Removal of appendicitis: types, course of surgery, complications. Appendectomy Prepare everything you need for an appendectomy

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All recommendations are indicative in nature and are not applicable without consulting a doctor.

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 solution - 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 the abdominal organs by the 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 anesthesia 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 appendage 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 appendage 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 will 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, with 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 performed 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

Appendicitis is a pathological condition of the body, which is accompanied by the development of an inflammatory process in the appendix (appendage of the rectum). This is a very dangerous phenomenon, so when the first symptoms appear, you should immediately seek medical help. If you consult a doctor in a timely manner, serious consequences can be avoided. What is appendicitis, how it is removed and how recovery proceeds - all this will be discussed in this article.

Appendicitis - how to remove it

The appendage of the rectum, vermiform appendix or appendix is a tubular formation, the length of which is 4-8 cm. The internal cavity of the appendix is filled with lymphatic fluid, and the appendix itself is responsible for performing the protective functions of the body. Inside the appendage there are beneficial microorganisms that help normalize the intestinal microflora. Many, unfortunately, do not know where exactly the appendix is located. It is located in the lower right side of the abdomen. If a person suffers from mirror disease, then the appendix is accordingly located in the left side of the abdominal cavity.

Note! Among all countries, only in the United States is it customary to remove the appendix immediately after the birth of the child. Doctors say that this appendix stores a lot of food waste, which negatively affects the condition of the entire body. But, according to various studies, such operations negatively affect the child’s immune system.

Causes of inflammation

Despite the rapid development of modern medicine, doctors cannot yet determine the exact cause of appendicitis. There are only two known causative factors contributing to the development of the disease:

infection of the intestines by pathogenic microorganisms;
obstruction of the lumen of the appendix or blockage. In this case, the communication between the lumens of the intestine and the appendix is lost.

The following factors can lead to blockage of the lumen:

accumulation of feces in the lumen of the appendix. In this case, hardening of the stool occurs, which can result in infection;
excessive consumption of various seeds from fruits or seeds. Once seeds or seeds enter the intestinal cavity in large quantities, they can lead to blockage;
the presence of foreign bodies (most often small toy parts). As a rule, the presence of foreign objects acts as a cause for the development of appendicitis in young children who constantly put everything in their mouth.

The danger of the disease is that Without timely medical care, the patient may die. Therefore, it is extremely important to be able to recognize the first signs of appendicitis in order to avoid serious complications.

Characteristic symptoms

Appendicitis differs from other diseases in its gradual development: during the first few hours, the appendix swells and gradually fills with a purulent mass. Without the help of a surgeon, the appendix may rupture, but this usually happens after 2-3 days. After a rupture, pus spills into the patient’s abdominal cavity, which leads to the development of peritonitis. In this case, the patient's condition is extremely serious.

The most common symptom of appendix inflammation is pain in the right side of the abdomen, which can gradually change location, moving up or down. In rare cases, pain may radiate to the anus or back.

Associated symptoms to look out for:

increased body temperature;
problems with bowel function (diarrhea, constipation);
attacks of nausea and vomiting;
constant tension in the patient's abdominal muscles;
even slight touches to the abdomen lead to severe pain. When you press your legs towards your stomach, they may loosen a little.

Elderly patients and children require special attention, since neither one nor the other will be able to clearly describe the nature of the symptoms. Loss of appetite in a child, inactivity and constant tearfulness may indicate the development of appendicitis. Elderly people are at risk of late diagnosis of the disease due to the fact that their pain is less pronounced (more smoothed out).

Diagnostic features

At the first suspicious symptoms, you should immediately consult a doctor for a diagnostic examination, which does not last very long. The doctor must find out the cause of pain in the abdomen, since signs of appendicitis may coincide with signs of other abdominal pathologies. Diagnosis must be carried out in the clinic. To begin with, the doctor asks the patient about his state of health and listens to complaints. At this stage of diagnosis, it is necessary to learn more about the symptoms.

During a visual examination, it is necessary to take into account the position in which the patient is lying or sitting, as well as gait. The fact is that pain, which often occurs with this pathology, can correct the patient’s posture. Body temperature may also be high. The condition of the abdominal wall should also be assessed and taken into account. When performing palpation of the abdomen, the doctor should pay special attention to those areas when examining which the patient feels pain. As noted earlier, inflammation of the appendix is accompanied by the appearance of acute pain in the right side of the abdomen. By tapping this area of the patient’s body, the doctor will be able to identify the intensity and nature of the pain.

