4-77
prior to randomly clamping large, important structures (such as the iliac artery and the ureter), that may
not be bleeding and will only cause further injury or damage if they are clamped.
- If you enter the abdomen with the plan of doing an appendectomy and the appendix is normal, leave the
appendix in place, and search for another obvious cause. However, there are not many easily correctable
causes of intra-abdominal sepsis that would not have been effectively treated by 72 hours of antibiotics. - Close one layer of the abdominal wall, the fascia, to complete the operation. The difficulty here is
closing without causing injury to the underlying bowel. This layer must be closed correctly, or the patient
will eviscerate with coughing at a later time. Take your time, do not hurry, and watch every pass of the
needle. Your assistants need to be as observant as you are. Take your O-Vicryl suture, start laterally,
tie your knot, and work medially. Take bites of the fascia one centimeter back from the cut edge and
advance only one centimeter at a time. It is imperative not to include loops of bowel in your sutures. It
is not necessary to include muscle in your sutures —that weakens your repair. The only thing you need
to put together is the fascia. - Once the fascia is closed, irrigate the wound again with a liter of sterile fluid and lightly pack the wound
with saline soaked gauze. Place a sterile dry dressing over the top of the packs. - Do not close the skin. Perforated appendices create contaminated wounds that should not be closed, but
should be allowed to heal by granulation. If evacuation becomes available in the next 48 hours, refrain
from closing the skin to facilitate later abdominal exploration by a surgeon. - If the appendix was not perforated, the wound is clean without hemorrhage, and evacuation has not
occurred by 5 days, close the skin and fat (as described in the C-Section Section) as a delayed primary
closure. Use lidocaine as for other skin procedures, such as Procedure: Skin Mass Removal. Wounds
handled by this approach are less likely to become infected than if closed immediately. - Have the anesthesia technician bring the patient out from under anesthesia.
Post-Operative Orders:
- Keep the patient on bed rest for several days, then begin ambulation slowly and advance as tolerated.
- Keep the NG tube in place until the patient has return of bowel function. The patient is very ill, so do
not anticipate that they will be eating for several days after surgery. Provide stress ulcer (see GI: Acute
Peptic Ulcer) and DVT (see Respiratory: Pulmonary Embolus) prophylaxis if available. Once bowel
function returns (bowel sounds and passing gas) pull the NG tube and begin a clear liquid diet. Advance
the diet as tolerated. - Monitor vital signs frequently, as often as every 2-4 hours. This patient should require almost constant
attention the first 24 hours. - Monitor the I & O to make sure the IV fluids are at a high enough rate. Leave the Foley catheter in place
as a way to monitor their output (should be 0.5-1.0 cc/kg/hr). Pull the Foley when patient is tolerating
liquid diet. Ensure he is able to urinate after Foley has been pulled. - Provide pain control (see Procedure: Pain Assessment and Control).
- Keep the patient from vomiting by using anti-emetic as needed (e.g., Compazine 5-10 mg IM q 3-4
hours, max 40 mg/d). - An elevated white blood cell count and spiking temperatures 3 days after operation may be concerning for
evidence of continued sepsis. It is not unusual to have temperature spikes for a day or two after operation
but these should decrease after 72 hours. - Drain output should decrease over 5 to 6 days, and the drain may be pulled at that time.
- Continue antibiotics for 10-14 days after surgery.
- Follow the principles in the Nursing: Wound Care section (on the CD-ROM) to keep the wound clean and
allow it to granulate closed over several weeks. Use Betadine for the first 48 hours, and then switch to
new dressings soaked in sterile saline until a pinkish layer of granulation tissue covers the fascia.
What Not To Do:
Take care not to cause unnecessary bleeding. There will be oozing from the surface of inflamed and cut
tissue. Most of this will stop with pressure and time.
Do not cut into the intestines inadvertently. If you do, close it in a single layer with 000-silk or Vicryl suture.
Make sure your assistants retract and help you. You must see the layers of bowel as you close them.
Do not make your skin incision too small. If you have difficulty seeing, make the incision bigger.