Early postoperative ambulation

Early postoperative ambulation

EARLY POSTOPERATIVE EDWIN Attending Surgeon SL. Bernard’s A. AMBULATION* BALCER, Hospital; Diplomate CHICAGO, T HE purpose of this paper is ...

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EARLY POSTOPERATIVE EDWIN Attending

Surgeon

SL. Bernard’s

A.

AMBULATION*

BALCER,

Hospital;

Diplomate

CHICAGO,

T

HE purpose of this paper is to describe the method used in earIy postoperative ambuIation in I 44 cases of varied abdomina1 operations performed by the author since JuIy 1944. HistoricaIIy, early surgica1 ambuIation dates back to 1899 when Ries in a written report advocated this practice. Since then, especiaIIy in this country, the idea has been adopted by onIy a few surgeons. However, within the Iast few years postoperative rising has gained in popuIarity. AIthough earIy postoperative ambuIation can be used practicaIIy in a11 types of surgery, this paper Iimits itseIf to abdomina1 procedures as the greatest degree of skepticism regarding earIy rising exists in this fieId of surgery, chiefIy because of the erroneous concept of increased wound dehiscense and hernia formation. The most important advantages are decreased puImonary and circuIatory compIications which resuIt mainIy from basa1 ateIectasis and periphera1 venous stasis. CIinicaIIy, this fact is supported by Iower postoperative temperatures, an earlier return to norma and a Iower puIse rate as compared with the strictIy confined bed patients; such observations were made and recentIy reported by Powers, Shafer and Dragstedt. PhysioIogicaIIy, it has been shown by Leithauser that the vita1 capacity in earIy ambuIatory patients returns to norma in approximateIy onehaIf the time required for bed confined postoperative patients, whiIe McMichaeI and McGibbon have demonstrated that recumbency decreases the tota voIume of air in the fuIIy expanded Iungs as we11

M.D. of the American

Board of Surgery

ILLINOIS

as the functiona residua1 air. The studies of Smith and AIIen reveaIed that exercise decreases the circuIation time in the extremities. Other advantages incIude reduced frequency of abdomina1 distention, absence of asthenia, shortened hospita1 duration and earIy restoration to norma activity. Having the patient attend to his persona1 hygiene and Iessening his hospita1 stay are of great importance psychoIogicaIIy and economicaIIy, to the patient as we11 as to the community having Iimited hospita1 beds, nursing personne1 or in a time of emergency. If earIy postsurgica1 rising is to be abdomina1 cIosures must be practiced, considered as one of the most important parts of the operation instead of a necessary finaIe. Rapid unanatomica1 cIosures resuIt in frequent wound dehiscense under any circumstances. ConsequentIy, such cIosures aIong with grossIy infected wounds are considered a contraindication to earIy rising. AI1 abdomina1 incisions regardIess of their Iocation are cIosed anatomicaIIy Iayer by Iayer with interrupted No. 24 cotton sutures. In the peritoneum and posterior rectus sheath these sutures are pIaced no further than I cm. apart and onIy a minima1 amount of tissue is incIuded in each suture. AI1 knots are tied squareIy with an additiona knot added so that the sutures can be cut adjacerit to it. In obhque or transverse incisions where the muscIe tissue has been severed, the cut muscIe is IooseIy approximated by sutures inserted somewhat further apart. The anterior fascia1

*The surgery and postoperative management referred to was performed at the Bronx Veterans HospitaI New York City by Dr. Baker during his assignment as assistant chief surgeon and is not to be construed as official or reAecting the views of the Veterans Administration or the Army MedicaI Corps. Presented as a narrated film before the Section of Surgery of the New York Academy of Medicine January 4, 1946. 472

VOL.

I XXIV,

No

4

BaIcer-EarIy

layer is made secure by interrupted No. 24 cotton sutures aIso pIaced about I cm. apart. Maximum reIaxation is extremeIy desirable and necessary to prevent the sutures from puIling through the tissue. Needless to mention, but certainIy of extreme importance, is perfect hemostasis. For this purpose mosquito forceps are used exclusively so that onIy smaI1 portions of tissue are grasped in each bite. Fine cotton ligatures, usuaIIy No. 60 to IOO, are used to replace the hemostats but cautery is often used for this purpose. The skin is sutured by whatever method suits the operator’s taste. AI1 patients are aIIowed out of bed the morning of the first postoperative day except when definite contraindications are present. These, in addition to those aIready mentioned, are shock, severe abdomina1 distention, cardiac decompensation and second side thoracoIumbar sympathectomies and demonstrabIe vasomotor unstabiIity in the upright position. In the extremeJy aged and when puImonary difhcuIties were suspected as in chronic asthmatics, arising was conducted Iate in the afternoon of the operative day. Prior to surgery, specific instructions in the manner of getting out and into bed were given to each patient by the nurse in charge of the ward, and if at a11 possibIe a rehearsa shouId be performed. The method in brief, consists of having the patient turn on his side and winding the bed to a sitting or semisitting position. The feet are then assisted over the edge of the bed by the attendant and with the heIp of the nurse the patients sits on the side of the bed. The next step consists of standing for a few seconds and taking deep inspirations. This usuahy resuIts in a productive cough, a very desirabIe feature, the mechanics being the emptying of the accumuIated bronchia secretions often a forerunner to puImonary ateIectasis. The patient then waIks to a chair and sits down for a few minutes, or Ionger if so desired. The return to bed is accompIished in the same manner but in the reverse order. The entire

