Bleeding in the neck after appendicitis surgery symptoms. Early adhesive intestinal obstruction. Common Complications of Appendicitis

The inflammatory process in the process of the appendix leads to a common disease of the abdominal cavity - appendicitis. Its symptoms are soreness in the abdominal region, fever and disorders of the digestive function.

The only correct treatment in case of an attack of acute appendicitis is an appendectomy - surgical removal of the appendix. If this is not done, severe complications can develop, leading to death. What threatens untreated appendicitis - our article is just about that.

Preoperative consequences

The inflammatory process develops at different speeds and symptoms.

In some cases, it goes into and may not manifest itself for a long time.

Sometimes between the first signs of the disease before the onset of a critical condition, 6-8 hours pass, so you should not hesitate in any case.

For any pain of unknown origin, especially against the background of fever, nausea and vomiting, you should definitely seek medical help, otherwise the consequences can be the most unpredictable.

Common complications of appendicitis:

• Perforation of the walls of the appendix. The most common complication. In this case, ruptures of the walls of the appendix are observed, and its contents enter the abdominal cavity and lead to the development of sepsis of the internal organs. Depending on the duration of the course and the type of pathology, severe infection can occur, even death. Such conditions account for approximately 8-10% of the total number of patients diagnosed with appendicitis. With purulent peritonitis, the risk of death increases, as well as exacerbation of concomitant symptoms. Purulent peritonitis, according to statistics, occurs in approximately 1% of patients.
• appendicular infiltrate. Occurs when adhesions of the walls of nearby organs. The frequency of occurrence is approximately 3 - 5% of cases of clinical practice. It develops approximately on the third - fifth day after the onset of the disease. The beginning of the acute period is characterized by a pain syndrome of indistinct localization. Over time, the intensity of pain decreases, the contours of the inflamed area are felt in the abdominal cavity. The inflamed infiltrate acquires more pronounced boundaries and a dense structure, the tone of the muscles located near it slightly increases. After about 1.5 - 2 weeks, the tumor resolves, abdominal pain subsides, general inflammatory symptoms decrease (fever and blood biochemical parameters return to normal). In some cases, the inflammatory area can cause the development of an abscess.
• . It develops against the background of suppuration of the appendicular infiltrate or after surgery with previously diagnosed peritonitis. Usually the development of the disease occurs on the 8th - 12th day. All abscesses must be opened and sanitized. Drainage is performed to improve the outflow of pus from the wound. Antibacterial therapy is widely used in the treatment of abscess.

The presence of such complications is an indication for urgent surgery. The rehabilitation period also takes a lot of time and an additional course of drug treatment.

Complications after removal of appendicitis

Surgery, even if performed before the onset of severe symptoms, can also lead to complications. Most of them are the cause of death in patients, so any alarming symptoms should alert.

Common complications after surgery:

• . Very often occur after the removal of the appendix. Characterized by the appearance of pulling pains and tangible discomfort. Adhesions are very difficult to diagnose, because they are not seen by modern ultrasound and X-ray devices. Treatment usually consists of absorbable drugs and laparoscopic removal.
• . Quite often appears after surgery. It manifests itself as a prolapse of a fragment of the intestine into the lumen between the muscle fibers. It usually appears when the recommendations of the attending physician are not followed, or after physical exertion. It visually manifests itself as a swelling in the area of ​​​​the surgical suture, which over time can significantly increase in size. Treatment is usually surgical, consisting of suturing, truncation, or complete removal of the intestine and omentum.

Photo of a hernia after appendicitis

• postoperative abscess. Most often manifested after peritonitis, can lead to infection of the whole organism. Antibiotics are used in the treatment, as well as physiotherapy procedures.
• . Fortunately, these are quite rare consequences of an appendectomy operation. The inflammatory process extends to the region of the portal vein, the mesenteric process and the mesenteric vein. Accompanied by high fever, acute pain in the abdominal cavity and severe liver damage. After the acute stage, it occurs, and, as a result, death. Treatment of this ailment is very difficult and usually involves the introduction of antibacterial agents directly into the portal vein system.
• . In rare cases (in about 0.2 - 0.8% of patients), the removal of the appendix provokes the appearance of intestinal fistulas. They form a kind of "tunnel" between the intestinal cavity and the surface of the skin, in other cases - the walls of internal organs. The reasons for the appearance of fistulas are poor sanitation of purulent appendicitis, gross errors of the doctor during the operation, as well as inflammation of the surrounding tissues during drainage of internal wounds and abscess foci. Intestinal fistulas are very difficult to treat, sometimes resection of the affected area or removal of the upper layer of the epithelium is required.

The occurrence of this or that complication is also facilitated by ignoring the recommendations of the doctor, non-compliance with the rules of hygiene after surgery and violation of the regimen. If the deterioration occurred on the fifth or sixth day after the removal of the appendix, most likely, we are talking about pathological processes in the internal organs.

In addition, in the postoperative period, other conditions may occur that require a doctor's consultation. They can be evidence of various ailments, and also not related to the operation at all, but serve as a sign of a completely different disease.

Temperature

An increase in body temperature after surgery can be an indicator of various complications. The inflammatory process, the source of which was in the appendix, can easily spread to other organs, which causes additional problems.

Most often, inflammation of the appendages is observed, which can make it difficult to determine the exact cause. Often the symptoms of acute appendicitis can be confused with such ailments, therefore, before the operation (if it is not urgent), a gynecologist's examination and an ultrasound examination of the pelvic organs are required.

An elevated temperature can also be a symptom of an abscess or other diseases of the internal organs. If the temperature has risen after an appendectomy, an additional examination and laboratory tests are necessary.

Diarrhea and constipation

Digestive disorders can be considered as the main symptoms and as consequences of appendicitis. Often the functions of the gastrointestinal tract are disturbed after surgery.

During this period, constipation is the worst tolerated, because the patient is forbidden to push and strain. This can lead to divergence of the seams, protrusion of the hernia and other consequences. For the prevention of digestive disorders, it is necessary to adhere to strict and prevent stool fixation.

Stomach ache

This symptom can also have a different origin. Usually, pain sensations appear for some time after the operation, but completely disappear for three to four weeks. Usually, this is how much the tissues will need for regeneration.

In some cases, abdominal pain may indicate the formation of adhesions, hernia, and other consequences of appendicitis. In any case, the best solution would be to see a doctor, and not try to get rid of uncomfortable sensations with painkillers.

