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Department of Surgery No. 2 KhNMU
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Definition and prevalence
Acute appendicitis - inflammation vermiform appendix cecum, one of the most common surgical diseases. The incidence of acute appendicitis is 4-5 people per 1000 population. Acute appendicitis most often occurs between the ages of 20 and 40; women are affected 2 times more often than men. Mortality is 0.1-0.3%, postoperative complications - 5-9%.
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In 1886, Reginald Fitz first described and named OA as “inflammation of the appendix.”
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Anatomy
The vermiform appendix is a direct continuation of the cecum. It is located at the confluence of three longitudinal ribbons (shadows). Its length varies within very wide limits. On average it is 7-10 cm, but can vary from 0.5 to 30 cm or more. In most cases, the appendix has a mesentery - a duplication of the peritoneum. Perivascularly along the artery of the appendix, nerves - derivatives of the superior mesenteric plexus - penetrate into it.
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Physiology
Most researchers consider it a kind of tonsil gastrointestinal tract, since it contains a large amount of lymphoid tissue in the mucous membrane. Lymphoid tissue is most developed in childhood, especially at 12-16 years old. Starting at the age of 30, the number of follicles decreases significantly, and by the age of 60 they completely disappear.
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Location options
Most often, the vermiform appendix is located inside the peritoneum and its apex is directed downward. However, there are various options its location both in relation to the cecum and depending on the location of the intestine itself.
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Appendix location options *
They are distinguished (according to Allen):
in the right iliac fossa
medial retrocecal
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They are distinguished (according to Allen):
under the terminal ileum
lateral
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ETIOLOGY AND PATHOGENESIS *
The causes of acute appendicitis have not been fully studied to date. Many theories have been proposed to explain the mechanisms of development of inflammation in the appendix. Main theories: Infectious; Neurovascular; Contributing factors: Obturation (stone, worms, etc.) Gastrointestinal diseases
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ETIOLOGY AND PATHOGENESIS
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Neurovascular theory: Proponents of the neurovascular theory believe that first there will be a reflex disturbance of regional blood flow in the appendix (vasospasm, ischemia), and then thrombosis of the supply vessels, leading to trophic disorders in the wall of the appendix, up to necrosis. Some researchers attach important allergic factor. This theory is supported by a significant amount of mucus and Charcot-Leyden crystals in the lumen of the appendix.
Slide 13
Modern views: The process begins with functional disorders from the side of the ileocecal angle (bauginospasm), the cecum and the vermiform appendix. Digestive disorders lead to the occurrence of spastic phenomena (increased putrefactive processes in the intestines, atony, etc.), as a result of which the large intestine and the appendix are poorly emptied. Those located in the appendix can provoke a spasm. foreign bodies, fecal stones, worms. Spasm of the smooth muscles of the appendix also leads to regional vascular spasm and local disruption of the trophism of the mucous membrane (primary Aschoff affect).
Slide 14
Modern ideas: Impaired evacuation, stagnation of intestinal contents contribute to an increase in the virulence of intestinal microflora, which, in the presence of a primary affect, easily penetrates the wall of the appendix and causes a typical inflammatory process. Initially, leukocyte saturation occurs only in the mucous membrane and submucosal layer, and then in all layers of the appendix. Infiltration is also accompanied by restructuring of lymphoid tissue (hyperplasia). The emergence of zones of ischemia and necrosis contributes to the formation of pathological enzymes (cytokinase, kallikrein, etc.) with high proteolytic activity, which leads to further destruction of the wall of the appendix, up to its perforation and the development of purulent peritonitis.
Slide 15
Classification (V.I. Kolesov, 1972) *
The following forms of acute appendicitis are distinguished: 1) mild (appendicular colic); 2) simple (superficial); 3) destructive: a) phlegmonous, b) gangrenous, c) perforative; 4) complicated: a) appendiceal infiltrate (well-demarcated, progressive), b) appendiceal abscess, c) purulent peritonitis, d) other complications of acute appendicitis (sepsis, pylephlebitis, etc.).
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Pathology
Acute simple appendicitis Acute phlegmonous Acute gangrenous Perforated
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Acute appendicitis is characterized by a certain symptom complex, which depends on a number of reasons: the time elapsed from the moment of the disease, the location of the appendix, the nature of the patho morphological changes both in the process itself and in the abdominal cavity, the age of the patient, the presence concomitant pathology And physiological state body.
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CLINIC *
The disease begins suddenly, in the midst of complete well-being, without a prodromal period. Most persistent symptom- abdominal pain, which is usually constant. The localization of pain at the onset of the disease is variable. Most often, it appears immediately in the right iliac region, but it can occur in the epigastrium (Kocher's sign) or in the periumbilical region (Kümmel's sign) and only after a few hours moves to the right iliac region. In some cases, the clinical picture of acute appendicitis develops very rapidly, and the pain is not localized, but occurs immediately throughout the abdomen.
Slide 23
Another important symptom- vomit. It is observed in approximately 40% of patients and is present in initial stages diseases are reflexive in nature. Vomiting is often one-time. Nausea usually occurs after pain and is wave-like. Sometimes there is stool retention and loss of appetite, but there may be one-time diarrhea, which becomes more frequent with a retrocecal or pelvic location of the inflamed process and can serve as a pathognomonic symptom atypical forms diseases. Urinary disorders are rare and may be associated with an unusual location of the process (adjacent to the kidney, ureter, bladder). The temperature reaction depends on the form of the disease and the presence of complications (from low-grade, febrile, rarely hectic)
Slide 24
Main symptoms: Razdolsky's symptom - with superficial palpation it is possible to identify a zone of hyperesthesia in the right iliac region Rovsing's symptom - the examining doctor with his left hand presses on the abdominal wall in the left iliac region according to the location descending department colon; Without removing the left hand, the right one makes a short push on the anterior abdominal wall on the overlying part of the colon. At positive symptom the patient feels pain in the right iliac region.
Slide 25
Main symptoms: Voskresensky's symptom - the doctor, positioned to the right of the patient, pulls on his shirt with his left hand, and with his right hand slides his fingertips along it from the epigastric region towards the right iliac region. At the end of the slide the patient feels sharp pain(the symptom is considered positive). Sitkovsky's symptom - The patient is placed on his left side. Intensification or occurrence of pain in the right iliac region is characteristic of acute appendicitis.
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Main symptoms: Dumbadze's symptom - the appearance of pain when examining the peritoneum with a fingertip through the navel. The Yaure-Rozanov symptom is used to diagnose appendicitis with a retrocecal location of the appendix: when pressing with a finger in the area of the lumbar triangle of Petit, pain appears.
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Main symptoms: Rectal (in men) or vaginal (in women) examination is important in recognizing acute appendicitis. They should be performed on all patients and are aimed at determining the sensitivity of the pelvic peritoneum (Douglas cry) and the condition of other pelvic organs, especially in women. The Shchetkin-Blumberg symptom is caused by slowly pressing your fingers on the abdominal wall and quickly withdrawing your hand. At the moment the hand is removed, acute localized pain appears due to irritation of the inflamed peritoneum.
