Possible early postoperative complications in appendicitis. Appendiceal abscess: clinic, autopsy

Developing acute appendicitis almost always requires emergency surgery, during which the inflamed appendix is ​​removed. Surgeons resort to surgery even if the diagnosis is in doubt. Similar treatment This is explained by the fact that complications of acute appendicitis are sometimes so serious that they can lead to death. Surgery - appendectomy reduces the risk of some of the dangerous consequences of appendicitis to a person.

When complications may occur with appendicitis

Acute inflammation vermiform appendix in humans it occurs in several stages. First, catarrhal changes occur in the walls of the processes, usually lasting for 48 hours. At this time, there are almost never serious complications. After the catarrhal stage, destructive changes follow; appendicitis from catarrhal can become phlegmonous, and then gangrenous. This stage lasts from two to five days. During this time, purulent melting of the walls of the appendix occurs and a number of dangerous complications may develop, such as perforation followed by peritonitis, infiltration and a number of other pathologies. If there is no surgical treatment during this period, then other complications of appendicitis arise, which can cause death. In the late period of appendicitis, which occurs on the fifth day from the onset of inflammation of the appendix, diffuse peritonitis develops, and an appendiceal abscess and pylephlebitis are often detected.

Various complications are possible after surgery. The causes of postoperative complications are associated with untimely surgery, late diagnosis of acute appendicitis, and surgeon errors. More often, pathological disorders after surgery develop in older people with a history of chronic diseases. Some complications may also be caused by patients’ non-compliance with doctor’s recommendations. postoperative period.

Thus, complications in patients with acute appendicitis can be divided into two groups. These are those that develop in the preoperative period and those that develop after surgery. Treatment of complications depends on their type, the patient’s condition and always requires a very careful attitude of the surgeon.

Complications of appendicitis in the preoperative period

The development of complications before surgery in most cases is associated with a person’s untimely visit to a medical facility. Less commonly, pathological changes in the appendix itself and the structures surrounding it develop as a result of incorrectly chosen tactics for the management and treatment of the patient by the doctor. The most dangerous complications that develop before surgery include diffuse peritonitis, appendicular infiltration, inflammation of the portal vein - pylephlebitis, abscess in different parts of the abdominal cavity.

Appendicular infiltrate

An appendiceal infiltrate occurs due to the spread of developing inflammation to organs and tissues located near the appendix, such as the omentum, loops of the small intestine and cecum. As a result of inflammation, all these structures are welded together, and an infiltrate is formed, which is a dense formation with moderate pain in the lower, right part of the abdomen. This complication usually occurs 3-4 days after the onset of the attack; its main symptoms depend on the stage of development. At an early stage, the infiltrate is similar in symptoms to destructive forms of appendicitis, that is, the patient has pain, symptoms of intoxication, and signs of peritoneal irritation. After the early stage comes the late stage, it is manifested by moderate pain, slight leukocytosis, and an increase in temperature to 37-38 degrees. On palpation, a dense tumor is determined in the lower abdomen, not very painful.

If the patient has an appendiceal infiltrate, then appendectomy is postponed. This approach to treatment is explained by the fact that when removing the inflamed appendix, the intestinal loops, omentum, and mesentery soldered to it may be damaged. And this, in turn, leads to the development of life-threatening postoperative complications for the patient. Appendiceal infiltration is treated in hospital conservative methods, these include:

• Antibacterial drugs. Antibiotics are necessary to eliminate inflammation.
• Using cold helps limit the spread of inflammation.
• Painkillers or bilateral blockade with novocaine.
• Anticoagulants are drugs that thin the blood and prevent the formation of blood clots.
• Physiotherapy with a resolving effect.

Throughout treatment, patients must adhere to strict bed rest and diet. It is recommended to consume less foods with coarse fiber.

Appendiceal infiltration may further manifest itself in different ways. If its course is favorable, it will resolve within a month and a half; if unfavorable, it will fester and be complicated by an abscess. In this case, the patient exhibits the following symptoms:

• Increase in body temperature to 38 degrees or above.
• Increasing symptoms of intoxication.
• Tachycardia, chills.
• The infiltrate becomes painful on palpation of the abdomen.

The abscess can break into the abdominal cavity with the development of peritonitis. In almost 80% of cases, the appendiceal infiltrate resolves under the influence of therapy, and then planned removal of the appendix is ​​indicated after about two months. It also happens that the infiltrate is detected even when surgery is performed for acute appendicitis. In this case, the appendix is ​​not removed, but drained and the wound is sutured.

Abscess

Appendiceal abscesses arise due to suppuration of an already formed infiltrate or when the pathological process is limited by peritonitis. IN the latter case An abscess most often occurs after surgery. A preoperative abscess forms approximately 10 days after the onset of the inflammatory reaction in the appendix. Without treatment, the abscess may rupture and release purulent contents into the abdominal cavity. The following symptoms indicate the opening of an abscess:

• Rapid deterioration in general health.
• Feverish syndrome – fever, periodic chills.
• Signs of intoxication.
• Increase in leukocytes in the blood.

