Appendectomy: methods and preparation for surgery. Phlegmonous appendicitis: signs and surgery to remove appendicitis Appendectomy indications

Treatment of appendicitis is done only through an operation in which a special set of instruments for appendectomy is used. Before removing the formation, preparatory measures are carried out: blood and urine are taken for analysis, tomographic and ultrasound examinations are performed, X-rays are taken, and the presence of pain is studied. If all the results are available, you can proceed with the appendectomy. There are different ways to carry out such a procedure: open (traditional) or, as it is also called, the Volkovich-Dyakonov method, laparoscopic and transluminal techniques.

An appendectomy is a procedure to eliminate inflammation of the appendix.

Types of appendectomy

Traditional removal

An open appendectomy is performed using incisions near the navel, in the right side. Then recognition of all abdominal organs occurs. The doctor analyzes the condition of the body for the presence of other diseases and disorders, and the cause of pain. To remove appendicitis, the damaged organ is disconnected from the cecum and other tissues, after which it can be excised. The part where the appendectomy was performed needs to be closed. This is done by stitching together the muscles and skin. The urgent procedure is carried out on a budgetary basis, but further restoration is paid for.

Laparoscopic

Laparoscopy is another type of surgical intervention, which is characterized by punctures of the abdominal wall. With this method, 4 cuts are made about 2-3 cm long. The first one is cut in the navel area, the next one is made between the pubic bone and the navel. It is also necessary to cut the right side, in the lower abdomen - such sections are smaller in size than the previous ones. Through these incisions, a camera and other special devices are inserted inside. This equipment makes it possible to examine the condition of internal organs in section and the formation of appendicitis. The vermiform appendix is ​​removed through previously made sections. At the end of the process, all auxiliary equipment is removed from the abdominal cavity, and the incisions are closed. This operation requires additional equipment and is performed for a fee.

Transluminal

With this method of removing postoperative scars, there are no postoperative scars left.

This method of appendectomy involves performing the operation through the natural openings of the body. For this purpose, specialized plastic tools are used. There are two types of insertion of equipment into the body: transvaginal and transgastric. In the first case, the operation is performed through a small incision in the vagina, and in the second, we cut a hole in the gastric wall with a puncture. This surgical intervention is convenient because recovery after the procedure is much faster, the pain is much less and there are no aesthetic problems - no scars are visible. This procedure is not available in all hospitals and is performed for a fee.

Traditional and laparoscopic: comparison

What type of appendectomy should you choose? Opinions on this matter are divided. If the doctor is experienced, it will not be difficult for him to perform any of these surgical interventions in a short time. Although, considering how much time it takes, the traditional one goes a little faster. When using laparoscopic surgery, there is a greater risk factor - the occurrence of unwanted complications. In addition, this type of appendicitis removal requires specialized instruments, and accordingly, its cost will be higher.

Laparoscopic appendectomy is more expensive, but causes less discomfort during surgery.

However, for women, laparoscopic appendectomy is a more viable option, as the process is complex for them. This is especially evident in the presence of gynecological diseases, such as inflammation of the ovaries and other pelvic organs, the presence of cysts, and endometriosis. They are often accompanied by attacks of pain. In general, both treatment methods are characterized by a similar diet and similar medications, and the recovery period is equivalent. Based on this, it is necessary to choose the type of appendectomy individually, taking into account the patient’s health condition.

How dangerous is the operation?

As with any surgical intervention, there are complications. Surgery for appendicitis is performed under general anesthesia so that the person being operated on does not experience pain. In this case, the abdominal cavity remains open. Based on this, deviations appear:

• Most often, collapse and pneumonia of the respiratory tract are observed - it is painful to breathe (smokers are more susceptible to postoperative abnormalities than non-smokers).
• It happens that thrombophlebitis or venous inflammation develops, accompanied by pain.
• Sometimes bleeding is observed - this necessitates a blood transfusion procedure.
• The formation of adhesions is also observed, which are dangerous because they lead to intestinal obstruction and the formation of cancer.

After appendix surgery, the likelihood of rupture is low.

How often abnormalities occur after appendectomy depends on how advanced the appendix is ​​at the time of removal. When there was no breakthrough, the possibility of deviations does not exceed 3%. However, if a rupture does occur, the risk factor increases to 60%. The most common ailments after surgery are infections that entered the body through a wound. They cause suppuration and attacks of pain.

