40 Care of the gastrointestinal, abdominal, and anorectal surgical patient
Cholecystostomy: Placement of a tube or drain into the gallbladder to permit drainage of the organ, and rarely can be used to remove stones. This procedure is performed infrequently except to provide relief in a patient with cholecystitis who has prohibitive operative risk precluding cholecystectomy. This procedure is usually performed percutaneously in the radiology suite.
Colostomy: Colon brought through the abdominal wall to drain into a drainage device (bag); may be permanent or temporary, single or double lumen. May be performed with either an open procedure or a laparoscopic approach.
Endoscopic Retrograde Cholangiopancreatography (ERCP): A side-viewing fiberoptic endoscope is used to cannulate pancreatic and biliary ducts through the ampulla of Vater for cholangiography, pancreatography, stone removal, and invasive manipulation such as sphincterotomy.
Esophagogastroduodenoscopy (EGD): Passage of a fiberoptic endoscope, usually with topical anesthesia and intravenous sedation, to view the esophagus, stomach, and duodenum. Biopsies or control of bleeding may also be performed with this procedure.
Esophagoscopy: Direct visualization of the esophagus and cardia of the stomach by means of a rigid or flexible lighted instrument (esophagoscope). Esophagoscopy can be used to obtain a tissue biopsy or secretions for study to aid in diagnosis.
Gastrectomy: Removal of the stomach. If less than a total gastrectomy is performed, in which only part of the stomach is removed, the procedure is typically described as distal gastrectomy, proximal gastrectomy, or subtotal gastrectomy, suggesting only a small proximal gastric remnant remains. Total gastrectomies are most commonly performed for cancers in the proximal part of the stomach.
Gastroscopy: Direct inspection of the stomach with possible removal of a tissue specimen by means of a lighted instrument (gastroscope); bleeding can also be controlled and biopsy specimens can be obtained with this procedure.
Hernia: The displacement of any viscus (usually bowel) or tissue through a congenital or acquired opening or defect in the wall of its natural cavity, most commonly the muscular wall of the abdomen. Usually this term is applied to protrusion of abdominal viscera; however, it is actually the defect itself through which abdominal contents have protruded.
Herniorrhaphy: Repair of a hernia. Hernias are classified according to anatomic site and condition of the viscus that has protruded. Reducible hernias are those in which the bowel or contents of the hernia sac can be replaced into the normal cavity. An irreducible, or incarcerated, hernia is one in which the contents cannot be replaced. A strangulated hernia is one in which the blood supply to the protruding segment of bowel is obstructed. When a segment of bowel becomes strangulated, it rapidly becomes necrotic. A strangulated hernia constitutes a surgical emergency. Hernias can be repaired with an open or laparoscopic technique.
Herniorrhaphy, Femoral: A defect in the region of the femoral ring, which is located just below the Poupart (inguinal) ligament and medial to the femoral vein. Femoral hernias are seldom found in children and occur most often in women.
Herniorrhaphy, Incisional: Repair of a defect in the abdominal wall that was a prior site of placement of a surgical incision. These types of repairs commonly involve placement of prosthetic (synthetic) mesh (e.g., Prolene, Gore-Tex, Parietex).
Herniorrhaphy, Inguinal: Repair of a defect in the inguinal region; may be direct (through Hesselbach triangle) or an indirect (through the internal ring) inguinal hernia. These repairs also commonly use some type of prosthetic mesh, most commonly Prolene or Parietex.
Herniorrhaphy, Umbilical: Reconstruction of the abdominal wall beneath the umbilicus (umbilical ring) can occur in pediatric patients and is most common in African American infants. In children, this hernia often closes spontaneously in infants before 2 years of age; therefore these repairs should generally not be performed until after the age of 2 years. Umbilical hernias in adults will never resolve spontaneously.
Ileostomy: Terminal ileum brought through the abdominal wall to empty into a drainage device (bag). Commonly used to treat inflammatory conditions of the bowel, such as ulcerative colitis and regional enteritis (Crohn disease), and to provide a permanent or temporary stoma after surgery for obstruction or cancer.
