR complications published between 2010 and 2025. Overall, 58 studies were screened and 33 were included for qualitative synthesis. Among the included studies, the level of evidence was Level I in five systematic reviews/meta-analyses, Level III–IV in seven observational clinical studies and registries, and Level V in biomechanical studies, narrative reviews, and expert consensus reports. In parallel, the recommendations were informed by the cumulative experience of a high-volume tertiary referral center with 187 PCLR procedures performed between 2010 and 2025 (136 MLKI, 51 isolated). Results: Evidence identifies several key predictors of postoperative complications: low posterior tibial slope (<6.54°), small graft diameter (<7.0 mm), untreated posterolateral corner insufficiency, excessive tibial tunnel angle, and surgical trauma at the “killer turn.” Neurovascular complications primarily arise during tibial tunnel instrumentation, with knee hyperflexion (>90°) significantly improving safety. Suture tape augmentation (STA) reduces graft elongation by 45–58% and is associated with improved biomechanical stability without increasing complication rates. Early controlled motion is critical to prevent arthrofibrosis, whereas HO—affecting up to 45% of MLKI patients—requires delayed surgical excision after maturation. Conclusions: Optimal outcomes after PCLR derive from a structured, complication-focused approach encompassing anatomical risk assessment, meticulous tunnel planning, neurovascular protection, biological augmentation, and disciplined postoperative rehabilitation. Adoption of standardized protocols—particularly in MLKIs—can substantially reduce the incidence of adverse events and improve long-term knee stability. Full article

Carotid paragangliomas are rare neuroendocrine tumors that, despite being typically benign, present significant surgical and anesthetic challenges. This manuscript outlines the anesthetic management for surgical resection, highlighting preoperative assessment, intraoperative monitoring, and postoperative care. A multidisciplinary approach is essential, particularly for functional tumors, requiring preoperative screening and pharmacologic preparation. Intraoperatively, cerebral perfusion monitoring is critical to prevent ischemic events. Postoperative vigilance is necessary to detect complications such as bleeding, cranial nerve deficits, and hemodynamic instability. A multidisciplinary team skilled in these surgical procedures is essential to improve safety in carotid paraganglioma surgery. Full article

Robotic retroperitoneal lymph node dissection (R-RPLND) represents an evolution in the surgical management of testicular germ cell tumors, offering reduced morbidity compared with open approaches. However, this procedure remains technically challenging, particularly after chemotherapy, due to dense fibrosis and distortion of the retroperitoneal anatomy. We report a case of an unrecognized intraoperative thermal injury causing a partial transection of the proximal ureter presenting postoperatively as a urinary fistula following R-RPLND for residual mass resection, along with a focused review of the contemporary literature on procedure-related complications. A review of large series highlights severe complications (Clavien–Dindo ≥ III) occurring in 6–12% of cases, with ureteral injuries occurring in up to 6%, often identified after surgery. This case underscores the importance of meticulous dissection, awareness of altered anatomy, and prompt intervention when unexpected events arise during R-RPLND. Full article

Necrotizing soft tissue infection (NSTI) is a rapidly progressive, life-threatening soft tissue infection that involves the skin, subcutaneous tissue, and fascia, with a natural evolution to septic shock and death if not treated. NSTI is typically associated with trauma, and rarely reported as a complication of aesthetic procedures such as liposuction. We report the case of a previously healthy 34-year-old woman who developed fulminant necrotizing soft tissue infection shortly after undergoing abdominal liposuction in a suspected non-accredited facility. She arrived at our institution with severe thoracoabdominal pain, ecchymosis, and refractory shock within hours postoperatively. Imaging studies performed in the emergency department revealed gas in the soft tissues, confirming the diagnosis. Emergent surgical debridement exposed extensive necrosis affecting a large body surface area. The patient required multiple surgeries, intensive care support, and broad-spectrum antibiotics to achieve infection control. Reconstructive treatment was initiated once stabilization was achieved, leading to full wound closure and a favorable clinical outcome. In addition, we provide a comprehensive review of the current literature regarding necrotizing soft tissue infection, emphasizing this condition as a postoperative complication, including its epidemiology, microbial etiology, pathophysiology, diagnostic challenges, treatment strategies, and reported cases. This review aims to contextualize this rare but severe postoperative complication and to guide clinicians in its early recognition and management, while also raising awareness about the potential consequences of aesthetic procedures performed in unregulated settings. Full article

Diabetic foot ulcers drive non-traumatic lower-limb amputation; limb salvage surgery is often pursued to preserve function and survival. Predictors of adverse outcomes remain incompletely defined, and evidence for multidisciplinary team (MDT) care is heterogeneous. We aimed to clarify risk factors for major amputation and death after diabetic limb salvage and evaluate MDT impact. We systematically reviewed 49 studies (2020–2025) reporting major amputation or mortality after limb salvage in diabetes (PROSPERO CRD420251044859). Risk factors spanned demographic, clinical, and surgical domains (e.g., older age, male sex, renal/cardiovascular disease, ischemia, osteomyelitis, advanced ulcer classification). MDT models generally showed lower amputation rates and improved wound healing, with occasional survival benefits; heterogeneity precluded meta-analysis. As a real-world comparator, the Mid Essex Diabetes Amputation Reduction Plan (MEDARP) treated 72 high-risk patients using a “toe and flow” MDT. Major amputation occurred in 6.9% and mortality in 12.5%, both at or below published ranges, with gains in patient-reported outcomes. Findings support MDT-based strategies, but conclusions should be interpreted cautiously given the predominantly observational evidence, and highlight the need for standardized outcome definitions and reporting. Full article