Appendiceal abscess can be found in the right iliac fossa, between the intestinal loops, retroperitoneally, in the pouch of Douglas (rectovesical recess), in the subphrenic space. If the abscess is located in the pouch of Douglas, then the general symptoms include painful, frequent stools, irradiation of pain into the rectum and perineum. To clarify the diagnosis, rectal and vaginal examinations are also carried out in women, as a result of which an abscess can be detected - an infiltrate with beginning softening.

The abscess is treated surgically, it is opened, drained and then antibiotics are used.

Perforation

On days 3-4 from the onset of inflammation in the appendix, its destructive forms develop, leading to melting of the walls or perforation. As a result, purulent contents, along with a huge amount of bacteria, enter the abdominal cavity and peritonitis develops. Symptoms of this complication include:

• Spread of pain throughout all parts of the abdomen.
• Temperature rises to 39 degrees.
• Tachycardia over 120 beats per minute.
• External signs are sharpening of facial features, sallow skin tone, anxiety.
• Retention of gases and stool.

Palpation reveals swelling, the Shchetkin-Blumberg symptom is positive in all parts. In case of peritonitis, emergency surgery is indicated; before surgery, the patient is prepared by administering antibacterial agents and antishock drugs.

Postoperative complications in patients with acute appendicitis

Postoperative complicated appendicitis leads to the development of pathologies from the wound and internal organs. It is customary to divide complications after surgery into several groups, these include:

• Complications identified from the sutured wound. These are hematoma, infiltration, suppuration, divergence of wound edges, bleeding, fistula.
• Acute inflammatory reactions in the abdominal cavity. Most often these are infiltrates and abscesses formed in different parts abdominal cavity. Also, after surgery, local or general peritonitis may develop.
• Complications affecting the gastrointestinal tract. Appendectomy can lead to intestinal obstruction, to bleeding, the formation of fistulas in different parts of the intestine.
• Complications from the heart, blood vessels and respiratory system. In the postoperative period, some patients experience thrombophlebitis, pylephlebitis, embolism pulmonary artery, pneumonia, abscesses in the lungs.
• Complications from the urinary system - acute cystitis and nephritis, urinary retention.

Most complications of the postoperative period are prevented by following the doctor's recommendations. For example, intestinal obstruction can occur due to non-compliance with the diet and under the influence of insufficient physical activity. Thrombophlebitis is prevented by the use of compression garments before and after surgery and the administration of anticoagulants.

Complications of acute appendicitis from the wound are considered the most common, but also the safest. The development of pathology is judged by the appearance of compaction in the wound area, an increase in general and local temperature, and the release of pus from the suture. Treatment consists of re-treating the wound, introducing drainage, and using antibiotics.

The most severe complications after surgery include pylephlebitis and intestinal fistulas.

Pylephlebitis

Pylephlebitis is one of the most severe complications of acute appendicitis. With pylephlebitis, the purulent process from the appendix spreads to the portal vein of the liver and its branches, resulting in the formation of numerous ulcers in the organ. The disease develops rapidly; it may be a consequence of untreated acute appendicitis. But in most patients it is a complication of appendectomy. Symptoms of the disease can appear either 3-4 days after surgery or after a month and a half. To the very obvious signs pylephlebitis includes:

• A sharp jump in body temperature, chills.
• The pulse is frequent and weak.
• Pain in the right hypochondrium. They can radiate to the scapula and lower back.
• Enlarged liver and spleen.
• The skin is pale, the face is haggard and jaundiced.

With pylephlebitis there is a very high mortality rate; rarely the patient can be saved. The outcome depends on how quickly this complication is detected and the operation is performed. During surgery, abscesses are opened, drained, and antibiotics and anticoagulants are administered.

Intestinal fistulas

Intestinal fistulas in patients with appendectomy occur for several reasons. This is most often:

• Inflammation spreading to the intestinal loops and their destruction.
• Failure to comply with the surgical technique.
• Bedsores that develop under the pressure of tight tampons and drains used during surgery.

The development of intestinal fistulas can be judged by increased pain in the right iliac region about a week after removal of the inflamed appendix. Signs of intestinal obstruction may be observed. If the wound is not completely sutured, then intestinal contents are released through the suture. Patients suffer much more severely from the formation of a fistula when the wound is sutured - the contents of the intestine penetrate into the abdominal cavity, where purulent inflammation develops. The resulting fistulas are eliminated surgically.

Complicated appendicitis requires careful diagnosis, identification pathological changes And quick treatment. Sometimes the patient’s life depends only on timely emergency surgery. Experienced surgeons can already assume the risk of complications after appendectomy based on the patient’s age and his history of chronic diseases, such as diabetes mellitus. Undesirable changes often occur in patients prone to obesity. All these factors are taken into account both in the preoperative and postoperative periods.

The possible number of complications can only be minimized by timely consultation with a doctor. Early surgery prevents the most serious complications and shortens the recovery period.

Purulent appendicitis- phlegmonous, gangrenous destruction of the appendix. This concept unites the most severe forms of acute appendicitis. Destructive appendicitis is fraught with serious complications, especially if misdiagnosed and delayed surgery.

