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Topic : Radical abdominal hysterectomy  for a bariatric patient (in operation theatre).

Topic should cover the following areas :

Identifies an appropriate patient for the case review and identifies why they are of concern or interest.

Demonstrates an in-depth analysis of the key patient issues that shaped their intraoperative nursing care.

Critically analyses intraoperative nursing care referring to evidence-based practice, literature, and consensus guidelines

Types of Hysterectomies

A hysterectomy can be defined as a surgical procedure done to take out a uterus from a woman (Magrina, Kho, Weaver, Montero, & Magtibay, 2008, p.88). This could be conducted due to various reasons. Such reasons may include; the uterine fibroids that may be causing bleeding, pain or any other related problem; in the case where the woman’s uterus slides from its initial position to the virginal duct; utterly, cervical or ovarian cancer; endometriosis; unusual virginal blood loss; prolonged genital discomfort; or the stiffening of the uterus. This, however, in a non-cancerous case is considered appropriate after all other possible therapies are proven to be ineffective ( Ko, Muto, Berkowitz, & Feltmate, 2008 p.429).

There are various types of hysterectomy. In choosing the most appropriate form to suit a given case, the involved surgeon is however expected to choose between the two major categories; the removal the uterus as a whole or partially, depending with the reasons as to why hysterectomy is done (Shafer, & Boggess, 2008, p.21).

In a noncancerous situation, supracervical or subtotal hysterectomy. In this hysterectomy, the surgeon removes only the uterus- upper part. In this scenario, the cervix is left in good shape, and in the right position. When this situation, however, becomes more dangerous, the total hysterectomy which involves the elimination of the reproductive organs like the uterus and cervix is recommended (Ghezzi et al., 2013, p.496).

Another case is a radical hysterectomy. These involve removing the whole uterus, the tissues around the womb, the cervix, the top parts of the vagina. In cases where the removal of ovaries is involved, the process is referred to as oophorectomy. The radical hysterectomy is most common in the cases where the women involved or rather the victim has cancer.

Hysterectomy is a surgical treatment mainly applied when dealing with bariatric patients (Shafer, & Boggess, 2008, p.21). When performed to a regular patient, this procedure seems natural and involves minimal complications; however, if implemented on an obese woman, this is very challenging to the involved surgeons and is associated with a lot of difficulties. These number of complications, however, has reduced significantly, due to the recent advancement in the worlds’ technology (Magrina, Kho, Weaver, Montero, & Magtibay, 2008, p.90).

Besides, this is a receptive field of operation, and in ensuring excellence in the outcomes of these surgeries, a thorough understanding of the process is required for the involved nurses. To provide the knowledge of the procedure, qualification of the nurses and experience is mandatory. This is also essential for the adequate provision of perioperative care. This paper will present Mrs S for the case study, an obese patient who is in for a radical abdominal hysterectomy (Ko, Muto, Berkowitz, & Feltmate, 2008 p.429).

Radical Abdominal Hysterectomy for Bariatric Patients

The case triggered attention, as hysterectomy was becoming a common practice in this hospital; with quite many similar cases presented in 1 year. The use of computer-aided technology for the navigation in this type of surgery has been rarely employed.  This case was one of those requiring the technology. This incident presented a very crucial opportunity for the involved nurses and staff involved, to learn one or two new things. The critical treatment concerns which arose throughout the intraoperative stages are addressed and deeply analysed, in the case-study (Magrina et al., 2011, p. 103).

Mrs S, a 50-year-old female patient, was scheduled to have a radical abdominal hysterectomy. This was recommended after being screened for cancer condition and found suffering from cervical cancer. The state was in its' early stage or slightly phase, and therefore the procedure was found the most appropriate for the case as it would help to curb the spread of this cancer to other parts of the body. Mrs S has suffered kidney stones in the past and has as a result undergone surgery, a couple of year ago. Besides, Mrs S had previously experienced a slight increase in heart rate. This patient was advised by a nutrition specialist to check on her diets and make sure she does some workouts on a daily basis, a thing that has slightly reduced her heart rate towards the standard rates. Additionally, Mrs S normal blood pressure was 140/60, categorising her among hypertensive patients. Apart from these, the patient was not suffering from any other co-morbidity conditions and was not under any prescriptions or herbal complements (Hatef, Trussler, & Kenkel, 2010, p. 357).

