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

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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).

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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.

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B. SCHEMATIC

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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

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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

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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:

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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

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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

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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

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Miscellaneous:

Scalpel – cutting skin incision, cutting small vessels and tissue, skin incisions and hand procedures

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