Appendicitis Case Study

Introduction The appendix is a small fingerlike appendage about 10 cm (4 in) long, attached to the cecum just below the ileocecal valve. No definite functions can be assigned to it in humans. The appendix fills with food and empties as regularly as does the cecum, of which it is small, so that it is prone to become obstructed and is particularly vulnerable to infection (appendicitis). Appendicitis is the most common cause of acute inflammation in the right lower quadrant of the abdominal cavity. About 7% of the population will have appendicitis at some time in their lives, males are affected more than females, and teenagers more than adults. It occurs most frequently between the age of 10 and 30. The disease is more prevalent in countries in which people consume a diet low in fiber and high in refined carbohydrates. The lower quadrant pain is usually accompanied by a low-grade fever, nausea, and often vomiting. Loss of appetite is common. In up to 50% of presenting cases, local tenderness is elicited at Mc Burneys point applied located at halfway between the umbilicus and the anterior spine of the Ilium. Rebound tenderness (ex. Production or intensification of pain when pressure is released) may be present. The extent of tenderness and muscle spasm and the existence of the constipation or diarrhea depend not so much on the severity of the appendiceal infection as on the location of the appendix. If the appendix curls around behind the cecum, pain and tenderness may be felt in the lumbar region. Rovsings sign maybe elicited by palpating the left lower quadrant. If the appendix has ruptured, the pain become more diffuse, abdominal distention develops as a result of paralytic ileus, and the patient condition become worsens. Constipation can also occur with an acute process such as appendicitis. Laxative administered in the instance may result in perforation of the in flared appendix. In general a laxative should never be given when a persons has fever, nausea or pain. Anatomy and Physiology of Digestive System The mouth, or oral cavity, is the first part of the digestive tract. It is adapted to receive food by ingestion, break it into small particles by mastication, and mix it with saliva. The lips, cheeks, and palate form the boundaries. The oral cavity contains the teeth and tongue and receives the secretions from the salivary glands.

Lips and Cheeks The lips and cheeks help hold food in the mouth and keep it in place for chewing. They are also used in the formation of words for speech. The lips contain numerous sensory receptors that are useful for judging the temperature and texture of foods. Palate The palate is the roof of the oral cavity. It separates the oral cavity from the nasal cavity. The anterior portion, the hard palate, is supported by bone. The posterior portion, the soft palate, is skeletal muscle and connective tissue. Posteriorly, the soft palate ends in a projection called the uvula. During swallowing, the soft palate and uvula move upward to direct food away from the nasal cavity and into the oropharynx. Tongue The tongue manipulates food in the mouth and is used in speech. The surface is covered with papillae that provide friction and contain the taste buds. Teeth A complete set of deciduous (primary) teeth contains 20 teeth. There are 32 teeth in a complete permanent (secondary) set. The shape of each tooth type corresponds to the way it handles food. Pharynx The pharynx is a fibromuscular passageway that connects the nasal and oral cavities to the larynx and esophagus. It serves both the respiratory and digestive systems as a channel for air and food. The upper region, the nasopharynx, is posterior to the nasal cavity. It contains the pharyngeal tonsils, or adenoids, functions as a passageway for air, and has no function in the digestive system. The middle region posterior to the oral cavity is the oropharynx. This is the first region food enters when it is swallowed. The opening from the oral cavity into the oropharynx is called the fauces. Masses of lymphoid tissue, the palatine tonsils, are near the fauces. The lower region, posterior to the larynx, is the laryngopharynx, or hypopharynx. The laryngopharynx opens into both the esophagus and the larynx. Esophagus The esophagus is a collapsible muscular tube that serves as a passageway between the pharynx and stomach. As it descends, it is posterior to the trachea and anterior to the vertebral column. It passes through an opening in the diaphragm, called the esophageal hiatus, and then empties into the stomach. The mucosa has glands that secrete mucus to keep the lining moist and well lubricated to ease the passage of food. Upper and lower esophageal sphincters control the movement of food into and out of the esophagus. The lower esophageal sphincter is sometimes called the cardiac sphincter and resides at the esophagogastric junction Stomach the stomach, which receives food from the esophagus, is located in the upper left quadrant of the abdomen. The stomach is divided into the fundic, cardiac, body, and

pyloric regions. The lesser and greater curvatures are on the right and left sides, respectively, of the stomach. Small Intestine The small intestine extends from the pyloric sphincter to the ileocecal valve, where it empties into the large intestine. The small intestine finishes the process of digestion, absorbs the nutrients, and passes the residue on to the large intestine. The liver, gallbladder, and pancreas are accessory organs of the digestive system that are closely associated with the small intestine. The small intestine is divided into the duodenum, jejunum, and ileum. The small intestine follows the general structure of the digestive tract in that the wall has a mucosa with simple columnar epithelium, submucosa, smooth muscle with inner circular and outer longitudinal layers, and serosa. The absorptive surface area of the small intestine is increased by plicae circulares, villi, and microvilli. Exocrine cells in the mucosa of the small intestine secrete mucus, peptidase, sucrase, maltase, lactase, lipase, and enterokinase. Endocrine cells secrete cholecystokinin and secretin. The most important factor for regulating secretions in the small intestine is the presence of chyme. This is largely a local reflex action in response to chemical and mechanical irritation from the chyme and in response to distention of the intestinal wall. This is a direct reflex action, thus the greater the amount of chyme, the greater the secretion. Large Intestine The large intestine is larger in diameter than the small intestine. It begins at the ileocecal junction, where the ileum enters the large intestine, and ends at the anus. The large intestine consists of the colon, rectum, and anal canal. The wall of the large intestine has the same types of tissue that are found in other parts of the digestive tract but there are some distinguishing characteristics. The mucosa has a large number of goblet cells but does not have any villi. The longitudinal muscle layer, although present, is incomplete. The longitudinal muscle is limited to three distinct bands, called teniae coli, that run the entire length of the colon. Contraction of the teniae coli exerts pressure on the wall and creates a series of pouches, called haustra, along the colon. Epiploic appendages, pieces of fat-filled connective tissue, are attached to the outer surface of the colon. Unlike the small intestine, the large intestine produces no digestive enzymes. Chemical digestion is completed in the small intestine before the chyme reaches the large intestine. Functions of the large intestine include the absorption of water and electrolytes and the elimination of feces. Rectum and Anus The rectum continues from the signoid colon to the anal canal and has a thick muscular layer. It follows the curvature of the sacrum and is firmly attached to it by connective tissue. The rectum and ends about 5 cm below the tip of the coccyx, at the beginning of the anal canal. The last 2 to 3 cm of the digestive tract is the anal canal, which continues from the rectum and opens to the outside at the anus. The mucosa of the rectum is folded to form longitudinal anal columns. The smooth muscle layer is thick and forms the internal anal sphincter at the superior end of the anal canal. This sphincter is under

