http://doi.org/10.33698/NRF0275-Reshma, Shruti, Neenavir Singh, A.K. Mandal
ABSTRACT
Introduction: Ileus is the functional inhibition of propulsive bowel activity which commonly occurs postoperatively following abdominal surgery, however it resolves spontaneously within 2 to 3 days. But if it lasts more than 3 days after surgery then it is postoperative paralytic ileus. Objective: To estimate the incidence of postoperative ileus among patients undergone robot–assisted urological surgery. Material and methods: A descriptive study was conducted in Advance Urology Centre, PGIMER,Chandigarh.Total 30 patients who had undergone robot assisted urogical surgery [The surgery were performed transperitoneally with a 4–arm robot (da Vinci Surgical System)] between July to September 2017 and admitted in Advance Urology Centre were selected by using total enumeration sampling technique. The patients among whom the robot assisted surgical procedure converted to open surgery were excluded.The patients and their attendants were interviewed as per interview schedule which included a) Sociodemographic prole b) Personal prole c) Clinical prole d) Symptoms of postoperative paralytic ileus. Observation was done as per observation checklist.Postoperative paralytic ileus was operationally dened as intolerance of a solid diet, continued until postoperative 3rd day and beyond. Intolerance is dened as the presence of nausea and vomiting, abdominal distension on physical examination. Results: Incidence of postoperative paralytic ileus was 16.7% (among them 3.3% had mild and 6.7% had moderate and 6.7% had severe postoperative paralytic ileus on Postop Day 4 and Postop Day 5 respectively). Conclusion: It was concluded that incidence of postoperative paralytic ileus was 16.7%.
Key Words: Postoperative paralytic ileus; robot-assisted surgery
Address of corresponding author
Reshma Nursing ofcer
Department of Radiotherapy, PGIMER, Chandigarh.
Phone No. 08727010699
Email ID: rumakhan519@yahoo.in
Introduction
Postoperative ileus refers to the intolerance to absorption and oral intake due to nonmechanical factors that disrupts normal coordinated propulsive motor activity of the gastrointestinal tract following abdominal or nonabdominal surgery. An ileus lasts more than three days is considered as postoperative paralytic ileus.1 The causes of postoperative paralytic ileus results from the use of postsurgical opoid pain relievers (e.g. morphine) which can decrease or inhibit normal intestinal m o t i l i t y a n d i n t r a p e r i t o n e a l o r retroperitoneal infection. Patients with postoperative paralytic i leus may experience distended and painful abdomen, nausea, vomiting, dehydration and pain has classic colicky pattern.2Hence various nursing interventions can be done for example early ambulation, limiting the use of opoid drugs for pain relief etc. to prevent the problem of postoperative paralytic ileus. In this regard a study done by Choi H et al. (2007-09) on stimulatory effect of chewing gum on bowel motility in patients after robot assisted radical cystectomy showed that there is decrease in time to passage of atus and bowel movements in gum chewing group.3
Postoperative ileus affects almost all segments of gastrointestinal tract. It is usually uncomplicated and resolves spontaneously within two to three days and if it lasts for six days or more it is called postoperative paralytic ileus.The resolution of this problem is identied by active bowel sounds, passage of atus and bowel movements. The most reliable marker of bowel function return are having bowel movements and being able to tolerate oral intake.2It may lead to 5% readmission after the major abdominal surgery hence the need was felt to conduct a study to know the actual burden of this disease condition.The economic impact of postoperative paralytic ileus has been estimated to $750 million to $1 billion in United States.4
Objective:
To e s t i m a t e t h e i n c i d e n c e o f postoperative paralytic ileus among patients undergone robot– assisted urological surgery.
