Description of appendectomy operation. Retrograde appendectomy: surgery to remove appendicitis, complications

Stages of the operation: preparation of the surgical field (wiping with alcohol and lubrication with a 5% alcohol solution of iodine), layer-by-layer anesthesia of all tissues in the surgical area, opening of the abdominal cavity (oblique skin incision in the right iliac region with spreading the muscles of the anterior abdominal wall, opening of the peritoneum), finding and removal of the appendix (Fig.), revision of the abdominal cavity, suturing of the surgical wound, bandage (sticker).

The appendectomy is performed by a surgeon; is assisted by a doctor or an operating nurse, whose help in such cases consists of expanding the edges of the abdominal wall with hooks when opening it, holding the cecum when removing it into the surgical wound and removing the appendix (an important moment!), cutting off the ends of a silk or catgut ligature when ligating blood vessels.

Necessary instruments: scalpels, scissors, hemostatic clamps, surgical needles and needle holders, tweezers (anatomical and surgical), forceps, sharp and blunt hooks for expanding the wound of the abdominal wall, silk, catgut, etc.

At the time of the operation, after opening the skin of the abdominal wall and after cutting off the appendix, some instruments are changed. The operating nurse ensures that the removed appendix is ​​sent for histological examination.

In the postoperative period, it is necessary to monitor the pulse, the condition of the patient’s tongue, the function of the gastrointestinal tract, and urination. Patient care - see Postoperative period. Prescribing enemas, laxatives, dressings - only as directed by a doctor; The timing of the patient's rise and his regimen in the immediate postoperative period are also determined by the doctor.

Appendectomy. In Russia, the first successful appendectomy was performed by A. A. Troyanov (1890). At the IX Congress of Russian Surgeons (1909), the issue of the need to operate on the first day was resolved. In widespread practice, early surgery has dramatically reduced mortality in acute appendicitis, which is now insignificant.

In Moscow, 70-72% of patients with acute appendicitis are taken to hospitals on the first day of the disease, and the remaining 28-30% - later than 24 hours. In Moscow hospitals, 85% of patients undergo surgery within the first 6 hours after delivery. Of the total number of diseases, 72% are acute appendicitis, 28% are chronic, and the latter are more common in women. The average mortality rate after operations in Moscow for acute appendicitis ranges from 0.17-0.21%, while among those operated on in the first 6 hours and delivered on the first day of the disease it was less than 0.1%, and among those delivered later than 24 hours .- 0.3-0.4%. At the Institute. Sklifosovsky for 1959-1963. postoperative mortality was 0.2-0.3%, with 0.05% of patients dying under the age of 40 years, and 3.4% after 60 years.

Among 8426 operated on in the group of destructive forms (339 patients), perforated appendicitis accounted for 23.1%, gangrenous - 65.1%, with gangrene of the mucous membrane - 11.8%. Of the 4230 operated on in the group of acute purulent forms of appendicitis, 77.1% were phlegmonous, with empyema - 21.8%, infiltrates - 0.5% and abscesses - 0.6%. Catarrhal changes in the appendix in acute appendicitis occur in 30% of all operations (L. A. Brushlinskaya, A. A. Saikin), which is partly explained by the inevitable exaggeration of indications when trying to operate as early as possible.

Appendectomy technique. Anesthesia is in most cases a flattering infiltration anesthesia. In case of developing peritonitis, intubation anesthesia or spinal anesthesia is necessary. It is more advisable to use an oblique incision with muscle spreading, which provides wide access for examining the abdominal cavity (Fig. 5.1-4). Sometimes, when peritonitis has developed, a median laparotomy is performed. Having opened the peritoneum, assess the quantity and nature (serous, purulent, ichorous) of the effusion. If a large accumulation of exudate is detected, it is sucked off with an aspirator, and then gauze pads are placed in all directions to absorb the serous-purulent contents during appendectomy. Usually the wound contains a cecum, which is determined by the presence of taenia libera and a grayish-bluish color; however, hyperemia can change the color of the intestine. If the cecum has to be looked for, then they are oriented along the lateral and then the posterior parietal peritoneum, which directly passes to the wall of the cecum, and above - to the mesentery of the ascending colon. Having discovered the caecum, it is carefully grabbed and removed from the abdominal cavity. The taenia libera is traced downwards, which leads to the base of the process.

After removing the appendage, the mesentery is crossed between hemostatic clamps and tied with thread; in this case, you need to make sure that the first (closest to the base of the process) branch a is included in the ligature. appendicularis to avoid bleeding (Fig. 5, 5). The so-called ligature method, in which the stump is not immersed in a pouch, is too risky; It should not be used in adults. A purse-string suture is placed (without tightening) around the base of the appendix on the cecum. The base of the appendage is tied with a ligature, the appendage is cut off, its stump is immersed in the intestinal lumen, after which the purse-string suture is tightened (Fig. 5,6-10).

