Age: 7.0
Sex: M
Vaccine: COVID19
Symptoms: Anion gap, Appendicectomy, Appendicitis perforated, Bilirubin urine, Blood chloride decreased
Clinical narrative: 12/7/21 - vomiting and nausea lasting 5 hours starting 8:30pm  12/8/21-12/9/21 constipation, loss of appetite , still nausea, excessive gas and bloat pain. bowel movements occur after honey water in night time. feels okay after.  12/10/21-12/12/2021 diarrhea starts once mild fever and nausea, 1 vomit leading to Er visit. 12/13/2021 - Findings:         Appendix: Perforated/infected: hole or blown-out tip and Abscess    Fluid amount: Diffuse (throughout the peritoneal cavity)    Fluid character: Thin serous/clear throughout, Fibrinopurulent/purulent localized to within right lower quadrant mesentery (contained abscess)    Other pertinent findings: distal small bowel obstruction due to fibrinous adhesions to proximal rectum/abscess cavity within distal small bowel mesentery.       Procedure in Detail: After informed consent was obtained the patient was transported to the OR. A timeout was performed and perioperative antibiotics were given. The patient was prepped and draped in the normal sterile fashion.   A 12mm port was inserted in the umbilical position under direct visualization and the abdomen was insufflated. A 5mm 30 degree laparoscope was introduced. Two additional ports were inserted, one in the suprapubic position and one in the left lower quadrant, under direct laparoscopic visualization without incident. There were numerous dilated small bowel loops with distally decompressed bowel loops as well as serous fluid throughout the peritoneal cavity, likely a reaction to the distal small bowel obstruction. The appendix was tucked under the distal ileal mesentery, where it had perforated, and upon mobilizing the distal ile um and its mesentery an abscess cavity was released, draining purulent fluid which was suctioned out. The appendix had a blown-out hole in its mid-body. The appendix was exposed and retracted anteriorly and inferiorly, splaying open the appendiceal mesentery. A window was made in the appendiceal mesentery with the Maryland ligasure cautery and then the appendiceal mesentery was then taken with the ligasure cautery. The base of the appendix was transected with an endoGIA stapler. The appendix was removed via the umbilical port site using a specimen retrieval bag and then the peritoneal cavity was suctioned out. The small bowel was run proximally starting at the terminal ileum, and some loose fibrinous adhesions from the small intestine to the proximal rectum/distal sigmoid were released bluntly. The transition point of the obstruction was positively identified and easily released. We ran the bowel proximally for several more feet, and there were no other points of obstruction. The bowel was still fairly dilated but was all viable.   Once this was completed the surgical bed was inspected and the staple line was noted to be intact and the hemostasis was adequate. A rectus sheath block was performed using 0.2% plain ropivacaine under laparoscopic visualization. The ports were removed under direct visualization and the abdomen was desufflated. The incisions were closed in layers with absorbable sutures, cleaned and dried, and sterile dressings were applied.