Appendicitis is a common pathology requiring surgical intervention. The inflammatory process that occurs in the process of the caecum can easily spread to other organs, lead to the formation of adhesions and abscesses, and also give many more serious consequences.

To prevent this from happening, it is important to seek help from the hospital in a timely manner, and also not to ignore the alarm signals that may indicate the development of the disease. What is dangerous appendicitis, and what complications it can lead to, is described in this article.

Despite great progress in the diagnosis and surgical treatment of appendicitis, this problem still does not fully satisfy surgeons. A high percentage of diagnostic errors (15-44.5%), stable, non-decreasing mortality rates (0.2-0.3%) in case of massive disease with acute appendicitis confirm the above [V.I. Kolesov, 1972; V.S. Mayat, 1976; YUL. Kulikov, 1980; V.N. Butsenko et al., 1983]

Mortality after appendectomy, due to diagnostic errors and loss of time, is 5.9% [I.L. Rotkov, 1988]. 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 and others]. The cause of complications is usually destructive forms of inflammation of the HO, 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 of medical workers, diagnostic errors due to the presence of atypical, difficult to diagnose forms of the disease, which is often found in elderly and senile people, in whom morphological and functional changes in various organs and systems worsen the severity of the disease, and sometimes come to the fore, masking the patient's acute appendicitis. Most patients cannot accurately name the onset of the disease, since at first they did not pay attention to mild persistent pain in the abdomen.
2. Delay of surgical intervention in the hospital due to errors in diagnosis, patient refusal or organizational issues.
3. Inaccurate assessment of the prevalence of the process during the operation, as a result, insufficient sanitation of the abdominal cavity, violation of the rules of drainage, lack of comprehensive treatment in the postoperative period.

Unfortunately, late admission of patients with this pathology to the hospital is not yet a rarity. In addition, no matter how annoying it is to admit, a large proportion of patients hospitalized and operated on late is the result of diagnostic and tactical errors of doctors in the polyclinic network, emergency care, and, finally, surgical departments.

Overdiagnosis of acute appendicitis by doctors of the prehospital stage is fully justified, since it is dictated by the specifics of their work: the short duration of observation of patients, the absence of additional examination methods in most cases.

Naturally, such errors reflect the well-known alertness of doctors in the pre-hospital network 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 polyclinic amount to 0.9%, due to the fault of ambulance doctors - 0.7% in relation to all those operated on for 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.

Often, diagnostic errors are observed in the differentiation of food poisoning, infectious diseases and acute appendicitis. Careful examination of patients, monitoring the dynamics of the disease, consultation with an infectious disease specialist, 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 pains in the abdomen, characteristic of perforation of gastroduodenal ulcers, are compared with pain from a dagger strike, they are called sudden, sharp, excruciating. Sometimes such pain can also be with perforated appendicitis, when patients often ask for urgent help, they can only move while bending over, the slightest movement causes increased pain in the abdomen.

It can also be misleading that sometimes, before perforation of the AO, the pain subsides in some patients and the general condition improves for a certain period. In such cases, the surgeon sees a patient in front of him who has had a catastrophe in the abdomen, but diffuse pain throughout the abdomen, tension in the muscles of the abdominal wall, a pronounced Blumberg-Shchetkin symptom - all this does not allow identifying the source of the catastrophe and making a confident diagnosis. But this does not mean that it is impossible to establish an accurate diagnosis. Studying the anamnesis of the disease, determining the characteristics of the initial period, identifying the nature of the acute pains that have arisen, their localization and prevalence, allows us to more confidently differentiate the process.

First of all, in the event of an abdominal catastrophe, it is necessary to check for the presence of hepatic dullness both percussion and radiographically. An additional determination of free fluid in sloping areas of the abdomen, a digital examination of the PC will help the doctor establish the correct diagnosis. In all cases, when examining a patient who has severe pain in the abdomen, tension of the abdominal wall and other symptoms indicating the sharpest irritation of the peritoneum, along with perforation of the 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 due to both the variety of clinical forms of acute appendicitis, the pathological process in the HO, and the mistakes of surgeons of the organizational, diagnostic, tactical and technical plan. The frequency of complications leading to LC in acute appendicitis is 0.23-0.55% [P.A. Aleksandrovich, 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%.

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

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

True postoperative peritonitis, which is not a consequence of purulent-destructive changes in the AO, usually develops as a result of tactical and technical errors made by surgeons. In this case, the insolvency of the fossa stump leads to the occurrence of postoperative peritonitis; through piercing 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 HO in the abdominal cavity, etc.

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

After appendectomy for complicated appendicitis, 0.35-0.8% of patients may develop intestinal fistulas [K.T. Ovnatanyan 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 region of the ileocecal angle, in which the walls of the organs are infiltrated and easily injured. Especially dangerous is the forcible division of the appendicular infiltrate, as well as the removal of the appendix when an abscess has formed.

The cause of intestinal fistulas can also be gauze swabs and drainage tubes that have been in the abdominal cavity for a long time, which can cause a decubitus of the intestinal wall. Of great importance is the method of processing the stump of the HO, its shelter in conditions of infiltration of the SC. When the stump of the appendix is ​​immersed in the inflammatory infiltrated wall of the SC by applying purse-string sutures, there is a risk of NK, insolvency of the appendix stump and the formation of an intestinal fistula.

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

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

Of particular importance is the decrease in blood pressure during surgery. Against this background, VC from transected and bluntly divided 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 unrecognized during surgery or postoperative VC [N.M. Zabolotsky and A.M. Semko, 1988]. This is most often observed in cases where the diagnosis of acute appendicitis in ovarian apoplexy in girls is made and an appendectomy is performed, and a small VC and its source go unnoticed. In the future, after such operations, severe VC may occur.

The so-called congenital and acquired hemorrhagic diatheses — hemophilia, Werlhof's disease, long-term jaundice, etc. — are of great danger in terms of the occurrence of postoperative VC. Unrecognized 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].

VC after appendectomy is very dangerous for the patient. The reasons for the complications 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 not uncommon. The reason in most cases - technical errors. The specific gravity of the VC after appendectomy is 0.02-0.07% [V.P. Radushkevich, I.M. Kudinov, 1967]. Some authors give even higher figures - 0.2%. Hundredths of a percent seem to be a very small amount, however, given the large number of appendectomies performed, this circumstance should seriously worry surgeons.

VC often arise from the artery of the PR due to slipping of the ligature from the stump of his 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 bandaged piecemeal. Particularly significant difficulties in stopping bleeding arise when it is necessary to remove the CHO retrogradely. The process is mobilized in stages [I.F. Mazurin et al., 1975; YES. Dorogan et al., 1982].