In addition to a visual examination, the doctor may prescribe laboratory tests of urine and blood, which determine the number of white blood cells. If a woman is being examined, the doctor will often order a pregnancy test. Such tests can detect inflammation, if any, or the presence of adhesions.

Note! For a more accurate picture, other types of diagnostics are needed, for example, computed tomography, ultrasound, x-ray examination, etc. With their help, pathological changes in the patient’s internal organs, including the appendix, can be identified.

In rare cases, when the symptoms of appendicitis are not clearly expressed, the doctor prescribes an additional diagnostic procedure - laparoscopy. But before this, the patient must be examined by an anesthesiologist. Based on the results of the tests, the doctor will be able to make an accurate diagnosis. If it is still appendicitis, then immediate surgical intervention is required.

Types of operations

It is worth noting that in some European countries, acute appendicitis is treated with antibacterial drugs. But almost everywhere surgery is required. This operation, during which the surgeon removes the appendix, is medically called an appendectomy. There are two methods for removing an inflamed appendix - the classical method and using laparoscopy. Now in more detail about each of the methods.

Classic method

This is an abdominal surgery performed under general anesthesia. The doctor makes a small incision on the surface of the patient's peritoneum using a scalpel. Then the process is carefully removed, and the incision made is sutured. The method is simple and cheap, but after it, marks from the stitches remain on the patient’s body, so during the recovery period the patient is forced to take special medications that dissolve the stitches.

Another method of surgical removal of the appendix, which differs from the previous one in its low level of trauma. The duration of the recovery period after laparoscopy is quite short, but despite these advantages, this type of operation has many different contraindications. Therefore, when choosing a method of surgical intervention, the doctor must fully inform the patient about all possible risks.

Important! If you suspect that you have appendicitis, you should not self-medicate to relieve symptoms. Many people apply hot or cold compresses to the sore spot and take painkillers. But all this can only worsen an already difficult situation.

Recovery after surgery

Upon completion of the operation, the patient is prescribed bed rest, which must be observed for 24 hours. On the second day you are allowed to walk a little, but only if there are no complications. Regular but moderate exercise can speed up the recovery process and also avoid the occurrence of adhesions. As a rule, removal of postoperative sutures occurs 6-7 days after removal of the appendix. But for the full formation of a scar after a classic operation, it takes much more time (about 6 months). This is provided that the patient correctly follows all the doctors’ instructions.

The recovery period includes more than just avoiding heavy physical activity. The patient must also follow a special diet and take medications that speed up scar healing. Let's look at each recovery stage separately.

Medications

To tighten postoperative scars, different drugs are used, each of them differs in its composition, properties or cost. But not all of them will be able to help in your case, so you need to use only those remedies prescribed by your doctor. Below are the most common medications used during the recovery period.

Table. Pharmacy preparations for scar care.

Name of the drug, photo	Description
	An effective anti-infective drug that protects the postoperative scar from various types of infections. With regular use, you can completely get rid of an unattractive scar on the surface of the abdomen.
	This drug contains highly purified silicone polymers, thanks to which the gel creates a special protective film on the surface of the patient’s skin. Designed for the treatment of various types of scars, including post-operative ones.
	Another drug for the treatment of scars and scars. The active components are allantoin and cellapin. Produced in the form of an ointment, the drug has anti-inflammatory and fibrinolytic properties. Promotes rapid regeneration of damaged tissues, improves blood circulation in the area of sutures after surgery.
	An effective medication based on silicone. It is used in medicine not only to treat scars on the body, but also to smooth out old defects in the patient’s skin. The active components are polysiloxane (organic substance) and silicon oxide. The medicine is used as follows: a small amount of gel is applied to dry skin and left there until completely dry. After this, the remaining gel should be washed off with warm water. Repeat the procedure 2-3 times a day until the traces of the operation completely disappear.
	The unique composition of the cream allows it to be used against acne, age spots on the skin or stretch marks. It also does an excellent job with post-operative scars. The drug contains exclusively natural ingredients, thanks to which the cream has become so popular. Its action consists of deep penetration into the epidermal layers, due to which the patient’s skin is enriched with oxygen and restored.
	Used in the treatment of acne, blackheads or post-surgical scars. The effect of the drug is to relieve inflammatory processes and accelerate skin regeneration. This allows not only to eliminate existing skin defects, but also to prevent the appearance of new ones. Sledocyte is used for the whole body. It must be applied to the problem area and wait until the product dries completely. Repeat the procedure several times a day.