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Features of the clinical course *
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Features of the course of acute appendicitis in children *
Acute appendicitis in children occurs at any age, and its course is due to the reduced resistance of the peritoneum to infection, the small size of the omentum, as well as increased reactivity child's body. In this regard, acute appendicitis in children is severe, the disease develops faster than in adults, with a large percentage of destructive and perforative forms.
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rapid onset of the disease; heat 38-40° C; cramping abdominal pain; repeated vomiting, diarrhea; The pulse rate often does not correspond to the temperature; rapid development destructive changes in the vermiform appendix; severe symptoms intoxication; frequent development of diffuse peritonitis.
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Features of the course of acute appendicitis in elderly and old age *
erased course of the disease due to the body’s unresponsiveness and concomitant diseases; the temperature is often normal, its rise to 38o C and higher is observed in a small number of patients; abdominal pain is slightly expressed; protective muscle tension is absent or weakly expressed; rapid development of destructive changes in the appendix (due to vascular sclerosis), slight increase in the number of blood leukocytes, moderate shift leukocyte formula to the left even in destructive forms.
Slide 36
Features of the course of acute appendicitis in pregnant women *
In the first half of pregnancy, the manifestations of acute appendicitis do not differ from its usual manifestations
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In the second half of pregnancy, the localization of pain and tenderness changes (displacement of the cecum and appendix by an enlarged uterus). The disease often begins suddenly with the appearance acute pain in the stomach, persistent in nature, nausea and vomiting. Due to changes in the location of the appendix, abdominal pain can be detected not only in the right iliac region, but also in the right lateral flank of the abdomen, the right hypochondrium, and even in the epigastric region. Muscle tension cannot always be detected, especially in the last third of pregnancy, due to pronounced overstretching of the anterior abdominal wall. Of the painful techniques, the Shchetkin-Blumberg, Voskresensky, and Rozdolsky symptoms are of greatest diagnostic value. Leukocytosis in acute appendicitis in pregnant women is in most cases 810912109 / l, often with a shift to the left.
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DIAGNOSTICS *
Careful collection and detailing of the patient’s complaints and medical history. Identification of symptoms characteristic of acute appendicitis (palpation, percussion of the abdomen). Rectal and vaginal examinations. Laboratory research. Exclusion of diseases simulating acute pathology in the abdominal cavity
Slide 39
Laboratory research *
The minimum laboratory tests to establish a diagnosis of acute appendicitis include: general analysis blood, urine, determination of the neutrophil-leukocyte ratio (n/l), leukocyte index of Kalf-Kalif intoxication.
Slide 40
Laboratory research
Leukocytosis is characteristic of all forms of acute appendicitis and has no pathognomonic significance, since it is also observed in other inflammatory diseases. It should only be viewed and interpreted in conjunction with clinical manifestations diseases. More significant diagnostic value has an assessment of the leukocyte formula (the presence of a neutrophil shift - the appearance of juvenile forms, an increase in the n/l coefficient of more than 4 indicates a destructive process). With the development of the destructive process, there may be a (sometimes very significant) decrease in the number of leukocytes compared to the norm with a predominance of band neutrophils and other young forms. This indicates a pronounced work stress hematopoietic system. This phenomenon is called “consumption leukocytosis.”
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X-ray OBP Ultrasound CT Laparoscopy These methods are used in doubtful cases, including for differential diagnosis and exclusion of other diseases simulating acute appendicitis
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X-ray examination of the obstructive artery makes it possible in some cases to diagnose OA and exclude other acute surgical diseases.
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DIFFERENTIAL DIAGNOSIS
Acute appendicitis must be differentiated from acute diseases abdominal organs and retroperitoneal space. This is revealed by the significant variability in the location of the appendix in the peritoneal cavity, often by the absence of a typical clinical picture diseases.
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DIFFERENTIAL DIAGNOSIS *
Acute pancreatitis Acute cholecystitis Perforated ulcer of the stomach or duodenum Acute intestinal obstruction Disturbed ectopic pregnancy Twisted cyst or ovarian rupture Acute adnexitis Crohn's disease Perforation of Meckel's diverticulum or Meckel's diverticulitis. Right-handed renal colic Food poisoning Acute mesenteric lymphadenitis Acute pleuropneumonia Myocardial infarction (abdominal form)
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SURGERY
All patients with an established diagnosis of acute appendicitis, regardless of the time elapsed from the onset of the disease, are subject to surgical treatment. Principle early surgery must be unshakable. Significant delay in surgery, even with a relatively mild course of the disease, creates the risk of severe and even fatal complications.
Slide 49
Surgical treatment not indicated for two categories of patients: with a well-demarcated, formed appendiceal infiltrate that does not have a tendency to abscess formation; with mild appendicitis, called “appendicular colic”. In this case, if there is normal temperature bodies, normal content leukocytes in the blood, observation of the patient for 4-6 hours with the necessary research methods (laboratory, x-ray, instrumental, etc.) is indicated.
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Accesses: Oblique variable incision in the right iliac region (according to McBurney, according to Volkovich-Dyakonov) Paramedian according to Lennander Laparoscopic Mid-median laparotomy
be above the indicated line and 2/3 below it (Fig. 5. 1).
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NOTES – Natural Orifice Translumenal Endoscopic Surgery
Endoscopic transluminal surgery through natural orifices
Transgastric Transvaginal Transrectal Transvesical Combined
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COMPLICATIONS OF ACUTE APPENDICITIS
Appendiceal infiltrate: with involution of infiltrate after 4-6 weeks. and with abscess formation Widespread purulent peritonitis Intra-abdominal abscesses (pelvic, interintestinal, subphrenic) Pylephlebitis (septic thrombophlebitis portal vein and its tributaries) Liver abscesses Sepsis
Slide 64
Appendiceal infiltrate
Appendicular infiltrate usually forms by 3-5 days from the onset of the disease. This is a conglomerate consisting of inflammatory-changed intestinal loops, an omentum, delimiting the inflamed appendix and the exudate accumulated around it from the free abdominal cavity. Clinical sign infiltration - detection upon palpation of a painful inflammatory tumor in the right iliac region. General state By this time, the patient is improving, body temperature is decreasing, and pain is decreasing. The patient notes dull pain in the right iliac region, aggravated by walking. There are no signs of peritoneal irritation. The appendicular infiltrate may resolve or abscess.
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In the first case, the temperature normalizes, the size of the infiltrate decreases, pain in the right iliac region disappears, and blood counts normalize after the procedure. conservative treatment, including bed rest, antibiotic therapy and physiotherapeutic procedures. To all patients who have conservative therapy turned out to be effective, appendectomy is recommended after 1.5-2 months. after discharge from the hospital.
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Abscess formation of appendicular infiltrate
In the second option, abscess formation of the appendiceal infiltrate occurs. The appendicular abscess is opened under endotracheal anesthesia using muscle relaxants through the usual Volkovich-Dyakonov surgical incision or extraperitoneal access closer to the iliac crest to prevent pus from entering the free abdominal cavity. After removing the pus, a careful inspection of the ileocecal area is performed and, if a gangrenous process is detected, it is removed. The abscess cavity is drained. Thus, with an abscessing appendiceal infiltrate, opening the abscess is indicated, but with a dense infiltrate that has formed, all manipulations except tamponade are contraindicated.
