MAY 2002, V O L 7 5 . N O 5

Home Study Program OUTPATIENT LAPAROSCOPIC NISSEN FUNDOPLICATION

T he article "Outpatient laparoscopic Nissen t'undoplication" is the basis for this AORNJozir ,d independent study. The behavioral objectives and examination [or this program were prepared by Rebecca Holm, RN, MSN, CNOR, clinical editor, with consulla- tion lrom Susan Bakcwell, RN, MS, education program profks-

sional, Center for Perioperative Education. A minimum score of 70% on the multiple-choice examination is

necessary to earn 3 contact hours for this independent study. Participants receive feedback on incorrect answers. Each applicant who successfiilly completes this study will receive a ccrtiticate of' comple- tion. The deadline for submitting this study is May 3 I , 2005.

Send the completed application form, multiple-choice examination, learner evaluation, and appropriate fec to

AORN Custoiner Service c/o Home Study Program

2 I70 S Parker Rd, Suite 300 Denver, CO 8023 1-57 I I

or fax the inlbrtiiatioii with a credit card nuiiiber to (303) 750-32 I ? .

BEHAVIORAL OBJECTIVES After reading and studying the article on outpatient laparoscopic

Nissen fundoplication, the nurse will be able to ( 1 ) identify thc anatomy of the tipper alimcntary tract, (2) discuss the preoperative care of the patient with gastroesophageal

retl iix disease, ( 3 ) explain the perioperativc nursing care of the patient uudergoing

laparoscopic Nissen liindoplication, (4) describe the surgical steps of the laparoscopic Nissen f'iindoplica-

tion procedure, and (5) discuss the postoperative course of the patient recovering f'rom

laparoscopic Nissen t'iindoplication.

This program meets criteria for CNOR and CRNFA recertification, as well as other continuing education requirements.

955 AOKN IOIIKNAI.

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G Outpatient Laparoscopic

Nissen Pundoplication astroesophageal reflux disease (CERD), commonly known as heartburn, acid stom- ach, or reflux esophagitis, is a common dis- order that affects people worldwide. More than 40% of Americans experience typical

heartburn on a regular basis, and 10% sutfer from heartburn at least once per day. Typically, symptoms occur after one o r more of the “four lines of defense provided by the esophagus fail and the noxious con- tents of tlie stomach have increased contact time with the esophagus.”’ The four lines of defense include

mcchanical barrier l’rom tlie stomach, 0 peristalsis of the esophagus along with gravity,

butliering the gastrointestinal (GI) Iluid content

~

within the esophagus by swallowing saliva, and preventing hydrogen ions froin entering the cells of the esophagus.

Swallowed saliva and esophageal bicarbonate secretions bufl’er the normally acidic GI fluids to a pH greater than four, which prevents the normal pliysio- logical reilux of stomach acid. Hydrogen ions are prevented from entering esophageal cells by the physiological reaction of hydrogen and sodium.

Intlammation and an inct-easc in microvascular perineability 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

A B S T R A C T Gastroesophageal reflux disease affects more than 40% of

Americans, causing heartburn and reflux of gastric contents into the esophagus when bending or lying down. 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. Avoiding exacerbating substances, such as mint, chocolate, alcohol, and tobacco, also may reduce symptoms. Medications may be pre- scribed to reduce persistent symptoms, although no medication cur- rently available cures the disease process. Patients who need antire- flux medication regularly for four to six weeks or more may be candi- dates for laparoscopic Nissen fundoplication. Patients who do not want to take antireflux medication for the rest of their lives, cannot afford the medication for an extended period of time, or suffer significant side effects from the medication also are candidates. This article describes performing Nissen fundoplication laparoscopically on an outpatient basis. The average length of hospital stay has been decreased to two to three hours when performed laparoscopically on an outpatient basis from 10 days for the open procedure and two to three days when per- formed laparoscopically on an inpatient basis. The incidence of recur- rent heartburn is less than 2% when the procedure is performed laparo- scopically and does not appear to be clinically significant. AORN J 75 (May 2002) 956-979.

the vascular papillae lengthen. This cellular process creates a thin- ner layer of cells between the sur- lace and the papillae. It also gives less mucosal resistance t o penctra- tion of irritating substances ’ Over time, acute and chronic inflamma- tion occurs after multiple recurrent rctlux events, leading to gastroe- sophageal rcllux and possibly esophageal stricture formation.

ANATOMY OF THE UPPER ALIMENTARY TRACT

The upper alimentary tract is composed of’ a series of organs, i nc I lid i ng the m o ti t 11, pharynx, esophagus, and stomach, which arc joined together to initiate the early stages 01’ food digestion and bodily nourishment (Figure I ). The mouth consists of the lips, teeth, tongue, and soli and Iiard palates. Every person’s mouth is anatomically unique and has its

S T E V E N T O D D . R N ; D E B O R A H C O R S N I T Z , R N ; S U B l R RAY, MD’; JAY N A S S A R , M D

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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 esopha- gus, which is positioned at approximately the level of the sixth cervical vertebra. The esophagus extends through the entire thoracic cavity, posterior to the tra- chea 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.‘ The esophagus then extends into the abdominal cavity for approximately 2.5 cm until reaching the esophagogastric junction (Figure 2).