Quite often there are VC 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 make a thorough check of hemostasis, to stop bleeding by capturing bleeding areas with hemostatic clamps, followed by stitching and dressing. Measures for the prevention of VC from the stump of the CJ are reliable bandaging of the stump, its immersion in a purse-string and Z-shaped sutures.

VC was also noted from deserized areas of the large and small intestines [D.A. Dorogan et al., 1982; AL. Gavura et al., 1985]. In all cases of bowel deserosis, peritonization of this area is necessary. This is a reliable measure to prevent such a complication. If, due to infiltration of the intestinal wall, seromuscular sutures cannot be applied, the deserotic area should be peritonized by suturing a flap of the omentum on the leg. Sometimes VC arises from a puncture of the abdominal wall made to introduce a drain, so after passing it through the counter-opening, it is necessary to make sure 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. These points, unfortunately, 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, VC 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: an extensive adhesive process, the wrong choice of anesthesia method, insufficient operative access, which complicates manipulations and increases technical difficulties, and sometimes even creates them.
Experience shows VC occur more often after operations performed at night [I.G. Zakishansky, I.L. Strugatsky, 1975 and others]. The explanation for this is that at night the surgeon is not always able to take advantage of the advice or help of an older comrade in difficult situations, as well as the fact that the surgeon's attention decreases at night.

VC may result from the melting of infected thrombi in the mesenteric vessels of the HO or vascular erosion [AI. Lenyushkin et al., 1964], with congenital or acquired hemorrhagic diathesis, but the main cause of VC should be considered defects in surgical equipment. This is evidenced by the identified errors in RL: relaxation or slipping of the ligature from the stump of the mesentery of the process, unligated, dissected vessels in adhesive tissues, poor hemostasis in the area of ​​the main wound of the abdominal wall.

VC can also occur from the wound channel of the counter-opening. With technically complex appendectomies, VC can arise from damaged vessels of the retroperitoneal tissue and the mesentery of the TC.

Non-intense VC often spontaneously stop. Anemia can develop after a few days, and often in these cases, due to the addition of an infection, peritonitis develops. If infection does not occur, then the blood remaining in the abdominal cavity, gradually organizing, gives rise to an adhesive process.
To prevent the occurrence of bleeding after appendectomy, it is necessary to follow a number of principles, the main of which are thorough anesthesia during the operation, ensuring free access, respect for tissues and good hemostasis.

Light bleeding is usually observed from small vessels that are damaged during separation of adhesions, isolation of the HO, with its retrocecal and retroperitoneal location, mobilization of the right flank of the large intestine, and in a number of other situations. These bleedings are the most secretive, hemodynamic and hematological parameters usually do not change significantly, therefore, in the early stages, 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% [MI. Matyashin, 1974]. In the development of this complication, adhesions that fix the ileum to the parental peritoneum at the entrance to the small pelvis are of particular importance. With an increase in paresis, intestinal loops located above the place of inflection, compression or infringement of the intestinal loop by adhesions overflow with liquid and gases, hang into the small pelvis, bending over adjacent, also stretched loops of the TC. A secondary torsion occurs [O.B. Milonov et al., 1990].

Postoperative NK 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, it develops in 18.7%. Gross trauma to the visceral peritoneum during surgery predisposes to the development of adhesions in the ileocecal angle.

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

Of the complications, intraperitoneal abscesses are relatively common (usually after 1-2 weeks) (Figure 5). In these patients, local signs of complications are indistinct. The general symptoms of intoxication, septic condition and multiple organ failure prevail more often, which are not only alarming, but also disturbing. With the pelvic location of the HO, abscesses of the recto-uterine or recto-vesical deepening occur. Clinically, these abscesses are manifested by a deterioration in the general condition, pain in the lower abdomen, high body temperature. A number of patients have frequent loose stools with mucus, frequent, difficult urination.

Figure 5. Scheme of the spread of abscesses in acute appendicitis (according to B.M. Khrov):
a - inside the peritoneal location of the process (front view): 1 - anterior or parietal abscess; 2 - intraperitoneal lateral abscess; 3 - iliac abscess; 4 - abscess and the cavity of the small pelvis (abscess of the Douglas space); 5 - subphrenic abscess; 6 - pretreatment abscess; 7—left-sided iliac abscess; 8 - inter-intestinal abscess; 9 - intraperitoneal abscess; b - retrocecal extraperitoneal location of the process (side view): 1 - purulent paracolitis; 2 - paranephritis, 3 - subdiaphragmatic (extraperitoneal) abscess; 4 - abscess or phlegmon of the iliac fossa; 5 - retroperitoneal phlegmon; 6 - pelvic phlegmon

The wound is expanded with 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 tissue is cut through the needle. The abscess cavity is drained with a rubber tube. After the opening of the abscess, the patient's condition quickly improves, after a few days the discharge of pus stops and recovery occurs.

Intestinal abscesses are rare. With development, a high body temperature persists for a long time after appendectomy, leukocytosis is noted with a shift of the leukocyte formula to the left. On palpation of the abdomen, pain is not clearly 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. When signs of abscess formation appear, it is drained.

Subdiaphragmatic abscess after appendectomy is even rarer. When it occurs, the general condition of the patient worsens, the body temperature rises, pains appear on the right above or below the liver. Most often, in half of the patients, the first symptom is pain. An abscess may appear suddenly or be masked by an obscure febrile state, erased onset. Diagnosis and treatment of subdiaphragmatic abscesses have been discussed above.

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

Figure 6. Distribution of diffuse peritonitis of appendicular origin to the entire peritoneum (scheme)

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

Postoperative thrombophlebitis of the mesenteric veins usually occurs when conditions are created for direct contact of a 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 stunning chills, fever with high temperature (39-40 ° C) appear. There is intense pain in the abdomen, more pronounced on the side of the lesion, 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, ascites appear.

Significant changes in laboratory parameters are noted: leukocytosis in the blood, a shift of the leukocyte formula to the left, toxic granularity of neutrophils, an increase in ESR, bilirubinemia, a decrease in the 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 usually produce RL for "peritonitis", "intestinal obstruction" and other conditions.

When opening the abdominal cavity, the presence of a light exudate with a hemorrhagic tinge is noted. During the revision of the abdominal cavity, an enlarged spotty color (due to the presence of multiple subcapsular abscesses) is found, a dense liver, a large spleen, a bluish paretic intestine with a congestive vascular pattern, dilated and tense mesentery veins, and 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 of the primary focus of infections, it is recommended to recanalize the umbilical vein and cannulate the VV. 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, fibrolytic drugs, and agents that improve the rheological properties of blood are administered transumbilically.

