Appendix

First description vermiform appendix cecum belongs to the Italian doctor and anatomist Berengno Da Carpi (Berengano Da Carpi) 1521. But the first image of the appendix was made by Leonardo Da Vinci in his anatomical drawings made in 1942.

VERMIFORMED PROCESS (processis vermiformis; appendix)

Hollow organ, part of the gastrointestinal tract

It arises from the dome of the cecum at the point where the three tendon bands of the colon (Valsalva bands) converge: tenia libera, tenia tesocolica, tenia omentalis. This place is on average 1.5-4.0 cm away from the confluence ileum in the blind. The appendix is ​​located intraperitoneally in the abdominal cavity and has a mesentery. The length of the appendix is ​​on average 7-10 cm, diameter 0.5-0.8 cm. The literature describes a vermiform appendix more than 23 cm long (L, Morel, 1905) and as a casuistry 40 cm long, 8 cm wide, with a wall thickness 1.5 cm (M, I. Reznitsky, N. r. Rabinovich, 1968). The structure of the vermiform appendix is ​​divided into: base, body and apex. The serosa of the appendix is ​​smooth and pale pink.

Forms of the appendix (T, F. Lavrova, 1942): embryonic (as a continuation of the cecum); stem-shaped (equal thickness throughout); cone-shaped (the base of the process is narrower than the apex).

The vermiform appendix opens into the lumen of the cecum with an orifice called the opening of the appendix (ostiut appendicis). Here is the proper valve of the appendix (valva appendicis), or Gerlach's valve (1, Gerlach, 1847), a fold of the mucous membrane. The appendix valve becomes well defined only by the 9th year of life. From the side of the intestinal lumen, the mouth of the appendix is ​​located 24 cm below the ileocecal opening.

Types of origin of the appendix from the cecum (E Treves, 1895):

the cecum, narrowing funnel-shaped, passes into the appendix;

the cecum passes into the appendix, sharply narrowing and curving;

the appendix extends from the dome of the cecum, but its base is displaced posteriorly;

extends posteriorly and inferiorly from the confluence of the ileum.

Location of the appendix in abdominal cavity(relative to the cecum):

The projection of the vermiform appendix onto the anterior abdominal wall of the abdomen is within Sherren’s “appendicular triangle”

The sides of the triangle are connected by the following anatomical formations: the umbilicus, the right pubic tubercle and the anterior superior spine of the right ilium. Moreover, the line running from the navel to the anterosuperior spine of the right ilium (lipea spipoutbilicalis) is called the Monroe-Richter line (A. Monro, 1797; A.G.Richter, 1797), and the line connecting the anterosuperior spines of both iliac bones, the interosseous line (lipea spipoutbilicalis) /is) or Lanz lines (O. Lanz, 1902).

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There are many topographic points of projection of the appendix onto the anterior abdominal wall of the abdomen:

· McBurney's point (Cb, McBurney, 1889) is located on the border of the middle and lateral third of the line connecting the umbilicus and the anterosuperior spine of the right ilium.

· Lanz's point (O, Lanz, 1902) is located on the border of the middle and right third of the interspinous line connecting the anterosuperior spines of both iliac bones,

· Kummell's point (H, Kummell, 1890) is located 2 cm below and to the right of the navel,

· The point rrey (T, C. Gray, 1971) is located below and to the right of the navel by 2.5 cm.

· Point 30nnenburg (E. Zonnenburg, 1894) is located at the intersection of the Pnea bispina/is (the line connecting the anterosuperior spines of both iliac bones) and the outer edge of the right rectus abdominis muscle,

Morris's point (R. T. Morris, 1904) is located at a distance of 4 cm from the navel along the line connecting the socket and the anterior superior spine of the right ilium,

Munro's point (1. S. Munro, 1910) is located at the intersection of the outer edge of the right rectus abdominis muscle and the line connecting the umbilicus and the anterosuperior spine of the right ilium.

Lenzmann's point (R, Lenzmann, 1901) is located 5 cm medially from the anterosuperior spine of the right ilium along the interspinous line,

Abrazhanov's point (A. A. Abrazhanov, 1925) is located in the middle of the line connecting McBurney's point with the point obtained by crossing the interspinous line and the white line of the abdomen.

The uberritsa point (M, M. uberrits, 1927) is located immediately under the inguinal ligament in the Scarpovian triangle. Used for pelvic location of the appendix.

Punin's point (B.V. Punin, 1927) is located to the right of the outer edge of the third PLUS vertebra. Used to determine the projection of the retroperitoneal appendix,

Rotter's point O. Rotter, 1911) is determined by digital examination of the rectum as the point of maximum pain in the anterior wall of the rectum to the right of the midline.

BoykoPronin's point (Fig. b,.N"!! 11), We have identified a point on the border of the distal and middle third of the perpendicular, lowered from the navel to the inguinal ligament,

In the literature there are many descriptions of the atypical, casuistic location of the appendix: behind the appendix (L, P. Semenova, E, A. Zinikhin, 1958); departure of the appendix from the hepatic region of the colon (N.S. Khaletskaya, 1955); intramesenteric (KL. Bokhan, 1987), etc. The facts of the presence of two appendixes are presented (D, E, Robertson, 1940; B, E. Im Naishvili, R, R, Anakhasyan, 1968; c, r, Dzhioev, M.r : Revzis, 1980; M, M. Mypzanov, 1981, etc.), The left-sided location of the appendix is ​​described with situs viscerum ipversus (H, Hebblethwaite, 1908; M, A, Kaliner, 1962, etc.), as well as with left-sided placement cecum (N, Damianos, 1902; M. Sokolova, 1910, etc.),

In more than 70% of cases, the appendix is ​​free from adhesions throughout its entire length. In approximately 30%, it is fixed in a zip-shaped manner due to fusions and adhesions

Histotopography of the appendix

1, The serous layer is a continuation of the general peritoneal layer, covering both the ileum and the cecum.

