APPENDECTOMY
An appendectomy is a surgical procedure to remove the appendix, a small, tube-like structure attached to the large intestine (colon) in the lower right side of the abdomen. The appendix has no known essential function in the human body, but it can become inflamed or infected, leading to a condition called appendicitis.
Appendicitis is a medical emergency and requires prompt treatment, as a ruptured appendix can lead to serious complications, including peritonitis (infection of the lining of the abdominal cavity) and sepsis (a life-threatening infection that can spread throughout the body).
There are two primary methods for performing an appendectomy:
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Open appendectomy: This method involves making a single, larger incision in the lower right side of the abdomen to access and remove the appendix. The surgeon then closes the incision with sutures or staples.
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Laparoscopic appendectomy: This is a minimally invasive procedure that utilizes a few small incisions in the abdomen. A laparoscope (a thin, flexible tube with a light and camera) is inserted through one of the incisions, allowing the surgeon to visualize the appendix and surrounding organs on a monitor. Specialized surgical instruments are then inserted through the other incisions to remove the appendix. This method typically results in less pain, faster recovery, and smaller scars compared to an open appendectomy.
The choice of surgical method depends on factors such as the patient's overall health, the severity of the appendicitis, and the surgeon's experience and preference. After surgery, most patients can return to normal activities within a few weeks, although full recovery may take longer in cases with complications.
Anesthetic Implications for Appendectomy
Anesthesia type: General
Airway: Endotracheal tube
Preoperative:
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Abdominal pain can result in atelectasis from respiratory splinting
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Patients may present nauseous, vomiting, and dehydrated
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Expect hemoconcentration if the patient is dehydrated (fever, emesis, decreased oral intake)
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Assess volume status and provide adequate hydration prior to induction
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If emergency case, full stomach precautions
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Rapid-sequence induction if abdominal distention or ileus is present
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1 peripheral IV (normally 18-20 gauge)
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Peritonitis can cause volume shifts
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Electrolyte abnormalities are common secondary to N/V.
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Orogastric or nasogastric tube for stomach suctioning
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If the appendix is perforated, or peritonitis is present, a nasogastric tube is commonly placed for 24 hours
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Position: Supine with arms out or tucked
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Usually, just the left arm is tucked
Intraoperative:
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Avoid using nitrous oxide to minimize gastric/bowel distention.
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If laparoscopic case, pneumoperitoneum is created to enhance visualization
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Pneumoperitoneum can impair ventilation by decreasing lung compliance and functional residual capacity
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Trendelenburg position may be implemented to displace bowel with gravity which can further impair ventilation
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Neuromuscular paralysis is indicated
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Approximate time 60 minutes
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EBL expected < 75 mL
Postoperative:
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Extubation/emergence: Ideally, patient should be fully awake and fully reversed, capable of protecting airway
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Increased risk of PONV
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Mild to moderate pain expected
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Regional techniques may be used (TAP block)
Complications:
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Perforation
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Wound abscess
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Fecal fistula
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Hematoma
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Illeus
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Appendiceal stump leak
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Injury to other structures
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Atelectasis
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Thromboembolism
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PONV
Sources:
Macksey, L. F. (2011). Surgical procedures and anesthetic implications: A handbook for nurse anesthesia practice.
Jaffe, R. A. (2020). Anesthesiologist's Manual of Surgical Procedures (6th ed.).
Singh-Radcliff, N. (2013). 5-Minute Anesthesia Consult.