Possible early postoperative complications in appendicitis. Postoperative complications of appendicitis Surgical complications of acute appendicitis

– late surgical intervention. They occur inevitably if the inflammatory process of the appendix is ​​left unattended for two days from the onset of the disease. And in children and older people it happens earlier. Many of them endanger a person’s life, excluding him from active life. Many people do not know that early diagnosis and treatment is a serious approach to eliminating complications.

Complications of acute appendicitis are divided into: preoperative and postoperative.

Appendicitis itself is not as dangerous as its complications. For example, adhesions of the appendix disrupt blood circulation in this organ. The solution to the problem comes after removing the process. The uncomplicated type of the disease is characterized by tolerable pain; one should not discount the sign and judge it to be minor inflammation. Until the diseased appendix is ​​cut out, the disease is considered untreated.

Appendiceal infiltrate

This is the most common complication of acute appendicitis. Inflammation of the appendix due to the accumulation of inflamed tissue near the affected appendix of the cecum. Appendicitis occurs more often in adolescents aged 10 to 14 years than in the older generation. Patients experience symptoms:

• Increasing pain on the right side of the abdomen;
• Chills;
• Nausea;
• Less commonly, vomiting;
• Difficulty in stool.

On the 3-4th day, a dense, painful formation measuring 8 cm by 10 cm is palpated. Without urgent treatment, the infiltrate rapidly festeres, and a cavity filled with pus is formed. An appendicular abscess begins. The patient's physical condition deteriorates sharply:

• The temperature rises;
• The pain intensifies;
• Chills appear;
• Tachycardia occurs;
• Paleness of the skin.

An effective diagnostic method is ultrasound.

Purulent peritonitis

Peritonitis is considered the most severe and dangerous to human health and even life. This is a common complication in which an infection from the appendix enters the abdominal cavity. Inflammation occurs in the serous membrane covering the inner walls of the abdominal cavity.

This infection can be caused by:

1. Microorganisms (bacteria): Pseudomonas aeruginosa, Escherichia coli, streptococci, staphylococci.
2. Inflammation of the injured peritoneum.
3. Surgical intervention in the peritoneal area.
4. Gastroenterological diseases.
5. Inflammatory processes in the pelvic area.
6. General infection in the body (tuberculosis, syphilis).

Stages of peritonitis:

• The reactive stage is the disease in its initial form. The duration is the first day. Subsequently, swelling of the peritoneum.
• The toxic stage lasts 48-52 hours from the onset of the lesion. Clinical signs: sharp symptoms of intoxication, hands and feet become cold, facial features become sharpened, impaired consciousness, sometimes loss of consciousness, dehydration due to vomiting and high temperature up to 42 degrees.
• Terminal is an irreversible, final stage. The duration does not exceed three days. Characterized by weakening of vital functions and protective functions. The skin is pale with a bluish tint, sunken cheeks, imperceptible breathing, no reaction to external irritants, severe swelling.

Postoperative complications

Surgery is a surgical intervention in medicine, in which there have been and will be complications. But their outcome depends on the patient’s early seeking of medical help. They can occur both during and after surgery.

In the postoperative period, complications from the operated wound may occur:

• Hematoma.
• Every fifth patient has suppuration at the incision site.
• Fistula.
• Bleeding.

Pylephlebitis

This is an acute, purulent inflammatory disease of the portal vein, accompanied by thrombosis. Secondary pathology that occurs as a complication of acute, especially advanced appendicitis. It can be recognized by ultrasound or x-ray diagnostic studies.

Symptoms:

• Fluctuations in body temperature with chills;
• Frequent pulse;
• Soft belly;
• Enlarged liver on palpation;
• Labored breathing;
• Increasing anemia;
• Increase in ESR.

In case of pylephlebitis, renal and liver failure is prevented. An operation will be performed to ligate the thrombosed vein located above the thrombosis to prevent the blood clot from moving towards the liver. This disease leads to death. It consists of inflammation of the portal vein, which accompanies and expands liver abscesses.

Clinical symptoms of pylephlebitis:

• Sudden temperature fluctuations;
• Chills;
• Skin with a yellow tint;
• Frequent pulse.

Intra-abdominal abscesses

Abdominal abscess is a severe complication after appendicitis. By quantity they can be single or multiple. The course of the features depends on the type and location of the abscess.

Classification of abscesses by location:

• Interintestinal;
• Subdiaphragmatic;
• Appendicular;
• Pelvic parietal;
• Intraorgan.

An interintestinal abscess of the peritoneum is an abscess sealed in a capsule. Local location outside the abdominal organs and inside it. Subsequent opening of the abscess threatens the penetration of pus into the abdominal cavity, causing intestinal obstruction. Possible sepsis.

The most characteristic symptoms:

• Dull pain in the right hypochondrium, radiating to the scapula;
• General malaise;
• Gases;
• Intestinal obstruction;
• Exhausting temperature changes;
• Asymmetry of the abdominal wall.

The multiple form of the disease has unfavorable consequences compared to single purulent formations. Often combined with pelvic ones. It usually develops in patients who have had peritonitis that has not resulted in recovery.

Subphrenic abscesses occur as a complication after appendectomy. The reason is the presence of exudate left in the abdominal cavity, the penetration of infection into the subdiaphragmatic space.

Clinic of the disease:

• Constant pain in the lower chest, aggravated by coughing;
• Chills;
• Tachycardia;
• Dry cough;
• Sweating;
• Paralytic intestinal obstruction.

Treatment is quick, surgical - opening and draining the abscess. Depends on the location and number of ulcers. Clinic: pus entering the free and pleural cavity, sepsis.

Pelvic abscess - occurs when, less often it is a consequence of diffuse peritonitis. The method of treatment is opening the abscess, drainage, antibiotics, physiotherapy. Characteristic features:

• Frequent urination with pain;
• Increased rectal temperature.

Liver abscesses - with diseases of the abdominal organs and a decrease in general immunity, microorganisms manage to spread beyond its boundaries and enter the liver tissue through the portal vein. The development of the disease occurs more often in patients over 40 years of age.

Signs:

• Pain in the right hypochondrium;
• Body temperature;
• State;
• Pain of varying degrees, from strong to dull, from aching to insignificant;
• Digestive disorder;
• Decreased appetite;
• Bloating;
• Nausea;
• Diarrhea.

Sepsis is the process of blood infection by bacteria. This is an extremely life-threatening condition for the patient. The appearance is possible after an attack of appendicitis. This is the most dangerous consequence of appendectomy surgery. When purulent inflammation becomes systemic in the postoperative period, bacteria in the blood spread the infection to all organs.

Possible treatments for sepsis include:

• Blood transfusion;
• Taking a comprehensive set of vitamins;
• Use of antibacterial drugs;
• Long-term treatment with a large number of bacterial drugs.

No one is immune from inflammatory processes in the body, but following simple recommendations will help minimize the occurrence of acute appendicitis and its complications. It is recommended to eat healthy, fiber-rich foods. Lead an active, healthy lifestyle for normal blood circulation in the abdominal organs. Undergo preventive examinations. For people with this, the risk of complications can be reduced to zero through surgery. Consult a doctor promptly with unknown symptoms, p. Before taking it, do not take antispasmodic and painkillers, limit your intake of liquids and food. Strictly follow the surgeon's recommendations after appendix removal.

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Despite great advances in the diagnosis and surgical treatment of appendicitis, this problem has not yet fully satisfied surgeons. A high percentage of diagnostic errors (15-44.5%), stable mortality rates with no tendency to decrease (0.2-0.3%) with the widespread incidence of acute appendicitis confirm what has been said [V.I. Kolesov, 1972; V.S. Mayat, 1976; YUL. Kulikov, 1980; V.N. Butsenko et al., 1983]

Mortality after appendectomy, caused by diagnostic errors and loss of time, is 5.9% [I.L. Rotkov, 1988]. The causes of death after appendectomy mainly lie in purulent-septic complications [L.A. Zaitsev et al., 1977; V.F. Litvinov et al., 1979; IL. Rotkov, 1980, etc.]. The cause of complications is usually destructive forms of inflammation of the cervical region, spreading to other parts of the abdominal cavity.

According to the literature, the reasons leading to the development of complications leading to repeated operations are as follows.
1. Late hospitalization of patients, insufficient qualifications of medical workers, diagnostic errors due to the presence of atypical, difficult to diagnose forms of the disease, which often occurs in elderly and senile people, in whom morphological and functional changes in various organs and systems increase the severity of the disease, and sometimes come to the fore, masking the patient’s acute appendicitis. Most patients cannot accurately name the onset of the disease, since at first they did not pay attention to mild, constant pain in the abdomen.
2. Delay of surgical intervention in the hospital due to errors in diagnosis, refusal of the patient or organizational issues.
3. Inaccurate assessment of the extent of the process during surgery, resulting in insufficient sanitation of the abdominal cavity, violation of drainage rules, and lack of comprehensive treatment in the postoperative period.

Unfortunately, late admission of patients with this pathology to the hospital is not very uncommon. In addition, no matter how annoying it is to admit, a considerable proportion of patients hospitalized and operated on with a delay are the result of diagnostic and tactical errors of doctors in the outpatient network, ambulance and, finally, surgical departments.

Overdiagnosis of acute appendicitis by prehospital doctors is completely justified, since it is dictated by the specifics of their work: short-term observation of patients, lack of additional examination methods in most cases.

