Possible early postoperative complications in appendicitis. Complications of acute appendicitis Complicated appendicitis

In an acute inflammatory process in the appendix of the caecum, a rapid change of stages occurs. Already 36 hours after the onset of inflammation, serious complications can occur that threaten the life of the patient. In pathology, a simple or catarrhal uncomplicated appendicitis first occurs, when the inflammation affects only the mucous membranes.

When the inflammatory process spreads in depth and captures the underlying layers, in which the lymphatic and blood vessels are located, then they are already talking about the destructive stage of appendicitis. It is at this stage that pathology is most often diagnosed (in 70% of cases). If surgery is not performed, then the inflammation spreads to the entire wall and pus accumulates inside the process, the phlegmonous stage begins.

The wall of the appendix is destroyed, erosions appear, through which the inflammatory exudate enters the abdominal cavity, and the cells of the organ die off, that is, gangrenous appendicitis develops. The last stage is perforative, in which the pus-filled appendix bursts and the infection enters the abdominal cavity.

What are the complications of acute appendicitis?

The number and severity of complications directly depends on the stage of the disease. So, in the early period (the first 2 days), complications of appendicitis usually do not occur, since the pathological process does not droop beyond the appendix. In rare cases, more often in children and the elderly, destructive forms of the disease and even rupture of the appendix may occur.

On the 3-5th day after the onset of the disease, complications such as perforation of the process, local inflammation of the peritoneum, thrombophlebitis of the mesenteric veins, and appendicular infiltrate may develop. On the fifth day of illness, the risk of developing diffuse peritonitis, appendicular abscesses, portal vein thrombophlebitis, liver abscesses, and sepsis increases. This division of complications according to the stages of the course is conditional.

Cause a complication in acute appendicitis can:

late surgical intervention, which happens when the patient is not treated in time, the rapid progression of the disease, long-term diagnosis;
surgical technique defects;
unforeseen factors.

Possible complications are divided into preoperative and postoperative. The former are especially dangerous because they can lead to death.

Preoperative pathologies

Preoperative complications of acute appendicitis include:

peritonitis;
perforation;
pylephlebitis;
appendicular abscesses;
appendicular infiltrate.

In destructive forms of the disease, perforation usually occurs 2-3 days after the onset of the disease. When an organ ruptures, pain suddenly increases, pronounced peritoneal symptoms occur, clinical manifestations of local peritonitis, and leukocytosis increases.

If in the early stages the pain syndrome was not very pronounced, then perforation is perceived by patients as the beginning of the disease. Mortality with perforation reaches 9%. Rupture of appendicitis occurs in 2.7% of patients who applied in the early stages of pathology and in 6.3% of patients who appeared to the doctor in the later stages.

In acute appendicitis, complications develop due to the destruction of the process and the spread of pus.

Peritonitis is an acute or chronic inflammation of the peritoneum, which is accompanied by local or general symptoms of the disease. Secondary peritonitis occurs when the bacterial microflora penetrates from the inflamed organ into the abdominal cavity.

The clinic distinguishes 3 stages:

reactive (pain syndrome, nausea, gas and stool retention, the abdominal wall is tense, body temperature rises);
toxic (shortness of breath, coffee vomiting appears, the general condition worsens, the stomach is swollen, the abdominal wall is tense, intestinal motility disappears, gas and stool retention occurs);
terminal (with treatment by the 3rd-6th day of the disease, the inflammatory process can be delimited and the intoxication syndrome reduced, due to which the patient's condition improves. In the absence of therapy, an imaginary improvement occurs on the 4th-5th day, abdominal pain decreases, eyes sink, vomiting of a greenish or brown liquid continues, shallow breathing.Death usually occurs on the 4-7th day.).

In the treatment of peritonitis, it is necessary to eliminate the source of infection, sanitize the abdominal cavity, drain, adequate antibacterial, detoxification and infusion therapy. Appendicular infiltrate is called fused around the appendix, altered by inflammation of the internal organs (omentum, intestines). According to various statistics, pathology occurs in 0.3-4.6 to 12.5 cases.

Rarely, such changes are detected in the initial stages of the disease, sometimes they are detected only during surgery. A complication develops on the 3-4th day of illness, sometimes after perforation. It is distinguished by the presence in the iliac region of a dense formation of a similar tumor, which is moderately painful when palpated.

Peritoneal symptoms subside, as the pathological process is limited, the abdomen becomes soft, and this makes it possible to probe the infiltrate. The patient's body temperature is usually subfebrile, leukocytosis and stool retention are noted. With an uncharacteristic location of the process, the infiltrate is palpated in the place where it is located, if it is located low, then it can be felt through the rectum or vagina.

Ultrasound examination can confirm the diagnosis. In difficult cases, a diagnostic operation (laparoscopy) is performed.

The presence of an infiltrate is the only circumstance in which an operation is not performed. It is impossible to carry out surgical intervention until the infiltrate has abscessed, since there is a high risk that when trying to separate the appendix from the conglomerate, the fused organs (messentery, intestine, omentum) will be damaged, and this can lead to serious consequences.

Therapy of the infiltrate is conservative and is carried out in a hospital setting. Cold on the stomach, a course of antibiotics, bilateral pararenal blockade, enzyme intake, diet therapy and other measures that help reduce inflammation are shown. The infiltrate resolves in the vast majority of cases, usually it occurs within 7-19 or 45 days.

