APPENDECTOMY

Case
Abstract

This is a case study of post operative client,

Mr. R.G.,a 30 years old man from #54A
Arevalo Compd. Purok 3, Cupang, Muntinlupa
City.
He was admitted at Medical Center of
Muntinlupa (MCM) last July 03, 2016 @
5:30 am,patient expressed abdominal
pain,colicky in character located at the RLQ,
Hypogastric and LLQ area, associated with
anorexia.Presence of tenderness during deep
palpation of the RLQ.admitting diagnosis was
urolithiasis r/t acute appendisitis

Upon admitting patient to the OR,

his vital signs was taken:
BP-120/80 , PR-79, RR-21
Temp-36.2
Total duration of operation last
for 2 hours under the service of
surgeon Dr. Inso, and
Anesthesiologist Dr. Dizon.
Certain lab test was also req.
such as urinalysis and cbc.

BIOLOGICAL/DEMOGRAPHIC PROFILE:
Name: Mr. R. G.
Age: 30 years old
Gender: Male
Status: Single
DoB : Aug.24, 1985
Place of Birth:#54A Arevalo Compd. Purok
3, Cupang, Muntinlupa City.
Religion: RC
Educational Attainment: College Grad.
Occupation: Financial analyst

Language spoken: Filipino, English

Admitting Diagnosis: urolethiasis r/t acute
appendicitis
Attending Physician: Dr. Inso
Source of information: Hospital records, Lab
result.

Past Medical History:

Allergies
-No known allergy
-Childhood

illnesses
-Negative on HTN,
-PTB,
-ASTHMA,
-HEART Ds
-Prior

Hospitalization due to APD

The Digestive System

ANATOMY AND PHYSIOLOGY

Mouth- breaks up food particles
Salivary glands- saliva moistens and
lubricates foods. Amylase digests
polysaccharides
Pharynx- swallows
Esophagus- transports food
Stomach- stores and churns food. Pepsin
digests protein. HCl activates enzymes,
breaks up food, kills germs. Mucus
protects stomach wall. Limited absorption.

Small intestine- completes digestion.

Mucus protects gut wall. Absorbs
nutrients, most water. Peptidase digests
proteins. Sucrose digest sugars. Amylase
digests polysaccharides.
Large intestine- reabsorbs some water
and ions. Forms and stores feces.
CecumAppendix- its function are not certain, but
some biologists believe that the appendix
serve as a sort of breeding ground for
intestinal bacteria.

Often called simply the intestinal flora, a community of

various bacterial populations normally inhibits the colon.
The predominance of nonpathogenic bacteria under
normal conditions is thought to help prevent disease.
Some of the non pathogenic bacteria are also thought to
aid in the digestion or absorption of essential nutrients.
Also, it bind extension of posteromedial cecum. It contains
many lymphoid nodules and serves as bacterial reservoir
of sorts.
Ascending colon- watery stool
Transverse colon- mushy stool
Descending colon- semi-formed stool
Sigmoid colon- feces are formed
Rectum- stores and expels feces.
Anus- opening for elimination of feces.

Pathophysiology .
Acute appendicitis is thought to begin with
obstruction of the lumen
Obstruction can result from:
Sub mucosal lymphoid hyperplasia
Fecolith / fecal stasis
Inspissated barium
Vegetable/fruit seeds
Worms (Entrobius vermicularis
Tumors of cecum/appendix

1.

2.

3.

4.

5.

Mucosal secretions continue to increase

intraluminal pressure .
Eventually the pressure exceeds capillary
perfusion pressure and venous and
lymphatic drainage are obstructed. .
With vascular compromise , epithelial
mucosa breaks down and bacterial
invasion by bowel flora occurs
Increased pressure also leads to arterial
stasis and tissue infarction .
End result is perforation and spillage of
infected appendicel contents into the
peritoneum .

Initial luminal distention triggers visceral

afferent pain fibers, which enter at the
10th thoracic vertebral level. .
This pain is generally vague and poorly
localized.
.Pain is typically felt in the periumbilical or
epigastric area.
As inflammation continues, the serosa and
adjacent structures become inflamed .
This triggers somatic pain fibers,
innervating the peritoneal structures. .

Typically causing pain in the RLQ .

The change in stimulation form visceral to
somatic pain fibers explains the classic
migration of pain in the periumbilical area
to the RLQ seen with acute appendicitis. .
Exceptions exist in the classic
presentation due to anatomic variability
of the appendix position . .Appendix can
be retrocecal causing the pain to localize
to the right flank .
In some males, retroileal appendicitis can
irritate the ureter and cause testicular
pain. .

Pelvic appendix may irritate the bladder or rectum

causing suprapubic pain, pain with urination, or
feeling the need to defecate .
Multiple anatomic variations explain the difficulty in
diagnosing appendicitis Clinical Features
Symptoms
Typical periumbilical/epigastric pain that shifts to
RIF (50%).
Afebrile/low grade fever (high in perf.)
Anorexia
Nausea
Constipation/Diarrhea
Percussion tenderness (rebound)
Tachycardia Clinical Features

Special Signs
McBurneys Point:
just below the middle of a line connecting the
umbilicus and the ASIS
Rebound tenderness sign:
Pain upon sudden release of pressure over the
McBurneys Point
Rovsings sign:
pain in RLQ with palpation to LLQ
Psoass Sign :place patient in L lateral
decubitus and extend R leg at the hip. If there
is pain with sign is positive this movement,
then the

Obturator test :passively flex the RT hip and

knee and internally rotate the hip. If there is
increased pain then the sign is positive
Pointing sign
Differential diagnosis
GIT
Gastroenteritis
Mesenteric adenitis
-Meckles diverticulitis
-Terminal ileitis
Acute typhlitis
Ca Cecum

