Why does infiltration appear after appendicitis surgery? Complications after appendicitis: possible problems and consequences

The infiltration manifests itself with pronounced symptoms, but the symptoms disappear a few days after the onset. A tumor is a contraindication to appendectomy.

Causes

The most common cause of this complication is late seeking medical help for appendicitis. Up to 90-95% of patients go to the hospital 1-2 days after inflammation of the appendix.

The appearance of infiltration may also be associated with deterioration general condition health, as well as anatomical features. Provoking factors:

• decreased immunity;
• specific location of the appendix (in front or behind the cecum);
• peritoneal reactivity (ability to limit acute inflammatory processes).

Most often, infiltration is diagnosed in children aged 10-14 years, much less often in adults.

Symptoms

Appendiceal infiltration is of two types - early and late. The first develops within 1-2 days after the first signs of appendicitis appear, and the second only on the 5th day.

Symptoms of infiltration:

• severe pain in the right iliac region;
• increased body temperature, chills;
• nausea and vomiting;
• lack of stool.

With late infiltration, symptoms come to the fore acute appendicitis, since the tumor forms only on the 4-5th day, when the pain already decreases. With palpation, you can feel a formation measuring 8x10 cm.

The tumor forms within 12-14 days. During this period, the symptoms are pronounced, then the signs gradually subside. Next n for appendicular infiltrateThere are 2 options for the development of events:

• The tumor will resolve itself. This happens in more than 90% of patients. The resorption stage can last 1-1.5 months.
• An appendicular abscess forms (the infiltrate suppurates).

The last option is dangerous for the patient's life. In case of such a complication, emergency surgery is performed. The infiltrate suppurates and increases significantly in size. Painful sensations in the right iliac region intensify, body temperature rises to 40˚C, general condition worsens, and signs of intoxication appear. Sometimes symptoms of peritoneal irritation are present.

If you do not provide timely assistance to the patient, then as a result of an abscess, even sepsis may develop. These complications can be fatal.

Symptoms that indicate life-threatening consequences:

• high body temperature up to 40 ˚С;
• rapid breathing and heart rate;
• increased sweating, cold sweat;
• pale skin;
• an increase in the level of leukocytes in the blood, which indicates an inflammatory process.

Quite rarely, a purulent infiltrate can develop into chronic form. In this case, when exposed to unfavorable factors, it becomes inflamed.

Which doctor treats appendiceal infiltration?

The infiltrate is treated by a gastroenterologist, and then by a surgeon.

Diagnostics

Primary diagnosis is similar to examination for. The doctor listens to the patient's complaints, palpates the abdomen, examines the skin and mucous membranes. As a result of intoxication, there is white coating. On palpation, the patient notes pain in the appendix area; a dense and elastic formation can be identified.

It is sometimes possible to palpate an abscess using a vaginal or rectal digital examination. During the examination, a dense, painful protrusion of the vaginal vault or rectal wall is detected.

To make an accurate diagnosis, the infiltrate must be differentiated from some diseases of the digestive tract and genitourinary system, which have similar symptoms. These are Crohn's disease, ovarian cyst, inflammation of the appendages, tumor of the cecum. For differentiation, the following instrumental examination methods are used:

• Ultrasound abdominal cavity, as well as organs of the genitourinary system (necessary to determine the size of the tumor, as well as the presence of fluid);
• X-ray of the abdominal organs.

Sometimes the patient is prescribed a CT scan.

Treatment

Treatment of appendiceal infiltrate is conservative. It is carried out in a hospital setting. The patient is monitored regularly. After the infiltrate has resolved, removal of the inflamed appendix is ​​indicated.

It takes up to 3-4 months for the infiltrate to resolve; in elderly patients and children, the tumor disappears after six months.

Conservative treatment:

• drug therapy;
• bed rest;
• dietary nutrition;
• physiotherapeutic procedures.