Naturally, such errors reflect the well-known wariness of prehospital doctors in relation to acute appendicitis and, in terms of their significance, cannot be compared with errors of the reverse order. Sometimes patients with appendicitis are either not hospitalized at all or are not sent to a surgical hospital, which leads to the loss of precious time with all the ensuing consequences. Such errors due to the fault of the clinic amount to 0.9%, due to the fault of emergency doctors - 0.7% in relation to all those operated on for this disease [V.N. Butsenko et al., 1983].

The problem of emergency diagnosis of acute appendicitis is very important, because in emergency surgery the frequency of postoperative complications largely depends on the timely diagnosis of the disease.

Diagnostic errors are often observed when differentiating food toxic infections, infectious diseases and acute appendicitis. A thorough examination of patients, monitoring the dynamics of the disease, consultation with an infectious disease specialist, and the use of all research methods available in a given situation will greatly help the doctor make the right decision.

It should be remembered that perforated appendicitis in some cases in its manifestations can be very similar to perforation of gastroduodenal ulcers.

Sharp abdominal pain, characteristic of perforation of gastroduodenal ulcers, is compared to the pain of being struck by a dagger and is called sudden, sharp, and painful. Sometimes such pain can occur with perforated appendicitis, when patients often ask for urgent help, they can only move bent over, the slightest movement causes increased abdominal pain.

It can also be deceptive that sometimes before perforation of the choroid, in some patients the pain subsides and the general condition improves for some period. In such cases, the surgeon sees in front of him a patient who has had a catastrophe in the abdomen, but widespread pain throughout the abdomen, tension in the muscles of the abdominal wall, a pronounced Blumberg-Shchetkin symptom - all this does not allow identifying the source of the catastrophe and confidently making a diagnosis. But this does not mean that it is impossible to establish an accurate diagnosis. Studying the history of the disease, determining the characteristics of the initial period, identifying the nature of the acute pain that has arisen, its location and prevalence allows us to more confidently differentiate the process.

First of all, when an abdominal catastrophe occurs, it is necessary to check for the presence of hepatic dullness, both percussion and x-ray. Additional determination of free fluid in sloping areas of the abdomen and digital examination of the PC will help the doctor establish the correct diagnosis. In all cases, when examining a patient who has severe abdominal pain, abdominal wall tension and other symptoms indicating severe irritation of the peritoneum, along with perforation of a gastroduodenal ulcer, acute appendicitis should also be suspected, since perforated appendicitis often occurs under the “mask” of an abdominal catastrophe .

Intra-abdominal postoperative complications are caused by both the variety of clinical forms of acute appendicitis, the pathological process in the emergency area, and the organizational, diagnostic, tactical and technical errors of surgeons. The frequency of complications leading to RL in acute appendicitis is 0.23-0.55% [P.A. Alexandrovich, 1979; N.B. Batyan, 1982; K.S. Zhitnikova and S.N. Morshinin, 1987], and according to other authors [D.M. Krasilnikov et al, 1992] even 2.1%.

Among the intra-abdominal complications after appendectomy, widespread and limited peritonitis, intestinal fistulas, bleeding, and NK are relatively often observed. The vast majority of these complications after surgery are observed after destructive forms of acute appendicitis. Of the limited gaso-inflammatory processes, pericultial abscess or, as it is mistakenly called, abscess of the stump of the central part, peritonitis limited in the right iliac region, multiple (interintestinal, pelvic, subdiaphragmatic) abscesses, infected hematomas, as well as their breakthrough into the free abdominal cavity are often observed.

The reasons for the development of peritonitis are diagnostic, tactical and technical errors. When analyzing medical histories of patients who died from acute appendicitis, many medical errors are almost always revealed. Doctors often ignore the principle of dynamic monitoring of patients who have abdominal pain, do not use the most basic methods of laboratory and X-ray examinations, neglect a rectal examination, and do not involve experienced specialists for consultation. Operations are usually performed by young, inexperienced surgeons. Often, in case of perforated appendicitis with symptoms of diffuse or diffuse peritonitis, appendectomy is performed from an oblique incision according to Volkovich, which does not allow completely sanitizing the abdominal cavity, determining the extent of peritonitis, and even more so performing such necessary aids as drainage of the abdominal cavity and intestinal intubation.

True postoperative peritonitis, which is not a consequence of purulent-destructive changes in the cervical region, usually develops as a result of tactical and technical errors made by surgeons. In this case, the occurrence of postoperative peritonitis is caused by the failure of the stump of the cerebral palsy; through puncture of the SC when applying a purse-string suture; undiagnosed and unresolved capillary bleeding; gross violations of the principles of asepsis and antisepsis; leaving parts of the choroid in the abdominal cavity, etc.

Against the background of diffuse peritonitis, abscesses of the abdominal cavity can form, mainly as a result of insufficiently thorough sanitation and inept use of peritoneal dialysis. After appendectomy, a pericultic abscess often develops. The causes of this complication are often violations of the technique of applying a purse-string suture, when puncture of the entire intestinal wall is allowed, the use of a Z-shaped suture for typhlitis instead of interrupted sutures, rough manipulation of tissues, desulfurization of the intestinal wall, failure of the stump of the partial intestine, insufficient hemostasis, underestimation of the nature of the effusion, and in resulting in an unjustified refusal to drain.

After appendectomy for complicated appendicitis, intestinal fistulas may occur in 0.35-0.8% of patients [K.T. Hovnatanyan et al., 1970; V.V. Rodionov et al., 1976]. This complication causes death in 9.1-9.7% of patients [I.M. Matyashin et al., 1974]. The occurrence of intestinal fistulas is also closely related to the purulent-inflammatory process in the area of ​​the ileocecal angle, in which the walls of the organs are infiltrated and easily wounded. Particularly dangerous is the forced division of the appendiceal infiltrate, as well as the removal of the appendix when an abscess has formed.

Intestinal fistulas can also be caused by gauze tampons and drainage tubes remaining in the abdominal cavity for a long time, which can cause a bedsore of the intestinal wall. The method of processing the stump of the choroid and its covering under conditions of SC infiltration are also of great importance. When the appendix stump is immersed in the inflammatory infiltrated wall of the appendix by applying purse-string sutures, there is a danger of the occurrence of NK, failure of the appendix stump and the formation of an intestinal fistula.

In order to prevent this complication, it is recommended to cover the stump of the process with separate interrupted sutures using synthetic threads on an atraumatic needle and peritonize this area with a greater omentum. In some patients, extraleritonealization of the SC and even the application of a cecostomy are justified to prevent the development of peritonitis or the formation of a fistula.

After appendectomy, intra-abdominal bleeding (IA) from the stump of the mesentery is also possible. This complication can clearly be attributed to defects in surgical technique. It is observed in 0.03-0.2% of operated patients.

Lowering blood pressure during surgery is of some importance. Against this background, VC from crossed and bluntly separated adhesions stops, but in the postoperative period, when the pressure rises again, VC can resume, especially in the presence of atherosclerotic changes in the vessels. Errors in diagnosis are also sometimes the cause of VK that was not recognized during surgery or that arose in the postoperative period [N.M. Zabolotsky and A.M. Semko, 1988]. Most often, this is observed in cases where a diagnosis of acute appendicitis is made with ovarian apoplexy in girls and an appendectomy is performed, while a small VK and its source go unnoticed. In the future, after such operations, severe VK may occur.

A great danger in terms of the occurrence of postoperative VK are the so-called congenital and acquired hemorrhagic diathesis - hemophilia, Werlhof's disease, long-term jaundice, etc. If not recognized in time or not taken into account during the operation, these diseases can play a fatal role. It should be borne in mind that some of them can simulate acute diseases of the abdominal organs [N.P. Batyan et al, 1976].

VK after appendectomy is very dangerous for the patient. The reasons for the complication are that, firstly, appendectomy is the most common operation in abdominal surgery, and secondly, it is often performed by inexperienced surgeons, while difficult situations during appendectomy are by no means common. The reason in most cases is technical errors. The specific gravity of VK after appendectomy is 0.02-0.07% [V.P. Radushkevich, I.M. Kudinov, 1967]. Some authors give higher figures - 0.2%. Hundredths of a percent seem to be a very small value, however, given the large number of appendectomies performed, this circumstance should seriously concern surgeons.

VC most often arise from the artery of the cerebral palsy due to the slipping of the ligature from the stump of its mesentery. This is facilitated by infiltration of the mesentery with novocaine and inflammatory changes in it. In cases where the mesentery is short, it must be ligated in parts. Particularly significant difficulties in stopping bleeding arise when it is necessary to retrogradely remove the PO. Mobilization of the appendix is ​​carried out in stages [I.F. Mazurin et al., 1975; YES. Dorogan et al., 1982].

Often there are VCs from crossed or bluntly separated and unligated adhesions [I.M. Matyashin et al., 1974]. To prevent them, it is necessary to achieve an increase in blood pressure, if it decreased during surgery, to carefully check hemostasis, to stop bleeding by grasping the bleeding areas with hemostatic clamps, followed by suturing and bandaging. Measures to prevent VK from the stump of the choroid are reliable ligation of the stump, immersion in a purse string and Z-shaped sutures.

VK from deserosed areas of the large and small intestines was also noted [D.A. Dorogan et al, 1982; AL. Gavura et al., 1985]. In all cases of intestinal deserosis, peritonization of this area is necessary. This is a reliable measure to prevent such complications. If, due to infiltration of the intestinal wall, it is impossible to apply seromuscular sutures, the deserosed area should be peritonized by suturing a pedicled omental flap. Sometimes VC arises from a puncture of the abdominal wall made to introduce drainage, therefore, after passing it through the counter-aperture, it is necessary to ensure that there is no VC.

