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Ventilatory patterns after vertical and transverse upper abdominal incisions
Ventilatory Patterns after Vertical and Transverse Upper Abdominal Incisions Charles David Williams, MD, Fort Worth, Texas Jerold B. Brenowitz, MD, Fort Worth, Texas
A remarkably high number of upper abdominal procedures are associated with postoperative pulmonary complications [I]. These complicationsatelectasis, pulmonary infection, and arterial hypoxemia-relate to surgical trauma, as pain, immobility, muscle injury, and abnormal respiratory patterns decrease the vital capacity and reduce the ability to cough and clear secretions. Transverse rather than vertical incisions are believed to reduce these complications [2]. Rees and Coller [3] reported a fourfold reduction in pulmonary complications after upper abdominal surgery when transverse rather than vertical incisions were used. A study was undertaken to determine whether this purported advantage truly exists. Material and Methods Twenty-four patients undergoing elective upper abdominal surgical procedures agreed to participate. A detailed history of previous pulmonary disease, environmental exposure, and smoking was combined with physical examination and chest x-ray studies to characterize each patient before study. Twelve patients in group I (vertical incisions) all had midline incisions through the upper abdomen. Group II (transverse incisions) included six patients with subcostel incisions and six patients with transrectus, bucket-handle type incisions. Group II was subdivided into IIa (subcostal) and IIb (transrectus). (Figures lA, lB, and 1C.) The procedures in group I included cholecystectomy with common duct exploration vagotomy and antrectoFrom the Department of Surgery, John Peter Smith Hospital, Fort Worth, Texas. Reprint requests should be addressed to C. D. WiUiams. M.D., Department of Surgery, John Peter Smith Hospital, 1500 South Main Street, Fort Worth, Texas 76104. Presented at the Twenty-Seventh Annual Meeting of the Southwestern Surgical Congress, Las Vegas, Nevada, April 21-24. 1975.
voflnne 130, December 1975
my for hiatal hernia repair cholecystectomy (two patients), vagotomy and antrectomy (two), total abdominal colectomy and cholecystostomy, small bowel and colon resection, right transverse colectomy, left sigmoid colectomy, transverse colectomy, and left transverse colectomy. The procedures in group IIa (subcostal) included cholecystectomy (three patients), splenectomy, and cholecystectomy with common duct exploration (two); in group IIb (transrectus), colectomy with small bowel resection, subtotal gastrectomy (two), gastrectomy and cholecystectomy, vagotomy and antrectomy, drainage of pancreatic abscess, and cholecystectomy with vagotomy and antrectomy. All patients received general endotracheal anesthesia, which was timed from induction to extubation in the recovery room or the operating room. Surgical procedures were believed to compare in complexity with the average anesthesia time (2.5 hours in group I and 2.6 hours in group II). Patients in group I averaged forty-seven years of age, with a range from fourteen to eighty years. Group II was comparable with an average age of forty-four years and a range from twenty-six to sixty-five years. Preoperative and postoperative arterial blood gases were analyzed in most patients. Preoperatively and again twenty-four hours postoperatively, patients underwent spirometry utilizing the Collins Lung Modular Unit. Vital capacity, tidal volume, functional residual capacity, maximum breathing capacity, residual volumes, and flow rates were measured. Lung volumes were measured using the helium dilution method. Before their postoperative study, all patients were given analgesics according to body weight. Both preoperative and postoperative studies were performed with the patient in a sitting position. Nasogastric tubes when present were removed during the postoperative study. Results of postoperative spirometry as compared with preoperative spirometry were calculated as a per cent change with each patient serving as his own control. Data were statistically examined using the Mann-Whitney U-test for comparing two samples.
725
Williams and Brenowitz
Figure 1. A, vertical Incision ( group I ); B, subcostal incision (group Ma); C, transrectus incision ( group Mb).