In the classification accepted by most surgeons, all forms of acute appendicitis, with the exception of catarrhal, belong to purulent appendicitis. There are catarrhal, phlegmonous (with and without perforation), gangrenous (with and without perforation), appendicular infiltrate (with and without suppuration).

The microflora in purulent appendicitis is diverse, but predominates coli, Proteus, Enterococci. In gangrenous, perforated appendicitis, anaerobic microorganisms are very common. However, the presence of microorganisms and mechanical damage to the mucous membrane do not determine the development of the disease. A major role is played by malnutrition of the appendage wall.

In the pathogenesis of acute appendicitis, the obstruction factor, microflora and circulatory disorder due to thrombosis of the vessels feeding the appendix play a role. The latter causes the development of gangrene and perforation of the appendix.

I.V. Davydovsky believed that separate forms appendicitis represent stages of a single inflammatory process. There is often a discrepancy between the clinical manifestations of the disease and changes in the removed processes. Purulent appendicitis (phlegmonous, gangrenous, perforated) is irreversible, unlike catarrhal one.

In most cases, changes in the appendix with purulent appendicitis begin from the mucous membrane, where an epithelial defect appears with a cone-shaped leukocyte infiltration, the apex directed to the serosa. At further development process, these foci increase, merge and form larger foci of purulent infiltration.

The entire appendix becomes tense, swollen, whitish, with dilated vessels and fibrinous deposits (phlegmon of the appendix). Merging, the abscesses can melt the wall of the appendix and lead to its perforation.

With rapid destruction of the wall of the appendix, release of the contents of the abscesses towards the serous integument and a relatively weak tendency to limit the process, perforated appendicitis and purulent peritonitis develop. The perforation hole can be microscopic in size. Subsequently, as a result of the expansion of the necrosis focus, the process covers a significant part of the wall or the entire process. The rapid development of the process is facilitated by thrombosis of the vessels of the mesentery of the appendix with acute circulatory disorder and gangrene.

Destructive forms of appendicitis with late recognition and a tendency to encystment lead to the formation of an infiltrate consisting of fused intestinal loops, omentum, and parietal peritoneum. As a rule, in children, purulent appendicitis (destructive forms) develops quickly; in old people, sometimes with an erased clinical picture, severe destruction often occurs - gangrene of the appendix

Clinical picture

In most cases, diagnosing acute appendicitis is not particularly difficult; It is much more difficult to identify with certainty purulent appendicitis. Based on the results of a thorough clinical examination and laboratory data, purulent appendicitis can be suspected. It is much easier to diagnose appendiceal infiltrate. Diagnosis of purulent appendicitis is based on a unique set of symptoms.

In case of diagnostic difficulties, careful observation of the patient for 2-3 hours is of great importance. The persistence and increase of signs of inflammation, the appearance of symptoms of peritoneal irritation indicate a destructive form of appendicitis. When a patient is admitted at a later stage of the disease, it is often possible to judge from the clinical picture the pathological changes in the appendix.

If the diagnosis of acute appendicitis is questionable, laparoscopy can be performed. Detection of signs of inflammation in the process or in its zone allows us to establish a diagnosis of the disease.

There can be no standard for patients with suspected acute appendicitis. The diagnosis of the disease should be based on a strictly individual approach

Differential diagnosis of purulent appendicitis is often difficult. Particular difficulties are presented by cases with a confusing history and blurred clinical picture. Firstly, it is necessary to distinguish acute appendicitis from other diseases, and secondly, to determine the nature of the changes in the appendix and the existing complications. Due to diversity clinical manifestations purulent appendicitis is difficult to differentiate from gynecological and other diseases.

This is largely facilitated by the varied location of the cecum, appendix and a number of other circumstances. Acute appendicitis is mixed with other diseases of the gastrointestinal tract, as well as diseases of the female genital organs, diseases urinary tract and infectious diseases.

Purulent appendicitis must be differentiated from other acute surgical diseases of the abdominal organs.

With a perforated stomach ulcer or duodenum The onset of pain is sharp, sudden, the pain is very strong. Diagnosis is aided by anamnestic information. From objective data, it is important to pay attention to the localization of pain, muscle tension, reduction of hepatic dullness, crescent of gas in the right subphrenic space. Differential diagnosis is difficult when the perforation is covered, as well as when gastric contents flow down the side channel into the right iliac region.

Recognition of cholecystitis is based on anamnestic data, the nature, localization, irradiation of pain, sometimes the presence of jaundice, and ultrasound data. Differential diagnosis is difficult when the appendix is ​​located high.

In case of acute intestinal obstruction due to cecal volvulus, differential diagnosis is complicated by severe peritonitis, bloating, and pain in all its parts. You should pay attention to the asymmetry of the abdomen, the level of fluid in the intestinal loops during X-ray examination, splashing noise and peristalsis of varying intensity during auscultation of the abdomen.

