Perioperative management - Appendectomy, open - general and visceral surgery
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Indication
- Any clinical suspicion of appendicitis.
- 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.
Contraindication
- Acute episode of Crohn disease with so-called "concomitant appendicitis". Initial medical treatment, surgery only in case of 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.
- Acute episode of Crohn disease with so-called "concomitant appendicitis". Initial medical treatment, surgery only in case of further clinical deterioration.
Preoperative diagnostic work-up
- Mandatory: 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]
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, nerves (e.g., ilioinguinal nerve on the internal oblique)
Anesthesia
Positioning
Operating room setup
Special instruments and fixation systems
None
Postoperative management
Postoperative analgesia: Nonsteroidal anti-inflammatory drugs usually suffice; if necessary, they can be enhanced by opioid analgesics.
Follow this link to PROSPECT (Procedures Specific Postoperative Pain Management)
Follow this link to the International Guideline Library.Postoperative care: In perforated appendicitis antibiotics continued for at least 48–72 hours.Deep venous thrombosis prophylaxis: Unless contraindicated, the moderate risk of thromboembolism (surgical operating time > 30min) 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, monitor platelets)
Follow this link to the International Guideline Library.Ambulation: Immediately
Physical therapy: Respiratory exercises for pneumonia prevention only in bedridden patients
Diet Liquid diet immediately, solid diet starting on postoperative day 1
Bowel management If neededWork disability 5-12 days