It happens that a rupture occurs before abdominal surgery to remove appendicitis has been performed, then the entire contents of the appendicitis end up in the stomach area. This situation is dangerous due to the development of peritonitis or infectious infection in the abdominal cavity. To eliminate the consequences of a rupture, it is necessary to carry out cleaning to remove the remains of the organ, as well as the introduction of rubber tubes and treatment of appendicitis with antibiotics. If there is a delay in making a diagnosis and performing an operation, serious complications occur, so excision is performed as soon as suspicions arise.

Contraindications

Traditional appendectomy has virtually no contraindications, but laparoscopic appendectomy may not be used in all cases. To perform an appendectomy safely, the doctor needs to assess the patient's condition. Deviations are possible in the following cases:

• More than 24 hours have passed since the onset of the disease. In such cases, abscesses and ruptures appear, and antibiotics may be needed for appendicitis.
• The presence of inflammatory processes in the digestive organs.
• Another contraindication is the presence of disorders in other organs (for example, the development of cancer). Why is this situation so dangerous? It can negatively affect the patient's health. This applies to diseases such as heart failure, destructive processes in the lungs and bronchi, myocardial infarction, etc.

As a rule, the appendix is ​​operated on urgently and the operation is not preceded by preliminary preparation.

Indications and preparation for surgery

This type of operation, such as appendectomy, is performed urgently in most cases. Preparation begins from the moment it was decided to cut out the appendix. It is also possible to have a planned removal of the appendix (appendiceal infiltrate) after the inflammation has decreased, several weeks after the onset of the pathology. If severe poisoning is observed and there is suspicion of a possible rupture, urgent surgical intervention is necessary.

The process takes no more than an hour. It is important under what anesthesia the appendicitis is removed. For appendectomy and hernia repair, either local or general anesthesia is used. The choice is made based on an analysis of the patient’s health status and individual indicators, such as age, weight, and the presence of other diseases that affect the abscess. For example, for teenagers, people with obesity and nervous instability, the indication is general anesthesia for appendicitis. This is due to the risk of injury during appendectomy. But for expectant mothers, healthy adults, local anesthesia is suitable without significant deviations.

Preparation

It is not always possible to prepare for surgery, since a person experiences severe pain when the appendix is ​​inflamed

Emergency assistance is required to eliminate the abscess when acute appendicitis is diagnosed (ICD code 10 K35). The patient experiences severe pain, so it is not always possible to carry out preparatory measures. However, at least a minimal part of the tests must be carried out - urine and blood tests, x-rays and ultrasound. For safety, it is advisable for women to visit a gynecologist. In order to reduce the risk of blood clots, the veins are tightly bandaged before surgery. To remove fluid from the bladder, a catheter is inserted during the procedure, and the stomach is cleansed using an enema. The preparatory part takes no more than 2 hours. Upon completion of the diagnosis, the patient is sent to the operating room, where anesthesia is administered and the field is prepared for the operation - disinfection, removal of body hair.

Technique for performing traditional appendectomy

The traditional surgical procedure is divided into two parts: surgical access and cecal exposure. It takes an hour to complete. To open access to the abscess, it is necessary to cut a section along the line located between the navel and the ilium. Its length is usually up to 8 cm. After an incision in the skin, the surgeon dissects the fatty tissues or simply moves them away (if the amount is small). Next are the connecting fibers of the oblique muscle - they are cut using special scissors. After this, the path opens to the inner muscle layer, under which there is abdominal tissue and peritoneum. After dissecting these layers, the surgeon observes the processes in the stomach cavity. If all steps are performed correctly, there should be a dome of the cecum.

During the operation, the surgeon must perform each action with extreme precision and care.

Then comes the next stage - elimination. In cases where removal of the appendix is ​​difficult, the incision can be enlarged. The doctor examines for the presence or absence of adhesions that complicate the operation. If there is no interference, the intestine is pulled out into the section, and an abscess emerges behind it. The surgeon's actions must be extremely careful so as not to damage anything. There are two types of appendectomy - antegrade and retrograde.

Antegrade

This type of appendectomy is characterized by applying a clamp to the mesentery from above the formation and piercing it from below. Through this passage, the mesentery is clamped and tightened with a nylon thread. It is possible to make more than one clamp, depending on the degree of swelling. Next comes the suture stage. It is placed 10 mm from the appendix. After applying a clamp to the catgut ligature, the process is cut off. The remainder of the cutting edge is returned to the cecum, and the applied purse-string suture is tightened. After this, the clamp is pulled out. At the end, another one is superimposed - seromuscular.