If the infiltrate has not disappeared, then a tumor is suspected. Before discharge, the patient must undergo an irrigoscopy to exclude a tumor process in the caecum. If the infiltrate was found only on the operating table, then the process is not removed. Drainage is done, and antibiotics are injected into the abdominal cavity.

Pylephlebitis is a thrombosis of the portal vein with inflammation of its wall and the formation of a thrombus that closes the lumen of the vessel. The complication develops as a result of the spread of the pathological process from the veins of the mesenteric appendix through the mesenteric veins. The complication is extremely severe and usually ends in death after a few days.

It leads to a high temperature with large daily fluctuations (in 3-4 C), cyanosis, jaundice appears. The patient has severe sharp pains all over the abdomen. Multiple liver abscesses develop. Treatment involves taking anticoagulants, broad-spectrum antibiotics, which are administered through the umbilical vein or spleen.

Appendicular abscesses appear in the late period, before surgery, mainly as a result of suppuration of the infiltrate, and after surgery as a result of peritonitis. A complication appears on the 8-12th day after the onset of the disease. By location there are:

ileocecal (paraappendicular) abscess;
pelvic abscess;
subhepatic abscess;
subphrenic abscess;
intestinal abscess.

Early complications of appendicitis can occur within 12-14 days, later complications can occur after a couple of weeks.

Ileocecal abscess occurs when the appendix is not removed due to abscessing of the infiltrate (other types of abscesses appear after the removal of appendicitis in destructive forms of the disease and peritonitis). Pathology can be suspected if the infiltrate increases in size or does not decrease.

It is opened under anesthesia, the cavity is drained and checked for the presence of fecal stones, then drained. The process is removed after 60-90 days. With phlegmonous-ulcerative appendicitis, perforation of the wall occurs, which leads to the development of limited or diffuse peritonitis.

If, with phlegmonous appendicitis, the proximal section of the process closes, then the distal section expands and an accumulation of pus (empyema) occurs. The spread of the purulent process to the tissues surrounding the process and the caecum (perityphlitis, periappendicitis) leads to the formation of encysted abscesses, inflammation of the retroperitoneal tissue occurs.

Postoperative conditions

Complications after removal of appendicitis are rare. They usually occur in elderly and debilitated patients, patients in whom the pathology was diagnosed late. The classification of complications in the postoperative period distinguishes:

complications arising from surgical wounds (suppuration, ligature fistula, infiltrate, seroma, eventration);
complications manifested in the abdominal cavity (peritonitis, abscesses, abscesses, intestinal fistulas, bleeding, acute postoperative intestinal obstruction);
complications from other organs and systems (urinary, respiratory, cardiovascular).

A pelvic abscess causes loose, loose stools with mucus, painful false urges to defecate, a gaping anus, or frequent urination. Characteristic of the complication is the difference between body temperature measured in the armpit and rectally (normally, the difference is 0.2-0.5 C, with a complication it is 1-1.5 C).

At the stage of infiltration, the treatment regimen includes antibiotics, warm enemas, and douching. When the abscess softens, it is opened under general anesthesia, then washed and drained. The subhepatic abscess is opened in the region of the right hypochondrium, if there is an infiltrate, then it is fenced off from the abdominal cavity, then the purulent inflammation is cut and drained.

A subdiaphragmatic abscess appears between the right dome of the diaphragm and the liver. It is quite rare. The infection penetrates here through the lymphatic vessels of the retroperitoneal space. Mortality with this complication is 30-40%. There is a complication of shortness of breath, pain when breathing on the right side of the chest, dry cough.

The general condition is severe, there is fever and chills, increased sweating, sometimes there is yellowness of the skin. Treatment is only surgical, access is difficult, because there is a danger of infection of the pleura or abdominal cavity. Surgery knows several ways to open the abdominal cavity, applicable in this case.

Prevention of complications consists in the early diagnosis of the inflammatory process and compliance with the doctor's recommendations in the postoperative period.

Complications with surgical wounds are the most common, but they are relatively safe. Infiltration, suppuration, and suture divergence are the most common, and they are related to how deep the incision had to be made and the suturing technique. In addition to observing asepsis, the method of operation, tissue sparing, and the general condition of the patient are also important.

Acute appendicitis is a dangerous disease that, if left untreated, can lead to death. Most complications occur if 2-5 days have passed since the appearance of the clinic. Preoperative complications are the most dangerous, since there is an infectious focus in the abdominal cavity, which can burst at any time.

Postoperative complications after appendectomy are less dangerous, but also more common. They can occur, including through the fault of the patient himself, for example, if he does not comply with bed rest or, conversely, does not get up for a long time after surgery, if in the postoperative period he does not follow dietary instructions, does not treat the wound or does exercises on the press.

The clinical picture of the consequences is very diverse and depends on the duration of inflammation, the degree of destruction of the process and the quality of the measures taken to eliminate the pathology.

Causes

The causes of complicated appendicitis are classified into manageable and unmanageable. In the first case, they include late or erroneous diagnosis and incorrectly chosen surgical tactics.

Among the uncontrollable causes, the patient's delay in seeking medical help is of the greatest importance.

Symptoms

The early period of acute appendicitis (the first 2 days) proceeds without pronounced signs, since the inflammatory process is just beginning. The main picture of the disease develops on the 3rd-5th day, manifested by destruction of the appendix and damage to adjacent organs and tissues.