Note! After laparoscopy, the patient is discharged after about 3-4 days, after the classical method - no earlier than a week. Throughout the recovery period, which lasts 6 months, doctors recommend refraining from intense physical activity.

Nutrition

Immediately after the anesthesia wears off after the operation is completed, the patient begins to experience severe thirst. But you can’t drink water during this period, you can only wet your lips. In rare cases, when there is no strength to endure thirst, the doctor may allow you to drink a small amount of boiled water. If the recovery period is not accompanied by any serious complications, then, starting from the second day, the patient can eat food. Of course, everything must be strictly according to plan.

The diet after appendectomy looks something like this:

1-2 days after surgery. The diet should include porridge, low-fat soup, and water. It is necessary to eat on the second day after the procedure to start the digestive system. If the patient is not able to eat on his own (he has no strength left), then he should be helped with this;
on day 3 You are allowed to eat a little butter and durum wheat bread. This is in addition to the above products;
starting from 4 days the patient can gradually expand his menu by adding various products. Of course, all actions must be agreed upon with the attending physician.

During the recovery period after appendix removal, it is extremely important to follow all the doctor's recommendations and report to him any suspicious symptoms that may arise. You should stop eating unhealthy foods, smoking and alcohol, as this will only slow down the healing process. The correct regimen will not only speed up the recovery process, but also prevent serious complications.

Complications of appendicitis

Despite the development of modern medicine, it is not always possible to avoid serious consequences. Failure to follow the doctor’s recommendations or making mistakes during surgery can lead to various complications, including:

The development of adhesions in the abdominal area often leads to the occurrence of fistulas. This requires additional treatment. It is worth noting that most complications can be prevented if you follow all doctor’s instructions during the recovery period.

Video - Removal of appendicitis using laparoscopy

The appendix becomes inflamed in 10% of the world's population. In the middle of the last century, the appendix of the cecum was considered a vestigial, unnecessary organ, and prophylactic removal of the appendix was widely introduced. However, observing people with an excised appendix in childhood, they found a decrease in intestinal immunity and a high susceptibility to inflammatory diseases of the gastrointestinal tract. Now the views of doctors on the role of the appendix have been radically revised. Appendicitis is excised according to compelling indications, without allowing the removal of a healthy organ.

What is the appendix

The cecum is located at the border of the large and small intestines. A 6-12 cm long intestinal appendage is called the appendix or vermiform appendix. In a small appendage of the cecum there is a concentration of lymphoid tissue responsible for intestinal immunity. Another important role of the organ is to create favorable conditions for the growth and reproduction of beneficial intestinal microflora in it. Intestinal symbionts lost after illness or antibiotic treatment are replenished by “young cadres” grown in the appendix.

Blocking the lumen of the appendicular process with fecal stones, accumulations of helminths or neoplasms leads to the active growth of microbes in a confined space. Having no other food, microorganisms “eat” the tissue of the appendix, provoking acute inflammation of the appendix or appendicitis.

Who needs surgery and why?

If appendicitis is suspected, surgery is performed after diagnostics and hardware studies - x-rays, ultrasound, MRI. Signs of acute inflammation of the appendage are lack of appetite, vomiting, diarrhea. The pain, arising in the navel area, intensifies and shifts to the right hypochondrium. The temperature rises, the tongue is coated, the mouth is dry. A timely operation for appendicitis saves the patient’s life. A rupture of the appendix causes diffuse purulent inflammation of the peritoneum - peritonitis.

If it (the appendix) does not hurt, there is no need to cut out a healthy appendix. After 40 years, the risk of appendicitis is minimal due to closure of the lumen of the appendage. The chronic form of the disease is extremely rare, mainly in older people with reduced immunity. When diagnosing chronic appendicitis, it is distinguished from other intestinal diseases, pathologies of the right ovary in women, and strangulated inguinal hernia in men.