involuntary control. There is an external anal sphincter at the inferior end of the anal canal. This sphincter is composed of skeletal muscle and is under voluntary control. Clinical Manifestations 1. Generalized or localized abdominal pain in the epigastric or periumbilical areas and upper right abdomen. Within 2 to 12 hours, the pain localizes in the right lower quadrant and intensity increases. 2. Anorexia, moderate malaise, mild fever, nausea and vomiting. 3. Usually constipation occurs ; occasionally diarrhea. 4. Rebound tenderness, involuntary guarding, generalized abdominal rigidity. Diagnostic Evaluation 1. Physical examination consistent with clinical manifestations. 2. WBC count reveal moderate leukocytosis (10,000 to 16,000/mm3) with shift to the left (increased immature neutrophils). 3. Urinalysis rule out urinary disorders. 4. Abdominal x-ray may visualize shadow consistent with fecalith in appendix; perforation will reveal free air. 5. Abdominal ultrasound or CT scan can visualize appendix and rule out other conditions, such as diverticulitis and crohns disease. Focused appendiceal CT can quickly evaluate for appendicitis. Medications

Analgesics Intravenous fluids replacements Analgesics

Treatment Appendectomy is the effective treatment if peritonitis develops treatment involves.

GI Intubation Parenteral replacement of IV fluids and electrolytes Administration of Antibiotics

Surgery is indicated if appendicitis is diagnosed. Antibiotics and IV fluids are administered until surgery is performed analgesics can be administered after the diagnosed is made. An appendectomy (surgical removal of the appendix) is performed as soon as possible to decrease the risk of perforation. T he appendectomy may be performed under a (general or spinal anesthetics) with a low abdominal incisions or by (laparoscopy) which is recently highly effective method.

Complications The major complication of appendicitis is perforation of the appendix, which can lead to peritonitis, abscess formation (collection of purulent material), or portal pylephlebitis, which is septic thrombosis of the portal vein caused by vegetative emboli that arise from septic intestines. Perforation generally occurs 24 hours after the onset of pain symptoms include a fever of 37.7 degree Celsius or 100 degree Fahrenheit or greater, a toxic appearance and continued abdominal pain or tenderness. Nursing Interventions 1. Monitor frequently for signs and symptoms of worsening condition, indicating perforation, abscess, or peritonitis (increasing severity of pain, tenderness, rigidity, distention, absent bowel sounds, fever, malaise, and tachycardia). 2. Notify health care provider immediately if pain suddenly ceases, this indicates perforation, which is a medical emergency. 3. Assist patient to position of comfort such as semi-fowlers with knees are flexed. 4. Restrict activity that may aggravate pain, such as coughing and ambulation. 5. Apply ice bag to abdomen for comfort. 6. Avoid indiscriminate palpation of the abdomen to avoid increasing the patients discomfort. 7. Promptly prepare patient for surgery once diagnosis is established. 8. Explain signs and symptoms of postoperative complications to report-elevated temperature, nausea and vomiting, or abdominal distention; these may indicate infection. 9. Instruct patient on turning, coughing, or deep breathing, use of incentive spirometer, and ambulation. Discuss purpose and continued importance of these maneuvers during recovery period. 10. Teach incisional care and avoidance of heavy lifting or driving until advised by the surgeon. 11. Advise avoidance of enemas or harsh laxatives; increased fluids and stool softeners may be used for postoperative constipation. Discharge Planning M E Antibiotics for infection Analgesic agent (morphine) can be given for pain after the surgery Within 12 hrs of surgery you may get up and move around. You can usually return to normal activities in 2-3 weeks after laparoscopic surgery.

T Pretreatment of foods with lactase preparations (e.g. lactacid drops) before ingestion can reduce symptoms. Ingestion of lactase enzyme tablets with the first bite of food can reduce symptoms.

H To care wound perform dressing changes and irrigations as prescribe avoid taking laxative or applying heat to abdomen when abdominal pain of unknown cause is experienced. Reinforce need for follow-up appointment with the surgeon Call your physician for increased pain at the incision site O Document bowel sounds and the passing of flatus or bowel movements (these are signs of the return of peristalsis) Watch for surgical complications such as continuing pain or fever, which indicate an abscess or wound dehiscence Stitches removed between fifth and seventh day (usually in physicians office) D Liquid or soft diet until the infection subsides Soft diet is low in fiber and easily breaks down in the gastrointestinal tract

Appendicitis
Is inflammation of the vermiform appendix caused by an obstruction attributable by infection, stricture, fecal mass, foreign body or tumor. It can affect by either gender at any age, but is most common in males ages 10 to 30. It is the most common disease requiring surgery. If left untreated, appendicitis may progress to abscess, perforation, subsequent peritonitis, and death.

Assessment 1. Generalized or localized abdominal pain occurs in the epigastric or periumbilical areas in the upper right abdomen. 2. Within 2 to 12 hours, the pain localizes in the right lower quadrant and intensity increases. 3. Anorexia, fever, nausea, vomiting, and constipation may also occur. 4. Bowel sounds may be diminished.

