appendectomy.docx

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A laparotomyis asurgical procedure involving a large incision through theabdominal wall to gain access

into theabdominal cavity.It is also known as coeliotomy.

Terminology

In diagnostic laparotomy (most often referred to as anexploratory laparotomy and abbreviated Ex-Lap),

the nature of the disease is unknown, and laparotomy is deemed the best way to identify the cause.

In therapeutic laparotomy, a cause has been identified (e.g.peptic ulcer,colon cancer)and laparotomy

is required for its therapy.

Usually, only exploratory laparotomy is considered a stand-alone surgical operation. When a specific

operation is already planned, laparotomy is considered merely the first step of the procedure.

Spaces accessed

Depending on incision placement, laparotomy may give access to any abdominal organ or space, and is

the first step in any major diagnostic or therapeutic surgical procedure of these organs, which include:
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the lower part of thedigestive tract (thestomach,duodenum,jejunum,ileum andcolon)

theliver,pancreas andspleen

thebladder

the female reproductive organs (theuterus andovaries)

theretroperitoneum (thekidneys,theaorta,abdominallymph nodes)

theappendix

Types of incisions

Midline

The most common incision for laparotomy is the midline incision, a vertical incision which follows

thelineaalba.

The upper midline incisionusually extends from thexiphoid process to theumbilicus.

A typical lower midline incisionis limited by the umbilicus superiorly and by thepubic

symphysis inferiorly.

Sometimes a single incision extending fromxiphoid process to pubic symphysis is employed,

especially intrauma surgery.

Midline incisions are particularly favoured in diagnostic laparotomy, as they allow wide access to most

of the abdominal cavity.

Other

Other common laparotomy incisions include:

TheKocher (right subcostal) incision(afterEmil Theodor Kocher); appropriate for certain

operations on theliver,gallbladder andbiliary tract.This shares a name with the Kocher incision

used for thyroid surgery: a transverse, slightly curved incision about 2 cm above the

sternoclavicular joints;

the Davisor Rockey-Davis"muscle-splitting" right lower quadrant incision forappendectomy;

thePfannenstiel incision,a transverse incision below the umbilicus and just above the pubic

symphysis. In the classic Pfannenstiel incision, the skin and subcutaneous tissue are incised

transversally, but thelineaalba is opened vertically. It is the incision of choice forCesarean

section and for abdominalhysterectomy for benign disease. A variation of this incision is

the Maylard incisionin which therectus abdominismuscles are sectioned transversally to permit

wider access to the pelvis.
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Lumbotomyconsists of alumbar incision which permits access to thekidneys (which

areretroperitoneal)without entering theperitoneal cavity.It is typically used only for benign renal

lesions. It has also been proposed for surgery of the upper urological tract.

Related procedures

A related procedure islaparoscopy,where cameras and other instruments are inserted into

theperitoneal cavity via small holes in the abdomen. For example, anappendectomy can be done either

by a laparotomy or by a laparoscopic approach.

An appendectomy(sometimes called appendisectomyor appendicectomy) is thesurgical removal of

thevermiform appendix.This procedure is normally performed as anemergency procedure,when the

patient is suffering from acuteappendicitis.In the absence of surgical facilities,intravenousantibiotics are

used to delay or avoid the onset ofsepsis;it is now recognized that many cases will resolve when treatedperioperatively. In some cases the appendicitis resolves completely; more often, an inflammatory mass

forms around the appendix, causing transruptural flotation. This is a relativecontraindication tosurgery.

Appendectomy may be performedlaparoscopically (this is called minimally invasive surgery) or as an

open operation. Laparoscopy is often used if thediagnosis is in doubt, or if it is desirable to hide

thescars in theumbilicus or in the pubic hair line. Recovery may be a little quicker with laparoscopic

surgery; the procedure is more expensive and resource-intensive than open surgery and generally takes

a little longer, with the (low in most patients) additional risks associated withpneumoperitoneum (inflating

the abdomen with gas). Advanced pelvic sepsis occasionally requires a lower midline laparotomy.

There have been some cases of auto-appendectomies, i.e. operating on yourself. One was performed by

Dr Kane in 1921, but the operation was completed by his assistants. Another case is Leonid

Rogozov who had to perform the operation on himself as he was the only surgeon on a remote Arctic

base.