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Generalized purulent peritonitis
If, upon opening the abdominal cavity, diffuse purulent peritonitis is discovered, the operation through local access in the right iliac region is stopped and a median laparotomy is performed. IN further tactics surgical intervention does not differ from the principles of treatment of widespread peritonitis.
Slide 69
POSTOPERATIVE COMPLICATIONS
Complications from surgical wound(infiltration, suppuration, ligature fistulas). Complications from the abdominal organs: purulent-septic (widespread peritonitis, intra-abdominal abscesses), as well as intra-abdominal bleeding, acute intestinal obstruction, intestinal fistulas. Complications from other organs and systems.
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Complications from the abdominal organs
This group of complications includes postoperative peritonitis, the formation of pericultural infiltrates, abscesses (interloop, pelvic and subphrenic abscesses), bleeding into the abdominal cavity, acute intestinal obstruction, and intestinal fistulas.
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Postoperative peritonitis is relatively rare, but dangerous complications. The cause of peritonitis is the failure of the sutures of its stump, as well as perforation of necrotic areas of the cecum or suppuration of hematomas. Treatment is relaparotomy and treatment of peritonitis according to all the rules for this complication.
Slide 72
Infiltrates and abscesses of the abdominal cavity. May be associated with errors made during execution surgical intervention, through punctures of the wall of the cecum when applying a purse-string suture. Infiltrates in the right iliac region can also occur as a result of other reasons, often independent of the surgeon, but most likely due to the characteristics of the pathology (perifocal inflammation, leaving areas of the inflamed serous membrane of the appendix during appendectomy, separation during rough isolation of its apex, prolapse of feces into the abdominal cavity stones, etc.) Such patients undergo relaparotomy and opening of the abscess and its drainage.
Slide 73
Intra-abdominal bleeding usually occurs when the ligature slips from the mesentery of the appendix or when the vessels are incompletely ligated during surgery. Acute intestinal obstruction after surgery for acute appendicitis is rare. Cause of acute intestinal obstruction, developing after surgery, is an adhesive process or the formation of an inflammatory infiltrate.
Slide 74
Intestinal fistulas occur after surgery for acute appendicitis, most often due to inflammatory destruction of the caecum and small intestine, developed during the transition of the destructive process from the appendix to the adjacent intestinal wall, or inflammatory and purulent complications, in particular peritonitis, abscesses, phlegmon. Often, intestinal fistulas develop against the background of eventration resulting from suture dehiscence. Technical errors during appendectomy allowed when applying a purse-string suture also play a role.
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Complications from other organs and systems
These are primarily postoperative pneumonia and thrombosis, for which appropriate conservative treatment is indicated. Complications from of cardio-vascular system may occur in elderly and senile patients if they have concomitant diseases. The main thing is the prevention of these complications at all stages of treatment of patients
Definition and prevalence Acute appendicitis is inflammation of the appendix of the cecum, one of the most common surgical diseases. The incidence of acute appendicitis is 4-5 people per 1000 population. Acute appendicitis most often occurs between the ages of 20 and 40; women are affected 2 times more often than men. Mortality is 0.1-0.3%, postoperative complications - 5-9%.
Anatomy The vermiform appendix is a direct continuation of the cecum. It is located at the confluence of three longitudinal ribbons (shadows). Its length varies within very wide limits. On average it is 7-10 cm, but can vary from 0.5 to 30 cm or more. In most cases, the appendix has a mesentery - a duplication of the peritoneum. Perivascularly along the artery of the appendix, nerves - derivatives of the superior mesenteric plexus - penetrate into it.
Physiology Most researchers consider it a kind of tonsil of the gastrointestinal tract, since it contains a large amount of lymphoid tissue in the mucous membrane. Lymphoid tissue is most developed in childhood, especially at 12-16 years of age. Starting at the age of 30, the number of follicles decreases significantly, and by the age of 60 they completely disappear.
Location options Most often, the appendix is located inside the peritoneum and its apex is directed downward. However, there are various options for its location both in relation to the cecum and depending on the location of the intestine itself.
ETIOLOGY AND PATHOGENESIS * The causes of acute appendicitis have not been fully studied to date. Many theories have been proposed to explain the mechanisms of development of inflammation in the appendix. Main theories: Infectious; Neurovascular; Contributing factors: Obturation (stone, worms, etc.) Gastrointestinal diseases
ETIOLOGY AND PATHOGENESIS Neurovascular theory: Proponents of the neurovascular theory believe that first there will be a reflex disturbance of regional blood flow in the appendix (vasospasm, ischemia), and then thrombosis of the feeding vessels, leading to trophic disorders in the wall of the appendix, up to necrosis. Some researchers attach importance to the allergic factor. This theory is supported by a significant amount of mucus and Charcot-Leyden crystals in the lumen of the appendix.
ETIOLOGY AND PATHOGENESIS Modern ideas: The process begins with functional disorders of the ileocecal angle (bauginospasm), the cecum and the vermiform appendix. Digestive disorders lead to the occurrence of spastic phenomena (increased putrefactive processes in the intestines, atony, etc.), as a result of which the large intestine and the appendix are poorly emptied. Foreign bodies in the appendix, fecal stones, and worms can provoke spasms. Spasm of the smooth muscles of the appendix also leads to regional vascular spasm and local disruption of the trophism of the mucous membrane (primary Aschoff affect).
ETIOLOGY AND PATHOGENESIS Modern ideas: Impaired evacuation, stagnation of intestinal contents contribute to an increase in the virulence of intestinal microflora, which, in the presence of a primary affect, easily penetrates the wall of the appendix and causes a typical inflammatory process in it. Initially, leukocyte saturation occurs only in the mucous membrane and submucosal layer, and then in all layers of the appendix. Infiltration is also accompanied by restructuring of lymphoid tissue (hyperplasia). The emergence of zones of ischemia and necrosis contributes to the formation of pathological enzymes (cytokinase, kallikrein, etc.) with high proteolytic activity, which leads to further destruction of the wall of the appendix, up to its perforation and the development of purulent peritonitis.
Classification (V.I. Kolesov, 1972) * The following forms of acute appendicitis are distinguished: 1) mild (appendiceal colic); 2) simple (superficial); 3) destructive: a) phlegmonous, b) gangrenous, c) perforative; 4) complicated: a) appendiceal infiltrate (well-demarcated, progressive), b) appendiceal abscess, c) purulent peritonitis, d) other complications of acute appendicitis (sepsis, pylephlebitis, etc.).
CLINIC Acute appendicitis is characterized by a certain symptom complex, which depends on a number of reasons: the time elapsed from the moment of the disease, the location of the appendix, the nature of pathomorphological changes both in the appendix itself and in the abdominal cavity, the age of the patient, the presence of concomitant pathology and the physiological state of the body.
CLINIC * The disease begins suddenly, in the midst of complete well-being, without a prodromal period. The most consistent symptom is abdominal pain, which is usually permanent. The localization of pain at the onset of the disease is variable. Most often, it appears immediately in the right iliac region, but it can occur in the epigastrium (Kocher's sign) or in the periumbilical region (Kümmel's sign) and only after a few hours moves to the right iliac region. In some cases, the clinical picture of acute appendicitis develops very rapidly, and the pain is not localized, but occurs immediately throughout the abdomen.
