Appendicitis and Fracture

8/6/2019 Appendicitis and Fracture

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Appendicitis Case Study

Introduction

The appendix is a small fingerlike appendage about 10 cm (4 in) long, attached to thececum just below the ileocecal valve. No definite functions can be assigned to it inhumans. The appendix fills with food and empties as regularly as does the cecum, ofwhich it is small, so that it is prone to become obstructed and is particularly vulnerable toinfection (appendicitis).

Appendicitisis the most common cause of acute inflammation in the right lower quadrantof the abdominal cavity. About 7% of the population will have appendicitis at some timein their lives, males are affected more than females, and teenagers more than adults. Itoccurs most frequently between the age of 10 and 30.

The disease is more prevalent in countries in which people consume a diet low in fiberand high in refined carbohydrates.

The lower quadrant pain is usually accompanied by a low-grade fever, nausea, and oftenvomiting. Loss of appetite is common. In up to 50% of presenting cases, local tendernessis elicited at Mc Burneys point applied located at halfway between the umbilicus and theanterior spine of the Ilium.

Rebound tenderness (ex. Production or intensification of pain when pressure is released)may be present. The extent of tenderness and muscle spasm and the existence of theconstipation or diarrhea depend not so much on the severity of the appendiceal infection

as on the location of the appendix.

If the appendix curls around behind the cecum, pain and tenderness may be felt in thelumbar region. Rovsings sign maybe elicited by palpating the left lower quadrant. If theappendix has ruptured, the pain become more diffuse, abdominal distention develops as aresult of paralytic ileus, and the patient condition become worsens.

Constipation can also occur with an acute process such as appendicitis. Laxativeadministered in the instance may result in perforation of the in flared appendix. In generala laxative should never be given when a persons has fever, nausea or pain.

Anatomy and Physiology of Digestive System

The mouth, or oral cavity, is the first part of the digestive tract. It is adapted to receivefood by ingestion, break it into small particles by mastication, and mix it with saliva. Thelips, cheeks, and palate form the boundaries. The oral cavity contains the teeth andtongue and receives the secretions from the salivary glands.
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Lips and CheeksThe lips and cheeks help hold food in the mouth and keep it in place for chewing. Theyare also used in the formation of words for speech. The lips contain numerous sensoryreceptors that are useful for judging the temperature and texture of foods.

PalateThe palate is the roof of the oral cavity. It separates the oral cavity from the nasal cavity.The anterior portion, the hard palate, is supported by bone. The posterior portion, the softpalate, is skeletal muscle and connective tissue. Posteriorly, the soft palate ends in aprojection called the uvula. During swallowing, the soft palate and uvula move upward todirect food away from the nasal cavity and into the oropharynx.

Tongue

The tongue manipulates food in the mouth and is used in speech. The surface is coveredwith papillae that provide friction and contain the taste buds.

TeethA complete set of deciduous (primary) teeth contains 20 teeth. There are 32 teeth in acomplete permanent (secondary) set. The shape of each tooth type corresponds to the wayit handles food.

Pharynx

The pharynx is a fibromuscular passageway that connects the nasal and oral cavities tothe larynx and esophagus. It serves both the respiratory and digestive systems as achannel for air and food. The upper region, the nasopharynx, is posterior to the nasalcavity. It contains the pharyngeal tonsils, or adenoids, functions as a passageway for air,and has no function in the digestive system. The middle region posterior to the oral cavity

is the oropharynx. This is the first region food enters when it is swallowed. The openingfrom the oral cavity into the oropharynx is called the fauces. Masses of lymphoid tissue,the palatine tonsils, are near the fauces. The lower region, posterior to the larynx, is thelaryngopharynx, or hypopharynx. The laryngopharynx opens into both the esophagus andthe larynx.

EsophagusThe esophagus is a collapsible muscular tube that serves as a passageway between thepharynx and stomach. As it descends, it is posterior to the trachea and anterior to thevertebral column. It passes through an opening in the diaphragm, called the esophagealhiatus, and then empties into the stomach. The mucosa has glands that secrete mucus tokeep the lining moist and well lubricated to ease the passage of food. Upper and loweresophageal sphincters control the movement of food into and out of the esophagus. Thelower esophageal sphincter is sometimes called the cardiac sphincter and resides at theesophagogastric junction

Stomachthe stomach, which receives food from the esophagus, is located in the upper leftquadrant of the abdomen. The stomach is divided into the fundic, cardiac, body, and


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pyloric regions. The lesser and greater curvatures are on the right and left sides,respectively, of the stomach.

Small IntestineThe small intestine extends from the pyloric sphincter to the ileocecal valve, where it

empties into the large intestine. The small intestine finishes the process of digestion,absorbs the nutrients, and passes the residue on to the large intestine. The liver,gallbladder, and pancreas are accessory organs of the digestive system that are closelyassociated with the small intestine. The small intestine is divided into the duodenum,jejunum, and ileum. The small intestine follows the general structure of the digestive tractin that the wall has a mucosa with simple columnar epithelium, submucosa, smoothmuscle with inner circular and outer longitudinal layers, and serosa. The absorptivesurface area of the small intestine is increased by plicae circulares, villi, and microvilli.Exocrine cells in the mucosa of the small intestine secrete mucus, peptidase, sucrase,maltase, lactase, lipase, and enterokinase. Endocrine cells secrete cholecystokinin andsecretin. The most important factor for regulating secretions in the small intestine is the

presence of chyme. This is largely a local reflex action in response to chemical andmechanical irritation from the chyme and in response to distention of the intestinal wall.This is a direct reflex action, thus the greater the amount of chyme, the greater thesecretion.

Large IntestineThe large intestine is larger in diameter than the small intestine. It begins at the ileocecaljunction, where the ileum enters the large intestine, and ends at the anus. The largeintestine consists of the colon, rectum, and anal canal. The wall of the large intestine hasthe same types of tissue that are found in other parts of the digestive tract but there aresome distinguishing characteristics. The mucosa has a large number of goblet cells but

does not have any villi. The longitudinal muscle layer, although present, is incomplete.The longitudinal muscle is limited to three distinct bands, called teniae coli, that run theentire length of the colon. Contraction of the teniae coli exerts pressure on the wall andcreates a series of pouches, called haustra, along the colon. Epiploic appendages, piecesof fat-filled connective tissue, are attached to the outer surface of the colon. Unlike thesmall intestine, the large intestine produces no digestive enzymes. Chemical digestion iscompleted in the small intestine before the chyme reaches the large intestine. Functionsof the large intestine include the absorption of water and electrolytes and the eliminationof feces.