An analysis of the causes of VC showed that in most cases they occur after non-standard operations, during which certain moments are noted that contribute to the occurrence of complications. Unfortunately, these points are not always easy to take into account, especially for young surgeons. There are situations when the surgeon foresees the possibility of postoperative VC, but the technical equipment is insufficient to prevent it. Such cases do not occur often. More often, VK are observed after operations performed by young surgeons who do not have sufficient experience [I.T. Zakishansky, I.D. Strugatsky, 1975].

Of the other factors contributing to the development of postoperative VC, first of all I would like to note technical difficulties: extensive adhesions, incorrect choice of anesthesia method, insufficient surgical access, which complicates manipulations and increases technical difficulties, and sometimes even creates them.
Experience shows that VCs occur more often after operations performed at night [I.G. Zakishansky, IL. Strugatsky, 1975, etc.]. The explanation for this is that at night the surgeon cannot always take advantage of the advice or help of a senior comrade in difficult situations, and also because the surgeon’s attention decreases at night.

VK can arise as a result of the melting of infected blood clots in the vessels of the mesentery of the cerebral palsy or vascular arrosion [AI. Lenyushkin et al., 1964], with congenital or acquired hemorrhagic diathesis, but the main cause of VK should be considered defects in surgical technique. This is evidenced by the identified errors during RL: relaxation or slipping of the ligature from the stump of the mesentery of the process, unligated, dissected vessels in the adhesive tissues, poor hemostasis in the area of ​​the main wound of the abdominal wall.

VC can also occur from the contraperture wound channel. In technically complex appendectomies, VC can arise from damaged vessels of the retroperitoneal tissue and mesentery of the TC.

Low-intensity VCs often stop spontaneously. Anemia can develop after a few days, and often in these cases, peritonitis develops due to infection. If infection does not occur, then the blood remaining in the abdominal cavity, gradually organizing, gives rise to the adhesive process.
To prevent bleeding after appendectomy, it is necessary to follow a number of principles, the main of which are careful pain management during surgery, ensuring free access, careful treatment of tissues and good hemostasis.

Light bleeding is usually observed from small vessels that are damaged during the separation of adhesions, isolation of the choroid, with its retrocecal and retroperitoneal location, mobilization of the right flank of the colon and in a number of other situations. These bleedings occur most covertly, hemodynamic and hematological parameters usually do not change significantly, therefore, in the early stages, these bleedings, unfortunately, are very rarely diagnosed.

One of the most severe complications of appendectomy is acute postoperative NK. According to the literature, it is 0.2-0.5% [IM. Matyashin, 1974]. In the development of this complication, the adhesions that fix the ileum to the parietal peritoneum at the entrance to the pelvis are of particular importance. With the increase of paresis, the intestinal loops located above the place of bending, compression or pinching of the intestinal loop by adhesions become overfilled with liquid and gases, hang down into the small pelvis, bending over the adjacent, also stretched loops of the intestinal tract. A kind of secondary volvulus occurs [O.B. Milonov et al., 1990].

Postoperative NC is observed mainly in destructive forms of appendicitis. Its frequency is 0.6%. When appendicitis is complicated by local peritonitis, NK develops in 8.1% of patients, and when it is complicated by diffuse peritonitis - in 18.7%. Severe trauma to the visceral peritoneum during surgery predisposes to the development of adhesions in the area of ​​the ileocecal angle.

The cause of complications can be diagnostic errors when, instead of a destructive process in Meckel's diverticulum, the appendix is ​​removed. However, if we consider that allendectomy is performed on millions of patients [O.B. Milonov et al., 1980], then this pathology is detected in hundreds and thousands of patients.

Among the complications, intraperitoneal abscesses occur relatively often (usually after 1-2 weeks) (Figure 5). In these patients, local signs of complications appear unclear. More often, general symptoms of intoxication, septic condition and multiple organ failure prevail, which are not only alarming, but also worrying. With the pelvic location of the choroid, abscesses of the rectouterine or rectovesical recess occur. Clinically, these abscesses are manifested by a deterioration in general condition, pain in the lower abdomen, and high body temperature. A number of patients experience frequent loose stools with mucus and frequent, difficult urination.

Figure 5. Scheme of distribution of abscesses in acute appendicitis (according to B.M. Khrov):
a—intraperitoneal location of the process (front view): 1—anterior or parietal abscess; 2 - intraperitoneal lateral abscess; 3 - ileal abscess; 4 - abscess in the pelvic cavity (abscess of the pouch of Douglas); 5 - subphrenic abscess; 6 - sub-treatment abscess; 7—left-sided iliac abscess; 8—interintestinal abscess; 9—intraperitoneal abscess; b — retrocecal extraperitoneal location of the process (side view): 1 — purulent paracolitis; 2 - paranephritis, 3 - subphrenic (extraperitoneal) abscess; 4 - abscess or phlegmon of the iliac fossa; 5 - retroperitoneal phlegmon; 6 - pelvic phlegmon

Digital examination of the PC in the early stages reveals pain in its anterior wall and overhang of the latter due to the formation of a dense infiltrate. When an abscess forms, the sphincter tone decreases and a softening area appears. In the initial stages, conservative treatment is prescribed (antibiotics, warm therapeutic enemas, physiotherapeutic procedures). If the patient's condition does not improve, the abscess is opened through the vaginal vault in men, through the posterior vaginal fornix in women. When opening an abscess through the PC after emptying the bladder, the sphincter of the bladder is stretched, the abscess is punctured and, having obtained pus, the intestinal wall is cut through the needle.

The wound is widened with a forceps, a drainage tube is inserted into the abscess cavity, fixed to the skin of the perineum and left for 4-5 days. In women, when opening an abscess, the uterus is retracted anteriorly. The abscess is punctured and the tissue is cut through the needle. The abscess cavity is drained with a rubber tube. After opening the abscess, the patient's condition quickly improves; after a few days, the discharge of pus stops and recovery occurs.

Interintestinal abscesses are rare. During development, a high body temperature persists for a long time after appendectomy, leukocytosis is noted with a shift in the leukocyte formula to the left. On palpation of the abdomen, pain is vaguely expressed at the location of the infiltrate. Gradually increasing in size, it approaches the anterior abdominal wall and becomes accessible to palpation. In the initial stage, conservative treatment is usually carried out. If signs of abscess formation appear, it is drained.

Subphrenic abscess after appendectomy is even less common. When it occurs, the patient’s general condition deteriorates, body temperature rises, and pain appears on the right side above or below the liver. Most often, in half of patients, the first symptom is pain. An abscess may appear suddenly or be masked by a vague feverish state, erased by the onset. Diagnosis and treatment of subphrenic abscesses were discussed above.

In another case, a purulent infection may spread to the entire peritoneum and diffuse peritonitis may develop (Figure 6).

Figure 6. Spread of diffuse peritonitis of appendicular origin to the entire peritoneum (diagram)

A severe complication of acute destructive appendicitis is pylephlebitis - purulent thrombophlebitis of the veins of the portal system. Thrombophlebitis begins in the veins of the cerebral palsy and spreads through the ileocolic vein to the veins. Against the background of complications of acute destructive appendicitis with pylephlebitis, multiple liver abscesses can form (Figure 7).

Figure 7. Development of multiple liver abscesses in acute destructive appendicitis complicated by pylephlebitis

VV thrombophlebitis, which occurs after alpendectomy and surgery on other organs of the gastrointestinal tract, is a serious and rare complication. It is accompanied by a very high mortality rate. When the venous vessels of the mesentery are involved in the purulent-necrotic process with the subsequent formation of septic thrombophlebitis, the venous vein is usually affected. This occurs due to the spread of the necrotic process of the choroid to its mesentery and the venous vessels passing through it. In this regard, during the operation it is recommended [M.G. Sachek and V.V. Anechkin, 1987] to excise the altered mesentery of the cerebral palsy to viable tissue.

Postoperative thrombophlebitis of the mesenteric veins usually occurs when conditions are created for direct contact of a virulent infection with the wall of the venous vessel. This complication is characterized by a progressive course and severity of clinical manifestations. It begins acutely: from 1-2 days of the postoperative period, repeated shaking chills and fever with high temperature (39-40 ° C) appear. There is intense abdominal pain, more pronounced on the affected side, progressive deterioration of the patient's condition, intestinal paresis, and increasing intoxication. As the complication progresses, symptoms of mesenteric vein thrombosis (stool mixed with blood), signs of toxic hepatitis (pain in the right hypochondrium, jaundice), signs of PN, ascites appear.

There are pronounced changes in laboratory parameters: leukocytosis in the blood, a shift of the leukocyte formula to the left, toxic granularity of neutrophils, an increase in ESR, bilirubinemia, a decrease in the protein-forming and antitoxic function of the liver, protein in the urine, formed elements, etc. It is very difficult to make a diagnosis before surgery. Patients are usually treated with RL for “peritonitis”, “intestinal obstruction” and other conditions.