Having finished removing the appendix, checking hemostasis and lowering the intestine into the abdominal cavity, gauze pads are removed. When diffuse purulent peritonitis has developed, it is especially important to carefully empty interintestinal abscesses and remove purulent accumulations from under the diaphragm and from the pelvic cavity. The abdominal cavity should not be rinsed. After draining, you need to check again to see if the mesenteric stump is bleeding. Then a solution of antibiotics is poured into the abdominal cavity: penicillin - ED, streptomycin - ED. The surgical wound can usually be sutured tightly. However, in case of severe symptoms of peritonitis, a thin rubber drain is left between the sutures for introducing antibiotics into the abdominal cavity, and in case of gangrene of the appendix, in case of ichorous effusion, the skin wound is not sutured and long ends of the threads are left on the sutured aponeurosis. If around the appendix there was an accumulation of pus limited by adhesions or there was retrocecal appendicitis, then the wound is not sutured at all, but is left in the abdominal cavity, in addition to thin drainage, delimiting gauze tampons, which begin to be tightened on the 7-8th day after the operation and are removed completely by 8 -10th day.

In the absence of sudden changes in the peritoneum, postoperative treatment is limited only to intramuscular administration of antibiotics during the first 3-4 days. A cleansing enema can be prescribed on the 4-5th day. Postoperative treatment in more severe cases - see Peritonitis.

The most common complication in the postoperative period is the formation of intraperitoneal abscesses, usually associated with insufficient removal of purulent effusion during surgery. The abscess can be localized between the loops of intestines (interintestinal abscesses), under the diaphragm, but most often in the pouch of Douglas. In a patient who has a persistent fever after surgery for acute appendicitis, first of all you need to examine the rectum with your finger in order to detect the accumulation of pus in time and open it.

Serious complications can arise as a result of inadequate hemostasis. If the mesentery of the appendix is ​​poorly ligated and bleeds into the abdominal cavity, then usually already on the first day a picture of cavitary bleeding is determined, in which relaparotomy is indicated.

Rice. 5. Appendectomy:

1 - skin incision line, bottom left - anesthesia diagram;

3 - exposure of the internal oblique muscle;

4 - the fibers of the internal oblique muscle are pushed apart bluntly, the peritoneum is exposed;

5 - ligature of the mesentery of the process;

6 - preparation of the purse-string suture; applying a ligature at the base of the process;

7 - applying a clamp to the process before cutting it off;

Removal of appendicitis: types, course of surgery, complications

Each method of surgical intervention has clear indications and contraindications. The course of the operation with laparoscopic and classical methods differs, as does the recovery period. Both methods can lead to complications.

Indications and contraindications

Removal of appendicitis using the classical and laparoscopic method is indicated in cases of clinically and laboratory confirmed appendicitis.

Removal of the appendix using the classical method has no contraindications, except for the patient's agonal condition. Appendectomy performed by laparoscopy has the following contraindications:

• more than 24 hours have passed since the onset of the pathology;
• presence of neoplasms;
• inflammatory diseases of the gastrointestinal tract;
• perforation of the appendix, development of peritonitis;
• atypically located process.

Surgery to remove appendicitis can be performed urgently or routinely. The first type of intervention is carried out if the inflammatory process began a long time ago and there is a possibility of developing peritonitis or sepsis. This treatment is performed within 2-4 hours after the patient’s admission to the surgical hospital.

Elective surgery is offered to the patient in the initial stages of appendicitis. In this case, the surgical intervention is performed at the appointed time, and the doctor has time to fully examine the patient. Planned treatment is more preferable, as the risk of complications is minimized. A positive aspect is the ability to select the type of anesthesia.

The operation to remove the appendix can be performed either classically or laparoscopically. The latter, unlike laparotomy, is performed through 3 punctures. Currently, there are improved laparoscopic techniques for appendectomy: transgastric and transvaginal.

The transgastric method is based on the penetration of a gastroscope and needle through the navel. That is, appendectomy is performed through one puncture. In this case, the risk of developing postoperative hernias or infection is reduced.

The transvaginal method involves inserting equipment through the vagina. If this method of surgery on the appendix is ​​used, no scars will remain on the patient’s body.

Preparation

Preparatory measures for appendectomy surgery are limited in time in case of emergency intervention. However, minimal research must be performed:

• general blood analysis;
• general urine analysis;
• ultrasound examination of the abdominal organs;
• radiography;
• for women - consultation with a gynecologist.

Before surgery to remove appendicitis, a catheter is inserted into the patient to drain urine. A cleansing enema is also performed. The lower extremities are tightly bandaged to prevent thromboembolism.

The patient's hair in the area of ​​the surgical field is shaved and an isotonic solution is administered intravenously to reduce intoxication. An important point is to determine the type of anesthesia and assess the presence of allergic reactions to the anesthetic agent.

The entire preparatory period takes about two hours. The patient is then transferred to the operating room.

Progress of the operation and duration

The operation to remove the appendix, performed laparotomically, involves an incision in the right iliac region about 10 cm long. The stages of the operation are distinguished:

• Anesthesia. The operation is performed under general or local anesthesia. In most cases, the first one is used.
• Layer-by-layer dissection of the abdominal wall. During the intervention, the surgeon makes tissue incisions in layers, while simultaneously cauterizing the damaged vessels. The muscles are separated with a blunt instrument or by hand.
• The next period of the operation is revision of the abdominal organs. After assessing the condition of the internal organs, the doctor finds the appendix. An important point during the appendectomy operation is the examination of 50 cm of intestine on both sides of the appendix. If adhesions are detected, a decision may be made to excise them. If there are no other problems, the surgeon proceeds to cutting off the appendix.
• Removal of the caecum is the final stage of the appendectomy operation. During this procedure, the doctor removes the appendix into the wound, bandages it and cuts it off. The intestinal stump is sutured, the suture is immersed inside the stump.
• The abdominal wall is sutured with absorbable threads, and silk sutures are placed on the skin. They are removed 7-10 days after the intervention.