Rectum and AnusThe rectum continues from the signoid colon to the anal canal and has a thick muscularlayer. It follows the curvature of the sacrum and is firmly attached to it by connectivetissue. The rectum and ends about 5 cm below the tip of the coccyx, at the beginning ofthe anal canal. The last 2 to 3 cm of the digestive tract is the anal canal, which continuesfrom the rectum and opens to the outside at the anus. The mucosa of the rectum is foldedto form longitudinal anal columns. The smooth muscle layer is thick and forms theinternal anal sphincter at the superior end of the anal canal. This sphincter is under


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involuntary control. There is an external anal sphincter at the inferior end of the analcanal. This sphincter is composed of skeletal muscle and is under voluntary control.

Clinical Manifestations

1. Generalized or localized abdominal pain in the epigastric or periumbilical areasand upper right abdomen. Within 2 to 12 hours, the pain localizes in the rightlower quadrant and intensity increases.

2. Anorexia, moderate malaise, mild fever, nausea and vomiting.3. Usually constipation occurs ; occasionally diarrhea.4. Rebound tenderness, involuntary guarding, generalized abdominal rigidity.

Diagnostic Evaluation

1. Physical examination consistent with clinical manifestations.2. WBC count reveal moderate leukocytosis (10,000 to 16,000/mm3) with shift to

the left (increased immature neutrophils).3. Urinalysis rule out urinary disorders.4. Abdominal x-ray may visualize shadow consistent with fecalith in appendix;

perforation will reveal free air.5. Abdominal ultrasound or CT scan can visualize appendix and rule out other

conditions, such as diverticulitis and crohns disease. Focused appendiceal CT canquickly evaluate for appendicitis.

Medications

Analgesics

Intravenous fluids replacements Analgesics

Treatment

Appendectomy is the effective treatment if peritonitis develops treatment involves.

GI Intubation Parenteral replacement of IV fluids and electrolytes Administration of Antibiotics

Surgery is indicated if appendicitis is diagnosed. Antibiotics and IV fluids areadministered until surgery is performed analgesics can be administered after thediagnosed is made.

An appendectomy (surgical removal of the appendix) is performed as soon as possible todecrease the risk of perforation. T he appendectomy may be performed under a (generalor spinal anesthetics) with a low abdominal incisions or by (laparoscopy) which isrecently highly effective method.


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Complications

The major complication of appendicitis is perforation of the appendix, which can lead toperitonitis, abscess formation (collection of purulent material), or portal pylephlebitis,which is septic thrombosis of the portal vein caused by vegetative emboli that arise from

septic intestines.

Perforation generally occurs 24 hours after the onset of pain symptoms include a fever of37.7 degree Celsius or 100 degree Fahrenheit or greater, a toxic appearance andcontinued abdominal pain or tenderness.

Nursing Interventions

1. Monitor frequently for signs and symptoms of worsening condition, indicatingperforation, abscess, or peritonitis (increasing severity of pain, tenderness,rigidity, distention, absent bowel sounds, fever, malaise, and tachycardia).

2. Notify health care provider immediately if pain suddenly ceases, this indicatesperforation, which is a medical emergency.3. Assist patient to position of comfort such as semi-fowlers with knees are flexed.4. Restrict activity that may aggravate pain, such as coughing and ambulation.5. Apply ice bag to abdomen for comfort.6. Avoid indiscriminate palpation of the abdomen to avoid increasing the patients

discomfort.7. Promptly prepare patient for surgery once diagnosis is established.8. Explain signs and symptoms of postoperative complications to report-elevated

temperature, nausea and vomiting, or abdominal distention; these may indicateinfection.

9. Instruct patient on turning, coughing, or deep breathing, use of incentivespirometer, and ambulation. Discuss purpose and continued importance of thesemaneuvers during recovery period.

10. Teach incisional care and avoidance of heavy lifting or driving until advised bythe surgeon.

11. Advise avoidance of enemas or harsh laxatives; increased fluids and stoolsofteners may be used for postoperative constipation.

Discharge Planning

M Antibiotics for infection

Analgesic agent (morphine) can be given for pain after the surgery

E Within 12 hrs of surgery you may get up and move around.You can usually return to normal activities in 2-3 weeks after laparoscopic surgery.

T Pretreatment of foods with lactase preparations (e.g. lactacid drops) before ingestioncan reduce symptoms.

Ingestion of lactase enzyme tablets with the first bite of food can reduce symptoms.


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H To care wound perform dressing changes and irrigations as prescribe avoid takinglaxative or applying heat to abdomen when abdominal pain of unknown cause isexperienced.

Reinforce need for follow-up appointment with the surgeonCall your physician for increased pain at the incision site

O Document bowel sounds and the passing of flatus or bowel movements (these aresigns of the return of peristalsis)

Watch for surgical complications such as continuing pain or fever, which indicate anabscess or wound dehiscence

Stitches removed between fifth and seventh day (usually in physicians office)

D Liquid or soft diet until the infection subsidesSoft diet is low in fiber and easily breaks down in the gastrointestinal tract

AppendicitisIs inflammation of the vermiform appendix caused by an obstruction attributable by

infection, stricture, fecal mass, foreign body or tumor.It can affect by either gender at any age, but is most common in males ages 10 to 30.It is the most common disease requiring surgery. If left untreated, appendicitis may

progress to abscess, perforation, subsequent peritonitis, and death.

Assessment

1. Generalized or localized abdominal pain occurs in the epigastric or periumbilicalareas in the upper right abdomen.

2. Within 2 to 12 hours, the pain localizes in the right lower quadrant and intensityincreases.

3. Anorexia, fever, nausea, vomiting, and constipation may also occur.4. Bowel sounds may be diminished.


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5. Tenderness anywhere in the right lower quadrant.o Often localized at McBurneys point, just below midpoint of line between

umbilicus and iliac crest on the right side.o Guarding and rebound tenderness to right lower quadrant and referred

rebound when palpating the left lower quadrant.

6. Positive Psoas Sign.o Have the patient attempt to raise the right thigh against the pressure of

your hand placed over the right knee.o Increased abdominal pain indicates inflammation of the psoas muscle in

acute appendicitis.7. Positive Obturator Sign.

o Flex the patients right hip and knee and rotate the leg internally.

o Hypogastric pain indicates inflammation of the obturator muscle.

Diagnostic Evaluation

1. WBC count shows moderate leukocytosis (10,000 to 16,000/mm) with shift to theleft (increased immature neutrophils) in WBC differential.

2. Urinalysis rules out urinary disorders.3. Abdominal X-ray visualizes shadow consistent with fecalith in appendix.4. Pelvic sonogram rules out ovarian cyst or ectopic pregnancy.