The following syndromes correspond to the general clinic of acute inflammation in the interstitial period:

painful. Discomfort can be intense or moderate in nature and have different localization;
dyspeptic. Manifested by nausea, single vomiting, sometimes diarrhea, bloating and slight intestinal paresis;
intoxication. With the development of preoperative complications of acute appendicitis, it is he who comes to the fore. The patient has weakness, lethargy, low temperature (37.0–37.2 °C), chills.

Symptoms of complications of the postoperative period occur on the 5-7th day after appendectomy and are intense:

moderate or severe pain;
temperature 37.8–38 °C;
rapid breathing;
flatulence;
bilateral bloating;
tachycardia;

In pregnant women, signs of acute appendicitis may occur atypically, but on closer examination, the presence of the same symptoms as in other patients is observed.

Preoperative complications

Complications of acute appendicitis before the procedure most often occur due to the late admission of the patient to the hospital. Much less often, unpleasant consequences develop against the background of incorrect diagnosis or an abnormal structure of the process.

In the interim and late period, the following complications are considered:

perforation;
appendicular abscesses (subhepatic, subphrenic, pelvic);

The most common preoperative complication of appendicitis is perforation of the appendix. The process develops 2–3 days after the onset of the attack and is manifested by sharp pain with an increase in peritoneal symptoms. It is diagnosed in 3% of patients who applied for help in the early stages and in 6% who were admitted to the hospital late. Death from perforation is recorded in 9-10% of all cases.

On the 3-4th day from the onset of the disease, an appendicular infiltrate develops. This complication is rarely diagnosed in the preoperative period and, according to various sources, is detected in 4–12% of patients only during the intervention. In a later period (8-10 days), appendicular abscesses occur.

Suppuration in the pelvic organs is more common with and accounts for 3.5-4% of all the consequences of inflammation. Manifested by loose stools and frequent urination, gaping anus, sometimes pain in the abdomen. Subdiaphragmatic abscess proceeds much more seriously. The complication is recorded infrequently, but in half of the cases ends in the death of the patient.

With pylephlebitis, the inflammatory process captures the mesenteric veins and is accompanied by debilitating fever, chills and yellowing of the skin. Often affects the liver and proceeds very hard. This is the most dangerous condition in existence, which ends in sepsis or death.

Postoperative complications

Complications after removal of appendicitis are much less common. Usually, elderly or debilitated patients and patients who are late on the operating table suffer from them.

In surgery, there are early and late consequences of the intervention. The first occur within 12-14 days from the moment of appendectomy. These include complications from the wound and adjacent organs:

divergence of the edges of the incision;
softening of the stump of the process, which leads to fecal peritonitis;
bleeding from the wound and veins of the mesentery, followed by inflammation of the peritoneum;
suppuration of tissues.

These consequences are the most common, but relatively safe for the health and life of the patient. All of them are subject to urgent sanitation and drainage.

The most dangerous complication of the early postoperative period is considered to be pylephlebitis. It occurs on the first day after surgery and develops very rapidly, often accompanied by liver damage and ascites.

Late consequences of surgical interventions occur after a two-week postoperative period.

Among them are:

abscesses and wound infiltrate;
keloid scars;
neuromas;
ligature fistula (usually colonic);
postoperative hernia;
acute intestinal obstruction;
abdominal abscess.

All considered complications require urgent conservative or surgical treatment with further observation.

The most terrible consequence after appendicitis is considered to be blockage of the pulmonary artery or its branches. It can develop both immediately after surgery and after 2 weeks if the patient is on strict bed rest.

Complete thromboembolism usually ends in instant death. A partial lesion is manifested by a sudden deterioration in well-being, pallor of the skin with a gradual transition to cyanosis, shortness of breath, chest pain. This condition requires urgent surgical intervention.

Prevention

Prevention of complications of acute appendicitis includes measures to prevent preoperative and postoperative consequences. Timely recognition of pathology and early seeking help will help to avoid problems of the intermediate and late periods.

If already removed, the patient must observe bed or semi-bed rest. With a simple inflammation, operated on in the early stages, the patient is allowed to get up and walk already 4-5 hours after the intervention. In the first 1-2 days, it is recommended to use only liquid foods: water, kefir, juice, tea, broth. After the restoration of intestinal motility, you can move on to regular food.

With severe pain, the patient is prescribed analgesics, and if necessary, antibacterial therapy is carried out.

Other Precautions:

within 2.5-3 months to avoid physical exertion, weight lifting;
protect the wound from water until the stitches are removed;
abstain from sex for 12-14 days.

In the first month after discharge from the hospital, the state of health should be monitored. At the slightest deviation from the norm (pain, temperature), it is urgent to go to the surgeon.

Despite tremendous advances in clinical medicine, the consequences of acute appendicitis still exist and are dangerous. Only early diagnosis and surgery will help save the health, and sometimes the life of the patient.

Useful video about acute appendicitis

Refers to diseases of the abdominal organs, characterized by a tendency to develop various complications. It is their presence that determines the unfavorable outcomes of appendectomy.

Complications are divided according to the periods of occurrence into preoperative and postoperative. Preoperative complications include appendicular infiltrate, appendicular abscess, retroperitoneal phlegmon, and peritonitis. Postoperative complications of acute appendicitis are classified according to the clinical and anatomical principle.

