Gastroesophageal reflux disease (GERD), commonly known as heartburn, acid stomach, or reflux esophagitis, is a common disorder that affects people worldwide. More than 40% of Americans experience typical heartbum on a regular basis, and 10% suffer from heartburn at least once per day. Typically, symptoms occur after one or more of the "four lines of defense provided by the esophagus fail and the noxious contents of the stomach have increased contact time with the esophagus. (1) The four lines of defense include
* mechanical barrier from the stomach,
* peristalsis of the esophagus along with gravity,
* buffering the gastrointestinal (GI) fluid content within the esophagus by swallowing saliva, and
* preventing hydrogen ions from entering the cells of the esophagus.
Swallowed saliva and esophageal bicarbonate secretions buffer the normally acidic GI fluids to a pH greater than four, which prevents the normal physiological reflux of stomach acid. Hydrogen ions are prevented from entering esophageal cells by the physiological reaction of hydrogen and sodium.
Inflammation and an increase in microvascular permeability occur when a breakdown occurs in the esophageal defense system. Initially, cellular growth increases markedly in an effort to regenerate tissue in response to irritation. The basal cell layer thickens and the vascular papillae lengthen. This cellular process creates a thinner layer of cells between the surface and the papillae. It also gives less mucosal resistance to penetration of irritating substances. (2) Over time, acute and chronic inflammation occurs after multiple recurrent reflux events, leading to gastroesophageal reflux and possibly esophageal stricture formation.
ANATOMY OF THE UPPER ALIMENTARY TRACT
The upper alimentary tract is composed of a series of organs, including the mouth, pharynx, esophagus, and stomach, which are joined together to initiate the early stages of food digestion and bodily nourishment (Figure 1). The mouth consists of the lips, teeth, tongue, and soft and hard palates. Every person's mouth is anatomically unique and has its own way of processing solid and liquid substances. Mastication and emulsification of solids and liquids start the digestion process. After passing the pharynx during swallowing, the food bolus enters the esophagus, which is positioned at approximately the level of the sixth cervical vertebra. The esophagus extends through the entire thoracic cavity, posterior to the trachea and heart and anterior to the vertebral column. The esophagus lies anterior to the thoracic aorta before exiting through the diaphragm slightly to the left of midline in the epigastric region of the abdomen. (3) The esophagus then extends into the abdominal cavity for approximately 2.5 cm until reaching the esophagogastric junction (Figure 2).
[FIGURE 1-2 OMITTED]
As the esophagus exits the thoracic cavity, it passes between two strap muscles known as the right and left crus muscles, which are considered the external sphincter of the stomach. The Crural diaphragm, therefore, becomes a key component to the admittance and retention of a food bolus passing into the stomach.
The stomach consists of the fundus, body, and antrum. The esophagogastric junction is at the level of the upper third of the stomach. The esophagus enters the stomach between the fundus and body of the stomach, commonly known as the cardiac portion of the stomach. The fundus lies beneath the diaphragm and behind the lower portion of the heart. The body and the antrum lie obliquely within the abdominal cavity. The lower portion of the esophagus and the upper portion of the duodenum, which is connected to the posterior peritoneum, hold the stomach in position. The omentum, peritoneal ligaments, and celiac vessel and its tributaries provide additional support. The stomach is a bulbous organ with the lateral area known as the greater curvature and the medial portion called the lesser curvature. The greater omentum, a double layer or fold of peritoneum containing fat, is attached to the greater curvature of the stomach. "The left border is continuous with the gastrosplenic ligament ... the. right border extends to the commencement of the duodenum." (5) The gastrosplenic ligament, previously known as omentum, officially has been named the gastrolienal ligament. (6) The greater omentum loosely covers the intestines to approximately the midabdominal cavity. The lesser omentum, also called the gastrohepatic omentum, is a fold of peritoneum that passes from the transverse fissure of the liver to the lesser gastric curvature where the duodenum begins. (7)
The short gastric arteries, left gastroepiploic branch of the splenic artery, and right gastroepiploic branch of the hepatic artery run through the greater omentum. The lesser omentum contains the left gastric artery, a branch of the celiac artery, and the right gastric branch of the hepatic artery.
Portions of the liver, such as the caudate lobe, have surgical landmark value, although they play no significant part in the disease process. The ligamentous attachment to the anterior portion of the peritoneum is located near the midline of the epigastric region of the abdomen. In the past, the liver was described as only having two lobes separated by the falciform ligament. Occasionally, a patient may have presented with an auxiliary lobe that was easily identifiable but had no significant value. Recent advancements in imaging studies and surgery have discovered that the liver has many surfaces and lobes. The caudate lobe, located in the lesser curvature of the stomach caudal to the duodenum, is one of the auxiliary lobes now used as a landmark for gastric surgery.