Researchers have recently argued that the rate at which people suffer cancerous conditions all over the world had been raised by the obesity prevalent. This has mainly been manifested in places such as the U.S., where the obesity occurrence has tripled over the past three decades. According to the most recent studies that focus on investigating the relationships between the rise in cervical cancer and the increase in the obesity occurrences, the findings are not very consistent; thus, they can neither be ignored nor be argued as real, until when there is a solid proof for the case (Ghezzi et al., 2013, p.496).

Upon the completion of the pre-assessment processes, there could be still a chance that a given patient will undergo some complications in the Operation Room. With this in minds, there are some of the matters that potential nurse for a given surgery must be aware of and put them into consideration, especially when selecting a bariatric patient for surgical operation. Therefore, the medics involved carried on with the intraoperative activities with a lot of care (Mendivil, Holloway, & Boggess, 2009, p.114).

Intraoperative Nursing Care

At first, a bariatric OR-table – with the capability of elating and providing the necessary for overweight patients during the operation was availed. This is crucial as patients who suffer obesity are often at high risk of falling-off the Operation-Room table because of instability and the frequently weight-load alterations (Ko, Muto, Berkowitz, & Feltmate, 2008 p.429). With the use of these unique tables which have side allowances to give sustenance to overweight patients, these cases are sporadic.

 The theatre technicians organised the table and placed the hover matt ready for the operation – The Bigger Jell Matt comes with the table and the extra operation table's attachments. Explicit knowledge of the equipment availed for the process and making sure they work as required is very crucial. The nurse involved in the perioperative procedure is expected to have a clear understanding of the structure and the potential problems to be prepared in case such issues arise (Magrina, Kho, Weaver, Montero, & Magtibay, 2008, p.88).

Most frequently hysterectomies are performed through 6-8-inch midline incision or across the lower abdomen near or below the hairline. The scrub person prepared the sterile trolley up to the surgeon preference and organised all the available primary self-retaining retractors to meet the surgeons' demands.  We had multiple bariatric surgeries going on that day; therefore, I was forced to negotiate with other theatres’ representative and surgeons to focus mostly on this particular patient. The main aim of carrying out all these planning and preoperative assessment is to reduce morbidity and mortality rate among the patients involved. The book Walter retractor was found very essential in exposing the intraoperative site with a midline incision. The scrub personnel performed a thorough hand-washing, gowning and glowing, and finally established a surgical field. Afterwards, all the availed items were opened into the sterile area, cautiously.

 The nurses who were present helped to check the expiry dates for each item, changes in sterile indicators and the integrity of the sterile packaging. Scrub scout team ensured to document every accountable piece in the count sheet, throughout the preoperative session. These are items which are likely to be forgotten in the body of the patient, due to their nature; therefore, must be documented in the right manner, before and after the operation. After that, the surgical team took a break, just before the anaesthesia. This has been proven to be crucial in enhancing the confidence of the surgeon, which is essential securing reduced chances of complications associated with hysterectomy, especially when dealing with bariatric patients (Love, & Billett, 2008).

Equipment and Table Arrangements

The other thing was to put ready the specialised instruments and equipment necessary for the conduction of the surgery. For this matter, instrumentation such as larger retractors, long staplers, and large devices, were availed. Proper planning and corroboration among the nurse, surgeon, and anesthesiologist were communicated by the senior surgeon to prevent delays in procedures and also, addressed all the potential problems before they occur (Ahmed et al., 2011, p. 385).