According to the timing of development, postoperative complications of acute appendicitis are divided into early and late. Early complications occur within two weeks from the moment. This group includes the majority of complications from the postoperative wound (purulent-inflammatory processes, divergence of the wound edges without or with eventration; bleeding from the wound of the anterior abdominal wall) and all complications from adjacent organs.

Late postoperative complications of acute appendicitis are diseases that develop after a two-week postoperative period. Among them, the most common are:

Of the complications from the postoperative wound - infiltrate, abscess, ligature fistula, postoperative, keloid scars, cicatricial neuromas.
From acute inflammatory processes in the abdominal cavity - infiltrates, abscesses, cultitis.
Of the complications from the gastrointestinal tract - acute mechanical,.

The causes of postoperative complications of acute appendicitis are:

Untimely treatment of patients for medical care.
Late diagnosis of acute appendicitis (due to the atypical course of the disease, incorrect interpretation of the available clinical data typical for inflammation of the appendix).
Tactical errors (lack of dynamic monitoring of patients with a dubious diagnosis of acute appendicitis, underestimation of the prevalence of the inflammatory process in the abdominal cavity, incorrect definition of indications for the abdominal cavity).
Errors in the technique of the operation (tissue injury, unreliable ligation of vessels, incomplete removal of the appendix, poor drainage of the abdominal).
Progression of chronic or occurrence of acute diseases of adjacent organs.

The article was prepared and edited by: surgeon

Video:

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Is bleeding. More often there is bleeding from the stump of the mesentery of the process, which occurs as a result of insufficiently strong ligation of the vessel supplying the process. Bleeding from this small vessel can quickly lead to massive blood loss. Quite often the picture of internal bleeding comes to light at the patient on an operating table.

No matter how minor bleeding into the abdominal cavity seems, it requires urgent surgical intervention. You should never hope to stop bleeding on your own. It is necessary to immediately remove all sutures from the surgical wound, if necessary, expand it, find a bleeding vessel and bandage it. If the bleeding has already stopped and the bleeding vessel cannot be detected, you need to grab the stump of the mesentery of the process with a hemostatic clamp and re-tie it at the very root with a strong ligature. The blood poured into the abdominal cavity must always be removed, since it is a breeding ground for microbes and thus can contribute to the development of peritonitis.

The vessels of the abdominal wall can also be a source of bleeding. When opening the vagina of the rectus abdominis muscle, the lower epigastric artery may be damaged. This damage may not be immediately noticed, since when the wound is diluted with hooks, the artery is compressed and does not bleed. After surgery, blood can infiltrate the tissues of the abdominal wall and enter the abdominal cavity between the peritoneal sutures.

It is quite understandable that in some patients the bleeding can stop on its own. All existing hemodynamic disturbances are gradually subsiding. However, the skin and visible mucous membranes remain pale, the hemoglobin content and the number of red blood cells in the blood are significantly reduced. When examining the abdomen, painful phenomena may not exceed the usual postoperative sensations; for percussion determination, the amount of liquid blood should be significant.

The blood which has poured out in an abdominal cavity at some patients can be resolved without the rest. Then only the presence of anemia and the appearance of jaundice as a result of resorption of an extensive hemorrhage make it possible to correctly assess the existing phenomena. However, such a favorable outcome, even with minor hemorrhage, is quite rare. If the blood accumulated in the abdominal cavity becomes infected, peritonitis develops, which is usually limited.

With more significant hemorrhage, in the absence of its delimitation and with delayed intervention, the outcome may be unfavorable.

As a complication in the postoperative course, the formation of an infiltrate in the thickness of the abdominal wall should be noted. Such infiltrates, if they occur without a pronounced inflammatory reaction, are usually the result of soaking the subcutaneous tissue with blood (with insufficient hemostasis during surgery) or serous fluid. If such an infiltrate is not large, then it resolves in the coming days under the influence of thermal procedures. If, in addition to infiltration, there is rippling along the suture line, indicating the accumulation of fluid between the edges of the wound, it is necessary to remove the fluid by puncture or pass a bellied probe between the edges of the wound. The latter method is more efficient.

If the formation of an infiltrate proceeds with a temperature reaction and an increase in pain in the wound, suppuration should be assumed. In order to timely diagnose this complication, each patient whose temperature does not decrease during the first two days after surgery, and even more so if it increases, must be bandaged to control the wound. The sooner 2-3 sutures are removed to drain the pus, the more favorable the course will be. In severe infections of the abdominal wall, the wound has to be opened wide and drained, removing all sutures from the skin, from the aponeurosis and from the muscles, if there is an accumulation of pus under them. In the future, wound healing occurs by secondary intention.

Sometimes, after the wound has healed, ligature fistulas form. They are characterized by small size, purulent discharge and growth of granulation tissue around the fistulous opening. After removing the ligature with anatomical tweezers or a crochet hook, the fistulas heal. It is even better to use for this a large fishing hook unbent on a flame, the tip of which is bent so that a second beard is formed.

In patients, especially with a severe process in the process and the caecum, operated on in the presence of peritonitis, an intestinal fistula may form after the operation. Fistulas can form when a lesion extends from the base of the process into the adjacent part of the caecum. If this is detected during the operation, then the affected area of the intestine is immersed with sutures that close it for the required length with the unchanged part of the wall of the caecum. If, when the process is removed, the lesion of the intestinal wall remains unidentified, with further progression of the process, its perforation may occur, which will lead to the release of feces into the free abdominal cavity or into its area limited by adhesions or tampons.

