Appendectomy indications. Appendicitis - diagnosis and treatment

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Appendectomy is one of the most common interventions on the abdominal organs. It involves removing the inflamed appendix, so appendicitis is the main indication for surgery. Inflammation of the appendix occurs in young people (mostly 20-40 years old) and in children.

Appendicitis is an acute surgical disease manifested by abdominal pain, symptoms of intoxication, fever, and vomiting. Despite the apparent simplicity of the diagnosis, sometimes it is quite difficult to confirm or refute the presence of this disease. Appendicitis is a “master of disguise”; it can simulate many other diseases and have a completely atypical course.

The vermiform appendix extends in the form of a narrow canal from the cecum. In early childhood, it participates in local immunity thanks to the lymphoid tissue in its wall, but with age this function is lost, and the process is a practically useless formation, the removal of which does not carry any consequences.

The cause of inflammation of the appendix has not yet been precisely determined; there are a lot of theories and hypotheses (infections, obstruction of the lumen, impaired trophism, etc.), but with its development there is always only one way out - surgery.

Based on the nature of changes in the appendix, destructive (phlegmonous, gangrenous) and non-destructive (catarrhal, superficial) forms of the disease are distinguished. Acute purulent appendicitis, when pus accumulates in the wall of the appendix and its lumen, as well as the gangrenous variant, a sign of which is necrosis (gangrene) of the appendix, are considered the most dangerous, since peritonitis and other dangerous complications are likely.

A special place belongs to chronic appendicitis, which occurs as a result of catarrhal disease that has not been operated on. This type of inflammation is accompanied by periodic exacerbations with pain, and an adhesive process develops in the abdominal cavity.

Appendiceal infiltrate is an inflammatory process in which the appendix merges with the surrounding areas of the intestine, peritoneum, and omentum. The infiltration is limited in nature and, as a rule, requires preliminary conservative treatment.

A special group of patients consists of children and pregnant women. In children, the disease practically does not occur until one year of age. The greatest diagnostic difficulties arise in young patients under 5-6 years of age, who have difficulty describing their complaints, and specific signs are less pronounced than in adults.

Pregnant women are more susceptible to inflammation of the appendix than others for a number of reasons: a tendency to constipation, displacement of abdominal organs by an enlarging uterus, decreased immunity due to changes in hormonal levels. Pregnant women are more prone to destructive forms that can lead to fetal death.

Indications and preparation for surgery

Appendectomy is one of the interventions that in most cases is performed as an emergency. Indication: acute appendicitis. A planned operation to remove the appendix is performed with appendiceal infiltrate after the inflammatory process has subsided, approximately 2-3 months from the onset of the disease. In case of increasing symptoms of intoxication, rupture of an abscess with peritonitis, the patient needs emergency surgical treatment.

There are no contraindications to appendectomy, except in cases of the patient's agonal state, when the operation is no longer advisable. If doctors have adopted a wait-and-see approach due to appendiceal infiltration, then severe decompensated diseases of the internal organs may be contraindications to surgery, but during conservative treatment the patient’s condition can be stabilized to such an extent that he can undergo the intervention.

The operation usually lasts about an hour, both general anesthesia and local anesthesia are possible. The choice of pain relief is determined by the patient’s condition, his age, and concomitant pathology. Thus, in children, people with excess body weight, which involves greater trauma when entering the abdominal cavity, with nervous overexcitation and mental illness, general anesthesia is preferable, and in thin young people, in some cases, it is possible to remove the appendix with local anesthesia. Pregnant women, due to the negative impact of general anesthesia on the fetus, are also operated on under local anesthesia.

The urgency of the intervention does not require sufficient time to prepare the patient, so the necessary minimum examinations are usually performed (general blood test, urine test, coagulogram, consultations with specialists, ultrasound, x-rays). To exclude acute pathology of the uterine appendages, women need to be examined by a gynecologist, possibly with an ultrasound examination. If there is a high risk of thrombosis of the veins of the extremities, the latter are bandaged before surgery with elastic bandages.

Before the operation, the bladder is catheterized, the contents are removed from the stomach if the patient ate later than 6 hours before the operation, and an enema is indicated for constipation. The preparatory stage should last no more than two hours.

When the diagnosis is beyond doubt, the patient is taken to the operating room, anesthesia is administered, and the surgical field is prepared (hair shaving, iodine treatment).

Progress of the operation

The classic operation to remove appendicitis is performed through an incision in the anterior abdominal wall in the right iliac region, through which the cecum with the appendix is removed, it is cut off, and the wound is sutured tightly. Depending on the location of the appendix, its length, and the nature of pathological changes, antegrade and retrograde appendectomy are distinguished.

The course of the operation includes several stages:

Formation of access to the affected area;
Removal of the cecum;
Severing the appendix;
Layer-by-layer suturing of the wound and control of hemostasis.

To “get” to the inflamed appendix, a standard incision about 7 cm long is made in the right iliac region. The reference point is McBurney's point. If you mentally draw a segment from the navel to the right upper iliac spine and divide it into three parts, then this point will lie between the outer and middle thirds. The cut passes at right angles to the resulting line through the indicated point, a third of it is located above, two thirds - below the specified landmark.

on the left – traditional open surgery, on the right – laparoscopic surgery

After the surgeon has cut through the skin and subcutaneous fat, he will have to penetrate the abdominal cavity. The fascia and aponeurosis of the oblique muscle are cut, and the muscles themselves are moved to the sides without incision. The last obstacle is the peritoneum, which is cut between the clamps, but first the doctor will make sure that the intestinal wall does not get into them.

Having opened the abdominal cavity, the surgeon determines the presence of obstacles in the form of adhesions and adhesions. When they are loose, they are simply separated with a finger, and when they are dense, connective tissue, they are cut with a scalpel or scissors. This is followed by the removal of a section of the cecum with the appendix, for which the surgeon carefully pulls the wall of the organ, removing it out. Upon penetration into the abdomen, inflammatory exudate may be detected there, which is removed with wipes or an electric suction.

appendectomy: progress of the operation

The appendix is removed antegrade (typically) and retrogradely (less commonly). Antegrade removal involves ligation of the vessels of the mesentery, then a clamp is applied to the base of the appendix, the appendix is sutured and cut off. The stump is immersed in the cecum, and the surgeon remains to apply stitches. The condition for antegrade removal of the appendix is the possibility of its unhindered removal into the wound.

Retrograde appendectomy is performed in a different sequence: first, the appendix is cut off, the stump of which is immersed in the intestine, sutures are applied, and then the vessels of the mesentery are gradually sutured and it is cut off. The need for such an operation arises when the appendix is localized behind the cecum or retroperitoneally, with a pronounced adhesive process that makes it difficult to remove the appendix into the surgical field.

After the appendix is removed, stitches are applied, the abdominal cavity is examined, and the abdominal wall is sutured layer-by-layer. Usually the suture is blind and does not imply drainage, but only in cases where there are no signs of the inflammatory process spreading to the peritoneum, and no exudate is found in the abdomen.

In some cases, it becomes necessary to install drains, indications for which are:

Development of peritonitis;
Possibility of incomplete removal of the appendix and insufficient hemostasis;
Inflammation of the retroperitoneal tissue and the presence of abscesses in the abdominal cavity.

When it comes to peritonitis, 2 drainages are needed - into the area of the removed process and the right lateral canal of the abdomen. In the postoperative period, the doctor carefully monitors the discharge from the abdominal cavity, and if necessary, a repeat operation is possible.

Suspect peritonitis(inflammation of the peritoneum) is possible even at the stage of examining the patient. In this case, an incision in the midline of the abdomen would be preferable, providing a good view of the abdominal cavity and the possibility of lavage (washing with saline or antiseptics).