2, The subserous layer is loose tissue containing fat cells. The subserous nerve plexus is located in it,

3, The outer muscular layer (a solid longitudinal muscular tube), at the base of the process, is divided into three separate longitudinal muscle strips, which pass to the cecum, and some of the fibers of this layer pass into the musculature of the baurinian valve. In the outer muscular layer there are Lockwood’s fissures (C, B, Lockwood, 1886) intermediate gaps through which there is constant communication of lymphoid accumulations opraHa,

4, Inner muscle layer (individual circular muscle fibers). The intermuscular nerve plexus of Auerbach (L, Auerbach, 1864) or Drasch (O, Drasch, 1886) is located here.

5. I10 MUCOUS LAYER interweaving of elastic and muscle fibers. Closely related to muscle layer, It contains the submucosal nerve plexus of Remak (R, Remak, 1847) or Meissner (G, Meissner, 1863). This layer also contains follicles that first appear in the first [ode of life, and atrophy by old age. Their number varies sharply in all age groups. The function of the fullicles is little studied,

6. Mucous membrane - numerous crypts, covered with single-row high prismatic epithelium, which, in turn, is covered with cuticle. The layer contains the glandular secretory apparatus; Kulchitsky's cells (N.K. Kulchitsky, 1882) are argentine substances that produce biologically active substances. L. Ashoff (1908) called them “ birthmarks mucous membrane of the appendix."

BLOOD SUPPLY OF THE WORMIC APPEAL

Types of blood supply to the appendix (H, A. Kel1y, E. Hurdon, 1905):

1, A single vessel (o. appendiculoris) feeds the entire process without the adjacent part of the cecum. This type occurs in 50% of cases,

2, The appendix is ​​supplied by more than one vessel. [the lava vessel (a. appendicularis) feeds only the distal 4/5 of the process, the proximal 1/5 of the process is supplied with blood by the branches of the posterior cecal artery (a, caecalis posterior). This type is observed in 25% of cases.

3, The appendix and the adjacent part of the cecum are supplied with blood from the posterior cecal artery. This type is identified in 2S% of cases.

4, Looping type is extremely rare,

This classification is of great practical importance. Thus, with the third type of blood supply, ligation of the mesentery in the proximal part entails necrosis of the portion of the cecum and failure of the purse-string suture when the stump of the process is formed. The main artery, which plays a major role in the blood supply to the appendix, is a, appendicularis, number 13. The average diameter is 1 mm. Departs: directly from the OCHoBHoro trunk a, i/eocolica (85%); from the iliac artery or “vascular island of Didkovsko” (14%); from anastomoses or other branches (1%). Passes a. appendicularis is more often Bcero behind the ileum at a distance of up to 3 cm from the ileocecal area. Types of branching a, appendicularis (B.V, OrHeB, 1925):

1. Maistral. Occurs in 55% of cases. This type of xapaK is suitable for a low-lying and maximally mobile vermiform appendix. The main trunk runs along the free edge of the mesentery of the appendix and gives off branches perpendicular to the process. The number of these branches is from 4 to 10. Their circular arrangement along the process indicates the cerMeHTapHOM nature of the ero blood supply (length cerMeHTa 8-12 mm).

2. Loopy. Observed in 15% of cases. This type is characteristic of a fixed, highly located process.

3, Loose. Occurs in 30% of cases. Inherent in the wide mesentery of the appendix. As a rule, with this type of branching there is always an additional source of blood supply (branches of the posterior cecal artery),

4. Mixed type is rare.

LYMPHATIC SYSTEM OF THE APPENDIX

Intraoral lymphatic vessels are located in all layers of the process. The main ones among them are the submucosal and postorous layers of capillaries, which form 25 lymphatic vessel, passing into the ero mesentery next to a, appendicularis. They flow into the main group of lymph nodes located in the form of a chain along a. ileoco/ica, From there they flow into the central l "RUPPE of mesenteric lymph nodes. It must be remembered that the regional lymph nodes for the distal 1/3 of the process are located in the mesentery of the process. And the regional lymph nodes for the proximal 2/3 of the appendix are located at the base of the appendix and along the cecum and ascending colon. This is extremely important to remember when determining the scope of the operation when malignant tumor appendix with metastases to regional lymph nodes,

INNERVATION OF THE WORMIC APPRESS

Sources of sympathetic innervation: superior mesenteric plexus, cecum plexus (located above and medially from the ileocecal plexus by 1 cm), inferior mesenteric plexus, aortic plexus. The source of parasympathetic innervation is the right trunk of Baryca. Ileocecal nerves have two forms of branching: main and scattered. More often, Bcero nerves accompany the nerves of the same name blood vessels.

physiology of the vermiform appendix

There are several points of view on the nature of the appendix. The vermiform appendix is ​​a phylogenetically new and young morphological, actively functioning formation, but does not perform vital functions (A.I. Tarenetsky, 1883; S.M.Rubashov, 1928; M.S.Kondratiev, 1941; B.M.Khromov, 1978; A. A. Pysakov et al., 1990, etc.).

The vermiform appendix is ​​a rudiment, devoid of any useful functions (I. I. Mechnikov, 1904; A. A. Bobrov, 1904; V. P. Vorobyov, 1936; A. r. Brzhozovsky, 1906; V, R, Braitsev, 1946; In, I. Kolesov, 1972, etc.).