The duration of the operation varies depending on the severity of the pathological process. Surgical intervention via laparotomy lasts at least 40 minutes. On average, the intervention lasts about an hour. If any complications arise during the operation (for example, a ruptured appendix), then surgical treatment will last up to several hours.

Laparoscopic appendectomy is performed through 3 punctures. All manipulations performed by the surgeon are displayed on the screen. The operation has the same steps as during laparotomy. Read more about laparoscopic appendectomy →

Rehabilitation

The duration of the recovery period depends on the method of appendectomy. Thus, with the laparoscopic method of removing the appendix, the patient can get up within a few hours after the operation, and is discharged from the hospital on the third day.

With the classic method of appendectomy, the patient gets up within 3-4 days. The patient is discharged 7 days after the intervention, the sutures are removed.

On the first day, the patient undergoes the following procedures:

• detoxification of the body;
• antibacterial therapy, pain relief (if necessary);
• prescribing laxatives;
• restoration of bowel and bladder function;
• monitoring the patient to identify bleeding, intestinal dysfunction, and the development of complications.

It is important to follow a diet. In the first days, you can eat low-fat yogurt, cereals and jelly. You should exclude from your diet foods that increase gas formation: cabbage, potatoes, peas, beans. To reduce the load on the gastrointestinal tract, it is better to cook food by steaming or in the oven. You should drink as much water as possible. You can switch to your usual diet every other day.

The motor mode should also be observed to prevent the sutures from coming apart. You can get out of bed after 3-4 days, move carefully, without sudden movements. You should not lift more than 1 kg for a month. After discharge from the hospital, you need to take walks.

Complications

The following complications may occur after surgery:

• stump suppuration;
• suppuration of sutures;
• peritonitis;
• bleeding;
• abscesses;
• pylephlebitis (inflammation of the portal vein);
• intestinal fistulas.

The method of surgical intervention for appendicitis is determined by the severity of the patient’s condition and the presence of concomitant pathologies. The classic method of removing the appendix has no contraindications, however, the duration of patient rehabilitation takes longer than after laparotomy.

Minimally invasive intervention, on the contrary, cannot be performed on all patients, as it has contraindications. The development of complications is possible with both types of appendectomy. The main thing to remember: with any type of intervention, the likelihood of complications is higher, the later the patient seeks help. Therefore, at the first symptoms of appendicitis, you should immediately see a doctor.

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Appendectomy

The incision line goes through McBurney's point, located on the border between the outer and middle third of the line connecting the navel with the anterior superior spine of the right ilium. The cut runs perpendicular to the line indicated above, with one third of the length of the cut falling on the area above the line, and two thirds below the line. The length of the incision should provide a good view of the surgical area and varies depending on the thickness of the patient's subcutaneous fat. Typically the length of the incision is 6-8 cm.

Before removing the dome of the cecum, an inspection is carried out using the index finger to ensure that there are no adhesions that would interfere with the removal of the cecum. If there are no obstacles, then the cecum is carefully pulled by its front wall, and thereby it is brought out into the wound. Most often, following the dome of the cecum, the appendix also emerges into the wound. If this does not happen, it is necessary to focus on the muscle lines running along the cecum and converging in the area where the appendix originates.

Then a clamp is applied at the base of the process and released. In this case, a groove is formed on the wall of the appendix. A catgut ligature is applied in the area of ​​this groove.

The next step is to apply a purse string suture. A purse-string seromuscular suture is placed at a distance of about 1 cm from the base of the appendix. A clamp is applied over the catgut ligature and the process is cut off. Using a clamp, the stump of the appendix is ​​immersed in the cecum and the purse-string suture is tightened around the clamp, after which it is necessary to carefully open and remove the clamp from the immersed cecum.

A seromuscular Z-shaped suture is placed over the purse-string suture.

1. For peritonitis

2. There is no certainty that the process is completely removed

3. If there is uncertainty about hemostasis

4. Presence of periappendiceal abscess

5. Spread of inflammation to the retroperitoneal tissue

6. If there is uncertainty about the reliability of immersion of the stump of the process

Appendectomy

Treatment of appendicitis is done only through an operation in which a special set of instruments for appendectomy is used. Before removing the formation, preparatory measures are carried out: blood and urine are taken for analysis, tomographic and ultrasound examinations are performed, X-rays are taken, and the presence of pain is studied. If all the results are available, you can proceed with the appendectomy. There are different ways to carry out such a procedure: open (traditional) or, as it is also called, the Volkovich-Dyakonov method, laparoscopic and transluminal techniques.

An appendectomy is a procedure to eliminate inflammation of the appendix.