Laparoscopic appendectomy

Recently, with the development of technical capabilities in medicine, minimally invasive techniques, also used in the surgery of abdominal diseases, are becoming increasingly popular. Laparoscopic appendectomy is a worthy alternative to classical surgery, but for a number of reasons it cannot be performed on every patient.

Laparoscopic removal of the appendix is considered a more gentle method of treatment, which has a number of advantages:

Low morbidity compared to abdominal surgery;
Possibility of local anesthesia in most patients;
Shorter recovery period;
The best result for severe diseases of internal organs, diabetes, obesity, etc.;
Good cosmetic effect;
Minimum complications.

However, laparoscopic appendectomy also has some disadvantages. For example, an operation requires the availability of appropriate expensive equipment and a trained surgeon at any time of the day, because the patient can be taken to the hospital at night. Laparoscopy does not allow a detailed examination of the entire volume of the abdominal cavity, adequate sanitation and removal of exudate in common forms of the inflammatory process. In severe cases, with peritonitis, it is impractical and even dangerous.

Through many years of discussions, doctors determined the indications and contraindications for laparoscopic removal of the appendix.

The following are considered indications:

If there are no risks, the patient’s condition is stable, and the inflammation has not spread beyond the appendix, then laparoscopic appendectomy can be considered the method of choice.

Contraindications to minimally invasive treatment:

More than a day from the onset of the disease, when the likelihood of complications is high (perforation of the appendix, abscess).
Peritonitis and the transition of inflammation to the cecum.
Contraindications for a number of other diseases - myocardial infarction, decompensated heart failure, bronchopulmonary pathology, etc.

In order for laparoscopic appendectomy to be a safe and effective treatment procedure, the surgeon will always weigh the pros and cons, and in the absence of contraindications to the procedure, it will be a low-traumatic treatment method with minimal risk of complications and a short postoperative period.

The course of laparoscopic appendectomy includes:

Laparoscopic surgery for appendicitis lasts up to one and a half hours, and the postoperative period takes only 3-4 days. Scars after such an intervention are barely noticeable, and after some time has passed for final healing, they can be difficult to find.

The suture after open surgery is removed after 7-10 days. A scar will remain at the site of the incision, which will thicken and fade over time. The scar formation process takes several weeks.

The cosmetic effect is largely determined by the efforts and skill of the surgeon. If the doctor treats the wound suturing conscientiously, the scar will be almost invisible. If complications develop, if it is necessary to increase the length of the incision, the surgeon will be forced to sacrifice the cosmetic side of the issue in favor of preserving the health and life of the patient.

Postoperative period

In cases of uncomplicated forms of appendicitis and a favorable course of the operation, the patient can be immediately taken to the surgical department, in other cases - to the postoperative ward or intensive care unit.

During the rehabilitation period, wound care and early activation of the patient are of great importance, allowing the intestines to “turn on” in time and avoid complications. Dressings are carried out every other day, if there are drainages - daily.

On the first day after the intervention, the patient may experience pain and increased body temperature. Pain is a natural phenomenon, because both the inflammation itself and the need for incisions imply tissue damage. Usually the pain is localized to the site of the surgical wound, it is quite tolerable, and the patient is prescribed analgesics if necessary.

Antibacterial therapy is indicated for complicated forms of appendicitis. Fever may be a consequence of surgery and a natural reaction during the recovery period, but it must be carefully monitored, since an increase in temperature to significant levels is a sign of serious complications. The temperature should not exceed 37.5 degrees during the normal course of the postoperative period.

Many patients prefer to lie in bed, citing weakness and pain. This is wrong, because the sooner the patient gets up and starts moving, the faster intestinal function will be restored and the lower the risk of dangerous complications, in particular thrombosis. In the very first days after the operation, you need to gather your courage and at least walk around the ward.

A very important role in interventions on the abdominal organs is given to diet and nutrition. On the one hand, the patient must get the calories he needs, on the other hand, he must not harm the intestines with an abundance of food, which during this period can cause adverse consequences.

You can start eating after the appearance of intestinal peristalsis, as evidenced by the first independent stool. The patient should be informed what can be eaten after surgery and what is better to avoid.

Patients who have suffered acute appendicitis are assigned to table No. 5. Safe to consume compotes and tea, lean meats, light soups and cereals, white bread. Fermented milk products, stewed vegetables, and fruits that do not contribute to gas formation are useful.

During the recovery period can't eat fatty meat and fish, legumes, fried and smoked foods, spices, alcohol, coffee, baked goods and sweets, carbonated drinks should be excluded.

On average, after surgery, the patient remains in the hospital for about a week in uncomplicated forms of the disease, otherwise longer. After laparoscopic appendectomy, discharge is possible already on the third day after the operation. You can return to work after a month with open operations, with laparoscopy - after 10-14 days. A sick leave certificate is issued depending on the treatment performed and the presence or absence of complications for a month or more.

Video: what should be the diet after appendicitis removal?

Complications

After surgery to remove the appendix, some complications may develop, so the patient needs constant monitoring. The operation itself usually proceeds well, but some technical difficulties may be caused by the unusual location of the appendix in the abdominal cavity.

The most common complication in the postoperative period is considered suppuration in the area of the incision, which in case of purulent types of appendicitis can be diagnosed in every fifth patient. Other options for unfavorable developments - peritonitis, bleeding into the abdominal cavity with insufficient hemostasis or sutures slipping off the vessels, seam dehiscence, thromboembolism, adhesive disease in the late postoperative period.

Considered a very dangerous consequence sepsis when purulent inflammation becomes systemic, as well as the formation of ulcers (abscesses) in the abdomen. These conditions are facilitated by rupture of the appendix with the development of diffuse peritonitis.

Appendectomy is an operation that is performed for emergency reasons, and its absence can cost the patient’s life, so it would be illogical to talk about the cost of such treatment. All appendectomies are performed free of charge, regardless of the patient’s age, social status, or citizenship. This procedure has been established in all countries, because any acute surgical pathology requiring urgent measures can occur anywhere and anytime.

Doctors will save the patient by performing an operation on him, but subsequent treatment and observation during a period when nothing threatens life may require some costs. For example, a general blood or urine test in Russia will cost an average of 300-500 rubles, and consultations with specialists - up to one and a half thousand. Post-surgery costs associated with continued treatment may be covered by insurance.

Since interventions like appendectomy are carried out urgently and unplanned for the patient himself, reviews of the treatment received will vary greatly. If the disease was limited in nature, the treatment was carried out quickly and efficiently, the feedback will be positive. Laparoscopic surgery can leave a particularly good impression when, just a few days after a life-threatening pathology, the patient finds himself at home and feeling well. Complicated forms that require long-term treatment and subsequent rehabilitation are much worse tolerated, and therefore the negative impressions of patients remain for life.

Video: appendicitis removal - medical animation

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Diagnosis of appendicitis

Diagnostics appendicitis in most cases based on objective examination data. It consists of examining the patient by a doctor and identifying certain symptom complexes. In parallel, laboratory diagnostics are carried out, which consists of conducting general blood tests and urine tests. If necessary, resort to instrumental diagnostics, which is based on ultrasound examination (ultrasound) and diagnostic laparoscopy.

Examination of a patient with appendicitis

A patient with acute appendicitis is usually in a lying position on the right side, with both legs bent at the knee and hip joints. This position limits the movement of the abdominal wall, thereby reducing the intensity of pain. If the patient gets up, he holds the right iliac region with his hand. Externally, the patient looks satisfactory - the skin is slightly pale, the pulse is increased to 80 - 90 beats per minute.

The appearance of the patient as a whole depends on the form and evolution of appendicitis. In destructive forms, the skin is sharply pale (bloodless), the pulse quickens to 100 - 110 beats per minute, consciousness may be slightly clouded (the patient is sleepy, lethargic, lethargic). The tongue, at the same time, is dry and covered with a gray coating. With catarrhal appendicitis, the patient is relatively active and able to move independently.