5. Tenderness anywhere in the right lower quadrant. o Often localized at McBurneys point, just below midpoint of line between umbilicus and iliac crest on the right side. o Guarding and rebound tenderness to right lower quadrant and referred rebound when palpating the left lower quadrant. 6. Positive Psoas Sign. o Have the patient attempt to raise the right thigh against the pressure of your hand placed over the right knee. o Increased abdominal pain indicates inflammation of the psoas muscle in acute appendicitis. 7. Positive Obturator Sign. o Flex the patients right hip and knee and rotate the leg internally. o Hypogastric pain indicates inflammation of the obturator muscle. Diagnostic Evaluation 1. WBC count shows moderate leukocytosis (10,000 to 16,000/mm) with shift to the left (increased immature neutrophils) in WBC differential. 2. Urinalysis rules out urinary disorders. 3. Abdominal X-ray visualizes shadow consistent with fecalith in appendix. 4. Pelvic sonogram rules out ovarian cyst or ectopic pregnancy. Surgical Interventions 1. Surgical removal is the only effective treatment (simple appendectomy or laparoscopic appendectomy). 2. Preoperatively, maintain patient on bed rest, NPO status, I.V. hydration, possible anti-biotic prophylaxis, and analgesia, as directed. Nursing Interventions 1. Monitor frequently for signs and symptoms of worsening condition, indicating perforation, abscess, or peritonitis (increasing severity of pain, tenderness, rigidity, distention, absent bowel sounds, fever, malaise, and tachycardia). 2. Notify health care provider immediately if pain suddenly ceases, this indicates perforation, which is a medical emergency. 3. Assist patient to position of comfort such as semi-fowlers with knees are flexed. 4. Restrict activity that may aggravate pain, such as coughing and ambulation. 5. Apply ice bag to abdomen for comfort. 6. Avoid indiscriminate palpation of the abdomen to avoid increasing the patients discomfort. 7. Promptly prepare patient for surgery once diagnosis is established. 8. Explain signs and symptoms of postoperative complications to report-elevated temperature, nausea and vomiting, or abdominal distention; these may indicate infection.

9. Instruct patient on turning, coughing, or deep breathing, use of incentive spirometer, and ambulation. Discuss purpose and continued importance of these maneuvers during recovery period. 10. Teach incisional care and avoidance of heavy lifting or driving until advised by the surgeon. 11. Advise avoidance of enemas or harsh laxatives; increased fluids and stool softeners may be used for postoperative constipation.

Appendectomy
DEFINITION Appendectomy is the surgical removal of the appendix. The appendix is a worm-shaped hollow pouch attached to the cecum, the beginning of the large intestine. PURPOSE Appendectomies are performed to treat appendicitis, an inflamed and infected appendix.

Description
After the patient is anesthetized, the surgeon can remove the appendix either by using the traditional open procedure (in which a 23 in [57.6 cm] incision is made in the

abdomen) or via laparoscopy (in which four 1-in [2.5-cm] incisions are made in the abdomen).

Traditional open appendectomy

When the surgeon uses the open approach, he makes an incision in the lower right section of the abdomen. Most incisions are less than 3 in (7.6 cm) in length. The surgeon then identifies all of the organs in the abdomen and examines them for other disease or abnormalities. The appendix is located and brought up into the wounds. The surgeon separates the appendix from all the surrounding tissue and its attachment to the cecum, and then removes it. The site where the appendix was previously attached, the cecum, is closed and returned to the abdomen. The muscle layers and then the skin are sewn together.

Laparoscopic appendectomy
When the surgeon performs a laparoscopic appendectomy, four incisions, each about 1 in (2.5 cm) in length, are made. One incision is near the umbilicus, or navel, and one is between the umbilicus and the pubis. Two other incisions are smaller and are on the right side of the lower abdomen. The surgeon then passes a camera and special instruments through these incisions. With the aid of this equipment, the surgeon visually examines the abdominal organs and identifies the appendix. The appendix is then freed from all of its attachments and removed. The place where the appendix was formerly attached, the cecum, is stitched. The appendix is removed through one of the incisions. The instruments are removed and then all of the incisions are closed.

To remove a diseased appendix, an incision is made in the patient's lower abdomen (A). Layers of muscle and tissue are cut, and large intestine, or colon, is visualized (B). The appendix is located (C), tied, and removed (D). The muscle and tissue layers are stitched (E). ( Illustration by GGS Inc. ) Studies and opinions about the relative advantages and disadvantages of each method are divided. A skilled surgeon can perform either one of these procedures in less than one hour. However, laparoscopic appendectomy (LA) always takes longer than traditional appendectomy (TA). The increased time required to do a LA the greater the patient's exposure to anesthetics, which increases the risk of complications. The increased time requirement also increases the fees charged by the hospital for operating room time and by the anesthesiologist. Since LA also requires specialized equipment, the fees for its use also increase the hospital charges. Patients with either operation have similar pain medication needs, begin eating diets at comparable times, and stay in the hospital equivalent amounts of time. LA is of special benefit in women in whom the diagnosis is difficult and gynecological disease (such as endometriosis, pelvic inflammatory disease, ruptured ovarian follicles, ruptured ovarian cysts, and tubal pregnancies) may be the source of pain and not appendicitis. If LA is done in these patients, the pelvic organs can be more thoroughly examined and a definitive diagnosis made prior to removal of the appendix. Most surgeons select either TA or LA based on the individual needs and circumstances of the patient. Insurance plans do cover the costs of appendectomy. Fees are charged independently by the hospital and the physicians. Hospital charges include fees for operating and recovery room use, diagnostic and laboratory testing, as well as the normal hospital room charges. Surgical fees vary from region to region and range between $250750. The anesthesiologist's fee depends on the health of the patient and the length of the operation.