Types of appendectomy

Traditional removal

An open appendectomy is performed using incisions near the navel, in the right side. Then recognition of all abdominal organs occurs. The doctor analyzes the condition of the body for the presence of other diseases and disorders, and the cause of pain. To remove appendicitis, the damaged organ is disconnected from the cecum and other tissues, after which it can be excised. The part where the appendectomy was performed needs to be closed. This is done by stitching together the muscles and skin. The urgent procedure is carried out on a budgetary basis, but further restoration is paid for.

Laparoscopic

Laparoscopy is another type of surgical intervention, which is characterized by punctures of the abdominal wall. With this method, 4 cuts are made about 2-3 cm long. The first one is cut in the navel area, the next one is made between the pubic bone and the navel. It is also necessary to cut the right side, in the lower abdomen - such sections are smaller in size than the previous ones. Through these incisions, a camera and other special devices are inserted inside. This equipment makes it possible to examine the condition of internal organs in section and the formation of appendicitis. The vermiform appendix is ​​removed through previously made sections. At the end of the process, all auxiliary equipment is removed from the abdominal cavity, and the incisions are closed. This operation requires additional equipment and is performed for a fee.

Transluminal

This method of appendectomy involves performing the operation through the natural openings of the body. For this purpose, specialized plastic tools are used. There are two types of insertion of equipment into the body: transvaginal and transgastric. In the first case, the operation is performed through a small incision in the vagina, and in the second, we cut a hole in the gastric wall with a puncture. This surgical intervention is convenient because recovery after the procedure is much faster, the pain is much less and there are no aesthetic problems - no scars are visible. This procedure is not available in all hospitals and is performed for a fee.

Traditional and laparoscopic: comparison

What type of appendectomy should you choose? Opinions on this matter are divided. If the doctor is experienced, it will not be difficult for him to perform any of these surgical interventions in a short time. Although, considering how much time it takes, the traditional one goes a little faster. When using laparoscopic surgery, there is a greater risk factor - the occurrence of unwanted complications. In addition, this type of appendicitis removal requires specialized instruments, and accordingly, its cost will be higher.

Laparoscopic appendectomy is more expensive, but causes less discomfort during surgery.

However, for women, laparoscopic appendectomy is a more viable option, as the process is complex for them. This is especially evident in the presence of gynecological diseases, such as inflammation of the ovaries and other pelvic organs, the presence of cysts, and endometriosis. They are often accompanied by attacks of pain. In general, both treatment methods are characterized by a similar diet and similar medications, and the recovery period is equivalent. Based on this, it is necessary to choose the type of appendectomy individually, taking into account the patient’s health condition.

How dangerous is the operation?

As with any surgical intervention, there are complications. Surgery for appendicitis is performed under general anesthesia so that the person being operated on does not experience pain. In this case, the abdominal cavity remains open. Based on this, deviations appear:

• Most often, collapse and pneumonia of the respiratory tract are observed - it is painful to breathe (smokers are more susceptible to postoperative abnormalities than non-smokers).
• It happens that thrombophlebitis or venous inflammation develops, accompanied by pain.
• Sometimes bleeding is observed - this necessitates a blood transfusion procedure.
• The formation of adhesions is also observed, which are dangerous because they lead to intestinal obstruction and the formation of cancer.

After appendix surgery, the likelihood of rupture is low.

How often abnormalities occur after appendectomy depends on how advanced the appendix is ​​at the time of removal. When there was no breakthrough, the possibility of deviations does not exceed 3%. However, if a rupture does occur, the risk factor increases to 60%. The most common ailments after surgery are infections that entered the body through a wound. They cause suppuration and attacks of pain.

It happens that a rupture occurs before abdominal surgery to remove appendicitis has been performed, then the entire contents of the appendicitis end up in the stomach area. This situation is dangerous due to the development of peritonitis or infectious infection in the abdominal cavity. To eliminate the consequences of a rupture, it is necessary to carry out cleaning to remove the remains of the organ, as well as the introduction of rubber tubes and treatment of appendicitis with antibiotics. If there is a delay in making a diagnosis and performing an operation, serious complications occur, so excision is performed as soon as suspicions arise.

Contraindications

Traditional appendectomy has virtually no contraindications, but laparoscopic appendectomy may not be used in all cases. To perform an appendectomy safely, the doctor needs to assess the patient's condition. Deviations are possible in the following cases:

• More than 24 hours have passed since the onset of the disease. In such cases, abscesses and ruptures appear, and antibiotics may be needed for appendicitis.
• The presence of inflammatory processes in the digestive organs.
• Another contraindication is the presence of disorders in other organs (for example, the development of cancer). Why is this situation so dangerous? It can negatively affect the patient's health. This applies to diseases such as heart failure, destructive processes in the lungs and bronchi, myocardial infarction, etc.

As a rule, the appendix is ​​operated on urgently and the operation is not preceded by preliminary preparation.

Indications and preparation for surgery

This type of operation, such as appendectomy, is performed urgently in most cases. Preparation begins from the moment it was decided to cut out the appendix. It is also possible to have a planned removal of the appendix (appendiceal infiltrate) after the inflammation has decreased, several weeks after the onset of the pathology. If severe poisoning is observed and there is suspicion of a possible rupture, urgent surgical intervention is necessary.

