40 Care of the gastrointestinal, abdominal, and anorectal surgical patient
Antrectomy: Removal of the distal part of the stomach.
Appendectomy: Removal of the vermiform appendix, performed with an open or laparoscopic technique.
Cholecystectomy: Removal of the gallbladder; the procedure can be performed with an open or a laparoscopic approach.
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.
Diverticulum: A herniation of mucosa or submucosa through a weakness in a muscular wall of the colon, most commonly in the sigmoid colon, but may be found throughout the colon.
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.
Endoscopy: Visualization of a body cavity with a lighted tube or scope. Most commonly performed to visualize the inside of the esophagus, stomach, and duodenum or colon.
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.
Hemorrhoidectomy: Surgical excision of dilated veins of the rectum.
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, Diaphragmatic: Replacement of abdominal contents that have entered the thorax through a defect in the diaphragm and repair of the diaphragmatic defect.
Herniorrhaphy, Epigastric and Hypogastric: Repair and closure of the abdominal wall defect.
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.
Intussusception: Telescoping of the bowel into itself.
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.
Laparotomy (Celiotomy): An opening made through the abdominal wall into the peritoneal cavity, to perform an operation in the abdomen in an open fashion (e.g., not laparoscopic).
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.
Splenectomy: Removal of the spleen; can be performed in an open or minimally invasive approach.
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.
Volvulus: Intestinal obstruction as a result of twisting of the bowel, most commonly sigmoid colon or cecum.
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).
FIG. 40-1 Digestive system and its associated structures.
(From Sole ML, et al: Introduction to critical care nursing, ed 5, Philadelphia, 2008, Saunders.)
General care after abdominal surgery
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.
The reader should review Chapters 26 through 31 for general care after surgery. See Chapter 45 for a discussion on bariatric surgical procedures and care.
Perianesthesia care
Dressings and drains
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.
Fluid and electrolyte balance
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.
