One of the most dangerous stages of inflammation of the appendix is appendicitis abscess.In this course of the disease the amount contained in the appendix of pus becomes so large that the appendix covered with purulent plaque rupture and can complicate life-threatening conditions such as peritonitis or sepsis. Content
When abscess form of appendicitis serosa and mesentery of the appendix becomes red and becomes edematous.Its mucosa and edematous, and friable, while phlegmonous appendicitis, ulcers form on its surface observed erosion and ulceration.
Appendix thickened and its surface covered with fibrin coating, which can spread to nearby tissues of the peritoneum, the cecum and small intestine.The appendiceal lumen is purulent fluid contents green
In some cases, the patient is formed empyema appendix .With such a variety of abscess appendicitis lumen occluded by scar tissue or fecal stones.Appendix dramatically tense because of swelling, and it is determined by the oscillatory motion of a fluid (fluctuation).Moreover, its serosa changes both in the catarrhal stage of appendicitis: it becomes reddened, dull, but there is no fibrin coating.
from the lumen of the appendix into the abdominal cavity may bleed sterile effusion serous nature, and when it is poured out of the opening of a large number of purulent liquid with a pungent odor and smelly.When empyema appendix inflammation rarely extends to the peritoneum and the surrounding tissue.
Development abscess appendicitis usually begins a few hours after catarrhal, and it may be suspected to increase the intensity of abdominal pain.First, attack the patient may not always clearly indicate the location of the pain, but eventually pain concentrated in the right part of the abdomen.In a typical arrangement of the appendix pain concentrated in the right iliac region, and atypical - in the right upper quadrant, suprapubic, pelvic or lower back.She felt sick all the time, can wear a pulsating character and strengthened by sneezing, coughing or laughing.The intensity of pain is constantly growing, and the patient is forced to take a forced situation for their ease - lying on his right side with legs bent at the knee and hip joints of the feet.
also phlegmonous appendicitis when the patient is showing signs of severe intoxication and disorders of the digestive system:
In general blood test revealed leukocytosis 12-20 × 109 / L-shift leukocyte formula to the left.
When inspection and palpation of the abdomen of the patient revealed the following symptoms:
also saved catarrhal symptoms of appendicitis:
peculiar signs of appendicitis abscess can occur in children, pregnant women, patients with atypical location of the appendix, and the elderly.In pregnant women the pain can be felt above the iliac region, and with the feeling of the abdomen characteristic symptoms will be less severe.With the development of abscess appendicitis in young children the clinical picture is accompanied by general symptoms that are characteristic of many childhood infectious diseases: moodiness, lethargy, poor appetite, vomiting, restlessness, diarrhea and febrile.Elderly patients symptoms are not erased and can be accompanied by fever.
When untimely abscess appendicitis surgery can be complicated by a number of severe complications:
In identifying appendicitis abscess shows immediate implementation of surgery to remove the appendix (appendectomy).The appearance of the characteristic symptoms of appendicitis is always a must occasion to call an ambulance.Call the doctor should be, even if the patient is temporarily subsided severe pain, t. To. A sign may indicate the transition of the disease into a more serious stage.Before medical examination is necessary to observe the following rules:
appendectomy is done under general anesthesia.As a rule, preference is given to implementation of endotracheal anesthesia, which not only provides the necessary conditions for the surgeon to perform any manipulation without limiting its movements and, if necessary, allows a wide revision abdomen.If contraindications to this type of anesthesia is possible to conduct operations after local anesthesia.
when phlegmonous appendicitis Appendectomy can be performed by traditional or laparoscopic.Laparoscopic surgery is indicated in the absence of propagation of the inflammatory process in the wall of the cecum.
Laparoscopic appendectomy when phlegmonous inflammation may be performed in the following cases:
also a contraindication for this technique of minimally invasive appendectomy may be the following factors: obesity, increased bleeding, the third trimester of pregnancy, an atypical location of the appendix and transferred before surgeryintervention.