Retrograde aspendectomy

Retrograde appendectomy is used in cases of difficulty in removing appendicitis. Such complications include: adhesions and atypical position of the abscess. In such a situation, a ligature is first applied from below the formation. The appendix is ​​removed under a clamp, and the remainder is returned inside the cecum. Threads can be placed on top. At the end of this procedure, they proceed to ligation of the appendix. At the end of the operation, the abdominal cavity must be drained. Electric suction and tuffers are used for this. Next, the incision is sutured tightly.

Inflammation of the appendix is ​​eliminated laparoscopically in just 1 hour.

There are stages of laparoscopic surgery:

1. The area next to the navel is cut and carbon dioxide is released into the stomach through it - this procedure improves visibility. Then a special device is inserted there - a laparoscope.
2. The passage is obtained through the right side, between the pubic bone and the ribs. Through it, with the help of instruments, the appendix is ​​captured, the vessels are ligated, the mesentery is cut off and appendicitis is removed.
3. After examining the condition of the internal organs, the incisions at this site are sutured.

This type of appendectomy occurs within an hour. The marks are almost invisible. The recovery period lasts no more than 4 days.

Appendectomy is a common operation performed in the abdominal area. Another name for surgical procedures is appendectomy.

Now the pathology is treated in two ways:

• Carrying out conservative therapy. Treatment is carried out using medications.
• Complete surgical removal of the inflamed area.

Often, after taking medications, the appendage has to be removed.

Surgery is performed using two main methods:

• A full longitudinal incision is made on the side of the abdomen, in the area where the appendix is ​​located.
• Three punctures are made where the organ is located.

There is also a method with one puncture and removal through the mouth or vagina. Gradually, these methods were abandoned in favor of the above.

• Pregnant women.
• Children under 6 years old.

Young patients cannot clearly and correctly explain their condition, the nature of the pain, and there is also a weak severity of the pain syndrome. Therefore, diagnosis is difficult.

In pregnant women, constant constipation, changes and compression of organs by the growing uterus lead to blocking of the appendix and the occurrence of inflammation. Decreased immunity due to hormonal changes.

The main reason indicating the need for surgery is an acute form of inflammation of the appendix or. Other factors that bring the patient to the operating table:

• Increased symptoms of body poisoning by products of the inflammatory process.
• Violation of the integrity of the appendix and penetration of purulent products into the internal organs, the development of peritonitis.
• Increased risk of rupture.

Depending on the patient’s condition and the stage of the disease, the operation is performed in two ways:

1. According to plan.
2. In an emergency, or urgent form.

Planned

Surgical intervention is used if removal is impossible or prohibited. This is usually carried out in the presence of infiltration. Initially, drug treatment is performed to relieve the acute form, and then cutting is prescribed when there is no threat to the health and life of the patient.

Urgent

The acute form of the disease provokes emergency removal. Occurs when an organ ruptures and peritonitis.

The development of chronic appendicitis is associated with the periodic occurrence of a discomfort state. Its treatment is carried out using medications and surgery. The doctor chooses the methods. If symptoms appear infrequently and not intensely, they try to treat with medications.

Diagnostic examination

Before removing an organ, an examination is carried out and tests are taken. This is done to exclude other pathologies to confirm the diagnosis.

Inspection

The surgeon first examines the patient to identify symptoms of appendicitis. The procedure consists of palpation and tapping the area of ​​the body where it hurts, and preliminary determination of the location of the appendix. Attention is paid to what position the patient takes. A visual examination of the condition of the abdomen is performed. At the site of inflammation, the skin will be raised and inflamed.

Blood and urine tests are taken to determine the degree of inflammation and rule out diseases with similar symptoms.

Instrumental examination

The use of equipment is necessary to make an accurate diagnosis and determine the location of the appendix:

• Ultrasonography.
• Computed tomography using contrast.

Types of surgery

An appendectomy is the surgical removal of an inflamed organ (appendix). The entire process is cut out, the remains are sutured and hidden inside the cecum.

In surgical practice, two main methods of intervention inside the patient’s body are used:

1. Laparotomy. An incision is made in the area where the inflamed appendix is ​​located. Open surgery.
2. Laparoscopy (endoscopy). For removal, small punctures (three) are made in the abdominal area.

The methods have both positive and negative aspects.

Laparotomy

Is the classic way. Laparotomy is the first abdominal operation performed on the appendix. Indications:

• The diagnosis was confirmed: acute appendicitis.
• The acute form gave complications - peritonitis.
• Consequences of an acute illness in the form of an infiltrate that connects the appendix, cecum, small intestine and omentum.
• Chronic appendicitis.