SYMPTOMS OF GERD
Patients with reflux disease present with one of three categories of clinical symptoms, including
* typical symptoms, which include heartburn and reflux of gastric contents into the esophagus when bending or lying down;
* secondary symptoms, which include complications of reflux affecting the esophagus; and
* tertiary symptoms, which include symptoms unrelated to the esophagus (Table 1) (8)
Patients who suffer from GERD most often complain about typical symptoms. The following problems are secondary symptoms of GERD.
* Mild to severe dysphagia (ie, difficult swallowing) occasionally is observed; however, it may or may not be associated with an esophageal stricture.
* Odynophagia (ie, painful swallowing) may be present in a patient who has severe GERD and usually is related to an esophageal stricture.
* Hematemesis (ie, vomiting blood) or melena (ie, blood in the stool) rarely is noted but may present clinically due to esophagitis.
Tertiary symptoms unrelated to the esophagus include
* reflux asthma caused by gastric contents being aspirated into the airway,
* hoarseness and pharyngitis caused by the airway's irritation as a result of gastric aspiration into the airway; and
* other nonesophageal symptoms, such as acidic taste, pyrosis (ie, waterbrash), dental decay, and chronic halitosis.
Secondary and tertiary symptoms must be considered nonspecific if present without esophageal changes. They must be investigated further to correlate the symptom with the disease process.
The most common problem treated in an esophageal clinic or esophageal investigational laboratory is GERD. The majority of patients with GERD are treated symptomatically only with recommendations for lifestyle changes. (9) Lifestyle modification, such as weight loss and a diet rich in protein and low in fat and glucose, should increase the patient's resting lower esophageal sphincter pressure (LESP), which should ease symptoms. Physical exercise also is encouraged to assist in weight reduction and increase muscle tone. Substances known to decrease LESP include mint, chocolate, alcohol, and tobacco, which should be avoided, if possible. (10)
Elevating the head of the bed when at rest significantly decreases the time the refluxate has contact with esophageal mucosa. This position does not stop the reflux but allows gravity to assist in emptying the refluxate from the esophagus into the stomach.
Forty percent of the adult population suffering from GERD takes medications, such as calcium supplements, H2-receptor antagonists, proton-pump inhibitors, or prokinetic agents, to reduce persistent symptoms. (11) No medication currently available cures the disease, although the aforementioned medications are effective in reducing the production of acid, increasing motility, or covering the lining of the esophagus.
More than 90% of patients who suffer symptoms of GERD will need to modify their diets in addition to undergoing medication therapy. Diet modification and medication therapy may be acceptable to patients who suffer symptoms on an irregular basis; however, patients who suffer from life-altering symptoms actively seek other options. For these patients, surgical intervention may be a beneficial alternative.
INDICATIONS FOR SURGICAL INTERVENTION
In the past, surgical treatment of GERD was reserved for patients who did not respond to medical management and had significantly increased symptoms. Conditions, such as esophageal ulceration, stricture of the esophagus, aspiration-induced asthma, and Barrett's esophagus, also were indications for the Nissen fundoplication procedure. The open Nissen fundoplication procedure, Belsey-Mark IV procedure, and other types of open antireflux procedures, however, were not performed on a regular basis because of their associated increase in morbidity and mortality. Additionally, the open procedures required a postoperative hospital stay of approximately seven to 10 days and had a high failure rate; therefore, surgery was considered an undesirable last resort.
Current indications for laparoscopic Nissen fundoplication. During the past 10 years, laparoscopic Nissen fundoplication has gained worldwide popularity because of its effectiveness and low morbidity and mortality rates, The average length of stay for inpatients undergoing laparoscopic Nissen fundopli cation is two to three days. At the surgery center in Harrisburg, Pa, the postoperative length of stay is approximately three hours. The incidence of recurrent heartburn is less than 2% and does not appear to be clinically significant.
Indications for laparoscopic Nissen fundoplication are significantly different than in the past. Patients who need antireflux medication regularly for four to six weeks or more may be candidates for the laparoscopic procedure. Patients who cannot afford antireflux medication for an extended period of time or who suffer significant side effects from the medication also are candidates. Patients who have a clinically significant complication from GERD or who do not want to take antireflux medication for the rest of their lives also could be candidates for the laparoscopic procedure (Table 2).
Patients with typical symptomatology (eg, heart-burn, reflux) may require only an in-depth history and physical examination, and an esophagogastroduo-denoscopy (EGD) to make a definitive diagnosis. The EGD, performed at the surgery center, must show that the patient has a hiatal hernia. These clinical examinations suffice, especially when the patient responds to antireflux medication to some extent.