Rtrdiologic stirdies show that swillowetl ,food .stops rnonientarili~ in the gastric end of the esophugia h<fi)r-e entering the stomach sugge,.st- ing the preseiicc of CI sphincter at this point. This ~iree(r htis heroine known CIS the lower esophrrgcwl .sphincter (LES). Tlle LES is an area of citrirlur niirscle ,fihet:s at the level qf the diiiphragm. This segion of the esophagtls is niuintttined itndet. tonic contiaction, e,xcept dir- ing t~ swnllow, w7hen it relmes britlfly to admit inges ta to the stomach. and dirring vomiting.“

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 Cniral diaphragm, therefore, becomes a key component to the admittance and retention o f 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 stom- ach, 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 ofthe esophagus and the upper por- tion of the duodenum, which is connected to the pos- terior 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 ofperitoneum containing fat, is attached to the greater curvature of the stomach. “The left border is

continuous with the gastrosplenic ligament . . . the right border extcnds to the commencement of the duodenum.”’ The gastrosplenic ligament, previously known as omentum, o f k a l l y has been named the gastrolienal ligament.6 The greater omenturn loosely covers the intestines to approximately the midabdom- inal cavity. The lesser omentum, also called the gas- trohepatic omentum, is a fold of peritoneum that pass- es from the transverse fissure of the liver to the lesser gastric curvature where the duodenum begins.’

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 gas- tric 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,

Figure 1 Anatomy of the alimentary tract. (Illustration by Mark Katnik, Denver)

Figure 2 Normal gastroesophageal anatomy. (Illustration by Mark Katnik, Denver)

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have surgical landmark value, although they play no significant part in the disease process. The ligainen- tous attachment to the anterior portion of the peri- toneum 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 iden- tifiable but had no significant value. Recent advance- ments in imaging studies and surgery have discov- ered 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 auxil- iary lobes now used as a landmark for gastric surgery.

SYMPTOMS OF GERD Patients with retlux disease present with one of

thrcc categories of clinical symptoms, including 0 typical symptoms, which include heartburn and

reflux of gastric contents into the esophagus when bending or lying down;

0 secondary symptoms, which include complica- tions o f reflux affecting the esophagus; and

0 tertiary symptoms, which include symptoms unre- lated to the esophagus (Table 1 ).%

Patients who suffer li-om GERD most often coin- plain about typical symptoms. The following prob- lems are secondary symptoms of GERD. 0 Mild to severe dysphagia (ie, difficult swallowing)

occasionally is observed; however, it may or may not be associated with an esophageal stricture.

0 Odynophagia (ie, painful swallowing) may be present in a patient who has severe GERD and usually is related to an esophageal stricture.

u Hematemesis (ie, vomiting blood) or melena (ie, blood in the stool) rarely i s notcd 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 01' gastric aspiration into the airway; and other nonesophagcal symptoms, such as acidic taste, pyrosis (ie, waterbrash), dental decay, and chronic halitosis.

Secondary and tertiaw symptoms must be con- < < ,

sidered nonspecific if present without esophageal changes. They must be investigated fiirther to corre- late the symptom with the disease process.

MEDICAL TREATMENT 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 recommenda- tions for lifestyle changes." Lifestyle modification, such as weight loss and a diet rich in protein and low in fat and glucose, should increase the patient's rest- ing 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."'

Elevating the head of the bed when at rest signif- icantly decreases the time the retluxate has contact with esophageal mucosa. This position does not stop the retlux but allows gravity to assist in emptying the retluxate 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." No medication currently available cures the disease, although the aforementioned med- ications are effective in reducing the production of acid, increasing motility, or covering the lining 01' the esophagus.

More than 90% of patients who sut'fer symptoms

Table 1 SYMPTOMS OF GASTROESOPHAGEAL REFUlX

Typical symptoms Heartburn Reflux

Secondatv svmotoms Hematemesis Melena Mild to severe dysphagia Odynophagia

Tertiary symptoms Acidic taste in mouth Chronic halitosis Dental decay Hoarseness Pharyngitis Reflux asthma Pyrosis (waterbrash)

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ot’GEKD will need to modify their diets in addition to undergoing medication thcrapy. Diet moditication and medication therapy may be acceptable to patients who suffer symptoms on an irregular basis; howevcr, patients who suffer froin life-altering symptoms actively seek other options. For these patients, surgi- cal intervention may be a beneticial alternative.

INDICATIONS FOR SURGICAL INTERVENTION In the past, surgical treatment of GERD was

reserved for patients wrho did not respond to medical management and had significantly increased symp- toms. Conditions, such as esophageal ulceration, stricture ol’the esophagus, aspiration-induced asthma, and Barrett’s esophagus. also were indications for the Nissen titndoplication procedure. The open Nissen Iundoplication procedure, Belsey-Mark IV proce- dure, 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, sur- gery was considered an undesirable last resort.

Current indications j i w laparoscopic Nissen ,fi~ndoplication. During the past 10 years, laparoscop- ic Nissen fundoplication has gained worldwide popu- larity because of its el’l’ectiveness and low morbidity and mortality rates. The average length of stay Ihr 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 lcss than 2% and does not appear to be clinically significant.