After an external examination, the doctor begins palpation. The abdomen of a patient with appendicitis is slightly distended, and in the presence of concomitant peritonitis, there is pronounced bloating and tension of the abdomen. With pronounced pain syndrome, there is a lag in the right part of the abdomen in the act of breathing. The key symptom upon palpation of the abdomen is local pain and protective tension of the abdominal muscles in the lower right quadrant (projection of the iliac region). In order to identify pain on palpation, the doctor compares the right and left sides of the abdomen. Palpation begins from the left side and then counterclockwise the doctor palpates the epigastric and right iliac region. Reaching the last one, he notes that the abdominal muscles in this area are more tense than in the previous ones. The patient also indicates the severity of pain in this particular location. Next, the doctor begins to identify appendiceal symptoms.

Diagnostic objective symptoms for appendicitis are:

Shchetkin-Blumberg symptom– the doctor presses on the abdominal wall in the right iliac region, after which he sharply withdraws his hand. This maneuver is accompanied by increased pain and even greater tension in the abdominal wall muscles.
Sitkovsky's symptom– when the patient turns on the left side, the pain in the right side intensifies. This symptom is explained by the displacement of the cecum and its tension, which increases the pain.
Cough symptom– when the patient coughs, the pain in the right iliac region (the site of projection of the appendix) intensifies.
Obraztsov's symptom(informative for atypical position of the appendix) - first the doctor presses on the right iliac region, and then asks the patient to raise his right leg. This leads to increased pain.

Diagnostic laparoscopy for appendicitis

Sometimes, when the clinical picture of appendicitis is blurred and the data obtained during ultrasound diagnostics are uninformative, the doctor resorts to the method of diagnostic laparoscopy. It should immediately be noted that laparoscopy can also be performed to remove the appendix. However, first, to find out the causes of the patient’s pain, laparoscopy is performed for diagnostic purposes, that is, to find out whether there is appendicitis or not.

Laparoscopy is a type of minimally invasive (low-traumatic) surgical intervention, during which special endoscopic instruments are used instead of a scalpel. The main instrument is the laparoscope, which is a flexible tube with an optical system. Through it, the doctor is able to visualize on the monitor the condition of the organs inside the abdominal cavity, namely the appendix. At the same time, laparoscopy allows you to visualize internal organs at thirty-fold magnification.

A small puncture is made with a trocar or a large needle in the umbilical area, through which carbon dioxide (CO 2) is supplied into the abdominal cavity. This maneuver allows you to straighten the folds of the intestine and visualize the appendix more clearly. Next, a laparoscope is inserted through the same hole, which is connected to a video monitor. Using a special clamp or retractor, which is also inserted into the abdominal cavity through a separate puncture, the doctor moves back the intestinal loops to better examine the appendix.

Signs of inflammation are hyperemia (redness) and thickening of the process. Sometimes it is covered with a whitish layer of fibrin, which speaks in favor of the development of destructive processes. If the above signs are present, then acute appendicitis should be suspected. In addition to the appendix, the doctor examines the terminal ileum, cecum, and uterine appendages. The right iliac fossa should also be carefully inspected for the presence of inflammatory exudate.

Tests for appendicitis

There are no specific tests that would indicate acute appendicitis. At the same time, a general blood test indicates the presence of an inflammatory process in the body, which, together with other studies conducted, will speak in favor of a diagnosis of acute appendicitis.

Changes in the general blood test for appendicitis are:

an increase in the number of leukocytes more than 9x10 9 - in catarrhal forms more than 12x10 9, in destructive forms more than 20x10 9;
a shift in the leukocyte formula to the left, which means the appearance of young forms of leukocytes in the blood;
lymphocytopenia – decreased number of lymphocytes.

Ultrasound for appendicitis

Ultrasound diagnosis of appendicitis is carried out if there is doubt about the diagnosis. It should be noted that the information content of the method is low - for catarrhal forms of appendicitis - 30 percent, for destructive forms - up to 80 percent.
This is explained by the fact that normally the appendix is not visible on ultrasound. However, during the inflammatory process, its walls thicken, which creates the appearance during examination. The longer the infectious process, the more pronounced the destructive changes in the appendix. Therefore, the ultrasound diagnostic method is most valuable for appendiceal infiltrates and chronic appendicitis.

With simple inflammation, the process is visualized on ultrasound as a tube with layered walls. When the sensor is compressed onto the abdominal wall, the appendix does not shrink and does not change its shape, which indicates its elasticity. The walls are thickened, which causes an increase in the diameter of the process compared to the norm. Inflammatory fluid may be present in the lumen of the appendix, which is clearly visible during examination. In gangrenous forms of appendicitis, the characteristic layering disappears.

A ruptured appendix leads to the release of pathological fluid into the abdominal cavity. In this case, the appendix ceases to be visible on ultrasound. The main symptom in this case is the accumulation of fluid, most often in the right iliac fossa.

Echo signs of acute appendicitis are:

thickening of the appendix wall;
infiltration of the appendix and ileocecal junction;
disappearance of layering of the process wall;
accumulation of fluid inside the appendix;
accumulation of fluid in the iliac fossa, between the intestinal loops;
the appearance of gas bubbles in the lumen of the appendix.

Diagnosis of chronic appendicitis

Diagnosis of chronic inflammation of the appendix is based on the exclusion of other diseases that have a similar clinical picture, and a history of signs of acute appendicitis.

The main diseases that are excluded when diagnosing chronic appendicitis are:

chronic form of pancreatitis (inflammation of the pancreas);
chronic form of cholecystitis (inflammation of the gallbladder);
chronic form of pyelonephritis (kidney inflammation);
inflammation of the genital organs;
benign and malignant abdominal tumors.

During an examination of a patient with suspected chronic appendicitis, the doctor prescribes a series of studies and tests that reveal indirect signs of inflammation of the appendix.

Studies that are carried out for suspected chronic appendicitis

Type of study	Purpose of the study	Possible changes in chronic appendicitis
*General blood analysis*	identify signs of inflammation.	moderate leukocytosis; increase in ESR ( erythrocyte sedimentation rate) .
*General urine analysis*	exclude pathology of the urinary organs.	no pathological changes.
*Ultrasound examination of the abdominal organs*	identify pathology of the appendix; exclude pathology of the pelvic and abdominal organs.	thickening ( more than 3 millimeters) the walls of the appendix; expansion of the appendix ( diameter more than 7 millimeters); a sign of inflammation in the form of increased echogenicity of tissues.
*X-ray of the intestine with contrast agent*	identify signs of partial or complete obliteration of the appendix.	retention of contrast agent in the lumen of the appendix; failure of the contrast medium to pass into the cavity of the appendix; fragmented filling of the appendix.
*Computed tomography of the abdomen*	determine the condition of the appendix; exclude pathology of other organs.	inflammation of the appendix and adjacent tissues; an increase in the size of the appendix and its walls.
*Diagnostic laparoscopy*	visual confirmation of the diagnosis of chronic appendicitis; exclusion of other pathologies of the abdominal organs.	changes in the appendix due to chronic inflammation ( enlargement, curvature); the presence of adhesions between organs and tissues surrounding the appendix; dropsy, mucocele, empyema of the appendix; inflammation of surrounding tissues.

Types of operations to remove appendicitis

For appendicitis, an operation called an appendectomy is performed. During this surgical procedure, the inflamed appendix is completely removed.

There are two main options for surgery for appendicitis. The first option is a classic abdominal appendectomy, which is performed by laparotomy. Laparotomy means cutting the anterior abdominal wall followed by opening the abdominal cavity. This type of surgery is also called open.

The second option for surgery for appendicitis is a closed operation - laparoscopic appendectomy. It is carried out using a special instrument inserted into the abdominal cavity through small holes. Each type of operation has its own characteristics, advantages and disadvantages.