The process takes no more than an hour. It is important under what anesthesia the appendicitis is removed. For appendectomy and hernia repair, either local or general anesthesia is used. The choice is made based on an analysis of the patient’s health status and individual indicators, such as age, weight, and the presence of other diseases that affect the abscess. For example, for teenagers, people with obesity and nervous instability, the indication is general anesthesia for appendicitis. This is due to the risk of injury during appendectomy. But for expectant mothers, healthy adults, local anesthesia is suitable without significant deviations.

Preparation

Emergency assistance is required to eliminate the abscess when acute appendicitis is diagnosed (ICD code 10 K35). The patient experiences severe pain, so it is not always possible to carry out preparatory measures. However, at least a minimal part of the tests must be carried out - urine and blood tests, x-rays and ultrasound. For safety, it is advisable for women to visit a gynecologist. In order to reduce the risk of blood clots, the veins are tightly bandaged before surgery. To remove fluid from the bladder, a catheter is inserted during the procedure, and the stomach is cleansed using an enema. The preparatory part takes no more than 2 hours. Upon completion of the diagnosis, the patient is sent to the operating room, where anesthesia is administered and the field is prepared for the operation - disinfection, removal of body hair.

Technique for performing traditional appendectomy

The traditional surgical procedure is divided into two parts: surgical access and cecal exposure. It takes an hour to complete. To open access to the abscess, it is necessary to cut a section along the line located between the navel and the ilium. Its length is usually up to 8 cm. After an incision in the skin, the surgeon dissects the fatty tissues or simply moves them away (if the amount is small). Next are the connecting fibers of the oblique muscle - they are cut using special scissors. After this, the path opens to the inner muscle layer, under which there is abdominal tissue and peritoneum. After dissecting these layers, the surgeon observes the processes in the stomach cavity. If all steps are performed correctly, there should be a dome of the cecum.

Then comes the next stage - elimination. In cases where removal of the appendix is ​​difficult, the incision can be enlarged. The doctor examines for the presence or absence of adhesions that complicate the operation. If there is no interference, the intestine is pulled out into the section, and an abscess emerges behind it. The surgeon's actions must be extremely careful so as not to damage anything. There are two types of appendectomy - antegrade and retrograde.

Antegrade

This type of appendectomy is characterized by applying a clamp to the mesentery from above the formation and piercing it from below. Through this passage, the mesentery is clamped and tightened with a nylon thread. It is possible to make more than one clamp, depending on the degree of swelling. Next comes the suture stage. It is placed 10 mm from the appendix. After applying a clamp to the catgut ligature, the process is cut off. The remainder of the cutting edge is returned to the cecum, and the applied purse-string suture is tightened. After this, the clamp is pulled out. At the end, another one is superimposed - seromuscular.

Retrograde aspendectomy

Retrograde appendectomy is used in cases of difficulty in removing appendicitis. Such complications include: adhesions and atypical position of the abscess. In such a situation, a ligature is first applied from below the formation. The appendix is ​​removed under a clamp, and the remainder is returned inside the cecum. Threads can be placed on top. At the end of this procedure, they proceed to ligation of the appendix. At the end of the operation, the abdominal cavity must be drained. Electric suction and tuffers are used for this. Next, the incision is sutured tightly.

Carrying out laparoscopic appendectomy

There are stages of laparoscopic surgery:

1. The area next to the navel is cut and carbon dioxide is released into the stomach through it - this procedure improves visibility. Then a special device is inserted there - a laparoscope.
2. The passage is obtained through the right side, between the pubic bone and the ribs. Through it, with the help of instruments, the appendix is ​​captured, the vessels are ligated, the mesentery is cut off and appendicitis is removed.
3. After examining the condition of the internal organs, the incisions at this site are sutured.

This type of appendectomy occurs within an hour. The marks are almost invisible. The recovery period lasts no more than 4 days.

Laparoscopy: types

1. Extracorporeal. Its characteristic is explained by the fact that laparotomy first helps to clarify the diagnosis. Then they find out the location of the end of the process and capture it using a clamp. Next, the appendix is ​​removed and sutured. This method is effective for mobility of the cecum and small size of the appendix.
2. Combined. This method is used for short mesentery lengths. It is cut open from the inside, and the appendix is ​​pulled to the surface. Next, the operation is carried out according to the process technology.
3. Intracorporeal. The most common method for laparoscopy. In this case, all actions are performed inside the abdominal cavity, using special instruments.

Postoperative complications and their prevention

When performing surgery, the possibility of complications must be taken into account. The most common type of abnormality in the postoperative period is suppuration of appendicitis; this consequence can be found in 10% of cases. In addition, peritonitis develops and bleeding occurs. This is provoked by divergence or slipping of the sutures, the presence of adhesions, and blood clots. Complications are possible, such as purulent inflammation and abscess formation.

Pylephlebitis

Special attention should be paid to the appearance of pylephlebitis - one of the most serious consequences. This disease is a purulent process in the appendix, which spreads to the hepatic system and contributes to the spread of purulent formations. Manifestations of such a deviation can be seen within a few days after the appendectomy or last up to several weeks. The main manifestations include:

• rise and fall of body temperature;
• rapid pulse, difficult to hear;
• pain on the right side of the ribs;
• pallor.