Procedure

In general terms, the procedure for an open appendectomy is as follows.

1. Antibiotics are given immediately if there are signs ofsepsis,otherwise a single dose of

prophylactic intravenous antibiotics is given immediately prior to surgery.

2. General anaesthesia is induced, withendotracheal intubation and fullmuscle relaxation,and the

patient is positionedsupine.

3. Theabdomen is prepared and draped and is examined under anesthesia.
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4. If a mass is present, the incision is made over the mass; otherwise, the incision is made

overMcBurney's point,one third of the way from theanterior superior iliac spine (ASIS) and the

umbilicus; this represents the position of the base of the appendix (the position of the tip is

variable).

5. The various layers of theabdominal wall are then opened.

6. The effort is always to preserve the integrity of abdominal wall. Therefore, theExternal

ObliqueAponeurosis is slitted along its fiber, and theinternal obliquemuscle is split along its

length, not cut. As the two run at right angles to each other, this prevents laterIncisional

hernia.

7. On entering theperitoneum,the appendix is identified, mobilized and then ligated and divided

at its base.

8. Some surgeons choose to bury the stump of the appendix by inverting it so it points into

thecaecum.

9. Each layer of the abdominal wall is then closed in turn.

10.The skin may be closed with staples or stitches.

11.The wound is dressed.

12.The patient will be brought to the recovery room.

NURSING MANAGEMENT:

Assess the severity and location of pain. If client presents with board-like rigidity and

severe pain, suspect for peritonitis. Administer analgesics after a diagnosis is made.

Assess the effectiveness of the analgesic given.

Position client in a supine position with thighs slightly flexed.
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Preoperative care

It is important to prepare a patient several hours pre-surgery. The patient may be dehydrated

due to symptoms such as vomiting. It may be necessary to administer IV fluids. The patient's

vital signs should be recorded every 2-4 hours. The nurse should not apply any heat over the

area of pain while the patient is awaiting diagnosis as this could cause the appendix to rupture

(Box 2).

Analgesia should not be administered before examination because this can lead to an

inaccurate diagnosis as the pain may subside and the examination will be ineffective.

Aperients should also be avoided as induced peristalsis may cause perforation. If appendicitis

has been diagnosed regular analgesia, usually an opioid depending on pain severity, should be

given to make the patient comfortable before treatment. They may feel anxious so the nurse

or surgical team should fully explain the procedure to them and answer any questions. The

operation site will be washed and shaved before surgery, depending on local procedures.

Postoperative care

The severity of the patient's pain needs to be assessed with the use of a pain scale.

Appropriate pain relief can then be administered. Vital signs should be regularly monitored at

half-hourly intervals for two hours postoperatively, hourly for two hours and, if stable, every

four hours while the patient is recovering in hospital.

If the patient has had a straightforward appendectomy the surgical team should review the

patient on recovery and decide when they may eat and drink.

A drain may have been inserted during surgery. If so, the output of the drain should be

recorded every 24 hours. The drain can be removed when there is minimal drainage - usually

50ml or less.

The wound should be managed aseptically. If the wound is covered with a dry dressing then it

should be changed every 1-2 days. Clips/stitches should be removed 10 days postoperatively.The patient can go home with these in place and the district or practice nurse can remove

them. If dissolvable stitches have been used this is unnecessary, although a visit to check the

wound will reduce anxiety. Before discharge, the patient must be confident in how to manage

their wound and have details of who they should contact in case of concern.

The patient should be encouraged to get up and out of bed as soon as possible to prevent the

formation of emboli. Anticoagulants are usually administered in the form of subcutaneous

injections before surgery and postoperatively. Antiembolism stockings should be worn. If

peritonitis has developed, the patient's postoperative management will be over a longer period

but will follow the same principles.

The patient will not be able to commence food and fluids for a few days, this is to enable thebowel to regain normal function. The convalescence period is almost invariably smooth and

the patient recovers rapidly (Colmer, 1986). The hospital stay for patients who have

undergone an uncomplicated appendectomy is usually 2-3 days. In most cases the patient will

be discharged when their temperature is normal and their bowels have started to function

again (Peterson, 2002).

People can live a full life without their appendix. Changes in diet, exercise or other lifestyle

factors are not necessary (NDDIC, 2004).

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