 When Mrs S was transferred to the anaesthetic room, the involved nurses conducted a preoperative checking per the availed preoperative checklist. These nurses checked the patient's identity, the consent and her allergic status. In this stage, if the nurses noticed any adverse reaction or allergic condition with the patient, the nurses are supposed to replace the white identification bands with the red ones. This is in accordance to the standard policy documentation, governing this process. Whenever clinical procedures are conducted for any patient, correct consent and identity are mandatory in the preoperative phase; as this is essential in minimising the possible harm to the patient. Besides, the medical safety check was used in ensuring no error would occur during the process.

Afterwards, the patient was appropriately placed on the OR table ready for the administration of the required anaesthetic drugs. The surgical team again performed a team timeout, before starting the anaesthesia (Oszvald, 2012). Ensuring safe and correct patient positioning is the responsibility of all operating theatre (Horn, Hentschel, Fischer, Peter, & Bilek, 2008, p. 279).  

Before positioning the patient ready for the procedure, the surgical team discussed in details, the operational plans; that is the expected surgery duration, mobility limitations, the weight, the skin condition of the patient, the basic anatomy of the patient, physiological state of the patient and the privacy of the patient. Also, they considered the safety of the patient and the staff before setting off, with the procedure. The nurses involved rechecked to ensure that all the necessary equipment was ready and in the right position. After confirmation that everything was available, Mrs S was positioned supine. This is the most common surgical position, which allows the access to the first body cavities.

Gel heel pads were then positioned below the heels to help in weight-area anticipation. According to Maragos (2009), pads were also kept below the elbows to avoid injury to other sensitive parts of the body. The arm-board was also kept less than 90-degree abduction to prevent brachial plexus damage. The diathermy pad was secured on the right thigh, and also we ensured that the body of the patient was not in contact with any metal. The intermittent calf compression devices that were preoperatively applied were essential in reducing DVT.

Surgical Procedure

After administration of general anaesthesia, patients do not produce body heat; however, the risk of hypothermia was reduced through provision of a warm blanket for the patient and an additional covering the patient with a forced air warming blanket. Hypothermia can cause impaired wound healing and surgical site infection. Throughout the process, Mrs S was placed in a Trendelenburg posture, to improve the surgeon’s visibility. The nurses took the necessary care in ensuring that Mrs S remained safe on the OR table. To achieve this, the nurses used strips, as the patient may also need to be rotated toward the surgeon during the case (Wu et al., 2013, p. 508).

After all these preparations the patient was set for the operation. Use of alcoholic chlorhexidine sterilised the surgical-site. The surgeon in charge did not start the procedure, until when the skin prep was dry and double-checked to ensure the absence of the surgical prep traces. This helped to minimise the chances of getting chemical burns, during the process. The next step involved was to cover the patients with sterile shades. Intensive care was given to the hand-held diathermies. In achieving this, they were placed in a dry favourable sterilised container. This preceded the slitting of the lower side patient's abdomen – by the surgeon. On achieving an adequate exposure, the surgeon put in place a self-retaining retractor in the operational area (Love, & Billett, 2008, p. 403).   

The surgeon also made use of valsalam forceps to hold the uterus and ask the assistant surgeon to use dever retractor to expose the ligaments. In our facility, hysterectomy tray got different types of zeppelin hysterectomy clamps. Zeppelin hysterectomy clamps provided the best performance with superior handling and minimal tissue trauma, once the uterus was removed and hemostasis had occurred. After the removal of the uterus, there was also the removal of the cervix and the upper part of the vagina – called the cuff, was sutured and closed. After that, a 14 f Blakes drain was placed and secured with a suture.

Right before the closure of the cavity, the circulation nurses together with the nurses in charge of the instruments carried an item count to ensure that there were no items forgotten in the body of the patient. Upon count conclusion, the number was vocally told, confirmed and approved by the in charge surgical team.  A compilation of records on all accountable objects was done, and the surgeon in charge was informed of the correctness of the first count, upon completion. Now, during the closure of the skin, the disposable and other instruments were counted and the message communicated to the surgical team. After the approval of the surgical team, this was recorded on the count sheet (Horn, Hentschel, Fischer, Peter, & Bilek, 2008).