This disease is extremely dangerous and can lead to the death of the patient.

Intestinal fistulas

Several reasons contribute to the appearance of fistulas:

• looping disorders in the intestines, peritonitis;
• incorrect implementation of technical instructions during the operation;
• the formation of bedsores due to too tight tampons and drainages, when it is painful to strain the abdominal muscles.

The appearance of an intestinal fistula is indicated by:

• pain in the area of ​​the removed process;
• intestinal obstruction;
• discharge of intestinal contents through a wound, or its entry into the abdominal area and when the area near the navel hurts.

This problem is eliminated by repeated surgical intervention. To prevent the occurrence of abnormalities, it is necessary to be under the supervision of a specialist after removal of the appendix, and also to follow a recovery regime. If you have symptoms of complications, seek help immediately.

Recovery

Analgesics

The patient's postoperative condition is often accompanied by pain, especially at the suture. To make the patient feel less pain, medications are prescribed that will help numb the wound. Such analgesic medications are tablets and intramuscular injections. During the inpatient period, injections are more often used, and treatment can be continued at home with the help of tablet analgesics.

Motor mode

How long it will take to heal at the incision site depends on the type of appendectomy performed and the individual characteristics of the patient’s body. If you have anemia and diabetes, you will have to limit your physical activity; there is no need to run during this period. Until the healing process is complete, it is necessary to support the abdominal area during periods of laughter and coughing, moving carefully so that the abdominal muscles do not tense. At first it will be useful to stay in bed, and then gradually start walking and increasing the load. In addition, physiotherapy procedures are prescribed, such as: UHF therapy and laser treatment. These treatments will promote healing.

Diet therapy

During the rehabilitation period after appendectomy, special nutritional conditions are recommended. In the very first days, you need to limit your diet. Liquid low-fat products are suitable: yoghurts, cereals, jelly. The body will require more water. You should not eat foods that promote flatulence - peas, beans, kvass, cabbage, lentils, milk, etc. Food with excess fat and spices will also be harmful. Subsequently, fruits and vegetables, poultry and fish can be introduced into the diet. It is better to cook food by baking or steaming to make it easier on the stomach. You can return to your usual diet in 2-3 weeks.

ATTENTION! The information on the site is provided for informational purposes only! No website can solve your problem in absentia. We recommend that you consult your doctor for further advice and treatment.

Behind the skin there is subcutaneous fatty tissue, which is dissected with a scalpel when there is a significant amount of it, or is pushed back bluntly using a tuffer (or the opposite end of the scalpel) when there is a small amount of fiber. The superficial fascia is incised, and behind it the fibers of the aponeurosis of the external oblique abdominal muscle become visible. These fibers are cut lengthwise using Cooper scissors, thereby opening access to the muscle layer. The fibers of the internal oblique and transverse muscles are pulled apart using two closed hemostatic forceps. After the muscle layer comes the preperitoneal tissue, which is pushed back in a blunt manner, and then the peritoneum. The parietal peritoneum is picked up with two clamps, making sure that there is no intestine under the clamps. After this, the peritoneum is dissected, and we find ourselves in the abdominal cavity.

b. Removal of the cecum into the wound

If access is made in a typical location, then in most cases the dome of the cecum is located in this area. If difficulties arise in identifying the dome and removing the appendix, the incision can be widened upward or downward.
Before removing the dome of the cecum, an inspection is carried out using the index finger to ensure that there are no adhesions that would interfere with the removal of the cecum. If there are no obstacles, then the cecum is carefully pulled by its front wall, and thereby it is brought out into the wound. Most often, following the dome of the cecum, the appendix also emerges into the wound. If this does not happen, it is necessary to focus on the muscle lines running along the cecum and converging in the area where the appendix originates.

There are two options for performing an appendectomy: antegrade appendectomy and retrograde.

1. Antegrade appendectomy

At the apex of the process, a clamp is applied to the mesentery. At the base of the appendix, the mesentery is pierced using a clamp. Through the resulting hole, the mesentery of the appendix is ​​clamped using a hemostatic clamp, tied with a nylon thread, and intersected. If the mesentery is swollen or profuse, it should be ligated and divided using several clamps.
Then a clamp is applied at the base of the process and released. In this case, a groove is formed on the wall of the appendix. A catgut ligature is applied in the area of ​​this groove.
The next step is to apply a purse string suture. A purse-string seromuscular suture is placed at a distance of about 1 cm from the base of the appendix. A clamp is applied over the catgut ligature and the process is cut off. Using a clamp, the stump of the appendix is ​​immersed in the cecum and the purse-string suture is tightened around the clamp, after which it is necessary to carefully open and remove the clamp from the immersed cecum.
A seromuscular Z-shaped suture is placed over the purse-string suture.

2. Retrograde appendectomy

Retrograde appendectomy is performed when difficulties arise in removing the appendix into the wound, for example, with adhesions in the abdominal cavity, retrocecal, retroperitoneal location of the appendix. In this case, a catgut ligature is first applied at the base of the process through the hole in the mesentery. The process is cut off under a clamp, its stump is immersed in the cecum and purse-string and Z-shaped sutures are applied, as described above. And only after this they begin to gradually ligate the mesentery of the appendix.