Functions of the appendix

1. The contractile function of the appendix is ​​very poorly developed, with no definite rhythm and strength of contractions. However, different layers of the appendix musculature can contract tonically and periodically.

2. Secretory function. The fact that the appendix secretes a secretion consisting of juice and mucus was first described by J. Lieberkuhn in 1739. The total amount of secretion released per day is 35 ml, ero pH is 8.38.9 (alkaline environment). The secretion contains biologically active substances.

3. Lymphocytic function. Research by E.I. Sinelnikov (1948) established that 1 sq. cm of the mucous membrane of the appendix contains about 200 lymphatic follicles. On average, the process contains 6000 lymphatic follicles. In one minute, from 18,000 to 36,000 leukocytes per 1 square meter migrate into the lumen of the appendix. cm surface of the mucous membrane";lKI. This function maximum developed at 11-16 years of age. In connection with the above, E.I. Sinelnikov introduced in the 19th century. the concept of “the tonsil is a vermiform appendix”. Although H. Sakhli (N. SahIi, 1895) believed that appendicitis is “an appendix of the vermiform appendix.” Migration of lymphocytes into the venous capillaries was also noted, V, I, Kolesov (J 972) believes that with l “odes of lymphatic follicles They ALROPHATE and by the age of 60 are extremely rare, and the wall of the appendix undergoes sclerotic changes, and degenerative changes develop in the muscular and nervous elements of the appendix. There is an opinion that in emergency circumstances, when lymphatic tissue is destroyed in other organs and parts of the body, the appendix can take on a protective role and is, as it were, a reserve apparatus that is for the time being in an inactive state.

4, Antibody production. Kawanichi (N. Kawanichi, 1987) believes that the lymphoid tissue of the appendix is ​​one of the important links in the B-lymphocyte system that ensures the production of antibodies. A. V. Rusakov et al. (1990) note that the main function of the appendix is ​​the ability to control according to the principle feedback the completeness of enzymatic breakdown of food products by assessing the degree of antigenicity of chyme. In addition to this, B, M. Khromov (1979) believes that the appendix may be responsible for the incompatibility reaction during opraHoB transplantation.

5. Endocrine function. This function was attributed to the secretion of the appendix by P.I. Dyakonov (1927). B.M. Khromov (1978) emphasized that the mucous membrane secretes a number of enzymes that affect the digestion process and affect the activity of other opl"aHoBs of the abdominal cavity. There is an assumption that the endocrine role is played by Kulchitsky cells.

6, Digestive function. B. DeBusch (W. DeBusch, 1814) believed that the appendix takes part in the digestion of fiber; he even coined the terms “second salivary gland” and “second pancreas.” O. Funke (O, Funke, 1858) proved that the secretion of the appendix is ​​capable of breaking down starch.

7, Maintaining a normal microbial background, K. H. Diby (K. N. Digby, 1923) and H. Kawanichi (N, Kawanichi, 1987) noted that the secretion of the appendix promotes the transition of microbial toxins to a neutral state and delays the proliferation of bacteria in initial parts of the colon,

8. Valve function. A. N. Maksimenkov (1972) believes that the valve function in the ileocecal region is carried out with the power of the appendix.

9. Effect on intestinal motility. W. McEven (1904) believed that the secretion of the appendix helps to enhance peristalsis and prevent coprostasis in the cecum. It is believed that this secretion is produced by Kulchytsko cells.

CLASSIFICATION OF PATHOLOGY OF THE APPENDIX

International Classification of Diseases, 10th Revision (ICD-10)

Class XI. Diseases of the digestive system (K00-K93)

	[hide]Diseases of the appendix (worm-shaped appendix)
		Spicy appendicitis
			Acute appendicitis with generalized peritonitis acute appendicitis with perforation, peritonitis (spread), rupture
			Acute appendicitis with peritoneal abscess abscess of the vermiform appendix
			Acute appendicitis, unspecified acute appendicitis without perforation, peritoneal abscess, peritonitis, rupture
		Other forms of appendicitis chronic and recurrent appendicitis:
		Appendicitis, unspecified
		Other diseases of the appendix
			Hyperplasia of the appendix
			Appendicular stones appendix fecal stone
			Appendiculum diverticulum
			Appendix fistula
			Other specified diseases of the appendix intussusception of the appendix
			Disease of the appendix, unspecified

Classification of pathologies of the appendix (Pronin, Boyko)

1. Inflammation of the appendix:

a) nonspecific inflammation;

b) specific inflammation,

2. Tumors of the appendix:

a) benign;

b) malignant;

c) metastatic.

3. Torsion of the appendix

4. Infringement of the appendix in the red area

5. Injury to the appendix

6, Endometriosis of the appendix

7, Diverticula of the appendix

8. Appendiceal cysts

9. Pneumatosis of the appendix

10. Invasion of the appendix

11. Foreign bodies of the appendix

12, Changes in the appendix in diseases of related opraHoB

Appendicitis

Acute appendicitis is an acute (usually nonspecific) inflammation of the appendix.

Currently, acute appendicitis is one of the most widespread diseases, accounting for 25-30% of all surgical diseases (its frequency is 1 case per 150-200 people). Acute appendicitis can develop at any age, but the peak incidence occurs between 20 and 40 years. It develops more often in urban residents. In civilized countries, 6-12% of people experience an attack of acute appendicitis during their lifetime. Usually it causes only temporary disability, but with late diagnosis, disability or even death is possible. The mortality rate for acute appendicitis has remained virtually unchanged over the past 20 years and is 0.05-0.3% (0.15-02% in the Republic of Belarus). Diagnostic errors with this disease occur in 12-31% of cases. Complications acute appendicitis occur on average in 10% of patients, their frequency increases sharply in women and elderly people and does not tend to decrease. Among acute surgical diseases of the abdominal organs, acute appendicitis accounts for 89.1%, ranking first among them.