At the same time, the correction of metabolic disorders caused by developing PI is carried out. In case of metabolic acidosis accompanying PI, a 4% solution of sodium bicarbonate is administered, body fluid losses are controlled, intravenous administration of solutions of glucose, albumin, rheopolyglucin, hemodez is carried out - the total volume is up to 3-3.5 liters. Large losses of potassium ions compensate for the introduction of an adequate amount of 1-2% potassium chloride solution.

Violations of the protein-forming function of the liver are corrected by the introduction of a 5% or 10% solution of albumin, native plasma, amino acid mixtures, alvesin, aminosterylhepa (aminoblood). For detoxification, a solution of Hemodez (400 ml) is used. Patients are transferred to a protein-free diet, concentrated (10-20%) glucose solutions with an adequate amount of insulin are injected intravenously. Hormonal preparations are used: prednisolone (10 mg/kg of body weight per day), hydrocortisone (40 mg/kg of body weight per day). With an increase in the activity of proteolytic enzymes, it is advisable to / in the introduction of contrical (50-100 thousand units). To stabilize the blood coagulation system, vikasol, calcium chloride, epsilon aminocaproic acid are administered. To stimulate tissue metabolism, B vitamins (B1, B6, B12), ascorbic acid, liver extracts (sirepar, campolon, vitogepat) are used.

To prevent purulent complications, massive antibiotic therapy is prescribed. Carry out oxygen therapy, including HBO therapy. To remove the products of protein breakdown (ammonia intoxication), gastric lavage (2-3 times a day), cleansing enemas, and stimulation of diuresis are recommended. If there are indications, hemo- and lymphosorption, peritoneal dialysis, hemodialysis, exchange blood transfusion, connection of allo- or xenogeneic liver are carried out. 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 itself in a variety of terms from the moment of the first operation. For example, an abscess or adhesive NK in some patients occurs in the first 5-7 days, in others - after 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, it is not the time elapsed after the first operation that is of decisive importance, but the time from the moment the first signs of a complication appeared.

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, local pain reaction.

The leading symptoms in tono-inflammatory complications that develop after appendectomy are pain, moderate and then increasing muscle tension and symptoms of peritoneal irritation. The temperature in this bowl is subfebrile and can reach 38-39 ° C. On the part of the blood, there is an increase in the number of leukocytes up to 12-19 thousand units with a shift in the formula to the left.

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

Summarizing the above, we conclude that the main etiological factors in the development of complications after appendectomy are:
1) neglect of acute appendicitis due to late admission 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 of concomitant diseases.

If complications occur after appendectomy, the urgency of RL is determined depending on its nature. Urgent RL is performed (in the first 72 hours after the initial intervention) for VC, incompetence of the process stump, adhesive NK. The clinical picture of complications in these patients increases rapidly and is manifested by symptoms of an acute abdomen. There are usually no doubts about the indications for RL in such patients. The so-called delayed RL (within 4-7 days) are performed for solitary abscesses, partial adhesive LE, less often in individual cases of progression of peritonitis. In these patients, the indications for RL are based more on local symptoms from the abdomen, which prevail over the general reaction of the body.

For the treatment of postoperative peritonitis caused by the incompetence of the appendix stump after median laparotomy and its detection through the wound in the right iliac region, the dome of the SC should be removed along with the appendix stump and fixed to the parietal peritoneum at the level of the skin; to make 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 perforation of the intestine.

For this, it is recommended [V.V. Rodionov et al., 1982] apply 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-opening, a segment of the intestine with a line of sutures is removed subcutaneously and fixed to the hole in the aponeurosis. The skin wound is sutured with rare interrupted sutures. Pinpoint intestinal fistulas developing in the postoperative period are eliminated in a conservative way.

Our long-term experience shows that the frequent causes leading to RL after appendectomy are inadequate revision and sanitation, and an incorrectly chosen method of abdominal cavity drainage. It is also noteworthy that quite often the operational approach during the first operation was small in size or was displaced relative to the McBurney point, creating additional technical difficulties. It can also be considered a mistake to perform technically complex appendectomy under local anesthesia. Only anesthesia with sufficient access allows for a full revision and sanitation of the abdominal cavity.

Unfavorable factors contributing to the development of complications include non-preoperative preparation for appendicular peritonitis, non-compliance with the principles of pathogenetic treatment of peritonitis after the first operation, the presence of severe chronic concomitant diseases, advanced and senile age. The progression of peritonitis, the formation of abscesses, and necrosis of the SC wall in these patients are due to a decrease in the overall resistance of the body, disorders of central and peripheral hemodynamics, and immunological changes. The immediate cause of death is the progression of peritonitis and acute CV insufficiency.

With appendicular peritonitis of late 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 the expediency of combined antibiotic therapy, changing antibiotics during treatment, taking into account the sensitivity of the flora to them, and especially small doses.

Other important points in 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 prevalence of the pathological process, technical difficulties and errors during the operation, unreliable processing of the stump of the AO and its mesentery, and defective toilet and drainage of the abdominal cavity.

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

Is bleeding. More often there is bleeding from the stump of the mesentery of the process, which occurs as a result of insufficiently strong ligation of the vessel supplying the process. Bleeding from this small vessel can quickly lead to massive blood loss. Quite often the picture of internal bleeding comes to light at the patient on an operating table.

No matter how insignificant bleeding into the abdominal cavity seems, it requires urgent surgical intervention. You should never hope to stop bleeding on your own. It is necessary to immediately remove all sutures from the surgical wound, if necessary, expand it, find a bleeding vessel and bandage it. If the bleeding has already stopped and the bleeding vessel cannot be detected, you need to grab the stump of the mesentery of the process with a hemostatic clamp and re-tie it at the very root with a strong ligature. Blood that has poured into the abdominal cavity must always be removed, since it is a breeding ground for microbes and thus can contribute to the development of peritonitis.

The vessels of the abdominal wall can also be a source of bleeding. When opening the vagina of the rectus abdominis muscle, the lower epigastric artery may be damaged. This damage may not be immediately noticed, since when the wound is diluted with hooks, the artery is compressed and does not bleed. After surgery, blood can infiltrate the tissues of the abdominal wall and enter the abdominal cavity between the peritoneal sutures.

