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Appendectomy

Definition
  • The excision of the appendix usually performed to remove an acutely inflamed organ.
  • Many surgeons perform an appendectomy as a prophylactic procedure when operating in the abdomen for other reasons. This procedure is then referred to as an incidental appendectomy.

Position
  • Supine, with arms extended on armboards

Incision Site
  • McBurney (muscle splitting) incision.

Packs/ Drapes
  • Laparotomy pack
  • Four folded towels

Instrumentation
  • Major Lap tray or minor tray
  • Internal stapling device

Supplies/ Equipment
  • Basin set
  • Blades
  • Needle counter
  • Penrose drain
  • Culture tubes
  • Solutions
  • Sutures
  • Internal stapling instruments
  • Medication

Procedure
  1. An incision is made in the right lower abdomen, either transversely oblique (McBurney) or vertically (for a primary appendectomy).
  2. The surgeon’s assistant retracts the wound edges with a Richardson or similar retractor.
  3. The appendix is identifies and its vascular supply ligated.
  4. The surgeon grasps the appendix with a Babcock clamp, and delivers it into the wound site.
  5. The tip of the appendix may then be grasped with a Kelly clamp to hold it up, and a moist Lap sponge is placed around the base of the appendix (stump) to prevent contamination of bowel contents, in case any spill out occurs during the procedure.
  6. The surgeon isolates the appendix from its attachments to the bowel (mesoappendix) using a Metzenbaum scissors.
  7. Taking small bits of tissue along the appendix, the mesoappendix is double-clamped, and ligated with free ties.
  8. The base of the appendix is grasped with a straight Kelly clamp, and the appendix is removed.
  9. The stump may be inverted into the cecum, using a purse-string suture on a fine needle, cauterize with chemicals, or simply left alone after ligation.
  10. Another technique is to devascularize the appendix and invert the entire appendix into the cecum.
  11. The appendix, knife, needle holder, and any clamps or scissors that have come in contact with the appendix are delivered in a basin in the circulating nurse.
  12. The wound is irrigated with warm saline, and is closed in layers, except when an abscess has occurred, as with acute appendicitis.
  13. A drain may be placed into the abscess cavity, exiting through the incision or a stab wound.
  14. An alternative technique may be use the internal stapling device, by placing the stapling instrument around the tissue at the appendiocecum junction.
  15. By using the technique, the possibility of contamination from spillage is greatly reduced.

Perioperative Nursing Consideration
  1. Instruments used for amputation of the appendix are to be isolated in a basin.
  2. If ruptured, the case must be considered contaminated, and the surgeon may elect to use antibiotic irrigation prior to closure of the abdomen with an insertion of a drain.
  3. There may be no skin closure of the wound if the appendix has rupture.

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