CLINIC Another important symptom is vomiting. It is observed in approximately 40% of patients and is of a reflex nature in the initial stages of the disease. Vomiting is often one-time. Nausea usually occurs after pain and is wave-like. Sometimes there is stool retention and loss of appetite, but there may be one-time diarrhea, which becomes more frequent with the retrocecal or pelvic location of the inflamed process and can serve as a pathognomonic symptom of atypical forms of the disease. Urinary disorders are rare and may be associated with the unusual location of the process (adjacent to the kidney, ureter, bladder). The temperature reaction depends on the form of the disease and the presence of complications (from low-grade, febrile, rarely hectic)
CLINIC * Main symptoms: Razdolsky's symptom - with superficial palpation it is possible to identify an area of hyperesthesia in the right iliac region Rovsing's symptom - the examining doctor with his left hand presses on the abdominal wall in the left iliac region according to the location of the descending colon; Without removing the left hand, the right one makes a short push on the anterior abdominal wall on the overlying part of the colon. With a positive symptom, the patient feels pain in the right iliac region.
CLINIC * Main symptoms: Voskresensky's symptom - the doctor, standing to the right of the patient, pulls on his shirt with his left hand, and with his right hand slides his fingertips along it from the epigastric region towards the right iliac region. At the end of the slide, the patient feels a sharp pain (the symptom is considered positive). Sitkovsky's symptom - The patient is placed on his left side. Intensification or occurrence of pain in the right iliac region is characteristic of acute appendicitis.
CLINIC * Main symptoms: Barthomier-Mikhelson symptom - increased pain on palpation of the right iliac region with the patient positioned on the left side. Krymov's symptom is pain when examining the peritoneum with a fingertip through the external opening of the right inguinal ring.
CLINIC * Main symptoms: Dumbadze's symptom - the appearance of pain when examining the peritoneum with a fingertip through the navel. The Yaure-Rozanov symptom is used to diagnose appendicitis with a retrocecal location of the appendix: when pressing with a finger in the area of the lumbar triangle of Petit, pain appears.
CLINIC * Main symptoms: Rectal (in men) or vaginal (in women) examination is important in recognizing acute appendicitis. They should be performed on all patients and are aimed at determining the sensitivity of the pelvic peritoneum (Douglas cry) and the condition of other pelvic organs, especially in women. The Shchetkin-Blumberg symptom is caused by slowly pressing your fingers on the abdominal wall and quickly withdrawing your hand. At the moment the hand is removed, acute localized pain appears due to irritation of the inflamed peritoneum.
Features of the course of acute appendicitis in children * Acute appendicitis in children occurs at any age, and its course features are due to the reduced resistance of the peritoneum to infection, the small size of the omentum, as well as the increased reactivity of the child's body. In this regard, acute appendicitis in children is severe, the disease develops faster than in adults, with a large percentage of destructive and perforative forms.
Features of the course of acute appendicitis in children * rapid onset of the disease; high temperature 38-40° C; cramping abdominal pain; repeated vomiting, diarrhea; The pulse rate often does not correspond to the temperature; rapid development of destructive changes in the appendix; severe symptoms of intoxication; frequent development of diffuse peritonitis.
Features of the course of acute appendicitis in elderly and senile people * erased course of the disease due to the unresponsiveness of the body and concomitant diseases; the temperature is often normal, its rise to 38o C and higher is observed in a small number of patients; abdominal pain is slightly expressed; protective muscle tension is absent or weakly expressed; rapid development of destructive changes in the appendix (due to vascular sclerosis), a slight increase in the number of blood leukocytes, a moderate shift in the leukocyte formula to the left even with destructive forms.
Features of the course of acute appendicitis in pregnant women * In the second half of pregnancy, the localization of pain and tenderness changes (displacement of the cecum and appendix by an enlarged uterus). The disease often begins suddenly with the appearance of acute, persistent abdominal pain, nausea and vomiting. Due to changes in the location of the appendix, abdominal pain can be detected not only in the right iliac region, but also in the right lateral flank of the abdomen, the right hypochondrium, and even in the epigastric region. Muscle tension cannot always be detected, especially in the last third of pregnancy, due to severe overstretching of the anterior abdominal wall. Of the painful techniques, the Shchetkin-Blumberg, Voskresensky, and Rozdolsky symptoms are of greatest diagnostic value. Leukocytosis in acute appendicitis in pregnant women is in most cases 810912109 / l, often with a shift to the left.
DIAGNOSTICS * Careful collection and detailing of the patient's complaints and medical history. Identification of symptoms characteristic of acute appendicitis (palpation, percussion of the abdomen). Rectal and vaginal examinations. Laboratory research. Exclusion of diseases simulating acute pathology in the abdominal cavity
Laboratory tests * The minimum laboratory tests to establish a diagnosis of acute appendicitis include: general blood test, urine test, determination of the neutrophil-leukocyte ratio (n/l), Kalf-Kalifa leukocyte intoxication index.
Laboratory studies Leukocytosis is characteristic of all forms of acute appendicitis and has no pathognomonic significance, since it is also observed in other inflammatory diseases. It should be considered and interpreted only in conjunction with the clinical manifestations of the disease. The assessment of the leukocyte formula has a more significant diagnostic value (the presence of a neutrophil shift - the appearance of juvenile forms, an increase in the n/l ratio of more than 4 indicates a destructive process). With the development of the destructive process, there may be a (sometimes very significant) decrease in the number of leukocytes compared to the norm with a predominance of band neutrophils and other young forms. This indicates a pronounced strain on the hematopoietic system. This phenomenon is called “consumption leukocytosis.”
DIFFERENTIAL DIAGNOSIS Acute appendicitis must be differentiated from acute diseases of the abdominal cavity and retroperitoneal space. This is due to the significant variability in the location of the appendix in the peritoneal cavity and often the absence of a typical clinical picture of the disease.
DIFFERENTIAL DIAGNOSIS * Acute pancreatitis Acute cholecystitis Perforated gastric or duodenal ulcer Acute intestinal obstruction Disturbed ectopic pregnancy Twisted cyst or ovarian rupture Acute adnexitis Crohn's disease Perforation of Meckel's diverticulum or Meckel's diverticulitis. Right-sided renal colic Food toxic infection Acute mesenteric lymphadenitis Acute pleuropneumonia Myocardial infarction (abdominal form)
SURGICAL TREATMENT All patients with an established diagnosis of acute appendicitis, regardless of the time elapsed from the onset of the disease, are subject to surgical treatment. The principle of early surgery must be unshakable. Significant delay in surgery, even with a relatively mild course of the disease, creates the risk of severe and even fatal complications.
SURGICAL TREATMENT Surgical treatment is not indicated for two categories of patients: with a well-demarcated, formed appendiceal infiltrate that does not have a tendency to abscess; with mild appendicitis, called “appendicular colic”. In this case, if there is a normal body temperature and a normal level of leukocytes in the blood, observation of the patient for 4-6 hours with the necessary research methods (laboratory, x-ray, instrumental, etc.) is indicated.
