Oscar Moran Sierra Tischri, general service of the regional hospital, ISSSTE Calzada Heroico Colegio
Militar 875 Sur, zip code 80000, Culiacán, Sinaloa, México. Email: email@example.com
Oscar Moran Sierra et al. (2017), Appendectomy realized con local anesthesia: a case report. Int J Sur & Trans Res. 1:5, 45-48. DOI: 10.25141/2476-2504-2017-5.0045
The first known appendectomy was performed in 1736 by Claudius
Amyand in London. He operated on an 11 – year-old boy with
a scrotal hernia and a fecal fistula. Within the hernia sac, Amyand
found a perforated appendix surrounded by omentum. The appendix
and omentum were amputated1.
it would be over a century later
before appendicitis was widely recognized as a common cause of
a right lower quadrant pain. In 1886, Reginald Fitz presented his
findings regarding appendicitis and recommended consideration
for operative treatment2
. In 1889, Charles McBurney published his
Landmark paper in the New York State Medical journal describing
the indications for early laparotomy for the treatment of appendititis3.
He notified in 1884 the incision that bears his name3
early appendectomy became the accepted standard of care, with
broad indications in order to prevent perforation. However, this
had almost no impact on the incidence of perforated appendicitis
or on the mortality of appendicitis4.
Despite the great progress over time to treat appendicitis, no one
had attempted an appendectomy under local anesthesia, despite
being less invasive, less morbility and less costly than general anesthesia.
We report the case of an appendectomy performed under
local anesthesia in the “hospital pediatrico de sinaloa”
8-year-old male patient originally from Cosala, Sinaloa, Mexico,
healthy, that goes to the emergency department because of abdominal
pain of two days of evolution of Sudden onset periumbilical
and diffuse pain, progressive, accompanied by nausea and vomiting
that eventually localizes to the right lower quadrant, was treated
with analgesics by his mother dulling pain momentarily, mothers
refers that pain increased as well as vomiting so she decided
to take him to the emergency room. In the physical exploration:
patient looked in accordance to his age, sweating, pulse rate increased,
dehydrated oral mucosa, thorax normal, the abdomen was
distended, decreased peristalsis, hard, barely depressible, tenderness
near McBurney’s point, muscular guarding in the right iliac
fossa, positive rebound tenderness, presenting results as alteration
leukocytosis >21,000 cells/mm3 accompanied by a polymorphonuclear
It was decided to have an emergency surgery
for acute appendicitis prior informed consent, using sedation with
fentanyl at dosis of 2mcg/Kg, dexmetomidina 1mcg/Kg, propofol
100mcg/Kg these are using to avoid the anxiety of the patient as
well as for the management of visceral pain, it was decided to
manage the somatic pain with local anesthesia with simple lidocaine
2% infiltrate deeply between the eleventh rib and anterior
superior iliac spine, The blockade with is taken as an anatomical
reference for the passage of the ilioinguinal and iliohipogastric
nerves two centimeters inside and two centimeters below to
the antero superior iliac spine. The block is applied with a single
puncture in the referred site (image 1), For some authors this technique
is insufficient, so it is complemented by local infiltration on
the skin to be incised (image 2, image 3), subcutaneous cellular
tissue blocking nerves T12, L1, and ilioinguinal, iliohypogastric
(image 4), perform Rockey – Davis incision, is dissected by planes
to reach cavity without presents data of pain, found it purulent
fluid, 10 cm long vermiform appendix retrocecal, perforated in
its middle third (image 5), the appendiceal stump was managed by ligation and inversion, proceeded to aspirate abdomen, cul-desac,
reviewed hemostasis and stitched by planes without drainage,
passed to floor of pediatric surgery. It was decided to start a clear
liquids diet in the few postoperative hours without distension it
was decided to progress the diet on the second day, decided to
discharge because of clinical improvement.
Image 1: Infiltrating anesthesia in extraperitoneal fascia.
Image 2: Infiltrating anesthesia in the incision line.
Image 3: Infiltrating anesthesia in the incision line
Image 4: Abdominal wall nerves
Image 5: Appendix perforated.
The lifetime risk of developing appendicitis is 8.6% for males
and 6.7% for females, with the highest incidence in the second
and third decades5.