TABLE
I Per Cent Change in Spirometry
Data in Group
I (vertical
incisions)
Arterial PO, (mm Hg) Patient
Preoperative
WB EP MA BM JM BD GB I-W TM PD JG SH Average
90 87 90 107 93 112 102 99 100 129 105 99 101
Postoperative 74 72
... iii 76 100 82 94 88 97 66 85
Vital Capacity -48 -59 -48 -43 -69 -57 -31 -47 -52 -58 -51 -24 -4 9%
Results Tables I, II, and III depict the per cent change in spirometry measurements in patients postoperatively. Vital capacity demonstrated no significant difference with -49 per cent change in group I as compared to -43 per cent change in group II. Tidal volume, likewise, showed no significant difference with -8 per cent change in group I and -29 per cent change in group II. Functional residual capacity was not significantly different with -3 per cent change in group I and -1 per cent change in group II. Maximal breathing capacity was reduced markedly in both group I (-45 per cent change) and group II (-42 per cent change). Group II was divided into patients with subcostal (group IIa) and transrectus (group IIb) incisions, and again no statistically significant difference was noted. Vital capacity demonstrated a -41 per cent change in group IIa and -45 per cent
726
Tidal Volume -13 +9 -34 +35 -44 -30 +5 -15 -54 -17 +11 +53 -8%
Functional Residual Capacity -18 -18 -7 -57 +38 -22 +43 +13 0 $4’ +19 -3%
Maximal Breathing Capacity -44 -24 -60 -52 -86 -38 -33 -59 -55 -58 -39 +10 -45%
change in group IIb. Tidal volume demonstrated a -28 per cent change in group IIa and -30 per cent change in group IIb. Functional residual capacity demonstrated a +4 per cent change in group IIa and -5 per cent change in group IIb. Maximal breathing capacity demonstrated a -40 per cent change in group IIa and -43 per cent change in group IIb. None of these differences is statistically significant. (Table IV.) Spirometry patterns are frequently depicted on the Miller quadrant (Figure 2) [4]. The preoperative to postoperative data show relatively equal restrictive defects, believed to be due to postoperative pain. Table V compares preoperative and postoperative arterial POs values; these differences are likewise insignificant, with POs decreasing in identical amounts and no patient exhibiting clinically significant hypoxemia. None of the twenty-four patients had a significant pulmonary complication.
The American Journal ol Surgery
Upper Abdominal Incisions
TABLE II
Per Cent Change in Spirometry Data in Group II (transverse incisions)
__-Arterial PO, (mm Hg) Patient
Preoperative
MM GH LM BC BD AC EF JM cc BZ MD AC
54 120 104 104 115 96 101 109 130 87 114 90
Average
TABLE III
Vital
Postoperative 77
+2 -64 -18 -42 -35 -61 -39 -59 -41 -68 -52 -37 -43%
... ‘99 105 77 100 83 81 62 86 ‘86
102
Age Anesthesia time (hr) Vital capacity (%A)Tidal volume (%A) Functional residual capacity (%A) Maximal breathing capacity (%A) * Differences
not statistically
Group
I
Group
47 2.5 -49% -8% -3%
2.6 -430/Q* -29%* -l%*
-45%
-42%*
-13 -43 +7 -15 -36 -43 -34 -34 -28 -8 -36 -70 -29%
TABLE IV
Comparison of Spirometry Data in Groups I and II
Measurement
Tidal Volume
Capacity
II
44
significant
Maximal Breathing Capacity -27 -39 -19 -48 -38 -54 -45 -25 -42 -43 -62 -56 -42%
Comparison of Subgroups Ila (subcostal) and I lb (transrectus)
Measurement Vital capacity (“/on) Tidal volume (“/,A) Functional residual capacity (“ha) ’ Maximal breathing capacity (%A)
Age (range) Anesthesia
Functional Residual Capacity ___ -34 -4 +40 -37 -24 +23 0 +17 +12 +30 0 -33 -1%
Group I -49% -1 1% -3%
-4 1% -28% +4%
-45%” -300/o* -5o/o*
-45%
-40%
-43%*
(14:: time
* Differences
(hr)
Group Ila Group Ilb _____
80) 2.5
not statistically
(26::
65) ‘2.6
(264t: 65) 2.6
significant
Comments’ Pulmonary complications after upper abdominal surgery have been appropriately emphasized. Postoperative ventilatory patterns recently reported by Ali et al [5] indicate that clinical pulmonary complications correlate closely with a decrease in functional residual capacity. If functional residual capacity does not decrease significantly, then small airway closure and resultant atelectasis has not occurred. If transverse incisions do result in fewer respiratory complications than vertical incisions, spirometry patterns should reflect this difference. This study reveals no significant differences in twentyfour patients with transverse and vertical incisions, making this assertion less tenable. The lack of significant reduction in functional residual capacity in patients of both groups correlates well with the lack of pulmonary complications. Factors known to decrease functional resid-
Figure
2,
Spirometry patterns depicted on the Miller
quadrant.