Preparation and Assessment

The management of these items was among the significant responsibilities given to the circulation and instrument nurses. The next step involved the removal of the sharp objects from the trolley and disposing of them in a box set correctly for this purpose – the sharp's box. The application of water-proof dressings and wet sheets was the next step, followed by the replacement of the patient's dress. Mrs S was then covered using a hot sheet (Barbash, & Glied, 2010, p.702).

That was that we had come to the end of Mrs S's surgical and anaesthetic process and the next thing was transferring her to her hospital bed. From there, a series of postoperative evaluation test was carried on. These include; the checking of pressure areas, observation of the integrity of the skin and checking diathermy site frequently to ensure there were no any further reactions. The proper planning of the surgery, the adequate positioning of the patient during the operation and cooperation among the medics involved helped achieve excellent outcomes for Mrs S.

 As a matter of facts this was not a very simple operation; however, we were able to complete it with no complications at all. In the recovery room, the patient was not accompanied by the scrub and scout team. Therefore, the recovery nurses have to skim through the count sheet to get informed about the instruments used in a particular case thus helping them decide how intensive their care for a specific patient would be (Chopin et al., 2009, p. 3060).

Some surgical processes can sometimes involve many complications. For this matter, the planning and assessment for a given surgical pathway should be one that is evidence-based, to acquire the best result out of it. In achieving the best outcomes and in the safest way possible, cooperation among all the medics involved is required. Quality care should also be employed, throughout the process. In Mrs S's case, for instance, the preoperative assessment, explicit evaluation of her situation and putting into consideration the pathophysiology and the potential comorbidities was essential for the preoperative team in establishing for the patient regarding her requirements (Magrina et al., 2008, p. 90).

Standard policies brought to existence to govern in the establishment of appropriate care for patients. These policies are essential as the communicate uniformity in the care provided for every patient in every place thus improving the quality and safety in the services offered across the nations. Most of the complications encountered during surgeries are mainly a result of poor quality of the care provided. Now, in accordance to WHO (2014), 50% of these complications could be avoided if the proper caution is taken throughout the surgical process. These can be further minimised through keen observation of the standard guidelines provided and regular review and issuing updates on the risks associated with the procedure (Kyo et al., 2009, p. 1658).

Postoperative Care

References.

Ahmed, K., Wang, T. T., Patel, V. M., Nagpal, K., Clark, J., Ali, M., ... & Paraskeva, P. (2011). The role of single-incision laparoscopic surgery in abdominal and pelvic surgery: a systematic review. Surgical Endoscopy, 25(2), 378-396.

Barbash, G. I., & Glied, S. A. (2010). New technology and health care costs—the case of robot-assisted surgery. New England Journal of Medicine, 363(8), 701-704.

Bratzler, D. W., Dellinger, E. P., Olsen, K. M., Perl, T. M., Auwaerter, P. G., Bolon, M. K., ... & Steinberg, J. P. (2013). Clinical practice guidelines for antimicrobial prophylaxis in surgery. Surgical infections, 14(1), 73-156.

Chopin, N., Malaret, J. M., Lafay-Pillet, M. C., Fotso, A., Foulot, H., & Chapron, C. (2009). Total laparoscopic hysterectomy for benign uterine pathologies: obesity does not increase the risk of complications. Human Reproduction, 24(12), 3057-3062.

Gala, R. B., Margulies, R., Steinberg, A., Murphy, M., Lukban, J., Jeppson, P., ... & Schaffer, J. (2014). The systematic review of robotic surgery in gynaecology: robotic techniques compared with laparoscopy and laparotomy. Journal of minimally invasive gynaecology, 21(3), 353-361.