Preoperative evaluation usually is completed in the surgeon's office. The surgeon performs an initial history and physical examination and, if indicated, an EGD is scheduled. This endoscopic examination of the esophagus is a simple procedure that usually is performed in a GI laboratory. After light sedation is administered and viscous local anesthetic is applied to the back of the patient's throat, the physician passes a flexible endoscope through the patient's mouth and into the esophagus. The physician thoroughly examines the esophagus for signs of inflammation, hyperemia, ulcerations, or strictures. He or she obtains a biopsy of the esophagogastric junction and stomach to assess the upper alimentary tract and look for any pathology.
Patients with tertiary (ie, atypical) GERD symptoms may require additional studies to assist in diagnosis. A manometry study may be indicated to rule out abnormal motility and to assess lower LESP. A 23-hour pH study also may be required.
If a hiatal hernia is diagnosed, a manometry study is scheduled for a later date and should reflect normal motility with a low LESP. The surgeon or office staff members provide the patient with an information packet describing the procedure and the preprocedure guidelines (eg, remain NPO after midnight, wear loose-fitting comfortable clothing). On the day of the test, the nurse brings the patient into the manometry room. After briefly describing the procedure, the nurse sprays approximately 3 ml viscous local anesthetic medication into the patient's nose and instructs the patient to snort the medication into the back of the throat. The nurse gives the patient a cup of cold water and instructs him or her to sip the water through a straw while the RN first assistant (RNFA) passes a four-channel esophageal probe into the patient's stomach approximately 60 cm at the nares. The RNFA attaches an external respiration and swallow probe to the esophageal probe so that intrathoracic pressure changes also can be monitored during the procedure. The RNFA moves the probe into the appropriate position by monitoring wave-forms generated via the esophageal probe. When the probe is in position, the nurse asks the patient to lie quietly and swallow 5 mL of water periodically throughout the test. As the patient swallows, the probe measures intraesophageal pressures, most importantly the LESP. The normal LESP is 10 mm Hg to 45 mm Hg with a residual pressure of less than 8 mm Hg. Patients who suffer from GERD have an LESP of less than 10 mm Hg.
A patient whose symptoms are atypical must undergo a 23-hour pH study to correlate the reflux disease. Atypical symptoms include
* upper back pain,
* nonobstructional dysphagia,
* dental decay,
* recurrent aspiration,
* excessive eructation, and
* aspiration-induced asthma.
The most accurate gauge of acid being present in the esophageal lumen is a 24-hour pH monitoring examination. A glass or antimony electrode is placed 5 cm above the LES to document the amount, frequency, and time of acid exposure so that acid reflux episodes experienced with typical esophageal symptoms can be objectively measured and correlated.
When assessing reflux, pH monitoring results are categorized as equivocal evidence and nonequivocal evidence. Equivocal evidence indicates that no reflux exists if acid stays in the esophagus less than 4% of a 24-hour period. It is questionable whether reflux exists if acid is present in the esophagus 4% to 7% of the time. (12) The physician instructs the patient to record in a diary any episodes of reflux during the testing period so the data can be correlated with the timed entries of the diary. The evidence suggests unequivocally that acid reflux is present if acid remains in the esophagus 8% to 12% of the time. (13)
The value of an upper gastrointestinal series (UGI) is very limited in the outpatient Nissen fundoplication. The UGI usually is reserved for the patient whose symptoms would suggest that the stomach and bowel might be herniating into the thoracic cavity. These patients may require a more extensive procedure known as a Collis gastroplasty, which is not performed in the surgery center.
WHEN HIATAL HERNIAS AND GERD COEXIST
"Radiologic examination plays a major role in defining the anatomic abnormalities present when hiatal hernia and reflux disease coexist. (14) Figures 3, 4, 5, and 6 show the four types of hiatal hernia that are defined as
[FIGURE 3-6 OMITTED]
* type one--the stomach is part of the hernia sac;
* type two--the fundus and/or antrum of the stomach protrude through the defect into the thoracic cavity;
* type three--the gastroesophageal junction and a portion of the stomach protrude into the mediastinum; and
* type four--huge hiatal hernias that have another abdominal organ next to the herniated stomach.