Removal of appendicitis using the classical method (classical appendectomy)

Currently, in case of appendicitis, they most often resort to classical surgery to remove the appendix. Like any surgical operation, it has its indications and contraindications.

Indications for performing a classic appendectomy are:

positive diagnosis of acute appendicitis;
acute appendicitis complicated by peritonitis;
appendicular infiltrate;
chronic appendicitis.

In case of a positive diagnosis of acute appendicitis or the presence of signs of peritonitis, surgical intervention should be performed urgently. In case of appendiceal infiltrate, abdominal surgery is performed only after a course of conservative treatment and is planned. It is usually prescribed several months after the acute process has stopped. Chronic appendicitis is also an indication for elective appendectomy.

Contraindications for performing a classic appendectomy include:

the patient is in a state of agony;
written refusal of the patient from surgical intervention;
in the case of a planned operation - severe decompensation of the cardiovascular and respiratory systems, kidneys or liver.

Preparing the patient for abdominal appendectomy
To perform a classic appendectomy, the patient does not undergo any special preoperative preparation. In case of severe water-salt imbalance and/or peritonitis, the patient is given intravenous fluids and antibiotics.
The entire surgical process of classical appendectomy is divided into several stages.

The stages of the surgical process of classical appendectomy are:

preparation of the surgical field;
creating access through the anterior abdominal wall;
revision of the abdominal organs and exposure of the appendix;
resection (cutting off) of the vermiform appendix;

Anesthesia
Surgeries to remove an inflamed appendix using the abdominal method are most often performed under general anesthesia. The patient is put under anesthesia using intravenous and/or inhaled drugs. Less commonly, during classical appendectomy, spinal (epidural or spinal) anesthesia is performed.

Preparation of the surgical field
Preparation of the surgical field begins with the positioning of the patient. During the operation, the patient is in a horizontal position - lying on his back. The skin of the anterior abdominal wall in the area of the future incision is treated with antiseptics - alcohol, betadine (povidone-iodine) or an alcohol solution of iodine.

Creating access through the anterior abdominal wall
Access through the anterior abdominal wall during classical appendectomy depends on the location of the appendix. During the examination of the patient, the doctor determines the point of maximum pain. The vermiform appendix is located in this place. Based on this, the surgeon chooses the most suitable access to expose it.

Options for access through the anterior abdominal wall during abdominal appendectomy are:

oblique incision according to Volkovich-Dyakonov;
longitudinal Lenander approach;
transverse access.

The Volkovich-Dyakonov oblique incision is most often used in operations for appendicitis. The surgeon visually draws a line from the navel to the apex of the iliac wing on the right, dividing it into three segments. At a point between the middle and lower segments, he makes a skin incision perpendicular to this line. The incision usually does not exceed 7–8 centimeters. One third of the incision length is above the visual line and two thirds are directed downward. Longitudinal access is obtained by cutting the skin in the lower abdomen along the edge of the right rectus muscle. For a transverse approach, an incision is made parallel to the costal arch in the middle third of the abdomen.
After dissection of the skin, layer-by-layer separation of all tissues of the anterior abdominal wall follows.

Layer-by-layer separation of tissues of the anterior abdominal wall during abdominal appendectomy

Layers of fabrics	Separation method
*Subcutaneous adipose tissue*	Scalpel incision.
*Superficial fascia*	Dissection with a scalpel.
*Aponeurosis of the external oblique muscle*	Cut with special scissors.
*External oblique muscle*	Shift to the side by the retractor ( surgical instrument for retracting soft tissues).
*Internal oblique and transverse abdominis muscles*	Expansion with two blunt instruments - closed clamps – parallel to muscle fibers or fingers.
*Preperitoneal tissue* *(adipose tissue)*	Shifting to the side with a blunt object or hands.
*Peritoneum* *(inner lining of the abdominal cavity)*	Grasping with two tweezers or clamps and cutting between them with a scalpel.

After dissection of the peritoneum, its edges are pulled back with clamps and attached to the tissues of the surgical field. During layer-by-layer separation of tissues, sutures are immediately applied to all cut vessels to avoid large blood losses.

Revision of the abdominal organs and exposure of the appendix
In the opened abdominal cavity, the surgeon uses his index finger to inspect the large intestine. He mainly pays attention to the presence of adhesions and formations that may interfere with the exposure of the appendix. If there are none, then the doctor pulls out the cecum from the abdominal cavity, holding it with damp gauze. Following this, the inflamed appendix is exposed. The rest of the intestine and abdominal cavity are fenced off with damp gauze. If difficulties arise in releasing the intestine or appendix, the incision is enlarged. During all manipulations, the surgeon assesses the condition of the internal organs and peritoneum, paying attention to any morphological defects.

Resection of the vermiform appendix
After identifying the inflamed appendix, they begin to resection it and suturing the defects in its mesentery and cecum. The suture material is threads made of catgut or synthetic absorbable material.

Step-by-step manipulations for resection of the appendix during classical appendectomy are:

applying a clamp to the mesentery of the appendix at its apex;
piercing the mesentery at the base of the appendix;
applying a second clamp to the mesentery along the appendix;
suturing or ligating the vessels of the mesentery;
cutting off the mesentery from the appendix;
applying a clamp at the base of the appendix;
ligation of the appendix between the clamp and the cecum;
placing a special suture on the cecum;
cutting off the appendix between the clamp and the dressing site;
immersion of the stump of the process into the intestinal lumen with tweezers or a clamp;
tightening the suture on the cecum and applying an additional superficial suture in the form of the letter Z.

With appendicitis, it is not always possible to easily expose and bring the vermiform appendix into the lumen of the wound. Based on this, resection of the appendix is carried out in two ways - antegrade and retrograde. In most cases of acute uncomplicated appendicitis, when the appendix is easily brought out, the operation is performed in an antegrade manner. This method is considered standard. At the first stage of the operation, the mesentery of the appendix is ligated and cut off. At the second stage, the appendix itself is bandaged and cut off. When many adhesions are found in the abdominal cavity that make it difficult to release the appendix, retrograde appendectomy is resorted to. The stages of resection are performed in reverse. Initially, the appendix is resected from the cecum, and its end is immersed in the intestinal lumen. All adhesions going from the appendage to the surrounding organs and tissues are gradually cut off. And only then the mesentery is bandaged and cut off.

After resection of the appendix, the surgeon performs sanitation of the abdominal cavity using tampons or electric suction. If there were no complications, the cavity is tightly sutured. If there are special indications, special drains are installed.

Indications for drainage of the abdominal cavity during strip appendectomy are:

peritonitis;
abscess in the appendix area;
inflammatory process in the retroperitoneal tissue;
incomplete hemostasis (stopping bleeding);
the surgeon’s uncertainty about complete removal of the appendix;
the surgeon’s uncertainty about the reliable immersion of the appendix stump into the cecum.

Drains are usually rubber tubes or strips through which inflammatory products are evacuated. They are placed into the abdominal cavity through an additional incision. Typically, after an appendectomy, one drain is left in the area of the removed appendix. But in case of peritonitis, additional drainage is installed along the right lateral canal of the abdominal cavity. As soon as the general condition of the body stabilizes and signs of inflammation disappear, the drains are removed. This happens in about 2 – 3 days.

Closing the surgical approach is performed layer by layer, in the opposite direction of the incisions.

Manipulations when closing surgical access are:

closure of the peritoneum with interrupted sutures;
removal of retractors and connection of muscle fibers of the oblique and rectus abdominis muscles;
bringing together the ends of the aponeurosis of the external oblique abdominal muscle without suturing;
placing absorbable sutures on the subcutaneous tissue;
placing an intermittent suture on the skin using silk threads.