History of appendectomy

The history of appendicitis and appendectomy dates back more than two centuries and can be divided into two main periods.

First period: random opening of appendiceal abscesses with or without removal of the appendix. The first reliable appendectomy was performed in 1735 in London by the royal surgeon, founder of St. George's Hospital, Claudius Amyand. He operated on an 11-year-old boy with an inguinal-scrotal hernia, complicated by a fecal fistula. During the operation, Amyand discovered in the contents of the hernia a folded process with a perforation hole and a salt-encrusted pin in it. The appendix was removed, the hernia was sutured. The whole operation lasted half an hour, the child recovered. Before this operation, only the opening of “abscesses” of the iliac fossa was performed. The attention of surgeons is increasingly being drawn to cases of inflammatory processes in the right iliac region, but they were interpreted as muscle inflammation (“psoitis”) or postpartum complications (“uterine abscesses”) and, as a rule, were treated conservatively. At this time, the first mentions of cases of perforated appendicitis and the formation of abscesses of the iliac fossa appeared in the literature, but the role of the appendix in the occurrence of intraperitoneal abscesses was ignored, and the disease was explained by primary damage to the cecum (typhlitis) due to injury from foreign bodies or bedsores from fecal stones.

The second period: recognition of the role of the appendix in inflammation of the area of ​​the right iliac fossa and the identification of “appendicitis” as an independent nosological form.

In 1839 British surgeons Bright and Addison, in their work “Elements of Practical Medicine,” described in detail the clinic of acute appendicitis and provided evidence of the existence of this disease and its primacy in relation to inflammation of the intestine (previously, the idea of ​​independence of inflammation of the appendix was put forward in the 20s by the French Louis Fillerme and Francois Miler, but the theory was not accepted then). Despite this, the treatment of acute appendicitis, peritonitis and intra-abdominal abscesses was in the hands of therapists. Treatment consisted of rest, diet, gastric lavage, enemas and the administration of opium tincture, the antiperistaltic and analgesic effect of which not only allowed the abscess to be localized, but rather enabled the patient to die peacefully.

However, with the advent of the era of analgesia (Marton 1846) and antiseptics (Lister 1867), a new milestone in the treatment of appendicitis began. In 1886, at the convention of the American Medical Association, Reginal Fitz, an American surgeon and professor at Harvard University, made a report in which he proposed the term “appendicitis,” emphasized that the root cause of abscesses in the right iliac fossa is the appendix, clearly described the clinical picture of the disease, and called for surgical removal of the process. From that moment on, surgical treatment of appendicitis began to be used everywhere, the surgical technique was improved, but was not completely standardized. A significant number of surgical approaches have been proposed, but some of them did not provide convenient exposure, others led to muscle denervation and the formation of ventral hernias. One of the most successful was the oblique variable incision of Mack Burney (1894); somewhat later, the same access was proposed by Russian surgeons N.M. Volkovich and P.I. Dyakonov. In 1933, at the All-Russian Conference on Acute Appendicitis, a unified tactics for the treatment of acute appendicitis was adopted, which amounted to the earliest possible placement of the patient in a surgical hospital and urgent surgery at any time from the onset of the disease.

Over time, diagnostic methods and treatment approaches have improved. In 1901 A Russian obstetrician-gynecologist, using mirrors and a head reflector, examined the abdominal cavity through an incision in the posterior vaginal vault. That same year, Kelling performed an endoscopic examination of the abdominal cavity using a cystoscope. This was the beginning of endoscopic surgery. In 1982, German gynecologist Kurt Semm performed the first laparoscopic appendectomy.

Appendectomy

Classification of appendectomies:

Classification of appendectomy:

1. Appendectomy from laparotomy access:

Typical (antegrade) - first, the mesentery of the process is ligated and cut off, and then the process itself is cut off and the stump is treated;

Atypical (retrograde) - first the process is cut off and its stump is processed, and then the mesentery of the process is ligated and cut off.

2. Laparoscopic appendectomies.

3. Appendectomy from extraperitoneal access when the appendix is ​​located retroperitoneally.

There are many surgical approaches to the vermiform; we will consider laparotomic appendectomy using an oblique variable incision according to Volkovich-Dyakonov (McBurney)