Type one hiatal hernias contain a portion of the stomach as part of the hernia sac. (15) This is called a sliding hernia because the gastroesophageal junction and proximal stomach move forth and back through the diaphragmatic hiatus. Sliding of the hernia is position dependent and varies in severity depending on the volume present in the stomach. Occasionally during a routine chest x-ray, a hiatal hernia is found. These hiatal hernias commonly are staged as type two because the gastroesophageal junction and phrenoesophageal ligament remain in normal position. A peritoneal sac protrudes through the hiatus into the mediastinum next to the esophagus. The fundus of the stomach protrudes through the defect into the thoracic cavity. (16) Type three hiatal hernias are a combination of both type one and type two. The gastroesophageal junction and a portion of the stomach protrudes into the mediastinum through the sliding hernia sac and the paraesophageal herniation. Type four hernias are huge hiatal hernias that have another abdominal organ within the herniated sac. The colon, small bowel, spleen, and pancreas, along with the stomach, may be contained in the large hernia sac. (17)
Preoperative preparation for patients undergoing laparoscopic Nissen fundoplication at the surgery center is relatively basic. Patients who are less than age 40 and have no cardiac history require no laboratory studies and must remain NPO after midnight the day of surgery. Patients who are older than 40 years of age must undergo a preoperative electrocardiogram (EKG), complete blood count (CBC), and electrolyte profile. Prescribed daily medications are not taken the rooming of surgery except for cardiac medications. Aspirin should be discontinued five to seven days before the day of surgery and may be restarted the day after surgery. If the patient is taking warfarin sodium, it is discontinued three days before surgery, and the patient is placed on 1 mg per kg of enoxaparin sodium (ie, low molecular weight heparin) subcutaneously twice per day. Warfarin sodium may be restarted the first postoperative day. The anesthesia care provider requests that the patient bring his or her own prescribed antireflux medication to the hospital and take it at the time of surgery to reduce the potential for aspiration during intubation.
Anesthesia evaluation. The anesthetic technique for outpatient laparoscopic Nissen fundoplication at the surgery center requires the same skills and knowledge needed for inpatients. The anesthesia classification for patients undergoing surgery in the surgery center should not exceed American Society of Anesthesiology class III. Before admission, the patient completes an anesthesia-related assessment sheet, which the anesthesia care provider uses as a guide for planning anesthesia care. After reviewing the assessment, the anesthesia care provider interviews the patient in the preoperative holding room to gain more specific information regarding previous surgeries and medical history. If the patient has a pertinent medical or surgical history, the anesthesia care provider adjusts his or her care accordingly. After the interview, the anesthesia care provider administers premedications designed to decrease the patient's anxiety and potential for nausea and vomiting. Table 3 describes anesthesia care of a patient undergoing outpatient laparoscopic Nissen fundoplication.
Perioperative nursing evaluation. The circulating nurse is an essential member of the health care team who is responsible for assessing the patient and planning, coordinating, implementing, and evaluating the total care of the patient during the intraoperative phase of the perioperative process. Through collaboration with all members, of the team, the circulating nurse develops a care plan to diagnose and treat the patient's and family members' response to hiatal hernias and the GERD disease process (Table 4). The circulating nurse continuously monitors and analyzes the patient's response and communicates his or her findings to the rest of the team members, thereby improving the performance of clinical personnel throughout the perioperative process.
Each member of the surgical team plays a vital role in the surgical procedure. Members of the team include the surgeon, anesthesia care provider, circulating nurse, scrub person, and the RNFA.
Operating room preparation. The scrub per son's major responsibilities are to set up and maintain the sterile field and instrumentation. Before the patient enters the OR, the scrub person prepares the back table and Mayo stand. The back table is covered with a disposable impervious cover, and supplies, such as a needle count pad and raytec sponges, are placed within easy reach. The scrub person places the minor instruments (eg, suture scissors, needle driver, Adson forceps) on the back table to be used at the end of the procedure for wound closure. He or she places the bulk of the laparoscopic instrumentation on the Mayo stand, including a
* 5-mm curved hemostat-shaped laparoscopic dissector,
* 5-mm roticulating nonlocking bowel grasper,
* 5-mm roticulating locking bowel grasper,
* pair of 5-mm endoshears,
* 5-mm triangulated liver retractor,
* 5-mm straight probe,
* 5-mm endoscopic needle holder,
* 5-mm knot pusher with a braided nonabsorbable endoscopic stitch,
* #10 knife handle with #15 blade,
* Verres needle,
* O-degree 5-mm laparoscope,
* 5-mm trocars X 5, and
* local anesthetic medication.
The secondary Mayo stand contains the 5-mm suction/irrigator and 5-mm curved ultrasonic shears. After the setup is complete and the procedure is underway, the scrub person acts as a second assistant and is responsible for retracting the liver throughout the surgical procedure.
The RNFA is responsible for assessing, planning, implementing, and evaluating care of the patient before and after the patient's surgical experience. Information obtained by the RNFA is passed on to the other members of the team to ensure that safe patient care is not jeopardized. The RNFA uses the advanced clinical skills of patient positioning, tissue handling, retraction, suturing, and wound dressing under the direct supervision of a qualified surgeon. At the surgery center, the RNFA
* provides preoperative and postoperative patient education,
* is responsible for operating the camera, and
* uses the 5-mm roticulating nonlocking bowel grasper to retract and create counter traction.