It is quite understandable that in some patients the bleeding can stop on its own. All existing hemodynamic disturbances are gradually subsiding. However, the skin and visible mucous membranes remain pale, the hemoglobin content and the number of red blood cells in the blood are significantly reduced. When examining the abdomen, painful phenomena may not exceed the usual postoperative sensations; for percussion determination, the amount of liquid blood should be significant.

The blood which has poured out in an abdominal cavity at some patients can be resolved without the rest. Then only the presence of anemia and the appearance of jaundice as a result of the resorption of an extensive hemorrhage make it possible to correctly assess the existing phenomena. However, such a favorable outcome, even with minor hemorrhage, is quite rare. If the blood accumulated in the abdominal cavity becomes infected, peritonitis develops, which is usually limited.

With more significant hemorrhage, in the absence of its delimitation and with delayed intervention, the outcome may be unfavorable.

As a complication in the postoperative course, the formation of an infiltrate in the thickness of the abdominal wall should be noted. Such infiltrates, if they occur without a pronounced inflammatory reaction, are usually the result of soaking the subcutaneous tissue with blood (with insufficient hemostasis during surgery) or serous fluid. If such an infiltrate is not large, then it resolves in the coming days under the influence of thermal procedures. If, in addition to infiltration, there is ripple along the suture line, indicating the accumulation of fluid between the edges of the wound, it is necessary to remove the fluid by puncture or pass a bellied probe between the edges of the wound. The latter method is more efficient.

If the formation of an infiltrate proceeds with a temperature reaction and an increase in pain in the wound, suppuration should be assumed. In order to timely diagnose this complication, each patient whose temperature does not decrease during the first two days after surgery, and even more so if it increases, needs to be bandaged to control the wound. The sooner 2-3 sutures are removed to drain the pus, the more favorable the course will be. In severe infections of the abdominal wall, the wound must be opened wide and drained, removing all sutures from the skin, from the aponeurosis and from the muscles, if there is an accumulation of pus under them. In the future, wound healing occurs by secondary intention.

Sometimes, after the wound has healed, ligature fistulas form. They are characterized by small size, purulent discharge and growth of granulation tissue around the fistulous opening. After removing the ligature with anatomical tweezers or a crochet hook, the fistulas heal. It is even better to use for this a large fishing hook unbent on a flame, the tip of which is bent so that a second beard is formed.

In patients, especially with a severe process in the process and the caecum, operated on in the presence of peritonitis, an intestinal fistula may form after the operation. Fistulas can form when a lesion extends from the base of the process into the adjacent part of the caecum. If this is detected during the operation, then the affected area of ​​​​the intestine is immersed with sutures that close it for the required length with the unchanged part of the wall of the caecum. If, when the process is removed, the lesion of the intestinal wall remains unidentified, with further progression of the process, its perforation may occur, which will lead to the release of feces into the free abdominal cavity or into its area limited by adhesions or tampons.

In addition, the cause of the development of intestinal fistulas can be either damage to the intestine during surgery, or a bedsore as a result of prolonged pressure from drains and tampons, or trauma to the intestinal wall during insufficiently delicate manipulations during dressing of wounds in which intestinal loops lie open. It is unacceptable to remove pus from the surface of the intestines with gauze balls and swabs, since this can very easily cause severe damage to the intestinal wall and its perforation.

In the formation of fistulas, the toxic effect of certain antibiotics, such as tetracyclines, which can lead to severe damage to the intestinal wall, up to complete necrosis of the mucous membrane, can also play a certain role. This applies to both the large and small intestines.

The formation of an intestinal fistula with a tightly sutured abdominal wound leads to the development of peritonitis, requiring immediate intervention, consisting in a wide opening of the wound and bringing drainage and delimiting tampons to the fistula. Attempts to sew up an existing hole are justified only at the earliest possible time. If the abdominal cavity has already been drained before the formation of the fistula, diffuse peritonitis may not be due to the formation of adhesions around the tampons. With a favorable course, peritoneal phenomena are more and more limited and gradually subside completely. The wound is filled with granulations surrounding the fistula, through which the intestinal contents are released.

Fistulas of the small intestine, transverse colon and sigmoid, the wall of which may be flush with the skin, are usually labial and require operative closure. Fistulas of the caecum, as a rule, are tubular and can close on their own with careful washing of the fistulous tract with an indifferent fluid. Surgical closure of the fistula is indicated only in case of unsuccessful conservative treatment for 6-7 months.

Long-term non-healing tubular fistulas of the caecum should suggest the presence of a foreign body, tuberculosis, or cancer, since removal of the process in these diseases can lead to the formation of fistulas.

Postoperative peritonitis may develop gradually. Patients do not always complain of increased pain, considering them to be an understandable phenomenon after surgery. However, the pain continues to intensify, in the right iliac region during palpation, more and more severe soreness, muscle tension and other symptoms characteristic of peritoneal irritation are noted. The pulse quickens and the tongue begins to dry. Sometimes the first and at first, as if the only sign of peritonitis may be vomiting or regurgitation, sometimes - increasing paresis of the intestines. The stomach gradually begins to swell, the gases do not go away, peristaltic noises are not heard, and in the future the picture develops in exactly the same way as with appendicular peritonitis in non-operated patients. In some patients, only an increase in heart rate, which does not correspond to temperature, is noted at first.

Signs of peritonitis can gradually come to light during the first days after the operation, growing very slowly. But sometimes they appear quickly, and in the next few hours a picture of diffuse peritonitis develops. The development of postoperative peritonitis is always an indication for urgent relaparotomy and elimination of the source of infection. The last is either the stump of the appendix that has opened due to the failure of the sutures, or a perforation in the intestinal wall. If the intervention is made early, it is possible to close the stump or perforation with sutures. In the later stages, this is not possible due to the fact that the sutures placed on the inflamed tissues are cut through, then it is necessary to confine ourselves to the supply of drainage and tampons.

When no local cause is identified, it is necessary to consider the development of peritonitis as the result of the progression of the diffuse inflammation of the peritoneum that was present before the first operation and proceed in the same way as described in the section on the treatment of peritonitis that developed before the operation.

With peritonitis that developed after surgery, the source of infection should be in the area of ​​the former operation. Therefore, relaparotomy must be performed by removing all sutures from the surgical wound and opening it wide. If the source of infection is located elsewhere and the development of peritonitis is not associated with the operation, but is due to some other disease, the choice of access should be determined by the localization of the painful focus. Antibiotic therapy and other measures to combat peritonitis should be more active.