After the appendectomy is performed, the abdominal cavity is drained using tuffers or an electric suction. In most cases, the postoperative wound is sutured tightly without leaving drainage in it. Drainage of the abdominal cavity is performed in the following cases:
1. For peritonitis
2. There is no certainty that the process is completely removed
3. If there is uncertainty about hemostasis
4. Presence of periappendiceal abscess
5. Spread of inflammation to the retroperitoneal tissue
6. If there is uncertainty about the reliability of immersion of the stump of the process

Drainage is carried out through a separate incision using a tube with several holes at the end. In case of peritonitis, two drains are installed. One - in the area of ​​the removed process and the small one, the second - along the right lateral canal. In other cases, one drainage is installed in the area of ​​the removed appendix and the small pelvis.

Recently, laparoscopic appendectomy has become increasingly popular. This type of appendectomy is considered less traumatic, but is not always technically feasible. Even if the surgical intervention began using the laparoscopic method, the surgeon should always be prepared to switch to a traditional appendectomy.

Possible complications after appendectomy:
1. Bleeding
2. Wound infection
3. Postoperative peritonitis
4. Acute intestinal obstruction
5. Pylephlebitis
6. Abscesses of various locations
7. Intestinal fistula

Anesthesia is usually local. For one operation, from 200 to 400 ml of 0.25% novocaine solution is consumed. If technical difficulties arise, general anesthesia is used.

1. Opening the abdominal cavity. A skin incision 8-10 cm long is made in the right iliac region in a direction perpendicular to the line connecting the navel with the anterior superior spine of the right ilium. After isolating the skin and ligating the vessels of the subcutaneous tissue, the nurse applies Farabeuf plate hooks to push back the subcutaneous fat layer.

During the operation, the surgeon will repeatedly need additional anesthesia, so the nurse should have a syringe filled with novocaine solution on the table at all times. Before opening the aponeurosis, the surgeon injects a solution of novocaine under it, after which the nurse applies a scalpel to cut the aponeurosis along its fibers, and then Cooper scissors to extend the cut of the aponeurosis along the entire length of the wound. The assistant moves the hooks deeper, grasping the edges of the aponeurosis and pushing them apart.

The nurse again hands the surgeon a scalpel to dissect the perimysium of the internal oblique muscle in the transverse direction, and then Cooper scissors and a Kocher probe (or two Cooper scissors) to bluntly dissect the muscles along the fibers. In this case, novocaine, previously injected into the thickness of the muscles, pours into the resulting cavity and makes it difficult for the surgeon to visually monitor the progress of the dissection. Therefore, you should have a drying pad at the ready, as well as several hemostatic clamps, since with vigorous separation of the muscles they can tear and cause bleeding. Once the surgeon reaches the preperitoneal tissue, the assistant moves the hooks in the longitudinal direction, moving them across the entire thickness of the abdominal wall. By this time, the nurse prepares large napkins to isolate the tissues of the anterior abdominal wall from the abdominal cavity and serves them as directed by the surgeon.

The peritoneum is opened. At the time of opening, a significant amount of infected effusion may be released from the abdominal cavity. The operating team should be prepared for this by having an electric suction device turned on or a sufficient number of drying wipes on the forceps.

2. Detection of the vermiform appendix and its removal into the wound u.

The surgeon takes the intestines and omentum to the side with a tupper and anesthetizes the parietal peritoneum around the wound, for which the nurse gives him three or four syringes filled with novocaine with a long needle. After anesthesia, the assistant moves Farabeuf hooks into the abdominal cavity, releasing them from under the napkins delimiting the abdominal cavity.

It is difficult to foresee all possible options used when a vermiform appendix is ​​detected. The surgeon may need two tuffers, long anatomical tweezers, a Luer lock clamp: a gauze or rubber strip 25-30 cm long, additional anesthesia. In technically difficult cases, delimiting tampons and long narrow abdominal speculum are inserted into the abdominal cavity. The nurse should attach a clip to the end of each tampon to prevent it from being accidentally left in the abdominal cavity.

Before manipulations related to the removal of the appendix, the surgeon must anesthetize the mesentery of the appendix with a thin needle. In most cases, the surgeon is able to remove the dome of the cecum into the wound. To fix the dome of the cecum, the assistant gives the nurse a medium napkin moistened with an isotonic solution of sodium chloride or novocaine. She gives the surgeon a hemostatic clamp to fix the apex of the appendix. In case of sudden changes and the threat of contamination of the abdominal cavity, careful isolation is carried out with several napkins with clips attached to them.

3. Removal of the appendix. The nurse gives a pointed, curved hemostatic clamp, with which the surgeon makes a hole in the mesentery at the base of the appendix, and then, using this clamp, draws a long ligature of catgut No. 6, which ties the mesentery of the appendix. Before applying this ligature, the nurse should carefully check its strength, since quite severe bleeding may occur from the mesenteric stump when it is cut. After ligation of the mesentery, the latter is cut off from the process using Cooper scissors. At this moment, the nurse should have several hemostatic clamps ready, which may be needed if any branch of the mesentery is crossed that is not captured in the ligature.