The incision is made perpendicular to the line connecting the navel and the superior anterior iliac spine, at the border of the middle and outer third of this line. A third of the incision is located up, 2/3 down. The incision ranges from 4 to 10-15 cm, it depends on the thickness of the anterior abdominal wall. After dissecting the skin, subcutaneous fat, and superficial fascia, the aponeurosis of the external oblique abdominal muscle is exposed and a small hole is made in it with a scalpel along the fibers. Scissors are inserted into the resulting hole and peeled along the fibers, first down and then up. At the same time, the muscle fibers of the external oblique muscle are separated to the corners of the skin wound. After spreading the edges of the aponeurosis and the external oblique abdominal muscle, the internal oblique abdominal muscle opens. Its perimysium is dissected, after which the muscle is bluntly separated with two closed tweezers together with the transverse abdominal muscle. The muscles are stretched with Farabeuf hooks, the transverse fascia is grasped and incised. The parietal peritoneum is exposed in the preperitoneal tissue. The peritoneum is carefully grasped into the fold with anatomical tweezers, carefully isolated from the wound canal with gauze napkins, lifted, and bent through the branch of Kupffer scissors, making sure that only the peritoneum is captured (the branch should be visible). The peritoneum is carefully incised, its edges are grasped with clamps, the edges of the wound are pulled apart in the longitudinal direction and the revision of the abdominal cavity begins. After opening the abdominal cavity, the cecum usually protrudes into the wound, distinguished by a bluish-purple color compared to the pink loops small intestine. If loops of the small intestine or greater omentum are adjacent to the wound, they are moved medially. When the cecum is in a low position, it is pulled up, moving the ascending colon from top to bottom along the free muscle band using anatomical tweezers or fingers, after which the base of the appendix becomes visible. Thus, the dome of the cecum and the vermiform appendix are brought into the wound. The distal edge of the mesentery of the appendix is ​​grasped at its apex and the appendix is ​​raised. At the very base of the process, its mesentery is bluntly perforated with a clamp, which is then used to compress the mesentery, it is crossed at the very base and tied with an absorbable thread. A clamp is applied to the base of the process and bandaged in the resulting groove. A purse-string seromuscular suture is placed around the base of the appendix, 10-15 mm away from it.

Acute appendicitis and its complications

Target: Study of pathogenesis, clinical picture, methods of diagnosis and treatment of acute appendicitis and its complications.

Need to know

General information. Anatomy of the anterior abdominal wall, cecum and appendix. Typical and atypical variants of the location of the appendix. Frequency and place of this pathology among other surgical diseases of the abdominal organs.

Classification(clinical and morphological) acute appendicitis.

Clinic and diagnostics. Characteristics of pain syndrome, dyspeptic symptoms, the sequence of their occurrence and the dynamics of development. Kocher-Wolkovich sign. Examination data, palpation of the abdomen. Signs of peritoneal irritation. Shchetkin-Blumberg symptom. Symptoms of Rovzing, Sitkovsky, Bartomier-Mikhelson, etc. The importance of vaginal and rectal examinations. Laboratory and instrumental diagnostics. Features of the course of acute appendicitis depending on the location of the appendix (subhepatic, pelvic, retrocecal, retroperitoneal, left-sided), during pregnancy, in children and elderly patients.

Differential diagnosis. Differential diagnostic signs (complaints, anamnesis, physical and instrumental examination data) that help distinguish acute appendicitis from the following groups of diseases:

1. Other surgical diseases of the abdominal organs: perforated ulcer; acute cholecystitis; acute pancreatitis; inflammation of Meckel's diverticulum; terminal ileitis (Crohn's disease), etc.

2. Acute urological diseases: renal colic, pyelonephritis.

3. Acute diseases of the pelvic organs - interrupted ectopic pregnancy, inflammatory diseases, etc.

4. Other diseases: enterocolitis; right-sided pleuropneumonia, etc.

Treatment. Surgical tactics for acute appendicitis. Anesthesia. Operational access. Appendectomy technique. Retrograde appendectomy. Laparoscopic appendectomy. Indications for revision of the terminal part of the small intestine and pelvic organs. Indications for drainage and tamponade of the abdominal cavity.

Postoperative management. Prevention and diagnosis of postoperative complications.

Complications of acute appendicitis

Appendicular infiltrate. Definition of the concept, mechanism of formation, time of occurrence from the onset of an acute attack. Dynamics of development of symptoms of appendicitis until the formation of infiltrate. Objective data during examination of the patient. Differential diagnosis of appendiceal infiltrate from tumors of the cecum. The course and possible outcomes of appendiceal infiltrate, their clinical manifestations and diagnosis. Tactics and methods of treatment. Further treatment tactics when the infiltrate resolves.

Periappendicular abscess. Clinical (general and local) manifestations. The nature of the temperature curve. Instrumental and laboratory diagnostics. Surgical tactics. Methodology and scope of surgical intervention. Further management of the patient.

Abdominal abscesses. Causes, localization, time of occurrence, clinical (general and local) signs. Instrumental and laboratory diagnostics. Pelvic(Douglas space) abscess. Diagnostic value of vaginal and rectal examinations. Technique for opening a pelvic abscess. Subphrenic abscess. Diagnostic value of x-ray examination chest and abdominal cavity. Technique for opening a subphrenic abscess.

Pylephlebitis. Causes of occurrence. Clinical symptoms. Prevention measures.

Peritonitis. Clinical picture. Methods of diagnosis and treatment.

Must be able to

1. Purposefully collect anamnesis if an acute surgical disease of the abdominal organs is suspected, taking into account the main clinical symptoms of acute appendicitis, the characteristics of the course of the disease, the age and gender of the patient.

2. Conduct an examination of a patient with a suspected diagnosis of “acute appendicitis” with the identification of special symptoms characteristic of the disease (Shchetkin-Blumberg, Rovzing, Sitkovsky, Bartomier-Mikhelson).

3. Perform a vaginal and rectal examination and evaluate the findings.

4. Make a preliminary diagnosis.

5. Draw up a plan for the necessary instrumental and laboratory studies.

6. Conduct a reasoned differential diagnosis based on anamnesis, complaints, examination of the patient, performed instrumental and laboratory research methods.

8. Formulate and justify the final detailed clinical diagnosis.

Definition.

Acute appendicitis is an acute destructive inflammation of the appendix of the cecum.

Epidemiology.

Acute appendicitis is one of the most common diseases in emergency surgery. The incidence of acute appendicitis is 4-5 cases per 1000 people per year. Acute appendicitis most often occurs between the ages of 20 and 40 years (Diagram 1). Women get sick 1.5-2 times more often.