The establishment of a diagnosis of acute appendicitis
has been a problem for many surgeons, even more so
in young children than in adults. The inability for them to give
an accurate history, diagnostic delays by both parents and physicians,
and the frequency of gastrointestinal distress in children are
all contributing factors to the misdiagnosis and delay in diagnosis6.
There is no doubt that the promptly surgical intervention is the
elective treatment.3 the question is: Why should I perform the appendectomy
with local anesthesia? The anesthesiologists had handled
the peripheral nerves in the members but not in the abdomen
because they have had the epidural or either subarachnoid anesthesia,7
However, sometimes we have older patients with high surgical
risk to operate, so have been sought more secure anesthetic
Over the years the techniques of abdominal peripheral
block have been refined,9
For more than forty years, inguinal repair
has been performed local anesthesia, offering less postoperative
pain10,11,12 being an approach simpler and secure, the procedures
performed have been used with good results, offering the advantages
in addition to producing less postoperative pain.13 In our
hospital, Dr. Garrido has performed more than 100 appendectomy
with local anesthesia with the same results as we described below,
so we decided to report this case.
But not everything is perfect because it requires an understanding
of the abdominal neuroanatomy, the time to perform the appendectomy
is limited, and at the same time not be able to use for visceral
analgesia but becomes available through the use of intravenous
sedation and with the gentle handling of tissues.12 However, these
disadvantages create better results than the norm.
The appendectomy under local anesthesia and sedation it can be
done, in case of failure of the epidural anesthesia and as an excellent
method of postoperative analgesia or if you are in remotes
places with special equipments. Can be considered an alternative
in high risk patients. Each surgeon, according to his criteria, might
use only in special cases to convert it into his technique of choice.
Now the surgeons should pay attention on the details, such as the
minimum risk, the optimum control of pain, early recovery of the
patient. The appendectomy performed with local anesthesia and
sedation for the control of visceral pain and anxiety it could be a
method with all these expectations.
- Ellis H. Appendix. In: Schwartz SI, ed. Maingot’s Abdominal
Operations. 8th ed., vol. 2. Norwalk: Appleton-Century-Crofts; 1985:1255.
- Fitz RH: perforating inflammation of the vermiform appendix:
With special reference to its early diagnosis and treatment. Trans
Assoc Am Physicians 1:107, 1886.
- McBurney C: Experience with early operative interference
in cases of disease of the vermiform appendix. N Y State Med J
- Loveland JE. Reginald Heber Fitz. The exponent of appendicitis.
Yale J Biol Med.1937; 9:509–520. [PubMed: 21433739]
- Addiss DG, Shaffer N, Fowler BS, Tauxe RV. The epidemiology
of appendicitis and appendectomy in the United States. Am J Epidemiol. 1990; 132:910–925. [PubMed: 2239906]
- Bundy DG, Byerley JS, Liles EA et al. Does this child have appendicitis? JAMA.2007;298:438–451. [PubMed: 17652298]
[JAMA and JAMA Network Journals Full Text]
- Davis JE: Cirugia general mayor en el paciente ambulatorio.
Tratamiento de enfermedades mamarias y hernias de la pared abdominal.
Clin Quir Norteam 1987; 67:749 - 777.
- Gianetta E, Civalleri D, Serventi A, Floris F, Mariana F et al.: Anterior tension - free repair under local anesthesia of abdominal
wall hernias in continuous ambulatory peritoneal dialysis patients.
Hernia 2004; 8:354-357.
- Malazgirt Z et al.: Preperitoneal mesh repair of Spiegelian hernias
under local anesthesia: description and clinical evaluation of
a new technique. Hernia 2003; 7:202 - 205.
- Peiper C, Tons C, Schippers E, Busch F, Schumpelick V: local
versus general anesthesia for shouldice repair of the inguinal hernia. World J Surg 1994; 18(6): 912-916.
- Amid PK, Shulman AG, Lichtenstein IL: Simultaneous repair
of bilateral hernias under local anesthesia. Ann Surg 1996; 223(3): 249-252.
- Elton C, Stoodley BJC: Repair of concomitant inguinal and femoral hernias under local anesthesia. Int J Clin pract 2001; 55(9):645 - 646.
- Murabito R, Vecchio R, Murabito P, Torrisi V, Alongi G et al.: Development of anesthesiological techniques in the surgical treatment
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