In technically difficult cases, the surgeon has to gradually apply clamps to the mesentery, cutting it off from the appendix. Then each portion of the mesentery taken with a clamp is ligated or sutured. When ligating, the sister gives long catgut ligatures; when stitching, she gives a needle holder with a steep cutting needle loaded with the same ligatures. In exceptional cases, stitching is done with silk No. 4.

Immediately after cutting off the mesentery, the nurse applies a serrated crushing clamp (Kocher), with which the surgeon compresses the process at the base; The clamp is immediately removed, and the process is tied along the existing crush groove with catgut thread No. 4, the ends of the thread are cut off with scissors.

By this time, the nurse should prepare a needle holder with a round intestinal needle loaded with a long (25 cm) and thin (No. 0 or No. 1) silk thread for applying a purse-string suture to the cecum. The placement of this suture, which immerses the stump of the appendix into the cecum, is the most critical stage of the operation. If the strength of the silk thread is insufficient, it can break, which forces the purse-string suture to be re-applied in unfavorable conditions of the already severed process and the wall of the cecum damaged by the previous suture. Therefore, the nurse must check the strength of the silk thread before presenting the needle holder to the surgeon.

Having applied a purse-string suture, the surgeon prepares to cut off the appendix. To do this, the nurse gives the assistant anatomical tweezers to fix the stump at the moment of cutting off and immerse it at the moment of tightening the suture. She gives the surgeon a Kocher clamp (this clamp is applied to the appendix immediately above the catgut ligature) and prepares a stick with iodonate. Then the nurse gives a scalpel, with which the surgeon cuts off the appendix between the clamps and the ligature: the scalpel and the appendix are immediately thrown into a basin for dirty instruments, the stump is carefully treated with iodonate, and the surgeon, with the help of an assistant, immerses the stump of the appendix into the purse-string suture. The tweezers used in this case are also thrown into the basin.

The immersion site of the stump is treated with a ball of alcohol, which the nurse gives along with clean tweezers. After this, the surgeon places a Z-shaped catgut suture over the purse-string suture, for which the nurse gives him a needle holder with a round intestinal needle charged with catgut thread No. 2, 20-25 cm long. At this point, the stages of the operation that threaten to contaminate the surgical field with intestinal contents end. They process gloves, change instruments and napkins, and remove tampons.

According to indications, the surgeon drains the abdominal cavity from effusion with large tampons and leaves micro-irrigators in the abdominal cavity or installs drainage through a counter-aperture.

Before suturing the surgical wound, a hemostasis test is carried out: a long turunda given by the sister, captured by a forceps, is passed deep into the pelvis and the forceps is removed; if there is unstoppable bleeding, the turunda will be moistened with blood. In such cases, the surgeon inspects the stump of the mesentery of the process, for which the nurse prepares long curved hemostatic clamps, a tampon, narrow abdominal speculum and several long catgut ligatures on a steep needle.

4. Layer-by-layer suturing of the wound of the anterior abdominal wall. In contrast to suturing a midline laparotomy wound, the surgeon can close the abdominal cavity by suturing both layers of the peritoneum under Mikulicz clamps with catgut No. 4 and tying this ligature on both sides of the clamps raised by the assistant. Two or three interrupted sutures are placed on the muscles with fairly thick catgut (No. 4, No. 5). The aponeurosis is sutured with 6-8 interrupted sutures made of catgut No. 4; in case of poorly defined aponeurosis in elderly patients and in some other circumstances, the surgeon can apply silk No. 4 interrupted sutures. In the future, the sequence of actions is the same as when suturing a median laparotomy wound. In purulent forms of acute appendicitis, complicated by the formation of an abscess, infiltrate, etc., the operation can end with leaving a gauze tampon in the abdominal cavity of the patient: its end is brought out into one of the corners of the wound and the abdominal wall is not completely sutured, only up to the tampon.

Is as follows:

Position of the patient during laparoscopic appendectomy: lying on his back with the head of the operating table down by 10-15° and turned to the left by 15-20°.

Technique. During laparoscopic appendectomy, 3 trocar insertion points are used:

• Point 1, trocar 10 mm - paraumbilical point for passing the laparoscope.
• Point 2 (McBurney), trocar 10 mm - in the right groin area.
• Point 3, trocar 5 mm - along the midline 3-5 cm above the pubis.

Progress of the operation

After revision of the abdominal and pelvic organs using atraumatic forceps, the appendix is ​​grabbed by the apex and base. The mesentery of the organ is clamped with a clamp, coagulated with high-frequency current and crossed. Part of the mesentery with the artery of the appendix is ​​clamped with clips. In chronic cases, clips (two pairs) are placed on the base of the process towards each other to completely block its lumen; in acute cases, the base of the process is tied with three ligatures (catgut loops), two of which are applied to the remaining part of the r. one - to be removed. The vermiform appendix is ​​divided using an electrosurgical instrument and pulled out of the abdominal cavity through a trocar with a diameter of 10 mm. In cases complicated by peritonitis, the operation ends in the abdominal cavity. Desufflation is carried out. The trocars are pulled out. The wounds are closed with one stitch.

The article was prepared and edited by: surgeon

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