Preparation
Once the diagnosis of appendicitis is made and the decision has been made to perform an appendectomy, the patient undergoes the standard preparation for an operation. This usually takes only one to two hours and includes signing the operative consents, patient identification procedures, evaluation by the anesthesiologist, and moving the patient to the operating area of the hospital. Occasionally, if the patient has been ill for a prolonged period of time or has had protracted vomiting, a delay of few to several hours may be necessary to give the patient fluids and antibiotics .

Aftercare
Recovery from an appendectomy is similar to other operations. Patients are allowed to eat when the stomach and intestines begin to function again. Usually the first meal is a clear liquid dietbroth, juice, soda pop, and gelatin. If patients tolerate this meal, the next meal usually is a regular diet. Patients are asked to walk and resume their normal physical

activities as soon as possible. If TA was done, work and physical education classes may be restricted for a full three weeks after the operation. If a LA was done, most patients are able to return to work and strenuous activity within one to three weeks after the operation.

Abdominal exploration
Normal anatomy
The abdomen contains many vital organs: the stomach, the small intestine (jejunum and ileum), the large intestine (colon), the liver, the spleen, the gallbladder, the pancreas, the uterus, the fallopian tubes, the ovaries, the kidneys, the ureters, the bladder, and many blood vessels (arteries and veins).

Indication
The surgical exploration of the abdomen, also called an exploratory laparotomy, may be recommended when there is abdominal disease from an unknown cause (to diagnose), or trauma to the abdomen (gunshot or stab-wounds, or "blunt trauma"). Diseases that may be discovered by exploratory laparotomy include:

inflammation of the appendix (acute appendicitis) inflammation of the pancreas (acute or chronic pancreatitis) pockets of infection (retroperitoneal abscess, abdominal abscess, pelvic abscess)) presence of uterine tissue (endometrium) in the abdomen (endometriosis) inflammation of the Fallopian tubes (salpingitis)

scar tissue in the abdomen (adhesions) cancer (of the ovary, colon, pancreas, liver) inflammation of an intestinal pocket (diverticulitis) hole in the intestine (intestinal perforation) pregnancy in the abdomen instead of uterus (ectopic pregnancy)

to determine the extent of certain cancers (Hodgkin's lymphoma)

Incision
While the patient is deep asleep and pain-free (general anesthesia), the surgeon makes an incision into the abdomen and examines the abdominal organs. Different incisions are sometimes used depending on the circumstance. Common incisions include a vertical midline incision, and right or left upper or lower quadrant transverse incisions. Tissue samples (biopsies) can be taken and diseased areas can be evaluated. When the treatment is complete, the incision is closed with either sutures or skin staples.

Aftercare
The outcome from surgery varies with the disease process, as does the course and duration of recovery. Exploratory laparotomy is most commonly performed for trauma, severe abdominal pain of unknown cause, intestinal obstruction, inflammatory diseases like appendicitis and diverticulitis, and cancer of any of the abdominal organs.

Anastomosis An anastomosis (plural anastomoses, from gr. , communicating opening) in a network of streams is the reconnection of two streams that previously branched out, such as blood vessels or leaf veins. The term is used in

medicine, biology, mycology and geology.

Anastomosis is the connection of two structures.[1] It refers to connections between blood vessels or between other tubular structures such as loops of intestine. In circulatory anastomoses, many arteries naturally anastomose with each other, for example the inferior epigastric artery and superior epigastric artery.The circulatory anastomosis is further divided into arterial and venous anastomosis. Arterial anastomosis includes actual arterial anastomosis (e.g. palmar arch, plantar arch) and potential arterial anastomosis (e.g. coronary arteries and cortical branch of cerebral arteries). An example of surgical anastomosis occurs when a segment of intestine is resected and the two remaining ends are sewn or stapled together (anastomosed), for example Roux-en-Y anastomosis. The procedure is referred to as intestinal anastomosis. Pathological anastomosis results from trauma or disease and may involve veins, arteries, or intestines. These are usually referred to as fistulas. In the cases of veins or arteries, traumatic fistulas usually occur between artery and vein. Traumatic intestinal fistulas usually occur between two loops of intestine (entero-enteric fistula) or intestine and skin (enterocutaneous fistula). Portacaval anastomosis, by contrast, is an anastomosis between a vein of the portal circulation and a vein of the systemic circulation, which allows blood to bypass the liver in patients with portal hypertension, often resulting in hemorrhoids, esophageal varices, or caput medusae.

Surgical anastomosis
Gastrointestinal (GI) tract: Esophagus, stomach, small bowel, large bowel, bile ducts, and pancreas. Virtually all elective resections of gastrointestinal organs are followed by anastomoses to restore continuity; pancreaticoduodenectomy is considered a massive operation, in part, because it requires three separate anastomoses (stomach, biliary tract and pancreas to small bowel). Bypass operations on the GI tract, once rarely performed, are the cornerstone of bariatric surgery. The widespread use of mechanical suturing devices (linear and circular staplers) changed the face of gastrointestinal surgery.

In all cases of intestinal obstruction, the intestine involved is carefully examined. If any parts of the intestine look unhealthy from lack of blood flow during the period of obstruction, they are removed and the healthy ends are reconnected. A patient's recovery depends on the cause of the intestinal obstruction and the length of time prior to relief of the obstruction. The outcome is usually good if the obstruction is treated before damage (ischemia) or death (necrosis) of the bowel occurs. Intestinal anastomosis Patients suffering from irresolvable intestinal obstruction or devitalization are among those that benefit from intestinal resection and the procedure described here, which reconnects the intestine end-to-end. INTESTINAL ANASTOMOSIS is an important surgical procedure that connects two sections of the intestines once a diseased portion has been removed. A key concern is to prevent leakage at the anastomosis site and subsequent peritonitis, but this complication can be avoided if the procedure is done correctly and preventive measures are taken. INDICATIONS Indications for intestinal resection and anastomosis include devitalization, irresolvable obstruction or segmental dysfunction, or irreparable perforation of the intestines.1-4 These conditions can result from a variety of causes, including foreign bodies, intussusception, neoplasia, abscess, trauma, volvulus or torsion, herniation, neurologic disorders, chronic constipation (e.g. feline idiopathic megacolon), or ulceration secondary to corticosteroid administration.4 Intestinal resection and anastomosis are most frequently performed in dogs and cats because of foreign bodies, neoplasia, and trauma.4,5

