Abdominal surgery

Abdominal surgery

The abdomen should be examined daily for excessive disten - sion, tenderness or drainage from wounds or drain sites. In certain operations, such as those for intestinal obstruction or oesophageal and gastric procedures, a nasogastric tube ma y be required. This is of particular value in those patients with ileus or a marked level of altered consciousness, who are therefore liable to aspirate. Paralytic ileus Paralytic ileus may present with nausea, vomiting, loss of appetite, bowel distension and absence of flatus or bowel movements. Following laparotomy , gastrointestinal motility temporarily decreases. Treatment is usually supportive, with maintenance of adequate hydration and electrolyte levels. However, intestinal complications may present as prolonged ileus and so should be actively sought and treated. It is important to note that nutrient absorption from the gut will be impaired in the context of paralytic ileus, and parenteral with prolonged ileus. Return of function of the intestine occurs in the following order: small bowel, large bowel and then stomach. This pattern allows the passage of faeces despite continuing lack of stomach emptying and, ther efore, vomiting may continue even when the lower bowel has already started functioning normally . Localised intra-abdominal infection or anastomotic leakage Intra-abdominal infection may develop from a complication such as anastomotic leakage or persistent abscess following a laparotomy for a perforated viscus, as well as from less common causes such as iatrogenic perforation of a viscus during an elective operation. Intra-abdominal infection may be local ised, presenting with focal tenderness, a spiking fever, raised inflammatory markers and sometimes positive blood cultures and a prolonged ileus. These patients can often be managed by radiological drainage, if accessible, and appropria te antibiotic treatment. In some patients the leak may be more widespread, causing generalised peritonitis and severe sepsis and necessitat ing urgent laparotomy (see also Chapters 64 and 75 ). Bleeding Postoperative bleeding is a well-recognised complication but can still sometimes be overlooked. Hb levels may not always decrease in patients who are bleeding because of the relative haemoconcentration, and drains may not demonstrate signif icant blood loss if blocked with clot. It is important to have a high index of suspicion for bleeding and a low threshold for appropriate intervention for any postoperative patient with a drop in blood pr essure, tachycardia, demonstrable bleeding in the drains, progressive distension of the abdomen or a drop in Hb. Summary box 24.9 The main complications after abdominal surgery /uni25CF /uni25CF /uni25CF

Paralytic ileus Localised infection or anastomotic leakage Bleeding