When opening the abdominal cavity, the presence of a light-colored exudate with a hemorrhagic tint is noted. When examining the abdominal cavity, they find an enlarged, spotted liver (due to the presence of multiple subcapsular ulcers), a dense liver, a large spleen, a paretic bluish intestine with a congestive vascular pattern, dilated and tense veins of the mesentery, and often blood in the intestinal lumen. Thrombosed veins are palpated in the thickness of the hepatoduodenal ligament and mesacolon in the form of dense cord-like formations. Treatment of pylephlebitis is a difficult and complex task.

In addition to rational drainage of the primary source of infection, it is recommended to perform recanalization of the umbilical vein and cannulation of the IV. When cannulating the portal vein, pus can be obtained from its lumen, which is aspirated until venous blood appears [M.G. Sachek and V.V. Anichkin, 1987]. Antibiotics, heparin, fibronolytic drugs, and agents that improve the rheological properties of blood are administered transumbilically.

At the same time, correction of metabolic disorders caused by developing PN is carried out. In case of metabolic acidosis accompanying PN, a 4% solution of sodium bicarbonate is administered, body fluid loss is monitored, solutions of glucose, albumin, rheopolyglucin, hemodez are administered intravenously - a total volume of up to 3-3.5 liters. Large losses of potassium ions are compensated by introducing an adequate amount of 1-2% potassium chloride solution.

Disturbances in the protein-forming function of the liver are corrected by administering a 5% or 10% solution of albumin, native plasma, amino acid mixtures, alvesin, aminosteryl hep (aminoblovin). For detoxification, use hemodez solution (400 ml). Patients are transferred to a protein-free diet, concentrated (10-20%) glucose solutions with an adequate amount of insulin are administered intravenously. Hormonal drugs are used: prednisolone (10 mg/kg body weight per day), hydrocortisone (40 mg/kg body weight per day). When the activity of proteolytic enzymes increases, it is advisable to administer intravenously Contrical (50-100 thousand units). To stabilize the blood coagulation system, vikasol, calcium chloride, and epsilonaminocaproic acid are administered. To stimulate tissue metabolism, B vitamins (B1, B6, B12), ascorbic acid, and liver extracts (sirepar, campolon, vitohepat) are used.

To prevent purulent complications, massive antibacterial therapy is prescribed. Oxygen therapy is administered, including HBOT therapy. To remove protein breakdown products (ammonia intoxication), gastric lavage (2-3 times a day), cleansing enemas, and stimulation of diuresis are recommended. If there are indications, hemo- and lymphorsorption, peritoneal dialysis, hemodialysis, exchange blood transfusion, connection of an allo- or xenogeneic liver are performed. However, with this postoperative complication, the therapeutic measures taken are ineffective. Patients usually die from hepatic coma.

Other complications (diffuse purulent peritonitis, NK, adhesive disease) are described in the relevant sections.

Any of the listed postoperative complications can manifest themselves at very different times from the moment of the first operation. For example, an abscess or adhesive NK occurs in some patients in the first 5-7 days, in others - 1-2, even 3 weeks after appendectomy. Our observations show that purulent complications are more often diagnosed at a later date (after 7 days). We also note that in terms of assessing the timeliness of RL performed, the decisive factor is not the time elapsed after the first operation, but the time since the appearance of the first signs of a complication.

Depending on the nature of the complications, their signs in some patients are expressed by local muscle tension with or without irritation of the peritoneum, in others - by bloating and asymmetry of the abdomen or the presence of a palpable infiltrate without clear boundaries, a local pain reaction.

The leading symptoms of toinoinflammatory complications developing after appendectomies are pain, moderate and then increasing muscle tension and symptoms of peritoneal irritation. The temperature in this case is often low-grade and can reach 38-39 °C. On the blood side, there is an increase in the number of leukocytes to 12-19 thousand units with a shift of the formula to the left.

The choice of surgical tactics during reoperation depends on the identified pathomorphological findings.

Summarizing what has been said, we come to the conclusion that the main etiological factors in the development of complications after appendectomy are:
1) neglect of acute appendicitis due to late presentation of patients to the hospital, most of whom have a destructive form of the pathological process, or due to diagnostic errors of doctors at the pre-hospital and hospital stages of treatment;
2) defects in surgical technique and tactical errors during appendectomy;
3) unforeseen situations associated with exacerbation of concomitant diseases.

If complications occur after appendectomy, the urgency of RL is determined depending on its nature. Urgent radiotherapy is performed (in the first 72 hours after the primary intervention) for VK, incompetence of the process stump, and adhesive NK. The clinical picture of complications in these patients increases quickly and is manifested by symptoms of an acute abdomen. There is usually no doubt about the indications for RL in such patients. The so-called delayed RL (in the period of 4-7 days) is performed for single abscesses, partial adhesive NK, less often in individual cases of progression of peritonitis. In these patients, the indications for RL are based more on local abdominal symptoms that prevail over the general reaction of the body.

To treat postoperative peritonitis caused by incompetence of the appendix stump after midline laparotomy and identifying it through a wound in the right iliac region, the dome of the SC should be removed along with the stump of the appendix and fixed to the parietal peritoneum at the skin level; perform a thorough toilet of the abdominal cavity with its adequate drainage and fractional dialysis in order to prevent postoperative progressive peritonitis due to insufficiency of interintestinal anastomoses or sutured intestinal perforation.

For this it is recommended [V.V. Rodionov et al, 1982] to use subcutaneous removal of a segment of the intestine with sutures, especially in elderly and senile patients, in whom the development of suture failure is prognostically most likely. This is done as follows: through an additional counter-aperture, a segment of the intestine with a line of sutures is brought out subcutaneously and fixed to the opening in the aponeurosis. The skin wound is sutured with rare interrupted sutures. Point intestinal fistulas that develop in the postoperative period are eliminated using a conservative method.

Our many years of experience show that the common causes leading to LC after appendectomy are inadequate revision and sanitation, and an incorrectly chosen method of drainage of the abdominal cavity. It is also noteworthy that quite often the surgical access during the first operation was small in size or was shifted relative to the McBurney point, creating additional technical difficulties. It can also be considered a mistake to perform a technically difficult appendectomy under local anesthesia. Only anesthesia with sufficient access allows for a full inspection and sanitation of the abdominal cavity.

Unfavorable factors contributing to the development of complications include failure to carry out preoperative preparation for appendiceal peritonitis, non-compliance with the principles of pathogenetic treatment of peritonitis after the first operation, the presence of severe chronic concomitant diseases, elderly and senile age. The progression of peritonitis, the formation of abscesses, and necrosis of the SC wall in these patients is due to a decrease in the general resistance of the body, disturbances in central and peripheral hemodynamics, and immunological changes. The immediate cause of death is progression of peritonitis and acute CV failure.

In case of late-stage appendicular peritonitis, even a wide median laparotomy under anesthesia with revision and radical treatment of all parts of the abdominal cavity with the participation of experienced surgeons cannot prevent the development of postoperative complications.

The reason for the development of complications is a violation of the principle of appropriateness of combination antibiotic therapy, changing antibiotics during treatment, taking into account the sensitivity of the flora to them, and especially small doses.

Other important aspects of the treatment of primary peritonitis are often neglected: correction of metabolic disorders and measures to restore the motor-evacuation function of the gastrointestinal tract.
So, we come to the conclusion that complications in the treatment of appendicitis are mainly due to untimely diagnosis, late hospitalization of patients, inadequate surgical access, incorrect assessment of the extent of the pathological process, technical difficulties and errors during surgery, unreliable treatment of the stump of the cervical region and its mesentery and defective toilet and drainage of the abdominal cavity.

Based on literature data and our own experience, we believe that the main way to reduce the frequency of postoperative complications, and therefore postoperative mortality in acute appendicitis, is to reduce the diagnostic, tactical and technical errors of operating surgeons.

Acute appendicitis is literally inflammation of the appendix. The vermiform appendix arises from the posterointernal segment of the cecum at the point where the three band muscles of the cecum begin. It is a thin convoluted tube, the cavity of which on one side communicates with the cavity of the cecum. The process ends blindly. Its length ranges from 7 to 10 cm, often reaching 15–25 cm, the diameter of the canal does not exceed 4–5 mm.

The vermiform appendix is ​​covered on all sides by peritoneum and in most cases has a mesentery that does not prevent its movement.

Depending on the position of the cecum, the appendix can be located in the right iliac fossa, above the cecum (if its position is high), below the cecum, in the pelvis (if its position is low), together with the cecum among the loops of the small intestine in the midline , even in the left half of the abdomen. Depending on its location, the corresponding clinical picture of the disease arises.

Acute appendicitis– nonspecific inflammation of the appendix caused by pyogenic microbes (streptococci, staphylococci, enterococci, E. coli, etc.).

Microbes enter it enterogenously (the most common and most likely), hematogenous and lymphogenous routes.

When palpating the abdomen, the muscles of the anterior abdominal wall are tense. Pain at the site of the appendix upon palpation is the main, and sometimes the only, sign of acute appendicitis. It is more pronounced in destructive forms of acute appendicitis and especially in perforation of the appendix.

An early and no less important sign of acute appendicitis is local tension in the muscles of the anterior abdominal wall, which is often limited to the right iliac region, but can spread to the right half of the abdomen or along the entire anterior abdominal wall. The degree of tension in the muscles of the anterior abdominal wall depends on the body’s reactivity to the development of the inflammatory process in the appendix. With reduced reactivity of the body in exhausted patients and elderly people, this symptom may be absent.

If acute appendicitis is suspected, vaginal (in women) and rectal examinations should be performed, in which pain in the pelvic peritoneum can be determined.