The average time for surgery for appendicitis using the classical method is 40 – 60 minutes. The presence of complications, pronounced adhesions and non-standard location of the appendix can prolong the operation by 2 - 3 hours. Recovery of general condition in the postoperative period occurs within 3 to 7 days. In the first 2–3 days, the patient must remain in bed. Skin sutures are removed 7–10 days after surgery.

Laparoscopy for appendicitis

Surgeries for appendicitis also include laparoscopic appendectomy. This type of surgical intervention is considered minimally invasive (low-traumatic), since the surgical wound is small. Removal of the inflamed appendix using the laparoscopic method has strict indications and contraindications.

Indications for laparoscopic appendectomy include:

acute appendicitis in the first 24 hours from the onset of the disease;
chronic appendicitis;
acute appendicitis in a child;
acute appendicitis in patients suffering from diabetes mellitus or high obesity;
the patient’s desire to be operated on laparoscopically.

Unlike the classic operation to remove the appendix, laparoscopic appendectomy has a wider range of contraindications. All contraindications can be divided into two groups - general and local.

Contraindications for laparoscopic appendectomy

Group of contraindications	Examples
*General contraindications*	pregnancy in the third trimester; acute diseases of the cardiovascular system ( acute heart failure, heart attack); acute respiratory failure due to pulmonary obstruction; pathology of blood clotting; contraindications for general anesthesia.
*Local contraindications*	acute appendicitis lasting more than 24 hours; generalization ( spreading) peritonitis; the presence of an abscess or phlegmon in the appendix area; pronounced adhesive process of the abdominal cavity; unusual location of the appendix; presence of appendicular infiltrate.

Preparing the patient for laparoscopic appendectomy
Laparoscopic surgery for appendicitis does not require any special preparation of the patient and should be performed as soon as possible from the onset of the disease. Before surgery, the patient is placed on an IV with saline or ringer's solution and given broad-spectrum antibiotics. In the operating room, the anesthesiologist, after administering intravenous premedication (sedatives), installs an endotracheal tube with inhalation anesthesia. All laparoscopic appendectomies are necessarily performed under general anesthesia.

Laparoscopic appendectomy technique
To remove the inflamed appendix, a medical device called a laparoscope and special endoscopic instruments are used. A laparoscope is a flexible tube with an optical system that allows you to visualize on a monitor what is happening inside the abdominal cavity. The operation is performed in stages and with great care.

The stages of the surgical process of laparoscopic appendectomy are:

providing operational access;
revision of the abdominal organs with detection of the appendix;
resection of the vermiform appendix with its mesentery;
sanitation and drainage of the abdominal cavity;
closing surgical access.

Providing operational access
Small openings in the anterior abdominal wall act as surgical access for laparoscopic appendectomy. Initially, three incisions of the skin and subcutaneous tissue are made, 10 to 15 millimeters long. The anterior wall of the abdomen is pierced through these incisions. Two punctures are located below the right hypochondrium and correspond to the projection of the cecum. The third puncture is made in the pubic area. Trocars (metal “tubes” through which endoscopic instruments are inserted) are installed into the resulting holes.

Revision of the abdominal organs with detection of the appendix
Through the first puncture, the abdominal cavity is filled with carbon dioxide to better visualize the internal organs. Then the laparoscope is inserted and the abdominal cavity and its contents are examined. If complications are found that make further manipulations difficult, they are considered contraindications for laparoscopic appendectomy. The laparoscope is removed, and subsequent removal of the appendix is performed using the classic open method.

Resection of the vermiform appendix with its mesentery
In the absence of contraindications, laparoscopic surgery continues. Endoscopic instruments are inserted into the remaining two holes, which are used to perform almost the same manipulations to remove the appendix as during a cavity appendectomy. The mesentery of the appendix is clamped and bandaged or special titanium clips are applied. A clamp and clip are then placed at the base of the appendix and an incision is made between them with scissors. The severed appendix is removed through the trocar. Due to limited space, all movements must be performed with extreme care and professionalism.

Sanitation and drainage of the abdominal cavity
The abdominal cavity is examined in detail using a laparoscope for the presence of bleeding and accumulation of pathological exudates. An electric suction helps remove all fluids and dry the cavity. For special indications, the abdominal cavity is drained.

Indications for drainage of the abdominal cavity during laparoscopic appendectomy are:

signs of peritonitis;
incomplete hemostasis;
the surgeon's uncertainty about sufficient resection of the appendix.

The drainage tube is left in one of the side punctures.

Closing operational access
After completing all manipulations and removing the laparoscope, the trocars are carefully removed one at a time. Then the subcutaneous tissue is sutured with absorbable threads and a silk suture is placed on the skin.
Laparoscopic appendectomy without complications is usually completed in 30 to 40 minutes. The patient's postoperative recovery occurs quite quickly. The drainage is removed on the second day. After 2–3 days, the patient is discharged home with limited physical activity for two months.
Compared with abdominal appendectomy, laparoscopic surgery has a wide range of advantages.

The advantages of laparoscopic surgery for appendicitis are:

short period of hospitalization and rehabilitation;
absence of large cosmetic skin defects;
absence of severe pain after surgical procedures;
the tissues of the anterior abdominal wall are not severely injured;
the abdominal cavity is well visualized, which allows for detailed sanitation and identification of concomitant pathologies;
Peristalsis of the large intestine is quickly restored;
no strict bed rest;
the risk of postoperative complications is very low.

Despite the whole list of positive aspects, laparoscopic appendectomy is currently not used often enough in public hospitals. The reason for this is its some shortcomings.

The main disadvantages of laparoscopic surgery for appendicitis include:

special expensive equipment and tools are required;
qualified, trained personnel are required;
general anesthesia is required;
the surgeon has no tactile sensitivity;
visualization takes place in two-dimensional space.

Based on these disadvantages, in particular, the high cost of equipment, most often appendicitis is operated on using the classical abdominal method.

Scar after appendectomy

After removal of the sutures, a scar remains on the patient’s body, the size of which depends on how the appendix was removed. When appendicitis is removed using the laparoscopic method, small, unnoticeable scars remain, which dissolve over time (from one to three years). The greatest problem for patients, especially women, are the marks that remain after traditional abdominal operations. The seam size varies from 8 to 10 centimeters and most often it looks like a horizontal line, which is located above the linen line. If the removal of appendicitis was accompanied by complications, the length of the suture can reach 25 centimeters.

How is a postoperative scar formed?
After removal of postoperative sutures, a dark burgundy incision mark remains on the patient’s body. As the incision site heals, a scar forms (approximately 6 months). A scar consists of connective tissue that the body uses to try to fill the wound left after surgery. Connective tissue is characterized by increased density. This is why post-operative scars feel harder to the touch. If the patient’s recovery after surgery occurs without complications, then the wound heals by primary intention, and a narrow, flat scar remains on the body.

If after the operation inflammation begins in the wound, and the doctor makes a second incision, the suture heals by secondary intention. In such cases, the formation of sloppy scars is possible, which after a long time are noticeably visible on the body.

Other circumstances also influence the formation of the final appearance of the scar. One of the primary factors is preventive care using special products.

Preventative care for a “fresh” scar
There are special absorbable preparations designed to care for “fresh” scars. Using them will not completely get rid of the scar, but will help make it less noticeable. After a course of using the correct product, the scar becomes less tall and voluminous, lighter and softer.
It is necessary to start using such drugs immediately after the postoperative wound has healed and all the crusts have disappeared from its surface.

