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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Board Review Questions
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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Board Review Questions
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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Board Review Questions
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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Board Review Questions
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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Board Review Questions
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.