Material and Methods
A descriptive study was conducted in Advance Urology Centre PGIMER, Chandigarh. Total 30 patients undergone robot assisted urology surgery [All urological surgery were performed transperitoneally with a 4–arm robot (da Vinci Surgical System, Intuitive Surgical, Sunnyvale, CA, USA) with 1 assistant port for a total of 5 ports used for the procedures were selected by using total enumeration sampling technique from the period between July to September 2017to assess the incidence of paralytic ileus. Ethical clearance was taken from Institute Ethics Committee of PGIMER, Chandigarh. Permission was taken from Head, Department of Urology, PGIMER, Chandigarh. Written informed consent were taken from all the participants.The patients and their attendants were interviewed as per interview schedule which included a) Sociodemographic prole b) Personal prole c) Clinical prole d) Symptoms of postoperative paralytic Observation was done as per observation checklist from postoperative day 1 to 7. Postoperative paralytic ileus was operationally dened as intolerance of a solid diet, continued until postoperative 3rd day and beyond. Intolerance is dened as the presence of nausea and vomiting, abdominal distension on physical examination. Before taking interview, patients were made comfortable and the patients who were not able to reply, their attendants weres interviewed. Patients were observed from postoperative day 1 to 7 for loss of appetite, nausea, vomiting, diffuse and persistent abdominal pain, passage of atus, bowel sounds and passage of stool. Observations were made every morning and evening by using observation checklist and bowel sounds were auscultated. Intolerance is dened as the presence of nausea and vomiting, abdominal distension at physical examination.Analysis and interpretation of collected data was entered in Statistical package for Social Sciences (SPSS version 20.0 Inc.) for descriptive and inferential analysis.
Results
Socio-demographic profile of the participants undergone Robot assisted urology surgery : Table 1 depicts the Socio- demographic prole of the participants undergone Robot assisted urology surgery. Half of the participants were in the age group of 20-40 years. More than half (60%) were male. Most of the participants (76.3) were married and half of them were from rural area. Most of the participants (83.3%) were following Hindu religion. Majority of the participants (96.7%) were literate and 36.7% had primary school qualication and another (30%) were professionals. Less than half participants were unemployed (40.0%). Most of the participants (80%) had per capita income Rs.<20,000/-. More than half (56.7%) were having sedentary lifestyle and 33% were doing moderate work and 10% were doing heavy work.
Table 2 depicts the personal prole of the participants undergone robot assisted urology surgery. More than half (53.3%) were vegetarian. Alcoholism was observed in16.7% of the participants and 13.3% were smokers and very few of them (6.7%) were addictive to other substances. Most of them (80.0%) had good appetite and normal elimination pattern. Majority of the patients were pre-obese (93.4%).
Clinical variables of the participants undergone Robot assisted urology surgery
Table 3 depicts the clinical variables of the participants undergone robot assisted urology surgery. Two third of the participants (66.7%) were diagnosed with renal mass and 20.0% were hypertensive. Less than half of them (43.3%) were having family history of some medical conditions and one fourth of them (23.3%) were having family history of some previous surgical interventions. Less than half of the participants (40.0%) had undergone nephrectomy.
Symptoms of postoperative paralytic ileus among participants undergone Robot assisted urology surgery
Table 4 depicts the postoperative complication of paralytic ileus among subjects underwent Robot assisted urology surgery. The symptoms experience by the 67% of the patients were loss of appetite, abdominal distension, abdominal pain, nausea and vomiting. Some of the patients had absence of bowel sounds (10%) and not passed stool (13.3%). Only one (3.3%) patient was on ryle’s tube and opoid drug.