Scar preventive care products

Name	Effect	Application
*Strataderm*	The gel forms a film on the surface of the scar that protects it from the external environment and provides sufficient moisture. As a result, the scar becomes smoother and softer.	Apply to washed and dried skin 2 times a day. To achieve the effect, it takes 2 to 6 months of daily use.
*Mederma*	The active components of the ointment well moisturize and nourish scar tissue, as a result of which it becomes softer. The drug also improves blood circulation in the suture area, which speeds up the healing process.	Apply with massage movements until completely absorbed. The scar is processed 3-4 times a day. The course must be continued from 3 months to six months.
*Contractubex*	Inhibits the formation of scar tissue. Moisturizes and nourishes the skin of the seam. Provides protection against infections.	Apply with light movements in a thin layer 3 times a day. Use for 3 – 6 months.
*Dermatix*	Softens the skin and forms a protective layer on the surface of the scar. As a result, the scar is formed more even and elastic.	Rub into the scar area twice a day for six months.
*Kelofibrase*	Removes the feeling of tightness in the seam area. Improves blood circulation, softens and smoothes the postoperative suture.	Apply to the skin, after which the seam area must be massaged. For large and deep scars, overnight compresses are recommended. Use for 2 – 3 months.

Fighting mature scars
If no prophylaxis was carried out for six months after the operation or it turned out to be ineffective, a scar with pronounced shapes and sizes remains on the patient’s body. Since the scar “matures” within 6 months, the use of absorbable drugs in the future is not advisable. To combat mature scars, there are other, more radical methods. Most of them are not able to completely eliminate this cosmetic defect, but they can significantly improve the appearance of the scar, making it more neat and less noticeable.

Methods that can help improve the appearance of a mature scar include:

Surgical plastic surgery. The method involves re-dissecting the scar in order to make a more accurate suture in its place. In some cases, the patient's fatty tissue from other parts of the body is injected into the area of the old suture. As the scar heals, it turns into a thin and almost invisible strip.
Laser grinding. A laser is used to “evaporate” scar tissue. This promotes the formation of a new epithelial layer, which makes the scar smoother and less noticeable.
Cryodestruction. Exposing the scar to liquid nitrogen, causing it to freeze and turn into a blister. After some time, the bubble becomes covered with a dry crust and disappears. At the site of the blister, a small pink swelling remains, which subsequently becomes lighter and decreases in size.
Dermabrasion. Using a special abrasive substance, the upper layers of scar tissue are destroyed, as a result of which the scar becomes less pronounced.
Chemical peeling. High concentration preparations are applied to the surface of the scar, which soften the scar and make it thinner.

Treatment of chronic appendicitis

For chronic appendicitis, doctors are not guided by a single treatment tactic. The severity of the inflammatory process and clinical symptoms contribute to the choice between conservative and surgical treatment.

Conservative method of treatment of chronic appendicitis

In the case of chronic appendicitis with mild pain and rare periods of exacerbation, a conservative method of treatment is used. This method is represented by drug therapy and physiotherapeutic procedures. Also, in case of chronic appendicitis, it is necessary to follow a certain diet.

The main points of the diet for chronic appendicitis are:

exclude spicy, fried, salty and fatty foods;
give up carbonated drinks;
reduce the consumption of seasonings and spices to a minimum;
exclude coffee and strong black tea;
maintain a balance of fats, proteins and carbohydrates;
five times daily meals in small portions.

Following a diet for acute appendicitis helps eliminate most intestinal disorders and normalize digestion. This improves the patient's quality of life.

There are a large number of medications that are used in the treatment of chronic inflammation of the appendix.

The main medications used in the treatment of chronic appendicitis

Prohibited products during the rehabilitation period are:

meat and fish with a high percentage of fat;
margarine and other types of modified fats;
foods fried or baked to a strong crust;
confectionery with a lot of cream;
carbonated and/or alcoholic drinks;
products containing a large number of chemical additives (dyes, flavor enhancers);
industrial or home-made pickles and marinades;
legumes (can be consumed in limited quantities from 5–6 weeks of rehabilitation).

Drinking the required amount of fluid
For the first 3 to 7 days, the patient needs to drink at least one and a half liters of liquid per day. The main volume should be clean water without gases. Subsequently, the daily amount of liquid should not be less than 2 liters. From the second week, various self-prepared juices from vegetables and fruits, rosehip decoctions, and weak teas are allowed.

Breathing exercises after surgery
Exercises to normalize breathing should begin immediately after surgery. Breathing exercises can speed up the process of removing anesthetics from the body and prevent the development of intoxication. Breathing training is also an effective preventative measure against pneumonia, which is a common complication after surgery.
All exercises are performed half-sitting in bed, and then standing. Inhalations must be taken through the nose, while inhaling as deeply as possible. Exhalations are made through the mouth. In this case, the exhalation should be loud and 3 times longer than the inhalation. Avoid excessive muscle tension during exercise. Gymnastics are performed several times a day.

Breathing exercises are:

the right hand must be placed on the chest, applying gentle pressure during exhalation;
hands should be placed under the chest on the ribs, squeezing the chest on both sides when exhaling;
As you inhale, you need to raise both shoulders, and as you exhale, lower them;
alternately raising and lowering the right, then the left shoulder;
With an inhalation, you need to raise your arms up, and with an exhalation, lower them.

In addition to these exercises, to normalize breathing, the patient should inflate balloons every hour. You can also exhale into the bottle through a straw, stretching one exhalation for 20 - 30 seconds.

Self-massage
After the operation, while in bed, the patient is recommended to independently massage his earlobes, temples, forehead, palms and other parts of the body that he can reach. Such actions will activate blood circulation and eliminate body numbness. Massaging is carried out using the fingertips in a circular motion without pressure.

To prevent constipation, it is recommended to perform self-massage of the abdomen, since massaging the muscles improves intestinal motility. The procedure is carried out in 3 stages in a lying position.

The stages of self-massage are:

The patient should bring his legs to his stomach and, focusing on his feet, spread his knees to the sides. After this, you need to start stroking the abdomen with both hands, moving from the ribs to the groin area. Actions should be smooth and soft.
For 2 - 3 minutes, you should make circular movements in the navel area. The direction of movement should correspond to the clockwise direction, and the effort should be slightly greater than in the previous exercise. Massaging is performed with hands placed one on top of the other.
After this, you need to move on to massaging the lower abdomen, moving clockwise from the right side to the left. The seam area cannot be massaged.

Limiting physical activity
In order for the postoperative suture to heal without complications, the patient must adhere to a gentle regime of physical activity. Immediately after the operation, it is forbidden to lift anything weighing more than 3 kilograms. This recommendation is valid for the next 2 - 3 months. In the first month, the only sports activities allowed are walks in the fresh air and simple exercises that do not involve the abdominal muscles. Then you can do swimming, race walking, and aerobics. Those sports that involve heavy lifting or excessive physical activity are not allowed for 5 to 6 months.

Sick leave after appendicitis removal

Surgery for appendicitis involves a recovery period, during which the patient is prescribed a home regimen. Therefore, people who have had their appendix removed are entitled to sick leave. The duration of sick leave is determined by the doctor, who takes into account the patient’s condition, the type of surgery undergone and the nature of the patient’s professional activity.

Most often, the duration of hospital rest after standard operations does not exceed 10 days. For appendicitis with various forms of complications, the duration of sick leave is at least 15–20 days.

If the patient was given rest for, for example, 10 days after being discharged from the hospital, but during this period his condition worsens, the sick leave is extended. When providing sick leave, the doctor also takes into account the current legislation.

The maximum period for a certificate that a doctor can issue independently does not exceed 30 days. If during this period the patient’s condition has not returned to normal and he cannot go to work, the extension of sick leave is carried out after agreement with a special medical commission.

Before use, you should consult a specialist.

In the body of every person there is a small (about 7 mm) worm-like appendage of the cecum, which plays the role of protector of the intestinal microflora from harmful bacteria. This appendix is called the appendix. Due to a number of factors, the latter can become inflamed, causing acute pain in the abdominal cavity localized in the right iliac region.

Signs of acute appendicitis

According to the forms, chronic and acute appendicitis are distinguished. The first is very rare in nature, and due to certain factors, surgical intervention is unacceptable here.