Surgical procedure. The anesthesia care provider and circulating nurse transfer the patient to the OR and help the patient move onto the OR bed. Cooperatively, they place the required monitoring equipment on the patient (ie, EKG, blood pressure cuff, pulse oximetry). The circulating nurse places a safety strap across the patient's thighs and places the patient's arms on padded arm boards. After ensuring that the patient's arms are abducted less than 90 degrees and secured with safety straps, the circulating nurse places a warm blanket over the patient. The anesthesia care provider administers a narcotic followed by the induction agent and the paralytic agent. When the patient is anesthetized, the anesthesia care provider pre-oxygenates him or her with 100% oxygen and performs tracheal intubation with the appropriately sized endotracheal tube. The patient then is oxygenated and anesthetized throughout the remainder of the procedure via the endotracheal tube. The anesthesia care provider administers lactated Ringer's solution through the IV line throughout the procedure.
The circulating nurse and RNFA reposition the patient to low lithotomy, gently placing the legs in well-padded boot-type stir-rups. The nurse takes special care when abducting the legs to prevent injuring the patient's femoral, obturator, and sciatic nerves. The anesthesia care provider lowers the bottom of the bed to allow the surgeon to stand between the patient's legs. The circulating nurse preps the patient's abdomen with antiseptic solution, then the surgeon, RNFA, and scrub person place disposable drapes on the patient, exposing the patient's upper abdomen.
The surgeon stands between the patient's legs and the RNFA stands to the right of the surgeon on the patient's left side. A suction/irrigation unit and a 5-mm curved ultrasonic shear are placed on a Mayo stand between the surgeon and RNFA. The second assistant or scrub person stands on the right side of the patient with the monitor cart at the upper right area (Figure 7).
[FIGURE 7 OMITTED]
The circulating nurse mixes three mL of 0.5% lidocaine with 3 mL of 0.5% bupivicaine with epinephrine 1:100,000 mixture. The surgeon administers this preemptive anesthesia by injecting it into each trocar placement site, unless the patient has a cardiac history. After the surgeon makes the skin incision, he or she is prepared to place the laparoscopic ports (Figure 8). He or she inserts the Verres needle at the left anterior subcostal axillary line and verifies placement by dripping sodium chloride irrigation solution into the Verres needle. Carbon dioxide is used to insufflate the abdomen to obtain a pneumoperitoneum and is maintained at 14 mm Hg. The surgeon replaces the Verres needle with a 5-mm trocar through which a O-degree 5-mm scope is introduced. The surgeon examines the abdominal cavity and places a second 5-mm trocar under direct visualization just left of the xyphoid process. This port will be used as the camera port when all the trocars are in place. The surgeon places the third 5-mm trocar approximately halfway between the first and second trocars at the costal margin. He or she places the fourth 5-mm port just left lateral to the falciform ligament, approximately three inches below the xyphoid process. The surgeon places the final 5-mm trocar in the right lateral abdomen at the level of the umbilicus. The surgeon passes a laparoscopic triangular retractor through the fifth (ie, right lateral) port to elevate the left lobe of the liver. This exposes the caudate lobe of the liver and hiatus. The RNFA moves the camera into the second (ie, subxyphoid) port to give a more direct view of the entire region. The anesthesia care provider repositions the OR bed to reverse Trendelenburg's position to increase the visual field for the surgeon and RNFA by allowing gravity to assist in retraction.
[FIGURE 8 OMITTED]
During the initial visual survey of the abdominal cavity, the surgeon checks to see whether the patient's stomach is full. If so, the anesthesia care provider places an orogastric tube and uses low suction to remove gastric contents. The anesthesia care provider immediately removes the orogastric tube after decompression. This procedure is performed under direct vision to ensure correct placement of the tube in the stomach. Orogastric tube placement has been needed less than 5% of the time at the surgery center because patients are kept NPO before surgery.
Using an atraumatic bowel grasper and 5-mm ultrasonic shears, the surgeon opens the hepatogastric ligament over the caudate lobe of the liver (Figure 9). The incision is continued cephalad up to the hiatus, where the surgeon transversely opens the phrenoesophageal ligament and continues dissecting to mobilize the anterior esophagus. After adequate mobilization of the anterior esophagus, the surgeon mobilizes the fundus of the stomach by partially dividing the short gastric vessels to attain adequate mobilization so that he or she can perform a loose, 360-degree wrap of the stomach around the esophagus.
[FIGURE 9 OMITTED]
After mobilization of the fundus, the surgeon separates the right crus muscle from the esophagus and develops an avascular plane to minimize potential bleeding when passing the stomach posterior to the esophagus when creating the fundus wrap. Both the anterior and posterior vagus nerves are left intact and pushed aside. Mobilizing the esophagus circumferentially provides adequate intra-abdominal length of the esophagus (ie, 3 cm to 5 cm).