Diagram 1. Incidence of acute appendicitis

at different ages.

Mortality in acute appendicitis has stabilized over the past decades and averages 0.1-0.3%. Given the frequency of occurrence of this disease, even such a small probability of death results in hundreds of lives every year.

INTRODUCTION

Acute appendicitis is one of the most frequent illnesses V childhood, requiring emergency surgical intervention and has a number of features compared to adults, its course is more severe, and diagnosis is much more difficult.

This is explained a large number diseases occurring with pseudo-abdominal syndrome, difficulty in examining and identifying local symptoms. All this leads to the fact that early dates appendicitis is not diagnosed, and surgery often reveals gross destructive changes up to gangrene and perforation of the appendix with the development of peritonitis.

In the pathogenesis of purulent-inflammatory diseases there are numerous factors of modern, rapidly changing environment. This is most clearly manifested in acute inflammatory diseases abdominal organs.

Features of the course of acute appendicitis, causing difficulties in diagnosis and untimely implementation surgical intervention, determines a high incidence of complications before surgery and during postoperative period.

Late conversion and imperfection existing methods diagnosis, other reasons lead to the fact that perforation of the appendix is ​​observed on average in 15 percent. With late diagnosis or irrational treatment, destruction of the wall of the appendix leads to the spread inflammatory process in the abdominal cavity and the development of diffuse peritonitis or an increase in local changes is observed, resulting in limited peritonitis.

So, acute appendicitis with an unfavorable course can lead to serious complications, one of which is peritonitis. This, in turn, causes a number of interdependent complications. Treatment of complicated forms of appendicitis is always complex, in which, along with adequate surgical sanitation of the purulent focus and corrective intensive care important has a rational purpose antibacterial therapy. The relevance of the above topic leaves no doubt, since the number of patients with acute appendicitis complicated by peritonitis remains high.

For the first time in the 16th century - Pare described the appendix, opened ulcers in the right iliac region, 18-19th century - Dupuytren formulated the theory of typhlitis, peritiphlitis, 19th century - statements about the significance of the appendix in the development of ulcers in the right iliac region. (1827 - Meslier, 1842 Rokitansky, 1850 - Nemmerg), 1884 - R. Fitz introduces the term appendicitis.

Object of study: acute appendicitis

Subject of study: modern approaches to the diagnosis and treatment of acute appendicitis.

Objectives of the study: study of the clinical features of the disease, the complexity of diagnosis and modern methods treatment.

Research objectives:

1. Study scientific, medical and special literature on the research topic and define the basic concepts.

2. Study the course of the disease, diagnostic difficulties at the prehospital and hospital levels. Explore features surgical interventions with this pathology.

Research method: theoretical, analytical

Practical significance: expand and generalize knowledge on diagnostic and therapeutic tactics acute disease of the appendix requiring emergency care.

CHAPTER 1 THEORETICAL APPROACHES TO STUDYING THE PROBLEM OF ACUTE APPENDICITIS, THE DIFFICULTIES OF DIAGNOSIS.

Peculiarities anatomical location vermiform appendix etiology and pathogenesis, classification, differential diagnosis acute appendicitis.

Knowledge about the features of the anatomical location of the appendix is ​​necessary due to the fact that they can affect clinical features course of the disease and differential diagnosis.

The following are distinguished: anatomical features appendix location

1. mesacecal;

2. retrocecal;

3. in front of the caecum;

4. retroperitoneal;

5. in the mesentery of the colon;

6. in the pelvic cavity;

7. under the liver;

Based on the frequency of the location of the appendix and the effect on the possible clinical picture, the following options are distinguished:

1. Descending (caudal) position is the most common; it is observed, according to most authors, in 40-50% of all cases. In childhood, this situation occurs even in 60% (N. P. Gundobin). In these cases, the process usually extends towards the small pelvis, where it can, to one degree or another, come into contact with its organs. The topographic proximity of the appendix to the pelvic organs often leads to the fact that acute appendicitis simulates their inflammation (adnexitis, cystitis, etc.).

2. Lateral (lateral) position of the process is observed on average in 25% of all cases. The process is directed outward, i.e., “looks” towards the Pupart ligament.

This position of the appendix promotes the formation of circumscribed appendiceal abscesses (“lateral abscesses”).

3. The internal (medial) position of the process is observed in 17-20% of all cases. The appendix is ​​directed inwards from the cecum and is freely located among the loops of the small intestines.

This creates favorable conditions for the spread of the inflammatory process to the peritoneum and the occurrence of interintestinal abscesses or peritonitis.

4. The anterior (ventral) position of the process, when it lies in front of the cecum (on its anterior surface), is much less common. This location favors the appearance of anterior wall abscesses.

5. The posterior (retrocecal, dorsal) position of the process, when it is located on the posterior wall of the cecum, occurs, according to most authors, only in 9-13% of all cases, but has a large clinical significance(retrocecal appendicitis).

The retrocecal position of the appendix occurs especially often in childhood (A. A. Honda, Ombredan) in such cases, inflammation of the appendix can simulate some kidney diseases ( renal colic, pyelitis, paranephritis, etc.). It is necessary to distinguish the following main types of posterior (retrocecal) location of the process.

Variants of retrocecal location of the process:

A. Intraperitoneal location, when the process departs from back wall cecum and is freely located between it and the parietal peritoneum.

B. Intrawall location, when the process is intimately fused to the posterior wall of the cecum (the so-called intramural form).

B. Extraperitoneal location, when the process extends from the area of ​​the cecum not covered by the peritoneum, and, therefore, is completely or partially located retroperitoneally, i.e., in the retroperitoneal (retrocecal) tissue. This location of the appendix usually leads to great difficulties both in the diagnosis of acute appendicitis and during the operation itself.