With postoperative peritonitis, as well as with peritonitis that developed before surgery, the formation of limited abscesses can be observed in the abdominal cavity. Most often, the accumulation of pus occurs in the Douglas space. The formation of such an abscess, as a rule, is accompanied by a temperature reaction and other general manifestations of a septic nature. The symptoms characteristic of this complication are frequent urge to defecate, loose stools with a large admixture of mucus, tenesmus and gaping of the anus, which is due to the involvement of the rectal wall in the inflammatory process and infiltration of sphincters. When examining the rectum with a finger, a pronounced protrusion of the anterior wall is noted to varying degrees, where a clear swaying is often determined.

It should be remembered that such phenomena of irritation of the rectum can develop very late, when the abscess has already reached a significant size. Therefore, with a non-smooth course of the postoperative period, it is necessary to systematically perform a digital examination of the rectum, bearing in mind that Douglas abscess is the most common of all severe intra-abdominal complications observed after surgery for appendicitis. It is opened through the rectum or (in women) through the vagina, emptying the purulent accumulation through the posterior fornix.

Abscess formation in other parts of the abdominal cavity is less common. Interintestinal abscesses at first can be shown only by the increasing septic phenomena. Sometimes it is possible to detect an infiltrate in the abdomen if the abscess is parietal. If it is not adjacent to the abdominal wall, then it is possible to probe it only when the swelling of the intestine and the tension of the abdominal muscles decrease. Abscesses must be opened with an incision corresponding to its location.

Subdiaphragmatic abscesses after appendectomy are extremely rare. A subdiaphragmatic abscess should be opened extraperitoneally. To do this, when the abscess is located in the posterior part of the subdiaphragmatic space, the patient is placed on a roller, as for a kidney operation. The incision is made along the XII rib, which is resected without damaging the pleura. The latter is carefully pushed up. Further, parallel to the course of the ribs, all tissues are dissected up to the preperitoneal tissue. Gradually separating it, together with the peritoneum, from the lower surface of the diaphragm, they penetrate with a hand between the posterolateral surface of the liver and the diaphragm into the subdiaphragmatic space and, moving their fingers to the level of the abscess, open it, breaking through the diaphragmatic peritoneum, which does not offer much resistance. The purulent cavity is drained with a rubber tube.

Pylephlebitis (thrombophlebitis of the portal vein branches) is a very severe septic complication. Pylephlebitis is manifested by chills with an increase in body temperature up to 40-41 ° C and with its sharp drops, pouring sweat, vomiting, and sometimes diarrhea. The appearance of jaundice is characteristic, which is less pronounced and appears later than jaundice with cholangitis. When examining the abdomen, mild peritoneal phenomena, some tension in the muscles of the abdominal wall are noted. The liver is enlarged and painful.

In the treatment of pylephlebitis, first of all, it is necessary to take all measures to eliminate the source of infection - emptying possible accumulations of pus in the abdominal cavity and in the retroperitoneal space, ensuring a good outflow through wide drainage. Vigorous antibiotic treatment. With the formation of abscesses in the liver - their opening.

It should be noted another rare complication of the postoperative period - acute intestinal obstruction. In addition to dynamic obstruction of the intestines as a result of their paresis with peritonitis.

In addition, in the coming days after an appendectomy, mechanical obstruction may develop as a result of compression of the intestinal loops in the inflammatory infiltrate, their kinking by adhesions, strangulation by strands formed during the fusion of the abdominal organs, etc. Obstruction may develop shortly after the operation, when still in Inflammatory phenomena did not subside in the abdominal cavity, or at a later date, when it already seemed that a complete recovery had come.

Clinically, the development of obstruction is manifested by all its characteristic symptoms. The diagnosis of this complication can be very difficult, especially when the obstruction develops early in the first days after surgery. Then the existing phenomena are regarded as the result of postoperative paresis of the intestines, and the correct diagnosis may be delayed because of this. In later periods, obstruction develops more typically. The sudden appearance of "among full health" cramping pains in the abdomen, local bloating, vomiting and other signs of intestinal obstruction greatly facilitate the diagnosis.

With the ineffectiveness of conservative measures, the treatment of mechanical obstruction should be surgical.

With obturation obstruction caused by a kink of the intestines as a result of their constriction by adhesions, or when they are compressed in the infiltrate, adhesions are separated, if this is easily done. If this is difficult and if it is associated with trauma to the inflamed and easily vulnerable intestinal loops, a bypass inter-intestinal anastomosis is made or limited to the position of the fistula.

After appendectomy, other complications, generally characteristic of the postoperative period, can sometimes develop both from the respiratory organs and from other organs and systems. This is especially true for elderly patients.

Long-term results of surgical treatment of acute appendicitis in the vast majority of patients are good. Rarely observed poor results are mostly due to the presence of some other disease that the patient had before the attack of appendicitis or arose after the operation. Much less often, the poor condition of patients is explained by the development of postoperative adhesions in the abdominal cavity.

Appendicitis is an inflammation of the appendix of the caecum. It can develop in women and men, regardless of their age. The only category of patients in whom this inflammation is never diagnosed is infants (under the age of 1 year).

Appendicitis: causes and factors provoking development

Absolutely exact causes of the onset and development of the inflammatory process in the appendix have not yet been established. There is an opinion that the disease can be provoked by eating sunflower seeds and watermelon with a peel, eating grapes with seeds, and poor chewing of food.

In fact, this version is not confirmed by anything and no one, but certain factors that can still provoke an inflammatory process in the vermiform appendix of the caecum have been identified by doctors and scientists:

1. Changes in the immune system that occurred for no apparent reason. In this condition, the walls of the appendix become more susceptible to irritation and infection.
2. Blockage of the lumen of the appendix of the caecum. The blockage can be caused by:
   • the formation of fecal stones;
   • helminthic invasions;
   • tumor diseases (benign and malignant).
3. Inflammatory processes in the walls of blood vessels - vasculitis.
4. Infectious diseases of a general nature - for example, tuberculosis, typhoid fever.

note: no one will ever be able to predict in advance the development of the inflammatory process in the appendix of the caecum. Even if a person undergoes regular examinations, it is impossible to prevent the development of acute inflammation.

Classification of appendicitis

According to the forms, acute appendicitis and chronic appendicitis are distinguished. In the first case, the symptoms will be pronounced, the patient's condition is very serious, emergency medical care is required. Chronic appendicitis is a condition after an acute inflammatory process with no symptoms.

Doctors distinguish three types of the disease in question:

• catarrhal appendicitis - penetration of leukocytes into the mucous membrane of the appendix occurs;
• phlegmonous - leukocytes are found not only in the mucous membrane, but also in the deeper layers of the tissue of the appendix;
• gangrenous - the wall of the appendix affected by leukocytes dies, inflammation of the peritoneum develops (peritonitis);
• perforative - the walls of the inflamed appendix are torn.