COMPLICATIONS OF ACUTE APPENDICITIS Appendicular infiltrate: with involution of the infiltrate after 4-6 weeks. and with abscess formation Widespread purulent peritonitis Intra-abdominal abscesses (pelvic, interintestinal, subphrenic) Pylephlebitis (septic thrombophlebitis of the portal vein and its tributaries) Liver abscesses Sepsis
Appendicular infiltrate Appendiceal infiltrate usually forms by 3-5 days from the onset of the disease. This is a conglomerate consisting of inflammatory-changed intestinal loops, an omentum, delimiting the inflamed appendix and the exudate accumulated around it from the free abdominal cavity. The clinical sign of infiltration is the detection upon palpation of a painful inflammatory tumor in the right iliac region. By this time, the patient’s general condition is improving, body temperature is decreasing, and pain is decreasing. The patient notes a dull pain in the right iliac region, which intensifies when walking. There are no signs of peritoneal irritation. The appendicular infiltrate may resolve or abscess.
Appendiceal infiltrate In the first case, the temperature normalizes, the size of the infiltrate decreases, pain in the right iliac region disappears, blood counts normalize after conservative treatment, including bed rest, antibiotic therapy and physiotherapeutic procedures. All patients in whom conservative therapy was effective are recommended to undergo appendectomy after 1.5-2 months. after discharge from the hospital.
Abscess formation of the appendicular infiltrate In the second option, abscess formation of the appendicular infiltrate occurs. The appendiceal abscess is opened under endotracheal anesthesia using muscle relaxants through the usual Volkovich-Dyakonov surgical incision or extraperitoneal access closer to the iliac crest to prevent pus from entering the free abdominal cavity. After removing the pus, a careful inspection of the ileocecal area is performed and, if a gangrenous process is detected, it is removed. The abscess cavity is drained. Thus, with an abscessing appendiceal infiltrate, opening the abscess is indicated, but with a dense infiltrate that has formed, all manipulations except tamponade are contraindicated.
Generalized purulent peritonitis If, upon opening the abdominal cavity, diffuse purulent peritonitis is discovered, the operation through local access in the right iliac region is stopped and a median laparotomy is performed. Subsequently, the tactics of surgical intervention do not differ from the principles of treatment of widespread peritonitis.
POSTOPERATIVE COMPLICATIONS Complications from the surgical wound (infiltration, suppuration, ligature fistulas). Complications from the abdominal organs: purulent-septic (widespread peritonitis, intra-abdominal abscesses), as well as intra-abdominal bleeding, acute intestinal obstruction, intestinal fistulas. Complications from other organs and systems.
Complications from the abdominal organs This group of complications includes postoperative peritonitis, the formation of pericultural infiltrates, abscesses (interloop, pelvic and subphrenic abscesses), bleeding into the abdominal cavity, acute intestinal obstruction, intestinal fistulas.
Complications from the abdominal organs Postoperative peritonitis is a relatively rare but dangerous complication. The cause of peritonitis is the failure of the sutures of its stump, as well as perforation of necrotic areas of the cecum or suppuration of hematomas. Treatment is relaparotomy and treatment of peritonitis according to all the rules for this complication.
Complications from the abdominal organs Infiltrates and abscesses of the abdominal cavity. May be associated with errors made during surgical intervention, through punctures of the wall of the cecum when applying a purse-string suture. Infiltrates in the right iliac region can also occur as a result of other reasons, often independent of the surgeon, but most likely due to the characteristics of the pathology (perifocal inflammation, leaving areas of the inflamed serous membrane of the appendix during appendectomy, separation during rough isolation of its apex, prolapse of feces into the abdominal cavity stones, etc.) Such patients undergo relaparotomy and opening of the abscess and its drainage.
Complications from the abdominal organs Intra-abdominal bleeding usually occurs when the ligature slips from the mesentery of the appendix or incomplete ligation of the vessels during surgery. Acute intestinal obstruction after surgery for acute appendicitis is rare. The cause of acute intestinal obstruction developing after surgery is an adhesive process or the formation of an inflammatory infiltrate.
Complications from the abdominal organs Intestinal fistulas occur after surgery for acute appendicitis, most often due to inflammatory destruction of the cecum and small intestines, which developed during the transition of the destructive process from the appendix to the adjacent intestinal wall, or inflammatory and purulent complications, in particular peritonitis , abscesses, phlegmon. Often, intestinal fistulas develop against the background of eventration resulting from suture dehiscence. Technical errors during appendectomy allowed when applying a purse-string suture also play a role.
Complications from other organs and systems These are primarily postoperative pneumonia and thrombosis, for which appropriate conservative treatment is indicated. Complications from the cardiovascular system can occur in elderly and senile patients if they have concomitant diseases. The main thing is to prevent these complications at all stages of treatment of patients
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“Genetic diseases” - Hemophilia is a hereditary disease characterized by a violation of the blood clotting mechanism. Russia was no exception. Historical reference. Hereditary diseases caused by the presence of a defect in the genetic material. Probability of heredity. Many of Queen Victoria's descendants suffered from the disease.
“Hereditary diseases” - Most common epileptic seizures occur in childhood. Cretinism. Hereditary diseases. Types of heredity. Sexual function not broken. Werding-Hoffman disease (hereditary spinal amyotrophy). Only growth and development delays are possible. There are also groups of chromosomes caused by changes in sex and non-sex chromosomes.
“Digestive diseases” - Relapses usually resolve within 4-16 weeks. regardless of treatment. "Suitcase handle." Pseudopolyp. Colon polyps. Ischemic disease intestines. Diseases anus- in 70-80% of subjects. Oral contraceptives. The most important colitis: Signs of Crohn's disease - segmentation, slit-like ulcers to serosa with fistulas and adhesions.
"Down Syndrome" - Character traits. Forms of Down syndrome. Discoverers. Children with Down syndrome are teachable. In other cases, the syndrome is caused by a sporadic or inherited translocation of chromosome 21. On this moment aminocentesis is considered the most accurate examination. This type of syndrome appears in 1-2% of cases. A pregnant woman may undergo testing to detect fetal abnormalities.
“Organ diseases” - 7. 1. 3. 8. Common boletus. Dysenteric amoeba. Tapeworm. 10. Microbes multiply in the intestines and secrete poisons that poison the body. 17. 9. Do not drink raw water. Signs of poisoning. Gastrointestinal diseases. Called pathogenic microbes. Self-medication is unacceptable! It is necessary to wash your hands, dishes, vegetables, fruits.
"Respiratory diseases" - Smoker's lungs! IN Russian Federation A network of special anti-tuberculosis dispensaries, hospitals, and sanatoriums has been created. Bronchitis (acute; chronic): diseases of the respiratory system with damage to the bronchial wall. Angina. L o r e n g i t. Structure of the lungs: Tonsillitis (acute; chronic). Lung cancer: Respiratory diseases.
There are 18 presentations in total
Slide 2
Definition and prevalence
Acute appendicitis is inflammation of the appendix of the cecum, one of the most common surgical diseases. The incidence of acute appendicitis is 4-5 people per 1000 population. Acute appendicitis most often occurs between the ages of 20 and 40; women are affected 2 times more often than men. Mortality is 0.1-0.3%, postoperative complications - 5-9%.
Slide 3
Story
In 1886, Reginald Fitz first described and named OA as “inflammation of the appendix.”