SURGICAL OPTIONS Intestinal anastomosis can be performed with sutures, staples, or anastomotic devices.1-3,6,7 Intestinal anastomoses can be strengthened by omentalization or serosal patch graft techniques, which reduce the risk of postoperative leakage and improve vascularity.1 Sutures A sutured anastomosis is the most common option because of the availability and cost of materials and familiarity with the procedure. Perform sutured anastomoses with appositional suture patterns since inversion reduces the lumen diameter and eversion can increase adhesion formation.2,3,8 Avoid double-layer closure because of luminal compromise, poor submucosal apposition, avascular necrosis, and prolonged healing time.2 Monofilament sutures are recommended for sutured anastomosis because multifilament material has more drag and is more likely to promote inflammation.2 Although nonabsorbable suture can be used for anastomosis, avoid it when using continuous suture patterns because of potential luminal extrusion and subsequent foreign body entrapment.2,9 Swaged, tapercut needles penetrate easily through the submucosa, which is the holding layer of the intestines, and limit tissue trauma.5 Tapercut needles have a round shaft and a cutting point that can penetrate both delicate and dense tissue. Taper needles, which are more commonly found in practice than tapercut needles, are also acceptable for intestinal surgery.2 Simple continuous suture patterns are quick to perform and provide better approximation than interrupted patterns.2,5,10 Histologically, mucosal eversion is reported in 66% of simple interrupted closures while inversion, eversion, or malalignment is seen in only 38% of simple continuous closures.2,6 With both techniques, mucosal eversion can be reduced by trimming excess mucosa or by using a modified Gambee suture pattern.5 Staples Using surgical staplers to anastomose intestines reduces surgery time and provides bursting strength, lumen diameter, and healing similar to anastomosis with simple interrupted sutures.6 Complications are reported in 13% to 14% of animals undergoing stapled anastomoses and include severe hemorrhage (13%), postoperative leakage at the anastomosis site (8%), and localized abscess formation at the staple line (4%).11,12 Anastomosis ring and laparoscopy Other options for anastomosis include biofragmentable intestinal anastomosis ring placement and laparoscopic-assisted anastomosis.7,13 Little information is available in the veterinary literature on the clinical use of these techniques.

TECHNIQUE FOR SINGLE-LAYER CONTINUOUS END-TO-END INTESTINAL ANASTOMOSIS For general perioperative considerations when performing this procedure, including diagnostic testing, patient monitoring, and postoperative support, please see the symposium introduction. To begin the procedure, isolate the affected area of intestines with moistened laparotomy pads. Ligate the blood vessels to the transection sites with absorbable suture (Figure 1); ligate the arcuate branches along the mesenteric surface by taking suture bites around the vessels immediately adjacent to the proposed transection sites. Milk luminal Figures 1,2 contents away from the area, and clamp the diseased intestines, along with 2 or 3 cm of healthy tissue, with Kelly or Carmalt forceps. Confine the luminal contents within the retained healthy intestines by using noncrushing forceps (e.g. Doyen intestinal forceps), umbilical tape, or Penrose drain tourniquets that collapse the intestinal lumen but do not inhibit blood flow. Alternatively, an assistant can occlude the intestinal lumen near the proposed transection sites with index and middle fingers. Place the occluding devices at least 3 cm away from the anastomotic ends to prevent interference with suturing. Transect the intestines adjacent to the ligated arcuate vessels. Luminal disparity can be corrected at this time by increasing the angle of the cut on the narrower segment of intestines so that the antimesenteric border of the intestines is shorter than the mesenteric border (Figure 2). Place stay sutures at the mesenteric and antimesenteric borders (Figure 3) to ensure that the remaining sutures are properly spaced and to facilitate intestinal manipulation.5 Start a simple continuous suture pattern at the mesenteric border, leaving the suture end long. Take bites about 3 mm wide and 3 mm apart, depending on the size of the intestines.2 If mucosa begins to evert, use a modified Gambee suture pattern: Pass the needle full thickness through the intestinal wall and then back through the mucosa on the near side. Then insert the needle at the mucosa-submucosa border on the far side to push the mucosa into the lumen, and pass the needle full thickness back out that side. Continue the pattern to the antimesenteric surface, and tie it in a Figures 3,4,5,6,7 knot to prevent a purse-string effect (Figure 4). Flip over the intestines to expose the opposite surface, and continue suturing back to the initial mesenteric suture and tie (Figures 5 & 6). Then close the mesentery with a simple continuous pattern of 4-0 absorbable suture material (Figure 7); take suture bites at the edge of the mesentery to avoid damaging the intestinal blood vessels. Check the anastomotic site for leaks by distending the segment with sterile saline injected into the lumen while continuing to occlude the intestinal segments distal to the site. Seal any leaks with interrupted sutures; the omentum can be tacked over the anastomotic site by using a separate omental flap for each side.

