1 Appendectomy

8/2/2019 1 Appendectomy

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Abdominal Surgery CurriculumJen Basarab-Tung

Appendectomy


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Background

Indicated for acute or perforated appendicitis Diagnosed or suspected

10-15% false positive rate acceptable

Laparoscopic vs. open Most appendectomies are laparoscopic

3 trocars (umbilical, suprapubic, LLQ)

Open appendectomy done through RLQ or rightparamedian incision

Cochrane review shows small benefit tolaparoscopic procedure, particularly for young,female, obese, and employed patients


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Benefits of Lap Approach

Shorter hospital stay

Faster return to work

Fewer wound infections Exception: more intra-abdominal

abscesses with laparoscopic

Decreased pain Better cosmetic result


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Relevant Anatomy

A. Trocar placement B. Internal anatomy


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Preoperative Considerations

Most common in teens and young adults,but can occur at any age

Patients may have received antibiotics inthe ED or on the floor

Pathogens are usually enteric gram negatives

Cefazolin or cefoxitin commonlyused at Stanford

Hypovolemia is common

Decreased po intake, vomiting


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Induction and Maintenance

Treat any acute abdomen as a full stomach

RSI or modified RSI and endotrachealintubation

Most patients require only standardmonitors and one PIV

Exception: septic pts from perforated appendix

Muscle relaxation is helpful when underpneumoperitoneum

Twitch monitoring (goal TOF 1 of 4)


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Fluid Management

Keep in mind: Foley often not placed dueto brevity of procedure (60-90 minutes)

Patients often present with vomiting anddecreased po intake and may be septic

Replace fluid deficit and intraoperative losses

Fortunately, insensible losses and blood

loss are minimal 5-8 mL/kg/hr of crystalloid as a

guideline, but let the vitals be your guide

Resuscitate more if patient is septic or

volume depleted


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Issues w/ Pneumoperitoneum

Avoidance of N2O Some use N2O for emergence after

discontinuation of pneumoperitoneum, butcheck with attending because of PONV

Difficulties with Ventilation Pneumoperitoneum can increase PIPs,

especially in obese patients

Consider pressure control ventilation

Cardiovascular changes Decreased venous return -> decreased CO

Compensatory increase in SVR


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Special Considerations

PONV is common Zofran for virtually everyone; consider additional

prophylaxis with decadron Extubate awake to protect airway

PregnancyAppendectomy is the most common non-OB

procedure performed on pregnant women Recent evidence shows laparoscopy is safe in all

stages of pregnancy Preop OB consult, left uterine displacement,

aspiration precautions, careful trocar placement Fetal monitoring generally preferred during

surgery in late-term pregnant women, but

not feasible as monitors would encroach onsurgical field


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Board Review Questions

In using general anesthesia forlaparoscopic appendectomy, which of thefollowing is true?

A. Inhaled N2O will diffuse into CO2-containingspaces and increase their volume or pressure B. Peak airway pressures usually do notchange under pneumoperitoneum. C. Small but detectable (via Doppler orTEE) CO2 emboli are the exception ratherthan the rule D. Minute ventilation will need to be

approximately tripled to eliminate the

exogenously administered CO2


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Answer: A N2O will diffuse into CO2-containing spaces and

increase the pressure and/or volume.

Pneumoperitoneum usually increases peakairway pressures.

CO2 emboli are common during laparoscopicprocedures; however, most are fortunately of

little clinical significance. Minute ventilation needs to be increased by

about a third in the average patient duringlaparoscopic surgery in order to maintain a

normal value for end-tidal CO2.


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A 27 year-old woman is anesthetized withpropofol, sevoflurane, N2O, and O2 forlaparoscopic appendectomy. She is placed in

Trendelenburg position after insertion of theneedle through the abdominal wall, and CO2 isinsufflated. There is sudden onset ofhypotension. The hypotension may be due to

any of the following EXCEPT:A. CO2 embolism B. Hemorrhage C. Compression of the IVC

D. Position


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Answer: D

The patient for laparoscopic appendectomy

may be hypotensive due to CO2 embolus,hemorrhage, and compression of the IVCfrom increased intra-abdominal pressure.The Trendelenburg position should not cause

hypotension.


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In the previous scenario, which of thefollowing is NOT an appropriate step to

take?A. Administer IV fluids

B. Inform the surgeon

C. Administer epinephrine D. Discontinue the N2O


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Answer: C After the onset of hypotension during laparoscopic surgery, the

surgeon should immediately be informed and the insufflation of CO2discontinued.

In the case of CO2 embolism, hypotension and desaturation are theusual presenting signs. Administration of 100% O2 may increaseoxygen saturation.

Placement of the patient in the left lateral position acts to trap thegas in the right ventricle and decrease the amount entering thepulmonary artery. Since CO2 is very soluble, aspiration of the gasvia a right atrial catheter is rarely necessary.

The occurrence of hemorrhage via laceration or cannulation of ablood vessel with the insufflating needle may require laparotomy forrepair.

If the hypotension is due to IVC compression, decreasing the intra-abdominal pressure should increase the blood pressure. Epinephrineis not indicated unless the hypotension persists and requiresbeginning ACLS.


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References

Curet MJ et al. (2009). Laparoscopic General Surgery.In Jaffe RA, Samuels SI (Eds.),AnesthesiologistsManual of Surgical Procedures(4th Ed., pp. 569-608).

Philadelphia: Lippincott Williams and Wilkins. Jeong J et al. Laparoscopic appendectomy is a safe

and beneficial procedure in pregnant women. SurgLaparosc Endosc Percutan Tech2011;21:1, 24-27.

Sauerland S, Jaschinski T, Neugebauer EA.Laparoscopic versus open surgery for suspectedappendicitis. Cochrane Database Syst Rev. 2010 Oct6;(10):CD001546.

Dershwitz M, ed. The MGH Board Review ofAnesthesiology, 5th ed. New York: Appelton & Lange,

1999.

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