The Shchetkin-Blumberg symptom has important diagnostic value in acute appendicitis. To determine it, carefully press on the anterior abdominal wall with the right hand and after a few seconds tear it off from the abdominal wall, and a sharp pain or noticeable increase in pain appears in the area of ​​the inflammatory pathological focus in the abdominal cavity. With destructive appendicitis and especially with perforation of the appendix, this symptom is positive throughout the right half of the abdomen or throughout the entire abdomen. However, the Shchetkin-Blumberg symptom can be positive not only in acute appendicitis, but also in other acute diseases of the abdominal organs.

The symptoms of Voskresensky, Rovzing, Sitkovsky, Bartomier-Mikhelson, Obraztsov are of certain importance in making the diagnosis of acute appendicitis.

When symptom Voskresensky pain appears in the right iliac region when the palm is quickly passed through the patient’s stretched shirt along the anterior wall of the abdomen to the right of the costal edge downwards. On the left, this symptom is not detected.

Symptom Rovsing and is caused by pressing or pushing with the palm of the hand in the left iliac region. In this case, pain occurs in the right iliac region, which is associated with a sudden movement of gases from the left half of the large intestine to the right, resulting in vibrations of the intestinal wall and the inflamed appendix, transmitted to the inflammatory-changed parietal peritoneum.

When symptom Sitkovsky in a patient lying on his left side, pain appears in the right iliac region caused by the tension of the inflamed peritoneum in the area of ​​the cecum and mesentery of the appendix due to its marking.

Symptom Barthomier–Mikhelson– pain on palpation of the right iliac region with the patient positioned on the left side.

Symptom Obraztsova– pain on palpation of the right iliac region at the moment of raising the straightened right leg.

A critical and objective assessment of these symptoms enhances the diagnosis of acute appendicitis. However, the diagnosis of this disease should not be based on one of these symptoms, but on a comprehensive analysis of all local and general signs of this acute disease of the abdominal organs.

To make a diagnosis of acute appendicitis, a blood test is of great importance. Changes in the blood are manifested by an increase in leukocytes. The severity of the inflammatory process is determined using the leukocyte formula. A shift in the leukocyte count to the left, i.e., an increase in the number of band neutrophils or the appearance of other forms with a normal or slight increase in the number of leukocytes, indicates severe intoxication in destructive forms of acute appendicitis.

There are several forms of acute appendicitis (according to histology):

1) catarrhal;

2) phlegmonous;

3) gangrenous;

4) gangrenous-perforative.

Differential diagnosis of acute appendicitis

Acute diseases of the abdominal organs have a number of main symptoms:

1) pain of various types;

2) reflex vomiting;

3) disorder of the normal passage of intestinal gases and feces;

Until a specific diagnosis of acute abdominal disease is established, patients should not be prescribed painkillers (the use of drugs relieves pain and smoothes the clinical picture of acute abdominal disease), gastric lavage, laxatives, cleansing enemas and thermal procedures.

Acute diseases of the abdominal organs are easier to differentiate in the initial stage of the disease. Subsequently, when peritonitis develops, it can be very difficult to determine its source. It is necessary to remember in this regard the figurative expression of Yu. Yu. Janelidze: “When the whole house is on fire, it is impossible to find the source of the fire.”

Acute appendicitis must be differentiated from:

1) acute diseases of the stomach - acute gastritis, food toxic infections, perforated ulcers of the stomach and duodenum;

2) some acute diseases of the gallbladder and pancreas (acute cholecystitis, cholelithiasis, acute pancreatitis, acute cholecystopancreatitis);

3) some intestinal diseases (acute enteritis or enterocolitis, acute ileitis, acute diverticulitis and its perforation, acute intestinal obstruction, Crohn's disease, terminal ileitis

4) some diseases of the female genital area (acute inflammation of the mucous membrane and wall of the uterus, pelvioperitonitis, ectopic pregnancy, ovarian rupture, twisted ovarian cyst);

5) urological diseases (nephrolithiasis, renal colic, pyelitis);

6) other diseases simulating acute appendicitis (acute diaphragmatic pleurisy and pleuropneumonia, heart disease).

Treatment of acute appendicitis

Currently, the only method of treating patients with acute appendicitis is early emergency surgery, and the earlier it is performed, the better the results. Even G. Mondor (1937) pointed out: when all doctors are imbued with this idea, when they understand the need for quick diagnosis and immediate surgical intervention, they will no longer have to deal with severe peritonitis, with cases of severe suppuration, with those remote infectious complications, which even now too often cloud the prognosis of appendicitis.

Thus, the diagnosis of acute appendicitis requires immediate surgery. The exception is patients with limited appendiceal infiltrate and patients requiring short-term preoperative preparation.

The phenomena of acute appendicitis can be detected in patients with myocardial infarction, severe pneumonia, acute cerebrovascular accidents, and decompensated heart disease. Such patients are monitored dynamically. If during observation the clinical picture does not subside, then, for health reasons, they resort to surgery. In acute appendicitis complicated by peritonitis, despite the severity of the somatic disease, the patient is operated on after appropriate preoperative preparation.

A number of authors indicate that in the complex of therapeutic measures for this category of patients with acute appendicitis, preoperative preparation is of great importance, which serves as one of the means of reducing the risk of surgical intervention, improves the general condition of the patient, normalizes homeostasis, and enhances immunoprotective mechanisms. It should not last more than 1 - 2 hours.

If during appendectomy it is impossible to use intubation anesthesia with muscle relaxants, then local infiltration anesthesia with a 0.25% solution of novocaine is used, which, if appropriate, can be combined with neuroleptanalgesia.

However, it is necessary to give preference to modern endotracheal anesthesia with the use of muscle relaxants, in which the surgeon has the maximum opportunity to conduct a thorough examination of the abdominal organs.

In mild forms of acute appendicitis, where the operation is short, appendectomy can be performed under mask anesthesia using muscle relaxants.

The most common access for uncomplicated acute appendicitis is the Volkovich-McBurney oblique incision. The incision proposed by Lennander is used somewhat less frequently; it is made for an atypical location of the appendix, widespread purulent peritonitis caused by perforation of the appendix, as well as for the possible appearance of peritonitis from other sources, when a wider inspection of the abdominal organs is necessary. The advantage of the Volkovich-McBurney incision is that it corresponds to the projection of the cecum and does not damage nerves and muscles, which minimizes the incidence of hernias in this area.

The transverse approach is convenient in that it can easily be expanded medially by intersecting the rectus abdominis muscle.

In most cases, after an appendectomy, the abdominal cavity is sutured tightly.

If, with perforated appendicitis, there is an effusion in the abdominal cavity, which is removed with gauze swabs or an electric suction device, then a thin rubber tube (polyvinyl chloride) is inserted into it for intraperitoneal administration of antibiotics.

For destructive forms of acute appendicitis in the postoperative period, antibiotics are prescribed intramuscularly, taking into account the patient's sensitivity to them.

Correct management of patients in the postoperative period largely determines the results of surgical intervention, especially in destructive forms of acute appendicitis. Active behavior of patients after surgery prevents the development of many complications.

In uncomplicated forms of acute appendicitis, the condition of patients is usually satisfactory, and no special treatment is required in the postoperative period.

After delivery from the operating room to the ward, the patient can immediately be allowed to turn on his side, change his body position, breathe deeply, and clear his throat.

Getting out of bed should begin gradually. On the first day, the patient can sit in bed and begin to walk, but he should not force himself to get up early. This issue must be approached strictly individually. The patient’s well-being and mood play a decisive role. It is necessary to start early nutrition of patients, which reduces the frequency of intestinal paresis and promotes normal function of the digestive organs. Patients are prescribed easily digestible food without overloading the gastrointestinal tract; from the sixth day they are transferred to a common table.

Most often, after an appendectomy, stool occurs on its own on the 4th – 5th day. During the first two days, gas retention occurs due to intestinal paresis, which most often stops on its own.

In the postoperative period, there is often urinary retention as a result of the fact that most patients cannot urinate while lying down. To eliminate this complication, a heating pad is applied to the perineum. If the patient’s condition allows, then he is allowed to stand near the bed, they try to evoke a reflex to urinate by releasing a stream from the kettle. You can administer 5–10 ml of a 40% solution of methenamine or 5–10 ml of a 5% solution of magnesium sulfate intravenously. If there is no effect from these measures, catheterization of the bladder is carried out with strict adherence to the rules of asepsis and mandatory washing it after catheterization with a solution of furatsilin (1: 5000) or silver sulfate (1: 10,000, 1: 5000).

In the postoperative period, physical therapy is of great importance.

If during the operation no changes are found in the appendix, then an inspection of the ileum should be performed (over 1 - 1.5 m) so as not to miss diverticulitis.

Complications of acute appendicitis

Complications in the preoperative period. If the patient does not consult a doctor in a timely manner, acute appendicitis can lead to a number of serious complications that threaten the patient’s life or leave him unable to work for a long time. The main, most dangerous complications of untimely operated appendicitis are considered to be appendiceal infiltrate, diffuse purulent peritonitis, pelvic abscess, and pylephlebitis.

Appendicular infiltrate. This is a limited inflammatory tumor that forms around a destructively modified appendix, to which intestinal loops, the greater omentum and nearby organs are soldered with fibrinous deposits. The appendicular infiltrate is localized at the location of the appendix.

In the clinical course of appendiceal infiltration, two phases are distinguished: early (progression) and late (delimitation).