Table 1: Socio-demographic variables of the participants underwent Robot assisted urology surgery
| Variable | Robotic surgery group (n=30)f (%) |
| Age(in years)* | |
| 20-40 | 15(50.0) |
| 40-60 | 9(30.0) |
| 60-80 | 6(20.0) |
| Gender | |
| Male | 18(60.0) |
| Female | 12(40.0) |
| Qualification | |
| Illiterate | 1(3.3) |
| Primary school | 11(36.7) |
| Secondary | 06(20.0) |
| Graduate and above | 03(10.0) |
| Professional | 09(30.0) |
| Marital status | |
| Unmarried | 06(20.0) |
| Married | 23(76.7) |
| Divorced/Widow/widowed | 1(3.3) |
| Religion | |
| Hindu | 25(83.3) |
| Others | 5(16.7) |
| Per capita income per month (in Rs)** | |
| <10000 | 24(80.0) |
| >10000 | 6(20.0) |
| Habitat | |
| Rural | 10(33.3) |
| Urban | 15(50.0) |
| Semiurban | 5(16.7) |
| Life-style Pattern | |
| Sedentary | 17(56.7) |
| Moderate worker | 10(33.3) |
| Heavy worker | 3(10.0) |
| Occupation | |
| Unemployed/Students/Retired/Housewi | 12(40.0) |
| ves | |
| Unskilled | 5(16.7) |
| Skilled | 3(10.0) |
| Clerical/shop/farmer | 3(10.0) |
| Professional | 7(23.3) |
Mean ±SD: Age(years): 42.87±15.74, Per capita Income(Rs.):7672.9±9432.0
Table 2: Personal profile of the participants underwent Robot assisted urology surgery
| Personal profile variable | Robot Assited surgery group
(n=30)f (%) |
| Dietary habits
Vegetarian Nonvegetarian |
16(53.3) 14(46.7) |
| Alcohol intake Smoker
Any other drug addiction/substance abuse (Gutka, opium, cannabis) |
05(16.7)
4(13.3) 2(6.7) |
| Sleep disturbance | 6(20.0) |
| Appetite | |
| Good | 24(80.0) |
| Poor | 06(20.0) |
| Elimination pattern | |
| Normal | 24(80.0) |
| Constipation | 6(20.0) |
| Body mass index | |
| Normal weight(18.5-24.9) | 1(3.3) |
| Pre-obesity (25.0–29.9) | 28(93.4) |
| Obesity class 1(30.0–34.9) | 1(3.3) |
Table 3: Clinical variables of the participants undergone Robot assisted urology surgery
| Variables | Robotic surgery group
(n=30)f (%) |
| Clinical diagnosis of patient
Ca Urinary Bladder Renal mass Adrenal mass Ca prostate |
4(13.3) 20(66.7) 01(3.3) 5(16.7) |
| Co-morbid conditions: Diabetes mellitus Hypertension Hypothyroidism
Others (depression, hyperthyroidism, arthritis, Obesity,tuberculosis) |
02(6.7) 6(20.0) 1(3.3) 1(3.3) |
| Family history of any medical condition | 13(43.3) |
| History of any previous surgical intervention | 7(23.3) |
| Present surgery done
Nephrectomy Nephron sparing surgery Radical cystectomy+ileal conduit Adrenelectomy Prostectomy Radical nephrectomy |
12(40.0) 02(6.7) 04(13.3) 03(10.0) 02(6.7) 07(23.3) |
Table 4: Symptoms of postoperative paralytic ileus among participants undergone Robot assisted urology surgery (assessed by postoperative paralytic ileus questionnaire)
| S.NO. | Symptoms of paralytic ileus | Robotic surgery group
(n=30)f (%) |
| 1. | Loss of appetite | 2(6.7) |
| 2. | Abdominal distension | 2(6.7) |
| 3. | Bloating | 3(10.0) |
| 4. | Nausea and vomiting | 3(10.0) |
| 5. | Diffuse, persistent abdominal pain | 2(6.7) |
| 6. | Intolerance to oral diet | 2(6.7) |
| 7. | Delayed passage or absence of atus | 1(3.3) |
| 8. | Bowel sounds not present | 3(10.0) |
| 9. | Not passed stool | 4(13.3) |
| 10. | On Ryle’s Tube | 1(3.3) |
| 11. | On any opoid drugs | 1(3.3) |
Incidence of postoperative complication paralytic ileus among participants undergone Robot assisted urology surgery (assessed by paralytic ileus questionnaire)
Table 5 depicts the incidence of paralytic ileus amongparticipantsundergone robot assisted urology surgery.Incidence of postoperative paralytic ileus was 16.7% among them 3.3% had mild and 2(6.7%) had moderate and 2(6.7%) had severe p o s t o p e r a t i v e p a r a l y t i c i l e u s o n postoperative day 4 and 5.
