Operative Note:Appendisectomy

Name of procedure

LAPAROSCOPY AND OPEN APPENDISECTOMY, T5 emergency procdure, General anaesthetic

Indication

Symptoms and signs of peritonitis maximal in the right iliac fossa.

Preparation

• Co-Amoxiclav (Augmetin) 1.2 g IV given at induction, subsequently patient given Cefuroxime (Zinacef) 750 mg IV and Metronidazole (Flagyl) 500 mg IV
• Enoxaparin (Clexane) 40 millegrams SC given in ward prior to transfer to theater. Patient wearing TED stockings.

Incision

12 mm Blunt port inserted subumbilically using open `Hassan' technique, 5 mm port inserted suprapubically under direct vision.

Findings

Acute retrocaecal gangrenous appendicitis, pus in pelvis and along right paracolic gutter. Normal uterus, tubes and ovaries, laparoscopy otherwise unremarkable; proceed to open appendisectomy

Procedure

Open appendisectomy;

Incision

Lanz incision including lateral part of rectus sheath

Findings

Pus ++ in peritoneal cavity swab sent for C/S. Acute retrocaecal gangrenous appendicitis with imminent perforation at site of faecolith

Procedure

Appendisectomy (stump not buried) specimen sent in formalin for histology, haemostasis, local peritonal wash out appendix bed and pelvis with warm saline

Closure

Layers 2/0 Vicryl, 2 x 3/0 nylon verticle mattress to skin, Betadine wick to skin wound. Wound pad. Fascia at umbilical incision closed with 0 Maxon, skin with 4/0 nylon. Steristips to suprapubic skin incision

Post operative instructions

• Post GA obs
• See anaesthetic orders
• Monitor T/PR/RR/BP and urinary output
• NG tube on free drainage and 4 hourly aspirations
• Monitor input output
• Nil PO, IV fluids as charted
• Analgesia as charted
• Continue DVT prophylaxis with Enoxaparin 40 millegrams SC OD and TED stockings, early mobilisation
• Continue antibiotics for 5 days, cefuroxime (Zinacef)750 mg IV TDS and metronidazole (Flagyl) 500 millegramms IV TDS , first doses given in theatre
• Wet wick daily with saline for three days and remove wick on the fourth day, Do not change the wick