Clinical picture and symptoms of appendicitis

Symptoms in this pathological condition are quite pronounced, doctors can make a diagnosis quickly and accurately, which reduces the risk of complications. The main symptoms of appendicitis include:

1. Pain syndrome. The localization of pain in appendicitis is the upper abdomen, closer to the navel, but in some cases the patient cannot indicate the exact concentration of pain. After an acute attack of pain, the syndrome "moves" to the right side of the abdomen - this is considered a very characteristic sign of inflammation of the appendix of the caecum. Description of pain: dull, constant, aggravated only by turning the torso.

note : after a severe attack of pain, this syndrome may completely disappear - patients take this condition for recovery. In fact, this sign is very dangerous and means that a certain fragment of the appendix has died and the nerve endings simply do not respond to irritation. Such imaginary calm always leads to peritonitis.

note : in chronic appendicitis, of all the above symptoms, only pain will be present. And it will never be acute and constant - rather, the syndrome can be described as periodically occurring. About the symptoms of appendicitis says the doctor:

Diagnostic measures

To diagnose appendicitis, you will need to conduct a series of examinations:

1. General examination with the definition of syndromes:
   • Kocher - intermittent pain from the upper abdomen to the right side;
   • Mendel - when tapping on the anterior wall of the abdomen, the patient complains of pain in the right iliac region;
   • Shchetkin-Blumberg - the right hand is inserted into the right iliac region and then abruptly removed - the patient experiences severe pain;
   • Sitkovsky - when the patient tries to turn on his left side, the pain syndrome becomes as intense as possible.
2. Laboratory research:
   • clinical blood test;
   • biochemical blood test;
   • coprogram;
   • analysis of feces for the presence of occult blood;
   • general urinalysis;
   • examination of feces for the presence of worm eggs;
   • Ultrasound (ultrasound examination) of the abdominal organs;
   • electrocardiogram (ECG).

Note: questioning the patient, collecting an anamnesis of life and illness is carried out only at the initial stage of the development of inflammation in the appendix of the caecum.

In an acute attack, emergency surgery is indicated when the diagnosis is confirmed using the above syndromes. Detailed information about the causes, signs of acute appendicitis, as well as treatment methods - in the video review:

Surgery to remove an appendix

Treatment of an acute attack of the inflammatory process of the appendix of the caecum can only be carried out surgically - no therapeutic measures should be taken. The patient is prepared for surgery to remove an inflamed appendix as follows:

1. A partial sanitization of the patient is carried out, but it is advisable to take a shower completely.
2. If diffuse varicose veins were previously diagnosed, then the patient should bandage the lower limbs with an elastic bandage. Please note: in case of a risk of developing thromboembolism, heparin preparations must be administered before surgery.
3. If the patient's emotional background is labile (he is very excited, irritated, panicking), then doctors prescribe sedative (sedative) drugs.
4. In the case of eating 6 hours before an attack of acute appendicitis, you will need to empty the stomach - vomiting is artificially induced.
5. Before the operation, the bladder is completely emptied.
6. The patient is given a cleansing enema, but if there is a suspicion of perforation of the appendix wall, then forced bowel cleansing is strictly prohibited.

The above activities should end two hours before the surgical intervention. Direct work of the surgeon can be carried out in several ways:

1. The classical method of the operation - the abdominal wall (anterior) is cut, the inflamed appendix is ​​cut out.
2. The laparoscopic method is a more gentle method of operation, all manipulations are carried out through a small hole in the abdominal wall. The reason for the popularity of the laparoscopic method of surgical intervention lies in the short recovery period and the virtual absence of scars on the body.

Note: if you experience symptoms of inflammation of the appendix of the caecum (or similar signs of appendicitis), you should immediately seek help from doctors. It is strictly forbidden to take any painkillers, apply a heating pad to the site of pain, give an enema and use drugs with a laxative effect. This may provide short-term relief, but subsequently such measures will hide the true clinical picture from the specialist.

Postoperative period and diet after appendicitis

After surgery to remove the appendix, the recovery period involves following a diet number 5. It includes:

• soups on vegetable broth;
• compotes;
• lean boiled beef;
• fruits (non-acidic and soft);
• legumes;
• crumbly porridge.

Fat, rich products, fatty meat and fish, black coffee, chocolate, hot spices and sauces, milk and sour-milk products are excluded from the diet.

note : in the first 2 days after surgery, only chicken broths, still water with lemon, weak tea can be included in the diet. From day 3, you can gradually introduce allowed products. You can return to the normal menu only 10 days after the removal of the inflamed appendix of the caecum. To maintain immunity in the postoperative period, you need to use vitamin complexes, as well as preparations containing iron and folic acid.

The surgeon tells about proper nutrition after removal of appendicitis:

Possible complications and consequences of appendicitis

The most serious complication of appendicitis is peritonitis. It can be limited and unlimited (spilled). In the first case, the patient's life is not in danger if the assistance is provided at a professional level.

With diffuse peritonitis, a rapid inflammation of the peritoneum develops - in this case, delay leads to death. Doctors identify other complications / consequences of the inflammatory process in question:

• suppuration of the wound left after surgical intervention;
• intra-abdominal bleeding;
• the formation of adhesions between the peritoneum, abdominal organs;
• sepsis - develops only with peritonitis or an unsuccessful operation. When the appendix ruptures under the hands of the surgeon and its contents pour out along the peritoneum;
• pylephlebitis of a purulent type - inflammation of a large vessel of the liver (portal vein) develops.

Preventive actions

There is no specific prevention of appendicitis, but to reduce the risk of developing an inflammatory process in the appendix of the caecum, the following recommendations can be followed:

1. Diet correction. This concept includes limiting the use of greens, hard vegetables and fruits, seeds, smoked and too fatty foods.
2. Timely treatment of chronic inflammatory diseases - there were cases when inflammation of the appendix of the caecum began due to the penetration of pathogenic microorganisms from diseased palatine tonsils (with decompensated tonsillitis).
3. Identification and treatment of helminthic invasions.

Appendicitis is not considered a dangerous disease - even the likelihood of complications after surgery does not exceed 5% of the total number of operations performed. But such a statement is appropriate only if the medical assistance to the patient was provided in a timely manner and at a professional level.

Tsygankova Yana Alexandrovna, medical observer, therapist of the highest qualification category.