Slide 4
Anatomy
The vermiform appendix is a direct continuation of the cecum. It is located at the confluence of three longitudinal ribbons (shadows). Its length varies within very wide limits. On average it is 7-10 cm, but can vary from 0.5 to 30 cm or more. In most cases, the appendix has a mesentery - a duplication of the peritoneum. Perivascularly along the artery of the appendix, nerves - derivatives of the superior mesenteric plexus - penetrate into it.
Slide 5
Physiology
Most researchers consider it a kind of tonsil of the gastrointestinal tract, since it contains a large amount of lymphoid tissue in the mucous membrane. Lymphoid tissue is most developed in childhood, especially at 12-16 years of age. Starting at the age of 30, the number of follicles decreases significantly, and by the age of 60 they completely disappear.
Slide 6
Location options
Most often, the vermiform appendix is located inside the peritoneum and its apex is directed downward. However, there are various options for its location both in relation to the cecum and depending on the location of the intestine itself.
Slide 7
Appendix location options *
They are distinguished (according to Allen): pelvic in the right iliac fossa medial retrocecal
Slide 8
They are distinguished (according to Allen): under the terminal segment of the ileum, lateral
Slide 9
In addition, they distinguish: Subhepatic (most often in pregnant women in the third trimester, but also occurs in other categories of patients) Left-sided (situs visceruminversus)
Slide 10
ETIOLOGY AND PATHOGENESIS *
The causes of acute appendicitis have not been fully studied to date. Many theories have been proposed to explain the mechanisms of development of inflammation in the appendix. Main theories: Infectious; Neurovascular; Contributing factors: Obturation (stone, worms, etc.) Gastrointestinal diseases
Slide 12
Neurovascular theory: Proponents of the neurovascular theory believe that first there will be a reflex disturbance of regional blood flow in the appendix (vasospasm, ischemia), and then thrombosis of the supply vessels, leading to trophic disorders in the wall of the appendix, up to necrosis. Some researchers attach importance to the allergic factor. This theory is supported by a significant amount of mucus and Charcot-Leyden crystals in the lumen of the appendix.
Slide 13
Modern ideas: The process begins with functional disorders of the ileocecal angle (bauginospasm), the cecum and the vermiform appendix. Digestive disorders lead to the occurrence of spastic phenomena (increased putrefactive processes in the intestines, atony, etc.), as a result of which the large intestine and the appendix are poorly emptied. Foreign bodies in the appendix, fecal stones, and worms can provoke spasms. Spasm of the smooth muscles of the appendix also leads to regional vascular spasm and local disruption of the trophism of the mucous membrane (primary Aschoff affect).
Slide 14
Modern ideas: Impaired evacuation, stagnation of intestinal contents contribute to an increase in the virulence of the intestinal microflora, which, in the presence of a primary affect, easily penetrates the wall of the appendix and causes a typical inflammatory process in it. Initially, leukocyte saturation occurs only in the mucous membrane and submucosal layer, and then in all layers of the appendix. Infiltration is also accompanied by restructuring of lymphoid tissue (hyperplasia). The emergence of zones of ischemia and necrosis contributes to the formation of pathological enzymes (cytokinase, kallikrein, etc.) with high proteolytic activity, which leads to further destruction of the wall of the appendix, up to its perforation and the development of purulent peritonitis.
Slide 15
Classification (V.I. Kolesov, 1972) *
The following forms of acute appendicitis are distinguished: 1) mild (appendicular colic); 2) simple (superficial); 3) destructive: a) phlegmonous, b) gangrenous, c) perforative; 4) complicated: a) appendiceal infiltrate (well-demarcated, progressive), b) appendiceal abscess, c) purulent peritonitis, d) other complications of acute appendicitis (sepsis, pylephlebitis, etc.).
Slide 16
Pathology
Acute simple appendicitis Acute phlegmonous Acute gangrenous Perforated
Slide 17
Acute simple appendicitis
Slide 18
Acute phlegmonous appendicitis
Slide 19
Acute gangrenous
Slide 20
Perforated
Slide 21
CLINIC
Acute appendicitis is characterized by a certain symptom complex, which depends on a number of reasons: the time elapsed from the moment of the disease, the localization of the appendix, the nature of pathomorphological changes both in the appendix itself and in the abdominal cavity, the age of the patient, the presence of concomitant pathology and the physiological state of the body.
Slide 22
CLINIC *
The disease begins suddenly, in the midst of complete well-being, without a prodromal period. The most consistent symptom is abdominal pain, which is usually permanent. The localization of pain at the onset of the disease is variable. Most often, it appears immediately in the right iliac region, but it can occur in the epigastrium (Kocher's sign) or in the periumbilical region (Kümmel's sign) and only after a few hours moves to the right iliac region. In some cases, the clinical picture of acute appendicitis develops very rapidly, and the pain is not localized, but occurs immediately throughout the abdomen.
Slide 23
CLINIC
Another important symptom is vomiting. It is observed in approximately 40% of patients and is of a reflex nature in the initial stages of the disease. Vomiting is often one-time. Nausea usually occurs after pain and is wave-like. Sometimes there is stool retention and loss of appetite, but there may be one-time diarrhea, which becomes more frequent with the retrocecal or pelvic location of the inflamed process and can serve as a pathognomonic symptom of atypical forms of the disease. Urinary disorders are rare and may be associated with the unusual location of the process (adjacent to the kidney, ureter, bladder). The temperature reaction depends on the form of the disease and the presence of complications (from low-grade, febrile, rarely hectic)
Slide 24
CLINIC *
Main symptoms: Razdolsky's symptom - with superficial palpation it is possible to identify a zone of hyperesthesia in the right iliac region Rovsing's symptom - the examining doctor with his left hand presses on the abdominal wall in the left iliac region according to the location of the descending colon; Without removing the left hand, the right one makes a short push on the anterior abdominal wall on the overlying part of the colon. With a positive symptom, the patient feels pain in the right iliac region.
Slide 25
Main symptoms: Voskresensky's symptom - the doctor, positioned to the right of the patient, pulls on his shirt with his left hand, and with his right hand slides his fingertips along it from the epigastric region towards the right iliac region. At the end of the slide, the patient feels a sharp pain (the symptom is considered positive). Sitkovsky's symptom - The patient is placed on his left side. Intensification or occurrence of pain in the right iliac region is characteristic of acute appendicitis.
Slide 26
Main symptoms: Barthomier-Mikhelson symptom - increased pain on palpation of the right iliac region with the patient positioned on the left side. Krymov's symptom is pain when examining the peritoneum with a fingertip through the external opening of the right inguinal ring.
Slide 27
Main symptoms: Dumbadze's symptom - the appearance of pain when examining the peritoneum with a fingertip through the navel. The Yaure-Rozanov symptom is used to diagnose appendicitis with a retrocecal location of the appendix: when pressing with a finger in the area of the lumbar triangle of Petit, pain appears.
Slide 28
CLINIC
Main symptoms: Cope's symptom - when the appendix is located near the obturator internus muscle, the appearance of pain in the ileocecal region when extending the right thigh hip joint
Slide 29
Cope's sign
Slide 30
Psoas - symptom
Slide 31
CLINIC *
Main symptoms: Rectal (in men) or vaginal (in women) examination is important in recognizing acute appendicitis. They should be performed on all patients and are aimed at determining the sensitivity of the pelvic peritoneum (Douglas cry) and the condition of other pelvic organs, especially in women. The Shchetkin-Blumberg symptom is caused by slowly pressing your fingers on the abdominal wall and quickly withdrawing your hand. At the moment the hand is removed, acute localized pain appears due to irritation of the inflamed peritoneum.