The vermiform appendix (appendix vermiformis) is integral part ileocecal angle, which represents the morphological unity of four sections of the intestine: the cecum, terminal department ileum, initial part of the ascending colon, colon and vermiform appendix. All components of the ileocecal angle are in strict interrelation, performing the function of an “internal analyzer” that coordinates the most important function intestines - carrying chyme from the small intestine to the large intestine [Maksimenkov, 1972].

An important element of the ileocecal angle is the ileocecal valve (valva ileocaecalis), which has a rather complex structure. The function of the ileocecal valve is to regulate the passage of intestinal contents into the cecum in separate portions and prevent its reverse movement from the cecum to the small intestine.

The ileocecal angle is located in the right iliac fossa. The bottom of the cecum is projected at a distance of 4-5 cm to the top from the middle inguinal ligament, and when the intestine is full, its bottom is located directly above the middle of the inguinal ligament or even descends into the small pelvis. Great variability in the topographic-anatomical position of the cecum and appendix largely explains the diversity of the clinical picture that is observed in acute appendicitis.

The most frequent and practically important deviations from normal position of the cecum are as follows [Kolesov, 1959]:

• 1. High or hepatic position, when the cecum with the appendix is ​​located high (at the level of the 1st lumbar vertebra), sometimes reaching the lower surface of the liver.
• 2. Low or pelvic position, when the cecum with the appendix is ​​located lower than usual (at the level of 2-3 sacral vertebrae), that is, it descends into the small pelvis.

More rarely, other options for the location of the cecum are found: its left-sided position, location along the midline of the abdomen, in the navel, in the left hypochondrium, in hernial sac etc.

According to F.I. Walker, there are some age-related changes in the position of the cecum with the appendix, which in small children are located relatively high, and in old age they tend to descend below their usual position. In practice, it is very important to take into account changes in the position of the cecum with the appendix associated with pregnancy. Starting from 4-5 months of pregnancy, the cecum with the appendix begins to gradually shift towards the lower surface of the liver. After childbirth, the ileocecal angle returns to its previous position, however, acquiring greater mobility.

The cecum in 90-96% of cases is covered on all sides by the peritoneum, that is, it is located intraperitoneally, which determines its mobility.

The pockets of the peritoneum in the area of ​​the ileocaecal angle are of great importance: recessus ileocaecalis superior et inferior, recessus retrocaecalis. In these pockets of the peritoneum, internal abdominal hernias can form, which can simulate appendicitis.

The vermiform appendix in adults begins from the medial posterior or medial side of the cecum and is a blindly ending section of the intestinal tube. The vermiform appendix extends from the cecum at the confluence of three taenia 2-3 cm below the level where the ileum enters the cecum. In the vast majority of cases, the process has a stem-like shape and is characterized by the same diameter along its entire length. Hence the name - worm-shaped. But there are also options. So, according to T.F. Lavrova (1960) the vermiform appendix in 17% of cases narrows towards the apex and resembles a cone in shape. In 15% of people, the so-called embryonic form is observed, when the process is a direct continuation of the funnel-shaped narrowed cecum.

The dimensions of the vermiform appendix vary within a very wide range from 0.5 to 9 cm. However, cases of very short and very long ones (up to 50 cm) have been described [Rostovtsev, 1968; Corning, 1939]. The thickness of the vermiform appendix is ​​on average 0.5-1 cm. Moreover, its size largely depends on the age of the person. Largest sizes observed between the ages of 10 and 30 years. In the elderly and old age the vermiform appendix undergoes noticeable involutional changes.

In rare cases of reverse arrangement of the abdominal organs, the appendix, together with the cecum, is located in the left iliac region with all the possible anatomical variations encountered in its right-sided position. It is also necessary to remember about occasionally occurring anomalies, when, for example, a process moves away from outer wall the cecum or from the ascending colon. An interesting observation by I.I. Khomich (1970), in which the arcuate vermiform appendix opened at both ends into the lumen of the cecum. It is also possible to duplicate the appendix, which is usually combined with other multiple malformations and deformities.

We must also remember about the possibility of congenital absence of the appendix, which is extremely rare. P.I. Tikhonov cites literature data that the appendix is ​​absent in 5 out of 1,000 people.

The vermiform appendix is ​​located intraperitoneally. It has its own mesentery - the mesenteriolum, which provides it with blood vessels and nerves.

Variability in the location of the cecum and the appendix itself is one of the factors causing different localization pain and a variety of clinical picture options during the development of inflammation of the appendix, as well as the difficulties that sometimes arise in detecting it during surgery.

The blood supply to the ileocecal angle is provided by the upper mesenteric artery- a. ileocolica, which is divided into the anterior and posterior arteries of the cecum. From a. ileocolica or its branches arise from the proper artery of the appendix a. appendicularis, which has a loose, mainline or mixed structure. The artery of the appendix passes through the thickness of the mesentery of the appendix, along its free edge, to the end of the appendix. Despite the small caliber (from 1 to 3 mm), bleeding from a. appendicularis in the postoperative period can be extremely intense, usually requiring relaparotomy.

The veins of the cecum and appendix are tributaries of the ileocolic vein v. ileocolica, flowing into the superior mesenteric (v. mesenterica superior).

The ileocecal angle is innervated by the superior mesenteric plexus, which is connected to the solar plexus and takes part in the innervation of all digestive organs. The ileocecal angle is called the “nodal station” in the innervation of the abdominal organs. The impulses coming from here influence the function of many organs. The peculiarity of the innervation of the appendix and ileocecal angle explains the occurrence of epigastric pain in acute appendicitis and its spread throughout the abdomen.

