Vertical Banded Gastroplasty: A Treatment for Morbid Obesity - 2

AORN Journal, Dec, 2000 by Susan Goldberg, Peggy Rivers, Kelly Smith, William Homan

Positioning. The patient is positioned supine on the OR bed for the VBG procedure. His or her arms are suspended from candy-cane stirrups using three-inch wide adhesive skin traction tape placed anteriorly and posteriorly on the forearms and secured with four-inch elastic wraps. This positioning prevents pressure damage to nerves and skin during the procedure. After the two padded safety straps are fastened in place, two footboards with gel pad liners are placed at the foot of the OR bed, and covered with sheets. The nurse places a temperature regulating blanket across the patient's chest and arms and applies extra-large sequential compression device (SCD) stockings. The nurse assesses and documents the patient's skin condition and pads pressure points to prevent skin and tissue damage during the procedure.

The nurse preps and drapes the patient for a midline abdominal incision. When the surgeon enters the peritoneum, the patient is placed in steep, reverse Trendelenberg's position (ie, almost standing uptight on the padded footboard). This position permits most of the patient's internal organs to fall naturally into place and gives surgical team members a clear view of the stomach. At this point, all scrub personnel need to stand on platforms or standing stools. When the surgeon is ready to create the pouch, the patient is returned to a neutral position, and scrub personnel members can step off of their platforms.

Creating and measuring the pouch. The circulating nurse needs a Toomey syringe and a 100-cm long dowel that has been premeasured and marked at 70 cm. The nurse will use this equipment to assist the surgeon with intraoperative measurement of the gastric pouch. It is the circulating nurse's responsibility to help measure the pouch. The nurse may do this independently or with the assistance of the anesthesia care provider. When the surgeon states that he or she is ready to measure the pouch, the nurse should measure 50 mL of sterile saline into the Toomey syringe and attach the syringe to the Ewald tube. The saline flows into the new pouch until the pouch is full. By raising and lowering the syringe and by tapping the Ewald tube, the nurse is assured that no air remains in the tubing or the pouch. The pouch now contains only the saline and the Ewald tube established preoperatively to take up 6 mL of space.

The surgeon now places the stapling device approximately where he or she estimates the edge of the pouch should be, but does not fire the staples. The circulating nurse holds the premeasured dowel in one hand and the Toomey syringe in the other hand. The bottom of the dowel is placed on the OR bed at the level of the patient's ear. The circulating nurse then lowers the Toomey syringe until the meniscus of fluid in the syringe is level with the patient's ear. Then the Toomey is raised to the 70-cm mark on the dowel, and the nurse notes the measurable difference in the amount of saline in the syringe. If this difference is less than 15 mL, the pouch is an appropriate size for the surgeon to safely place the staple line. If the difference is more than 15 mL, the surgeon repositions the stapler, and the circulating nurse repeats the measuring sequence until the pouch is the correct size and the surgeon can fire the stapler. After the pouch is created, the Ewald tube is removed, the table is returned to steep reverse Trendelenberg's position, and then returned to the neutral position when surgery is complete. The surgeon closes the wound with fascial staples and skin staples and dresses the wound with petroleum jelly-impregnated gauze and 4 by 4 dressing sponges. These dressings may need frequent changing as the incisions on patients undergoing VBG tend to weep serum postoperatively.

POSTOPERATIVE CARE

After the table is returned to a neutral position, the circulating nurse removes the patient's arms from the suspended position and assesses skin and tissue integrity and the color of the patient's arms. The foot-boards are removed from the table to make the patient's transfer from the OR bed easier. The nurse removes the ESU dispersive pad and visually assesses the patient's skin integrity. The sequential compression devices are disconnected, and the patient's vital signs are assessed. The temperature regulating blanket is removed and replaced by warm blankets. Perioperative team members transfer the patient to an extra-large stretcher and transport him or her to the postanesthesia care unit (PACU) accompanied by the anesthesia care provider and the circulating nurse.

In the PACU, the patient's level of pain is assessed and a patient-controlled analgesia (PCA) pump is connected to the IV line for postoperative pain management. Although intrathecal morphine might be helpful for pain management, our anesthesia care providers have decided not to use this medication for patients undergoing VBG. Intrathecal morphine commonly depresses patients' respirations in the PACU. The majority of our patients' respiratory systems already are compromised from weight-related factors, and the anesthesia care providers prefer to use IV morphine to manage patients' pain. The PACU nurse also must consider that anesthetic agents normally are stored in body fat. As there is additional body fat in patients undergoing VBG, they may experience