In addition, the cause of the development of intestinal fistulas may be either damage to the intestine during surgery, or a bedsore as a result of prolonged pressure from drains and tampons, or injury to the intestinal wall during insufficiently delicate manipulations during dressing of wounds in which intestinal loops lie open. It is unacceptable to remove pus from the surface of the intestines with gauze balls and swabs, since this can very easily cause severe damage to the intestinal wall and its perforation.

In the formation of fistulas, the toxic effect of certain antibiotics, such as tetracyclines, which can lead to severe damage to the intestinal wall, up to complete necrosis of the mucous membrane, can also play a certain role. This applies to both the large and small intestines.

The formation of an intestinal fistula with a tightly sutured abdominal wound leads to the development of peritonitis, requiring immediate intervention, consisting in a wide opening of the wound and bringing drainage and delimiting tampons to the fistula. Attempts to sew up an existing hole are justified only at the earliest possible time. If the abdominal cavity has already been drained before the formation of the fistula, diffuse peritonitis may not be due to the formation of adhesions around the tampons. With a favorable course, peritoneal phenomena are more and more limited and gradually subside altogether. The wound is filled with granulations surrounding the fistula, through which the intestinal contents are released.

Fistulas of the small intestine, transverse colon and sigmoid, the wall of which may be flush with the skin, are usually labial and require operative closure. Fistulas of the cecum, as a rule, are tubular and can close on their own with careful washing of the fistulous tract with an indifferent fluid. Surgical closure of the fistula is indicated only in case of unsuccessful conservative treatment for 6-7 months.

Long-term non-healing tubular fistulas of the caecum should suggest the presence of a foreign body, tuberculosis, or cancer, since removal of the process in these diseases can lead to the formation of fistulas.

Postoperative peritonitis may develop gradually. Patients do not always complain of increased pain, considering them to be an understandable phenomenon after surgery. However, the pain continues to intensify, in the right iliac region during palpation, more and more severe pain, muscle tension and other symptoms characteristic of peritoneal irritation are noted. The pulse quickens and the tongue begins to dry. Sometimes the first and at first, as if the only sign of peritonitis may be vomiting or regurgitation, sometimes - an increasing paresis of the intestines. Gradually, the abdomen begins to swell, gases do not go away, peristaltic noises are not heard, and in the future the picture develops in exactly the same way as with appendicular peritonitis in non-operated patients. In some patients, only an increase in heart rate, which does not correspond to temperature, is noted at first.

Signs of peritonitis can gradually come to light during the first days after the operation, growing very slowly. But sometimes they appear quickly, and in the next few hours a picture of diffuse peritonitis develops. The development of postoperative peritonitis is always an indication for urgent relaparotomy and elimination of the source of infection. The last is either the stump of the appendix that has opened due to the failure of the sutures, or a perforation in the intestinal wall. If the intervention is made early, it is possible to close the stump or perforation with sutures. In the later stages, this is not possible due to the fact that the sutures placed on the inflamed tissues are cut through, then it is necessary to confine ourselves to the supply of drainage and tampons.

When no local cause is identified, it is necessary to consider the development of peritonitis as the result of the progression of the diffuse inflammation of the peritoneum that was present before the first operation and proceed in the same way as described in the section on the treatment of peritonitis that developed before the operation.

With peritonitis that developed after surgery, the source of infection should be in the area of the former operation. Therefore, relaparotomy must be performed by removing all sutures from the surgical wound and opening it wide. If the source of infection is located elsewhere and the development of peritonitis is not associated with the operation, but is due to some other disease, the choice of access should be determined by the localization of the painful focus. Antibiotic therapy and other measures to combat peritonitis should be more active.

With postoperative peritonitis, as well as with peritonitis that developed before surgery, the formation of limited abscesses can be observed in the abdominal cavity. Most often, the accumulation of pus occurs in the Douglas space. The formation of such an abscess, as a rule, is accompanied by a temperature reaction and other general manifestations of a septic nature. The symptoms characteristic of this complication are frequent urge to defecate, loose stools with a large admixture of mucus, tenesmus and gaping of the anus, which is due to the involvement of the rectal wall in the inflammatory process and infiltration of sphincters. When examining the rectum with a finger, a pronounced protrusion of the anterior wall is noted to varying degrees, where a clear swaying is often determined.

It should be remembered that such phenomena of irritation of the rectum can develop very late, when the abscess has already reached a significant size. Therefore, with a non-smooth course of the postoperative period, it is necessary to systematically perform a digital examination of the rectum, bearing in mind that Douglas abscess is the most common of all severe intra-abdominal complications observed after surgery for appendicitis. It is opened through the rectum or (in women) through the vagina, emptying the purulent accumulation through the posterior fornix.

Abscess formation in other parts of the abdominal cavity is less common. Interintestinal abscesses at first can be shown only by the increasing septic phenomena. Sometimes it is possible to detect an infiltrate in the abdomen if the abscess is parietal. If it is not adjacent to the abdominal wall, then it is possible to probe it only when the swelling of the intestine and the tension of the abdominal muscles decrease. Abscesses must be opened with an incision corresponding to its location.

