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Jinky Rose Villamor

Sunshine Sanchez

REPORT:APPENDICITIS

CASE:
Appendicitis means inflammation of the appendix. It is thought that appendicitis begins
when the opening from the appendix into the cecum becomes blocked. The blockage may
be due to a build-up of thick mucus within the appendix or to stool that enters the
appendix from the cecum. The mucus or stool hardens, becomes rock-like, and blocks the
opening. This rock is called a fecalith (literally, a rock of stool). At other times, the
lymphatic tissue in the appendix may swell and block the appendix. After the blockage
occurs, bacteria which normally are found within the appendix begin to invade (infect)
the wall of the appendix. The body responds to the invasion by mounting an attack on the
bacteria, an attack called inflammation. An alternative theory for the cause of
appendicitis is an initial rupture of the appendix followed by spread of bacteria outside
the appendix.

PROCEDURE:(Appendectomy)
The surgical procedure for the removal of the appendix is called an appendicectomy (also
known as an appendectomy). Often now the operation can be performed via a
laparoscopic approach, or via three small incisions with a camera to visualize the area of
interest in the abdomen. If the findings reveal suppurative appendicitis with
complications such as rupture, abscess, adhesions, etc., conversion to open laparotomy
may be necessary. An open laparotomy incision if required most often centers on the area
of maximum tenderness, McBurney's point, in the right lower quadrant. A transverse or a
gridiron diagonal incision is used most commonly.
During an appendectomy, an incision two to three inches in length is made through the
skin and the layers of the abdominal wall over the area of the appendix. The surgeon
enters the abdomen and looks for the appendix which usually is in the right lower
abdomen. After examining the area around the appendix to be certain that no additional
problem is present, the appendix is removed. This is done by freeing the appendix from
its mesenteric attachment to the abdomen and colon, cutting the appendix from the colon,
and sewing over the hole in the colon. If an abscess is present, the pus can be drained
with drains that pass from the abscess and out through the skin. The abdominal incision
then is closed.

SIGNS:
These include localized findings in the right iliac fossa. The abdominal wall becomes
very sensitive to gentle pressure (palpation). Also, there is rebound tenderness. In case of
a retrocecal appendix, however, even deep pressure in the right lower quadrant may fail
to elicit tenderness (silent appendix), the reason being that the cecum, distended with gas,
prevents the pressure exerted by the palpating hand from reaching the inflamed appendix.
Similarly, if the appendix lies entirely within the pelvis, there is usually complete absence
of the abdominal rigidity. In such cases, a digital rectal examination elicits tenderness in
the rectovesical pouch. Coughing causes point tenderness in this area (McBurney's point)
and this is the least painful way to localize the inflamed appendix. If the abdomen on
palpation is also involuntarily guarded (rigid), there should be a strong suspicion of
peritonitis requiring urgent surgical intervention.

CAUSES:
On the basis of experimental evidence, acute appendicitis seems to be the end result of a
primary obstruction of the appendix lumen. Once this obstruction occurs the appendix
subsequently becomes filled with mucus and swells, increasing pressures within the
lumen and the walls of the appendix, resulting in thrombosis and occlusion of the small
vessels, and stasis of lymphatic flow. Rarely, spontaneous recovery can occur at this
point. As the former progresses, the appendix becomes ischemic and then necrotic. As
bacteria begin to leak out through the dying walls, pus forms within and around the
appendix (suppuration). The end result of this cascade is appendiceal rupture (a 'burst
appendix') causing peritonitis, which may lead to septicemia and eventually death.

POSSIBLE NURSING DIAGNOSIS:


>Elevated body temperature r/t post operative complication:wound infection
>Acute pain r/t post surgical incision
>Mild anxiety r/t upcoming surgery

NURSING RESPONSIBILITIES:

PREOPERATIVE:
>identify and greet the patient
>establish trust and rapport
>restrict patient from eating and drinking
>initial v/s taken
>used IV drip to hydrate patient
>explain tests to the patient
hematology
blood test
urinalysis
>obtain results
>informed consent signed by the patient
>ask if the patient understood the procedure
>provide comfort to the patient

INTRAOPERATIVE:
>monitor v/s
>skin preparation
>secure patient in place in the OR table
>srub nurse prepare surgical set-up
>initial counting of instruments
>maintain surgical asepsis
>assist surgeon by passing instruments and other supplies
>circulating nurse obtain additional supplies
>carry out NCP
>assist surgeon and scrub nurse to do sterile gowns and gloves
>anticipate the need of equipments,instruments and medications
>arrange the transfer of specimens to laboratory for analysis
>discard used gauze and sponges

POSTOPERATIVE:
>take patient to PACU
>monitor v/s
>when patient stabilizes,transfer to surgical ward
>administer pain medication
>position and safety of the patient
>raise side rails
>check wound dressing
>assess bleeding
>check IVF
>assess patient’s skin,color and temperature
>ensure patient is warm and comfortable
>document medications given and care rendered
Sanchez,Sunshine

Journal:
Laparoscopic appendectomy performed during pregnancy by gynecological
laparoscopists.