Surgical Interventions

1. Surgical removal is the only effective treatment (simple appendectomy orlaparoscopic appendectomy).

2. Preoperatively, maintain patient on bed rest, NPO status, I.V. hydration, possible

anti-biotic prophylaxis, and analgesia, as directed.

Nursing Interventions

1. Monitor frequently for signs and symptoms of worsening condition, indicatingperforation, abscess, or peritonitis (increasing severity of pain, tenderness,rigidity, distention, absent bowel sounds, fever, malaise, and tachycardia).

2. Notify health care provider immediately if pain suddenly ceases, this indicatesperforation, which is a medical emergency.

3. Assist patient to position of comfort such as semi-fowlers with knees are flexed.4. Restrict activity that may aggravate pain, such as coughing and ambulation.

5. Apply ice bag to abdomen for comfort.6. Avoid indiscriminate palpation of the abdomen to avoid increasing the patientsdiscomfort.

7. Promptly prepare patient for surgery once diagnosis is established.8. Explain signs and symptoms of postoperative complications to report-elevated

temperature, nausea and vomiting, or abdominal distention; these may indicateinfection.


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9. Instruct patient on turning, coughing, or deep breathing, use of incentivespirometer, and ambulation. Discuss purpose and continued importance of thesemaneuvers during recovery period.

10. Teach incisional care and avoidance of heavy lifting or driving until advised bythe surgeon.

11. Advise avoidance of enemas or harsh laxatives; increased fluids and stoolsofteners may be used for postoperative constipation.

Appendectomy

DEFINITION

Appendectomy is the surgical removal of the appendix. The appendix is a worm-shapedhollow pouch attached to the cecum, the beginning of the large intestine.

PURPOSE

Appendectomies are performed to treat appendicitis, an inflamed and infected appendix.

Description

After the patient is anesthetized, the surgeon can remove the appendix either by using thetraditional open procedure (in which a 23 in [57.6 cm] incision is made in the


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abdomen) or via laparoscopy (in which four 1-in [2.5-cm] incisions are made in theabdomen).

Traditional open appendectomy

When the surgeon uses the open approach, he makes an incision in the lower right sectionof the abdomen. Most incisions are less than 3 in (7.6 cm) in length. The surgeon thenidentifies all of the organs in the abdomen and examines them for other disease orabnormalities. The appendix is located and brought up into the wounds. The surgeonseparates the appendix from all the surrounding tissue and its attachment to the cecum,and then removes it. The site where the appendix was previously attached, the cecum, isclosed and returned to the abdomen. The muscle layers and then the skin are sewntogether.

Laparoscopic appendectomy

When the surgeon performs a laparoscopic appendectomy, four incisions, each about 1 in(2.5 cm) in length, are made. One incision is near the umbilicus, or navel, and one isbetween the umbilicus and the pubis. Two other incisions are smaller and are on the rightside of the lower abdomen. The surgeon then passes a camera and special instrumentsthrough these incisions. With the aid of this equipment, the surgeon visually examines theabdominal organs and identifies the appendix. The appendix is then freed from all of itsattachments and removed. The place where the appendix was formerly attached, thececum, is stitched. The appendix is removed through one of the incisions. Theinstruments are removed and then all of the incisions are closed.
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To remove a diseased appendix, an incision is made in the patient's lower abdomen

(A). Layers of muscle and tissue are cut, and large intestine, or colon, is visualized

(B). The appendix is located (C), tied, and removed (D). The muscle and tissue

layers are stitched (E). (Illustration by GGS Inc.

)

Studies and opinions about the relative advantages and disadvantages of each method aredivided. A skilled surgeon can perform either one of these procedures in less than onehour. However, laparoscopic appendectomy (LA) always takes longer than traditionalappendectomy (TA). The increased time required to do a LA the greater the patient'sexposure to anesthetics, which increases the risk of complications. The increased timerequirement also increases the fees charged by the hospital foroperating room time andby the anesthesiologist. Since LA also requires specialized equipment, the fees for its usealso increase the hospital charges. Patients with either operation have similar painmedication needs, begin eating diets at comparable times, and stay in the hospital

equivalent amounts of time. LA is of special benefit in women in whom the diagnosis isdifficult and gynecological disease (such as endometriosis, pelvic inflammatory disease,ruptured ovarian follicles, ruptured ovarian cysts, and tubal pregnancies) may be thesource of pain and not appendicitis. If LA is done in these patients, the pelvic organs canbe more thoroughly examined and a definitive diagnosis made prior to removal of theappendix. Most surgeons select either TA or LA based on the individual needs andcircumstances of the patient.

Insurance plans do cover the costs of appendectomy. Fees are charged independently bythe hospital and the physicians. Hospital charges include fees for operating and recoveryroom use, diagnostic and laboratory testing, as well as the normal hospital room charges.

Surgical fees vary from region to region and range between $250750. Theanesthesiologist's fee depends on the health of the patient and the length of the operation.

Preparation

Once the diagnosis of appendicitis is made and the decision has been made to perform anappendectomy, the patient undergoes the standard preparation for an operation. Thisusually takes only one to two hours and includes signing the operative consents, patientidentification procedures, evaluation by the anesthesiologist, and moving the patient tothe operating area of the hospital. Occasionally, if the patient has been ill for a prolongedperiod of time or has had protracted vomiting, a delay of few to several hours may be

necessary to give the patient fluids andantibiotics .

Aftercare

Recovery from an appendectomy is similar to other operations. Patients are allowed to eatwhen the stomach and intestines begin to function again. Usually the first meal is a clearliquid dietbroth, juice, soda pop, and gelatin. If patients tolerate this meal, the nextmeal usually is a regular diet. Patients are asked to walk and resume their normal physical
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activities as soon as possible. If TA was done, work and physical education classes maybe restricted for a full three weeks after the operation. If a LA was done, most patients areable to return to work and strenuous activity within one to three weeks after theoperation.

Abdominal explorationNormal anatomy

The abdomen contains many vital organs: the stomach, the small intestine (jejunum andileum), the large intestine (colon), the liver, the spleen, the gallbladder, the pancreas, theuterus, the fallopian tubes, the ovaries, the kidneys, the ureters, the bladder, and manyblood vessels (arteries and veins).

Indication

The surgical exploration of the abdomen, also called an exploratory laparotomy, may berecommended when there is abdominal disease from an unknown cause (to diagnose), ortrauma to the abdomen (gunshot or stab-wounds, or "blunt trauma").