Lymphatic drainage from the appendix and from the ileocecal angle as a whole is carried out to the lymph nodes located along the ileocolic artery. In total, along the course of this artery there is a chain of lymph nodes (10-20), which stretches to the central group of mesenteric lymph nodes. The topographic proximity of the mesenteric and iliac lymph nodes explains the similarity of the clinical picture with inflammation of these nodes (acute mesoadenitis) and inflammation of the appendix.

In 3% of women, the appendix and right appendages of the uterus have common lymphatic (and sometimes blood) vessels and nerves. In such cases, inflammatory changes easily pass from one organ to another, and differential diagnosis between diseases of the appendix and female genital internal organs on the right can be extremely difficult.

There are five main types of location of the appendix in relation to the cecum: descending (caudal); lateral (lateral); internal (medial); anterior (ventral); posterior (retrocecal).

With a descending, most common location, the vermiform appendix, heading towards the small pelvis, to one degree or another comes into contact with its organs. When positioned laterally, the process lies outside the cecum. Its apex is directed towards the Poupart ligament. The medial location is also common. In these cases, it lies on the medial side of the cecum, located between the loops of the small intestine, which creates favorable conditions for the wide spread of the inflammatory process throughout the abdominal cavity and the occurrence of ligative abscesses. The anterior position of the process, when it lies in front of the cecum, is rare. This location favors the appearance of anterior wall abscesses. Some surgeons distinguish the ascending type of location of the process. There are two possible options here. Or the entire ileocecal angle is located high, under the liver, then the term is appropriate - subhepatic location of the appendix. Or, what happens more often, the tip of the retrocecally located vermiform appendix is ​​directed towards the liver. With the retrocecal location of the appendix, which is observed in 2-5% of patients, two variants of its location in relation to the peritoneum are characteristic: in some cases, the appendage, being covered by the peritoneum, lies behind the cecum in the iliac fossa, in others it is released from the peritoneum and lies extraperitoneally. This location of the process is called retrocecal retroperitoneal. This option should be considered the most insidious, especially in cases of purulent, destructive appendicitis, since in the absence of peritoneal cover on the appendix, the inflammatory process spreads to the perinephric tissue, causing deep retroperitoneal phlegmon.

Table of contents of the topic "Topography of the small intestine. Topography of the large intestine.":

Appendix. Appendix. Topography of the appendix. Position of the appendix.

Appendix, appendix vermiforrnis, is a vestigial continuation of the cecum. It starts from the medial-posterior or medial side of the cecum; the length of the appendix in an adult is on average 9 cm. The diameter is about 8 mm.

Appendix It is located intraperitoneally and usually has a well-defined mesentery, mesoappendix, in which vessels and nerves pass. Thanks to the mesentery, the peripheral part of the appendix has significant mobility.

Position of the base of the appendix also very variable. More often it is projected onto the anterior wall of the abdomen at the point between the right and middle third of the linea bispinalis (Lanc's point), less often - between the outer and middle third of the line connecting the navel with the right anterior superior iliac spine (Mac Barney's point).

However, both of these projections correspond to the position base of the appendix in less than half of the cases.

The following are possible position of the appendix in the abdominal cavity:
1) pelvic, or descending position of the appendix, - the process is directed downwards into the pelvic cavity;
2) medial position of the appendix- the process lies parallel to the ileum;
3) lateral position of the appendix- the process is located in the right lateral paracolic groove (canal);
4) anterior position of the appendix- the process lies on the anterior surface of the cecum;
5) ascending or subhepatic position of the appendix, - the process is directed upward with its apex, often to the subhepatic recess;
6) retrocecal position of the appendix- the process is located behind the cecum.

With this position of the appendix two options are possible: the process lies intraperitoneally, closely adjacent to the peritoneum of the posterior wall of the cecum; the process lies retroperitoneally, or retroperitoneally. In the latter case, the appendix is ​​located in the retroperitoneal tissue, often reaching the point where the femoral nerve exits the intermuscular gap between m. psoas major and m. ileacus.
This explains the possible irradiation of pain into the thigh when appendicitis. Often appendix rises to the lower end of the fascial sheath of the kidney.

Ways of spread of the purulent process (peritonitis) with purulent appendicitis largely depend on the position of the appendix. The spread of purulent exudate into the pelvic cavity with the pelvic position of the appendix seems obvious. At medial position of the appendix the pus spreads through the right mesenteric sinus, but remains within the lower floor. In the upper floor, purulent exudate can spread when the process is in a lateral position along the right paracolic groove (canal) up to the diaphragm. This is facilitated by the patient's lying position, as a result of which the subdiaphragmatic space appears deeper than the iliac fossa, and the exudate simply flows into a lower location. The suction action of the diaphragm and intestinal peristalsis play a certain role in the process of spread of the abscess.

Retroperitoneal location of the appendix complicates the diagnosis of acute appendicitis, and the transition of the inflammatory process to the tissue of the retroperitoneal space may be the cause severe complications(paracolitis and retroperitoneal subdiaphragmatic abscesses).

To see base of the appendix, the cecum must be pulled laterally and upward. Then the place where all three muscle bands of the cecum converge becomes visible. This is where the base of the vermiform appendix is ​​located. When locating the appendix during appendectomy, colonic bands should be used as permanent landmarks. In cases of retrocecal and retroperitoneal position of the appendix, the parietal layer of the peritoneum is incised at the outer wall of the cecum, which allows you to evert the intestine and find the appendage at its posterior wall.