Peritonitis and clinical signs of acute illness are indicators for urgent surgery. When there is an infiltrate inside, conservative treatment is used aimed at relieving the inflammatory process. Therapy can take 2-3 months. Then a planned removal is scheduled.

When laparotomy should not be performed:

• The patient is in agony.
• If the patient independently refuses surgical procedures in writing.
• Planned intervention. Dysfunction of the cardiovascular system, breathing, kidneys and liver.

Preparation for the operation does not require special measures. If the patient has a violation of the water-salt balance or peritonitis has developed inside, then liquids and broad-spectrum antibiotics enter the body through intravenous administration.

Progress of the operation:

1. Introduction of anesthetic solution. General anesthesia is given. The solution enters the body either through injection into a vein or through an inhalation device. It is extremely rare that anesthesia is administered through the spinal canal.
2. The site of the future operation is treated with antiseptic agents. Iodine in alcohol, betadine, and alcohol are used as disinfectants.
3. An incision is made in the area where the appendicitis is located. Penetration inside is carried out by cutting tissue layer by layer.
4. A visual inspection of the internal contents is carried out. The appendix rises above the organs.
5. The process is cut off (resection is performed). In this case, sutures are placed at the site of the incision of the mesentery and appendix.
6. Then excess fluid is removed, a drainage system is installed (tubes for removing inflammation products), and sanitation is carried out with tampons and electric suction.
7. The incision in the peritoneum is sutured with special threads. Access is closed by layer-by-layer stitching of tissues in the reverse order of penetration.

Access to the peritoneum is carried out according to the following options:

• Volkovich-Dyakonov method, oblique incision.
• Lenander's method. Longitudinal section.
• Access via transverse incision.

Drainage is performed in several cases:

• Rupture of the appendix and development of peritonitis.
• Formation of pus at the site of surgery.
• Inflammation develops in the retroperitoneal tissue.
• Incomplete blockage of blood vessels damaged as a result of surgery. Incomplete hemostasis of arteries.
• There are no clear indications for cutting out an inflamed organ.
• There was an incomplete immersion of the remnants of the process into the body of the cecum.

The drainage is removed after 2-3 days if healing proceeds without complications.

The cutting process during laparotomy takes from 40 minutes to one hour. If complications are present (adhesive disease, incorrect location of the organ), then the surgical process lasts from two to three hours. The recovery process lasts up to a week. It is recommended to remain in bed for 2-3 days from the day of surgery. External sutures are removed on the 7th or 10th day.

Laparoscopy

There is another method of removal, which is less traumatic - laparoscopy. It is limited in use and has both indications and contraindications for cutting.

When is the use of minimally invasive appendix removal indicated:

• The first day of development of an acute form of the disease or a mild form of the disease.
• The disease is chronic.
• The child develops acute appendicitis.
• Concomitant diseases of the patient that provoke poor wound healing and subsequent suppuration. These include diabetes and excess weight.
• Written statement from the patient regarding the use of laparoscopic appendectomy.

Let's consider cases when the use of the method is prohibited or undesirable.

General contraindications:

• Last months of pregnancy.
• Acute cardiovascular diseases. Failure or infarction.
• Lung dysfunction causing respiratory failure.
• Poor blood clotting.
• General anesthesia is not recommended.

Local contraindications:

• Appendicitis takes longer to develop than a day.
• Development of peritonitis.
• Areas of purulent processes with clear or blurred edges.
• Adhesive disease in the peritoneum.
• Access to the appendix is ​​difficult due to its incorrect location.
• Around the organ, small intestine and large intestine there are inflamed tissues with a changed structure - infiltrate.

The removal operation is carried out without special preparation. In case of appendicitis, the process takes a minimum of time: an IV containing saline solution is installed, antibiotics with a wide spectrum of action are administered. In the operating room, a tube containing an anesthetic solution is inserted into the patient, which is administered by inhalation. Laparoscopy is performed only under general anesthesia.

Appendicitis is removed without an incision, using special medical instruments:

• Laparoscope.
• A tube for pumping carbon dioxide, called an insufflator.
• Laser for cutting off the appendage.
• A monitor that allows you to monitor the progress of the operation and examine the internal situation.