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. Such treatment is explained by the fact that complications of acute appendicitis are sometimes so serious that they can be fatal. Operation - appendectomy minimizes the risk of a part of the consequences of appendicitis dangerous for a person.

When Can Appendicitis Complications Occur?

Acute inflammation of the appendix in humans passes through several stages. First, catarrhal changes occur in the walls of the processes, usually they last 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 fusion 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 during this period there is no surgical treatment, 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, appendicular abscess, pylephlebitis are often detected.

Various complications are possible after the operation. The causes of postoperative complications are associated with an untimely operation, late diagnosis of acute appendicitis, and surgeon errors. More often, pathological disorders after surgery develop in people aged, with a history of chronic diseases. Some of the complications can also be caused by patients' non-compliance with the doctor's recommendations in the 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 develop after surgery. The treatment of complications depends on their type, the condition of the patient and always requires a very careful attitude of the surgeon.

Complications of appendicitis in the preoperative period

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

Appendicular infiltrate

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

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

• Antibacterial drugs. Antibiotics are needed to eliminate inflammation.
• Use of cold to limit the spread of inflammation.
• Pain medications or bilateral blockade with novocaine.
• Anticoagulants are drugs that thin the blood and prevent the formation of blood clots.
• Physiotherapy with absorbing effect.

Throughout the treatment, patients should be observed strict bed rest and diet. It is recommended to eat fewer foods with coarse fiber.

Appendicular infiltrate can further manifest itself in different ways. With a favorable variant of its course, it resolves within a month and a half, with an unfavorable one, it suppurates and is complicated by an abscess. In this case, the patient has the following symptoms:

• An increase in body temperature to 38 degrees and above.
• The increase in symptoms of intoxication.
• Tachycardia, chills.
• The infiltrate becomes painful on palpation of the abdomen.

Abscess can break into the abdominal cavity with the development of peritonitis. In almost 80% of cases, the appendicular infiltrate resolves under the influence of therapy, and then a planned removal of the appendix is ​​indicated after about two months. It also happens that the infiltrate is also detected when an operation is performed for acute appendicitis. In this case, the appendix is ​​not removed, but drainage is carried out and the wound is sutured.

Abscess

Appendicular abscesses occur as a result of suppuration of an already formed infiltrate or when the pathological process is limited in peritonitis. In the latter case, an abscess most often occurs after surgery. A preoperative abscess is formed approximately 10 days after the onset of an inflammatory reaction in the appendix. Without treatment, the abscess may open, and the purulent contents come out into the abdominal cavity. The following symptoms testify to the opening of the abscess:

• Rapid deterioration of general well-being.
• Feverish syndrome - temperature, periodic chills.
• Signs of intoxication.
• The growth of leukocytes in the blood.

Appendicular abscess can be found in the right iliac fossa, between intestinal loops, retroperitoneally, in the Douglas pouch (rectal-vesical depression), in the subdiaphragmatic space. If the abscess is in the Douglas pocket, then symptoms such as painful, frequent stools, irradiation of pain in the rectum and perineum join the common signs. To clarify the diagnosis, rectal and vaginal examinations are also performed in women, as a result of which an abscess can be detected - an infiltrate with incipient softening.

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

Perforation

On the 3-4th day 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 number of bacteria, enter the abdominal cavity and peritonitis develops. Symptoms of this complication include:

• The spread of pain in all parts of the abdomen.
• The temperature rises to 39 degrees.
• Tachycardia over 120 beats per minute.
• External signs - sharpening of facial features, earthy skin tone, anxiety.
• Gas and stool retention.

Palpation reveals swelling, the Shchetkin-Blumberg symptom is positive in all departments. With peritonitis, an emergency operation is indicated; before surgery, the patient is prepared with the introduction of antibacterial agents and anti-shock drugs.

Postoperative complications in patients with acute appendicitis

Postoperative complicated appendicitis leads to the development of pathologies from the wound and internal organs. Complications after surgery are divided into several groups, they include:

• Complications identified from the side of the sutured wound. This is a hematoma, infiltrate, suppuration, divergence of the edges of the wound, bleeding, fistula.
• Acute inflammatory reactions from the abdominal cavity. Most often, these are infiltrates and abscesses that form in different parts of the abdominal cavity. Also, after surgery, local or general peritonitis may develop.
• Complications affecting the gastrointestinal tract. Appendectomy can lead to intestinal obstruction, bleeding, fistula formation in different parts of the intestine.
• Complications from the heart, blood vessels and respiratory system. In the postoperative period, some patients develop thrombophlebitis, pylephlebitis, pulmonary embolism, 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 the implementation of the doctor's recommendations. So, for example, intestinal obstruction can occur when the diet is not followed and under the influence of insufficient physical activity. Thrombophlebitis is prevented by the use of compression underwear before and after surgery, the introduction of anticoagulants.

Complications of acute appendicitis from the side of the wound are considered the most frequent, but at the same time the safest. The development of pathology is judged by the appearance of a seal in the wound area, an increase in general and local temperature, and the release of pus from the suture. Treatment consists in re-treatment of the wound, in the introduction of drainage, the use of 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, a purulent process from the appendix extends to the portal vein of the liver and its branches, as a result of which numerous abscesses form in the organ. The disease develops rapidly, it may be the result of untreated acute appendicitis. But in most patients it is a complication of appendectomy. Symptoms of the disease can appear both 3-4 days after the operation, and after a month and a half. The most obvious signs of pylephlebitis include:

• A sharp jump in body temperature, chills.
• Pulse is frequent and weak.
• Pain in the right hypochondrium. They can radiate to the shoulder blade, lower back.
• Enlargement of the liver and spleen.
• The skin is pale, the face haggard with icteric coloration.

When pylephlebitis is very high mortality, rarely the patient can be saved. The outcome depends on how this complication is detected in time and the operation is performed. During surgery, abscesses are opened, drained, antibiotics and anticoagulants are used.

Intestinal fistulas

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

• Inflammation extending to intestinal loops and their destruction.
• Non-compliance with the technique of the operation.
• Pressure sores developing under the pressure of tight tampons and drains used in surgical intervention.

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

Complicated appendicitis requires careful diagnosis, detection of pathological changes and prompt treatment. Sometimes the patient's life depends only on a timely emergency operation. Experienced surgeons can already assume the risk of developing complications after appendectomy based on the age of the patient, the presence of a 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 period.

It is possible to minimize the possible number of complications only by timely contacting a doctor. Early surgery is the prevention of the group of the most serious complications and shortens the recovery period.