Diseases that may be discovered by exploratory laparotomy include:

inflammation of the appendix (acute appendicitis) inflammation of the pancreas (acute or chronic pancreatitis) pockets of infection (retroperitoneal abscess, abdominal abscess, pelvic abscess)) presence of uterine tissue (endometrium) in the abdomen (endometriosis) inflammation of the Fallopian tubes (salpingitis)


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scar tissue in the abdomen (adhesions) cancer (of the ovary, colon, pancreas, liver) inflammation of an intestinal pocket (diverticulitis) hole in the intestine (intestinal perforation) pregnancy in the abdomen instead of uterus (ectopic pregnancy)

to determine theextent of certaincancers(Hodgkin'slymphoma)

Incision

While the patient is deepasleep and pain-free(general anesthesia), thesurgeon makes anincision into theabdomen and examinesthe abdominal organs.Different incisions are

sometimes used depending on the circumstance. Common incisions include a verticalmidline incision, and right or left upper or lower quadrant transverse incisions. Tissuesamples (biopsies) can be taken and diseased areas can be evaluated. When the treatment

is complete, the incision is closed with either sutures or skin staples.


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Aftercare

The outcome from surgery varies with the disease process, as does the course andduration of recovery. Exploratory laparotomy is most commonly performed for trauma,severe abdominal pain of unknown cause, intestinal obstruction, inflammatory diseases

like appendicitis and diverticulitis, and cancer of any of the abdominal organs.

Anastomosis

An anastomosis (plural anastomoses, fromgr. , communicating

opening) in a network of streams is the

reconnection of two streams that

previously branched out, such as blood

vessels or leaf veins. The term is used in


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medicine, biology, mycology and

geology.

Anastomosis is the connection of two structures.[1]

It refers to connections betweenbloodvessels or between other tubular structures such as loops ofintestine. In circulatoryanastomoses, many arteries naturally anastomose with each other, for example theinferior epigastric artery and superior epigastric artery.The circulatory anastomosis isfurther divided into arterial and venous anastomosis. Arterial anastomosis includes actualarterial anastomosis (e.g. palmar arch, plantar arch) and potential arterial anastomosis(e.g. coronary arteries and cortical branch of cerebral arteries). An example ofsurgicalanastomosis occurs when a segment of intestine is resected and the two remaining endsare sewn or stapled together (anastomosed), for example Roux-en-Y anastomosis. Theprocedure is referred to as intestinal anastomosis.

Pathological anastomosis results from trauma or disease and may involve veins,arteries,or intestines. These are usually referred to asfistulas. In the cases of veins or arteries,traumatic fistulas usually occur between artery and vein. Traumatic intestinal fistulasusually occur between two loops of intestine (entero-enteric fistula) or intestine andskin(enterocutaneous fistula). Portacaval anastomosis, by contrast, is an anastomosis betweena vein of theportal circulation and a vein of the systemic circulation, which allows bloodto bypass the liver in patients withportal hypertension, often resulting in hemorrhoids,esophageal varices, orcaput medusae.

Surgical anastomosis

Gastrointestinal (GI) tract:Esophagus,stomach,small bowel,large bowel,bile ducts,andpancreas. Virtually all elective resections of gastrointestinal organs are followed byanastomoses to restore continuity;pancreaticoduodenectomy is considered a massiveoperation, in part, because it requires three separate anastomoses (stomach, biliary tractand pancreas to small bowel). Bypass operations on the GI tract, once rarely performed,are the cornerstone ofbariatric surgery. The widespread use of mechanical suturingdevices (linear and circular staplers) changed the face of gastrointestinal surgery.
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In all cases of intestinal obstruction, the intestine involved is carefully examined. If anyparts of the intestine look unhealthy from lack of blood flow during the period ofobstruction, they are removed and the healthy ends are reconnected.

A patient's recovery depends on the cause of the intestinal obstruction and the length oftime prior to relief of the obstruction. The outcome is usually good if the obstruction istreated before damage (ischemia) or death (necrosis) of the bowel occurs.

Intestinal anastomosis

Patients suffering from irresolvable intestinal obstruction or devitalization are amongthose that benefit from intestinal resection and the procedure described here, whichreconnects the intestine end-to-end.

INTESTINAL ANASTOMOSIS is an important surgical procedure that connects twosections of the intestines once a diseased portion has been removed. A key concern is toprevent leakage at the anastomosis site and subsequent peritonitis, but this complicationcan be avoided if the procedure is done correctly and preventive measures are taken.

INDICATIONS

Indications for intestinal resection and anastomosis include devitalization, irresolvableobstruction or segmental dysfunction, or irreparable perforation of the intestines.1-4 Theseconditions can result from a variety of causes, including foreign bodies, intussusception,neoplasia, abscess, trauma, volvulus or torsion, herniation, neurologic disorders, chronicconstipation (e.g. feline idiopathic megacolon), or ulceration secondary to corticosteroidadministration.4 Intestinal resection and anastomosis are most frequently performed indogs and cats because of foreign bodies, neoplasia, and trauma.4,5


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SURGICAL OPTIONS

Intestinal anastomosis can be performed with sutures, staples, or anastomotic devices.1-3,6,7

Intestinal anastomoses can be strengthened by omentalization or serosal patch grafttechniques, which reduce the risk of postoperative leakage and improve vascularity.1

Sutures

A sutured anastomosis is the most common option because of the availability and cost ofmaterials and familiarity with the procedure. Perform sutured anastomoses withappositional suture patterns since inversion reduces the lumen diameter and eversion canincrease adhesion formation.2,3,8 Avoid double-layer closure because of luminalcompromise, poor submucosal apposition, avascular necrosis, and prolonged healingtime.2

Monofilament sutures are recommended for sutured anastomosis because multifilament

material has more drag and is more likely to promote inflammation.

2

Althoughnonabsorbable suture can be used for anastomosis, avoid it when using continuous suturepatterns because of potential luminal extrusion and subsequent foreign bodyentrapment.2,9 Swaged, tapercut needles penetrate easily through the submucosa, which isthe holding layer of the intestines, and limit tissue trauma.5 Tapercut needles have a roundshaft and a cutting point that can penetrate both delicate and dense tissue. Taper needles,which are more commonly found in practice than tapercut needles, are also acceptable forintestinal surgery.2

Simple continuous suture patterns are quick to perform and provide better approximationthan interrupted patterns.2,5,10 Histologically, mucosal eversion is reported in 66% of

simple interrupted closures while inversion, eversion, or malalignment is seen in only38% of simple continuous closures.2,6 With both techniques, mucosal eversion can bereduced by trimming excess mucosa or by using a modified Gambee suture pattern.5

Staples

Using surgical staplers to anastomose intestines reduces surgery time and providesbursting strength, lumen diameter, and healing similar to anastomosis with simpleinterrupted sutures.6 Complications are reported in 13% to 14% of animals undergoingstapled anastomoses and include severe hemorrhage (13%), postoperative leakage at theanastomosis site (8%), and localized abscess formation at the staple line (4%).11,12

Anastomosis ring and laparoscopy

Other options for anastomosis include biofragmentable intestinal anastomosis ringplacement and laparoscopic-assisted anastomosis.7,13 Little information is available in theveterinary literature on the clinical use of these techniques.


