MANAGEMENT

Preoperative Interventions
 Keep the patient at rest in semi-Fowler’s position to relax the abdominal muscles and
reduce the pain. Gravity localizes inflammatory exudate into the lower abdomen or
pelvis, relieving abdominal tension, which is accentuated by supine position.
 Maintain NPO status 6-8 hours prior to surgery to prevent intraoperative aspiration.
 Order for Cardio-Pulmonary Clearance before surgery.
 Establish an IV line and administer D50.9 NSS with a maintenance fluid rate of 100
mL/hr to prevent dehydration.
 Monitor for changes in the level of pain, signs of ruptured appendix and peritonitis, the
bowel sounds.
 Monitor vital signs and blood glucose levels every 4 hours.
 Apply ice packs to the abdomen every hour for 20-30 minutes. Doing so will soothe and
relieves pain through the desensitization of nerve endings.
 Administer prophylactic cefoxitin 2 g IV every 8 hours or at least 30-60 mins before skin
incision
 Avoid the application of heat in the abdomen as this may cause the appendix to rupture.
 Avoid laxatives or enema.

Position of the patient and surgical team in the OR

 Position the patient in a supine position, combined with the Trendelenburg position and
left lateral position (10-150, inclined towards the surgeon) to sweep the bowel away.
 Have the surgeon and the assistant stand on the left side of the patient.
 Position the monitor on the right side of the patient.

Perioperative intervention: Laparoscopic Appendectomy

 Practice aseptic technique and initiate corrective action when the sterile field is
compromised.
 Ask the anesthesiologist to administer general anesthesia.
 Attach endotracheal intubation.
 Monitor blood glucose level and maintaining it at the target glucose level <200 mg/dL.
 Decompress bladder with a Foley catheter to avoid injury while inserting the suprapubic
ports.
 Perform povidone-iodine scrub in the abdominal area starting at the center and move
outward in reverse concentric circles.
 Place a sterile towel over the cleaned field to dry the area and remove it from end to
end.
 Paint iodophor on the skin starting from the center working outwards.
 Place new sterile towels around the field and held it in place by towel clips.
 Place sterile drapes over the patient revealing only the abdominal area.
 Establish pneumoperitoneum with a Veress needle through the umbilicus and then
introduce a laparoscope.
 Insert a 12 mm trocar into the suprapubic region, a little to the left.
 Insert a 5 mm trocar in the right lower quadrant at the level of the first 12-mm port, to
provide triangulation.
  Grasp the end of the appendix by a Maryland grasper through the right lower abdominal
5-mm port.
 Elevate the appendix upwards to identify the window between the mesoappendix and
the cecum.
 Dissect and divide the mesoappendix from the top to the base using a harmonic scalpel
placed through the left lower quadrant port.
 Introduce three endoloops through the left lower quadrant port, passed over the tip of the
appendix, and secured at the base of the appendix.
 Place two ligatures 5 mm apart, close to the cecum, and one ligature placed distal to the
first two.
 Transect the appendix between the ties, leaving two loops on the cecum end.
 Retrieve the appendix through the midline port in a sterile specimen bag
 If exudate is present, place a drain in the pouch of Douglas.
 After the procedure is done, removed the instruments and close the incisions with
stitches.
 Place bandage over the incisions.

Postoperative Interventions
 Move the patient to a recovery room and closely monitor her vital signs, urine output,
sedation score, pain score, and nausea score for at least 15 minutely.
 Initiate continuous oximetry monitoring in the recovery room.
 Transfer the patient to the ward once her core temperature is within the normal range
(36.5 - 37.5 C), sedation score 2 or less, no active vomiting, and manageable pain
(reflected by pain score).
 Monitor temperature for signs of infection, vital signs, pain score, urine output, the
passing of flatulence, and neurologic state every 4 hours.
 Assess incision for signs of infection such as redness, swelling, discharges, and pain.
 Maintain IV fluids and NPO status until bowel function has returned.
 Advance diet gradually or as tolerated when bowel sound returns.
 If a rupture of the appendix occurred, expect that the drainage from the Penros drain
may be profuse for the first 2 hours and monitor the bag every 4 hours.

PATIENT EDUCATION
 Encourage the patient to early ambulation after surgery to promote normalization of
organ function (stimulate peristalsis and passing of flatus, reducing abdominal
discomfort).
 Make sure that the patient understands any pain medication prescribed, including doses,
route, action, and side effects. Advice the patient to avoid operating a motor vehicle or
heavy machinery while taking such medication.
 Have the patient come back for a follow-up in 5 to 7 days to remove sutures (if soluble
ones were not used).
 Explain to the patient the need to keep the surgical wound clean and dry.
 Teach the patient to observe the wound and report back to the physician any increased
swelling, redness, odor, or separation of wound edges. Also, instruct the patient to notify
the doctor if a fever develops.
 Instruct the patient that a possible complication of appendicitis is peritonitis. Discuss with
the patient symptoms that indicate peritonitis, including sharp abdominal pains, fever,
nausea and vomiting, and increased pulse and respiration. The patient must know to
seek medical attention immediately should these symptoms occur.
 Strongly discourage drinking alcoholic beverages as this may cause uncoordinated
movements and may negatively interact with the patient’s medication. Also, strongly
advice patient to smoking cessation.
 Instruct the patient that diet can be advanced to her normal food pattern as long as no
gastrointestinal distress is experienced. Take this opportunity to also educate the patient
on the importance of a complete and balanced meal.