727
Williams and Brenowitz
TABLE
V
Preoperative
and Postoperative
Oxygen
Tension
GroupI Preoperative Arterial PO, (average) Range Functional residual capacity
(%A)
ual capacity, namely circulatory overload, immobility, and retained secretions, were prevented in these patients, as indicated by spirometry data. This was accomplished by careful attention to intake and output of intravenous fluid volume, early mobilization of patients, and appropriate chest physiotherapy. Absence of postoperative hypoxemia avoids the necessity for high oxygen concentrations, which may contribute to reduction in functional residual capacity by enhancing reabsorption atelectasis. Summary and Conclusions Preoperative and postoperative respiratory patterns in twelve patients with vertical and twelve patients with transverse incisions in the upper abdomen were examined. Preoperatively, as well as twenty-four hours postoperatively, patients underwent spirometry measuring vital capacity, tidal volume, functional residual capacity, and maximal breathing capacity. A moderately severe restrictive pattern of respiratory function was noted but without a significant difference in any measurement between the two groups. Transverse incisions in the upper abdomen may have advantages over vertical incisions relative to wound strength and cosmetic result, but the postoperative respiratory mechanics indicate postoperative respiratory,complications are related more to the location than the direction of the incision. Careful avoidance of factors that reduce functional residual capacity will result in fewer postoperative complications. Acknowledgment: We gratefully acknowledge the assistance of Patricia Ann Jackson, CPT, Coordinator of Cardiopulmonary Services, for her help in compiling the pulmonary function results for our study. References 1. Wightman JAK: A prospective survey of the incidence of postoperative pulmonary complications. Br J Surg 55: 85, 1968. 2. Schwartz SI: Complications, p 365. Principals of Surgery, 1st ed. New York, McGraw-Hill, 1969.
728
Postoperative
101 129 to 87
85 104to66
-
-3%
Preoperative
Group II Postoperative
102 130 to 54
86 105 to 77 -1%
3. Rees VL, Coller FA: Anatomic and clinical study of the transverse abdominal incision. Arch Surg 47: 136, 1943. 4. Miller WF, Wu N, Johnson RL Jr: Convenient method of evaluating pulmonary ventilatory function with single breath test. Anesthesiology 17: 480, 1965. 5. Ali J, Weisel RD, Layug AB, Kripke BJ, Hechtman HB: Consequences of postoperative alterations in respiratory mechanics. Am J Surg 128: 376, 1974.
Discussion Kent C. Westbrook (Little Rock, AR) I have always believed that transverse incision is superior to vertical in almost all respects, that is, that it provided better exposure, closed easier, was stronger, and produced fewer pulmonary complications. The authors’ data show that all upper abdominal incisions produce a restrictive pulmonary defect. There was no difference in those with transverse and vertical incisions. I would like to ask Doctor Williams to comment on three questions. First, were these patients comparable with regard to smoking and pulmonary function? Second, does he think these data can be extrapolated to include patients with severe pulmonary disease preoperatively? Third, is there anything that we can do as surgeons to decrease this restrictive defect and hope that we can prevent pulmonary complications? Barry Fisher (Las Vegas, NV): I would like to ask whether pain is the cause of the restrictive component. Was the use of the self-retaining retractor comparable in both vertical and horizontal incisions? Charles David Williams (closing): In regard to smoking, about half of each group smoked. I do not know whether these figures can be correlated with what happens to the patient with severe pulmonary disease. I do not know what can be done to decrease complications: reduce anesthesia time and reduce the amount of retraction. Whether self-retaining retractors are worse than residents and interns, I do not know. As to how many patients in this group had self-retaining retractors employed, probably almost all. Again, I believe less retraction is required for the average patient through a transverse incision, but in this group of patients we could not demonstrate any spirometric difference. I am sure the restrictive defect is due to pain almost completely; all these patients were given an equivalent dose of either morphine or meperidine (DemeroF) before their postoperative study in an effort to reduce this variable, but this will always be a variable in such a study.
