Appendectomy

Appendectomy

Anesthesia type	General
Airway	Endotracheal tube
Lines and access	Peripheral IV
Monitors	Standard ASA / 5-Lead EKG
Primary anesthetic considerations
Preoperative	Full stomach precautions
Intraoperative	Rapid sequence induction
Postoperative	PONV
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An appendectomy is generally performed as an urgent or emergent procedure to treat appendicitis. Appendicitis can occur at any age, but is more common in patients 19-25 years old. Appendicitis is common, occurring in about 7% of the population. An appendectomy can be performed laparoscopically or as an open procedure. Surgical practice has largely transitioned to the laparoscopic approach.

Preoperative management

Preoperative evaluation

Respiratory	Acute abdominal pain can cause respiratory impairment (respiratory splinting) resulting in atelectasis
Cardiovascular	May be dehydrated due to fever, emesis, and reduced oral intake Assess volume status by checking vital signs, mucus membranes, skin turgor. IV hydration before anesthetic induction
Gastrointestinal	Patients typically present with nausea and vomiting. Patients with acute abdomen should be treated as if they have full stomachs. Muscular resistance to palpation (muscle guarding) can correlate with severity of the inflammatory process.
Hematologic	Patients typically have moderate leukocytosis with left shift Expect hemoconcentration if patient dehydrated
Labs	CBC Chemistry Panel Pregnancy test (for women of child bearing age)

Operating room preparation

• NG Tube
• Verify pre-incisions antibiotics required

Regional and neuraxial techniques

• Consider pre-incision nerve blocks

Intraoperative management

Monitoring and access

• Standard ASA monitors
• 5-lead EKG
• Urinary catheter
• 1 peripheral IV (typically 16-18 gauge)

Induction and airway management

• Pre-oxygenate with 100% FiO2
• Rapid Sequence Induction (RSI)
• Intubation

Positioning

• Supine
• Secure or tuck the arms

Maintenance and surgical considerations

• Standard maintenance
  • Consider avoiding nitrous oxide given potential for bowel dissension and increased risk of PONV
• Place OG/NG before surgical incision to decompress the stomach
• Maintain norovolemia and normothermia

Emergence

• Extubate when patient awake and able to protect airway
• PONV prophylaxis

Postoperative management

Disposition

• PACU
  • Patients undergoing laparoscopic appendectomy can often be discharged home from PACU
• Encourage early post-operative ambulation

Pain management

• Oral analgesics
• Non-opioid analgesics
  • Ketoralac (Toradol)
  • Acetaminophen (Tylenol)
• IV narcotics for breakthrough pain

Potential complications

• PONV
• Urinary retention (consider straight catheterization of bladder prior to emergence)

Procedure variants

	Open Appendectomy	Laparoscopic Appendectomy
Position	Supine	Supine
Surgical time	1 hour	30-90 mins
EBL	<75 mL	<75 mL
Postoperative disposition	PACU	PACU
Mortality	Perforated: 2% Non-perforated: <0.1%	Perforated: 2% Non-perforated: <0.1%
Complications	Perforation Abscess Fistula Hematoma Illeus	Perforation Abscess Fistula Hematoma Illeus Conversion to Open
Pain	5-7	4