The main point of therapy is to stop inflammatory process, prevent its spread to neighboring organs, relieve pain. For appendicitis complicated by infiltrate, the patient is hospitalized in surgery department. He must remain in bed and eat properly. The diet involves eliminating carbonated drinks and alcohol, avoiding foods high in fiber (vegetables and fruits), and also eliminating smoked, hot and spicy foods from the diet.

As first aid to inhibit the spread of bacterial flora and reduce painful sensations An ice compress is placed on the patient's stomach.

Drug therapy:

• broad-spectrum antibiotics (Ceftriaxone, Amoxiclav, Azithromycin, Cefepime, Tienam and Metronidazole);
• probiotics to normalize microflora after antibacterial treatment;
• antispasmodics (No-Shpa);
• NSAIDs (Nimesil, Nurofen);
• detoxification therapy to remove toxic substances from the body (Hemodez or Reopoliglyukin);
• vitamins.

The course of treatment is up to 10 days. If the therapy is successful, then the signs of inflammation of the appendix should disappear. The patient is observed for up to 3 months, if his condition has returned to normal, a planned appendectomy is performed. Surgical intervention involves removal of the appendix, separation of fused organs and sanitation of the cavity.

Emergency surgery to remove the appendix is ​​performed in the following cases:

• suppuration of infiltrate;
• perforation of the abscess;
• septic shock;
• ineffectiveness of therapy in the first 3-4 days of illness;
• other complications of infiltration.

The abscess is punctured and then drained. In some cases, the vermiform appendix itself is removed.

You can prevent the appearance of infiltration and its complications if you go to the hospital on the first day with appendicitis.

If treatment is not timely, the likelihood of complications is very high. The most common are colitis, paranephritis, adhesive intestinal obstruction, phlegmon, subdiaphragmatic abscesses.

Appendiceal infiltration can cause severe complications and even death of the patient, so you should not hesitate to go to the hospital. The decision about the need for surgical treatment must be made by the doctor.

Useful video about complications of appendicitis

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

What is appendicitis?

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

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

Main symptoms

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

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

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

Classification of appendicitis

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

The following types of appendicitis are distinguished:

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

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

Types of complications

Complications after appendicitis can be divided into two large groups.

The first includes complications of the inflammation itself, which often results from failure to seek medical help in a timely manner. These are complications such as:

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

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

Appendiceal infiltrate

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

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

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

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

Appendiceal abscess

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

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

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

Purulent peritonitis and pylephlebitis

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

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

Complications arising from the surgical wound

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

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

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

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

• hematoma;
• bleeding;
• divergence of edges.

Hematoma

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

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

Bleeding

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

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

Among common features The following symptoms are identified:

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

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

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

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

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

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

Infiltration and abscess: treatment

How to treat the most common complications after appendectomy?

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

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

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

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

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

Complications from other organs and systems

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

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

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

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

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

Postoperative complications in children

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

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

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

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

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

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

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

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

What complications are possible with acute appendicitis?

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

On days 3-5 after the onset of the disease, complications such as perforation of the appendix, local inflammation of the peritoneum, thrombophlebitis of the mesenteric veins, and appendiceal infiltration may develop. On the fifth day of the disease, the risk of developing diffuse peritonitis, appendiceal abscesses, portal vein thrombophlebitis, liver abscesses, and sepsis increases. This division of complications into stages is conditional.

The following can cause complications in acute appendicitis:

• late surgical intervention, which happens when the patient does not apply in a timely manner, rapid progression of the disease, or long-term diagnosis;
• defects in surgical technique;
• unforeseen factors.

Possible complications are divided into preoperative and postoperative. The former are especially dangerous because they can be fatal.

Preoperative pathologies

Preoperative complications of acute appendicitis include:

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

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

If in the early stages the pain syndrome was not very pronounced, then perforation is perceived by patients as the beginning of the disease. The mortality rate for perforation reaches 9%. Rupture of appendicitis occurs in 2.7% of patients who applied in the early stages of the pathology and in 6.3% of patients who saw a doctor in the later stages.