COMPLICATIONS Potential complications include dehiscence, peritonitis from leakage or necrosis, ileus, recurrence of clinical disease, or short-bowel syndrome. Anastomotic leakage is reported in 3% of animals undergoing continuous sutured anastomosis and up to 11% of animals undergoing interrupted sutured anastomosis; leakage is more likely to be associated with anastomoses performed for foreign body removal or resection of traumatized intestines.4,5,14 The risk for anastomotic leakage also increases in patients with preexisting peritonitis or hypoalbuminemia.4 Dehiscence and leakage can be reduced by ensuring adequate blood supply, reducing tension across the anastomotic site, and providing adequate apposition.5 Ileus may result from chronic intestinal distention, excessive tissue handling, pain, sepsis, opioid use, or electrolyte imbalances.2 Magnesium, potassium, calcium, and fluid imbalances should be corrected, and food should be offered as soon as possible. Prokinetics such as metoclopramide, erythromycin, and lidocaine may be useful for stimulating motility.5,15 Resecting more than 70% of the intestines may result in short-bowel syndrome, depending on the site of the resection and the health of the remaining intestines.2,16 Maldigestion and malabsorption from reduced surface area will result in persistent watery diarrhea and weight loss. Dietary modifications, including increasing soluble fiber content, may reduce clinical signs.2 Anastomosis of the ileum to the distal colon or rectum in cats with megacolon may result in the development of watery feces because of loss of the ileocolic valve, which reduces access of colonic bacteria into the small intestines.3 Additionally, loss of ileum may reduce water absorption capacity of the intestines. Colocolic anastomosis results in more tension across the anastomotic site because the vascular pedicle to the ascending colon is shorter than that to the ileum.

Laparotomy, exploratory
Definition
A laparotomy is a large incision made into the abdomen. Exploratory laparotomy is used to visualize and examine the structures inside of the abdominal cavity.

Purpose
Exploratory laparotomy is a method of abdominal exploration, a diagnostic tool that allows physicians to examine the abdominal organs. The procedure may be recommended for a patient who has abdominal pain of unknown origin or who has sustained an injury to the abdomen. Injuries may occur as a result of blunt trauma (e.g., road traffic accident) or

penetrating trauma (e.g., stab or gunshot wound). Because of the nature of the abdominal organs, there is a high risk of infection if organs rupture or are perforated. In addition, bleeding into the abdominal cavity is considered a medical emergency. Exploratory laparotomy is used to determine the source of pain or the extent of injury and perform repairs if needed. Laparotomy may be performed to determine the cause of a patient's symptoms or to establish the extent of a disease. For example, endometriosis is a disorder in which cells from the inner lining of the uterus grow elsewhere in the body, most commonly on the pelvic and abdominal organs. Endometrial growths, however, are difficult to visualize using standard imaging techniques such as x ray, ultrasound technology, or computed tomography (CT) scanning. Exploratory laparotomy may be used to examine the abdominal and pelvic organs (such as the ovaries, fallopian tubes, bladder, and rectum) for evidence of endometriosis. Any growths found may then be removed. Exploratory laparotomy plays an important role in the staging of certain cancers. Cancer staging is used to describe how far a cancer has spread. A laparotomy enables a surgeon to directly examine the abdominal organs for evidence of cancer and remove samples of tissue for further examination. When laparotomy is used for this use, it is called staging laparotomy or pathological staging. Some other conditions that may be discovered or investigated during exploratory laparotomy include:

cancer of the abdominal organs peritonitis (inflammation of the peritoneum, the lining of the abdominal cavity) appendicitis (inflammation of the appendix) pancreatitis (inflammation of the pancreas) abscesses (a localized area of infection) adhesions (bands of scar tissue that form after trauma or surgery) diverticulitis (inflammation of sac-like structures in the walls of the intestines) intestinal perforation ectopic pregnancy (pregnancy occurring outside of the uterus) foreign bodies (e.g., a bullet in a gunshot victim) internal bleeding

Demographics
Because laparotomy may be performed under a number of circumstances to diagnose or treat numerous conditions, no data exists as to the overall incidence of the procedure.

Description
The patient is usually placed under general anesthesia for the duration of surgery. The advantages to general anesthesia are that the patient remains unconscious during the procedure, no pain will be experienced nor will the patient have any memory of the procedure, and the patient's muscles remain completely relaxed, allowing safer surgery.

Incision
Once an adequate level of anesthesia has been reached, the initial incision into the skin may be made. A scalpel is first used to cut into the superficial layers of the skin. The incision may be median (vertical down the patient's midline), paramedian (vertical elsewhere on the abdomen), transverse (horizontal), T-shaped, or curved, according to the needs of the surgery. The incision is then continued through the subcutaneous fat, the abdominal muscles, and finally, the peritoneum. Electrocautery is often used to cut through the subcutaneous tissue as it

During a laparotomy, and an incision is made into the patient's abdomen (A). Skin and connective tissue called fascia is divided (B). The lining of the abdominal cavity, the peritoneum, is cut, and any exploratory procedures are undertaken (C). To close the incision, the peritoneum, fascia, and skin are stitched (E). ( Illustration by GGS Inc.

) has the ability to stop bleeding as it cuts. Instruments called retractors may be used to hold the incision open once the abdominal cavity has been exposed.

Abdominal exploration
The surgeon may then explore the abdominal cavity for disease or trauma. The abdominal organs in question will be examined for evidence of infection, inflammation, perforation, abnormal growths, or other conditions. Any fluid surrounding the abdominal organs will be inspected; the presence of blood, bile, or other fluids may indicate specific diseases or injuries. In some cases, an abnormal smell encountered upon entering the abdominal cavity may be evidence of infection or a perforated gastrointestinal organ. If an abnormality is found, the surgeon has the option of treating the patient before closing the wound or initiating treatment after exploratory surgery. Alternatively, samples of various tissues and/or fluids may be removed for further analysis. For example, if cancer is suspected, biopsies may be obtained so that the tissues can be examined microscopically for evidence of abnormal cells. If no abnormality is found, or if immediate treatment is not needed, the incision may be closed without performing any further surgical procedures. During exploratory laparotomy for cancer, a pelvic washing may be performed; sterile fluid is instilled into the abdominal cavity and washed around the abdominal organs, then withdrawn and analyzed for the presence of abnormal cells. This may indicate that a cancer has begun to spread (metastasize).

Closure
Upon completion of any exploration or procedures, the organs and related structures are returned to their normal anatomical position. The incision may then be sutured (stitched closed). The layers of the abdominal wall are sutured in reverse order, and the skin incision closed with sutures or staples.