Table 5: Incidence of paralytic ileus among participants undergone Robot assisted urology surgery
(N=30)
| Level of Paralytic ileus (Score) | Robotic surgery group | |
| Postoperative Day 4 | Postoperative Day 5 | |
| No Paralytic ileus (0) | 25(83.3) | 26(86.7) |
| Paralytic ileus | 5(16.7) | 4(13.4) |
| Mild (1 – 4) | 1(3.3) | — |
| Moderate (5 – 8) | 2(6.7) | 2(6.7) |
| Severe (9 – 11) | 2(6.7) | 2(6.7) |
| Mean±SD
Paralytic ileus score |
0.5±1.1 | 0.3± 0.8 |
Postoperative outcomes among participants undergone Robot assisted urology surgery
Table 6 depicts the postoperative outcomes of subjects underwent Robot assisted urology surgery.Half of the participants had passed atus (46.7%),had return of bowel sounds (50.0%) and half of them were orally allowed(50.0%) on Postoperative Day1. Thirty percent of them passed stool on Postoperative Day 2, 60.0% of them were ambulated on Postoperative Day 2. One fourth of the patients (23.3%) had loss of appetite on Postoperative Day 1, 33.3% patients had abdominal distension on Postoperative Day 1. One third of them (36.7%) had nausea and vomiting on Postoperative Day 1, 26.7% had diffuse persistent abdominal pain, 16.7% had delayed passage and absence of atus, 30% patients had absence of bowel sounds, 16.7% patients were on ryles tube and opoid drugs on Postoperative Day 1.
The problem existed among t he participants on Postoperative Day 4th were loss of appetite (3.3%), abdominal distension (3.3%), bloating(3.5%) and nausea vomiting (3.5%). Most of these problems were relieved but abdominal distension (3.3%) and bloating ( 3 . 3 %) were even continued for 6 t h postoperative day as well. All these problems relieved on 7th postoperative day.
Table 6: Postoperative outcomes among the participants underwent Robot assisted urology surgery
|
Variables |
Number of the participants having sympoms |
||||||
| POD1 (n=30)
f (%) |
POD2 (n=30)
f (%) |
POD3 (n=30)
f (%) |
POD4 (n=30)
f (%)s |
POD5 (n=30)
f (%) |
POD6 (n=30)
f (%) |
POD7 (n=30)
f (%) |
|
| Passage of flatus | 14(46.7) | 9(30.0) | 3(10.0) | 2(6.7) | — | 1(3.3) | 1(3.3) |
| Return of bowel sounds | 15(50.0) | 6(20.0) | 4(13.3) | 2(6.7) | — | 1(3.3) | 2(6.7) |
| Orally allowed | 15(50.0) | 6(20.0) | 4(13.3) | 2(6.7) | — | 1(3.3) | 2(6.7) |
| Stool passed | — | 9(30.0) | 7(23.3) | 6(20.0) | 4(13.3) | 2(6.7) | 2(6.7) |
| Ambulation | 18(60.0) | 10(33.3) | 2(6.7) | — | — | — | — |
| Loss of appetite | 7(23.3) | 3(10.0) | 2(6.7) | 1(3.3) | 1(3.3) | — | — |
| Abdominal distension | 10(33.3) | 5(16.7) | 2(6.7) | 1(3.3) | 1(3.3) | 1(3.3) | — |
| Bloating | 12(40.0) | 6(20.0) | 3(10.0) | 1(3.3) | 1(3.3) | 1(3.3) | — |
| Nausea and vomiting | 11(36.7) | 6(20.0) | 3(10.0) | — | 1(3.3) | — | — |
| Diffuse, persistent abdominal pain | 7(23.3) | 4(13.3) | 2(6.7) | — | — | — | — |
| Intolerance to oral diet | 8(26.7) | 5(16.7) | 2(6.7) | 1(3.3) | — | — | — |
| Delayed passage or absence of
flatus |
5(16.7) | 3(10.0) | 2(6.7) | 1(3.3) | — | — | — |
| Bowel sounds not present | 9(30.0) | 5(16.7) | 3(10.0) | — | — | — | — |
| Not passed stool | 11(36.7) | 6(20.0) | 4(13.3) | — | — | — | — |
| On Ryle’s Tube | 5(16.7) | 3(10.0) | 1(3.3) | — | — | — | — |
| On any opoid drugs? | 5(16.7) | 3(10.0) | 1(3.3) | — | — | — | — |
Discussion
Intolerance to oral intake postoperatively following abdominal or nonabdominal surgery is called postoperative ileus.. Normally it gets resolved by 3rd day but if it lasts more than three days it is considered as postoperative paralytic ileus.1Thus it may be responsible for 5% readmission after the major abdominal surgery hence the study was conducted to know the actual burden of paralytic ileus.4
Patients operated with this new technology i.e. robot assisted urogical surgery were enrolled in the study to know the extent of problem.The patients and their attendants were interviewed as per interview schedule due to low literacy level of the participants.Symptoms of postoperative paralytic ileus and observation was done as per observation checklist. Postoperative paralytic ileus was operationally dened as intolerance of a solid diet, continued until postoperative 3rd day and beyond.Hence to rule out incidence of paralytical ileus participants were observed upto 7 post- operative days.
