Case Report
ISSN: 2476 2504
Appendectomy realized con local anesthesia: A case report
Moran Sierra Oscar Tischri*1, Canizales Adrian2, Trujillo Bracamontes Francisco3, Quintero García Benjamin3, Ríos Beltrán Jose del Carmen3, Garrido Rojo Miguel4, Niebla Torres Mariela5, Lopez Huitron Melissa6
1Resident physician of general surgery at regional hospital ISSSTE, Mexico
2Chief of researching apartment of the school of medicine of universidad autonoma de sinaloa, Mexico
3Attending physician of general surgery at regional hospital ISSSTE, Mexico
4Attending physician of pediatrics surgery at regional hospital ISSSTE, Mexico
5Attending physician of anesthesia at hospital pediatrico de sinaloa, Mexico
6Physician in emergency room service at regional hospital ISSSTE Regional Hospital “Manuel Cárdenas de la Vega”, Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado. Culiacán, Sinaloa, México
Corresponding author: Oscar Moran Sierra Tischri, general service of the regional hospital, ISSSTE Calzada Heroico Colegio Militar 875 Sur, zip code 80000, Culiacán, Sinaloa, México. Email: droscarmoran@gmail.com
Citation: 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
Copyright: ©2017 Oscar Moran Sierra et al. (2017), This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited
Received Date: September 29, 2017; Accepted Date: October 10, 2017; Published Date: November 15, 2017

Introduction :


Historical background:

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 eventually, 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”

Clinical Case:

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 prominence.

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.

Discussion:

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 techniques.8 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.

Conclusion:

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.

References:

  1. Ellis H. Appendix. In: Schwartz SI, ed. Maingot’s Abdominal Operations. 8th ed., vol. 2. Norwalk: Appleton-Century-Crofts; 1985:1255.
  2. Fitz RH: perforating inflammation of the vermiform appendix: With special reference to its early diagnosis and treatment. Trans Assoc Am Physicians 1:107, 1886.
  3. McBurney C: Experience with early operative interference in cases of disease of the vermiform appendix. N Y State Med J 50:676, 1889.
  4. Loveland JE. Reginald Heber Fitz. The exponent of appendicitis. Yale J Biol Med.1937; 9:509–520. [PubMed: 21433739]
  5. 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]
  6. 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]
  7. 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.
  8. 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.
  9. 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.
  10. 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.
  11. Amid PK, Shulman AG, Lichtenstein IL: Simultaneous repair of bilateral hernias under local anesthesia. Ann Surg 1996; 223(3): 249-252.
  12. Elton C, Stoodley BJC: Repair of concomitant inguinal and femoral hernias under local anesthesia. Int J Clin pract 2001; 55(9):645 - 646.
  13. Murabito R, Vecchio R, Murabito P, Torrisi V, Alongi G et al.: Development of anesthesiological techniques in the surgical treatment of inguinal hernia. Chir Ital 2000; 52(1): 73 -77.

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