The American Journal of Surgery
A remarkably high number of upper abdominal procedures are associated with postoperative pulmonary complications [I]. These complicationsatelectasis, pulmonary infection, and arterial hypoxemia-relate to surgical trauma, as pain, immobility, muscle injury, and abnormal respiratory patterns decrease the vital capacity and reduce the ability to cough and clear secretions. Transverse rather than vertical incisions are believed to reduce these complications [2]. Rees and Coller [3] reported a fourfold reduction in pulmonary complications after upper abdominal surgery when transverse rather than vertical incisions were used. A study was undertaken to determine whether this purported advantage truly exists. Material and Methods Twenty-four patients undergoing elective upper abdominal surgical procedures agreed to participate. A detailed history of previous pulmonary disease, environmental exposure, and smoking was combined with physical examination and chest x-ray studies to characterize each patient before study. Twelve patients in group I (vertical incisions) all had midline incisions through the upper abdomen. Group II (transverse incisions) included six patients with subcostel incisions and six patients with transrectus, bucket-handle type incisions. Group II was subdivided into IIa (subcostal) and IIb (transrectus). (Figures lA, lB, and 1C.) The procedures in group I included cholecystectomy with common duct exploration vagotomy and antrectoFrom the Department of Surgery, John Peter Smith Hospital, Fort Worth, Texas. Reprint requests should be addressed to C. D. WiUiams. M.D., Department of Surgery, John Peter Smith Hospital, 1500 South Main Street, Fort Worth, Texas 76104. Presented at the Twenty-Seventh Annual Meeting of the Southwestern Surgical Congress, Las Vegas, Nevada, April 21-24. 1975.
voflnne 130, December 1975
my for hiatal hernia repair cholecystectomy (two patients), vagotomy and antrectomy (two), total abdominal colectomy and cholecystostomy, small bowel and colon resection, right transverse colectomy, left sigmoid colectomy, transverse colectomy, and left transverse colectomy. The procedures in group IIa (subcostal) included cholecystectomy (three patients), splenectomy, and cholecystectomy with common duct exploration (two); in group IIb (transrectus), colectomy with small bowel resection, subtotal gastrectomy (two), gastrectomy and cholecystectomy, vagotomy and antrectomy, drainage of pancreatic abscess, and cholecystectomy with vagotomy and antrectomy. All patients received general endotracheal anesthesia, which was timed from induction to extubation in the recovery room or the operating room. Surgical procedures were believed to compare in complexity with the average anesthesia time (2.5 hours in group I and 2.6 hours in group II). Patients in group I averaged forty-seven years of age, with a range from fourteen to eighty years. Group II was comparable with an average age of forty-four years and a range from twenty-six to sixty-five years. Preoperative and postoperative arterial blood gases were analyzed in most patients. Preoperatively and again twenty-four hours postoperatively, patients underwent spirometry utilizing the Collins Lung Modular Unit. Vital capacity, tidal volume, functional residual capacity, maximum breathing capacity, residual volumes, and flow rates were measured. Lung volumes were measured using the helium dilution method. Before their postoperative study, all patients were given analgesics according to body weight. Both preoperative and postoperative studies were performed with the patient in a sitting position. Nasogastric tubes when present were removed during the postoperative study. Results of postoperative spirometry as compared with preoperative spirometry were calculated as a per cent change with each patient serving as his own control. Data were statistically examined using the Mann-Whitney U-test for comparing two samples.
725
Williams and Brenowitz
Figure 1. A, vertical Incision ( group I ); B, subcostal incision (group Ma); C, transrectus incision ( group Mb).