AmbuIation

American

Journal

(11Surpwv

4-3

procedure is again repeated in the afternoon; at this time most patients usuahy waIk for short distances and stay up somewhat Ionger periods of time. On each successive day the degree of activity is graduahy increased so that at the end of the week the preoperative status is reached.

I ‘I

, Postopedive cbys

FIG. I. Postoperative average rectal temperatures. Note sharp fall in temperatures and absence of secondary elevation.

Examination of the operative Iist in TabIe I reveaIs a tota of 144 cases with one death and eight compIications. The one death resuIted from biIiary and pancreatic Ieakage foIIowing a partia1 gastrectomy for TABLE LIST

OF

I

OPERATIVE

CASES

I

I

Operation

Partial gastrectomy. BiIiary tract surgery.. Herniorrhaphy, all types. Appendectomy.

33

.

Closure of duod. ulcer perf. Gastroenterostomy Drainage of subphrenic absces: Cecostomy.................. Resection of marginal ulcer. Resection of sigmoid colon. Closure of abd. evisceration. IIeostomy . SpIenectomy

Drainage

of app. abscess.

2 2

II

3 2 3

3

42 21

Sympathectomy

I

22

2 2

1

1

474

American Journal of Surgery

BaIcer-EarIy

a deep-seated duodena1 uIcer. The compIications in&de three cases of pneumonia, two foIIowing gastrectomies and one subsequent to a ventra1 herniorrhaphy. AI1 recovered foIIowing treatment. SmaII hematoma formations resuIted in two wounds, one a gastrectomy and the other a ventra1 herniorrhaphy. A singIe wound infection appeared after an appendectomy. PeniciIIin therapy resuIted in a spontaneous resoIution of a probabIe subphrenic abscess which deveIoped after a choIecystectomy. The remaining compIications, a case of parotitis, appeared after gaIIbIadder surgery but compIeteIy subsided under x-ray treatment. It is obvious that none of the compIications mentioned can be attributed of earIy postoperative to the practice rising. The graph in Figure I, dispIaying postoperative temperatures incIudes four groups of abdomina1 operations. This was done for the sake of simplicity. The highest recta1 temperatures for the respective days were averaged and pIotted. It is noted that the highest temperatures occurred on the first postoperative day, foIIowed by a comparativeIy sharp faI1 with norma temperatures occurring on the fifth to the tenth day. The sudden, sharp, increased temperatures often seen on the second, third and fourth days, which are indicative usuaIIy of puImonary compIications, are noticeabIy absent in this group. AIthough the above figures on the resuIts obtained indicate to some degree the ad-

AmbuIation

OCTW3ER, 194,

vantages of earIy post-operative ambuIation, the rea1 benefits can be fuIIy appreciated only by actuaIIy watching a group of patients undergo this form of postoperative management. The improved genera1 appearance of the patient, the absence of abdomina1 distention, the reduced necessity of catheterization and gastric decompression and the very infrequent need for oxygen therapy makes a vivid impression on the surgeon as to the astounding progress postsurgica1 patients make when conditions are made as physioIogica1 as possibIe. In concIusion it may be said that early postoperative rising foIIowing abdomina1 surgery minimizes the frequency of postoperative complications, aids in the faster restoration of the norma state physicaIIy and mentaIIy and in no apparent way interferes with norma wound heaIing. REFERENCES

LEITHAUSER, D. J. Early rising and ambulatory activity after operation. Arch. Surg., 42: 1086, ,941. MCMICHAEL. J. and MCGIBBON. J. P. PosturaI changes in the l&g volume. J. Cl&. SC., 4: 175, 1939. I POWERS, JOHN H. The abuse of rest as a therapeutic measure in surgery. J. A. M. A., 125: IoTg-1083, 1944.

RIES, EMIL. Some radical changes in the after treatment of celiotomy cases. J. A. M. A., 33: 454, r8gg. SHAFER, PAUL W. and DRAGSTEDT, LESTER R. Early rising foIIowing major surgical operations. Surg., Gynec. 8 Obst., 8 I : 93, I 945. SMITH, L. A., ALLEN, E. V. and CRAIG, W. M. Time required for blood to flow from the arms and from the foot of man to the carotid sinuses. I. Effect of increased intramuscular temperature, exercise, tension, eIevation of Iimbs and sympathectomy. Arch. Surg., 41: 1366-1376, rg4o.