The surgeon carefully approximates the crus muscles with 0 braided nonabsorbable endoscopic suture, making sure that the aorta lying posterior to the left crus muscle and the inferior vena cava lying posterior to the right crus muscle are not injured. The surgeon approximates the crural muscles to close the hiatal hernia but does not pull so tightly as to encroach on the esophagus.
The surgeon passes the fundus of the stomach posterior to the esophagus to create a loose 360-degree wrap around the intra-abdominal esophagus while making sure the stomach is not twisted (Figure 10). Using an atraumatic grasper, the surgeon grabs the left side of the stomach and passes the needle of a 0 braided nonabsorbable endoscopic suture through the seromuscular portion of the stomach. Then the surgeon uses the needle to catch a shallow piece of the esophagus and right side of the stomach, ensuring a completely secure wrap (Figure 11). When tying the suture, the surgeon ensures that the stomach contents do not leak at the suture site. Leakage of stomach acid into the peritoneal cavity can cause peritonitis, which dramatically increases the potential for infection; therefore, the surgeon sutures the stomach to the esophagus three times to ensure a secure repair. The surgeon wraps the fundus of the stomach to create an external esophageal sphincter so that food or fluid entering the stomach is unable to exit via the esophagus (Figure 12). Vomiting still is possible after the surgical procedure.
[FIGURE 10-12 OMITTED]
After the surgeon creates the new sphincter, he or she irrigates the entire hiatus region with warm normal saline irrigation. The surgeon then completely removes the irrigant with suction. The surgeon removes the triangular retractor and reverses the pneumoperitoneum, evacuating as much carbon dioxide as possible. The five trocars are removed and an additional 3 mL of the lidocaine/bupivicaine mixture is infiltrated into the port sites. The surgical wounds are then closed using only a 4-0 monofilament subcuticular suture; the fascia does not need to be closed. The surgeon applies benzoin and 1/4-inch self-adhesive wound approximating strips and covers them with sterile adhesive bandage strip dressings before removing the drapes. The RNFA cleanses the patient's skin with warm saline. The anesthesia care provider reverses the anesthetic, extubates the patient, and administers antiemetic and IV nonsteroidal anti-inflammatory medications. The surgical team then moves the patient to the stretcher. The circulating nurse and anesthesia care provider transfer the patient to the postanesthesia care unit (PACU) for observation.
The circulating nurse and anesthesia care provider report to the PACU nurse regarding the preoperative and intraoperative phases of the patient's surgical experience. The PACU nurse observes the patient two to four hours postoperatively, measuring the patient's vital signs every 15 minutes. He or she provides fluid replacement for rehydration and assesses the patient's surgical sites, ensuring that the sterile adhesive bandage strip dressings are dry and intact. The PACU nurse gives the patient a noncarbonated drink and oral analgesics. The patient is not required to void before discharge because bladder catheterization is not performed. Vomiting causes the patient pain and increases the risk of tearing the surgical repair; therefore, the PACU nurse administers 4 mg of ondansetron (ie, antiemetic) before removing the IV line as a precaution to prevent nausea and vomiting during the ride home.
Discharge instructions. Before discharge, the RNFA provides the patient with discharge instructions, including ambulating early and often to aid in the dissipation of the residual carbon dioxide in the abdominal cavity. He or she explains to the patient the importance of avoiding vomiting to prevent tearing the repair. The RNFA ensures that the patient is discharged with antiemetics and written instructions about prevention of nausea and vomiting. The RNFA also provides the patient with written dietary guidelines as follows:
* foods and beverages that are encouraged;
* restricted foods and beverages;
* information about carbonated beverages (ie, do not drink for at least six weeks postoperatively because carbonation creates pressure on the surgical repair); and
* instructions for consuming a liquid diet for five days increasing from a soft diet to a full diet during the next five to six weeks;
* weight loss guidelines (ie, it is acceptable for the patient to lose approximately 10 to 20 pounds, although losing 20 pounds is rare; men tend to lose more weight than women).
The RNFA explains that the patient can remove the sterile adhesive bandage strip dressings the morning after surgery, but he or she should leave the self-adhesive wound approximating strips in place until the surgeon removes them at the postoperative appointment. The patient may shower starting on postoperative day one but is encouraged not to rub the incision site. Instead, he or she can allow the soap and water to pour over the wounds. The patient is taught signs and symptoms of wound infection (eg, increased basal core temperature, purulent wound drainage, excessive pain at the wound site). Shoulder pain is a common complaint among patients after undergoing laparoscopic surgery, so the RNFA teaches the patient to lie on the affected side and to place a pillow under the hip. This maneuver allows the gas to move from the diaphragm to the pelvic area, alleviating the shoulder pain.