Ileal intussusception is more common in children 2–3 years of age. Recognition is facilitated by the presence of blood in the stool and increasing signs of intestinal obstruction. During digital examination, a sausage-shaped formation in the right iliac region is palpated through the rectum. Less commonly, purulent appendicitis must be differentiated from inflammation, perforation or inversion of Meckel's diverticulum (1 case in 5000 appendectomies) and from terminal or regional ileitis.

It is almost impossible to distinguish purulent appendicitis from inflammation of Meckel's diverticulum before surgery. Phlegmonous lesions of the intestines are more characterized by a significant deterioration of the condition (intoxication), a rapid change in pain points due to displacement of the intestine.

The condition of the cardiovascular system, the rapidly developing phenomena of widespread peritonitis with sudden bloating, and the rapid increase in intoxication help to distinguish the initial phenomena of thrombosis of the mesenteric vessels from purulent appendicitis.

The differential diagnosis of purulent appendicitis and pneumococcal peritonitis, acute tuberculous peritonitis and acute inflammation of the mesenteric lymph nodes is very difficult and important.

These diseases are more common in children. In old age, with a reduced reaction of the body, purulent appendicitis is sometimes confused with tumors (cancer) of the dome of the cecum. The final diagnosis is determined by laparoscopy or during surgery.

IN advanced cases with an atypical location of the appendix and girdle pain, purulent appendicitis can be mistaken for pancreatitis. Anamnesis, amylase activity in the blood and urine, ultrasound, and the dynamics of the process play a role in clarifying the diagnosis.

Casuistry is a purulent inflammation of the appendix that has entered the internal opening of the inguinal or femoral canal due to a hernia. Usually in such cases there are clinical signs strangulated hernia.

Purulent appendicitis often has to be distinguished from gynecological diseases. Inflammation of the uterine appendages is indicated by lower pain closer to midline, vaginal discharge. At vaginal examination They find smoothness of the vaults, pain when the cervix is ​​displaced, and a painful formation on the lateral surfaces of the uterus.

If the ectopic pregnancy signs predominate internal bleeding(pallor, increased heart rate, drop in blood pressure), fluid is detected in the sloping areas of the abdomen, appearing from the vagina spotting; changes in the external genitalia and mammary glands are evident, consistent with pregnancy.

When the pedicle of an ovarian cyst is torsed, the pain is often cramping; examination through the abdominal wall and vagina can identify the cyst. Perimeteritis, parametritis, and pelvioperitonitis can lead to an erroneous diagnosis. Ultrasound is of particular importance in the diagnosis of gynecological diseases.

Kidney stone disease, pyelitis, sometimes nephroptosis, cystitis, cause renal colic on the right, which differs in the nature of pain and temperature reaction. Colic is confirmed by urine analysis and ultrasound.

Clinical picture lobar pneumonia on the right when the pleura is involved in the process is often similar to purulent appendicitis, especially in people young Correct diagnosis is facilitated by physical data during examination of the lungs, high fever, X-ray results.

Serious consequences can occur when myocardial infarction is combined with purulent appendicitis.

Sometimes purulent appendicitis has to be differentiated from acute gastroenteritis, colitis, or gonorrheal funiculitis on the right.

Distinguish purulent appendicitis from typhoid fever Vidal reactions help and skin rash in the late period of the disease.

All diseases with which purulent appendicitis has to be differentiated can be divided into two groups. For patients of the first group, in any case, it is indicated emergency surgery. For diseases of the second group, emergency surgery is not indicated; it can worsen the patient's condition (myocardial infarction, pneumonia, etc.).

In the event of an erroneous diagnosis in the case of diseases of the first group, it is necessary to correctly resolve the issue of access during the operation (change, expand the incision made, sew it up, make a new one, etc.).

We must remember about the possibility of very rare purulent appendicitis on the left with situs viscerum inversus or with a very long mesentery of the cecum.

When antibiotics are used, the clinical manifestations of purulent appendicitis change significantly. Antibiotic use obscures initial manifestations disease, a blurred clinical picture leads to diagnostic errors.

Morphological changes (cellulitis, gangrene, perforation), different rates of development of these changes, characteristics of the body's reaction and a number of other circumstances determine the diversity of the clinical course of appendicitis. With typical purulent appendicitis pronounced signs develop 20-24 hours after the onset pain, although significant deviations are possible. Without timely surgery, a picture of local or widespread purulent peritonitis develops.

In erased forms, the manifestations of appendicitis are not clearly expressed, some signs (irritation of the peritoneum, changes in blood composition, increased body temperature) are absent, despite significant changes in the appendix itself (gangrene). This usually occurs in elderly people and those weakened by long-term general illness (tuberculosis, diabetes).

Purulent appendicitis in children is usually severe, with rapid developing symptoms. The rapid destruction of the appendix, weak body resistance, and reduced plastic properties of the peritoneum and omentum create conditions for the rapid course of the process, which in a short time leads to the development of purulent peritonitis. Fever, vomiting, nausea, and stool disorders are not significant when diagnosing appendicitis in children. Greater importance is attached to the tension of the abdominal wall and the discrepancy between temperature and heart rate.