Slide 32
Features of the clinical course *
Slide 33
Features of the course of acute appendicitis in children*
Acute appendicitis in children occurs at any age, and its course is due to the reduced resistance of the peritoneum to infection, the small size of the omentum, as well as the increased reactivity of the child’s body. In this regard, acute appendicitis in children is severe, the disease develops faster than in adults, with a large percentage of destructive and perforative forms.
Slide 34
rapid onset of the disease; high temperature 38-40° C; cramping abdominal pain; repeated vomiting, diarrhea; The pulse rate often does not correspond to the temperature; rapid development of destructive changes in the appendix; severe symptoms of intoxication; frequent development of diffuse peritonitis.
Slide 35
Features of the course of acute appendicitis in elderly and senile people*
erased course of the disease due to the body’s unresponsiveness and concomitant diseases; the temperature is often normal, its rise to 38o C and higher is observed in a small number of patients; abdominal pain is slightly expressed; protective muscle tension is absent or weakly expressed; rapid development of destructive changes in the appendix (due to vascular sclerosis), a slight increase in the number of blood leukocytes, a moderate shift in the leukocyte formula to the left even with destructive forms.
Slide 36
Features of the course of acute appendicitis in pregnant women*
In the first half of pregnancy, the manifestations of acute appendicitis do not differ from its usual manifestations
Slide 37
In the second half of pregnancy, the localization of pain and tenderness changes (displacement of the cecum and appendix by an enlarged uterus). The disease often begins suddenly with the appearance of acute, persistent abdominal pain, nausea and vomiting. Due to changes in the location of the appendix, abdominal pain can be detected not only in the right iliac region, but also in the right lateral flank of the abdomen, the right hypochondrium, and even in the epigastric region. Muscle tension cannot always be detected, especially in the last third of pregnancy, due to severe overstretching of the anterior abdominal wall. Of the painful techniques, the Shchetkin-Blumberg, Voskresensky, and Rozdolsky symptoms are of greatest diagnostic value. Leukocytosis in acute appendicitis in pregnant women is in most cases 810912109 / l, often with a shift to the left.
Slide 38
DIAGNOSTICS *
Careful collection and detailing of the patient’s complaints and medical history. Identification of symptoms characteristic of acute appendicitis (palpation, percussion of the abdomen). Rectal and vaginal examinations. Laboratory research. Exclusion of diseases simulating acute pathology in the abdominal cavity
Slide 39
Laboratory research *
The minimum laboratory tests to establish a diagnosis of acute appendicitis include: general blood test, urine test, determination of the neutrophil-leukocyte ratio (n/l), Kalf-Kalifa leukocyte intoxication index.
Slide 40
Laboratory research
Leukocytosis is characteristic of all forms of acute appendicitis and has no pathognomonic significance, since it is also observed in other inflammatory diseases. It should be considered and interpreted only in conjunction with the clinical manifestations of the disease. The assessment of the leukocyte formula has a more significant diagnostic value (the presence of a neutrophil shift - the appearance of juvenile forms, an increase in the n/l ratio of more than 4 indicates a destructive process). With the development of the destructive process, there may be a (sometimes very significant) decrease in the number of leukocytes compared to the norm with a predominance of band neutrophils and other young forms. This indicates a pronounced strain on the hematopoietic system. This phenomenon is called “consumption leukocytosis.”
Slide 41
Rectal examination
Slide 42
Instrumental studies
X-ray ABP Ultrasound CT Laparoscopy These methods are used in doubtful cases, including for differential diagnosis and exclusion of other diseases simulating acute appendicitis
Slide 43
Instrumental diagnostics
X-ray examination of the obstructive artery makes it possible in some cases to diagnose OA and exclude other acute surgical diseases.
Slide 44
Ultrasound
Slide 45
CT
Slide 46
DIFFERENTIAL DIAGNOSIS
Acute appendicitis must be differentiated from acute diseases of the abdominal cavity and retroperitoneal space. This is due to the significant variability in the location of the appendix in the peritoneal cavity and often the absence of a typical clinical picture of the disease.
Slide 47
DIFFERENTIAL DIAGNOSIS*
Acute pancreatitis Acute cholecystitis Perforated gastric or duodenal ulcer Acute intestinal obstruction Disrupted ectopic pregnancy Twisted cyst or ovarian rupture Acute adnexitis Crohn's disease Perforation of Meckel's diverticulum or Meckel's diverticulitis. Right-sided renal colic Food toxic infection Acute mesenteric lymphadenitis Acute pleuropneumonia Myocardial infarction (abdominal form)
Slide 48
SURGERY
All patients with an established diagnosis of acute appendicitis, regardless of the time elapsed from the onset of the disease, are subject to surgical treatment. The principle of early surgery must be unshakable. Significant delay in surgery, even with a relatively mild course of the disease, creates the risk of severe and even fatal complications.
Slide 49
Surgical treatment is not indicated for two categories of patients: with a well-demarcated, formed appendiceal infiltrate that does not have a tendency to abscess; with mild appendicitis, called “appendicular colic”. In this case, if there is a normal body temperature and a normal level of leukocytes in the blood, observation of the patient for 4-6 hours with the necessary research methods (laboratory, x-ray, instrumental, etc.) is indicated.
Slide 50
Accesses: Oblique variable incision in the right iliac region (according to McBurney, according to Volkovich-Dyakonov) Paramedian according to Lennander Laparoscopic Mid-median laparotomy is located above the indicated line and 2/3 below it (Fig. 5. 1). be above the indicated line and 2/3 below it (Fig. 5. 1). be above the indicated line and 2/3 below it (Fig. 5. 1).
Slide 51
Methods of intervention: Typical appendectomy. Retrograde appendectomy
Slide 52
Slide 53
Retrograde appendectomy technique
Slide 54
Slide 55
Slide 56
Slide 57
Laparoscopic appendectomy
Slide 58
Slide 59
Slide 60
Slide 61
NOTES – Natural Orifice Translumenal Endoscopic Surgery Endoscopic transluminal surgery through natural orifices Transgastric Transvaginal Transrectal Transvesical Combined
Slide 62
da Vinci Surgical System
Slide 63
COMPLICATIONS OF ACUTE APPENDICITIS
Appendiceal infiltrate: with involution of infiltrate after 4-6 weeks. and with abscess formation Widespread purulent peritonitis Intra-abdominal abscesses (pelvic, interintestinal, subphrenic) Pylephlebitis (septic thrombophlebitis of the portal vein and its tributaries) Liver abscesses Sepsis
Slide 64
Appendiceal infiltrate
Appendicular infiltrate usually forms by 3-5 days from the onset of the disease. This is a conglomerate consisting of inflammatory-changed intestinal loops, an omentum, delimiting the inflamed appendix and the exudate accumulated around it from the free abdominal cavity. The clinical sign of infiltration is the detection upon palpation of a painful inflammatory tumor in the right iliac region. By this time, the patient’s general condition is improving, body temperature is decreasing, and pain is decreasing. The patient notes a dull pain in the right iliac region, which intensifies when walking. There are no signs of peritoneal irritation. The appendicular infiltrate may resolve or abscess.
