Perioperative management - Appendectomy, laparoscopic - new - general and visceral surgery

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  • Indications

    • Any clinical suspicion of appendicitis (standard: open appendectomy)
    • An unremarkable ultrasound study and normal inflammation parameters do not rule out this diagnosis!
    • In young women laparoscopic appendectomy should be performed (particularly in the context of possible gynecologic differential diagnoses).
    • Laparoscopy whenever the clinical situation is marked and other differential diagnoses (e.g., sigmoid diverticulitis, gynecologic causes, etc.) cannot be ruled out.
  • Contraindications

    • Acute episode of Crohn disease with so-called "concomitant appendicitis". Initially medical treatment, and surgery only in further clinical deterioration Caution: Inflammatory changes at the cecum increase residual stump rupture rate and secondary fistula formation.
    • So called "concomitant appendectomy" during other abdominal procedures.
  • Preoperative diagnostic work-up

    • Medical history, clinical examination, lab tests.
    • Optional:
      • Ultrasonography is optional (operator-dependent).
    • Gynecologic consultation in women and whenever medical history demonstrates possible gynecologic causes (e.g., adnexitis
    • CT study in "acute abdomen" if diagnosis is still uncertain after all other studies (clinical picture, lab panel, ultrasound) [NG CS et al. BMJ. 2000; 325: 1387].
  • Special preparation

    None

  • Informed consent

    • Secondary healing
    • Intraabdominal abscess requiring revision or percutaneous drainage
    • Postoperative ileus
    • Adhesions
    • Stump rupture
    • Injury to other segments of the bowel, vessels, ureter, nerves (e.g., ilioinguinal nerve on the internal oblique)
    • Cutaneous emphysema
    • Postlaparoscopic shoulder pain syndrome
    • General surgical risks (intra-/postoperative bleeding, thrombosis, embolism, HIT)
    • In case of complications convert to open technique, if necessary
  • Anesthesia

  • Positioning

    Paid content (image)

    Supine, with left arm adducted and right arm abducted.
    Horizontal position while establishing pneumoperitoneum, and light Trendelenburg position of 20° – 30° during actual procedure. Irrigate the surgical field with the patient in anti-Trendelenburg position; this way the fluid will collect in the Douglas pouch where it can be suctioned. If necessary, reposition patient to light left lateral recumbent position.

  • Operating room setup

    Paid content (image)
    • Surgeon: On left side of patient at level of pelvis.
    • 1. Assistant: On left side of patient at chest level.
    • Scrub nurse: At feet of patient.
    • Monitor / Laparoscopy tower: On right side of patient
  • Special instruments and fixation systems

    • Trocar 5mm (1x)
    • Trocar 13.5mm (1x)
    • Endo GIA™ (30mm, white cartridge)
    • Possibly laparoscopic irrigation and specimen retrieval bag
  • Postoperative management

    Postoperative analgesia: Adequate analgesia (e.g., metamizole and ibuprofen).
    Follow this link to PROSPECT (Procedures Specific Postoperative Pain Management) This link will take you to the International Guideline Library.

    Postoperative care: If perforated, continue antibiotics for at least 48-72 hours.

    Deep venous thrombosis prophylaxis: Yes (e.g,. 1x 0,3mL dalteparin). Unless contraindicated, the moderate risk of thromboembolism (surgical operating time > 30 min) calls for prophylactic physical measures and low-molecular-weight heparin, possibly adapted to weight or dispositional risk, until full ambulation is reached.
    Note: Renal function, HIT II (history, platelet check).
    This link will take you to the International Guideline Library.
    Ambulation: ImmediatelyPhysical therapy: Not required.
    Diet Liquid diet immediately, solid diet starting on postoperative day 1
    Bowel managementIf neededWork disability For about 1 week, depending on intraoperative finding possibly 2–3 weeks.