Although the role of the appendicular process has been established to some extent and it is no longer considered a vestigial extra part of the intestine, it is not a vital organ. Removal of the appendix is justified if it is inflamed.

Types of surgical intervention for appendicitis

The operation to remove the inflamed appendage of the cecum is called appendectomy. A An appendectomy is a surgical procedure whose purpose is to remove appendicitis.

According to the timing of the event, they are distinguished:

elective surgery for appendicitis is performed if less than 24 hours have passed since the first symptoms were detected. The patient is given antibiotics to relieve acute inflammation and prevent wound infection. The operating room is prepared, where the patient is transferred;
Emergency appendectomy surgery is prescribed for severe pain, high fever and symptoms lasting more than a day. It should be removed no later than 2-4 hours from the moment of admission to the clinic.

The type of surgical approach differs for different forms of appendicitis. Two main methods of surgery to remove appendicitis:

open access through an incision in the abdominal wall. Performed when complications are caused by a ruptured appendix or peritonitis. Indications also include a previous heart attack, cardiovascular failure, severe lung disease;
often used during planned surgery, when there are no complications or concomitant pathologies. It is done using special equipment through 3-4 punctures of the abdominal wall.

Each surgical method has advantages and disadvantages. When choosing a method for removing appendicitis, the final word remains with the doctor, taking into account the wishes of the patient.

Preparing the patient for surgery

After the fastest possible registration procedure in the emergency room, the patient is sent for an urgent examination. The doctor palpates the abdomen, questions and examines the patient. A general blood and urine test is given. X-rays, tomography, ultrasound and other studies are performed. To prevent wound infection, antibiotics are administered intravenously. Before the operation to remove appendicitis, the anesthesiologist determines the condition of the heart and blood vessels, and determines the patient’s sensitivity to medications.

In the operating room, the patient is placed on the table, the hair in the area of the surgical field is shaved, and the skin is treated with an antiseptic. The appendix is removed under the general procedure. Local anesthesia methods are now considered obsolete. However, if there are contraindications for general anesthesia, infiltration or conduction local anesthesia is used. To perform the operation under general anesthesia, the patient is given an intravenous narcotic and a muscle relaxant to successfully intubate the trachea.

How the operation is performed

The operation to remove the appendix lasts from 40 minutes to 2 hours. Depending on the chosen method of appendectomy, the surgical technique changes. Removal of the appendix is performed at any age and physiological condition. For each case, an individual surgical intervention technique is selected, followed by a rehabilitation program. Regardless of the method of appendicitis removal, during the operation the anesthesiologist monitors the patient’s blood pressure, pulse, and breathing on monitors.

Classic appendectomy

The surgeon uses a scalpel to cut through the skin and subcutaneous tissue in the right side. The incision is 7 to 9 cm long. The abdominal muscle ligaments are cut with scissors. The muscles themselves are carefully pulled apart with a clamp. The walls of the peritoneum are cut with a scalpel. The doctor assesses the condition of the internal organs, tightens the appendix and the edges of the incision, and removes it from the surgical wound. Now you can cut out the appendix.

Here the surgeon, acting according to circumstances, uses two methods:

antegrade removal, when the mesentery is clamped at the apex and base of the process. The mesentery is crossed and tied with a nylon thread. The base of the appendix is clamped and bandaged with catgut. A suture is placed at the base of the process and a clamp is placed. The vermiform appendix with its mesentery is cut off. The resulting stump is pushed into the cecum with a clamp and the suture is tightened. Remove the clamp and apply another suture;
if the process cannot be removed into the wound, a retrograde technique is used. Catgut is applied to the base of the appendix, the appendix is cut off, and the stump is sutured. Only after this the mesentery of the process is tightened and removed.

In addition, the surgeon examines other internal organs. Particular attention is paid to the intestinal loops near the appendix to see if there are any adhesions or other damage. The last stage of appendectomy is drainage of the abdominal cavity using electric suction. Drainage installation is possible. The time required to manipulate the appendix is from half an hour to one and a half hours. In children, surgical treatment of the appendix takes from 30 minutes to an hour. Surgery in adults may take a little longer due to frequent complications.

If the doctor’s work in the abdominal cavity is completed, layer-by-layer sutures are applied. The abdominal wall is stitched with catgut, and 7-10 stitches of silk thread are applied to the skin incision. The duration of application of internal and external sutures is 10-15 minutes. The removed process looks like a thin tube with a diameter of about a centimeter and a length of 5 to 15 cm.