Laparoscopy (Peritoneoscopy): Direct visualization of the peritoneal cavity by means of a lighted instrument (often connected to a color video monitor) inserted through the abdominal wall via a trocar placed through a small incision. An increasing number of abdominal procedures are performed assisted via laparoscopic techniques. Gastrointestinal or abdominal procedures commonly performed via laparoscopy include cholecystectomy, gastrojejunostomy, splenectomy, Nissen fundoplication, inguinal herniorrhaphy, appendectomy, jejunostomy, colostomy, colectomy, ileocolectomy, and pancreatectomy.
Pancreaticoduodenectomy (Whipple Procedure): Removal of the head of the pancreas, the entire duodenum, the gallbladder, a portion of the jejunum, the distal third of the stomach, and the lower half of the common bile duct, with reestablishment of continuity of the biliary, pancreatic, and gastrointestinal systems. The procedure, which is used primarily for the treatment of malignant disease of the pancreas, duodenum, and ampulla, is associated with a less than 3% risk of perioperative mortality if performed in a high volume center. Sometimes a pylorus-sparing procedure is performed, which leaves the entire stomach intact.
Percutaneous Endoscopic Gastrostomy (PEG): Endoscopic procedure for the insertion of a tube into the stomach, either for the purpose of decompression or feeding, performed with local anesthesia and intravenous sedation.
Pyloromyotomy (Fredet-Ramstedt Operation): Enlargement of the lumen of the pylorus with longitudinal splitting of the hypertrophied circular muscle without severing of the mucosa; used as treatment for pyloric stenosis in infants. Pyloric stenosis is most common in firstborn male infants.
Pyloroplasty: A longitudinal incision made in the pylorus (full thickness) and closed transversely to permit the muscle to relax and establish an enlarged outlet. Heineke-Mikulicz is the most common type of procedure.
Transduodenal Sphincteroplasty: Partial division of the sphincter of Oddi and exploration of the common bile duct for treatment of recurrent attacks of acute pancreatitis caused by formation of calculi in the pancreatic duct or blockage of the sphincter of Oddi. Can also be used in treatment of biliary stones which cannot be removed by endoscopic or percutaneous means.
Care of the patient after abdominal surgery or surgery on the gastrointestinal tract is an extremely broad subject. Surgical intervention within the abdominal cavity is generally directed toward restoring normal function and therefore involves repair of congenital abnormalities, reconstruction of deformities, removal of obstructions to restore patency of the gastrointestinal tract and the biliary tract, treatment of malignant disease, and maintenance of the integrity of related organs, such as the liver, pancreas, and spleen (Fig. 40-1).
(From Sole ML, et al: Introduction to critical care nursing, ed 5, Philadelphia, 2008, Saunders.)
Abdominal or gastrointestinal surgery can be performed with regional or general anesthesia. The choice of anesthesia varies with the type of procedure, the patient’s cardiac and pulmonary status, and the surgeon’s need for muscle relaxation. Usually only short, simple procedures are performed with regional (spinal or epidural) anesthesia. Diagnostic procedures such as endoscopy, biopsy, and percutaneous gastrostomy often are performed with sedation only. Inguinal or femoral herniorrhaphies are often performed with regional (spinal) or general anesthesia, and occasionally with only local anesthesia. Most other abdominal surgical and laparoscopic procedures are performed with general anesthesia. All laparoscopic procedures require general anesthesia because of the need for relaxation of the abdominal wall and the need to control the patient’s respirations.
A number of abdominopelvic incisions have been developed and are commonly used (Fig. 40-2). An ideal incision ensures ease of entrance, maximal exposure of the operative site, and minimal trauma. It should also provide good primary wound healing with maximal wound strength.
FIG. 40-2 Commonly used abdominal incisions. 1, Kocher incision: right side, gallbladder and biliary tract surgery; left side, splenectomy. 2, Upper abdominal midline incision: rapid entry to control bleeding ulcer. 3, Lower abdominal midline incision: female reproductive system. 4, Upper paramedian incision: right side, biliary tract surgery, cholecystectomy; left side, splenectomy, gastrectomy, vagotomy, hiatal hernia repair. 5, Lower paramedian incision: right side, appendectomy, small bowel resection; left side, sigmoid colon resection. 6, McBurney incision: appendectomy. 7, Inguinal incision: inguinal herniorrhaphy. 8, Infraumbilical: umbilical herniorrhaphy.
