Appendectomy

Appendectomy - removal of the vermiform process. Indications: acute, chronic appendicitis. Preparation for the operation, see the Preoperative period. Pain in the appendectomy local 0,25-0,5% solution novokaina; in complicated cases when developing peritonitis appendectomy is performed under General anesthesia.
The steps involved are: preparation of the operating field (rubbing alcohol and lubrication 5% alcoholic iodine solution), layer-by-layer anesthesia all tissues in the area of operations, opening the abdominal cavity (slash incision of the skin in the right iliac region with razdvigaya of muscles of the anterior abdominal wall, the opening of peritoneum), finding and removing process (Fig.), revision of the abdominal cavity, stitching operating wounds, bandage (sticker).
Appendectomy produces a surgeon who is assisted by a doctor or operating sister, which in such cases is to expand hooks edges of the abdominal wall at its opening, sticking to the cecum at its extraction in the operating wound and the removal of the Appendix (important moment!), the shaving all silk or Katsutoshi ligatures in ligation of vessels.
Necessary tools: scalpels, scissors, hemostatic clips, surgical needles and needle-holders, tweezers (anatomical and surgical), korangi, acute and obtuse hooks to extend the wounds of the abdominal wall, silk, catgut, and other
At the moment of operation after opening the skin of the abdominal wall and after the cut-off process produce a shift of some instruments. Operating sister ensures that remote vermiform process was sent for histological examination.
In the postoperative period it is necessary to monitor the pulse, the state language of the patient, the function of the gastrointestinal tract, urinary. Patient care - see the Postoperative period. The purpose of enemas, laxatives, ligation is only as instructed by the doctor; the terms of rising patient, his regime in the immediate postoperative period are determined also by the doctor.

Appendectomy. In Russia, the first successful appendectomy made A. A. Trojans (1890). At the IX Congress of Russian surgeons (1909) was solved the question of the need to operate on the first day. In the General practice of the early operation have sharply reduced mortality in acute appendicitis, which is now insignificant.
In Moscow on the first day of the disease deliver in hospitals 70-72% of patients with acute appendicitis, and the rest of 28-30% - 24 hour later. In hospitals of Moscow in the first 6 hours after delivery undergo surgery 85% of patients. Of the total number of acute appendicitis 72%, chronic 28%, the latter being more common in women. The average mortality after operations in Moscow in acute appendicitis varies 0,17-0,21%, while in patients operated on in the first 6 hours and delivered in the first days of the disease it was less than 0.1%, and among delivered later than 24 hours.- 0,3-0,4%. At the Institute. Sklifosovsky for 1959-1963, postoperative lethality amounted to 0.2-0.3%, and in the age of 40, died of 0.05% of patients, after 60 years - 3,4%.
Among 8426 operated in a group of destructive forms (339 patients) perforated appendicitis was 23.1%, gangrenous from 65.1%, with gangrene of the mucous membrane and 11.8%. From 4230 operated group ostrovnoye forms A. phlegmonously was 77.1 percent, with empyema is 21.8%, infiltrates - 0.5% and abscess - 0,6%. Catarrhal changes in the process in acute appendicitis occur in 30% of all transactions (L. A. Brushlinsky, A. A. roly-poly), partly due to the inevitable exaggeration readings in the desire to operate as soon as possible.
Technique appendectomy. Anesthesia - in most cases flattering infiltration anesthesia. When events developing peritonitis necessary endotracheal anesthesia or spinal anesthesia. Better to use the angle cut with razdvigaya muscles, which provides wide access for inspection of the abdominal cavity (Fig. 5,1-4). Sometimes when developed peritonitis produce median laparotomy. Hit the 'peritoneum, assess the number and nature (serous, purulent, ihorozny) effusion. If you discover a large concentration of exudate, it sucked off aspirator, and then in all directions lay gauze napkins, which absorb the sero-purulent contents during appendectomy. Usually in the wound slated to be actually cecum, which is determined by the presence of taenia libera and grayish-bluish color; however, hyperemia can change the color of the colon. If a blind gut is necessary to search, guided along the side, and then the posterior parietal peritoneum, which goes directly to the wall of the caecum and above on the mesentery of the ascending colon. Find caecum, her gently captured and is removed from the abdominal cavity. Track down taenia libera, which leads to the base of the ridge.
On the extraction process of the mesentery his cross between a styptic clips and tie a thread; it is essential that the ligature and got the first (closest to the base of the Appendix) a sprig. appendicularis avoid bleeding (Fig. 5, 5). The so-called ligature method in which the stump is not immersed in the pouch, too risky; adults to use it should not be. Around the base of the process on a blind gut impose (loosely) purse string suture. The Foundation process of the tie with ligature, cut off the process, the stump of his immersed in the bowel lumen, then tighten purse string suture (Fig. 5,6-10).
After removal of the Appendix, checking hemostasis and lowering the intestine into the abdominal cavity, remove the gauze napkins. When developed generalized purulent peritonitis is especially important thorough emptying interintestinal abscesses and destruction of purulent accumulations from under the diaphragm and of the pelvic cavity. Rinse the abdominal cavity should not be. After drying it is necessary to check up once again, do not bleeding stump of bruecke process. Then in the abdominal cavity pour in a solution of antibiotics: penicillin - 100 000 IU, streptomycin - 500 000 UNITS. The operating wound can usually be sewn tightly. However, when expressed events peritonitis between seams leave a thin rubber drainage for intraperitoneal administration of antibiotics, and at gangrene process, when ihoroznom effusion skin wound not sew and sewn on the aponeurosis leave long ends of threads. If the process was limited spikes collection of pus or had retroatelie appendicitis, the wound did not sew, and leave in the abdominal cavity, except for a thin drainage, demarcates gauze tampons, which are beginning to tighten, 7-8th day After the surgery and removed entirely to the 8-10th day.
In the absence of dramatic changes in the peritoneum postoperative treatment is limited only by intramuscular injection of antibiotics during the first 3-4 days. Cleansing enema may be appointed for 4-5 day. Postoperative treatment in more severe cases - see Peritonitis.
Of complications in the postoperative period, the most frequently observed education intraperitoneal bleeding usually associated with inadequate removal of purulent exudates during the operation. The abscess may be localized between loops gut (interintestinal abscesses), under the diaphragm, but most often in dopasowa space. The patient persistently febrile after surgery for acute appendicitis, you must first investigate finger rectum time to detect a collection of pus and dissect him.
Threatening complications may occur as a result of incomplete hemostasis. If bruecke process bad bandaged and bleeding in the abdomen, usually in the first day is determined by the picture abdominal bleeding, which shows the relaparotomy.

appendectomy Fig. 5. Appendectomy:
1 - line of skin incision, bottom left diagram anesthesia;
2 - incision external oblique muscles;
3 - the exposure of the internal oblique muscle;
4 - fiber internal oblique muscle apart stupidly, exposed the peritoneum;
5 - ligature of bruecke process;
6 - preparation purse string suture; the imposition of ligatures at the base of the process;
7 - overlay clip on the process before it is cut off;
8 - clipping process;
9 - dive stump sprouts in the package;
10 - the operation is finished.