Indications for laparoscopic Nissen firndoplication are signili- cantly different than in the past. Patients who need antiretlux medication regularly for four to six weeks or more may be candi- dates for the laparoscopic proce- dure. Patients who cannot afford antiretlux medication for an extended period of time or who suffer signilicant side effects from the medication also are candi- dates. Patients who have a clini- cally signiflcant 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).

PATIENT EVALUATION Patients with typical symptomatology (cg. heart-

bum, reflux) may require only an in-depth history and physical examination, and an esopliagogastlodtio- 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 exami- nations suffice, especially when the patient responds to antiretlux medication to some extent.

Preoperative evaluation usually is completed in the surgeon’s otlice. The surgeon perfomis 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. Alter light scdation is adrninistered 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 cxam- ines the esophagus for signs of intlammation, hyper- emia, ulcerations, or strictures. He or she obtains a biopsy o t the esophagogastric .junction and stomach to assess the upper alimentary tract and look fix any pathology.

Patients with tertiary (ie, atypical) G E R D symptoms may require additional studiscs to assist in

Table 2 INDICATIONS FOR SURGICAL TRWTMENT

Open Nissen Laparoscopic fundoplication Nissen fundoplication

Complex esophageal X process (ie, stricture, ulceration)

Barrett’s esophagus X

Unsuccessful treatment with antireflux rnedi- cations for more than six weeks

Inability to pay for long- term medication therapy

Desires not to take medications long term

X

X

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A 24-hour monitoring

test measures and correlates

acid reflux episodes with

typical esophageal symptoms.

diagnosis. A manometry study may be indicated to rule o u t 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 ot’fice staff members provide the patient with an infbrmation packet describing the procedure and the preprocedure guidelines (eg, remain NPO after mid- night, 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 vis- cous 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 ofcold 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 m L of water periodically throughout the test. As the patient swallows, the probe measures intraesophageal pressures, most importantly the LESP. The normal LESP is 10 m m 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 retlux 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 amoiint. lye- quency, and time ofacid exposure so that acid re fus episodes experienced with typical esophageal symp- toms can be objectively measured and correlated.

When assessing reflux, pH monitoring results are categorized as equivocal evidence and nonequiv- ocal evidence. Equivocal evidence indicates that no retlux exists if acid stays in the esophagus less than 4% of a 24-hour period. It is questionable whether retlux exists ifacid is present in the esophagus 4%) to 7% of the time.’’ The physician instructs the patient to record i n a diary any episodes of retlux 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.’’

The value of an upper gastrointestinal serics (UGI) is very limited in the outpatient Nissen fun- doplication. The UGI usually is reserved for the patient whose symptoms would suggest that the stomach and bowel might be herniating into tlie mo- racic cavity. These patients may require a more extensive procedurc 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 abnormalitics present when hiatal hernia and reflux disease coexist.”“ Figures 3, 4, 5 , and 6 show the four types of hiatal hernia that are defined as

type one-the stomach is part of the hernia sac; type two-the fundus and/or antruni of the stoin- ach protrude through the defect into tlie thoracic cavity; type three-the gastroesophageal junction and a portion of the stomach protrude into the medi- astinum; 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.” This is called a

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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 phre- noesophageal 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 tho- racic cavity.“’ Type three hiatal hemias are a combi- nation of both type one and type two. The gastroe- sophageal junction and a portion of the stomach pro- trudes into the mediastinum through the sliding her- nia 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.”

PREOPERATIVE PREPARATION Preoperative preparation for patients undergoing

laparoscopic Nissen fiindoplication at the surgery center is relatively basic. Patients who are less than age 40 and have no cardiac history require no labora- tory studies and must remain NPO after midnight the day ofsurgery. Patients who are older than 40 years of age mcst undergo a preoperative electrocardiogram (EKG). completc blood count (CBC), and electrolyte profile. Prescribed daily medications are not taken the morning of surgery except for cardiac medications. Aspirin should be discontinued five to seven days before the day ofsurgery 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 ofenoxaparin sodi- um (ie, low molecular weight heparin) subcutaneous- ly twice per day. Warfarin sodium may be restarted the lirst postoperative day. The anesthesia care provider requests that the patient bring his or her own prescribed antiretlux medication to the hospital and take it at the time ofsurgery to reduce the potential for aspiration during intubation.

Anestliesia evaluation. The anesthetic tech- nique for outpatient laparoscopic Nissen fundoplica- tion 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 111. Before admission, the patient completes an anesthesia-related assessment sheet, which the anesthesia care provider uses as a guide fbr planning anesthesia care. After reviewing

Figure 3 Type one hiatal hernia demonstrating that the stomach is part of the hernia sac. (Illustration by Murk Kutnik, Denver)

Figure 4 Type two hiotal hernia showing stomach fundus protruding into the thoracic cavity through the hernia defect. (Illustrotion by Murk Kutnik, Denver)

Figure 5 Type three hiatal hernia showing the gas- troesophageal junction and a portion of the stomach protruding into the mediastinum (Illustration by Murk Kutnik, Denver)