Diagnosis/Preparation
Various diagnostic tests may be performed to determine if exploratory laparotomy is necessary. Blood tests or imaging techniques such as x ray, computed tomography (CT) scan, and magnetic resonance imaging (MRI) are examples. The presence of intraperitoneal fluid (IF) may be an indication that exploratory laparotomy is necessary; one study indicated that IF was present in nearly three-quarters of patients with intraabdominal injuries.

Directly preceding the surgical procedure, an intravenous (IV) line will be placed so that fluids and/or medications may be administered to the patient during and after surgery. A Foley catheter will be inserted into the bladder to drain urine. The patient will also meet with the anesthesiologist to go over details of the method of anesthesia to be used.

Aftercare
The patient will remain in the postoperative recovery room for several hours where his or her recovery can be closely monitored. Discharge from the hospital may occur in as little as one to two days after the procedure, but may be later if additional procedures were performed or complications were encountered. The patient will be instructed to watch for symptoms that may indicate infection, such as fever, redness or swelling around the incision, drainage, and worsening pain.

Risks
Risks inherent to the use of general anesthesia include nausea, vomiting, sore throat, fatigue, headache, and muscle soreness; more rarely, blood pressure problems, allergic reaction, heart attack, or stroke may occur. Additional risks include bleeding, infection, injury to the abdominal organs or structures, or formation of adhesions (bands of scar tissue between organs).

Normal results
The results following exploratory laparotomy depend on the reasons why it was performed. The procedure may indicate that further treatment is necessary; for example, if cancer was detected, chemotherapy, radiation therapy, or more surgery may be recommended. In some cases, the abnormality is able to be treated during laparotomy, and no further treatment is necessary.

Morbidity and mortality rates

The operative and postoperative complication rates associated with exploratory laparotomy vary according to the patient's condition and any additional procedures performed. Read more: Laparotomy, Exploratory - procedure, recovery, blood, tube, pain, complications, infection, pregnancy, heart, cells, risk, cancer, nausea, Definition,

Purpose, Demographics, Description http://www.surgeryencyclopedia.com/LaPa/Laparotomy-Exploratory.html#ixzz1BE4ostcf

Exploratory laparotomy
An exploratory laparotomy is the standard of care in various blunt and penetrating trauma situations in which there may be multiple life-threatening injuries, and in many diagnostic situations in which the operation is undertaken in search of a unifying cause for multiple signs and symptoms of disease. The trauma ex-lap is the most comprehensive ex-lap, usually undertaken after evidence of internal bleeding (a positive FAST, DPL, or other overwhelming evidence for internal hemorrhage). A midline incision is carried down to the linea alba and the fascia is incised. The peritoneum is entered and the immediate, life-threatening bleeding is controlled. The lateral, superior, and anterior surfaces of the liver are packed with sponges, and the superior and lateral spaces around the spleen are similarly packed. The bowel is run from the ligament of Trietz to the terminal ileum. The gastrocolic ligament is incised and the lesser sac is explored, including the posterior stomach and the anterior pancreas. The surface of the spleen is examined for evidence of laceration and fracture. The liver is similarly examined. If necessary, Cattell and Mattox maneuvers may be performed to expose retroperitoneal structures. If the duodenum is at risk, a Kocher maneuver may be performed to examine the posterior duodenum and the head of the pancreas. The ex-lap can lead immediately to a number of other procedures, including splenectomy, repairs of the vena cava, repairs of the aorta, distal pancreatectomy, enterotomy and bowel repair, left hemicolectomy, right hemicolectomy, pyloric exclusion, gastric diversion, partial or complete nephrectomy, and the "trauma Whipple".

Laparotomy
A laparotomy is a surgical procedure involving a large incision through the abdominal wall to gain access into the abdominal cavity. It is also known as coeliotomy.

In diagnostic laparotomy (most often referred to as an exploratory laparotomy and abbreviated Ex-Lap), the nature of the disease is unknown, and laparotomy is deemed the best way to identify the cause. In therapeutic laparotomy, a cause has been identified (e.g. peptic ulcer, colon cancer) and laparotomy is required for its therapy. Usually, only exploratory laparotomy is considered a stand-alone surgical operation. When a specific operation is already planned, laparotomy is considered merely the first step of the procedure.

Spaces accessed
Depending on incision placement, laparotomy may give access to any abdominal organ or space, and is the first step in any major diagnostic or therapeutic surgical procedure of these organs, which include:

the lower part of the digestive tract (the stomach, duodenum, jejunum, ileum and colon) the liver, pancreas and spleen the bladder the female reproductive organs (the uterus and ovaries) the retroperitoneum (the kidneys, the aorta, abdominal lymph nodes)

Types of incisions
Midline
The most common incision for laparotomy is the midline incision, a vertical incision which follows the linea alba.

The upper midline incision usually extends from the xiphoid process to the umbilicus.

A typical lower midline incision is limited by the umbilicus superiorly and by the pubic symphysis inferiorly. Sometimes a single incision extending from xiphoid process to pubic symphysis is employed, especially in trauma surgery.

Midline incisions are particularly favoured in diagnostic laparotomy, as they allow wide access to most of the abdominal cavity.

Girdiron's incision
An oblique incision made in the right lower quadrant of the abdomen, classically used for appendectomy

McBurney incision
This is the incision used for open appendectomy, it begins 2 to 5 centimeters above the anterior superior iliac spine and continues to a point one-third of the way to the umbilicus (McBurney's point). Thus, the incision is parallel to the external oblique muscle of the abdomen which allows the muscle to be split in the direction of it's fibers, decreasing healing times and scar tissue formation. This incision heals rapidly and generally has good cosmetic results, especially if a subcuticular suture is used to close the skin.

Midline incision
The most common incision for laparotomy is the midline incision, a vertical incision which follows the linea alba.

The upper midline incision usually extends from the xiphoid process to the umbilicus. A typical lower midline incision is limited by the umbilicus superiorly and by the pubic symphysis inferiorly. Sometimes a single incision extending from xiphoid process to pubic symphysis is employed, especially in trauma surgery.