In the early stage, the appendiceal infiltrate is just beginning to form; it is soft, painful, without clear boundaries. Its clinical picture is similar to that of acute destructive appendicitis. There are symptoms of peritoneal irritation, leukocytosis with a shift in the leukocyte count to the left.

In the late stage, the clinical course is characterized by the general satisfactory condition of the patient. General and local inflammatory reactions subside, the temperature is within 37.5 - 37.8 ° C, sometimes normal, the pulse is not rapid. Palpation of the abdomen reveals a low-painful dense infiltrate, which is clearly demarcated from the free abdominal cavity.

After the diagnosis is made, appendiceal infiltration begins to be treated conservatively: strict bed rest, food without a large amount of fiber, bilateral perinephric blockade with a 0.25% solution of novocaine according to Vishnevsky, antibiotics.

After treatment, the appendiceal infiltrate can resolve; if treatment is ineffective, it can fester and form an appendicular abscess, be replaced by connective tissue, not resolve for a long time and remain dense.

7–10 days after resorption of the appendiceal infiltrate, without discharging the patient from the hospital, an appendectomy is performed (sometimes 3–6 weeks after resorption as planned when the patient is re-admitted to the surgical hospital).

The appendicular infiltrate can be replaced by massive development of connective tissue without any tendency to resorption. V. R. Braitsev called this form of infiltration fibroplastic appendicitis. At the same time, a tumor-like formation is palpated in the right iliac region, there is also aching pain, and symptoms of intermittent intestinal obstruction appear. Only histological examination after hemicolectomy reveals the true cause of the pathological process.

If the appendiceal infiltrate does not resolve within 3–4 weeks and remains dense, then the presence of a tumor in the cecum should be assumed. For differential diagnosis, it is necessary to perform irrigoscopy.

When the appendiceal infiltrate transitions into an appendiceal abscess, patients experience a high intermittent temperature, high leukocytosis with a shift in the leukocyte formula to the left, and intoxication.

Pelvic appendicular abscess. It can complicate pelvic appendicitis, and sometimes accompany phlegmonous or gangrenous forms of acute appendicitis.

With a pelvic appendicular abscess, purulent effusion descends to the pelvic floor and accumulates in the pouch of Douglas. The purulent contents push upward the loops of the small intestine and are delimited from the free abdominal cavity by adhesions that form between the intestinal loops, the greater omentum and the parietal peritoneum.

Clinically, a pelvic appendicular abscess is manifested by pain in the depths of the pelvis, pain when pressing above the pubis, and bloating. In some cases, there may be vomiting, which is caused by relative dynamic intestinal obstruction due to paresis of the small intestinal loops involved in the inflammatory process.

A pelvic appendicular abscess is characterized by high temperature (up to 38–40 °C), high leukocytosis with a shift in the leukocyte count to the left. The tension in the muscles of the anterior abdominal wall is weak.

Local symptoms of irritation of organs and tissues adjacent to the abscess - rectum, bladder - are of great importance for establishing the diagnosis of pelvic appendicular abscess. In this case, there are frequent fruitless urges to lower oneself, diarrhea mixed with mucus, swelling of the mucous membrane around the anus, and the sphincter gapes. Urination is frequent, painful, and sometimes delayed. During a digital examination of the per rectum, a fluctuating painful tumor-like formation is determined on the anterior wall of the rectum, upon puncture of which pus is detected.

Treatment of pelvic infiltration before suppuration is the same as for appendicular infiltration; in case of suppuration, it is surgical (median incision with drainage of the abdominal cavity).

Pylephlebitis. This is purulent thrombophlebitis of the portal vein, a very rare but very dangerous complication of acute appendicitis, which almost always ends in purulent hepatitis.

The initial symptoms of pylephlebitis are an increase in temperature to 38–40 °C, chills, indicating developing purulent hepatitis, and they are accompanied by intermittent pain in the right hypochondrium. Palpation reveals a painful liver, characterized by early-onset, not very intense jaundice, and high leukocytosis. The general condition of the patient is very serious. An X-ray examination reveals high standing and limited mobility of the right dome of the diaphragm; sometimes there is effusion in the right pleural cavity.

Complications in the postoperative period. The classification of postoperative complications in acute appendicitis is based on the clinical and anatomical principle:

1. Complications from the surgical wound:

1) hematoma;

2) suppuration;

3) infiltrate;

4) divergence of the edges without eventration;

5) divergence of edges with eventration;

6) ligature fistula;

7) bleeding from a wound in the abdominal wall.

2. Acute inflammatory processes in the abdominal cavity:

1) infiltrates and abscesses of the ileocecal area;

2) abscesses of the pouch of Douglas;

3) interintestinal;

4) retroperitoneal;

5) subdiaphragmatic;

6) subhepatic;

7) local peritonitis;

8) diffuse peritonitis.

3. Complications from the gastrointestinal tract:

1) dynamic intestinal obstruction;

2) acute mechanical intestinal obstruction;

3) intestinal fistulas;

4) gastrointestinal bleeding.

4. Complications from the cardiovascular system:

1) cardiovascular failure;

2) thrombophlebitis;

3) pylephlebitis;

4) pulmonary embolism;

5) bleeding into the abdominal cavity.

5. Complications from the respiratory system:

1) bronchitis;

2) pneumonia;

3) pleurisy (dry, exudative);

4) abscesses and gangrene of the lungs;

4) pulmonary atelectasis.

6. Complications from the excretory system:

1) urinary retention;

2) acute cystitis;

3) acute pyelitis;

4) acute nephritis;

5) acute pyelocystitis.

Chronic appendicitis

Chronic appendicitis usually develops after an acute attack and is the result of the changes that occurred in the appendix during the period of acute inflammation. Sometimes changes remain in the appendix in the form of scars, kinks, adhesions with nearby organs, which can cause the mucous membrane of the appendix to continue a chronic inflammatory process.

Clinical picture in various forms of chronic appendicitis is very diverse and not always sufficiently characteristic. Most often, patients complain of constant pain in the right iliac region, sometimes this pain is paroxysmal in nature.

If, after an attack of acute appendicitis, painful attacks in the abdominal cavity periodically recur, then this form of chronic appendicitis is called recurrent.

In some cases, chronic appendicitis occurs without an acute attack from the very beginning and is called primary chronic appendicitis or attack-free.

With chronic appendicitis, some patients associate attacks of abdominal pain with food intake, others with physical activity, and many cannot name the reason for their occurrence. They often complain of intestinal disorders, accompanied by constipation or diarrhea with vague pain in the lower abdomen.

If patients have a history of one or more acute attacks of appendicitis, the diagnosis of chronic appendicitis sometimes does not present great difficulties.

During an objective examination, patients with chronic appendicitis complain only of pain on palpation at the location of the appendix. However, this tenderness may be associated with other abdominal diseases. Therefore, when diagnosing “chronic appendicitis,” it is always necessary to exclude other diseases of the abdominal organs through a thorough and comprehensive examination of the patient.

Chronic appendicitis must be differentiated from uncomplicated gastric and duodenal ulcers, kidney diseases, liver diseases, etc.; chronic kidney diseases (pyelitis, kidney stones); chronic cholecystitis - duodenal intubation, cholecystography. In women, chronic diseases of the uterine appendages are excluded. In addition, it is necessary to differentiate chronic appendicitis from helminthic infestation and tuberculous mesoadenitis.

Treatment chronic appendicitis – surgical.

The technique of this operation is similar to the technique of surgery for acute appendicitis.

Despite the ongoing development of modern surgery, there are still a large number of complications of this pathology. This is due both to low awareness of the population and reluctance to seek medical help, and to the insufficient qualifications of some doctors. Therefore, let's figure out how this disease manifests itself and what complications after appendicitis may occur.

What is appendicitis?

Appendicitis is a disease characterized by inflammation of the wall of the appendix (the vermiform appendix of the cecum). It is located in the lower right part of the abdomen, which is also called the iliac region. In the adult body, the appendix has no function, so its removal (appendectomy) does not harm human health.

Most often, the appendix becomes inflamed in people aged 10 to 30 years.

Main symptoms

Before moving directly to what complications may occur after acute appendicitis, let’s look at what symptoms will help you suspect the presence of inflammation in order to promptly seek medical help.

If chronic inflammation of the appendix may not manifest itself for a long time and not cause inconvenience to the patient, then acute appendicitis has clear symptoms:

• sharp, severe pain in the upper abdomen (epigastric region), which gradually descends down and to the right (into the iliac region);
• increased pain when turning to the right side, when coughing, walking;
• tension in the muscles of the anterior abdominal wall, which occurs due to pain that the patient experiences when moving the abdominal muscles;
• possible accumulation of gases in the intestines, constipation;
• low-grade fever (up to 37.5 °C).

Classification of appendicitis

Perhaps for ordinary people it does not matter much what kind of inflammation of the appendix is ​​observed in his case. However, it is very important for the surgeon to know the type of appendicitis, because depending on this, the prognosis for the further course of the disease and the likelihood of complications can be determined. This also determines surgical tactics.

The following types of appendicitis are distinguished:

• catarrhal or simple - the most common form;
• surface;
• phlegmonous - purulent inflammation of the appendix;
• gangrenous - with the development of necrosis of the process;
• perforated - with destruction of the appendix and penetration of intestinal contents into the abdominal cavity.