TABLE
I Per Cent Change in Spirometry
Data in Group
I (vertical
incisions)
Arterial PO, (mm Hg) Patient
Preoperative
WB EP MA BM JM BD GB I-W TM PD JG SH Average
90 87 90 107 93 112 102 99 100 129 105 99 101
Postoperative 74 72
... iii 76 100 82 94 88 97 66 85
Vital Capacity -48 -59 -48 -43 -69 -57 -31 -47 -52 -58 -51 -24 -4 9%
Results Tables I, II, and III depict the per cent change in spirometry measurements in patients postoperatively. Vital capacity demonstrated no significant difference with -49 per cent change in group I as compared to -43 per cent change in group II. Tidal volume, likewise, showed no significant difference with -8 per cent change in group I and -29 per cent change in group II. Functional residual capacity was not significantly different with -3 per cent change in group I and -1 per cent change in group II. Maximal breathing capacity was reduced markedly in both group I (-45 per cent change) and group II (-42 per cent change). Group II was divided into patients with subcostal (group IIa) and transrectus (group IIb) incisions, and again no statistically significant difference was noted. Vital capacity demonstrated a -41 per cent change in group IIa and -45 per cent
726
Tidal Volume -13 +9 -34 +35 -44 -30 +5 -15 -54 -17 +11 +53 -8%
Functional Residual Capacity -18 -18 -7 -57 +38 -22 +43 +13 0 $4’ +19 -3%
Maximal Breathing Capacity -44 -24 -60 -52 -86 -38 -33 -59 -55 -58 -39 +10 -45%
change in group IIb. Tidal volume demonstrated a -28 per cent change in group IIa and -30 per cent change in group IIb. Functional residual capacity demonstrated a +4 per cent change in group IIa and -5 per cent change in group IIb. Maximal breathing capacity demonstrated a -40 per cent change in group IIa and -43 per cent change in group IIb. None of these differences is statistically significant. (Table IV.) Spirometry patterns are frequently depicted on the Miller quadrant (Figure 2) [4]. The preoperative to postoperative data show relatively equal restrictive defects, believed to be due to postoperative pain. Table V compares preoperative and postoperative arterial POs values; these differences are likewise insignificant, with POs decreasing in identical amounts and no patient exhibiting clinically significant hypoxemia. None of the twenty-four patients had a significant pulmonary complication.
The American Journal ol Surgery
Upper Abdominal Incisions
TABLE II
Per Cent Change in Spirometry Data in Group II (transverse incisions)
__-Arterial PO, (mm Hg) Patient
Preoperative
MM GH LM BC BD AC EF JM cc BZ MD AC
54 120 104 104 115 96 101 109 130 87 114 90
Average
TABLE III
Vital
Postoperative 77
+2 -64 -18 -42 -35 -61 -39 -59 -41 -68 -52 -37 -43%
... ‘99 105 77 100 83 81 62 86 ‘86
102
Age Anesthesia time (hr) Vital capacity (%A)Tidal volume (%A) Functional residual capacity (%A) Maximal breathing capacity (%A) * Differences
not statistically
Group
I
Group
47 2.5 -49% -8% -3%
2.6 -430/Q* -29%* -l%*
-45%
-42%*
-13 -43 +7 -15 -36 -43 -34 -34 -28 -8 -36 -70 -29%
TABLE IV
Comparison of Spirometry Data in Groups I and II
Measurement
Tidal Volume
Capacity
II
44
significant
Maximal Breathing Capacity -27 -39 -19 -48 -38 -54 -45 -25 -42 -43 -62 -56 -42%
Comparison of Subgroups Ila (subcostal) and I lb (transrectus)
Measurement Vital capacity (“/on) Tidal volume (“/,A) Functional residual capacity (“ha) ’ Maximal breathing capacity (%A)
Age (range) Anesthesia
Functional Residual Capacity ___ -34 -4 +40 -37 -24 +23 0 +17 +12 +30 0 -33 -1%
Group I -49% -1 1% -3%
-4 1% -28% +4%
-45%” -300/o* -5o/o*
-45%
-40%
-43%*
(14:: time
* Differences
(hr)
Group Ila Group Ilb _____
80) 2.5
not statistically
(26::
65) ‘2.6
(264t: 65) 2.6
significant
Comments’ Pulmonary complications after upper abdominal surgery have been appropriately emphasized. Postoperative ventilatory patterns recently reported by Ali et al [5] indicate that clinical pulmonary complications correlate closely with a decrease in functional residual capacity. If functional residual capacity does not decrease significantly, then small airway closure and resultant atelectasis has not occurred. If transverse incisions do result in fewer respiratory complications than vertical incisions, spirometry patterns should reflect this difference. This study reveals no significant differences in twentyfour patients with transverse and vertical incisions, making this assertion less tenable. The lack of significant reduction in functional residual capacity in patients of both groups correlates well with the lack of pulmonary complications. Factors known to decrease functional resid-
Figure
2,
Spirometry patterns depicted on the Miller
quadrant.