Figure 6 Type four hiatal hernia showing another abdominal organ next to the herniated stomach. (Illustrotion by Murk Kutnik, Denver)

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the assessment, the anesthesia care provider inter- views the patient in the preoperative holding room to gain more specific information regarding previous surgeries and medical history. Ifthe patient has a per- tinent medical or surgical history, the anesthesia care provider adjusts his or her care accordingly. After the interview, the anesthesia care provider administers preinedications 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 circulat- ing 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 collabo- ration 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 her- nias and the GERD disease process (Table 4). The circulating nurse continuously monitors and analyzes

Table 3 m m l s l ~ am H)R m n m UNDERGOING uwutoscowc NISSEN FUNDOWCATION

Preoperative medications Administer metoclopromide hydrochloride 10 mg IV to prevent or reduce postoperative nausea and vomiting (N&V). Administer droperidol 1.25 mg IV os a premedication to induce relaxation and drowsiness. Administer midazolam hydrochloride 1 mg IV for sedation. Administer glycopyrrolote 0.2 mg IV to decrease secretions and block cardiac vagol reflexes.

Induction agents Administer 100% oxyoen vio mask to preoxvgenate. Administer fentanyl cltrite 1 00 pg IV to’ induce anesthesia. Administer propofol/lidocoine hydrochloride 200 mg/50 mg IV to induce general anesthesia Administer rocuronium bromide 50 mg IV to facilitate endotrocheal intubotion.

lntraoperative devicedtechniques Lubricate endotrocheol tube (Em with lidocaine gel. Choose appropriately sized ETT according to gender and size of patient (eg, 7.0 mm E l l for females, 7.5 mm En

Suction stomach after intubation with 18-Fr long orol 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

e Extubate when appropriate.

Maintenance medications Administer 100% oxygen via ETT.

0 Administer sevoflourane via E l l to maintain anesthesia. Administer fentanyl citrate 50 to 100 pg IV to maintain anesthesia

ReversaVpostoperative medications Administer neostigmine methylsulfate/glycopyrrolate 3 mg10.6 mg IV to reverse neuromuscular blockers. Administer ondansetron hydrochloride 4 mg IV to prevent postoperative N&V. Administer ketorolac tromethomine 30 mg IV for short-term monogement of moderately severe, acute pain.

Postoperative phase Administer oxygen vio nasal connula. 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 intromuscular (IM) for pain PRN. Administer ondansetron hydrochloride 4 mg if patient experiences N&V.

Special concerns Administer dexamethasone 10 mg IV preoperatively if patient has o history of N&V. Deflate E l l balloon slowly just before extubotion.

* Administer ephedrine sulfate 25 mg intramuscular (IM) if patient experiences intraoperative hypotension (<lo0 mm

Administer ephedrine sulfate 25 mg IM if patient experiences N&V, labile blood pressure, or dizziness postoperatively.

for moles).

procedure.

-

Hg systolic).

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the patient’s response and communicates his or her findings to the rest 01’ the team members, thereby improving the performance of clinical personnel throughout the perioperative process.

INTRAOPERATIVE PHASE Each member of the surgical teaiu plays a vital

role i n the surgical procedure. Members of the team include the surgeon, anesthesia care provider, circu- lating nurse, scrub person, and the RNFA.

Operating mom preparation. The scrub per-

son’s major responsibilities are to set up and maintain the sterile field and instmmentation. 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, arc placed within easy reach. The scrub person places the minor instruinents (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

Table 4 CARE PLAN FOR PATIENTS UNDERGOING LAPAROSCOPIC NISSEN FUN DOPLICATION

Nursing Interim Outcome diagnosis Interventions outcome criteria statement

Acute pain related to tissue trauma scale; secondory to surgical neutral low-lithotomy position; procedure

Implements pain management program by educating patient about postoperative zero to 10 pain

placing patient’s legs in well-padded boot-type stirrups in a

encouraging surgeon to administer short-term local anes-

handling tissue delicately during the surgical procedure; encouraging surgeon to administer long-term local anes- thetic medication before transferring patient from the OR.

Evaluates response to pain management interventions by assessing patient‘s type, character, and location of pain; encouraging patient to use analgesic medication routinely; encouraging splinting while coughing and deep breathing; providing noninvasive pain relief measures (eg, distrac- tion, relaxation techniques, comfort measures); educating patient regarding premedicating with prescribed analgesics before strenuous activities; and completing follow-up telephone calls to patient at home on day of discharge and second day after discharge to ensure effectiveness of comfort-inducing techniques.

thetic medication before making the incision;

Patient displays Patient freedom from pain. demon-

strates Patient does not demonstrate nonver- and/or bal pain behaviors reports eg, crying, moaning, adequate

guarding behaviors). pain control throughout perioperative period.

