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I.

PATIENTS 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 The attached appendix to the cecum with just below the

ileocecal

valve.

fills

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 becoming appendix kinked or becomes inflamed by a and edematous (ie, as a result mass of of

occluded

fecalith

hardened

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 McBurneys point when pressure is applied. Rebound tenderness (ie, production or intensification of pain when pressure and is released) spasm so much and on may the the be present. of of The extent of or

tenderness diarrhea

muscle not

existence severity

constipation the

depend

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 patients condition worsens.

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B. SCHEMATIC INFLAMMATION

INTRALUMINAL PRESSURE

LYMPHOID SWELLING DECREASED VENOUS DRAINAGE THROMBOSIS BACTERIAL INVASION

ABSCESS

GANGRENE

PERFORATION (24-36 hrs.)

PERITONITIS

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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 shell have an empty stomach. The surgery was done under subarachnoid block. Having an empty will be stomach helps but does can not guarantee to into that

vomiting

prevented. in) of

Vomiting stomach

lead

possible lungs.

aspiration

(breathing

contents

Irritation of the lung and possible pneumonia could result from such an aspiration event. Prescription for pain medication by the attending nail physician polish, was also given were prior to surgery. from the

Dentures, patient. maintained.

jewelleries

removed

Moreover, bowel and bladder content evacuation was

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.

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V. DISCUSSION

Appendectomy

is

the

excision

of

the

appendix,

usually

performed to remove the acutely inflamed organ. When spilling the appendix of is the acutely bowel inflamed, the it may rupture, cavity;

contents

into

peritoneal

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. Page | 6

VI. INSTRUMENTATION
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

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Forceps: 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 pedia patients

used

to

hold

sutures

aside

from

3) Babcock organs)

used

to

grasp

delicate

tissue

(tubular

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 blood; sunctioning in small areas of fluid/

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

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