Author:
Park SH, Park MI, Choi JS, Lee JH, Kim HO, Kim H

Source:
Eur J Obstet Gynecol Reprod Biol 2009 Nov 3.

Report:
OBJECTIVE: To evaluate the safety, feasibility, and pregnancy outcomes of laparoscopic
appendectomy (LA) during pregnancy.
STUDY DESIGN: A retrospective review of eight pregnant women who underwent LA
from January 2007 to December 2008.
RESULTS: The median age of the patients and median parity were 29.5 years (range, 25-
34 years) and 0 (range, 0-1), respectively. The median operating time of LA was 22.5min
(range, 15-40min). The median length of hospital stay was 3 days (range, 2-4 days).
There was no maternal or fetal mortality or morbidity, conversion to laparotomy, or
uterine injury. Seven women delivered seven healthy infants. One patient chose to have
an elective abortion in another hospital. The histopathological diagnoses of the resected
appendices were of acute appendicitis.

CONCLUSION/REACTION: LA performed by gynecologic laparoscopists in pregnant


women is safe, feasible, and effective.

REFERENCE:
http://www.unboundmedicine.com/medline/ebm/record/19892457/full_citation/Laparosc
opic_appendectomy_performed_during_pregnancy_by_gynecological_laparoscopists_
Villamor,Jinky Rose

JOURNAL:
A clinicopathological review of 324 appendices removed for acute appendicitis
in Durban, South Africa: a retrospective analysis.

Source:
Ann R Coll Surg Engl 2009 Nov; 91(8):688-92.

INTRODUCTION: Acute appendicitis remains a common surgical condition and the


importance of specific elements in the clinical diagnosis remain controversial. A variety
of neoplastic and inflammatory conditions mimic acute appendicitis. The purpose of this
study was to determine the presenting pattern of acute appendicitis and to review the
pathological diagnosis.
PATIENTS AND METHODS: This is a retrospective analysis of 324 patients who had
appendicectomy for acute appendicitis at Prince Mshiyeni Memorial Hospital (Natal,
South Africa) during the period January 2002 to December 2004. Patient demographics,
clinical features, white cell count, operative findings, outcome and histology results were
recorded on a special patient proforma.
RESULTS: A total of 371 patients underwent appendicectomy during this period and 324
(M:F, 3.6:1) were available for analysis. The majority of our patients were in the second
decade (43.1%) with only 29.3% presenting within 24 h of onset of symptoms. The most
common symptoms were abdominal pain (100%), vomiting (57.4%) and anorexia
(49.0%). Generalised and localised abdominal tenderness were present in 62.0% and
19.4% of patients, respectively. Pyrexia was noted in 41.0%. Localised and generalised
peritonitis were present in 26.4% and 14.0%, respectively. The most common incisions
were lower midline laparotomy (47.2%) and gridiron (37.3%). The negative
appendicectomy rate was 17.0%. Acute appendiceal inflammation and gangrenous
appendicitis was present in 36.1% and 9.6%, respectively. The perforation rate was
34.0% and there was a direct correlation with delayed presentation. There were no
patients with carcinoid tumour or adenocarcinoma. Parasites and other associated
conditions were seen in 8.6% of cases. Postoperative complications included: wound
sepsis (25.3%), prolonged ileus (6.2%), peritonitis (4.6%) and chest infection (3.4%).
Four patients died (1.2%) all from the perforated group.

REACTION:
Patients present late with advanced disease and complications. All surgeons should bear
in mind the possibility of parasitic infestations mimicking acute appendicitis and the
presence of significant unusual histological findings in our setting justifies routine
histopathological examination of appendices.

Ref:
http://www.unboundmedicine.com/medline/ebm/record/19909612/full_citation/A_clinico
pathological_review_of_324_appendices_removed_for_acute_appendicitis_in_Durban_S
outh_Africa:_a_retrospective_analysis_

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