It is the phlegmonous and gangrenous types that are the most unfavorable from the point of view of the development of complications. These types of appendicitis require the greatest attention from the surgeon and immediate surgical intervention. And the perforated appearance, in fact, is a complication after

Types of complications

Complications after appendicitis can be divided into two large groups.

The first includes complications of the inflammation itself, which often results from untimely seeking of medical help. These are complications such as:

• appendicular infiltrate - the formation of a conglomerate from intestinal loops, mesentery and other abdominal organs around the appendix;
• abscesses in the abdominal cavity (in the pelvis, between the intestinal loops, under the diaphragm);
• peritonitis - inflammation of the peritoneum;
• pylephlebitis - inflammation of the portal vein (the vessel that carries blood to the liver), as well as its branches.

Complications after appendicitis surgery most often develop in the wound and abdominal cavity. However, there may be complications in the respiratory organs, genitourinary and cardiovascular systems.

Appendiceal infiltrate

When answering the question of what complications there may be after appendicitis, first of all it is necessary to highlight the formation of appendiceal infiltrate. It is a group of abdominal organs and tissues fused together that limit the appendix from the rest of the abdominal cavity. As a rule, this complication develops a few days after the onset of the disease.

Symptoms of complications after appendicitis, specifically appendicular infiltrate, are characterized by a decrease in the intensity of pain in the lower abdomen. It becomes less sharp, but more dull, has no clear localization, and only increases slightly when walking.

When palpating the abdominal cavity, you can feel a fuzzy formation characterized by pain. Further, the infiltrate thickens, the contours become more blurred, and the pain disappears.

The infiltrate can resolve within one and a half to two weeks, however, it can also fester with the formation of an abscess. When suppuration occurs, the patient's condition sharply worsens, fever appears, the abdomen becomes painful on palpation, and the muscles of the anterior abdominal wall are tense.

Appendiceal abscess

A purulent, prognostically unfavorable complication after appendicitis is the formation of an abscess of the appendix. But ulcers can form not only directly in the appendix, but also in other places in the abdominal cavity. This occurs when the peritoneal effusion encystes and prevents the development of widespread peritonitis. Often this picture occurs as a complication after phlegmonous appendicitis.

To diagnose this complication and search for abscesses in the abdominal cavity, it is recommended to use ultrasound and computed tomography. If an abscess formed as a complication after appendicitis in women, its pelvic localization is typical. Then its presence can be determined using a vaginal examination.

Above is a CT scan showing the formation of an abscess in the anterior abdominal wall.

Purulent peritonitis and pylephlebitis

These two types of complications occur least frequently, but are most unfavorable for the patient. Peritonitis as a complication after appendicitis occurs only in 1% of cases. But this pathology is the main cause of death in patients with appendicitis.

The rarest condition with inflammation of the appendix is ​​pylephlebitis (septic inflammation of the portal vein). As a rule, it is a complication after appendectomy, however, it can develop even before surgery. It is characterized by a sharp deterioration in the patient’s general condition, high fever, and a sharply swollen abdomen. If the veins that pass directly into the liver tissue are damaged, jaundice occurs, the liver becomes enlarged, and liver failure develops. The most likely outcome of this condition is the death of the patient.

Complications arising from the surgical wound

And now we will talk about complications after appendicitis surgery. The first group of complications are those that are limited to the surgical wound. Inflammatory infiltrates and suppuration develop most often. As a rule, they occur 2-3 days after removal of the appendix, while pain in the wound that has already subsided returns again, body temperature rises, and general condition worsens.

On the wound, when the bandage is removed, redness and swelling of the skin are visualized, and the threads of the postoperative sutures cut into the skin. On palpation, sharp pain is observed and a dense infiltrate is palpable.

After a few days, if you do not intervene in time and prescribe treatment, the infiltrate may fester. Then its boundaries become less clear; upon palpation, one can detect a symptom of fluctuation, which characterizes the presence of purulent fluid. If the abscess is not opened and drained, it can become chronic. Then the patient's condition becomes worse and worse. He loses weight, becomes exhausted, his appetite is reduced, and constipation occurs. After a certain time, the purulent process from the subcutaneous tissue spreads to the skin and opens on its own. This is accompanied by the leakage of pus and relief of the patient’s condition.

In addition to the most common complications listed above after removal of appendicitis, the following pathological conditions may occur in the postoperative wound:

• hematoma;
• bleeding;
• divergence of edges.

Hematoma

Incomplete stoppage of bleeding during surgery can cause hematoma formation. The most common location is in subcutaneous fat; less often, blood accumulation occurs between muscle fibers. The day after the operation, the patient is bothered by dull pain in the wound area and a feeling of pressure. Upon examination, the surgeon determines swelling on the right side of the lower abdomen and pain on palpation.

To eliminate the process, it is necessary to partially remove the surgical sutures and remove blood clots. Next, the stitches are applied again and secured with a bandage on top. Something cold is applied to the wound. In cases where the blood has not yet coagulated, you can make a puncture and remove the hematoma using a puncture. The main thing in treating a hematoma is not to delay it, as the wound may fester, which will worsen the patient’s condition and the prognosis of the disease.

Bleeding

The photo in the article shows one of the types of surgical elimination of the source of bleeding - clipping the vessel.

A serious complication can be bleeding from the stump of the appendix. At first it may not manifest itself in any way, but later general and local signs of blood loss appear.

Common signs include the following:

• headache and dizziness;
• general weakness;
• pale skin;
• cold sweat;
• decreased blood pressure and decreased heart rate during severe bleeding.

Among the local manifestations of this complication after removal of appendicitis, the most characteristic symptom is gradually increasing abdominal pain. At first, moderate and not very disturbing to the patient, it indicates irritation of the peritoneum. But if the bleeding is not stopped in time, the pain becomes more and more intense, which may indicate the development of

If there is a significant accumulation of blood in the abdominal cavity, upon examination, the surgeon determines the irregular shape of the abdomen. With percussion (tapping on the anterior abdominal wall), a dull sound is detected in places where blood accumulates, and peristaltic sounds of the intestines are muffled.

In order not to miss this complication and to provide timely assistance to the patient, it is necessary to regularly check these indicators:

• general condition of the patient;
• blood pressure and pulse;
• abdominal condition, including symptoms of peritoneal irritation (the most common and informative is the Shchetkin-Blumberg symptom).

The only possible treatment method in this situation is relaparotomy, that is, re-opening the abdominal wall, identifying the source of bleeding and stopping it surgically.

Infiltrate and abscess: treatment

How to treat the most common complications after appendectomy?

Treatment of infiltration begins with novocaine blockade. Antibiotics and cold are also prescribed to the site of this formation. In addition, the surgeon, together with the physiotherapist, can prescribe a number of procedures, for example, UHF. If all these therapeutic measures are applied on time, recovery is expected within a few days.

If drug treatment does not help, the patient’s condition worsens, and signs of abscess formation appear, it is necessary to resort to surgical intervention.

If the abscess is not deep, but subcutaneous, it is necessary to remove the stitches, widen the edges of the wound and remove the pus. Next, the wound is filled with tampons moistened with a solution of chloramine or furatsilin. If the abscess is located deeper in the abdominal cavity, which often occurs when an abscess is recognized a week after surgery, it is necessary to perform a repeat laparotomy and remove the suppuration. After the operation, it is necessary to do daily dressings with cleansing the wound with a solution of hydrogen peroxide; after the formation of granulation on the wound, bandages with ointments are used, which promote rapid healing.

Usually these complications do not leave any trace, however, with severe muscle separation, the formation of hernias is possible.

Women after an appendectomy may develop an infiltrate of the pouch of Douglas, which is a depression between the uterus and rectum. The approach to treating this complication is the same as for infiltration of another location. However, here you can add procedures such as warm enemas with furatsilin and novocaine, douching.

Complications from other organs and systems

During the recovery period after surgery, not only complications in the postoperative wound, but also pathologies of other organs may occur.

Thus, in the spring, the appearance of bronchitis and pneumonia is quite common. The main preventive method is therapeutic exercises. It should be started as soon as possible after surgery. It is necessary to prevent the patient from lying passively in bed, as this contributes to the occurrence of congestion in the respiratory tract. The patient must bend and straighten his legs, turn from side to side, and perform breathing exercises. To control the regularity and correctness of the exercises, the hospital must have a methodologist. If there is none, control of the exercises falls on the department nurse.

If pulmonary complications do develop, antibiotic therapy, expectorants and sputum thinners (mucolytics) are prescribed.

One of appendicitis is its cause. Its cause can be either a reflex effect on the nerve plexuses from the side of the surgical wound, or simply the patient’s inability to go to the toilet in a supine position. And although surgeons regularly ask patients about their urination, some patients are embarrassed to talk about this problem. In such cases, the surgeon may observe tension and swelling in the suprapubic region, and the patient experiences pain in the lower abdomen.

After catheterization and removal of the bladder contents, all complaints disappear and the patient's condition improves. However, before resorting to catheterization, simpler methods can be used. Sometimes, after the patient gets to his feet, the act of urination occurs. It is also possible to use heating pads on the lower abdomen, diuretics.

Postoperative complications in children

Unfortunately, at this time, a high percentage of complications after appendectomy in children under three years of age is determined - from 10 to 30%. This is associated with a more severe course of the disease and the frequent development of destructive forms of appendicitis.

Among the complications after appendicitis in children, the following pathological conditions most often occur:

• infiltration and abscess;
• postoperative intestinal obstruction due to the formation of adhesions;
• intestinal fistula;
• prolonged course of peritonitis.