727
Williams and Brenowitz
TABLE
V
Preoperative
and Postoperative
Oxygen
Tension
GroupI Preoperative Arterial PO, (average) Range Functional residual capacity
(%A)
ual capacity, namely circulatory overload, immobility, and retained secretions, were prevented in these patients, as indicated by spirometry data. This was accomplished by careful attention to intake and output of intravenous fluid volume, early mobilization of patients, and appropriate chest physiotherapy. Absence of postoperative hypoxemia avoids the necessity for high oxygen concentrations, which may contribute to reduction in functional residual capacity by enhancing reabsorption atelectasis. Summary and Conclusions Preoperative and postoperative respiratory patterns in twelve patients with vertical and twelve patients with transverse incisions in the upper abdomen were examined. Preoperatively, as well as twenty-four hours postoperatively, patients underwent spirometry measuring vital capacity, tidal volume, functional residual capacity, and maximal breathing capacity. A moderately severe restrictive pattern of respiratory function was noted but without a significant difference in any measurement between the two groups. Transverse incisions in the upper abdomen may have advantages over vertical incisions relative to wound strength and cosmetic result, but the postoperative respiratory mechanics indicate postoperative respiratory,complications are related more to the location than the direction of the incision. Careful avoidance of factors that reduce functional residual capacity will result in fewer postoperative complications. Acknowledgment: We gratefully acknowledge the assistance of Patricia Ann Jackson, CPT, Coordinator of Cardiopulmonary Services, for her help in compiling the pulmonary function results for our study. References 1. Wightman JAK: A prospective survey of the incidence of postoperative pulmonary complications. Br J Surg 55: 85, 1968. 2. Schwartz SI: Complications, p 365. Principals of Surgery, 1st ed. New York, McGraw-Hill, 1969.
728
Postoperative
101 129 to 87
85 104to66
-
-3%
Preoperative
Group II Postoperative
102 130 to 54
86 105 to 77 -1%
3. Rees VL, Coller FA: Anatomic and clinical study of the transverse abdominal incision. Arch Surg 47: 136, 1943. 4. Miller WF, Wu N, Johnson RL Jr: Convenient method of evaluating pulmonary ventilatory function with single breath test. Anesthesiology 17: 480, 1965. 5. Ali J, Weisel RD, Layug AB, Kripke BJ, Hechtman HB: Consequences of postoperative alterations in respiratory mechanics. Am J Surg 128: 376, 1974.
Discussion Kent C. Westbrook (Little Rock, AR) I have always believed that transverse incision is superior to vertical in almost all respects, that is, that it provided better exposure, closed easier, was stronger, and produced fewer pulmonary complications. The authors’ data show that all upper abdominal incisions produce a restrictive pulmonary defect. There was no difference in those with transverse and vertical incisions. I would like to ask Doctor Williams to comment on three questions. First, were these patients comparable with regard to smoking and pulmonary function? Second, does he think these data can be extrapolated to include patients with severe pulmonary disease preoperatively? Third, is there anything that we can do as surgeons to decrease this restrictive defect and hope that we can prevent pulmonary complications? Barry Fisher (Las Vegas, NV): I would like to ask whether pain is the cause of the restrictive component. Was the use of the self-retaining retractor comparable in both vertical and horizontal incisions? Charles David Williams (closing): In regard to smoking, about half of each group smoked. I do not know whether these figures can be correlated with what happens to the patient with severe pulmonary disease. I do not know what can be done to decrease complications: reduce anesthesia time and reduce the amount of retraction. Whether self-retaining retractors are worse than residents and interns, I do not know. As to how many patients in this group had self-retaining retractors employed, probably almost all. Again, I believe less retraction is required for the average patient through a transverse incision, but in this group of patients we could not demonstrate any spirometric difference. I am sure the restrictive defect is due to pain almost completely; all these patients were given an equivalent dose of either morphine or meperidine (DemeroF) before their postoperative study in an effort to reduce this variable, but this will always be a variable in such a study.
The American Journal of Surgery