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{{Infobox surgical case reference
| anesthesia_type = General
| airway = Endotracheal tube
| lines_access = Peripheral IV
| monitors = Standard ASA  /  5-Lead EKG
| considerations_preoperative = Full stomach precautions
| considerations_intraoperative = Rapid sequence induction
| considerations_postoperative = PONV
| 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>.   
==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. -->===


{| class="wikitable"
|+
!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


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* 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<!-- 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 (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<!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. -->===
 
* Standard ASA monitors
* 5-lead EKG
* Urinary catheter
* 1 peripheral IV (typically 16-18 gauge)
*
 
===Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. -->===
 
* Pre-oxygenate with 100% FiO2
* Rapid Sequence Induction (RSI)
* Intubation
*
 
===Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. -->===
 
* Supine
* 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. -->===
 
* 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<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. -->===
 
* Extubate when patient awake and able to protect airway
* PONV prophylaxis
 
==Postoperative management==
===Disposition<!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. -->===
 
* PACU
** Patients undergoing laparoscopic appendectomy can often be discharged home from PACU
* Encourage early post-operative ambulation
 
===Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. -->===
 
* Oral analgesics
* Non-opioid analgesics
** Ketoralac (Toradol)
** Acetaminophen (Tylenol)
* IV narcotics for breakthrough pain
 
===Potential complications<!-- List and/or describe any potential postoperative complications for this case. -->===
 
* PONV
** Consider multiple PONV prophylactics
* Urinary retention (consider straight catheterization of bladder prior to emergence)
*
 
==Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). -->==
 
 
{| class="wikitable"
|+
!
!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==
<references />
 
[[Category:Surgical procedures]]
[[Category:General surgery]]
[[Category:Intestinal surgery]]

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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