Unfortunately, children are more likely to die after surgery than adults.

And although complications after appendicitis are becoming less common these days, it is important to know their symptoms to prevent dangerous consequences.

One of the most common diseases in people who need surgery is inflammation of appendicitis.

The atrophied part of the large intestine is the appendix; it looks like a vermiform appendix of the cecum. The appendix forms between the large and small intestines.

Doctors note that it is quite difficult to predict and prevent the disease. Experts do not recommend taking painkillers in case of appendicitis.

The appointment will prevent the doctor from making a correct diagnosis of the patient. This should be done exclusively by a specialist who will prescribe an ultrasound.

Thanks to them, it will be possible to understand what shape the inflamed appendix has. It may be clogged or swollen. It can only be removed surgically.

Forms of appendicitis

Today, the disease is divided into acute and chronic forms. In the first case, the clinical picture is pronounced.

The patient is very ill, and therefore emergency hospitalization cannot be avoided. In the chronic form, the patient feels a condition caused by acute inflammation with no symptoms.

Types of appendicitis

Today there are 4 types of appendicitis known. These are: catarrhal, phlegmonous, perforative; gangrenous.

The diagnosis of catarrhal appendicitis is made by a doctor if the penetration of leukocytes into the mucous membrane of the worm-shaped organ has been noted.

Phlegmonous is accompanied by the presence of leukocytes in the mucosa, as well as other deep layers of appendix tissue.

Perforated is observed if the walls of the inflamed appendix of the cecum have been torn, but gangrenous appendicitis is the wall of the appendix affected by leukocytes, which is completely dead.

Symptoms

Symptoms of the disease include:

• acute pain in the abdominal area, or more precisely in the right half in the area of ​​the inguinal fold;
• increased body temperature;
• vomiting;
• nausea.

The pain will be constant and dull, but if you try to turn your body, it will become even stronger.

It should be noted that it is possible that after a severe attack of pain the syndrome disappears.

Patients will mistake this condition for the fact that they feel better, but in fact, the subsidence of pain carries a great danger, indicating that a fragment of the organ has died off, and it is not for nothing that the nerve endings have ceased to respond to irritation.

Such pain relief ends with peritonitis, which is a dangerous complication after appendicitis.

Problems with the gastrointestinal tract may also be observed in symptoms. A person will feel a feeling of dry mouth, he may be bothered by diarrhea and loose stools.

Blood pressure may jump and heart rate may increase to 100 beats per minute. The person will suffer from shortness of breath, which will be caused by impaired heart function.

If the patient has a chronic form of appendicitis, then all of the above symptoms do not appear, with the exception of pain.

The most common complications after appendicitis

Of course, doctors set themselves the task of eliminating all complications after appendicitis removal, but sometimes they simply cannot be avoided.

Below are the most common consequences of appendicitis.

Perforation of the walls of the appendix

In this case, there are ruptures in the walls of the appendix. Its contents will end up in the abdominal cavity, and this provokes sepsis of other organs.

The infection can be quite severe. A fatal end is not ruled out. Such perforation of the walls of appendicitis is observed in 8-10% of patients.

If it is purulent peritonitis, the risk of death is high, and exacerbation of symptoms cannot be ruled out. This complication after appendicitis occurs in 1% of patients.

Appendiceal infiltrate

These complications after surgery to remove appendicitis are observed in the case of adhesions of organs. The percentage of such cases is 3-5.

The development of complications begins 3-5 days after the formation of the disease. Accompanied by pain of unclear localization.

Over time, the pain subsides, and the contours of the inflamed area appear in the abdominal cavity.

The infiltrate with inflammation acquires pronounced boundaries and a dense structure, and tension in nearby muscles will also be observed.

In about 2 weeks the swelling will go away and the pain will stop. The temperature will also subside, and blood counts will return to normal.

In many cases, it is possible that the inflamed part after appendicitis will cause the development of an abscess. It will be discussed below.

Abscess

The disease develops against the background of suppuration of the appendiceal infiltrate or surgery if peritonitis is diagnosed.

As a rule, it takes 8-12 days for the disease to develop. All abscesses need to be covered and debrided.

In order to improve the outflow of pus, doctors install drainage. During the treatment of complications after appendicitis, it is customary to use antibacterial drug therapy.

If there is a similar complication after appendicitis, urgent surgery is necessary.

After this, the patient will have to wait for a long rehabilitation period, accompanied by drug treatment.

Complications after appendectomy

Even if the operation to remove appendicitis was performed before the onset of severe symptoms, this does not guarantee that there will be no complications.

Many cases of death after appendicitis make people pay closer attention to any warning signs.

Below are the most common complications that may occur after removal of an inflamed appendix.

Spikes

One of the most common pathologies that appears after removal of the appendix. Accompanied by nagging pain and discomfort.

It is difficult to diagnose, because ultrasound and x-rays cannot see them. It is necessary to carry out a course of treatment with absorbable drugs and resort to the laparoscopic method of removing adhesions.

Hernia

The phenomenon is really common after appendicitis. There is a prolapse of part of the intestine into the area of ​​the lumen between the muscle fibers.

A hernia looks like a tumor in the suture area, increasing in size. Surgical intervention is provided. The surgeon will sew it up, trim it, or remove part of the intestine and omentum.

Abscess

Occurs in most cases after appendicitis with peritonitis. It can infect organs.

A course of antibiotics and special physiotherapeutic procedures is required.

Pylephlebitis

A very rare complication after surgery to remove appendicitis. Inflammation is observed, which spreads to the area of ​​the portal vein, mesenteric vein and process.

Accompanied by fever, severe liver damage, and acute pain in the abdominal area.

If this is an acute stage of the pathology, then everything can lead to death. Treatment is complex, requiring the introduction of antibiotics into the portal vein systems.

Intestinal fistulas

Occurs after appendicitis in 0.2-0.8% of people. Intestinal fistulas form a tunnel in the intestines and skin, sometimes in the walls of internal organs.

The reasons for their appearance may be poor sanitation of purulent appendicitis, surgeon errors, tissue inflammation during drainage of internal wounds and foci of abscess development.

It is difficult to treat the pathology. Sometimes doctors prescribe resection of the affected area, as well as removal of the top layer of epithelium.

It should be noted that the occurrence of complications is facilitated by ignoring the doctor’s advice, failure to comply with hygiene rules, and violation of the regime.

Deterioration of the condition can be observed 5-6 days after surgery.

This will indicate the development of pathological processes in the internal organs. During the postoperative period, it is possible that you will need to consult with your doctor.

You should not avoid this; on the contrary, your body gives signals that other ailments are developing, they may not even be related to the appendectomy.

It is important to pay due attention to your health and do not hesitate to seek help from a doctor.

Increased body temperature

The inflammatory process can also affect other organs, and therefore the occurrence of additional health problems is possible.

Women often suffer from inflammation of the appendages, which makes diagnosis and the exact cause of the disease difficult.

Often, the symptoms of acute appendicitis can be confused with similar pathologies, and therefore doctors prescribe an examination by a gynecologist and an ultrasound of the pelvic organs if the operation is not emergency.

Also, an increase in body temperature indicates that an abscess or other diseases of the internal organs are possible.

If the temperature rises after the operation, then you need to undergo an additional examination and be tested again.

Digestive disorders

Diarrhea and constipation may indicate a malfunction of the gastrointestinal tract after appendicitis. At this time, the patient is having a hard time with constipation; he cannot push or strain, because this is fraught with protrusion of hernias, ruptured sutures and other problems.

To avoid indigestion, you need to stick to a diet, making sure that the stool is not fixed.

Pain attacks in the abdomen

As a rule, there should be no pain for 3-4 weeks after surgery. This is how long it takes for tissue regeneration to take place.

In some cases, pain indicates hernias or adhesions, and therefore there is no need to take painkillers, you should consult a doctor.

It is worth noting that appendicitis is often encountered in the medical practice of doctors. The pathology requires urgent hospitalization and surgery.

The thing is that inflammation can quickly spread to other organs, which will entail many serious consequences.

To prevent this from happening, it is important to visit a doctor in a timely manner and call an ambulance. Do not ignore those signals from the body that indicate the development of the disease.

Appendicitis is dangerous; even with a successful operation, deaths have been observed more than once, let alone when patients neglect their health.

Prevention

There are no special preventive measures for appendicitis, but there are some rules that should be followed to reduce the risk of developing inflammation in the area of ​​the appendix of the cecum.

1. Adjust your diet. Moderate your intake of fresh herbs (parsley, green onions, dill, sorrel, lettuce), hard vegetables and ripe fruits, seeds, fatty and smoked treats.
2. Take care of your health. It is worth paying attention to all signals about a malfunction in your body. There have been many cases in medical practice where inflammation of the appendix was caused by the penetration of pathogenic microorganisms into it.
3. Detect helminthic infestations and provide timely treatment.

Summing up

Although appendicitis is not considered a dangerous disease, the pathology has a high risk of developing complications after surgical removal of the appendix of the cecum. Typically, they occur in 5% of people after appendicitis.

The patient can count on qualified medical care, but it is important not to miss the moment and consult a doctor in a timely manner.

You need to wear a bandage, women can wear panties. This measure will help not only to eliminate complications after appendicitis, but also to keep the seam neat, without causing it to become defective.

Pay attention to your health, and even if appendicitis has been detected, try to do everything that the doctor directs to avoid problems in the future.

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