A special case is purulent appendicitis in combination with pregnancy. Violation of the usual anatomical relationships of the gastrointestinal tract, upward displacement of the appendix, deterioration of blood supply and other changes contribute to the rapid destruction of the appendix and the development of widespread purulent peritonitis.

An appendiceal abscess is a consequence of destructive appendicitis, when local purulent peritonitis is delimited by fibrin adhesions. Another cause of an appendiceal abscess can be suppuration of the appendicular infiltrate, which complicates acute appendicitis in 1-3% of cases, more often becomes the result of a patient’s untimely contact with a doctor and much less often - the result of a diagnostic error at pre-hospital or stationary stage(Savelyev B.S. et al., 1986).

An appendicular abscess is most often localized in the iliac fossa, less often - retrocecally in the retroperitoneum and in the pelvis.

In the diagnosis of appendiceal infiltrate exclusively important role Anamnesis plays a role: if the appearance of a mass in the right iliac region was preceded by an attack of abdominal pain and the Volkovich-Kocher symptom characteristic of acute appendicitis, single vomiting and a moderate increase in body temperature, one can be confident in the diagnosis of appendiceal infiltrate.

The typical picture of appendiceal infiltrate develops, as a rule, 3-5 days after the onset of the disease. Abdominal pain that occurred in the first days of the disease almost completely subsides. The patient's health and general condition improve, but the body temperature remains low-grade. An objective examination of the abdomen does not reveal muscle tension or other symptoms of peritoneal irritation.

In the right iliac region, where the infiltrate is most often localized, one can palpate a rather dense, painless tumor-like formation of various sizes, sometimes it occupies the entire right iliac region. Symptoms of Rovsing and Sitkovsky are often positive. Leukocytosis is usually mild, with a neutrophil shift indicating inflammation.

Unlike a tumor of the cecum, which can also cause the formation of an infiltrate of this localization, with an appendiceal infiltrate the medical history is shorter, the pain is acute and accompanied by an increase in body temperature, and with a tumor of the ileocecal angle, a long history contains indications of a gradual increase in pain without a significant increase body temperature, and sometimes there are phenomena of partial intestinal obstruction, which is rarely observed with appendiceal infiltrate.

During dynamic observation of a patient with appendiceal infiltrate, a decrease in tumor formation is noted, but the tumor of the ileocecal angle does not decrease. The outcome of appendicular infiltrate can be either its complete resorption or abscess formation.

An appendicular abscess can break into the intestinal lumen, the free abdominal cavity, and out through the anterior abdominal wall. An appendicular abscess in the retroperitoneum can spread along the iliopsoas muscle to the anterior surface of the thigh. Appendiceal abscess is the result of appendiceal infiltration in 14-19% of cases and is most often located in the right iliac region, less often in the pouch of Douglas or retrocecally.

1, 2 — abscesses of the iliac fossa; 3 - pelvic abscess; 4 - retrocecal abscess

An abscess in the pouch of Douglas creates certain diagnostic difficulties: in women it has to be differentiated from purulent inflammation uterine appendages. With the retrocecal location of the appendix, the picture of retroperitoneal phlegmon of the iliac fossa, purulent psoitis, comes to the fore.

Retrocecal or retroperitoneal purulent appendicitis is atypical, when, with relatively weakly expressed local signs in the right iliac region, pronounced general phenomena of inflammation and intoxication develop. With this localization of the appendix, the retroperitoneal tissue is often affected. The clinical picture is dominated by signs of retroperitoneal phlegmon. Pylephlebitis may develop with the formation of multiple liver abscesses.

Ultrasound in some cases allows us to identify direct or indirect signs acute appendicitis: thickening of the walls, increase in the volume of the appendix, change in its shape. However, due to the topographic position, swelling of the cecum and ileum, the appendage cannot always be identified.

Infiltration of adjacent tissues, in particular the omentum, local effusion indirectly indicate an inflammatory process in the right iliac fossa, and the detection of pyosalpinx, cyst torsion, and rupture of the fallopian tube play a decisive role in the differential diagnosis. Ultrasound allows you to determine the limited accumulation of fluid in the area of ​​the appendix with a periappendiceal abscess, infiltrate, or abscess formation.

In the diagnosis of acute inflammatory diseases of the abdominal organs and peritonitis, laparoscopy is becoming increasingly important. The method was developed in detail by B.C. Savelyev, V.M. Buyanov, A.S. Balalykin (1977).

Indications for laparoscopy for acute surgical diseases:
. unclear clinical picture of the disease;
. the need for differential diagnosis of acute surgical diseases and acute diseases of the genitals, retroperitoneal organs and other diseases with an “acute abdomen”;
. clarification of the condition of the abdominal and peritoneal organs in the postoperative period;
. drainage of the abdominal cavity.

Laparoscopic signs of inflammation of the appendix depend on the stage of the disease. With catarrhal appendicitis, there is some thickening, swelling of the appendix, hyperemia of the serous layer, sometimes with hemorrhages. The peritoneal reaction is usually absent or mild.