Endoscopic surgery

An operation using endoscopic equipment, performed through 3-4 punctures of the abdominal wall, is called laparoscopy. The small size of the abdominal cavity and anterior abdominal wall in children makes laparoscopy the preferred method for appendix extraction.

Endoscopic surgery of the appendix is performed with three trocars. The vermiform appendix is grasped with a clamp and the mesentery is pulled. Electric forceps are used to coagulate the mesentery from apex to base. The mesentery is cut off. Then they tighten the base of the process, coagulate it and cut it off. The stump is tightened with catgut and treated. Then the trocar in the stump area is changed to another one with a diameter of 11 mm. The separated appendix is grasped through the trocar with a clamp, pulled into the lumen of the trocar and removed out. The edges of the wounds are sutured with layer-by-layer sutures; if necessary, a drainage is inserted to drain the exudate.

The operation takes place with minimal complications. Laparoscopic intervention virtually eliminates suture dehiscence, wound suppuration, bleeding, and intestinal adhesions. In terms of duration, such an operation takes less time than a classic one. The duration of laparoscopy is approximately 30-40 minutes.

Recovery after surgery

Patients with a removed appendix face a critical period of recovery. At the end of the operation, the patient is taken to the ward on a gurney and placed on the bed on his back. During the first 5-8 hours a person recovers from anesthesia and is not allowed to move. Then you are allowed to carefully turn onto your left side. Bed rest after abdominal surgery may take up to 24 hours.

On the first day, it is forbidden not only to get up, but also to eat food. Drink a few sips of boiled water after 2-3 hours. Medical personnel measure temperature, pressure, and check the condition of the stitches. The sutures are treated with antiseptics to prevent suppuration. Postoperative pain syndrome is relieved with analgesics - Promedol, Diclofenac, Ketonal.

Complications after surgery include suppuration or suture dehiscence, fever, severe pain, vomiting, stool and urination problems. In severe cases, peritonitis is observed. The infection is fought with the use of antibiotics. The suture is supported by wearing a bandage. To prevent unwanted consequences, strictly follow the doctor’s instructions.

Depends on the type of operation, the presence of complications, the condition and age of the patient. External sutures are removed before discharge on the 10th day. Internal damage heals in about 2 months.

Showering is permitted after the outer stitches are removed. It is recommended to lie in a hot bath, swim in a pool, or take a steam bath no earlier than 2-3 months from the date of surgery.

During the rehabilitation period, diet is also extremely important. The first day a fasting diet was prescribed. On the second day, the patient is given vegetable or chicken broth or liquid jelly. In the following days, pureed porridge, vegetable purees, steamed meatballs, steamed omelettes, and tender cottage cheese are gradually introduced into the diet. Eat small meals up to 6 times a day. You can drink clean water, compote, rosehip decoction, weak tea, jelly. After appendicitis is removed, bowel function must be restored. For this purpose, the use of probiotics and vitamin-mineral complexes is indicated.

Physical activity is introduced in doses and gradually. From the 2nd day the patient gets up and walks several steps. After discharge, he does light work at home, without lifting more than 2-3 kg. Hiking for a distance of up to 3 km is done at a leisurely pace, with periodic rest. From 2 weeks, if you feel well, you can perform a special set of physical therapy. Dosed, adequate physical activity is needed to stimulate blood circulation, accelerate tissue regeneration, and prevent adhesions.

Surgical removal of the inflamed appendix of the cecum is the only way to treat appendicitis. Detection of symptoms of appendicitis gives rise to calling an ambulance and placing the patient in a hospital. Appendectomy is performed based on the results of urgent diagnosis in order to avoid an erroneous operation. Full recovery after surgery occurs after 2 months.

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Gastroenterologist, professor, doctor of medical sciences. Prescribes diagnostics and carries out treatment. Expert of the group for the study of inflammatory diseases. Author of more than 300 scientific papers.

Appendectomy is performed under general anesthesia.

Stages of the operation: preparation of the surgical field (wiping with alcohol and lubrication with a 5% alcohol solution of iodine), layering of all tissues in the area of operation, opening (oblique skin in the right iliac region with spreading the anterior muscles, opening), finding and removing the appendage (Fig.), revision of the abdominal cavity, suturing of the operating room, bandage (sticker).