Differential diagnosis
Urinary tract
Renal colic
Pyelonephritis

Pathophysio
Episodes of Constipation
Low Fiber
Occlusion of Appendix by Fecalith
Decreased flow drainage of mucosal
secretions
Increased ILP in the Appendix
Vasocongestion
Decreased blood supply in the appendix
Decreased O2 supply in the appendix
Appendix start to be necrotic:bacteria invade the appendix

Disruption of Cell Membrane of Appendix

Starts of inflammatory process

Inflammation of Appendix (Appendicitis)

Appendectomy
Tissue Trauma
Open wound

Disruption
of Cell membrane

Nociceptors on the
dermis

Impaired
Tissue Integrity

Start of inflammatory
Process

Risk for Infection

Release of Prosta
glandin,Bradykinin
Activity Intolerance

Send Impluse
to CNS
Pain on Surg.site

Preoperative Workup and Preparation

for Appendix Removal
Fluid Resuscitation this usually
consists of crystalloid fluids
intravenously to restore any
intravascular fluid depletion that might
be present due to inflammation of the
peritoneum (peritonitis) and fluid
sequestration in the intraabdominal
tissues (third spacing). The fluid given
is usually normal saline solution or
lactated Ringers solution.

Antibiotics uniformly given. Since the

appendix comes off the terminal ileum at
the juncture of the colon, rupture leads to
spillage into the peritoneal cavity of gram
negative and anaerobic bacteria. The
type antibiotics given are Unasyn and
Flagyl (metronidazole) or Zosyn
(pipercillin-tazobactam) or in the case of a
person with a penicillin allergy
ciprofloxacin and Flagyl

Incision for Appendix Removal

McBurney incision most appendix removal
proceduree use this mall incision that runs
diagonally on the abdominal wall in the right
lower quadrant (i.e., parallel to the edge of
the external oblique muscle or in the direction
running from the hip bone to the pubic bone.)
Rocky-Davis incision small incision that runs
horizontally on the abdominal wall in the right
lower quadrant
Midline incision this is sometimes done is the
patient is obese or if the surgeon is
anticipating the need for a formal resection of
the terminal ileum and cecum (i.e., if the
appendix has ruptured at the base)

Surgical Details of Procedure for

Appendix Removal
1. To start an appendix removal, the skin
incision is made with a knife.
2. Bovie electrocautery is used to dissect
through subcutaneous tissue and control
small skin bleeding.
3. The aponeurosis (muscle sheath) of
the outer layer of the external oblique
muscle is visualized and split by a small
incision with a knife and then further
opened along the direction of the fibers
with a scissors or the Bovie.

4. The muscle belly of the external

oblique is then bluntly retracted (but not
cut) using the classic muscle splitting
technique via a hemostat or Kelly clamp
until the aponeurosis of the internal
oblique is visualized.
5. The aponeurosis of the internal
oblique is split in a similar manner as
the external oblique.
6. The muscle belly of the internal
oblique is bluntly retracted in a similar
manner as the external oblique until the
peritoneum is visualized.

7. The peritoneum is grasped on either

side by two forceps, pulled up and into the
wound, and palpated to insure there is no
bowel caught in the fold of the peritoneum.
8. The peritoneum is opened with a small
incision using either a knife or scissors.
9. The peritoneal fluid is immediately
inspected for amount and prurulence and
cultures are taken.
10. The opening in the peritoneum is
widened and two hand-held retractors are
placed to expose the cecal area.

11. Manual and visual exploration for

the appendix is performed by locating
the convergence of the cecum and the
terminal ileum.
12. The appendix is delivered up into
the wound either by digitally flipping it
up or be grasping the base with a
Alice or Babcock and applying traction
to allow dissection of any adhesions
holding it in the abdominal cavity

13. The entire appendix is inspected with

close attention to the base to insure that
the area of rupture is sufficiently distant
from the base to allow a margin of healthy
tissue.
14. If the base of the appendix is involved
in the rupture a limited right hemi
colectomy is done (see right hemi
colectomy).
15. If the base of the appendix is not
involved, the mesoappendix or mesentery
of the appendix is divided, cross-clamped
with Kelly clamps or hemostats and tied
with 2-0 or 3-0 silk usually.

16. When the appendix has been

isolated from the meso appendix, the
appendix proximal to the rupture is
crushed with a straight clamp.
17. Two chromic ties are then placed on
the area of crushed appendix.
18. The appendix is then resected off
the stump distal to the ties using a
knife.
19. The exposed mucosa is then
ablated by the Bovie cautery

20. Some surgeons then prefer to dunk

the tied-off appendiceal stump by placing
a running purse string suture around the
stump.
21. The intra abdominal area is inspected
for bleeding and pockets of remaining
infection.
22. Most surgeons will irrigate the
abdominal cavity with saline solution or
antibiotic-containing saline solution.
23. The edges of the peritoneum are re
approximated using a running 3-0 or 4-0
Vicryl suture.

24. The edges of the internal oblique

aponeurosis are re approximated using
a 1-0 or 2-0 Vicryl suture.
25. The edges of the external oblique
aponeurosis are likewise re
approximated.
26. The superficial wound is irrigated.
27. If the appendix has ruptured before
the appendix removal surgery and
there was frank pus, many surgeons will
leave the subcutaneous tissue and skin
open to heal by secondary intention.

28. If the appendicitis was in the early

stages or was normal the subcutaneous
tissue can be closed at the level of
Scarpas fascia with interrupted or
running 2-0 Vicryl suture.
29. The skin is closed with interrupted
Nylon sutures, or a subcuticular
absorbable suture such as Monocryl

Medication: (post-op)
Metronidazole