Midline incisions are particularly favoured in diagnostic laparotomy, as they allow wide access to most of the abdominal cavity.

Appendectomy
An appendectomy (sometimes called appendisectomy or appendicectomy) is the surgical removal of the vermiform appendix. This procedure is normally performed as an emergency procedure, when the patient is suffering from acute appendicitis. In the absence of surgical facilities, intravenous antibiotics are used to delay or avoid the onset of sepsis; it is now recognized that many cases will resolve when treated non-operatively.

In some cases the appendicitis resolves completely; more often, an inflammatory mass forms around the appendix. This is a relative contraindication to surgery. Appendectomy may be performed laparoscopically (this is called minimally invasive surgery) or as an open operation. Laparoscopy is often used if the diagnosis is in doubt, or if it is desirable to hide the scars in the umbilicus or in the pubic hair line. Recovery may be a little quicker with laparoscopic surgery; the procedure is more expensive and resource-intensive than open surgery and generally takes a little longer, with the (low in most patients) additional risks associated with pneumoperitoneum (inflating the abdomen with gas). Advanced pelvic sepsis occasionally requires a lower midline laparotomy. There have been some cases of auto-appendectomies, i.e. operating on yourself. One was performed by Dr Kane in 1921, but the operation was completed by his assistants. Another case is Leonid Rogozov who had to perform the operation on himself as he was the only surgeon on a remote Arctic base.[1] In general terms, the procedure for an open appendectomy is as follows. 1. Antibiotics are given immediately if there are signs of sepsis, otherwise a single dose of prophylactic intravenous antibiotics is given immediately prior to surgery. 2. General anaesthesia is induced, with endotracheal intubation and full muscle relaxation, and the patient is positioned supine. 3. The abdomen is prepared and draped and is examined under anesthesia. 4. If a mass is present, the incision is made over the mass; otherwise, the incision is made over McBurney's point, one third of the way from the anterior superior iliac spine (ASIS) and the umbilicus; this represents the position of the base of the appendix (the position of the tip is variable). 5. The various layers of the abdominal wall are then opened. 6. The effort is always to preserve the integrity of abdominal wall. Therefore, the External Oblique Aponeurosis is slitted along its fiber, and the internal oblique muscle is split along its length, not cut. As the two run at right angles to each other, this prevents later Incisional hernia. 7. On entering the peritoneum, the appendix is identified, mobilized and then ligated and divided at its base. 8. Some surgeons choose to bury the stump of the appendix by inverting it so it points into the caecum. 9. Each layer of the abdominal wall is then closed in turn. 10. The skin may be closed with staples or stitches. 11. The wound is dressed. 12. The patient will be brought to the recovery room.

A fracture is any break in the continuity of bone. Fractures are named according to their severity, the shape or position of the fracture line, or even the physician who first described them. It is defined according to type and extent. In some cases, a bone may fracture without visibly breaking. Fractures occur when the bone is subjected to stress greater than it can absorb. It can be caused by a direct blow, crushing force, sudden twisting motion, or even extreme muscle contraction. When the bone is broken, adjacent structures are also affected, resulting in soft tissue edema, hemorrhage into the muscles and joints, joint dislocations, ruptured tendons, severed nerves, and damaged blood vessels. Body organs may be injured by the force that caused the fracture or by the fracture fragments. Among the common kinds of fractures are the following: Open (compound) fracture: The broken ends of the bone protrude through the skin. Conversely, a closed (simple) fracture does not break the skin. Comminuted fracture: The bone splinters at the site of impact, and smaller bone bone fragments lie between the two main fragments. Greenstick fracture: A partial fracture in which one side of the bone is broken and the other side bends; occurs only in children, whose bones are not yet fully ossified and contain more organic material than inorganic material Impacted fracture: One end of the fractured bone is forcefully driven into the interior of the other. Potts fracture: A fracture of the distal end of the lateral leg, with one serious injury of the distal tibial articulation. Colles fracture: A fracture of the distal end of the lateral forearm in which the distal fragment is displaced posteriorly. Fractures may also be described according to anatomic placement of fragments, particularly if they are displaced or nondisplaced. Causes Rib fracture is any break in a rib. There may be one or more breaks. An injury, such as a blow to the chest or a fall, forces the broken rib inward. The jagged edges of the broken rib could cut or tear the lung. This could cause bleeding inside the chest or could cause one of the lungs to collapse (deflate). Hard coughing or hard sneezing can also fracture a rib but the broken rib is forced outward. With this kind of fracture there is less chance of injury to the lungs. Rib fractures usually heal on their own without treatment in about 3 to 6 weeks. Rib fractures are the most common type of chest trauma, occuring in more than 60% of patients admitted with blunt chest injury. Most rib fractures are benign and are treated conservatively. Fractures of the first three ribs are rare but can result in a high mortality rate because they are associated with laceration of the subclavian artery or vein. The fifth through ninth ribs are the

common sites of fractures. Fractures of the lower ribs are associated with injury to the spleen and liver, which may be lacerated by fragmented sections of the rib. Signs & Symptoms Patients with rib fractures have clinical manifestations such as severe pain, point tendernessa and muscle spasm over the area of the fracture, which is aggravated by coughing, deep breathing and movement. The area around the fracture may be bruised. To reduce the pain, the patient splints the chest by breathing in a shallow manner and avoids sighs, deep breaths, coughing, and movemnet. This reluctance to move or breathe deeply results in diminished ventilation, collapse of unaerated alveoli (atelectasis), pneumonitis, and hypoxemia. Respiratory insufficiency and failure can be the outcomes of such a cycle.

Fractures

Risk for trauma Acute pain Risk for peripheral neurovascular dysfunction Risk for impaired gas exchange Impaired physical mobility Risk for impaired skin or tissue integrity Risk for infection Deficient knowledge (learning need) regarding condition, prognosis, treatment, self-care, and discharge needs.