Laparoscopic Appendectomy

Patient Considerations

  • Disease Specific Considerations

    • Patients have an intra-abdominal process and should be considered "full stomach” even in absence of nausea/vomiting

    • Some patients may have decreased PO intake for hours/days prior to presentation

      • Consider pre-induction fluid bolus in patients showing signs of dehydration

    • Patients with perforated appendicitis may have early sepsis

  • Associated Comorbidities/Syndromes

    • None

Case Planning

  • Specific or Unique Room Set-Up Requirements

    • Airway

      • Rapid Sequence Induction is indicated

    • Drugs/Infusions

      • Standard Emergency Drugs

      • RSI drugs

        • +/- Lidocaine

        • Fentanyl

        • Propofol

        • Succinylcholine/Rocuronium

      • Antibiotics

        • Check to see what patient has already received

        • Surgeons frequently request Cefoxitin 40mg/kg for cases involving bowel manipulation

          • Re-dose if more than 3h since last dose

        • Ceftriaxone + Metronidazole may be requested in cases of perforation

      • Post-Op Pain Control

        • Surgeon should inject local at port sites

        • Consider giving only short-acting narcotics (fentanyl) until patient is extubated

          • Long acting narcotic may delay emergence

        • Maximize non-opioid pain control

          • IV Acetaminophen if none given in past 6h

          • Ask surgeon if Ketorolac is OK

            • They may request no NSAIDs in setting of suspected perforation

      • PONV Prophylaxis

        • Ondansetron

        • +/- Dexamethasone

          • Consider avoiding steroids in setting of perforation/ abscess

    • Monitors

      • Standard ASA Monitors

    • Blood Availability

      • Usually not required

    • PICU Bed Availability

      • Usually not required

Anesthetic Considerations

  • Induction

    • Rapid Sequence Induction

  • Positioning

    • Supine

  • Maintenance

    • Maintenance of Anesthesia

      • Volatile anesthesia

      • +/- neuromuscular blockade if none given at induction

        • Re-dose frequently not required if RSI dose of rocuronium given at induction

    • Hemodynamic/Physiologic goals

      • No unique case-specific goals

  • Surgical Considerations

    • Surgeons may require neuromuscular blockade to facilitate adequate exposure with laparoscopy

  • Emergence/Disposition

    • Neuromuscular blockade should be appropriately reversed prior to extubation

      • Consider Sugammadex if RSI dose of rocuronium was given at induction

      • Glycopyrrolate/Neostigmine may be used if twitches have returned by end of case

  • Post-Op Pain Management

    • Surgeon should inject local at port sites

    • Consider giving only short-acting narcotics (fentanyl) until patient is extubated

      • Long acting narcotic may delay emergence

    • Maximize non-opioid pain control

      • IV Acetaminophen if none given in past 6h

      • Ask surgeon if Ketorolac is OK

        • They may request no NSAIDs in setting of suspected perforation

Surgical Considerations

  • Ask surgeon if NG or OG is needed

  • Case is frequently short (<1hr)

Case-Specific Complications

  • Patients should be considered to be at risk for aspiration