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TECHNIQUE FOR SINGLE-LAYER CONTINUOUS END-TO-END

INTESTINAL ANASTOMOSIS

For general perioperative considerations when performing this procedure,including diagnostic testing, patient monitoring, and postoperative

support, please see the symposium introduction.

To begin the procedure, isolate the affected area of intestines withmoistened laparotomy pads. Ligate the blood vessels to the transectionsites with absorbable suture (Figure 1); ligate the arcuate branches alongthe mesenteric surface by taking suture bites around the vesselsimmediately adjacent to the proposed transection sites. Milk luminalcontents away from the area, and clamp the diseased intestines, along with

2 or 3 cm of healthy tissue, with Kelly or Carmalt forceps. Confine the luminal contentswithin the retained healthy intestines by using noncrushing forceps (e.g. Doyen intestinalforceps), umbilical tape, or Penrose drain tourniquets that collapse the intestinal lumen

but do not inhibit blood flow. Alternatively, an assistant can occlude the intestinal lumennear the proposed transection sites with index and middle fingers. Place the occludingdevices at least 3 cm away from the anastomotic ends to prevent interference withsuturing. Transect the intestines adjacent to the ligated arcuate vessels. Luminal disparitycan be corrected at this time by increasing the angle of the cut on the narrower segmentof intestines so that the antimesenteric border of the intestines is shorter than themesenteric border (Figure 2).

Place stay sutures at the mesenteric and antimesenteric borders (Figure 3) to ensure thatthe remaining sutures are properly spaced and to facilitate intestinalmanipulation.5 Start a simple continuous suture pattern at the

mesenteric border, leaving the suture end long. Take bites about 3mm wide and 3 mm apart, depending on the size of the intestines.2

If mucosa begins to evert, use a modified Gambee suture pattern:Pass the needle full thickness through the intestinal wall and thenback through the mucosa on the near side. Then insert the needle atthe mucosa-submucosa border on the far side to push the mucosainto the lumen, and pass the needle full thickness back out that side.Continue the pattern to the antimesenteric surface, and tie it in aknot to prevent a purse-string effect (Figure 4). Flip over theintestines to expose the opposite surface, and continue suturing back to the initialmesenteric suture and tie (Figures 5 & 6). Then close the mesentery with a simplecontinuous pattern of 4-0 absorbable suture material (Figure 7); take suture bites at theedge of the mesentery to avoid damaging the intestinal blood vessels.

Check the anastomotic site for leaks by distending the segment with sterile saline injectedinto the lumen while continuing to occlude the intestinal segments distal to the site. Sealany leaks with interrupted sutures; the omentum can be tacked over the anastomotic siteby using a separate omental flap for each side.

Figures 1,2

Figures 3,4,5,6,7
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COMPLICATIONS

Potential complications include dehiscence, peritonitis from leakage or necrosis, ileus,recurrence of clinical disease, or short-bowel syndrome. Anastomotic leakage is reportedin 3% of animals undergoing continuous sutured anastomosis and up to 11% of animals

undergoing interrupted sutured anastomosis; leakage is more likely to be associated withanastomoses performed for foreign body removal or resection of traumatizedintestines.4,5,14 The risk for anastomotic leakage also increases in patients with preexistingperitonitis or hypoalbuminemia.4 Dehiscence and leakage can be reduced by ensuringadequate blood supply, reducing tension across the anastomotic site, and providingadequate apposition.5

Ileus may result from chronic intestinal distention, excessive tissue handling, pain, sepsis,opioid use, or electrolyte imbalances.2 Magnesium, potassium, calcium, and fluidimbalances should be corrected, and food should be offered as soon as possible.Prokinetics such as metoclopramide, erythromycin, and lidocaine may be useful for

stimulating motility.

5,15

Resecting more than 70% of the intestines may result in short-bowel syndrome,depending on the site of the resection and the health of the remaining intestines.2,16

Maldigestion and malabsorption from reduced surface area will result in persistent waterydiarrhea and weight loss. Dietary modifications, including increasing soluble fibercontent, may reduce clinical signs.2

Anastomosis of the ileum to the distal colon or rectum in cats with megacolon may resultin the development of watery feces because of loss of the ileocolic valve, which reducesaccess of colonic bacteria into the small intestines.3 Additionally, loss of ileum may

reduce water absorption capacity of the intestines. Colocolic anastomosis results in moretension across the anastomotic site because the vascular pedicle to the ascending colon isshorter than that to the ileum.

Laparotomy, exploratory

Definition

A laparotomy is a large incision made into the abdomen. Exploratory laparotomy is usedto visualize and examine the structures inside of the abdominal cavity.

Purpose

Exploratory laparotomy is a method of abdominal exploration, a diagnostic tool thatallows physicians to examine the abdominal organs. The procedure may be recommendedfor a patient who has abdominal pain of unknown origin or who has sustained an injury tothe abdomen. Injuries may occur as a result of blunt trauma (e.g., road traffic accident) or


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penetrating trauma (e.g., stab or gunshot wound). Because of the nature of the abdominalorgans, there is a high risk of infection if organs rupture or are perforated. In addition,bleeding into the abdominal cavity is considered a medical emergency. Exploratorylaparotomy is used to determine the source of pain or the extent of injury and performrepairs if needed.

Laparotomy may be performed to determine the cause of a patient's symptoms or toestablish the extent of a disease. For example, endometriosis is a disorder in which cellsfrom the inner lining of the uterus grow elsewhere in the body, most commonly on thepelvic and abdominal organs. Endometrial growths, however, are difficult to visualizeusing standard imaging techniques such as x ray, ultrasound technology, or computedtomography (CT) scanning. Exploratory laparotomy may be used to examine theabdominal and pelvic organs (such as the ovaries, fallopian tubes, bladder, and rectum)for evidence of endometriosis. Any growths found may then be removed.

Exploratory laparotomy plays an important role in the staging of certain cancers. Cancer

staging is used to describe how far a cancer has spread. A laparotomy enables a surgeonto directly examine the abdominal organs for evidence of cancer and remove samples oftissue for further examination. When laparotomy is used for this use, it is called staginglaparotomy or pathological staging.