After discharge. The surgeon makes a telephone call on the night of the surgery to check on the patient and to ensure he or she is comfortable. The next day an RN from the center makes a follow-up telephone call to assess the patient and answer any questions. The patient returns to the physician's office in seven days and again in four to six weeks. A long-term follow-up office visit is scheduled for six months later to assess nutritional status and to ensure that there are no problems with excessive weight loss or swallowing difficulties.
Mrs L is a 66-year-old widow in apparent good health who presented to the surgeon's office with a chief complaint of generalized upper-abdominal pain and occasional heartburn. The RNFA took a thorough history and noted that Mrs L had begun having an increased amount of reflux since the death of her husband three years earlier. It also was noted that the pain could be localized around the subxyphoid region of her abdomen. The surgeon completed a physical examination, which showed a well-healed midline incision and a fight subcostal scar, both of which were consistent with the patient's described surgeries (ie, hysterectomy and cholecystectomy). The surgeon recommended that Mrs L undergo an EGD examination to rule out gastric ulceration, GERD, or hiatal hernia. An EGD was performed, and a hiatal hernia was noted, although no gastric ulcers were noted. Biopsies of the lower esophagus and stomach were taken and demonstrated chronically inflamed tissue. The surgeon recommended that the patient undergo a manometry study of her lower esophagus. The manometry study was indicative of GERD because the LESP was 3.2 mm Hg.
After a long discussion with the surgeon and RNFA, it was recommended that Mrs L undergo a laparoscopic Nissen fundoplication. Mrs L stated that she would like to talk to her two daughters and would get back to the surgeon regarding the recommended procedure. Several days later, Mrs L telephoned the surgeon. She desired medical therapy before surgery, so the surgeon prescribed a common proton pump inhibitor medication to inhibit the action of the proton acid pump in the acid-secreting cells of the stomach lining.
Three months later, Mrs L again presented in the surgeon's office stating that although the symptoms had diminished somewhat, they never went away completely. Mrs L now desired surgical treatment, so she was scheduled for a preoperative EKG, CBC, and an electrolyte profile. No additional studies were required. The RNFA performed preoperative teaching. Mrs L was provided with a copy of the history and physical examination performed by the surgeon and an educational folder with information regarding every step of the perioperative process. She was instructed to remain NPO after midnight the evening before surgery. Mrs L was informed that a nurse from the outpatient surgery center would call her the day before surgery with details about arrival time. Mrs L also was instructed to stop taking aspirin seven days before surgery.
After arrival at the outpatient center, Mrs L was admitted to the preoperative preparation area. The preoperative nurse reviewed the procedure with Mrs L and her daughters, answered Mrs L's questions, and provided emotional support. Mrs L assured nursing and medical staff members that she had remained NPO after midnight. The preoperative nurse then placed an IV catheter and started an IV infusion of 5% dextrose and lactated Ringer's solution, along with 2 g of cefazolin IV piggyback. The RNFA reinforced the preoperative teaching and assisted the anesthesia care provider in transporting Mrs L to the OR. In the OR, Mrs L was placed under general anesthesia and positioned in a low lithotomy position. A laparoscopic Nissen fundoplication and diaphragmatic hernia repair were completed, and Mrs L was admitted to the PACU in stable condition.
On admission to the PACU, Mrs L's vital signs were stable, and she was aroused from sleep easily. An IV of 5% dextrose and lactated Ringer's solution was infused into her left forearm through a 22-g IV catheter. The IV site was slightly reddened and sore to the touch. The IV line was discontinued and restarted in the right wrist. Before discharge from the PACU, Mrs L complained of nausea, so the PACU nurse administered 4 mg of ondansetron IV. Mrs L was reunited with her daughters in the postoperative holding area where she was offered and accepted a noncarbonated beverage, which she tolerated well. Four hours and 10 minutes after admission, Mrs L was discharged from the surgery center in stable condition. Her postoperative instructions included removing the sterile adhesive bandage strip dressings the next day and showering as necessary without rubbing the incisions. She also was instructed to consume a liquid diet, increasing slowly to a soft diet. Mrs L was given a prescription for hydrocodone and acetaminophen and was instructed about their administration for pain control. Mrs L stated she would remain with her youngest daughter postoperatively.
On the evening of surgery, the surgeon called Mrs L at her daughter's residence and was informed that Mrs L was recovering uneventfully. Mrs L was seen in the surgeon's office seven days postoperatively. At that time, she stated she was feeling generally well although tired. She had lost 2 lbs since her initial office visit, her abdominal assessment was normal, and her incisions were healing. Mrs L's initial postoperative visit was otherwise unremarkable.