In case of acute appendicitis, surgery is necessary. According to the structural features, this form of the disease in question is divided into:

catarrhal. There is a slight increase in the volume of the process. The upper ball becomes dull, visually we can talk about the expansion of the venous vessels. On palpation – tension in the right iliac region, slight pain. The patient's body temperature rises (up to 37.5 C, not higher), complaints of nausea and moderate pain in the abdominal cavity arise. One-time vomiting may occur. The catarrhal form of appendicitis lasts about 6 hours. It is difficult to diagnose appendicitis within this group - the symptoms are quite ambiguous and can indicate various diseases;

destructive. This group has several forms:

phlegmatic inflammation. With this form, all the balls of the appendix are absorbed by the process of inflammation. The walls of the process thicken, the diameter of its vessels increases. Purulent films form from inside the appendix, which explains the presence of pus when it is opened. In almost 50% of patients with this form of appendicitis, the formation of turbid fluid with the presence of protein in the abdominal cavity can be observed. In terms of duration, this form of destructive appendicitis lasts about 20 hours. During this time, the patient begins to complain of increased pain in the abdominal area; Due to the increase in temperature, regular dry mouth occurs.
gangrenous inflammation, abscess. Due to the huge number of blood clots that form in the vessels of the appendix, blood circulation is disrupted and necrosis of its tissue occurs. The rotting process is actively developing, which is accompanied by a sharp unpleasant odor. The process is soft to the touch, green in color, its tissue is damaged, resulting in bleeding. Options are also possible when there is not total necrosis, but the death of individual areas. Characteristic is the death of nerve cells, which is why the pain stops and the state of health improves. But due to the resulting intoxication, vomiting and nausea do not stop, the temperature remains at 38 C, and the heartbeat increases. With an abscess, the appendage changes its shape, turning into a ball or cylinder containing pus. The walls of such a ball/cylinder are very thin.
perforated form. The last and most dangerous form/stage of appendicitis. Surgical intervention here is not a guarantee of recovery. The purulent fluid of the appendix enters the abdominal cavity, causing infection of the latter. This happens due to a violation of the integrity of the walls of the appendix. The patient's condition changes dramatically: vomiting almost never stops; total weakness does not allow you to get out of bed; the temperature rises to 39 C. The pain is not concentrated only in the right side - the whole stomach begins to ache.

Two surgical techniques

Today, surgical treatment of appendicitis offers patients a choice of two methods:

Traditional appendectomy .

Duration of stages of this type of appendectomy:

30-60 minutes of the actual operation: depending on the patient’s age, body structure, stage of the disease, exacerbations;
7-8 days hospital stay. You can start working in a month.

Operation technique:

making an oblique incision in the area under the right rib, 6-7 cm long. If during this process a turbid liquid was detected, take a sample of it for examination;
searching for the appendage, removing it (together with the base of the cecum) through the hole made;
compression of the process, with fixation of the mesentery with tweezers;
suturing the cecum;
using medical thread to bandage the base of the process;
cutting off the shoot () slightly above the fixed thread. The remaining stump is disinfected, cauterized, hidden in the cecum, and the suture is tightened;
if there is no bleeding, the cecum is immersed in the abdominal cavity, the latter is dried, and the wound is sutured.

Laperoscopic appendectomy which includes 3 stages:

preoperative (2 hours): the operating area is prepared, the patient is given the necessary medications (antibiotics/sedatives);
the actual operation, which can last from 40 to 90 minutes;
postoperative. If no complications arise, then after 3 days the patient is discharged, and after 15 days he can start working.

Technique for this type of appendectomy:

use of general anesthesia;
injection of carbon dioxide into the abdominal cavity through a special needle. The latter enters the body through a small incision made in the left anterior pubic region;
studying the condition of internal organs, the degree of infection of the latter; location, shape, consistency of the appendix, by inserting a telescope through a 5 mm incision in the navel, which is connected to the camera. If the surgeon detects exacerbations that do not allow the use of a laparoscope, the patient undergoes a traditional appendectomy. If the audit does not reveal the presence of complications, laparoscopic appendectomy is performed;
introduction of an additional 2 catheters: through incisions in the subcostal and suprapubic region;
fixation of the process using clamps, inspection;
in the place that connects the appendage to the cecum, a hole is made through which a medical thread is passed to ligate the mesentery. Three more threads are placed at the base of the appendix;
extraction of the appendage through a catheter with a diameter of 10 mm;
disinfection of the abdominal cavity; elimination of hemorrhages;
examination of the abdominal cavity with a laparoscope.

Possible complications

There are three groups of complications that can occur after an appendectomy:

Local: may arise as a result of insufficient sterility of equipment, poor disinfection of the wound, due to the individual characteristics of the body. These include:

hematomas that can form near the wound in the first days after surgery;
redness and swelling in the wound area, discharge of pus;
accumulation of atypical fluid in the suture area, mixed with red blood cells and lymph.

Intra-abdominal. They pose a considerable danger to the health of the person undergoing surgery. It can be:

abscesses inside the abdominal cavity, and more. We can talk about the formation of pelvic pustules in the presence of pain in the pelvic area, the prepubic area, and an increase in temperature. With an interintestinal abscess, the person operated on feels normal, but as the purulent bladder increases, intoxication develops, pain appears in the navel area (especially with muscle tension);
peritonitis;
inflammation of the venous trunk running from the stomach to the liver. It is rare, but often (about 85%) leads to death. Signs of this complication include fever, enlargement and abscess of the liver, severe intoxication, attacks of hysteria;
intestinal obstruction. The result of scars and adhesions.

System: diverse in nature and location. These include pneumonia, heart attacks, changes in the functioning of the genitourinary system, etc.

Patient status

Not all patients know what to do after appendicitis surgery, which causes an increase in rehabilitation time.

for 12 hours after appendectomy, do not get out of bed or eat;
After 12 hours, you can try to take a sitting position. If there is no nausea, water with lemon is allowed in small portions;
You can start walking 24 hours after surgery. If you have an appetite and no nausea, you can talk to your doctor about your allowed diet in the coming days. The standard menu at this time for such patients is liquid, low-fat food;
after 48 hours, protein foods are allowed to be introduced: boiled beef, chicken, fish, liquid broths;
on day 8 you can return to your usual diet;
You should refrain from heavy physical activity for 3-6 months, depending on how quickly the wound heals. But 2 months after discharge from the hospital, you can get exercise from running, swimming, and horse riding.

Appendicitis is a disease that occurs suddenly and causes severe discomfort. Acute manifestations of appendicitis require urgent surgical intervention, so the patient is prescribed surgery. Therefore, the questions arise, how long does the operation take and how complex is it? To answer these questions, it is necessary to take into account all the points that can increase the operating time.

Every surgeon, based on theoretical knowledge, will confidently answer that the simplest typical operation takes about forty minutes, but can last up to one hour. But, unfortunately, this is only a theory, and in medical practice there are many factors that influence the duration of surgical treatment. In addition, each organism is individual, so certain factors in appendicitis can manifest themselves differently and take up a certain amount of time from the surgeon.

The first thing to consider is the chosen method of performing the operation. As you know, there are several of them:

access (laparoscopic or laparotomic);
appendectomy (transvaginal or transgastric).

The above operating methods differ in the method of penetration into the abdominal cavity. Therefore, the essence of the surgical intervention itself essentially does not matter. The time that the operation itself will take within normal limits is defined as 40-60 minutes and no more.

Stage of illness

Brief description of the operation

Acute appendicitis

Before surgery, an examination is carried out to identify additional pathologies; if there are none, then the surgeon begins to act. The first thing to do is to penetrate the abdominal cavity; if there are no complications, then the inflamed appendage is removed. The duration of such surgical manipulation takes no more than one hour.

