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Acute appendicitis is a clinical diagnosis, the accuracy of which has improved with modern diagnostic imaging techniques, including computed tomography scan of the abdomen and pelvis, which has an accuracy of 90% or more. The diagnosis is made using a combination of history, physical examination, and laboratory tests plus an elevated temperature and white blood cell count. A positive imaging study is helpful and gives reassurance about the diagnosis. In equivocal cases, serial observations and studies over time improve the accuracy of diagnosis, but at the risk of an increasing rate of perforation.
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Laparoscopic appendectomy is appropriate for virtually all patients and is preferred in obese patients, who require longer open incisions with increased manipulation and the resulting increase in surgical-site infections. The laparoscopic technique is also indicated in females, especially during the reproductive years, when tubal and ovarian pathology may mimic appendicitis. Laparoscopy not only provides direct observation of the appendix but also allows evaluation of all intra-abdominal organs, especially those in the female pelvis. Laparoscopic appendectomy has been shown to be as safe as open appendectomy in the first trimester of pregnancy, but there is always a risk to the fetus with any anesthesia or operation. Later or third-trimester pregnancies as well as any process that creates intestinal distension will make peritoneal entry more difficult and reduce operative space for maneuvering the instruments for a safe laparoscopic operation. Finally, laparoscopic appendectomy results in less incisional pain after surgery, allows a faster return to normal function or work, and produces a better cosmetic result.
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PREOPERATIVE PREPARATION
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Because healthy youngsters and young adults constitute the most common population with appendicitis, the usual preoperative evaluation for anesthesia and surgery is performed. Intravenous fluids for hydration and preoperative antibiotics are given. Extra time may be needed in the very young or old for correction of electrolyte and fluid imbalances. Hyperpyrexia should be treated with antipyretic agents or even external cooling so as to lessen the risk of general anesthesia.
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General anesthesia with placement of an endotracheal tube is preferred. After induction, an orogastric tube may be placed by the anesthesiologist. This tube is removed before the end of the operation or is replaced with a nasogastric tube if prolonged decompression is anticipated.
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The patient is placed in a supine position. The right arm may be extended for intravenous and blood pressure cuff access by the anesthesiologist, while the left arm with the pulse oximeter is tucked in at the patient's side. This allows for easier movement by the surgeon and the assistant operating the videoscope. The fiber-optic light cable and gas tubing are usually placed at the head of the table, the video monitor is placed across from the operating team, and the electrocautery and suction irrigator are placed toward the foot of the ...