Patient. coughs effectively with minimal complaints of dis- comfort

Risk of infection Implements aseptic technique to include Patient remains Patient is related to creating and maintaining sterile environment in the OR, afebrile free from impaired skin 8 ensuring that the patient is well hydrated with parenteral demonstrates signs and

dry, nonreddened, symptoms integrity due to fluids, surgical incision 8 inspecting the wound at the time of wound closure for nontender wound of infection

healing by primary hemostasis and wound edge approximation, and washing the wound and surrounding area to ensure that preoperative prep solution and blood are removed before self-adhesive wound approximating strips and/or sterile dressings are applied

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Mayo stand, including a 0 5-nim curved hemostat-shaped laparoscopic dis-

sector, 0 5-mm roticulating nonlocking bowel grasper,

5-mm roticulating locking bowel grasper, pair of 5-min endoshears, 5-mm triangulated liver retractor, 5-mm straight probe, 5-mm endoscopic needle holder,

0 5-mm knot pusher with a braided nonabsorbable endoscopic stitch.

0 #I0 knife handle with #I5 blade, 9 Verres needle,

0-degree 5-mtn laparoscope, 0 5-mtn trocars X 5, and 9 local anesthetic medication.

The secondary Mayo stand contains the 5-inn1 suctioniirrigator and 5-min curved ultrasonic shears. After the setup is complete and the procedure is underway, the scrub person acts as a sccond assistant and is responsible for retracting the liver throughout the surgical procedure.

Table 4 CARE PLAN RBR pATlENls UNDERGOING ~ O S C O P I C NISSEN FUNDOWCATION (CONTINUED)

Nursing Interim Outcome diagnosis Interventions outcome criteria statement

Risk of infection related to

Educates the patient and family members regarding care of the surgical wound to include

impaired skin integrity due to surgical incision 9

(conlinued) 0

performing wound care according to surgeon's instructions, taking showers only (ie, no baths), leaving self-adhesive wound approximating strips in place until first postoperative visit, drinking enough fluids to prevent dehydration, and eating a nutritional diet.

Educates patient and family members regarding signs and symptoms of wound infection, including 9 increased swelling and redness,

wound separation, purulent drainage, and temperature greater than 101 O F (38" C)

Identifies physiological status by acquiring patient's baseline

Collaborates in maintenance and corrective therapies by

removing as much carbon dioxide as possible from the

Risk of imbal- Patient will maintain anced nutrition weight and nutritional history. body weight or lose

no more than 10 to related to inabil- 20 Ibs after surgery. ib' to ingest food administering parenteral nutrition as ordered and Patient will consume an adequate amount peritoneal cavity at the end of the procedure. of fluids and nutrients to meet the basal metabolic needs of the postoperative period.

Educates patient and family members regarding increased potential for weight loss postoperatively; nutritional components of wound healing; dietary restrictions (eg, no carbonated beverages, soft foods initially);

Patient demon- strates knowledge of nutritional requirements related to the surgical or other invasive procedure.

eating small frequent meals of high quality foods (eg, fresh fruits and vegetables, finely chopped meats, protein drinks); preventing gastric distention by consuming liquid or pureed diet, eating slowly, and limiting gas producing foods; and weighing daily to monitor weight lass and gain.

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The KNFA is responsible for assessing, plan- ning, implementing, and evaluating care of the patient before and after the patient’s surgical experi- ence. Infomiation obtained by the RNFA is passed on to the other members of tlie 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 tinder the direct supcrvision o fa qualified surgeon. At the siirgery center, the RNFA 0 provides preoperative and postoperative patient

education, 0 is responsible for operating the camera, and 0 uses tlic 5-mm roticuiating nonlocking bowel

grasper to retract and create counter traction. Siirgical procedure. Th e a nes t lies i a care

provider and circulating nursc transfer the patient to the OR and help the patient mo\c onto the OR bed. Cooperatively. they place the reqiiircd monitoring equipment on the patient (ie. EKG, blood pressure cuff, pulsc oximetiy). 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, tlie circulating nurse places a wariii blanket over the patient. The anesthesia care provider administers a narcotic fol- lowed by tlie induction agent and the paralytic agent. When thc patient is ancsthetizcd, 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 re- mainder of the procedure via the endotracheal tube. The anesthesia care provider administers lactated Ringer’s solution through tlic IV line throughout the procedure.

The circulating nurse and RNFA reposition the patient to low lithotomy, gently placing tlic legs in well-padded boot-type stir- rups. The nurse takes special care when abducting the legs to pre- vent injuring the patient’s femoral. obturator, and sciatic nerves. The

surgeon to stand between the patient’s legs. The cir- culating nurse preps the patient’s abdomen with anti- septic solution, then the surgeon, RNFA, and scrub person place disposable drapes on the patient, expos- ing the patient’s upper abdomen.

The surgeon stands between the patient’s legs and the RNFA stands to the right of the surgeon on thc patient’s left side. A suction/irrigation unit and a 5-mni curved ultrasonic shear are placed on a Mayo stand between the surgeon and RNFA. The second assistant or sciub person stands on the right side of the patient with the monitor cart at the upper right area (Figure 7).