Some other conditions that may be discovered or investigated during exploratorylaparotomy include:

cancer of the abdominal organs peritonitis (inflammation of the peritoneum, the lining of the abdominal cavity) appendicitis (inflammation of the appendix)

pancreatitis (inflammation of the pancreas) abscesses (a localized area of infection) adhesions (bands of scar tissue that form after trauma or surgery) diverticulitis (inflammation of sac-like structures in the walls of the intestines) intestinal perforation ectopic pregnancy (pregnancy occurring outside of the uterus) foreign bodies (e.g., a bullet in a gunshot victim) internal bleeding

Demographics

Because laparotomy may be performed under a number of circumstances to diagnose ortreat numerous conditions, no data exists as to the overall incidence of the procedure.


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Description

The patient is usually placed under general anesthesia for the duration of surgery. Theadvantages to general anesthesia are that the patient remains unconscious during theprocedure, no pain will be experienced nor will the patient have any memory of the

procedure, and the patient's muscles remain completely relaxed, allowing safer surgery.

Incision

Once an adequate level of anesthesia has been reached, the initial incision into the skinmay be made. A scalpel is first used to cut into the superficial layers of the skin. Theincision may be median (vertical down the patient's midline), paramedian (verticalelsewhere on the abdomen), transverse (horizontal), T-shaped, or curved, according to theneeds of the surgery. The incision is then continued through the subcutaneous fat, the

abdominal muscles, and finally, the peritoneum. Electrocautery is often used to cutthrough the subcutaneous tissue as it

During a

laparotomy,

and an incision

is made into the

patient's

abdomen (A).

Skin andconnective

tissue called

fascia is divided

(B). The lining

of the

abdominal

cavity, the

peritoneum, is

cut, and any

exploratory

procedures areundertaken

(C). To close

the incision, the

peritoneum,

fascia, and skin

are stitched (E). (Illustration by GGS Inc.


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)has the ability to stop bleeding as it cuts. Instruments called retractors may be used tohold the incision open once the abdominal cavity has been exposed.

Abdominal exploration

The surgeon may then explore the abdominal cavity for disease or trauma. The abdominalorgans in question will be examined for evidence of infection, inflammation, perforation,abnormal growths, or other conditions. Any fluid surrounding the abdominal organs willbe inspected; the presence of blood, bile, or other fluids may indicate specific diseases orinjuries. In some cases, an abnormal smell encountered upon entering the abdominalcavity may be evidence of infection or a perforated gastrointestinal organ.

If an abnormality is found, the surgeon has the option of treating the patient beforeclosing the wound or initiating treatment after exploratory surgery. Alternatively, samplesof various tissues and/or fluids may be removed for further analysis. For example, if

cancer is suspected, biopsies may be obtained so that the tissues can be examinedmicroscopically for evidence of abnormal cells. If no abnormality is found, or ifimmediate treatment is not needed, the incision may be closed without performing anyfurther surgical procedures.

During exploratory laparotomy for cancer, a pelvic washing may be performed; sterilefluid is instilled into the abdominal cavity and washed around the abdominal organs, thenwithdrawn and analyzed for the presence of abnormal cells. This may indicate that acancer has begun to spread (metastasize).

Closure

Upon completion of any exploration or procedures, the organs and related structures arereturned to their normal anatomical position. The incision may then be sutured (stitchedclosed). The layers of the abdominal wall are sutured in reverse order, and the skinincision closed with sutures or staples.

Diagnosis/Preparation

Various diagnostic tests may be performed to determine if exploratory laparotomy isnecessary. Blood tests or imaging techniques such as x ray, computed tomography (CT)scan, and magnetic resonance imaging (MRI) are examples. The presence ofintraperitoneal fluid (IF) may be an indication that exploratory laparotomy is necessary;one study indicated that IF was present in nearly three-quarters of patients with intra-abdominal injuries.
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Directly preceding the surgical procedure, an intravenous (IV) line will be placed so thatfluids and/or medications may be administered to the patient during and after surgery. AFoley catheter will be inserted into the bladder to drain urine. The patient will also meetwith the anesthesiologist to go over details of the method of anesthesia to be used.

Aftercare

The patient will remain in the postoperative recovery room for several hours where hisor her recovery can be closely monitored. Discharge from the hospital may occur in aslittle as one to two days after the procedure, but may be later if additional procedureswere performed or complications were encountered. The patient will be instructed towatch for symptoms that may indicate infection, such as fever, redness or swellingaround the incision, drainage, and worsening pain.

Risks

Risks inherent to the use of general anesthesia include nausea, vomiting, sore throat,fatigue, headache, and muscle soreness; more rarely, blood pressure problems, allergicreaction, heart attack, or stroke may occur. Additional risks include bleeding, infection,injury to the abdominal organs or structures, or formation of adhesions (bands of scartissue between organs).

Normal results

The results following exploratory laparotomy depend on the reasons why it wasperformed. The procedure may indicate that further treatment is necessary; for example,if cancer was detected, chemotherapy, radiation therapy, or more surgery may berecommended. In some cases, the abnormality is able to be treated during laparotomy,and no further treatment is necessary.

Morbidity and mortality rates

The operative and postoperative complication rates associated with exploratorylaparotomy vary according to the patient's condition and any additional proceduresperformed.

Read more: Laparotomy, Exploratory - procedure, recovery, blood, tube, pain,complications, infection, pregnancy, heart, cells, risk, cancer, nausea, Definition,
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Purpose, Demographics, Descriptionhttp://www.surgeryencyclopedia.com/La-Pa/Laparotomy-Exploratory.html#ixzz1BE4ostcf

Exploratory laparotomy

An exploratory laparotomy is the standard of care in various blunt and penetratingtrauma situations in which there may be multiple life-threatening injuries, and in manydiagnostic situations in which the operation is undertaken in search of a unifying causefor multiple signs and symptoms of disease.

The trauma ex-lap is the most comprehensive ex-lap, usually undertaken after evidenceof internal bleeding (a positive FAST, DPL, or other overwhelming evidence for internalhemorrhage). A midline incision is carried down to thelinea alba and the fascia isincised. The peritoneum is entered and the immediate, life-threatening bleeding iscontrolled. The lateral, superior, and anterior surfaces of the liverare packed with

sponges, and the superior and lateral spaces around thespleenare similarly packed. Thebowel is run from the ligament of Trietz to the terminal ileum. The gastrocolic ligamentis incised and the lesser sac is explored, including the posteriorstomachand the anteriorpancreas. The surface of the spleen is examined for evidence of laceration and fracture.The liver is similarly examined. If necessary,Cattell and Mattox maneuvers may beperformed to expose retroperitoneal structures. If the duodenum is at risk, a Kochermaneuvermay be performed to examine the posteriorduodenumand the head of thepancreas.