Ghezzi, F., Cromi, A., Uccella, S., Bogani, G., Sturla, D., Serati, M., & Bolis, P. (2013). Nerve-sparing minilaparoscopic versus conventional laparoscopic radical hysterectomy plus systematic pelvic lymphadenectomy in cervical cancer patients. Surgical innovation, 20(5), 493-501.

Hatef, D. A., Trussler, A. P., & Kenkel, J. M. (2010). The procedural risk for venous thromboembolism in abdominal contouring surgery: a systematic review of the literature. Plastic and reconstructive surgery, 125(1), 352-362.

Horn, L. C., Hentschel, B., Fischer, U., Peter, D., & Bilek, K. (2008). Detection of micrometastases in pelvic lymph nodes in patients with carcinoma of the cervix uteri using step sectioning: frequency, topographic distribution, and prognostic impact. Gynecologic oncology, 111(2), 276-281.

Ko, E. M., Muto, M. G., Berkowitz, R. S., & Feltmate, C. M. (2008). Robotic versus open radical hysterectomy: a comparative study at a single institution. Gynecologic oncology, 111(3), 425-430.

Kusy, M., Obrzut, B., & Kluska, J. (2013). Application of gene expression programming and neural networks to predict adverse events of radical hysterectomy in cervical cancer patients. Medical & biological engineering & computing, 51(12), 1357-1365.

Kyo, S., Mizumoto, Y., Takakura, M., Hashimoto, M., Mori, N., Ikoma, T., ... & Inoue, M. (2009). Experience and efficacy of a bipolar vessel sealing system for radical abdominal hysterectomy. International Journal of Gynecological Cancer, 19(9), 1658-1661.

Liu, H. P., Zhang, Y. C., Zhang, Y. L., Yin, L. N., & Wang, J. (2011). Drain versus no-drain after gastrectomy for patients with advanced gastric cancer: systematic review and meta-analysis. Digestive surgery, 28(3), 178-189.

Love, A. L., & Billett, H. H. (2008). Obesity, bariatric surgery, and iron deficiency: genuine, real, right and related. American journal of haematology, 83(5), 403-409.

Maeso, S., Reza, M., Mayol, J. A., Blasco, J. A., Guerra, M., Andradas, E., & Plana, M. N. (2010). Efficacy of the Da Vinci surgical system in abdominal surgery compared with that of laparoscopy: a systematic review and meta-analysis, 126-130.

Magrina, J. F., Kho, R. M., Weaver, A. L., Montero, R. P., & Magtibay, P. M. (2008). Robotic radical hysterectomy: comparison with laparoscopy and laparotomy. Gynecologic oncology, 109(1), 86-91.

Magrina, J. F., Zanagnolo, V., Noble, B. N., Kho, R. M., & Magtibay, P. (2011). Robotic approach for ovarian cancer: perioperative and survival results and comparison with laparoscopy and laparotomy. Gynecologic oncology, 121(1), 100-105.

Mendivil, A., Holloway, R. W., & Boggess, J. F. (2009). The emergence of robotic-assisted surgery in gynecologic oncology: An American perspective. Gynecologic oncology, 114(2), S24-S31.

Nam, J. H., Park, J. Y., Kim, D. Y., Kim, J. H., Kim, Y. M., & Kim, Y. T. (2011). Laparoscopic versus open radical hysterectomy in early-stage cervical cancer: long-term survival outcomes in a matched cohort study. Annals of Oncology, 23(4), 903-911.

Shafer, A., & Boggess, J. F. (2008). Robotic-assisted endometrial cancer staging and radical hysterectomy with the da Vinci® surgical system. Gynecologic oncology, 111(2), S18-S23.

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Wu, Y., Liu, F., Tang, H., Wang, Q., Chen, L., Wu, H., ... & Goldsworthy, M. (2013). The analgesic efficacy of subcostal transversus abdominis plane block compared with thoracic epidural analgesia and intravenous opioid analgesia after radical gastrectomy. Anesthesia & Analgesia, 117(2), 507-513.

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