The operation is performed under general anesthesia.After the abdominal wall three small puncture in length from 5 to 10 cm (one of them is located at the navel) is injected into the abdominal cavity laparoscopic instruments and a video camera with which removes the appendix.
Performing this type of appendectomy has many advantages: the patient feels less intense pain after surgery, bowel function is restored more quickly, provided the cosmetic effect and time of hospital stay is reduced.
operation is performed using the variable oblique access to the right iliac fossa.The length of the skin incision with conventional appendectomy is about 10-12 cm. After treatment of the surgical field, for lining material and its sterile dissection of the skin and subcutaneous fat the surgeon performs stop bleeding and is carried out using a scalpel and a surgical scissors sectional oblique muscle fascia.Next in the upper corner of the operative wound incised along the external oblique muscle fibers.When the surgeon pushes the notched section perimysium using blunt hooks and lateral oblique muscle, exposing the peritoneum.
Operational field again draped with sterile gauze.The surgeon gently lifts the peritoneum with forceps and performs its dissection scissors.Use the cotton swab gauze wound osushivaetsya.Part of the gauze is analyzed effusion of the abdominal cavity for sowing to identify the bacterial flora.
After penetration into the abdominal cavity of the surgeon finds the cecum and extracts it into the wound.If this part of the intestine is fixed spikes, they are carefully dissected.However, if the process of allocation of the cecum prevent loops of the small intestine, their medial zone is removed and treated iliac fossa and the lateral canal.
Typically, the appendix is located on the dome of the cecum and easily displayed in the surgical field along with the cecum.At its distal fixation in deeper layers it does not appear in the section of the operating surgeon and for this you need to spend at its base a narrow strip of wet gauze or thick ligature and lower dome cecum into the abdominal cavity.
Stretching outstretched ribbon, operating can see the seam that interfere with the removal of the appendix in the operating field, and cut them.If after these manipulations doctor can not withdraw the appendix in the wound, it begins to conduct retrograde technique appenektomii.
If successful breeding of the appendix in the wound with the help of clamping is performed overlaying the ligature on the mesentery of the appendix.The thread is tied off so that the artery was tied necessarily appendix.If mesentery too swollen or friable, then the overlaying ligatures its pre-sewn to prevent the slipping of the thread.
After ligation cut from the mesentery of the appendix in its entirety.Next, the surgeon using the clip clamps the appendix at its base and ties his thin thread absorbable (catgut, vikrilom or others.).Stepping 1-1.5 cm from the base of the appendix, the doctor performs a sero-muscular circumferential weld using synthetic yarns and atraumatic needle.
At a distance of 0.3-0.5 cm from suture clamp is applied, and the appendix is cut off.The resulting stump is treated with 5% solution of iodine, an assistant surgeon grasps her anatomical forceps and leads into a circular seam, which is delayed by the surgeon.FIELD circular seam again sutured Z-stitch using atraumatic needle and synthetic yarns.After the closure of the dome of the cecum is returned to the abdominal cavity and reduce a her.
surgeon completely dries the abdominal cavity from vypotevshego exudate and performs control of stopping the bleeding.To do this, the abdominal cavity is lowered gauze strip, and in the absence of traces of blood performed suturing the peritoneum.Next, to remove residual tissue infected blood effusion and surgical wound was washed with sterile saline.With the imposition of 2-3 or more separate stitches sutured oblique and transverse muscles.Next, using synthetic or silk sutured aponeurosis of the external oblique muscle.For the closure of the subcutaneous fat with fine sutures, and the skin - some silk sutures.
If unable to free allocation of the appendix in the operating wound surgeons use a technique of retrograde appendectomy.At the first stage the incision carefully draped with sterile cloths and administered under the base of the appendix narrow webbing wet gauze.On the basis of appendix impose two clips and the appendix is cut off between the two.The edges of the cuts on both sides is treated with 5% solution of iodine.Appendix stump and tie up as well as at a typical appendectomy introduced it in the circular seal and additionally sutured Z-shaped seam silk thread and atraumatic needle.