The ex-lap can lead immediately to a number of other procedures, including splenectomy,repairs of the vena cava, repairs of the aorta,distal pancreatectomy,enterotomy and

bowel repair,left hemicolectomy,right hemicolectomy,pyloric exclusion, gastricdiversion, partial or complete nephrectomy, and the "trauma Whipple".

Laparotomy

A laparotomy is asurgical procedure involving a large incision through theabdominalwall to gain access into theabdominal cavity. It is also known as coeliotomy.
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In diagnostic laparotomy (most often referred to as anexploratory laparotomy andabbreviated Ex-Lap), the nature of the disease is unknown, and laparotomy is deemed thebest way to identify the cause.

In therapeutic laparotomy, a cause has been identified (e.g.peptic ulcer,colon cancer)and laparotomy is required for its therapy.

Usually, only exploratory laparotomy is considered a stand-alone surgical operation.When a specific operation is already planned, laparotomy is considered merely the firststep of the procedure.

Spaces accessed

Depending on incision placement, laparotomy may give access to any abdominal organ

or space, and is the first step in any major diagnostic or therapeutic surgical procedure ofthese organs, which include:

the lower part of the digestive tract (thestomach,duodenum,jejunum,ileum andcolon)

the liver,pancreas and spleen thebladder the female reproductive organs (theuterus and ovaries) the retroperitoneum (thekidneys, theaorta, abdominal lymph nodes)

Types of incisions

Midline

The most common incision for laparotomy is the midline incision, a vertical incisionwhich follows the linea alba.

The upper midline incision usually extends from the xiphoid process to theumbilicus.
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A typical lower midline incision is limited by the umbilicus superiorly and by thepubic symphysis inferiorly.

Sometimes a single incision extending from xiphoid process to pubic symphysisis employed, especially intrauma surgery.

Midline incisions are particularly favoured in diagnostic laparotomy, as they allow wideaccess to most of the abdominal cavity.

Girdiron's incision

An oblique incision made in the right lower quadrant of the abdomen, classically used forappendectomy

McBurney incision

This is the incision used for open appendectomy, it begins 2 to 5 centimeters above theanterior superior iliac spine and continues to a point one-third of the way to the umbilicus(McBurney's point). Thus, the incision is parallel to the external oblique muscle of theabdomen which allows the muscle to be split in the direction of it's fibers, decreasinghealing times and scar tissue formation. This incision heals rapidly and generally hasgood cosmetic results, especially if a subcuticular suture is used to close the skin.

Midline incision

The most common incision for laparotomy is the midline incision, a vertical incisionwhich follows the linea alba.

The upper midline incision usually extends from the xiphoid process to theumbilicus.

A typical lower midline incision is limited by the umbilicus superiorly and by thepubic symphysis inferiorly.

Sometimes a single incision extending from xiphoid process to pubic symphysisis employed, especially intrauma surgery.

Midline incisions are particularly favoured in diagnostic laparotomy, as they allow wideaccess to most of the abdominal cavity.

Appendectomy

An appendectomy (sometimes called appendisectomy orappendicectomy) is thesurgical removalof the vermiform appendix. This procedure is normally performed as anemergency procedure, when the patient is suffering from acute appendicitis. In theabsence of surgical facilities, intravenousantibioticsare used to delay or avoid the onsetofsepsis; it is now recognized that many cases will resolve when treated non-operatively.
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In some cases the appendicitis resolves completely; more often, an inflammatory massforms around the appendix. This is a relativecontraindication to surgery.

Appendectomy may be performed laparoscopically (this is called minimally invasivesurgery) or as an open operation. Laparoscopy is often used if thediagnosis is in doubt,

or if it is desirable to hide the scars in the umbilicusor in the pubic hair line. Recoverymay be a little quicker with laparoscopic surgery; the procedure is more expensive andresource-intensive than open surgery and generally takes a little longer, with the (low inmost patients) additional risks associated withpneumoperitoneum(inflating the abdomenwith gas). Advanced pelvic sepsis occasionally requires a lower midline laparotomy.

There have been some cases of auto-appendectomies, i.e. operating on yourself. One wasperformed by Dr Kane in 1921, but the operation was completed by his assistants.Another case is Leonid Rogozovwho had to perform the operation on himself as he wasthe only surgeon on a remote Arctic base.[1]

In general terms, the procedure for an open appendectomy is as follows.

1. Antibiotics are given immediately if there are signs ofsepsis, otherwise a singledose of prophylactic intravenous antibiotics is given immediately prior to surgery.

2. General anaesthesia is induced, with endotracheal intubation and full musclerelaxation, and the patient is positioned supine.

3. The abdomen is prepared and draped and is examined under anesthesia.4. If a mass is present, the incision is made over the mass; otherwise, the incision is

made overMcBurney's point, one third of the way from the anterior superior iliacspine (ASIS) and the umbilicus; this represents the position of the base of theappendix (the position of the tip is variable).

5. The various layers of the abdominal wall are then opened.6. The effort is always to preserve the integrity of abdominal wall. Therefore, theExternal ObliqueAponeurosis is slitted along its fiber, and the internal obliquemuscle is split along its length, not cut. As the two run at right angles to eachother, this prevents laterIncisional hernia.