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

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

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

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

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

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

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

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

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

Having finished removing the appendix, checking hemostasis and lowering the intestine into the abdominal cavity, gauze pads are removed. When diffuse purulent peritonitis has developed, it is especially important to carefully empty interintestinal abscesses and remove purulent accumulations from under the diaphragm and from the pelvic cavity. The abdominal cavity should not be rinsed. After draining, you need to check again to see if the mesenteric stump is bleeding. Then a solution of antibiotics is poured into the abdominal cavity: penicillin - 100,000 units, streptomycin - 500,000 units. The surgical wound can usually be sutured tightly. However, in case of severe symptoms of peritonitis, a thin rubber drain is left between the sutures for introducing antibiotics into the abdominal cavity, and in case of gangrene of the appendix, in case of ichorous effusion, the skin wound is not sutured and long ends of the threads are left on the sutured aponeurosis. If around the appendix there was an accumulation of pus limited by adhesions or there was retrocecal appendicitis, then the wound is not sutured at all, but is left in the abdominal cavity, in addition to thin drainage, delimiting gauze tampons, which begin to be tightened on the 7-8th day after the operation and are removed completely by 8 -10th day.

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

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

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

Rice. 5. Appendectomy:
1 - skin incision line, bottom left - anesthesia diagram;
2 - direction of incision of the external oblique muscle;
3 - exposure of the internal oblique muscle;
4 - the fibers of the internal oblique muscle are pushed apart bluntly, the peritoneum is exposed;
5 - ligature of the mesentery of the process;
6 - preparation of the purse-string suture; applying a ligature at the base of the process;
7 - applying a clamp to the process before cutting it off;
8 - cutting off the process;
9 - immersion of the stump of the process into a pouch;
10 - operation completed.

Appendectomy is an operation to remove the appendicular process of the cecum. It is carried out in case of inflammation of an organ or its mechanical damage. It is considered one of the most common surgical interventions in abdominal surgery. Postoperative mortality is 0.4%. “On the table” no more than 0.01% of patients die. As a rule, these are people with advanced and complicated forms of the disease. Modern surgery strives to minimize patient trauma during appendectomy. Minimally invasive laparoscopic, transgastric and transvaginal techniques are actively developing.

Types of surgical removal of the appendix

Surgical removal of the appendix can be performed either through classical laparotomy or using minimally invasive techniques. The advantage of the latter is minor trauma to the patient, low risk of postoperative complications, and a short recovery period. As a rule, after laparoscopic removal of the problem area, a person is discharged from the hospital on the 3-4th day and returns to work with minor restrictions on physical labor after 1 week. Recovery after a classic appendectomy takes 7 days in the hospital and about 1 month under outpatient supervision.

Laparotomic removal of the appendix is today used in small clinics that do not have the necessary laparoscopic equipment. In addition, the operation is used to remove an excessively hypertrophied appendix in the phlegmonous form of appendicitis. Laparoscopy is the technique of choice and is used in almost all cases of catarrhal and gangrenous appendicitis. Transgastric and transvaginal appendectomy techniques are considered experimental and are not widely used.

Laparotomy appendectomy

Suture after laparotomy appendectomy

Laparotomy appendectomy is an open operation to remove the appendix. Until recently, it was performed under local anesthesia. The exception was pediatric patients. Today, this practice has been abandoned, since the patient being conscious makes it difficult for the doctor to work and limits the ability to expand access and discuss the clinical situation with colleagues. In addition, there is a risk of inappropriate patient behavior, which also does not contribute to a successful outcome of the operation. In modern clinics, the operation is performed under endotracheal anesthesia. The presence of peritonitis is an indication for intravenous administration of anesthesia.

The McBurney oblique incision is considered classic:

After opening the peritoneum, the dome of the cecum with the inflamed appendix is removed into the wound.
During the process of removal, the mesentery of the process is gradually crossed from the apex to the base.
After bringing the dome and the process out, a purse-string suture is placed around the appendix, the process is ligated and cut off.
Next, the seam is tightened and tied, the stump is immersed in the dome and secured with a Z-shaped seam.

