~ by Robert P. Driscoll, M.D., FACS
Chief of Trauma and Acute Care Surgery
South Shore Hospital
One of the most stressful experiences a patient and their family may face is the need for emergency surgery. By definition, it is a crisis situation that has developed unexpectedly and often at the most inconvenient time. Even for the most forward thinking patient, all of the rehearsed dialogue developed in the anticipation of elective surgery is forgotten or omitted. However, because surgical emergencies have some predictability across a lifetime, it is possible to develop an organized and calm approach to these situations.
The American College of Surgeons and the Massachusetts Medical Society also serve as valuable information resources (www.facs.org and www.mms.org). You may be confronted with a surgical emergency when you are away, but most emergencies will develop while you are close to home. You should be familiar with the resources and capabilities of your local community hospital. As a minimal standard, hospitals should be JCAHO accredited and the surgeons on staff should be Board Certified. Hospitals maintain a coverage roster to handle surgical emergencies and surgeons must be credentialed and reviewed in order to perform the procedures. The best place to obtain information on a hospital would be the hospital’s website.
At South Shore Hospital we have developed a specific and comprehensive program in response to our community’s predictable need for emergency surgical services. As a state designated Trauma Center, we have an in-house Trauma and Acute Care Surgical team that will immediately respond to these problems 24/7. The program requires a rigorous credentialing process that assures outstanding care. This is a very valuable asset to the patients in our community. We will review the most common surgical emergencies.
The most common surgical emergency, appendicitis can occur within any age group. Symptoms usually begin as vague mid abdominal pain that is progressive. This pain often migrates to the right lower abdomen and is made worse with movement. It is associated with fever and loss of appetite. The symptom complex usually evolves over 24 to 36 hours. The diagnosis can be made on physical exam only, but often blood test and CT scan imaging are used to confirm the diagnosis. The treatment is surgical removal of the appendix. The operation is usually performed within several hours of diagnosis and often accomplished laparoscopically. For uncomplicated cases, hospital stay is one to two days with return to work or school in one week.
Acute inflammation of the gallbladder is the second most common emergency. Pain may be sudden or insidious in onset and occurs when a gallstone blocks the gallbladder from emptying. This problem is seen mostly in adults. Patients may have one or two antecedent episodes before the more serious one. Pain is crampy or constant and localized to the mid upper or right upper abdomen. Sometimes there is migration to the right upper back. There may be associated fever but pain is usually not made worse with movement. Symptoms usually progress over a one to a two day period. The diagnosis is suspected on physical exam and confirmed with blood testing and ultrasonography. The treatment is surgical removal of the gallbladder, usually performed laparoscopically and within 24 hours of diagnosis. Hospital stay is one to two days, with return to work in one week if uncomplicated.
This is the third most common surgical emergency, but not all patients require immediate operation. Although occasionally encountered in patients in their late 20’s, this is largely a disease of older adults. It is also insidious in onset and is characterized by pain in the lower abdomen. Pain is constant and sharp and made worse with movement. It progresses over several days and is associated with low-grade fever, anorexia, and change in bowel function. Diagnosis is confirmed with blood testing and CT scan imaging. Initial treatment is usually antibiotics, which can be given in pill form and administered outside the hospital. For more severe cases, hospitalization and intravenous antibiotics are necessary. Surgery is reserved for the most severe cases or following multiple recurrent episodes. Operative treatment involves removing the affected portion of the large intestine and often a colostomy or ileostomy is required (bag). Hospitalization is longer, usually one week, with return to work in four weeks.
SMALL BOWEL OBSTRUCTION
This is another frequently encountered problem. It is seen largely in adults. Abdominal pain, crampy in nature and associated with nausea and vomiting is typically noted. There may be no bowel movement for one to two days and the abdomen is often distended. Surgery is often required if the blockage is complete or there are signs of compromised blood flow to the intestine. The cause is often scar tissue from previous surgery, but patients may also have an incarcerated hernia or malignancy. Recovery in the hospital is usually one week.
As with elective surgery, emergency surgical patients should not be afraid to ask their surgeon about their professional experience and credentials. In addition, your surgeon should make clear the indications for surgery and expected natural history of the problem if surgery is not performed. You should also discuss the expected outcome of the operation, and complications of the procedure. You should inquire about the length and location of recovery. This will help establish a trusting relationship between you and your surgeon. For you and your family, this is an important experience. We understand this and are fully committed to see you through the crisis.