Laparoscopy takes place in several stages:

• The site of future intervention is being prepared. Holes are made in the abdomen for insertion of medical instruments.
• The abdominal cavity is examined from the inside. Carbon dioxide is released into the abdominal cavity, which allows for a better inspection.
• Once located, the appendix is ​​fixed at the center or end. Then the cutting is performed: first of the mesentery, and then of the organ itself. After the excised organ, stumps of the process and connective tissue remain. Sutures are placed at the cut-off sites: separately on the mesentery, separately on the appendix. The organ is brought out using a trocar. The procedure is performed carefully and professionally.
• The pus and other fluids that appeared during the cutting process are removed. If necessary, drainage is installed.
• Sutures are placed on the holes where the instruments were.

If at the examination stage complications were identified that are part of the contraindications to laparoscopy, then the instruments are removed and a classic cut is performed.

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Appendectomy is one of the most common surgical procedures. Acute appendicitis occurs in 7% of the population throughout life. Unsolved problems in the treatment of this disease include not only late diagnosis with the development of severe complications, but also unnecessary appendectomies, the frequency of which reaches 20-40%. A full inspection of the abdominal cavity when an unchanged appendix is ​​detected through an incision in the right iliac region is impossible.

Unnecessary appendectomy can lead to undesirable consequences both in the immediate and long-term postoperative period. The latter include secondary infertility in women, adhesive intestinal obstruction, hernia formation, etc. Laparoscopy makes it possible to establish an accurate diagnosis of acute appendicitis in 95-97% of cases, and, if appropriate, perform laparoscopic appendectomy (LA).

In the practice of a gynecologist, the need for appendectomy during the main intervention arises quite often. This applies to operations performed for endometriosis, adhesive disease, purulent-inflammatory diseases of the appendages, when the appendix is ​​involved in a scar-infiltrative process that extends to the ileocecal part of the intestine. Preserving the appendix in this situation is dangerous and pointless. Immediate involvement of a surgeon is not always organizationally possible, and his skills and attitude towards laparoscopy may not suit the operating gynecologist. Therefore, we believe that a gynecological surgeon should be proficient in the LA technique, just as a general surgeon should be proficient in the adnexectomy and cystectomy technique.

Operative technique

Position of the patient. Laparoscopy begins in a horizontal position. If a decision is made about LA, a Trendelenburg position is created on the left side (30°), which allows the intestinal loops and greater omentum to be retracted from the right iliac fossa. The monitor is placed on the right near the foot end of the operating table. The surgeon is to the left of the patient, the assistant is opposite him (Fig. 18-1).

Rice. 18-1. Positioning of the operating team and monitor during laparoscopic appendectomy.

Anesthetic care. The operation is performed under general intravenous or endotracheal anesthesia. The latter is preferable, as it provides relaxation and is safer during the stages of electrosurgical action.

Accesses. The Veress needle and the first trocar are inserted paraumbilically, making a semilunar incision above the umbilicus. A detailed examination of the cecum, appendix and pelvic organs usually requires an additional 5 mm instrument, which is inserted through a puncture in the left iliac region. If there is effusion in the abdominal cavity, it is carefully aspirated. If LA is performed, a third, 10-mm trocar is inserted in the right mesogastric region at the level of the umbilicus (Fig. 18-2). Some surgeons use a fourth, 5-mm trocar, which is inserted above the pubis. In destructive forms of acute appendicitis, pre- and intraoperative administration of antibiotics is indicated.

Rice. 18-2. Trocar insertion points for LA.

Laparoscopic appendectomy options

After completing the diagnostic stage of laparoscopy, a final decision is made on the extent of the intervention. Normally, the appendix is ​​easily moved with an instrument, changes its shape, which indicates the absence of tension, its peritoneum is pale, and the vascular pattern is not disturbed. As with open appendectomy, the method of treating the mesentery and stump of the appendix is ​​of fundamental importance. There are three ways to perform LA: extracorporeal, combined and intracorporeal.

1. The extracorporeal method consists of clarifying the diagnosis laparoscopically, finding and grasping the distal end of the appendix with a clamp, and then, together with the mesentery, removing it out through access 3. Next, a conventional appendectomy is performed with the application of purse-string and Z-shaped sutures. The abdominal cavity is washed, dried and drained. The method can be performed with a mobile cecum, a small diameter of the appendix and the absence of infiltrative changes in the mesentery. This option can be recommended at the stage of mastering aircraft technology (Fig. 18-3).

2. The combined method is used for a short infiltrated mesentery, which is coagulated inside the abdominal cavity (Fig. 18-4). The mobilized appendix is ​​removed and processed traditionally.