With phlegmonous inflammation, the appendix looks swollen, it is purple, with sharply dilated vessels and fibrinous deposits. The peritoneum around the appendix is ​​swollen and hyperemic, with fibrin deposits. In the abdominal cavity around the appendix and in the pelvis there may be an accumulation of serous or purulent effusion.

At gangrenous appendicitis vermiform appendix of dark color, and its color changes to various areas depending on the depth of the lesion. There is a cloudy exudate around the appendix, which can spread throughout the entire abdominal cavity. The peritoneum is cloudy, swollen, with hemorrhages, and a gray fibrinous-purulent coating.

Perforated appendicitis is most often associated with phlegmonous or gangrenous changes in the appendix. Anatomical violations of the integrity of its wall are visually manifested in the form of a limited area of ​​necrosis.

Treatment

Early surgery for acute appendicitis gives good results. It should be the main measure to reduce mortality, but excessive and thoughtless enthusiasm for early surgery and overdiagnosis of acute appendicitis lead to the fact that appendectomy is performed when it is not necessary and, possibly, harmful.

On the pages of periodicals, surgical tactics for acute appendicitis were widely discussed. Sometimes, to confirm the diagnosis of acute appendicitis, a more or less long (1-3 hours, and sometimes more) observation is necessary. At this time, the surgeon studies the main clinical manifestations of the disease (increased pain, its movement to the right iliac region, increasing symptoms of muscle protection, increased leukocytosis, etc.) and is convinced of the diagnosis of acute appendicitis.

Experience shows that this is the only correct tactic for acute appendicitis, allowing to avoid the death of patients from peritonitis and unnecessary or even harmful surgery. Ultrasound and laparoscopy play an important role in the differential diagnosis of acute appendicitis.

Proper organization is of great importance in reducing mortality in acute appendicitis. emergency assistance and health education work among the population for early admission of patients to the hospital.

During late hospitalization, patients may be admitted with an already formed infiltrate, which is palpated in the right iliac region in the form of a limited, painful, dense and immobile formation of varying sizes. If the patient’s condition is satisfactory, the symptoms do not increase, wait-and-see with antibiotic therapy with broad-spectrum drugs is indicated; in the future, resorption therapy and physiotherapeutic treatment are used.

If the patient's condition worsens, he has a high fever, and symptoms of peritoneal irritation increase, i.e. If there are signs of abscess formation, then surgery is indicated. Pediatric surgeons advocate active tactics for appendiceal infiltrates, since due to the poor development of the omentum, delimitation of the process in the appendix in children is less reliable.

Appendectomy is the most common abdominal surgery, it accounts for 30-40% of all emergencies surgical interventions on the abdominal organs. In 60-70% of cases, appendectomies are performed for purulent appendicitis. Preparation of the patient for emergency surgery should be minimal and include measures to improve the general condition (if there are grounds for this).

Creating good wide access to the inflammatory focus is of great importance. The most rational, if you are confident in the diagnosis, is an oblique incision (Dyakonov-Volkovich) about 8-12 cm long. In doubtful cases, when it is not possible to confidently differentiate purulent appendicitis from other diseases that require emergency surgery for widespread peritonitis, it is better to make a median or pararectal incision .

The method of isolating the process is chosen depending on the circumstances (adhesions, retrocecal location, etc.). It is recommended to ligate the mesentery with absorbable thread and stitching. One should strive to peritonize the stump of the process, which is of particular importance during operations in conditions of incipient peritonitis.

The best method is considered to be ligation of the stump of the appendix with its immersion after lubrication with an iodine solution using a purse-string suture and subsequent application of a Z-shaped suture with a synthetic thread. Indications for drainage are the transition purulent process on retroperitoneal tissue, perforation of the appendix and purulent peritonitis. Tubular drainages are used, and if capillary bleeding is not stopped, tamponing is performed.

Changes in the process may be secondary. In these cases, it is always necessary to find the main cause of the inflammatory process (cholecystitis, perforated ulcer stomach, intestinal obstruction, terminal ileitis, inflammation of Meckel's diverticulum, uterine appendages, etc.), which requires either widening the incision or midline transection.

In 1982, K. Semm first performed appendectomy through a laparoscope and described it as an alternative to the surgical method.

In advanced forms of acute appendicitis with the clinical picture of a periappendiceal abscess or widespread purulent peritonitis, laparoscopic surgery is not advisable.

Local contraindications to laparoscopic appendectomy: late pregnancy; advanced widespread peritonitis; periappendicular abscess; pronounced adhesive process.

Surgical access to the appendiceal abscess is determined by its location. When the suppurating appendicular infiltrate is located in the right iliac region, when it is motionless, it is adjacent laterally with its lower edge to the wing ilium, a right-sided lateral extraperitoneal approach is used.

A skin incision about 10 cm long is made above and parallel to the right inguinal ligament in close proximity to the iliac crest and superior anterior iliac spine. The incision begins at the superior anterior iliac spine and ends at the level of the middle of the inguinal ligament. The skin, subcutaneous fat, fascia and fibers of the external oblique abdominal muscle are dissected. Along the fibers, the internal oblique and transverse muscles are bluntly separated.