The circulating nurse mixes three mL of’ 0.5%) lidocaine with 3 niL of 0.5% bupivicaine with epi- nephrine 1 : 100,000 mixture. The surgeon administcrs this preemptive anesthesia by injecting it into each tro- car placement site, unless the patient has a cardiac his- tory. 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 ante- rior subcostal axillary line and verities placement by dripping sodium chloride irrigation solution into tlic Verres needle. Carbon dioxide is used to insuftlate the abdomen to obtain a pneumoperitoneiiin and is main- tained at 14 mm Hg. The surgeon replaces tlie Verres needle with a 5-nini trocar through which a 0-degree 5-mm scope is introduced. The surgeon examines the abdominal cavity and places a second ~-tilln trocar

anesthesia care provider lowers Figure 7 Illustration of the OR setup. (Mustrution by Murk Kutnik, the bottom of the bed to allow the Denver)

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Figure 8 Illustration of trocar port placement. (Illustration by Mark Katnik, Denver)

under direct visualization just left of tlie xyphoid process. This port will be used as the camera port when all thc trocars are in place. The surgeon places the third 5-111nl trocar approximately halfway between the first and second trocars at the costal margin. He or she placcs the fourth 5-mm port just left lateral to the falcifonii ligament, approximately three inches below the xyphoid process. The surgeon places the final 5-min 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 repsitions the OK bed to reverse Trendelenburg’s position to increase the visual tield for the surgeon and RNFA by allowing gravity to assist in retraction.

During the initial visual survey of the abdominal cavity, the surgeon checks to see whether the patient’s stomach is fiill. 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‘thc time at the surgery center because patients are kept N PO before surgery.

Using an atraumatic bowel grasper and 5-mm ultrasonic shears, the surgeon opens thc hepalogastric ligament over the caudate lobe ofthe liver (Figure 9). The incision is continued cephalad up to thc hiatus. where the surgeon transversely opens thc phrenoe- sophageal ligainent and continues dissecting to mobi- lize the anterior esophagus. Atier adequate mobiliza- tion 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.

Afier mobilization ol’ the fundus, the surgeon separates the right crus inuscle from the esophagus and develops an avascular plane to minimix potcn- tial bleeding when passing the stomach posterior to the esophagus when creating the liindus wrap. Both the anterior and posterior vagus nerves are leli intact and pushed aside. Mobilizing the esophagus circum- ferentially provides adequate intra-abdominal length of the esophagus (ie, 3 cm to 5 cni).

The surgeon carefully approximates thc crus muscles with 0 braided nonabsorbable endoscopic suture, making sure that the aorta lying posterior to the left cnis muscle and the inrcrior vena cavil lying posterior to the right crus muscle are not injured. The surgeon approximates tho crural muscles to close the hiatal hernia but does not pull so tightly as to encroach on the esophagus.

The surgeon passes the I’undus of’ the stomach posterior to the esophagus to create ;I loose 360- degree wrap around the intra-abdoininal 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 bra i d ed nona bso r ba b I e en do sco p i c s ti t ti re thcough the seromuscular portion ot’ tlie stomach. Then the surgeon uses the nccdle to catch a shallow piece of the esophagus and right side ol’the stomach, ensuring a completely secure wrap (Figure 1 I ). When tying the stittire, the surgeon ensures tha t the stomach contents do not leak at the suture site. Leakage of stomach acid into the pcritoneal cavity can cause peritonitis, which dramatically increases the potential for infection; therefore, the surgeon sutures the stomach to the esophagus tlircc times to ensure a secure repair. The surgeon wraps the fiindus

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F

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.

After the surgeon creates the new sphincter. he or she irrigates the entire hiatus region with warm nornial saline irrigation. The surgeon then completely removes the irrigant with suction. The surgeon removes the triangular retractor and reverses the pneu- moperitoneum, evacuating as much carbon dioxide as possible. The five trocars are removed and an addi- tional 3 mL of the lidocaine/bupivicaine mixtitre is infiltrated into the port sites. The surgical wounds are then closed using only a 4-0 monotilament subcuticu- lar suture; the fascia does not need to be closed. The surgeon applies benzoin and I i4-inch self-adhesive wound approximating strips and covers them with sterile adhesive bandage strip dressings before remov- ing the drapes. The RNFA cleanses the patient’s skin with warm saline. The anesthesia care provider revers- es the anesthetic, extubates the patient, and adminis- ters antiemetic and IV nonsteroidal anti-iiifammatoryntiiatory 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.

1 Figure 9 The caudal lobe of the liver is the landmark where the surgeon makes the initial internal incision.

Figure 10 The stomach is pulled under the esopha- gus to ensure enough length for a complete wrap.

: I r POSTOPERATIVE CARE

The circulating nurse and anesthesia care provider report to the PACU nurse regarding the pre- operative 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. HC 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 noncar- bonated 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 sur- gical 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 instruc- tions, 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 tear- ing the repair. The RNFA ensures that the patient is discharged with antiemetics and written instructions about prevention of nausea and vomiting. The RNFA

Figure 11 Hiatal hernia repaired with braided nonab- sorbable endoscopic suture.

Figure 12 The stomach is pulled through and sutured together to create a new valve.

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also provides the patient with written dietary guide- lines as follous:

lbods 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 surgi- cal repair); and instructions for consuming a liquid diet for five days increasing from a soft diet to a full diet dur- ing 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 wonien).

