# Situation: A 66-year-old man with adenocarcinoma of the lower rectum undergoes abdominoperineal resection with a permanent sigmoid colostomy. He has no other medical conditions. On the second postoperative day, which position is BEST for his comfort and protection of the perineal wound?

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> subject: Nursing Practice III — Care of Clients with Problems in Surgery, Oxygenation, Fluid and Electrolytes, Infectious, Inflammatory and Immunologic Response, Cellular Aberrations

## 문제

Situation: A 66-year-old man with adenocarcinoma of the lower rectum undergoes abdominoperineal resection with a permanent sigmoid colostomy. He has no other medical conditions.

On the second postoperative day, which position is BEST for his comfort and protection of the perineal wound?

## 보기

1. Side-lying, supported with pillows **✔ 정답**
2. Supine with the legs raised on two pillows
3. Sitting upright in a chair for most of the day
4. High Fowler's position with the knees flexed

**정답: 1**

## 해설

Abdominoperineal resection leaves a perineal wound that is painful and at risk of breakdown and infection. A side-lying position keeps pressure off the perineum, and a pressure-relieving cushion is used when he sits. Sitz baths begin once permitted.

## 심화 해설

Core concept: protecting the perineal wound after abdominoperineal resection

Abdominoperineal resection removes the rectum and anus, leaving a large perineal wound where the anus used to be. This wound sits directly in the midline of the buttocks and is subjected to pressure, moisture, and contamination whenever the patient lies flat or sits directly on it. On the second postoperative day, the wound is still fresh, painful, and highly vulnerable to breakdown and infection.

The side-lying position shifts body weight away from the midline perineum and distributes it across the lateral hip and thigh, which reduces direct pressure on the surgical site and improves air exposure to the wound. Supporting the position with pillows prevents the patient from rolling backward onto the wound and reduces muscle strain that could cause involuntary movement and pain.

The other positions create direct or indirect pressure on the perineal area. Supine places the sacrum and perineum against the mattress, and raising the legs on pillows does not relieve that contact. Sitting upright in a chair places the full weight of the trunk directly on the perineal wound, which is the most harmful option at this stage. High Fowler's position with flexed knees shifts weight toward the sacrum and buttocks and also increases tension across the perineal closure.

Key point! The goal is not only comfort but also wound protection. Any position that loads the sacral-perineal region delays healing and raises the risk of dehiscence or infection.

The evidence from surgical positioning studies supports this principle. A prospective cohort trial evaluating transperineal pelvic drainage combined with lateral positioning after extralevator abdominoperineal resection reported that perineal infection rates can approach 70% without effective intervention, and the lateral position was part of the strategy to promote perineal wound healing [1]. A retrospective study from Massachusetts General Hospital found that patient positioning during the perineal portion of the procedure influenced postoperative perineal wound dehiscence and infection, with prone positioning associated with reduced perineal infections compared with supine or lithotomy positioning [2]. Another retrospective cohort study also examined the relationship between patient position and postoperative perineal surgical site infection, reinforcing that positioning is a modifiable factor affecting wound outcomes . A systematic review and meta-analysis confirmed that prone positioning during abdominoperineal resection is linked to better outcomes, although the analysis focused on intraoperative positioning rather than postoperative positioning .

These studies address intraoperative positioning, but the underlying principle transfers directly to postoperative nursing care: reducing pressure and contamination on the perineal wound is a central determinant of healing. In the postoperative period, the side-lying position achieves the same protective effect at the bedside that prone positioning achieves in the operating room.

Watch out! Do not confuse the intraoperative prone jackknife position with the postoperative side-lying position. The question asks about the best position for the patient on the second postoperative day, not the position used during surgery. The side-lying position is the practical bedside equivalent that keeps weight off the perineum while allowing the patient to rest comfortably.

When the patient does need to sit, a pressure-relieving cushion or inflatable ring should be placed under the thighs and buttocks so the perineum remains suspended without direct contact. Sitz baths are introduced only after the surgeon confirms that the wound can tolerate moisture and that drainage is controlled. Until then, keeping the perineal area clean, dry, and free of pressure remains the priority.

| Position | Effect on perineal wound | Clinical judgment |
| --- | --- | --- |
| Side-lying with pillows | Weight shifted to lateral hip and thigh; perineum off the mattress | Best choice for comfort and wound protection |
| Supine with legs raised | Sacrum and perineum remain in contact with the bed | Does not relieve perineal pressure |
| Sitting upright in a chair | Full trunk weight directly on the perineal wound | Contraindicated on the second postoperative day |
| High Fowler's with knees flexed | Weight shifted toward sacrum and buttocks; tension across perineal closure | Increases pressure and wound tension |

References (research sources)

- [1]Transperineal pelvic drainage combined with lateral position to promote perineal wound healing after abdominoperineal resection: A prospective cohort trial.Research articleShang A, Wang M, Yang Y, Zhao Z, Li D, Guo Y (2022) · DOI: 10.1097/MD.0000000000029104

- [2]Prone positioning reduces perineal infections when performing the miles procedure.Research articleDinaux AM, Amri R, Berger DL (2017) · DOI: 10.1016/j.amjsurg.2017.05.021

## 임상 시나리오

Perineal Wound Protection After APRPostoperative positioning to reduce pressure and infection risk
After abdominoperineal resection, the perineal wound is painful and vulnerable to breakdown. Position the patient side-lying with pillows for support to shift weight away from the midline perineum and improve air exposure.

Avoid supine, sitting upright, and High Fowler's with flexed knees because they load the sacral-perineal region and delay healing. When sitting is permitted, use a pressure-relieving cushion.

CautionDo not start sitz baths until the surgical team confirms the wound is ready. Early sitting without offloading can cause wound breakdown and infection.

## 핵심 개념

- **abdominoperineal resection** — Surgical removal of the rectum and anus, leaving a perineal wound and permanent colostomy
- **perineal wound** — Surgical site in the midline buttocks area that is painful and at high risk for pressure, moisture, and infection
- **side-lying position** — Position that shifts weight to the lateral hip and thigh, offloading the perineum
- **pressure-relieving cushion** — Device used when sitting to reduce direct pressure on the perineal wound
- **sitz bath** — Warm-water immersion of the perineal area, started only after wound healing is permitted

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