The edematous preperitoneal fatty tissue adjacent to the incision is opened, which is peeled off along with the peritoneum medially and thus approaches the lateral side of the infiltrate. The swelling is determined by palpation and in this place, carefully, so as not to open the abdominal cavity and not damage the adjacent intestine, the peritoneum is spread with a blunt instrument or a finger and the abscess is opened. The hole is bluntly expanded, the pus is aspirated with an electric suction or the abscess cavity is dried with tampons.

Use your finger to examine the size and location of the abscess cavity. The vermiform appendix is ​​removed only when it is accessible. In all other cases, one should not strive to remove it due to the danger of pus penetrating into the free abdominal cavity, damaging the inflamed infiltrated intestinal wall, which is included in the infiltrate and forms the abscess wall.

The abscess cavity is drained with a tube wrapped in a gauze swab, or a cigar-shaped drainage is used (gauze swab wrapped in glove rubber). The insertion of a conventional tube is fraught with the risk of developing a bedsore in the wall of the inflammatory cecum. After 5-7 days the drainage is changed, by this time the wound channel has already been formed. If the cavity is drained with a cigar-shaped drainage, then only gauze swabs are changed; new swabs are inserted through a channel formed by a rubber glove sleeve.

With an appendiceal abscess located closer to the midline, when its center is projected at McBurney's point or more medially and when palpating the anterior abdominal wall it is possible to pass the hand between the lateral edge of the infiltrate and the wing of the ilium and the inguinal ligament, extraperitoneal lateral access cannot be used. A typical Volkovich-Mc-Burney oblique incision is used.

Quite often, the internal oblique and transverse abdominal muscles are infiltrated. They are moved apart along the fibers, and then the transverse abdominal fascia is separated. The swelling should be determined by palpation and the abscess should be carefully opened using a blunt method (preferably with a finger). Its cavity is drained, examined with a finger and drained.

If the abscess is located retrocecally, a lateral extraperitoneal approach is used, the abscess cavity is drained and drained. In case of a large cavity, it is advisable to apply contrapertures in the lumbar region at the lowest point of the abscess. To do this, with the end of a forceps inserted into the cavity of the abscess, soft tissues in the lumbar region are protruded, the skin is dissected, and the muscles are moved apart with the forceps. A drainage tube with several side holes is grabbed with a forceps and inserted into the cavity of the abscess. The tube is fixed to the skin of the lumbar region with one suture.

The course of the postoperative period is determined by the general condition and age of the patient, the severity of purulent intoxication, complications, pathomorphological changes in the appendix, etc. After surgery, it is necessary to prevent possible complications and combat those that have already arisen, to activate the immunobiological forces of the body and suppress the activity of microflora.

The fight against intoxication and normalization of the functions of the patient’s organs and systems are of great importance for recovery. The state of the cardiovascular and central nervous systems, gastrointestinal tract, liver function, kidneys require special attention. The patient's condition in the first 3-5 days after surgery is usually of decisive importance.

Active management of the patient within reasonable limits is indicated during an uncomplicated postoperative period. If the course is smooth and the surgical wound heals by primary intention, the patient is discharged on the 7-8th day, the period of incapacity for work is a total of 25-30 days.

Misdiagnosis and other circumstances that prevent timely appendectomy often lead to the development of purulent peritonitis. If there is a tendency to limit the process, an infiltrate forms in the right iliac region, which can subsequently gradually resolve or turn into an abscess. In such cases, complications such as intestinal obstruction, fecal fistulas, and intestinal bleeding are possible.

In the postoperative period, bleeding from the vessels of the mesentery, wound suppuration, pneumonia, intestinal obstruction, fistulas, thrombophlebitis, pyelonephritis, abscess of the pouch of Douglas, interintestinal, subdiaphragmatic abscess cannot be excluded.

Complications with destructive forms of appendicitis occur in 10-25% of cases. Careful monitoring of the patient from the first hours after surgery is of great importance for treatment and prevention of complications.

With timely recognition and surgical treatment, the prognosis for purulent appendicitis is favorable. The outcome of the disease during surgical treatment of advanced forms, especially complicated by widespread purulent peritonitis, is questionable.

Pelvic abscesses (abscesses of the rectouterine cavity) occur in 0.03-1.5% of patients who have undergone appendectomy. They are localized in the lowest part of the abdominal cavity: in men in excavatio retrovesicalis, and in women in excavatio retrouterina. The occurrence of ulcers is associated with poor sanitation of the abdominal cavity during treatment, inadequate pelvic cavity, and the presence in the small pelvis of an infiltrate prone to abscess formation when the appendix is ​​located in the pelvis.

Clinical picture of pelvic abscesses after appendectomy. An abscess of the rectal uterine cavity forms within 6 to 30 days after appendectomy. It is characterized by the presence of two groups of symptoms: general and local. General symptoms are accompanied by hectic temperature, weakness, and sweating.

Local symptoms include pain in lower sections abdomen, behind the womb, dysfunction pelvic organs(dysuric disorders, tenesmus, mucus discharge from the rectum).