Tlic RNFA explains that tlie patient can remove the sterile adhesive bandage strip drcssings the morn- ing aftcr surgery, but he or she should leave the self- adhcsive 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, lie or she can allow tlie soap and water to pour over the wounds. The patient is taught signs and symptoms of wound infection (eg, increased Iwsal core tempcraturc, purulent wound drainage, excessive pain at the wound site). Shoulder pain is a common complaint among patients after undcrgoing laparoscopic surgery, so the RNFA teacli- es tlic patient to lie on the aff‘ected side and to place a pillow under the hip. This maneuver allows the gas to move from the diaphragm to the pelvic area, alle- viating the shoulder pain.

Ajter disckcirge. 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 fol- low-LIP 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 swallow- ing diiticulties.

CASE STUDY 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 histoiy and noted that Mrs L had begun having an increased amount of reflux since the death of her hus- band 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

Shoulder pain is a common

complaint among patients

after undergoing

laparoscopic surgery.

examination, which showed a well-healed midline incision and a right subcostal scar, both of which were consistent with the patient’s described surgeries (ie, hysterectomy and cholecystectomy). The surgeon rec- onmiended 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 sur- geon recommended that the patient undergo a manometry study of her lower esophagus. The inanoinetry study was indicative of GERD because the LESP was 3.2 inin 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 recom- mended procedure. Several days later. Mrs L tde- phoned 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 symp- toms had diminished somewhat, they never went away completely. Mrs L now desired surgical treat- ment, so she was scheduled for a preoperative EKG, CBC, and an electrolyte profile. No additional stud- ies were required. The RNFA performed preopera- tive teaching. Mrs L was provided with a copy of the history and physical examination performed by the surgeon and an educational folder with informa- tion regarding every step of the periopcrative 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

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to stop taking aspirin seven days before surgery. After arrival at the outpatient center, Mrs L was

admitted to the preoperative preparation area. The pre- operative 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 slaty members that she had remained NPO after midnight. The preoperative nurse then placed an IV catheter and started an IV infusion ofS% dextrose and lactated Ringer’s solution, along with 2 g of cefamlin IV piggyback. The RNFA reinforced the preoperative teaching and assisted the anesthesia care provider in transporting Mrs L to the OR. In tlie OR, Mrs L was placed under general anesthesia and positioned in a low lithotomy position. A laparoscop- ic Nissen fundoplication and diaphragmatic hernia repair were completed, and Mrs L was admitted to tlie 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 of5% dextrose and lactated Ringer’s solution was infused into her left forcami through a 22-g IV catheter. The 1V 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 ing of ondansetron IV. Mrs L was reunited with her daughters in the postoperative holding arca where she was ot’f’ered 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 con- dition. Her postoperative instructions included removing the sterile adhesive bandage strip dressings the next day and showering as necessary without rub- bing the incisions. She also was instructed to con- sume a liquid diet, increasing slowly to a soft diet. Mrs L was given a prescription for hydrocodone and acetaminophen and was instructed about their admin-

N O T E S 6. Ibid. 1. C Wastell et al, Sz/r;qeii, ofthe 7. Ihicl, 174 I .

Esoplittgt 1.7. Stomcic,h. and Sinall Intec.tinr. fifth ed (Boston: Little, Brown, and Co, 1995) 173.

2. Ibid 175. 3. L ti Bannister, “Alimentary

System,” in Gr.c!i:s Anatomy, 38th ed, P L Williams, ed (London: Churchill Livingstone. 1995) 1733.

4. Illid, 1767. 5 . Ibid 1742.

istration 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 tlie surgeon’s office seven days postopcrativc- ly. At that time, she stated she was feeling generally well although tired. She had lost 2 Ibs since her initial office visit, her abdominal assessment was nornial, and her incisions were healing. Mrs L‘s initial post- operative visit was otl?envise unremarkable.

Six weeks after surgery, Mrs L ag,ain was seen in the surgeon’s oflice, 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 o f 6 3 Ibs throughout the entire surgical process and was tolerating a regular diet well. Mrs L had resumed her normal retired lifestyle and was enjoy- ing her grandchildren. A

Subir Ray, MD. FACS. is a hriu~d co.lIfid giwivtil wr - gcon at The Pitinuc~leHi~iilllt Syvtivn, Htirri.vlwrx. Pa, ond the Su.squi4iunnu vtillc~y Sirrxiv?. Certter: Litiglrstown. Pa. He u/.w is the primur? sui~i~i)t i , f i ir Sirtgicid Physicians. Adviiiictd Luparr,seripic Si i t~ety Harrisbutg Pa.

Jay Nassar, MD. is a board ccv-tified aties~ht~.~ir)lcgist. medicui director; utid director oj’ancstliesia siwices at the Susquehanria Valley Sutgery Ccntcier: Ling1.str~wn. Pu.

8. D C Sabiston, H K Lyerly, Suhiston .i Te.rtbook cfSzttgeiI~; The Biologicul Bmlc qf Modem Stitget?: 15th ed (Philadelphia: W B Saunders CO, 1997) 707-71 0, 767-783.

9. Ihill, 778. 10. Ihid Wastell et al, Sz/rgeg> o j

the E.sophc7gir.s. Stomuch. und Stnull Intestine. tifth ed, 76 1.

1 1 . Wastell et al, S u q e p of’the

E.vophtigu.s, Stoiwcli. at id Snitill Intr.stine. tifih ed, 76 I .

