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Perioperative management - Appendectomy, laparoscopic - new - general and visceral surgery
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- 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.
- 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.
- 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].
- Secondary healing
- Intraabdominal abscess requiring revision or percutaneous drainage
- Postoperative ileus
- 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
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
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 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.