Slide 65
In the first case, the temperature normalizes, the size of the infiltrate decreases, pain in the right iliac region disappears, blood counts normalize after conservative treatment, including bed rest, antibiotic therapy and physiotherapeutic procedures. All patients in whom conservative therapy was effective are recommended to undergo appendectomy after 1.5-2 months. after discharge from the hospital.
Slide 66
Abscess formation of appendicular infiltrate
In the second option, abscess formation of the appendiceal infiltrate occurs. The appendiceal abscess is opened under endotracheal anesthesia using muscle relaxants through the usual Volkovich-Dyakonov surgical incision or extraperitoneal access closer to the iliac crest to prevent pus from entering the free abdominal cavity. After removing the pus, a careful inspection of the ileocecal area is performed and, if a gangrenous process is detected, it is removed. The abscess cavity is drained. Thus, with an abscessing appendiceal infiltrate, opening the abscess is indicated, but with a dense infiltrate that has formed, all manipulations except tamponade are contraindicated.
Slide 67
Appendiceal abscess
Slide 68
Generalized purulent peritonitis
If, upon opening the abdominal cavity, diffuse purulent peritonitis is discovered, the operation through local access in the right iliac region is stopped and a median laparotomy is performed. Subsequently, the tactics of surgical intervention do not differ from the principles of treatment of widespread peritonitis.
Slide 69
POSTOPERATIVE COMPLICATIONS
Complications from the surgical wound (infiltration, suppuration, ligature fistulas). Complications from the abdominal organs: purulent-septic (widespread peritonitis, intra-abdominal abscesses), as well as intra-abdominal bleeding, acute intestinal obstruction, intestinal fistulas. Complications from other organs and systems.
Slide 70
Complications from the abdominal organs
This group of complications includes postoperative peritonitis, the formation of pericultural infiltrates, abscesses (interloop, pelvic and subphrenic abscesses), bleeding into the abdominal cavity, acute intestinal obstruction, and intestinal fistulas.
Slide 71
Postoperative peritonitis is a relatively rare but dangerous complication. The cause of peritonitis is the failure of the sutures of its stump, as well as perforation of necrotic areas of the cecum or suppuration of hematomas. Treatment is relaparotomy and treatment of peritonitis according to all the rules for this complication.
Slide 72
Infiltrates and abscesses of the abdominal cavity. May be associated with errors made during surgical intervention, through punctures of the wall of the cecum when applying a purse-string suture. Infiltrates in the right iliac region can also occur as a result of other reasons, often independent of the surgeon, but most likely due to the characteristics of the pathology (perifocal inflammation, leaving areas of the inflamed serous membrane of the appendix during appendectomy, separation during rough isolation of its apex, prolapse of feces into the abdominal cavity stones, etc.) Such patients undergo relaparotomy and opening of the abscess and its drainage.
Slide 73
Intra-abdominal bleeding usually occurs when the ligature slips from the mesentery of the appendix or when the vessels are incompletely ligated during surgery. Acute intestinal obstruction after surgery for acute appendicitis is rare. The cause of acute intestinal obstruction developing after surgery is an adhesive process or the formation of an inflammatory infiltrate.
Slide 74
Intestinal fistulas occur after surgery for acute appendicitis, most often due to inflammatory destruction of the cecum and small intestine, which developed during the transition of the destructive process from the appendix to the adjacent intestinal wall, or inflammatory and purulent complications, in particular peritonitis, abscesses, phlegmon. Often, intestinal fistulas develop against the background of eventration resulting from suture dehiscence. Technical errors during appendectomy allowed when applying a purse-string suture also play a role.
Slide 75
Complications from other organs and systems
These are primarily postoperative pneumonia and thrombosis, for which appropriate conservative treatment is indicated. Complications from the cardiovascular system can occur in elderly and senile patients if they have concomitant diseases. The main thing is to prevent these complications at all stages of treatment of patients
Lecture by Associate Professor Ph.D.
Nikolaeva N.E.
Acute appendicitis
(appendicitis acuta)
vermiform appendix (appendix vermiformis)
originates from the posteromedial wall of the cecum at the convergence of three ribbons of longitudinal muscles. Its length is variable, but more often 6-12 cm, diameter 6-8 mm. It is usually located anterior and medial to the cecum. However, the location of its localization can be varied - in the pelvis, near the liver and gallbladder, behind the cecum (retrocecal) and retroperitoneally (retroperitoneal). With a mobile cecum, even in the left half of the abdomen. In reverse position internal organs The cecum and appendix are located in the left iliac fossa. It is very rare to have two appendixes.
The appendix has serous, muscular submucosa and mucous membranes. The vermiform appendix has its own mesentery, which contains adipose tissue, blood vessels and nerves. A. Appendicularis departs from A. ileokolika, and it from A. Mesenterika superior. The outflow of blood occurs along V. ileokolika, flowing into the superior mesenteric vein, which participates in the formation of the portal vein. Lymphatic drainage is carried out through intraorgan lymphatic vessels, forming a dense network in the mucous membrane, submucosa, muscular and serous layers.
Innervation comes from the superior mesenteric and celiac plexus ( sympathetic innervation), as well as fibers vagus nerve(parasympathetic innervation).
Acute appendicitis is one of the most
common acute surgical diseases among our population. Out of every 200-250 people, one gets acute appendicitis.
Postoperative mortality in the Soviet Union was 0.2-0.4%, in Belarus -0.1%. They usually diefrom the occurrence of complications developing before or after surgery - peritonitis, intra-abdominal abscesses, bleeding, obstruction.
Etiology and pathogenesis.
The true reason has not yet been fully elucidated. Among Europeans, acute appendicitis occurs quite often, while among Africans, Indians, Japanese, and Vietnamese it occurs very rarely. Perhaps it has something to do with the way you eat. In these countries, the population eats mainly plant foods, while in European countries it eats meat. Foods rich in animal proteins tend to cause putrefactive processes in the intestines, which contribute to atony.
Some authors (M.I. Kuzin, 1995) associate its occurrence with a violation of nervous regulation
vermiform appendix, which leads to impaired blood circulation and the development of trophic changes.
The causes of dysregulation are divided into three groups:Sensitization of the body.
(food allergy, helminthic infestation)
Reflex path
(b - no stomach, intestines, gall bladder)
Direct irritation of nerve endings
(foreign bodies in the appendix, fecal stones, coprolites, kinks).
Violation nervous regulation appendixa leads to spasm of its muscles and blood vessels. As a result of poor circulation in the appendix, swelling of its wall occurs. The swollen mucous membrane closes the mouth of the appendix. Contents accumulate in its lumen, which stretches the walls and thereby increases the disturbance of trophism, and the mucous membrane loses resistance to microflora, which penetrate the wall and cause inflammation.
One of the reasons for inflammation of the appendixa may be the presence of coprolites in the appendix, which cause obstruction of the appendix and leads to a significant increase in pressure in it and thereby disrupt blood circulation in the wall of the appendix.
By clinical course appendicitis is divided into
acute and chronic.
According to the degree of morphological changes in the process, the following forms are distinguished.