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

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

The clinic distinguishes 3 stages:

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

When treating peritonitis, it is necessary to eliminate the source of infection, perform sanitation of the abdominal cavity, drainage, adequate antibacterial, detoxification and infusion therapy. Appendiceal infiltrate is called internal organs (omentum, intestines) that have grown together around the appendix and are changed by inflammation. According to various statistics, pathology occurs in 0.3-4.6 to 12.5 cases.

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

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

An ultrasound examination can confirm the diagnosis. IN difficult cases A diagnostic operation (laparoscopy) is performed.

The presence of infiltrate is the only circumstance under which surgery is not performed. Surgical intervention cannot be performed until the infiltrate has abscessed, since there is a high risk that when trying to separate the appendix from the conglomerate, the fused organs (mesentery, intestines, omentum) will be damaged, and this can lead to serious consequences.

Therapy for infiltration is conservative and carried out in a hospital setting. Cold on the abdomen, a course of antibiotics, bilateral perinephric blockade, taking enzymes, diet therapy and other measures that help reduce inflammation are indicated. The infiltrate resolves in the vast majority of cases, usually within 7-19 or 45 days.

If the infiltrate does not disappear, then a tumor is suspected. Before discharge, the patient must undergo irrigoscopy to exclude tumor process in the cecum. If the infiltrate was detected only on the operating table, then the appendage is not removed. Drainage is done and antibiotics are injected into the abdominal cavity.

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

It leads to high temperature with large daily fluctuations (3-4 C), cyanosis and jaundice appear. The patient has severe acute pain throughout the abdomen. Multiple liver abscesses develop. Treatment involves taking anticoagulants, broad-spectrum antibiotics, which are administered through the umbilical vein or spleen.

Appendiceal abscesses appear in the late period, before surgery, mainly as a consequence of suppuration of the infiltrate, and after surgery as a result of peritonitis. Complications appear 8-12 days after the onset of the disease. By location they distinguish:

• ileocecal (paraappendicular) abscess;
• pelvic abscess;
• subhepatic abscess;
• subphrenic abscess;
• interintestinal abscess.

Early complications appendicitis can occur within 12-14 days, late ones can occur in a couple of weeks

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

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

If, with phlegmonous appendicitis, the proximal part of the appendix closes, then distal section expands and a collection of pus (empyema) occurs. The spread of the purulent process to the tissues surrounding the appendix and the cecum (peritiphlitis, periappendicitis) leads to the formation of encysted ulcers, and inflammation of the retroperitoneal tissue occurs.

Postoperative conditions

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

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

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

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

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

The general condition is serious, there is fever and chills, increased sweating, and sometimes jaundice of the skin is noted. Treatment is only surgical; access is difficult, since there is a danger of infection of the pleura or abdominal cavity. Surgery knows several methods of opening the abdominal cavity, applicable in in this case.

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

Complications from surgical wounds are the most common, but they are relatively harmless. Infiltration, suppuration and suture dehiscence most often occur, and they are associated with how deep the incision had to be made and the suturing technique. In addition to observing asepsis, the method of surgery, tissue sparing, and the general condition of the patient are also important.

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

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

Is bleeding. More often, bleeding is observed from the stump of the mesentery of the process, which occurs as a result of insufficiently strong ligation of the vessel feeding the process. Bleeding from this small-diameter vessel can quickly lead to massive blood loss. Often the picture of internal bleeding is detected in the patient while still on the operating table.

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

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

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

In some patients, blood spilled into the abdominal cavity can be absorbed without a trace. Then only the presence of anemia and the appearance of jaundice as a result of the resorption of extensive hemorrhage make it possible to correctly assess the existing phenomena. However, such a favorable outcome even with minor hemorrhage is observed quite rarely. If the blood accumulated in the abdominal cavity becomes infected, peritonitis develops, which is usually limited in nature.