In present study the incidence of postoperative paralytic ileus was 16.7% (among them 3.3% had mild and less than half (6.7%) moderate and 6.7%severe postoperative paralytic ileus on POD 4 and POD 5). A similar study done by Bisanz A. et al. in a retrospective medical record review of 101 patients who had abdominal surgery found that, 44 developed postoperative ileus.5 Another study conducted by Ahmet et al. (2014) included 228 patients reveals that majority of patients who undergone robot assisted surgery had no complaint of postoperative ileus.6
In the present study it was found that majority of patients reported to tolerate diet (50%), passage of atus (46.7%) and stool (50%) on POD1.A similar study conducted by Sungwon Lim et al. (2016) found that the patients who underwent robot assisted surgery had a shorter time to resumption of a regular diet (MD, –0.62 days; 95% CI, –0.97 to –0.28), rst passage of atus (MD, –0.44 days; 95% CI, –0.66 to –0.23) and defecation (MD, –0.62days; 95% CI, –0.77 to –0.47).7
Conclusion
It was concluded that in the present study the incidence of postoperative paralytic ileus was 16.7% (among them 3.3% had mild, 6.7% moderate and 6.7% of the patients had severe postoperative paralytic ileus on postoperative day 4 and 5). A similar study can be conducted in different settings in various hospitals on a large sample to generalise the ndings.
References:
- Cannon WB, Murphy The movement of the stomach and intestine in some surgical conditions, Annals of Surgery1906;43:512–36.
- Livingston E H, Passaro E P Postoperative ileus. Dig Dis 1990;35:121-31.
- Choi H, Kang SH, Yoon DK, Kang SG, Ko HY, Moon DG et al.Chewing gum has stimulatory effect on bowel motility in patients after open or robot assisted radical cystectomy for bladder cancer. Urology 2011 Apr;77(4):884-90.
- Waldhausen JH, Shaffrey ME, Skenderis BSII, Jones RS, Schirmer BD. Gastro intestinal myoelectric and clinical patterns of recovery after laparotomy. Ann 1990;211:777-84.
- Bisanz A, Palmer J, Reddy S, Cloutier L, Dixon, Marlene Z, Bruera E. Characterizing Postoperative Paralytic Ileus as Evidence for Future Research and Clinical Practice.2008 Sep 25;16(8):336-44.
- The incidence of postoperative ileus in patients who underwent robotic assisted radical prostatectomy.Central European Journal of Urology, 2014, 67(01). [Accessed 13 Mar, 2017] Available on http://europepmc.org/abstract/med/24982 775
- Lim S, Kim J H, Baek S H, Kim S H, Lee S
- Comparison of perioperative and short- term outcomes between robotic and conventional laparoscopic surgery for colonic cancer: a systematic review and meta-analysis. 2016 Jun;90(6): 328-39 doi: 10.4174/astr.2016.90.6.328.