VisualWikitext
Tag: 2017 source edit
Tag: 2017 source edit
 
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| considerations_postoperative = PONV
| considerations_postoperative = PONV
| image_file =  
| image_file =  
}}An appendectomy is generally performed as an urgent or emergent procedure to treat appendicitis. Appendicitis can occur at any age, but is more common in patients 19-25 years old.  Appendicitis is common, occurring in about 7% of the population. An appendectomy can be performed laparoscopically or as an open procedure.  Surgical practice has largely transitioned to the laparoscopic approach<ref>{{Cite journal|last=Bhangu|first=Aneel|last2=Søreide|first2=Kjetil|last3=Di Saverio|first3=Salomone|last4=Assarsson|first4=Jeanette Hansson|last5=Drake|first5=Frederick Thurston|date=2015|title=Acute appendicitis: modern understanding of pathogenesis, diagnosis, and management|url=https://linkinghub.elsevier.com/retrieve/pii/S0140673615002755|journal=The Lancet|language=en|volume=386|issue=10000|pages=1278–1287|doi=10.1016/S0140-6736(15)00275-5|via=}}</ref>.     
}}
An appendectomy is generally performed as an urgent or emergent procedure to treat appendicitis. Appendicitis can occur at any age, but is more common in patients 19-25 years old.  Appendicitis is common, occurring in about 7% of the population. An appendectomy can be performed laparoscopically or as an open procedure.  Surgical practice has largely transitioned to the laparoscopic approach<ref>{{Cite journal|last=Bhangu|first=Aneel|last2=Søreide|first2=Kjetil|last3=Di Saverio|first3=Salomone|last4=Assarsson|first4=Jeanette Hansson|last5=Drake|first5=Frederick Thurston|date=2015|title=Acute appendicitis: modern understanding of pathogenesis, diagnosis, and management|url=https://linkinghub.elsevier.com/retrieve/pii/S0140673615002755|journal=The Lancet|language=en|volume=386|issue=10000|pages=1278–1287|doi=10.1016/S0140-6736(15)00275-5|via=}}</ref>.     
==Preoperative management==
==Preoperative management==
===Preoperative evaluation<!-- Provide a brief overview of the preoperative evaluation and optimization of patients for this case. Also list relevant labs, studies, or physical exam findings. If none, this section may be removed. -->===
===Preoperative evaluation<!-- Provide a brief overview of the preoperative evaluation and optimization of patients for this case. Also list relevant labs, studies, or physical exam findings. If none, this section may be removed. -->===
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* May be dehydrated due to fever, emesis, and reduced oral intake
* May be dehydrated due to fever, emesis, and reduced oral intake
* Assess volume status by checking vital signs, mucus membranes, skin turgor.
* Assess volume status by checking vital signs, mucus membranes, skin turgor
* IV hydration before anesthetic induction
* IV hydration before anesthetic induction to avoid hypotension, as patients may be volume depleted
|-
|-
|Gastrointestinal
|Gastrointestinal
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* Patients typically present with nausea and vomiting.   
* Patients typically present with nausea and vomiting.   


* Patients with acute abdomen should be treated as if they have full stomachs.
* Use full stomach precautions


* Muscular resistance to palpation (muscle guarding) can correlate with severity of the inflammatory process.
* Muscular resistance to palpation (muscle guarding) can correlate with severity of the inflammatory process.
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===Operating room preparation<!-- List any special, non-standard equipment, medications, fluids, or other preparations that should be made prior to surgery. If none, this section may be removed. -->===
===Operating room preparation<!-- List any special, non-standard equipment, medications, fluids, or other preparations that should be made prior to surgery. If none, this section may be removed. -->===


* NG Tube
* NG Tube (warming can make insertion easier)
* Verify pre-incisions antibiotics required
* Verify pre-incisions antibiotics required
*


=== Regional and neuraxial techniques ===
=== Regional and neuraxial techniques ===


* Consider pre-incision nerve blocks. Bilateral TAP blocks may be useful in open approach.
* Consider pre-incision nerve blocks. Bilateral TAP blocks may be useful in open approach


==Intraoperative management==
==Intraoperative management==
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* Supine
* Supine
* Secure or tuck the arms
* Secure or tuck the arms
*  
* Check angle of arm


===Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. -->===
===Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. -->===
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* PONV
* PONV
** Consider multiple PONV prophylactics
* Urinary retention (consider straight catheterization of bladder prior to emergence)
* Urinary retention (consider straight catheterization of bladder prior to emergence)
*  
*  

Latest revision as of 13:56, 9 February 2022

Appendectomy
Anesthesia type

General

Airway

Endotracheal tube

Lines and access

Peripheral IV

Monitors

Standard ASA / 5-Lead EKG

Primary anesthetic considerations
Preoperative

Full stomach precautions

Intraoperative

Rapid sequence induction

Postoperative

PONV

An appendectomy is generally performed as an urgent or emergent procedure to treat appendicitis. Appendicitis can occur at any age, but is more common in patients 19-25 years old. Appendicitis is common, occurring in about 7% of the population. An appendectomy can be performed laparoscopically or as an open procedure. Surgical practice has largely transitioned to the laparoscopic approach[1].

Preoperative management

Preoperative evaluation

System Considerations
Respiratory
  • Acute abdominal pain can cause respiratory impairment (respiratory splinting) resulting in atelectasis
Cardiovascular
  • May be dehydrated due to fever, emesis, and reduced oral intake
  • Assess volume status by checking vital signs, mucus membranes, skin turgor
  • IV hydration before anesthetic induction to avoid hypotension, as patients may be volume depleted
Gastrointestinal
  • Patients typically present with nausea and vomiting.
  • Use full stomach precautions
  • Muscular resistance to palpation (muscle guarding) can correlate with severity of the inflammatory process.
Hematologic
  • Patients typically have moderate leukocytosis with left shift
  • Expect hemoconcentration if patient dehydrated
Labs
  • CBC
  • Chemistry Panel
  • Pregnancy test (for women of child bearing age)

Operating room preparation

  • NG Tube (warming can make insertion easier)
  • Verify pre-incisions antibiotics required

Regional and neuraxial techniques

  • Consider pre-incision nerve blocks. Bilateral TAP blocks may be useful in open approach

Intraoperative management

Monitoring and access

  • Standard ASA monitors
  • 5-lead EKG
  • Urinary catheter
  • 1 peripheral IV (typically 16-18 gauge)

Induction and airway management

  • Pre-oxygenate with 100% FiO2
  • Rapid Sequence Induction (RSI)
  • Intubation

Positioning

  • Supine
  • Secure or tuck the arms
  • Check angle of arm

Maintenance and surgical considerations

  • Standard maintenance
    • Consider avoiding nitrous oxide given potential for bowel dissension and increased risk of PONV
  • Place OG/NG before surgical incision to decompress the stomach
  • Maintain normovolemia and normothermia

Emergence

  • Extubate when patient awake and able to protect airway
  • PONV prophylaxis

Postoperative management

Disposition

  • PACU
    • Patients undergoing laparoscopic appendectomy can often be discharged home from PACU
  • Encourage early post-operative ambulation

Pain management

  • Oral analgesics
  • Non-opioid analgesics
    • Ketoralac (Toradol)
    • Acetaminophen (Tylenol)
  • IV narcotics for breakthrough pain

Potential complications

  • PONV
    • Consider multiple PONV prophylactics
  • Urinary retention (consider straight catheterization of bladder prior to emergence)

Procedure variants

Open Appendectomy Laparoscopic Appendectomy
Position Supine Supine
Surgical time 1 hour 30-90 mins
EBL <75 mL <75 mL
Postoperative disposition PACU PACU
Mortality Perforated: 2%

Non-perforated: <0.1%

Perforated: 2%

Non-perforated: <0.1%

Complications Perforation

Abscess

Fistula

Hematoma

Illeus

Perforation

Abscess

Fistula

Hematoma

Illeus

Conversion to Open

Pain 5-7 4

References

  1. ↑ Bhangu, Aneel; Søreide, Kjetil; Di Saverio, Salomone; Assarsson, Jeanette Hansson; Drake, Frederick Thurston (2015). "Acute appendicitis: modern understanding of pathogenesis, diagnosis, and management". The Lancet. 386 (10000): 1278–1287. doi:10.1016/S0140-6736(15)00275-5.
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