After reduction and closure of the stump dome cecum reduce a into the abdominal cavity and proceed to other manipulation: in the mesentery gradually applied clamps, cut off from her appendix and dissected it.Pinching jaws of the mesentery bandage and stitch.Next, an operation is conducted in the same manner as in the typical appendectomy.
This is the most difficult method to remove the appendix is used in the location of the appendix in the retroperitoneal space.In identifying such misplaced surgeon expands the field of surgical approach using a maximum internal dilution of the transverse and oblique muscles of the vagina and the notched section on the edge of the rectus muscle.Next, you hold lace gauze under the base of the appendix and the mobilization of the dome of the cecum.
In parallel, the dissection of parietal peritoneum lateral canal.Next, the surgeon removes the cecum to the middle of the abdominal cavity and penetrates pozadislepokishechnuyu fiber to isolate the rest of the appendiceal artery and its detection.After the final selection of the appendix of his artery ligated and perform excision of the appendix.Thereafter, the surgeon places a continuous seam dissected parietal peritoneum and ends the operation in the same way as a traditional appendectomy.
main feature appendectomy when phlegmonous appendicitis is the possible detection of effusion in the right iliac fossa, which is formed as a result of inflammation of the appendix serous cover.In identifying this process, the doctor performs surgery during the sampling of fluid for analysis of flora and carefully osushivaet iliac fossa, pelvic cavity and right side channel.If you notice cloudy exudate puruloid nature lead to the patient parenterally antibacterial drugs.
If the surgeon is confident careful and total removal of the inflamed appendix, phlegmonous, and no significant exudate, it can take a decision on the deep wound closure.In the presence of abdominal turbid effusions physician establishes drain the abdominal cavity and leave it for 3-4 days for administration of antibiotics postoperatively.
When phlegmonous appendicitis complicated by perforation, appendectomy is performed with the broad access to the surgical field, which facilitates complete removal of pathological tissues and sanitation of the abdominal cavity.For this nizhnesredinnoy autopsy performed abdominal surgery and after completion of a compulsory drainage (depending on the severity of the disease can be installed one or two drainage).
After the appendectomy patient is shown to comply with gentle treatment for a month, and heavy physical exertion contraindicated for 3 months.Get out of bed and walk after uncomplicated appendicitis abscess is allowed after 6-8 hours after surgery.The main criterion for the possibility of such action is the complete restoration of consciousness, respiratory depression after general anesthesia.In complicated appendicitis and complicated surgery, the doctor allows the patient to get out of bed after the normalization of the general condition and physical activity had expanded gradually (movement with hands and feet on the bed, turning over on his side, trying to sit with support, and so on. N.).All patients who underwent appendectomy, recommended exercises breathing exercises and physical therapy (their intensity as determined by your doctor).
To prevent constipation after removing the abscess appendicitis in the postoperative period and for 2-4 weeks after discharge is recommended diet.The diet may include only certain products of the doctor.In the first two days, as a rule, allowed to eat cereal or liquid vegetable puree and broth to drink low-fat, low-fat yogurt or pudding.
Eating should be carried out in small portions, better 5-6 times a day.On the third day, the menu can be turned on black bread and a small amount of butter.On the fourth day, in the absence of contraindications, normalization of stool and good overall health, the patient is allowed a regular diet with exception of spicy, fatty, marinated, fried, smoked and solid food.It is also necessary to exclude from the diet of strong tea and coffee, sodas and pastries from the pastry.After cooking by baking or cooking food should be liquid, mushy and soft.
In the first days after surgery for stomach banding may apply special post-surgical bandages.As a rule, we recommend the wearing of patients with a high risk of the formation of post-operative hernias.
Dressings postoperative wound daily.This applies antiseptics and the estimate of the healing process.If the patient was introduced into the abdominal cavity drainage, then it can be administered antibiotics.In uncomplicated postoperative wound healing stitches applied to the skin, are removed on day 7 or 8 (if used for sewing absorbable sutures - the joints can not be removed).
postoperatively to prevent suppurative complications patients received antibacterials.