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

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

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

Sometimes after the wound heals, ligature fistulas form. They are characterized by small size, purulent discharge and the growth of granulation tissue around the fistula opening. After removing the ligature using anatomical tweezers or a crochet hook, the fistulas heal. It’s even better to use a large fish hook bent over a flame, the tip of which is bent so that a second barb is formed.

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

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

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

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

Fistulas of the small intestine, transverse colon and sigmoid, the wall of which may be flush with the skin, are usually labiform and require surgical closure. Fistulas of the cecum, as a rule, are tubular and can close on their own with careful washing of the fistula tract with an indifferent liquid. Surgical closure of the fistula is indicated only if conservative treatment has failed for 6-7 months.

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

Postoperative peritonitis may develop gradually. Patients do not always complain about increased pain, considering it a self-evident phenomenon after surgery. However, the pain continues to intensify; in the right iliac region, upon palpation, increasingly sharp pain, muscle tension and other symptoms characteristic of peritoneal irritation are noted. The pulse quickens and the tongue begins to dry out. Sometimes the first and initially seemingly only sign of peritonitis may be vomiting or regurgitation, sometimes - increasing intestinal paresis. The abdomen gradually begins to swell, gases do not pass away, peristaltic sounds are not heard, and in the future the picture develops in exactly the same way as with appendiceal peritonitis in non-operated patients. In some patients, at first there is only an increase in heart rate that does not correspond to the temperature.

Signs of peritonitis may gradually appear during the first days after surgery, increasing very slowly. But sometimes they appear quickly, and in the next few hours a picture of diffuse peritonitis develops. The development of postoperative peritonitis is always an indication for urgent relaparotomy and elimination of the source of infection. The latter is either the stump of the appendix, which has opened due to incompetence of the sutures, or a perforation hole in the intestinal wall. If the intervention is performed early, it is possible to close the stump or perforation hole with sutures. In the later stages, this is not possible due to the fact that the sutures placed on the inflamed tissues are cut, then we have to limit ourselves to supplying drainage and tampons.

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

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

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

It should be remembered that such phenomena of irritation of the rectum can develop very late, when the abscess has already reached a significant size. Therefore, if the course of the postoperative period is not smooth, it is necessary to systematically perform a digital examination of the rectum, bearing in mind that Douglas abscess is the most common of all severe intra-abdominal complications observed after surgery for appendicitis. It is opened through the rectum or (in women) through the vagina, emptying the purulent collection through the posterior fornix.

The formation of abscesses in other parts of the abdominal cavity is less common. At first, interintestinal abscesses can manifest themselves only as increasing septic phenomena. Sometimes it is possible to detect an infiltrate in the abdomen if the abscess is parietal. If he doesn't belong to abdominal wall, then it can be felt only when the bloating of the intestines and the tension of the abdominal muscles decrease. Abscesses must be opened with an incision appropriate to its location.

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

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

When treating pylephlebitis, first of all, it is necessary to take all measures to eliminate the source of infection - emptying possible accumulations of pus in the abdominal cavity and retroperitoneal space, ensuring good outflow through extensive drainage. Vigorous treatment with antibiotics. When abscesses form in the liver, open them.

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

In addition, in the coming days after appendectomy, mechanical obstruction may develop as a result of compression of intestinal loops in the inflammatory infiltrate, bending them with adhesions, pinching by cords formed during the fusion of abdominal organs, etc. Obstruction can develop soon after the operation, when still in Inflammatory phenomena in the abdominal cavity did not subside, or at a later date, when it already seemed that a complete recovery had occurred.

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

If conservative measures are ineffective, treatment of mechanical obstruction should be surgical.

In case of obstructive obstruction caused by bending of the intestines as a result of their contraction by adhesions, or when they are compressed in the infiltrate, the adhesions are separated if this is easily feasible. If this is difficult and if it is associated with injury to inflamed and easily vulnerable intestinal loops, a bypass interintestinal anastomosis is performed or limited to the position of the fistula.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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