Diagnosis of pelvic abscesses after appendectomy. Leukocytosis, a shift in the leukocyte blood count to the left, toxic granularity of neutrophils, and an increased ESR testify in favor of a purulent-inflammatory process in the abdominal cavity.

Per rectum they find a decrease in sphincter tone, which is associated with toxic damage to the p. pelvicum; soreness of the anterior wall of the rectum, its overhang. With long-standing abscesses, a painful infiltrate along the anterior wall of the intestine with areas of softening is palpated.

Per vaginal pain in the posterior fornix and intense pain when the cervix is ​​displaced are noted. To clarify the diagnosis, a diagnostic puncture is also used. Puncture of the suspected abscess in women is performed through the posterior vaginal fornix, and in men and children - through the anterior wall of the rectum.

Treatment of pelvic abscesses after appendectomy. After obtaining pus during puncture, a posterior colpotomy is performed in women, and in men and children the abscess is opened using a needle. A drainage tube is inserted into the abscess cavity for 2-3 days.

A pelvic abscess that is not diagnosed in time is complicated by a breakthrough: a) into the free abdominal cavity with the development of peritonitis; b) into adjacent hollow organs (urinary bladder, rectum and cecum, fallopian tube).

The article was prepared and edited by: surgeon

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Intestinal fistulas can also be caused by gauze tampons and drainage tubes that have been in the abdominal cavity for a long time, which can cause a bedsore of the intestinal wall. The method of processing the stump of the choroid and its covering under conditions of SC infiltration are also of great importance. When the appendix stump is immersed in the inflammatory infiltrated wall of the appendix by applying purse-string sutures, there is a danger of the occurrence of NK, failure of the appendix stump and the formation of an intestinal fistula.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

With appendicular peritonitis late dates Upon admission, even a wide median laparotomy under anesthesia with revision and radical treatment of all parts of the abdominal cavity with the participation of experienced surgeons cannot prevent the development of postoperative complications.

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

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

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

An appendicular abscess occurs as a result of inflammatory processes in the area of ​​the appendix in the preoperative or postoperative period, due to suppuration of the appendiceal infiltrate. In the preoperative period, the appendicular infiltrate is formed by the appendix itself, the omentum and nearby intestinal loops, which limit the inflammatory process from spreading throughout the entire abdominal cavity. In the postoperative period, when the appendix is ​​removed, but the inflammatory process in the area of ​​the appendix bed persists, the formation of postoperative infiltrate, which also consists of the omentum and nearby intestinal loops. The appendiceal infiltrate may disappear under the influence of the therapy, or in unfavorable cases it suppurates and an appendiceal abscess forms.

Clinic and diagnostics. When the appendiceal infiltrate passes into an appendiceal abscess, the patient's condition worsens. Almost constant pain appears in the right iliac region. The child begins to have a high fever. Temperature ranges are especially characteristic: in the morning there is a slight increase in temperature, and in the evening it rises to 39-40 °C. Sweating occurs, toxicosis increases, and appetite worsens. Vomiting may occur, especially when larger areas of the peritoneum are involved in the inflammatory process and the pattern of intestinal obstruction increases.

The right half of the abdominal wall lags behind when breathing. If the abscess is close to the anterior abdominal wall, swelling and local hyperemia of the skin are possible. In advanced cases, fluctuation is determined. The pain also spreads to areas of the abdominal cavity adjacent to the abscess. However, there are no symptoms of peritoneal irritation distant from the abscess.

Upon palpation, a sharply painful tumor-like formation is determined in the right iliac region. If the abscess is located deep in the infiltrate, then a dense and painful formation is palpated, and if the abscess is large, then an elastic, painful formation is determined.

Due to the inflammatory process, the difference between the temperature measured in armpit and in the rectum, more than 1 °C. Local temperature increases are also determined using a thermal imager.

Examination through the rectum may not give signs characteristic of an abscess or appendiceal infiltrate, especially if the abscess is located high and a finger inserted into the rectum does not reach it.

X-ray examination also does not provide absolute signs of the presence of an abscess or appendiceal infiltrate. However, with a survey radiography performed in vertical position patient, one can note the presence homogeneous darkening in the right iliac region with a slight displacement of intestinal loops to the midline. In advanced cases, a level of fluid may appear in the area of ​​the abscess. Fluid levels appear in the intestinal loops if the abscess has led to intestinal obstruction.

Abscess formation is characterized by a change in the blood picture. A shift in the white blood count to the left, an increase in the number of leukocytes with an increase in the percentage of band neutrophils are noted. ESR is usually increased.

Treatment Appendiceal abscess is usually surgical. An operation is performed to open and drain the abscess. The operation is almost always performed under general anesthesia. If technical difficulties arise, the appendix is ​​not removed immediately. In the postoperative period, drainages and tampons are carefully looked after. Drains are systematically washed 2-3 times a day with solutions containing antibiotics. Tampons begin to be tightened on the 3-4th day and are completely removed as soon as they become slimy - on the 5-7th day. After removing the tampons, the catheters are left in place for another 2-3 days, until the pus is separated from the wound. If appendectomy is not performed, then it is performed 2-3 months after the inflammatory process has subsided.