As with any procedure, the surgeon and anesthesia care provider should give the perianesthesia nurse a full report on the anesthesia used and the procedure performed. With every procedure, the surgeon will write an operative note, which describes the procedure performed, viscera removed, drains present, and any other relevant intraoperative findings or complications. This action assists those who are caring for the patient in an assessment of the wounds, dressings, and expected drainage.
After abdominal surgery, patients are often positioned on the side until laryngeal reflexes have started to return. The patient is then placed in a semi-Fowler position to ease the tension on suture lines and to promote respiratory effort. After some procedures on the stomach or esophagus, strict aspiration precautions with the head of the bed elevated to 30 degrees may be required. After hemorrhoidectomy, the patient may assume any position of comfort, which is most likely on the right or left side.
All dressings should be checked. The nurse must know what kind of incision was used and whether any drains are in place. Drains are discussed in more detail in the specific procedures. Drainage should be assessed for character, volume, and odor. The nurse should determine who can or should remove the dressing if needed. Some surgeons reinforce the abdominal incision and dressing with a binder; they believe that this gives the incision valuable support. Others, however, believe that binders restrict respiratory effort and that this disadvantage outweighs the limited advantage of incisional support.
Because drainage may be copious after gastrointestinal surgery, frequent reinforcement of dressings may be necessary. Ask the surgeon for anticipated or expected amounts of drainage for the patient and procedure. If drainage becomes excessive (more than expected from the particular procedure), the surgeon should be notified and the incision directly inspected.
All tubes should be connected to the appropriate drainage devices, usually straight-gravity or closed-bulb suction drainage, as the surgeon specifies. Nasogastric tubes will usually be attached to constant or low intermittent wall suction. Maintenance of the patency of these tubes is one of the most important nursing functions after gastrointestinal surgery. Irrigation of nasogastric tubes after esophageal or gastric surgery should be directed by the surgeon’s orders.
The promotion of good respiratory function is a nursing priority for the patient who has had abdominal surgery. Painful abdominal incisions cause the patient to restrict chest expansion voluntarily, which is especially true with high abdominal incisions. The patient must be coached often in sustained maximal inspirations, coughing, and changing position to prevent respiratory complications. Assisting the patient with splinting of the incision and judicious use of pain medications aid in deep breathing and coughing and help to prevent the development of atelectasis. Coughing and incentive spirometry in the postanesthesia care unit (PACU) setting are valuable in promotion of respiratory function.
Frequent assessment of breath sounds during the postoperative period can alert the nurse to impending respiratory problems. An unrecognized injury to the diaphragm during upper abdominal surgery is possible and can result in respiratory distress. Positive pressure ventilation during anesthesia can also lead to respiratory problems. Breath sounds must be monitored closely to assess for pneumothorax and other respiratory complications.
Fluid and electrolyte shifts or losses can be substantial during gastrointestinal surgery. Losses continue after surgery through gastrointestinal tubes or other drains, and through third-spacing of fluid into the abdomen. For this reason, accurate intake and output records are mandatory. This recording begins with the intake and output report from the anesthesia care provider, which should be the first PACU entry. All drainage from incisions should be included in the assessment of electrolyte balance. Frequent serum electrolyte determinations may be necessary if losses are great. Intravenous fluids are used for replacement for at least the first 24 hours after surgery and at least until the nasogastric tube is removed. See Chapter 14 for a discussion of the specific problems in electrolyte loss from the gastrointestinal tract.
For patients who do not arrive in the PACU with a urinary catheter in place, urinary retention can become a problem after abdominal surgery because of incisional pain, opioid analgesics, anesthetics, and physiologic splinting. Urine output should be checked frequently, and accurate records should be kept. The nurse should also check for bladder distention and document the findings; the patient might not recognize the need to void, particularly after spinal or epidural anesthesia. Ultrasound examination of the bladder with a bedside scanner can aid in assessment of bladder status. The patient should void within 6 to 8 hours after surgery. If the patient has not voided by the time of discharge from the PACU, the receiving unit should be notified to check specifically for urinary retention. If permissible, the male patient may benefit by standing to void. If urinary retention causes pain, distends the abdomen, or becomes prolonged, urinary catheterization may become necessary. Patients who have had extensive surgery will return to the PACU with a urinary catheter in place. Accurate output records should be maintained. For an adult with normal renal function, a minimum of 30 mL/hour of urine output is expected; if less than this, the surgeon should be notified.