Download - Appendectomy O.R. Write Up
I. PATIENT’S PROFILE
Hospital: Notre Dame de Chartres Hospital
Name: patient x
Age: 20 years old
Sex: female
Birthday: March 21, 1991
Civil status: single
Nationality: Filipino
Date of Admission: September 5, 2011
Religion: Roman Catholic
Address: 031 Shangrila Village, Baguio City, Benguet
Chief complaint: Right lower quadrant pain
Pre-operation Diagnosis: Acute Appendicitis
Post-operation Diagnosis: Ruptured Appendicitis
Surgeon: Dr. Pablo Candelario
Anesthesiologist: Dr. Edgar Montenegro
Type of Anesthesia: Subarachnoid Block Anesthesia
Time anesthesia began: 6:45 pm
Operation Date: September 5, 2011
Time Operation Began: 06:50 pm
Time Operation Ended: 07:55 pm
Title of Operation: Exploratory Appendicitis Peritoneal Lavage
Page | 1
II. ANATOMY AND PHYSIOLOGY
The appendix is a small, fingerlike appendage about 10 cm (4
in) long that is attached to the cecum just below the ileocecal
valve. The appendix fills with food and empties regularly into
the cecum. Because it empties inefficiently and its lumen is
small, the appendix is prone to obstruction and is particularly
vulnerable to infection (ie, appendicitis).
Appendicitis, the most common cause of acute surgical
abdomen in the United States, is the most common reason for
emergency abdominal surgery. Although it can occur at any age, it
more commonly occurs between the ages of 10 and 30 years (NIH,
2007).
Page | 2
III. PATHOPHYSIOLOGY
A. NARRATIVE:
The appendix becomes inflamed and edematous as a result of
becoming kinked or occluded by a fecalith (ie, hardened mass of
stool), tumor, or foreign body. The inflammatory process increases
intraluminal pressure, initiating a progressively severe, generalized,
or periumbilical pain that becomes localized to the right lower
quadrant of the abdomen within a few hours. Eventually, the inflamed
appendix fills with pus.
Vague epigastric or periumbilical pain (ie, visceral pain that is
dull and poorly localized), progresses to right lower quadrant pain
(ie, parietal pain that is sharp, discrete, and well localized) and is
usually accompanied by a low-grade fever and nausea and sometimes by
vomiting. Loss of appetite is common. In up to 50% of presenting
cases, local tenderness is elicited at McBurney’s point when pressure
is applied. Rebound tenderness (ie, production or intensification of
pain when pressure is released) may be present. The extent of
tenderness and muscle spasm and the existence of constipation or
diarrhea depend not so much on the severity of the appendical
infection as on the location of the appendix. If the appendix curls
around behind the cecum, pain and tenderness maybe felt in the lumbar
region. If its tip is in the pelvis, these signs maybe elicited only
on rectal examination. Pain on defecation suggests that the tip of the
appendix is resting against the rectum; pain on urination suggests
that the tip is near the bladder or impinges on the ureter. Some
rigidity of the lower portion of the right rectus muscle may occur. If
the appendix has ruptures, the pain becomes more diffuse; abdominal
distention develops as result of paralytic ileus, and the patient’s
condition worsens.
Page | 3
B. SCHEMATIC
Page | 4
INFLAMMATION
INTRALUMINAL PRESSURE
LYMPHOID SWELLING DECREASED VENOUS DRAINAGE THROMBOSIS BACTERIAL INVASION
GANGRENE
PERFORATION (24-36 hrs.)
ABSCESS
PERITONITIS
IV. PREPARATION OF THE PATIENT
Signed Consent was obtained. A physical examination was
performed along with laboratory tests. The patient was asked and
ordered to fast (not to eat or drink anything) for eight hours
before the procedure. This was to ensure that she’ll have an
empty stomach. The surgery was done under subarachnoid block.
Having an empty stomach helps but does not guarantee that
vomiting will be prevented. Vomiting can lead to possible
aspiration (breathing in) of stomach contents into lungs.
Irritation of the lung and possible pneumonia could result from
such an aspiration event. Prescription for pain medication by the
attending physician was also given prior to surgery. Dentures,
nail polish, jewelleries were removed from the patient.
Moreover, bowel and bladder content evacuation was maintained.
Leggings were applied to the patient. She is placed in
supine postion; arms have been extended on padded armboards.
Skin preparation was done aseptically; on lower right
quadrant, extending from the nipples to upper thighs and down to
the table at the sides.
V. DISCUSSION
Page | 5
Appendectomy is the excision of the appendix, usually
performed to remove the acutely inflamed organ.
When the appendix is acutely inflamed, it may rupture,
spilling contents of the bowel into the peritoneal cavity;
peritonitis and abscess formation ensues. Earlier diagnosis and
appendectomy can prevent this potentially serious complication.
Procedure:
Appendectomy is described as an incision made in the right
lower abdomen either transversely, obliquely with a McBurney or a
vertical incision for primary appendectomy. The appendix is
identified and its vascular supply ligated. The appendix is
ligated at its base, i.e., the stump is tied off with absorbable
suture. The appendix is removed, and the stump maybe inverted in
the cecum within a placed pursestring suture, cauterized with
chemicals or ESU, or simply left alone after ligation.
VI. INSTRUMENTATION
Page | 6
A. Retractors:
1) U.S. Army Navy – exposing superficial wound
2) Deaver – retractng deep abdominal/ chest incisions
3) Goulet – retracting superficial tissue
4) Richardson – used to pull layers of tissues aside in deep abdominal or chest incisions to better visualize surgery site
5) Senn – exposing superficial wound
Forceps:
Page | 7
1) Adson – used only for heavy duty grasping such as the skin and suturing
2) DeBakey – used to grasp delicate tissue
Scissors:
1) Curved Mayo – heavy tissue/ muscle
2) Straight Mayo – sutures, dressing, drains
3) Metzenbaum – tissue dissection and are defined and are curved for easy se, for delicate tissue
Page | 8
Clamps:
1) Towel Clip – used to hold towels and drapes in place, w/c restrict the surgical field attached to the patient
2) Curved Mosquito – used to hold sutures aside from pedia patients
3) Babcock – used to grasp delicate tissue (tubular organs)
4) Allis – to hold tissue firmly and on tissues which will be excised
Page | 9
5) Ochsner – used to grasp heavy tissue; also used as a clamp
6) Needle Holder – used to hold needle in suturing
7) Forester Sponge Forceps – used to grasp sponges
Suction tubes:
Frazier – sunctioning small quantities of fluid/ blood; sunctioning in small areas
Page | 10
Miscellaneous:
Scalpel – cutting skin incision, cutting small vessels and tissue, skin incisions and hand procedures
Page | 11