3. Intracorporeal method is a generally accepted method of performing LA, when all stages of the intervention are performed laparoscopically inside the abdominal cavity.

Rice. 18-3. Extracorporeal LA.

Rice. 18-4. Combined aircraft. Coagulation of the mesentery in monopolar mode.

Operation stages

Traction. The distal end of the appendix is ​​grabbed with a clamp inserted through access 3 and lifted towards the anterior abdominal wall. The vermiform appendix is ​​freed from adhesions and adhesions, and then positioned so that the mesentery is in the frontal plane.

The mesentery is transected in one of 4 ways.
1. An electrosurgical monopolar clamp or dissector is inserted through access 2. In small portions of 2-3 mm, the mesenteric tissue is captured and coagulated, moving towards the base of the appendix (Fig. 18-5, see color insert). Particular care is required near the dome of the cecum. The following sequence of actions is strictly observed: a small portion of tissue is captured with a dissector, removed from the intestine, and only then coagulated. Pay attention to the proximity of intestinal loops to the instrument. This method is the simplest, provides reliable hemostasis and takes little time. It is necessary to completely isolate the base of the appendix along the entire circumference, preparing it for the application of a ligature.
2. To treat the mesentery, you can use bipolar coagulation, which is safer, but requires a special instrument and is somewhat longer in time. With an infiltrated thickened mesentery, bipolar coagulation is less effective and requires fragmentation of the mesentery.
3. Ligation of the mesentery with a ligature: a window is formed at the base of the appendix in the mesentery, a ligature is passed through it, both ends of which are removed out through a trocar. The node formed extracorporeally is lowered into the abdominal cavity (Fig. 18-6, see color insert). The mesentery is divided with scissors. The application of individual titanium clips is quite expensive and unreliable, especially in infiltrated tissues.
4. The mesentery is crossed with a stapler. The appendix stump is formed in one of 3 ways.

1. The ligature method is the most common in laparoscopy. It is recognized as safe by domestic and foreign surgeons. After crossing the mesentery, an endoloop is inserted through access 3, placed over the appendix and lowered to the base using a clamp (Fig. 18-7, see color insert). The loop is tightened and the ligature is cut off. Typically, one or two ligatures are left on the stump of the appendix, superimposed on each other (one of them can be replaced with an 8-mm clip). A ligature, clip or surgical clamp is also applied to the distal stump of the appendix, using which the specimen is immediately removed after cutting off (Fig. 18-8—18-10, see color insert and Fig. 18-11). The size of the stump above the ligature is 2-3 mm. After cutting off the appendix, the mucous membrane of the stump is superficially coagulated with a spherical electrode inserted through access 2 (Fig. 18-12). We remind you that coagulation near metal clips is unacceptable. With sufficient experience, the duration of LA does not exceed the time of open surgery, amounting to 20-30 minutes.

2. Hardware method. Through a 12-mm trocar from access 3, an endosurgical stapler is inserted, which is applied separately to the appendix and its mesentery, crossing sequentially. If the tissue thickness is small, both structures are stitched at the same time (Fig. 18-13). Hardware appendectomy reduces the operating time and allows, if necessary, aseptic resection of the dome of the cecum. The only drawback of the method is the high cost of the stitching machine.

Rice. 18-11. The vermiform appendix is ​​removed immediately after cutting off.

Rice. 18-12. The mucous membrane of the stump is carefully coagulated with a spherical electrode.

Rice. 18-13. Hardware appendectomy.

Rice. 18-14. Removing the drug through a 10/20 mm adapter sleeve.

3. Immersion of the stump into the dome of the cecum by applying intracorporeal purse-string and Z-shaped purse-string sutures. The technique was developed by the founder of LA K. Semm. It requires quite painstaking work and perfect mastery of the endosurgical suture technique.

Removing the drug is a crucial moment of the operation. To avoid the spread of intra-abdominal infection, the drug is removed immediately after cutting off. It is necessary to prevent contact of the inflamed appendix with the tissues of the anterior abdominal wall, otherwise infection of the tissues will most likely lead to the development of purulent complications. To do this, use one of the following methods:
1 . If the diameter of the appendix and mesentery is less than 10 mm, the drug can be easily removed through trocar 3.
2. For a larger diameter of the preparation, use a 10/20 mm adapter sleeve (Fig. 18-14).
3. The appendix is ​​placed in a container before removal.