Six weeks after surgery, Mrs L again was seen in the surgeon's office, where it was noted that her abdomen was soft and slightly tender around the well healed incisions. At that time, she had lost a total of 6.5 lbs throughout the entire surgical process and was tolerating a regular diet well. Mrs L had resumed her normal retired lifestyle and was enjoying her grandchildren.
ANESTHESIA CARE FOR PATIENTS UNDERGOING LAPAROSCOPIC NISSE RUNDOPLICATION
* Administer metoclopramide hydrochloride 10 mg IV to prevent or reduce postoperative nausea and vomiting (N&V).
* Administer droperidol 1.25 mg IV as a premedication to induce relaxation and drowsiness.
* Administer midazolam hydrochloride 1 mg IV for sedation.
* Administer glycopyrrolate 0.2 mg IV to decrease secretions and block cardiac vagal reflexes.
* Administer 100% oxygen via mask to preoxygenate.
* Administer fentanyl citrate 100 [micro]g IV to induce anesthesia.
* Administer propofol/lidocaine hydrochloride 200 mg/50 mg IV to induce general anesthesia.
* Administer rocuronium bromide 50 mg IV to facilitate endotracheal intubation.
* Lubricate endotracheal tube (ETT) with lidocaine gel.
* Choose appropriately sized ETT according to gender and size of patient (eg, 7.0 mm ETT for females, 7.5 mm ETT for males).
* Suction stomach after intubation with 18-Fr long oral suction catheter, which then is removed.
* Rapidly infuse 1,000 mL lactated Ringer's (LR) solution followed by 500 mL to 1,000 mL LR during the procedure.
* Extubate when appropriate.
* Administer 100% oxygen via ETT.
* Administer sevoflourane via ETT to maintain anesthesia.
* Administer fentanyl citrate 50 to 100 [micro]g IV to maintain anesthesia.
* Administer neostigmine methylsulfate/glycopyrrolate 3 mg/0.6 mg IV to reverse neuromuscular blockers.
* Administer ondansetron hydrochloride 4 mg IV to prevent postoperative N&V.
* Administer ketorolac tromethamine 30 mg IV for short-term management of moderately severe, acute pain.
* Administer oxygen via nasal cannula.
* Infuse 1,000 mL LR during the next hour with a total perioperative amount of no more than 3,000 mL to 3,500 mL.
* Administer morphine sulfate or meperidine hydrochloride IV or intramuscular (IM) for pain PRN.
* Administer ondansetron hydrochloride 4 mg if patient experiences N&V.
* Administer dexamethasone 10 mg IV preoperatively if patient has a history of N&V.
* Deflate ETT balloon slowly just before extubation.
* Administer ephedrine sulfate 25 mg intramuscular (IM) if patient experiences intraoperative hypotension (<100 mm Hg systolic).
* Administer ephedrine sulfate 25 mg IM if patient experiences N&V, labile blood pressure, or dizziness postoperatively.
(1.) C Wastell et al, Surgery of the Esophagus, Stomach, and Small Intestine, fifth ed (Boston: Little, Brown, and Co, 1995) 173.
(2.) Ibid, 175.
(3.) L H Bannister, "Alimentary System," in Grays Anatomy, 38th ed, P L Williams, ed (London: Churchill Livingstone, 1995) 1733.
(4.) Ibid, 1767.
(5.) Ibid, 1742.
(7.) Ibid, 1741.
(8.) D C Sabiston, H K Lyerly, Sabiston's Textbook of Surgery: The Biological Basis of Modern Surgery, 15th ed (Philadelphia: W B Saunders Co, 1997) 707-710, 767-783.
(9.) Ibid, 778.
(10.) Ibid; Wastell et al, Surgery of the Esophagus, Stomach, and Small Intestine, fifth ed, 761.
(11.) Wastell et al, Surgery of the Esophagus, Stomach, and Small Intestine, fifth ed, 761.
(12.) Sabiston, Lyerly, Sabiston Textbook of Surgery: The Biological Basis of Modern Surgery, 15th ed, 778.
(14.) Ibid, 775.
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Steven Todd, RN, CNOR, CRNFA, is a privately contracted RN first assistant for Surgical Physicians, Advanced Laparoscopic Surgery, Harrisburg, Pa.
Deborah Corsnitz, RN, BS, CNOR, CRNFA, is an RN first assistant at The PinnacleHealth System, Harrisburg, Pa.
Subir Ray, MD, FACS, is a board certified general surgeon at The PinnacleHealth System, Harrisburg, Pa, and the Susquehanna Valley Surgery Center, Linglestown, Pa. He also is the primary surgeon for Surgical Physicians, Advanced Laparoscopic Surgery, Harrisburg, Pa.
Jay Nassar, MD, is a board certified anesthesiologist, medical director, and director of anesthesia services at the Susquehanna Valley Surgery Center, Linglestown, Pa.
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