Subdiaphragmatic abscesses after appendectomy are extremely rare. A subdiaphragmatic abscess should be opened extraperitoneally. To do this, when the abscess is located in the posterior part of the subdiaphragmatic space, the patient is placed on a roller, as for a kidney operation. The incision is made along the XII rib, which is resected without damaging the pleura. The latter is carefully pushed up. Further, parallel to the course of the ribs, all tissues are dissected up to the preperitoneal tissue. Gradually separating it together with the peritoneum from the lower surface of the diaphragm, they penetrate with a hand between the posterolateral surface of the liver and the diaphragm into the subdiaphragmatic space and, moving their fingers to the level of the abscess, open it, breaking through the diaphragmatic peritoneum, which does not offer much resistance. The purulent cavity is drained with a rubber tube.

Pylephlebitis (thrombophlebitis of the portal vein branches) is a very severe septic complication. Pylephlebitis is manifested by chills with an increase in body temperature up to 40-41 ° C and with its sharp drops, pouring sweat, vomiting, and sometimes diarrhea. The appearance of jaundice is characteristic, which is less pronounced and appears later than jaundice with cholangitis. When examining the abdomen, mild peritoneal phenomena, some tension in the muscles of the abdominal wall are noted. The liver is enlarged and painful.

In the treatment of pylephlebitis, first of all, it is necessary to take all measures to eliminate the source of infection - emptying possible accumulations of pus in the abdominal cavity and in the retroperitoneal space, ensuring a good outflow through wide drainage. Vigorous antibiotic treatment. With the formation of abscesses in the liver - their opening.

It should be noted another rare complication of the postoperative period - acute intestinal obstruction. In addition to dynamic obstruction of the intestines as a result of their paresis with peritonitis.

In addition, in the next few days after an appendectomy, mechanical obstruction may develop as a result of compression of the intestinal loops in the inflammatory infiltrate, their bending with adhesions, infringement by strands formed during the fusion of the abdominal organs, etc. Obstruction may develop shortly after the operation, when still in Inflammatory phenomena did not subside in the abdominal cavity, or at a later date, when it already seemed that a complete recovery had come.

Clinically, the development of obstruction is manifested by all its characteristic symptoms. The diagnosis of this complication can be very difficult, especially when the obstruction develops early in the first days after surgery. Then the existing phenomena are regarded as the result of postoperative paresis of the intestines, and the correct diagnosis may be delayed because of this. In later periods, obstruction develops more typically. The sudden appearance of "among full health" cramping pains in the abdomen, local bloating, vomiting and other signs of intestinal obstruction greatly facilitate the diagnosis.

With the ineffectiveness of conservative measures, the treatment of mechanical obstruction should be surgical.

With obturation obstruction caused by a kink of the intestines as a result of their contraction by adhesions, or when they are compressed in the infiltrate, adhesions are separated, if this is easily done. If this is difficult and if it is associated with trauma to the inflamed and easily vulnerable intestinal loops, a bypass inter-intestinal anastomosis is made or limited to the position of the fistula.

After appendectomy, other complications, generally characteristic of the postoperative period, can sometimes develop both from the respiratory organs and from other organs and systems. This is especially true for elderly patients.

Long-term results of surgical treatment of acute appendicitis in the vast majority of patients are good. Rarely observed poor results are mostly due to the presence of some other disease that the patient had before the attack of appendicitis or arose after the operation. Much less often, the poor condition of patients is explained by the development of postoperative adhesions in the abdominal cavity.

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I. M. MATYASHIN Y. V. BALTAITIS
A. YA. YAREMCHUK
Complications of appendectomy
Kyiv - 1974
The monograph gives a description of the most important causes that cause complications of appendectomy, outlines the basic principles of managing the pre- and postoperative period, measures to prevent and eliminate complications from the surgical wound, abdominal organs and other systems. Describes late complications that occur in the abdominal wall and abdominal organs, methods of their treatment.
The book is intended for surgeons and senior students of medical institutes.

From the authors
Appendectomy has gained fame as one of the easiest abdominal operations, and, perhaps, this is one of the first interventions that is entrusted to a young specialist. This is largely due to the fact that the technique of the operation is developed in detail, all its techniques are typical and, in most cases, it is not accompanied by great technical difficulties.
Perhaps this is also due to the huge flow of appendectomy, in connection with which it has become the most common and affordable operation for a young doctor. Sometimes a student who has completed subordination has already performed several dozen appendectomies, while at the same time not having performed a number of simpler and safer operations.
The young doctor, who quickly mastered the skills of the operation of removing the appendix, without encountering significant difficulties and observing how quickly the condition of the patients normalizes, comes to the false conclusion that he has become a fully trained and qualified surgeon, and this gives him the right to treat with some indulgence such "running" operations. In an effort to demonstrate his skill, such a doctor does not resist the temptation to show his surgical virtuosity. To do this, he makes too small incisions, reduces the operation time to a few minutes, hoping that it is these moments that can characterize him as an experienced and brilliant master surgeon.

This continues until the young doctor encounters severe complications. Often in acute appendicitis there is a very complex surgical situation, when a seemingly extremely simple operation becomes very complex. The idea of appendicitis as a fairly mild surgical disease has crossed the threshold of surgical clinics and is widely used among the population. If this is true to some extent for uncomplicated forms of the disease, then often after appendectomy there are terrible complications that can cause death or a long-term illness with a whole series of subsequent surgical interventions, which ultimately leads patients to disability.
The death of an operated patient is always tragic, especially in cases where a complication of a disease or operation could be prevented or eliminated with the right surgical tactics with timely rational actions. The relative numbers of postoperative mortality in appendicitis are small, usually reaching two to three tenths of a percent, but when taking into account the huge number of patients operated on for acute appendicitis, these tenths of a percent grow into a three-digit number of actually dead patients. And behind each such death is a serious set of circumstances, a disease or its complication not recognized in time, a technical or tactical error of a doctor.
That is why the problem of appendicitis and appendectomy is still extremely relevant, and there is a need to once again focus the attention of practitioners, especially young ones, on the details of the operation, its possible severe consequences and warn them against tactical and technical errors in the future.