End of operation. The intervention area is thoroughly washed with 500-700 ml of antiseptic solution. The patient is returned to the original position, and the rinsing water is aspirated. A drainage is installed in the abdominal cavity. The wounds are sutured.

The postoperative period is much easier than after a traditional appendectomy. The patient is activated by the end of the first day after removal of the drainage. Liquid food is allowed. Antibiotics are prescribed to all patients. The duration of the hospital period after LA is 3-7 days. In uncomplicated cases, the period of disability does not exceed 14 days.

Complications and their prevention

Wound infection is one of the most likely complications of LA and is directly related to the method of removing the appendix from the abdominal cavity.

Intra-abdominal infection in the form of abscesses or peritonitis may be the result of inadequate sanitation and drainage of the abdominal cavity or incomplete aspiration of lavage water. According to V.M. Sedova et al., in general, purulent complications after LA are observed 4 times less often than after open surgery.

Recurrence of acute appendicitis is an uncommon complication of LA. Clinically manifested by symptoms of acute appendicitis 3-6 months after LA. During repeated surgery, an inflamed stump of the appendix 2-3 cm long is found. The cause of the complication is inadequate mobilization of the base of the appendix during LA.

Appendiceal stump failure is a rare complication that was first described by Schreber. It is associated with an unjustified expansion of the indications for the ligature method in pulmonary artery (typhlitis, infiltration of the base of the appendix) or is a consequence of thermal damage to the dome of the cecum due to careless coagulation.

Day 5 syndrome is acute typhlitis that occurs on the 5th day after surgery. Its occurrence is associated with an electrosurgical burn of the dome of the cecum due to the careless use of monopolar coagulation. The complication is characterized by severe pain in the right iliac region, defence, peritoneal symptoms, and fibrile temperature. At surgery, fibrinous typhlitis is detected, usually without perforation.

A hernia at the point of insertion of one of the trocars usually appears 1-4 weeks after surgery, when the patient returns to his normal lifestyle. The cause of the complication is wound suppuration, hematoma of the abdominal wall, or a defect in surgical technique when suturing tissue.

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9. Semm K. Endoscopic appendectomy // Endoscopy. - 1983. - No. 15. - R. 59-64.

Access for appendectomy. As a rule, a skew variable is used Volkovich-Dyakonov access. Lennander's perirectal incision is less commonly used.

An oblique incision 9-10 cm long in the right groin area is used to open the anterior wall of the abdomen layer by layer. The middle of the incision should pass at the border of the middle and outer thirds of the line connecting the anterior superior iliac spine to the umbilicus ( dot mac barney). The skin, subcutaneous tissue and superficial fascia are dissected. The aponeurosis of the external oblique muscle of the abdomen is exposed and, using a grooved probe or curved scissors, it is peeled off from the muscles and cut along the entire length of the skin wound towards the upper and then to its lower corner (the muscle is dissected in the upper corner of the wound).

Using blunt scissors, the internal oblique and transverse abdominal muscles are separated bluntly along the muscle fibers. In this case, the edges of the muscle wound are located almost perpendicular to the edges of the skin incision. The transversus abdominis fascia is dissected by lifting it with tweezers. The peritoneum is raised in the wound in the form of a cone anatomical tweezers, check whether any organ is captured along with it, and incise it with scissors or a scalpel. The edges of the peritoneum are grabbed with Mikulicz clamps, lifted and the peritoneum is cut along the entire length of the wound.

Stages of appendectomy.
I - removal of the cecum and appendix; II - ligation of the mesentery;
III - cutting off the process from the mesentery; IV - application of a purse-string suture around the base of the process;
V - ligation of the appendix with a catgut ligature; VI - cutting off the process, processing its stump;
VII - immersion of the stump of the process into the purse-string suture; VIII - application of a Z-shaped seam.

Removal of the cecum during appendectomy. The cecum is found, being guided by its grayish color, ribbons, absence of mesentery and omental processes on the side of the right lateral sulcus. Grab the cecum with your fingers using a gauze napkin, carefully remove it along with the appendix from the incision, cover it with gauze napkins and proceed to the part of the operation that is performed outside the abdominal cavity.

Cutting off the mesentery of the appendix during appendectomy. The mesentery of the appendix is ​​grabbed with a clamp at its apex (15-20 ml of a 0.25% novocaine solution can be injected into the mesentery). Hemostatic clamps are applied to the mesentery of the appendix, and the mesentery is cut off.