Peritonitis

Another development of circumstances is possible when the patient is diagnosed with peritonitis, in which case the surgeon will act differently. During the operation, all efforts will be made to get rid of the consequences of perforation of the appendix, which led to peritonitis. Based on this, the duration of the surgical procedure will depend on several points:

Location of the inflammatory process;
the nature of the manifestation of peritonitis;
the presence of concomitant pathologies that led to the process of intoxication of the body.
The duration of such an operation is at least two hours.

Attention! Removing appendicitis is one of the simplest surgical procedures, which can take no more than half an hour. If complications are detected, the surgeon’s actions may take up to two hours. The operation time will increase significantly if peritonitis is detected.

If pathological factors are identified (atypical location or presence of adhesions)

During the operation, it is possible that the surgeon may detect adhesions. They are often a consequence of previous surgical interventions. In addition, access to the abdominal cavity may reveal other pathologies of tissues or organs. Then the surgeon decides to eliminate the identified pathologies. Accordingly, the time allotted for the operation will increase exactly in proportion to the number of pathologies.

If the surgeon discovers an atypical location of appendicitis, then the time for surgical treatment will increase significantly. The complexity of this phenomenon lies in the fact that the atypical location is very difficult to diagnose, and therefore can only be detected during surgical procedures. An hour and a half is allotted to perform such an operation.

Reference! An atypical location of the inflamed appendix is observed in almost 30% of patients.

There may be additional factors that influence the duration of surgical procedures. For example, the age of the person being operated on. If a child under three years of age is placed on the operating table, the operation will last at least two hours. This is explained by the fact that these babies have not yet fully formed their immune system, so the possibility of complications cannot be ruled out.

Video - What are the complications of appendicitis?

Types of surgical treatment of the appendix

Regardless of which method of operation is chosen, the immediate removal of the inflamed appendix is preceded by the following manipulations:

The patient is given anesthesia.
After the patient is under anesthesia, the surgeon begins to dissect the abdominal wall, this happens layer by layer.
Next comes an examination of the organs to identify additional pathologies that may take up the time of the operation.
If no pathological processes other than appendicitis are detected, the appendix is removed and the edges of the appendix are sutured.
The operation is completed by stitching with absorbable threads.

Type of surgical treatment	Short description
Laparotomy	Before the surgical procedure begins, the patient is prepared. To do this, he is prohibited from eating food several hours before the operation. If there is hair on the abdominal cavity, it is removed, and the intestines are cleansed through an enema. A preliminary laparotomy is required to clarify the clinical picture. This operation is generally performed under local anesthesia.
Laparoscopy	Surgical procedures are performed using endoscopic instruments, which are inserted directly through small punctures into the abdominal cavity (its anterior wall). A microcamera is inserted through one of the holes, clearly showing the clinical situation. Then the organs are examined and, if there are no pathologies, the appendix is pulled out. After this, the abdominal tissue is excised, the inflamed appendage is fixed, and then removed
Transgastric method	This is a unique type of surgery that does not involve incisions. Penetration into the abdominal cavity occurs using a needle and a gastroscope through the navel. This method of eliminating appendicitis eliminates the occurrence of a hernia or the penetration of infection into the abdominal cavity. Unfortunately, the technique is not widely used, since it remains at the experimental level
Transvaginal method	The first thing you need to pay attention to is that this type of operation is intended only for women. The endoscope is inserted directly through the vagina (hence the name of the method) through a small hole in it. The method can be used in combination with laparoscopy. The only advantage of this type of operation is the absence of scars.

Note! All of the above methods, excluding the presence of complications such as peritonitis and other pathologies, will take no more than one hour.

Duration of recovery period after surgery

type of surgical intervention;
possible complications;
the presence of adhesions;
localization of the inflamed process.

Attention! At later stages of rehabilitation, it is very important to monitor the restoration and normalization of defecation and urination functions.

When acute appendicitis is diagnosed, most patients are advised to undergo surgery to remove it. This is due to the fact that conservative treatment is quite long and does not always have the desired effect. And if you leave appendicitis, especially if it is purulent appendicitis, without constant monitoring, you can cause it to rupture, leakage of pus into the abdominal cavity, the development of peritonitis and, as a result, death. Naturally, no one wants such a result, so you should find out more about the operation in order to understand what awaits the patient.

Options for appendix removal surgery

Removal of appendicitis can be carried out in 2 types: planned and emergency. Emergency methods are used either when an acute disease is already too developed, or when there is an overly acute exacerbation of a chronic form. Indications for the fastest possible surgical intervention are spillage of pus into the peritoneum, perforation of the walls of the appendix, and the presence of peritonitis. The deadline for execution is no later than 4 hours after admission to the hospital. Purulent appendicitis is usually removed as quickly as possible to avoid various complications.

Elective surgical intervention is carried out after eliminating threats that may interfere with the operation, but they are not considered fatal to the patient.

Various types of intervention can be used - from conventional laparoscopy to full abdominal surgery. In the first case, no incisions are made, penetrating to the site of inflammation of the appendix through. This method is preferable for patients, because it does not leave any scars or marks on the body. However, it can be performed only when appendicitis is not complicated by purulent streaks.

If the situation is complex, you will have to perform abdominal surgery with cutting into the abdominal cavity and examining the internal organs. It happens that it is necessary to wash them in situations where pus has already begun to develop in the abdomen.

Preparing for surgery

We can talk about preparation for surgery only in case of planned intervention. The requirements are, as a rule, standard - a cleansing diet (i.e., everything is only boiled and steamed), no eating or drinking on the day of surgery. The operation must be carried out on an empty stomach. All this is connected with the administration of anesthesia. After all, a person, when he is unconscious, may vomit, which he cannot control, and as a result, the patient will either choke on it, or it will enter the lungs, causing inflammation and infection there.

Postoperative period: what are its features?

The postoperative period is also very important. After all, how the patient recovers depends on this. First of all, you need to solve the question - what to eat after appendicitis. Doctors say: ideally, meals should be fractional - at least 5-6 times a day. Moreover, food should be as light as possible.

True, on the first day you will have to be patient - the patient is only allowed water. This is necessary so that the stomach begins to work in its usual mode, and food is absorbed in full. They start a water diet with literally a couple of drops that moisten their lips. Then you can move on to a few sips. If vomiting occurs, you should slow down the pace. And, naturally, against the background of vomiting, you cannot start eating properly - you risk worsening the situation even more. After all, vomiting is a sign that recovery is not going well. And it often requires the use of special drugs to stop this.

What can you eat after appendicitis? Immediately after the operation (about 2-3 days), food must be liquid so as not to overstrain the digestive system and allow it to recover after the intervention. An excellent option would be chicken broths, jelly, porridge, and rice broth. You can use diluted juices, weak teas and rosehip decoction. On the 4th day after the operation, if everything goes well, the patient is allowed to add butter and bread. And after 7 days, you are allowed to return to the usual table, of course, excluding potentially dangerous foods from the diet.

What are the restrictions?

During the postoperative rehabilitation period, which must be endured after surgery to remove the appendix, patients are prohibited from various loads, incl. lifting weights and intimate entertainment. But in order not to cause problems with muscles as a result of their stagnation, it is worth paying attention to light walks in the fresh air.

It is also recommended to pay special attention to special exercises from the category of physical therapy, which will help disperse the blood and prevent the development of pathologies such as thrombophlebitis, etc. All movements in this gymnastics must be measured, smooth, and careful, because too vigorous activity quickly and easily leads to divergence of postoperative sutures, which will lengthen the rehabilitation period and significantly worsen the situation.

Try to change your lifestyle after surgery by adding walks in the fresh air, which will saturate the body with oxygen and normalize metabolism. Don’t forget about correcting your diet - give up obviously unhealthy foods, giving preference to healthier options.