If necessary, the intervention can be performed deep in the abdominal cavity, without bringing out the dome of the cecum. Similar operations are performed when the intestine is fixed or the location of the affected area is atypical. After completing the main part of the work, an inspection of the abdominal cavity is carried out. If necessary, it is drained. The operation is completed by suturing the wound tightly or installing drainage (if there is a purulent process).

Laparoscopic appendectomy

During laparoscopic surgery, as with its open version, endotracheal anesthesia is used. To provide working space, carbon dioxide is pumped into the abdominal cavity. This is necessary to move the anterior abdominal wall away from the internal organs. The work is carried out through 3 trocars inserted above the navel, womb and in the right hypochondrium. One of them is used for inserting the laparoscope, the remaining two are for instruments.

The stages of laparoscopic appendectomy are somewhat different from those described above:

The mesentery of the appendix is not ligated, but ligated or coagulated.
The stump of the appendix is not immersed in the intestinal dome, limiting itself to coagulation.
Before cutting, a clip is placed at the base of the appendix rather than a purse-string suture.

Removal of appendicitis using the laparoscopic method is completed by revision of the abdominal cavity, removal of instruments and trocars, removal of carbon dioxide, and application of skin sutures to the insertion sites of medical equipment.

Transgastric appendectomy

Scientists are developing several innovative appendectomy techniques that have already been tested in practice. These include a transgastric type of operation, as well as a transumbilical (through the navel) appendectomy, which some sources mistakenly classify as a type of transgastric intervention. In the first case, appendicitis is removed through a puncture of the stomach wall, in the second - through a puncture near the navel.

During the development of the method, attempts were made to puncture directly at the navel in order to minimize the external consequences of the operation. But this led to an increase in septic complications.

Both methods are not widely used due to technical complexity and the need for instruments of special shapes and lengths. Equipping clinics with such equipment and training surgeons in the method of transgastric or transumbilical removal of the appendix is impractical. In addition, these operations have a wide list of contraindications. They can be used in no more than 1/6 cases.

Transvaginal appendectomy

Transvaginal appendectomy is a type of laparoscopic intervention. For obvious reasons, it is performed only on female patients. During the operation, trocars are inserted through punctures in the posterior vaginal fornix. A trocar with a diameter of 10 cm for the laparoscope and 2 cm for the instrument is used. The intervention is performed in the Trendelenburg position, under general endotracheal anesthesia, muscle relaxation and artificial ventilation.

The stages of the operation are practically no different from those during classical laparoscopic appendectomy. The transvaginal method is preferable when removing the appendix for women and girls of reproductive age. After the intervention, there are no traces left on the body - there is no scar after appendicitis, which avoids aesthetic discomfort. Sexual intercourse is contraindicated for a month after surgery. The considered method is feasible only for catarrhal appendicitis without regional peritonitis.

How long does appendicitis surgery take?

Classic laparotomy appendectomy, without taking into account the preparation time of the patient, takes about 40 minutes. If it is necessary to expand access and revision of the abdominal cavity, the intervention can last one and a half hours. Peritonitis, which develops when a phlegmonous appendix ruptures, requires 2-4 hours of work by the operating team.

The laparoscopic method takes slightly longer. Uncomplicated intervention takes 40-60 minutes. This is due to the need for additional manipulations: applying carboxyperitonium, setting up video equipment, inserting trocars. The increase in operating time also occurs due to the somewhat greater technical complexity of the operation.

Transvaginal, transumbilical, transgastric interventions may require an indefinite amount of time. This is due to the technical complexity, the unusual position of the instruments for the surgeon, the difficulty of providing access, and the need to work with a minimum number of instruments. On average, such operations last 60-90 minutes.

Possible complications

Possible complications after appendectomy include early postoperative bleeding, septic processes, trauma to surrounding organs during the operation, and intestinal contents entering the abdominal cavity.

Postoperative complications develop with poor-quality vascular coagulation. In this case, the patient experiences all the signs of blood loss:

pallor;
tachycardia;
decrease in blood pressure;
impaired thinking abilities;
loss of consciousness.

Revision of the wound with repeated coagulation is required. If necessary, blood transfusion.

Septic processes are the result of non-compliance with the rules of asepsis and antiseptics, and the entry of pathogenic microflora into the wound. If there is no purulent contents in the abdominal cavity, they are treated with antibiotics. The presence of purulent effusion requires revision of the wound, washing of the affected area, and installation of drains.