7. On entering theperitoneum, the appendix is identified, mobilized and then ligatedand divided at its base.

8. Some surgeons choose to bury the stump of the appendix by inverting it so itpoints into the caecum.

9. Each layer of the abdominal wall is then closed in turn.10. The skin may be closed with staples or stitches.11. The wound is dressed.12. The patient will be brought to the recovery room.
http://en.wikipedia.org/wiki/Contraindicationhttp://en.wikipedia.org/wiki/Contraindicationhttp://en.wikipedia.org/wiki/Surgeryhttp://en.wikipedia.org/wiki/Laparoscopic_surgeryhttp://en.wikipedia.org/wiki/Medical_diagnosishttp://en.wikipedia.org/wiki/Medical_diagnosishttp://en.wikipedia.org/wiki/Scarhttp://en.wikipedia.org/wiki/Navelhttp://en.wikipedia.org/wiki/Navelhttp://en.wikipedia.org/wiki/Pneumoperitoneumhttp://en.wikipedia.org/wiki/Pneumoperitoneumhttp://en.wikipedia.org/wiki/Laparotomyhttp://en.wikipedia.org/wiki/Leonid_Rogozovhttp://en.wikipedia.org/wiki/Leonid_Rogozovhttp://en.wikipedia.org/wiki/Appendectomy#cite_note-0http://en.wikipedia.org/wiki/Sepsishttp://en.wikipedia.org/wiki/General_anaesthesiahttp://en.wikipedia.org/wiki/Endotracheal_tubehttp://en.wikipedia.org/wiki/Muscle_relaxanthttp://en.wikipedia.org/wiki/Muscle_relaxanthttp://en.wikipedia.org/wiki/Supine_positionhttp://en.wikipedia.org/wiki/Abdomenhttp://en.wikipedia.org/wiki/McBurney's_pointhttp://en.wikipedia.org/wiki/Anterior_superior_iliac_spinehttp://en.wikipedia.org/wiki/Anterior_superior_iliac_spinehttp://en.wikipedia.org/wiki/Abdominal_wallhttp://en.wikipedia.org/wiki/External_Obliquehttp://en.wikipedia.org/wiki/External_Obliquehttp://en.wikipedia.org/wiki/Aponeurosishttp://en.wikipedia.org/wiki/Internal_obliquehttp://en.wikipedia.org/wiki/Musclehttp://en.wikipedia.org/wiki/Incisional_herniahttp://en.wikipedia.org/wiki/Incisional_herniahttp://en.wikipedia.org/wiki/Peritoneumhttp://en.wikipedia.org/wiki/Peritoneumhttp://en.wikipedia.org/wiki/Caecumhttp://en.wikipedia.org/wiki/Caecumhttp://en.wikipedia.org/wiki/Contraindicationhttp://en.wikipedia.org/wiki/Surgeryhttp://en.wikipedia.org/wiki/Laparoscopic_surgeryhttp://en.wikipedia.org/wiki/Medical_diagnosishttp://en.wikipedia.org/wiki/Scarhttp://en.wikipedia.org/wiki/Navelhttp://en.wikipedia.org/wiki/Pneumoperitoneumhttp://en.wikipedia.org/wiki/Laparotomyhttp://en.wikipedia.org/wiki/Leonid_Rogozovhttp://en.wikipedia.org/wiki/Appendectomy#cite_note-0http://en.wikipedia.org/wiki/Sepsishttp://en.wikipedia.org/wiki/General_anaesthesiahttp://en.wikipedia.org/wiki/Endotracheal_tubehttp://en.wikipedia.org/wiki/Muscle_relaxanthttp://en.wikipedia.org/wiki/Muscle_relaxanthttp://en.wikipedia.org/wiki/Supine_positionhttp://en.wikipedia.org/wiki/Abdomenhttp://en.wikipedia.org/wiki/McBurney's_pointhttp://en.wikipedia.org/wiki/Anterior_superior_iliac_spinehttp://en.wikipedia.org/wiki/Anterior_superior_iliac_spinehttp://en.wikipedia.org/wiki/Abdominal_wallhttp://en.wikipedia.org/wiki/External_Obliquehttp://en.wikipedia.org/wiki/Aponeurosishttp://en.wikipedia.org/wiki/Internal_obliquehttp://en.wikipedia.org/wiki/Musclehttp://en.wikipedia.org/wiki/Incisional_herniahttp://en.wikipedia.org/wiki/Peritoneumhttp://en.wikipedia.org/wiki/Caecum


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A fracture is any break in the continuity of bone. Fractures are named according to their severity,the shape or position of the fracture line, or even the physician who first described them. It isdefined according to type and extent. In some cases, a bone may fracture without visiblybreaking. Fractures occur when the bone is subjected to stress greater than it can absorb. It canbe caused by a direct blow, crushing force, sudden twisting motion, or even extreme musclecontraction. When the bone is broken, adjacent structures are also affected, resulting in softtissue edema, hemorrhage into the muscles and joints, joint dislocations, ruptured tendons,severed nerves, and damaged blood vessels. Body organs may be injured by the force thatcaused the fracture or by the fracture fragments. Among the common kinds of fractures are thefollowing:

Open (compound) fracture: The broken ends of the bone protrude through the skin.

Conversely, a closed (simple) fracture does not break the skin.

Comminuted fracture: The bone splinters at the site of impact, and smaller bone bone

fragments lie between the two main fragments.

Greenstick fracture: A partial fracture in which one side of the bone is broken and the

other side bends; occurs only in children, whose bones are not yet fully ossified and

contain more organic material than inorganic material

Impacted fracture: One end of the fractured bone is forcefully driven into the interior of

the other.

Potts fracture: A fracture of the distal end of the lateral leg, with one serious injury of the

distal tibial articulation.

Colles fracture: A fracture of the distal end of the lateral forearm in which the distal

fragment is displaced posteriorly.

Fractures may also be described according to anatomic placement of fragments, particularly if

they are displaced or nondisplaced.

Causes

Rib fracture is any break in a rib. There may be one or more breaks. An injury, such as a blow to

the chest or a fall, forces the broken rib inward. The jagged edges of the broken rib could cut or

tear the lung. This could cause bleeding inside the chest or could cause one of the lungs to

collapse (deflate). Hard coughing or hard sneezing can also fracture a rib but the broken rib is

forced outward. With this kind of fracture there is less chance of injury to the lungs. Rib fractures

usually heal on their own without treatment in about 3 to 6 weeks.

Rib fractures are the most common type of chest trauma, occuring in more than 60% of patients

admitted with blunt chest injury. Most rib fractures are benign and are treated conservatively.

Fractures of the first three ribs are rare but can result in a high mortality rate because they are

associated with laceration of the subclavian artery or vein. The fifth through ninth ribs are the


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common sites of fractures. Fractures of the lower ribs are associated with injury to the spleen and

liver, which may be lacerated by fragmented sections of the rib.

Signs & Symptoms

Patients with rib fractures have clinical manifestations such as severe pain, point tendernessa

and muscle spasm over the area of the fracture, which is aggravated by coughing, deep

breathing and movement. The area around the fracture may be bruised. To reduce the pain, the

patient splints the chest by breathing in a shallow manner and avoids sighs, deep breaths,

coughing, and movemnet. This reluctance to move or breathe deeply results in diminished

ventilation, collapse of unaerated alveoli (atelectasis), pneumonitis, and hypoxemia. Respiratory

insufficiency and failure can be the outcomes of such a cycle.

Fractures

Risk for trauma Acute pain Risk for peripheral neurovascular dysfunction Risk for impaired gas exchange Impaired physical mobility Risk for impaired skin or tissue integrity Risk for infection Deficient knowledge (learning need) regarding condition, prognosis, treatment,

self-care, and discharge needs.

Appendicitis and Fracture

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