Causes of postoperative complications of appendectomy

The problem of complications of acute and chronic appendicitis and appendectomy since the first operation (Mahomed in 1884 and Kronlein in 1897) is sufficiently covered in the literature. The increased attention to this problem is not accidental. Mortality after appendectomy, despite its significant decrease from year to year, still remains high. Currently, mortality in acute appendicitis averages about 0.2%. If we take into account that 1.5 million appendectomies are performed annually in our country, it becomes obvious that such a small percentage of postoperative mortality corresponds to a large number of deaths. In this regard, the indicators of postoperative mortality in the Ukrainian SSR in 1969 are very illustrative - 0.24%, or 499 deaths after appendectomy. In 1970, they were reduced to 0.23% (449 deaths), that is, due to a decrease in mortality by 0.01%, the number of deaths decreased by 50 people. In this regard, the desire to clearly establish the causes of those complications that are a mortal danger for the operated patient is completely understandable.
The study of the causes of mortality after appendicitis and appendectomy by many authors (G. Ya. Iosset, 1958; M. I. Kuzin, 1968; A. V. Grigoryan et al., 1968; A. F. Korop, 1969; M. Kh. Kanamatov , 1970; M. I. Lupinsky et al., 1971; T. K. Mrozek, 1971, etc.) made it possible to identify the most formidable complications that turned out to be fatal for the outcome of the disease. Among them, first of all, diffuse peritonitis, thromboembolic complications, including pulmonary embolism, sepsis, pneumonia, acute cardiovascular insufficiency, adhesive intestinal obstruction, etc.
The most severe, formidable complications are named, but not all. It is difficult to foresee what complication can lead to particularly serious consequences, up to death. Quite often, even relatively mild postoperative complications, having received a completely unexpected severe development in the future, significantly aggravate the course of the disease and lead patients to death.
On the other hand, these not so severe complications, especially in the case of a sluggish, torpid course of the disease, delay the duration of treatment and subsequent rehabilitation of patients in outpatient care. Considering the huge number of appendectomies performed, it turns out that such, even relatively easy complications, become a serious obstacle in the overall system of appendicitis treatment.
All this required a deeper study of all complications of appendectomy and their causes. Various classifications of postoperative complications are given in the literature (G. Ya. Iosset, 1959; L. D. Rosenbaum, 1970, etc.). Most fully these complications are presented in the classification of G. Ya. Iosset. In an effort to create the most complete classification, many authors have made it extremely cumbersome. We consider it appropriate to cite one of them in full.

Classification of complications after appendectomy(according to G. Ya. Iosset).

Complications from the surgical wound:
Suppuration of the wound.
Infiltrate.
Hematoma in the wound.
Divergence of the edges of the wound, without eventration and with eventration.
Ligature fistula.
Bleeding from a wound in the abdominal wall.
Acute inflammatory processes in the abdominal cavity:
Infiltrates and abscesses of the ileocecal region.
Douglas space infiltrates.
Infiltrates and abscesses interintestinal.
Retroperitoneal infiltrates and abscesses.
Subdiaphragmatic infiltrates and abscesses.
Hepatic infiltrates and abscesses.
local peritonitis.
Diffuse peritonitis.
Complications from the respiratory system:
Bronchitis.
Pneumonia.
Pleurisy (dry, exudative).
Abscesses and gangrene of the lungs.
Lung atelectasis.
Complications from the gastrointestinal tract:
Dynamic obstruction.
Acute mechanical obstruction.
Intestinal fistulas.
Gastrointestinal bleeding.
Complications from the cardiovascular system:
Cardiovascular insufficiency.
Thrombophlebitis.
Pylephlebitis.
Embolism of the pulmonary artery.
Bleeding into the abdominal cavity.
Complications from the excretory system:
Urinary retention.
Acute cystitis.
Acute pyelitis.
Acute nephritis.
Acute pyelocystitis.
Other complications:
Acute parotitis.
postoperative psychosis.
Jaundice.
Fistula between the process and the ileum.