12. Sabiston, Lyerly, Suhi,vtoii .\ Te.xthook ~ ~ ‘ S I I I ~ I : ~ ~ : Tlir Biologicid Busi,s of Modern Szti~et:”: 15th ed. 778.

13. Ihid. 14. lhid, 775. 15. lhid 16. lhid. 17. Ihid.

978 AOKN JOURNAL

Steven Todd, RN. CNOR. CRNFA. is a privddy con- traclcd RN,/irsl ussislaiil. for Sutgical Physicians. Advanced Laparoscopic Suigcry. Hurrisbutg Pa.

Deborah Corsnitz RN. BS. CNOR. C'RNE.1. is uii RN j k v ~ ci.vsi.v/unl trl The Pinntt~~lc~t~c~iil~li .ywtcwi. t l w r i . v l w ~ ~ Ptl.

MAY 2002. VOL 75, NO 5 Todd Corsnitz Ruy Nas.scr 9

R E S 0 ti R C E S

“Treating benign colon disorders using laparoscopic colectoniy,” A O R N J o w n u l 73 (February 2001 )

Fernando. H C; Schauer, P R; riosenblalt, M. “Quality of life after antireflux surgery compared with nonoperative management for severe gastroesophageal retlux disease,” Joinntr~ of’~lllerican c’o/legcJ (?f Sin:yon.s I94 (January 2002) 23-27.

Finley. C R; McKernan, J B. “Laparoscopic antireflux surgery at an outpatient surgery center,” Srrigic~ul Ent/o.c.cop~ (August 200 I )

Cox, .I A; Rogers, M A; Cox S D.

375-410.

823-826. Haubrich, W S: Schaffner, F; Berk

J E. Bockiis ’ Gustsoenfesologv vol 1. fifth ed (Philadelphia: W B Saunders CO, 1995) 44 1-465.

Loeb, S, ed Illirstrrrted Giiide to Diugnostic Testv (Springhouse, Pa: Springhouse Corp, 1994) 8 13- 818.

Mayers. M C; Pankratz, C. Clinicul Cuse P1un.s in iWedicul Si/sgicd Nwsing (New York: McGraw-Hill, 1989) 253-255.

Petty, L R. “Gastrointestinal Surgery,” in A1e.rtrna‘L.r .\ Cure offlie Pufient in Surgeiy I 1 th ed, M H Meeker, J C Rothrock, eds (St Louis:

Mosby, 1999) 3 13-370. Schlossberg, L; Zuidema, G D.

The Johns Hopkins Atlas cf Human Eiinctionul Anutony fourth ed, G D Zuidenia, ed (Baltimore: Johns Hopkins University Press, 1997) 91 - 95, 118-135.

Taylor, D. “How facilities are fighting for outpatient laparoscopic nissen fiindoplication.” OufpcitI’ent S~irgei?j Magazine 2 no 4 (April

Zarkin, D; Dannenberg, A J. Peptic Ulcer Di.c.ec1.c.e ma‘ Othcs Acid Rcdrrtcd Di.voro‘cr.s ( Armonk, NY: Academic Research Associates. Inc. 1991 ) 247-296.

2001) 63-65.

Plastic Surgery Rates on the Rise in Older Adult Population Sewn percent of cosmetic procedures performed in 2000 were performed on women and men age 65 and older, according to a Fcb I , 2002, news release from the American Society for Aesthetic Plastic Surgery. Since 1997, the number of cosmetic proce- dures performed on people in this age group has increased by 352%. There are special considera- tions when performing plastic surgery on people of this age group, but age is not a contraindication to surgery.

longevity of cosmetic surgery results is skin elastici- ty. which diminishes with age. Patients who wait unt i l later in life to undergo their first cosmetic pro- cedure tnay not see the same results as a younger patient or a person who has undergone previous cos- i-nctic procedures, but results still can be dramatic.

For older patients, surgical techniques may need to be altcrcd. When performing a facelift on patients with thinning hair, for example, the surgeon may need to place incisions to better camouflage scars. Older patients also may choose to have their earlobes reduced when undergoing a facelift because earlobes grow and stretch with age and tnay look out ot‘pro- portion after a facial procedure.

One of the factors that affects the quality and

When performing eyelid surgery on older patients, tissue removal tnay need to be more con- servative because patients may have a greater ten- dency to develop “dry eye.” Older adults may prefer to have several mild facial peels as opposed to one deep chemical peel because their skin is thin. They also may need a modified “tummy tuck” when undergoing lipoplasty to get rid of excess skin that has lost its elasticity.

Extra precautions may be necessary for older patients with certain types of medical conditions. This may mean that additional medical personnel are needed during the procedure or that the proce- dure should be performed in a hospital. Special accommodations increase the cost of surgery. Patients age 65 and older also may require longer recovery periods than younger patients. Their bruis- ing may take longer to subside, and incisions may take longer to heal.

Older Patients Benefit From Modified Cosmetic Plastic Surgery Techniques (news release, New York: American Socie/y for Aesthetic Plastic Surgery, Feb 1, 2002) http:// www. surgery. org/news_releoses/febO I02oge65. hfrnl (accessed 5 Feb 2002).

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