Removal of the appendix during appendectomy. Pulling the mobilized appendix up using a clamp placed on the mesentery at its apex, a seromuscular purse-string suture is placed on the wall of the cecum with silk or nylon around the base of the appendix. The suture is not tightened. At this point, the appendix is ​​clamped with a hemostatic clamp, then the clip is removed and the appendage is tied with catgut along the resulting groove. A hemostatic clamp is applied above the ligature lying at the base of the process, and between it and the ligature the process is cut off with a scalpel and removed. The mucous membrane of the stump of the appendix is ​​treated with an alcohol solution of iodine, the ends of the catgut thread are cut off and the stump is immersed into the wall of the cecum using a previously applied purse-string suture. Holding the ends of the tightened purse-string suture, apply a Z-shaped suture and tighten it after cutting off the ends of the purse-string suture thread. Then the ends of the Z-stitch threads are cut off.

Caecum during appendectomy carefully immersed into the abdominal cavity. The abdominal cavity is closed in layers. The parietal peritoneum is sutured with a continuous suture. The edges of the muscles are brought together with 2-3 interrupted sutures. The aponeurosis of the external oblique abdominal muscle, as well as the skin, is sutured with interrupted silk sutures.

Appendectomy is one of the most common operations in surgical practice. Indications for it are acute and chronic appendicitis, as well as tumors of the appendix. The operation is performed under general anesthesia

Surgical tactics 1. If OA is suspected, hospitalization in the surgical department. 2. OA is an indication for emergency surgery; in the presence of appendiceal infiltrate, but no signs of infection, conservative treatment is required. 3. Surgical treatment if the diagnosis is established in the first 2 hours from the moment of admission to the surgical department. 4. If the diagnosis is unclear, diagnostic laparoscopy or dynamic observation is not >6 hours. 5. KBC in dynamics every 3 hours with the leukocyte formula.

5. If for some reason laparoscopy cannot be used or it gives unclear results, and the diagnosis of acute appendicitis cannot be excluded, an operation for diagnostic purposes is indicated. 6. Patients with a complicated form of acute appendicitis (peritonitis, severe intoxication) should be prepared for surgery as soon as possible (in this case, it is necessary to compensate not only water-electrolyte disorders, acid-base status, but also the cardiovascular and urinary systems). 7. Pregnancy is not a contraindication to surgery for acute appendicitis (remember: the clinical picture of the disease may be blurred).

Surgical access To approach the cecum and appendix, various incisions of the anterior abdominal wall have been proposed: Volkovich-Dyakonov-McBurney, Lennander, Winkelman, Schede, etc.

Scheme of incisions of the anterior abdominal wall used in operations on the large intestine Volkovich-Dyakonov-Mack Burney incision Lennander pararectal incision Winkelmann incision

Volkovich-Dyakonov-Mac Burney incision During appendectomy and operations on the cecum, the Volkovich-Dyakonov-Mac Burney oblique incision is more often used. This incision, 6-10 cm long, is made parallel to the inguinal ligament, through Mac Burney's point, located between the outer and middle third of the line connecting the umbilicus to the right anterior superior iliac spine. One third of the cut should be located above, two thirds - below the indicated line. The length of the incision should be sufficient to provide wide access. Excessive stretching of the wound with hooks injures the tissue and promotes suppuration.

Surgery technique An incision in the anterior abdominal wall is made according to Volkovich-Dyakonov-McBurney. The skin and subcutaneous tissue are dissected, the bleeding vessels are grabbed with clamps and bandaged. The edges of the skin wound are covered with napkins and the aponeurosis of the external oblique muscle of the abdomen is cut along the fibers using a Kocher probe or tweezers.

Retrograde appendectomy Retrograde removal of the appendix is ​​performed in cases where it cannot be removed into the wound, which sometimes happens when the appendix is ​​in a retrocecal position or in the presence of adhesions with surrounding organs and tissues. When isolating the appendix from the adhesions, the abdominal cavity should be carefully fenced off with gauze to avoid infection. To remove the vermiform appendix in a retrograde manner, the intestine is pulled into the wound as much as possible and its base is found, guided by the place of convergence of the taeniae.

Appendectomy with retroperitoneal position of the appendix If there are no adhesions in the abdominal cavity and the appendix is ​​not found, then you should think about its retroperitoneal position. The vermiform appendix is ​​located behind the ascending colon and its apex can reach the lower pole of the kidney. When the appendix is ​​in a retroperitoneal position, to expose it, the parietal peritoneum is dissected over 10–15 cm, 1 cm outward from the cecum and ascending colon

Suturing the parietal peritoneum