Unfortunately, the author did not include a large group of late appendectomy complications. It is impossible to fully agree with the proposed systematization: for example, intra-abdominal bleeding for some reason is referred by the author to the section “Complications from the cardiovascular system”.
Later, a slightly modified classification of early complications was proposed (LD Rosenbaum, 1970), which also has certain defects. In an effort to systematize complications according to the principle of the generality of the pathological process, the author attributed to various groups such close complications as divergence of the wound edges, suppuration, bleeding; abdominal abscesses are considered in one group, and peritonitis is completely separate, meanwhile, an abdominal abscess can rightfully be considered limited peritonitis.
In the study of early and late complications of appendectomy, we based the existing classifications, however, striving to strictly distinguish between their main groups. We believe that early and late complications are fundamentally different, since they are separated not only by the timing of their occurrence, but also by the causes, features of the clinical course due to the changing reactivity of patients and their adaptation to the pathological process at various stages of the disease. This, in turn, requires different tactical settings regarding the timing of treatment, the appointment of surgical intervention, the features of the techniques of these interventions, etc.
Early complications are considered more formidable, requiring the majority of patients to take the most urgent measures to eliminate them and prevent the spread of the pathological process. The urgency of these measures is determined by the nature of the complication itself, its localization. Therefore, it is logical to consider in separate groups the complications that arise in the surgical wound (within the anterior abdominal wall) and in the abdominal cavity. In turn, both of these groups include complications of an inflammatory nature (suppuration, peritonitis), which are predominant, and others, among which the main place is occupied by bleeding. General complications that are not directly related to the operating area (from the respiratory organs, the cardiovascular system, etc.) can be highlighted.
Similarly, late complications are also logically considered in two large groups: complications from the abdominal organs and complications in the anterior abdominal wall.
The third group consists of complications of a functional nature, in which it is usually not possible to detect gross morphological changes. In the practice of each surgeon, there are many observations when, in the long term after appendectomy, patients notice pain in the area of the surgery, which is long and persistent and is accompanied by disorders of the intestinal tract. Various therapeutic measures prescribed in this case do not bring relief. The failure of treatment in some cases prompts them to be associated with a special emotional and psychological attitude of patients. As a rule, such recurrences of pain after appendectomy are based on structural changes that are not detected by conventional methods of clinical examination. This problem seems to us to be serious and requires special consideration.
Concerning the frequency of postoperative complications in the modern literature, there are conflicting reports. V. I. Kolesov (1959), referring to the information of other authors, indicates that before the use of antibiotics, the number of complications ranged from 12 to 16%. The use of antibiotics led to a decrease in the number of complications by 3-4%. At a later time, due to some discredit of antibiotic therapy, this decrease is not established. G. Ya. Iosset (1956) does not generally attach such decisive importance to the use of antibiotics, since he did not observe a decrease in the number of purulent complications during the period of their most intensive use. B. I. Chulanov (1966), referring to literature data (M. A. Azina, A. V. Grinberg, X. G. Yampolskaya, A. P. Kiyashov), writes about 10-12% of complications after appendectomy. At the same time, E. A. Sakfeld (1966) observed complications in only 3.2% of operated patients. Interesting data are provided by Kazarian (1970), noting that the use of sulfonamides and antibiotics has significantly reduced mortality in acute appendicitis. The number of complications not only does not decrease, but tends to increase (Table 1).
An analysis of the statistical data of the clinic for 6 years (1965-1971) found that out of the total number of operated patients (5100), complications were observed in 506 (9.92%), 12 (0.23%) died during this period. Information about the frequency of various complications is given in the relevant sections.

TABLE 1. Ratio of perforations, complications and mortality in acute appendicitis according to Kazarian

	Before antibiotics	Sulfanil amides	Modern data
Number of patients
Percentage of perforations
appendicitis
Percentage of complications
Mortality

Considering the causes of unfavorable outcomes of the surgical treatment of appendicitis, most surgeons refer to the following: late admission, late diagnosis in the department, a combination of acute appendicitis with other diseases, advanced age of patients (T. Sh. Magdiev, 1961; V. I. Struchkov and B. P. Fedorov, 1964, etc.).
When studying the causes of postoperative complications, their main groups should be distinguished. This includes late diagnosis of the disease. Undoubtedly, the degree of development of the pathological process, the occurrence of a number of pathological symptoms on the part of adjacent organs, the reaction of the peritoneum, certain changes in a number of systems of the diseased organism determine the nature of the course of the postoperative period and become the cause of the most important postoperative complications.
The second reason is the peculiarities of the course of the pathological process in this individual. The course of the disease is closely related to the individual characteristics of the organism, its development, immunobiological properties, and finally, the reserve of its spiritual strength, the age of the patient. Diseases transferred in the past, and simply experienced, undermine a person’s strength, reduce his resistance, his ability to fight against various harmful influences, including those with an infectious onset.
However, both of these groups of causes should probably be considered as creating a background against which the disease or developed complication proceeds in the future. The need to take them into account is obvious. This should guide the surgeon regarding the choice of the method of anesthesia and suggest certain tactics in order to prevent the development of formidable complications or mitigate them.
To what extent is it legitimate to consider the complications that arose in the patient in the postoperative period in connection with the intervention, if their main cause was pathological conditions established before the operation? This also applies to those complications that were the result of transient moments and were revealed already in the postoperative period. This issue is extremely important, it has repeatedly attracted the attention of surgeons. Recently, a discussion on this issue has been held in special journals, which arose on the initiative of Yu. I. Datkhaev. A number of well-known surgeons of our country took part in it: V. I. Struchkov, N. I. Krakovsky, D. A. Arapov, M. I. Kolomiychenko, V. P. Teodorovich. Most of the participants in the discussion considered it right to consider separately the complications of the disease itself and postoperative complications. A very special group is made up of concomitant diseases, sometimes very severe, even leading patients to death. At the suggestion of some authors (M.I. Kolomiychenko, V.P. Teodorovich), they cannot be included in the group of postoperative complications.
We can agree with the opinions of the participants in the discussion that these complications are not postoperative in the truest sense of the word, that is, they are not the result of incorrect tactical settings and certain technical errors, of the intervention itself. However, for many reasons, they should be considered in this general group.