From Big Medical Encyclopedia

APPENDECTOMY (an appendix + Greek ektome cutting, excision) — removal of a worm-shaped shoot. Operation is made at acute or an appendicism, most often under a local infiltration anesthesia; in the presence of the general peritonitis, at children of early age, uneasy patients the intubation anesthesia is shown. The slanting section in the right ileal area with drawing apart muscles [Mack-Berney (S. of Mc Burney), is in most cases applied 1894; H. M. Volkovich, 1898]. This section provides sufficient access for survey and actions in the field of a caecum and terminal department ileal (fig., 1 — 4). At an arrangement of a worm-shaped shoot under a liver, between loops of a small bowel or in a cavity of a small pelvis expansion of a section by a section of an aponeurosis of an outside oblique muscle and broad drawing apart edges of a wound quite often is required.

Appendectomy (stages of operations): 1 — the line of a skin section (it is perpendicular to the line connecting a navel to an upper front awn); 2 — the direction of a section of an outside oblique muscle; 3 — the direction of a section of an internal oblique muscle; 4 — an exposure of a peritoneum; 5 — bandaging of a mesenteriolum of a shoot; 6 — preparation of a purse-string seam, deligation at the basis of a shoot; 7 — imposing of a clip on a shoot before its cutting off; 8 — the shoot is dissected away; 9 — immersion of a stump of a shoot in a purse-string seam; 10 — the purse-string seam is tightened.

At far come forms of peritonitis the median laparotomy that, except is necessary And., to make very carefully by means of the sucking-away device and big gauze napkins drainage of all departments of an abdominal cavity. Special attention should be paid on drainage of subphrenic spaces, cavities of a small pelvis, side channels, pockets between intestinal loops. This reception not only helps with treatment of peritonitis, but also considerably prevents development of residual abscesses — subphrenic, interintestinal and a duglasova of space (pryamokishechio-uterine deepening).

In the presence even a small exudate before removal of a shoot in an abdominal cavity for its drying in all directions put gauze napkins.

After extraction of a shoot its mesenteriolum is crossed between styptic clips and tied up (fig., 5). Around the basis of a shoot on a wall of a caecum put a purse-string serous and muscular stitch fine silk or capron, without tightening (rice., 6). Processing of a stump of a shoot can be made in two ways. Many surgeons tie up the basis of a shoot a catgut ligature and after its cutting off immerse a stump in a gleam of a caecum. For fear of an inflammation and suppuration in the closed cavity, edges it is created after tightening of a purse-string seam over the tied-up stump, some surgeons prefer P. I. Dyakonov's method: the basis of a shoot is crushed a strong styptic clip then the stump without ligature is immersed in a gleam of a caecum (fig., 7 — 10). Bleeding in a gut from a stump of a shoot warn careful separation from a stump and an alloying of a mesenteriolum of a shoot. The stump of a shoot created on this or that way is immersed in a gleam of a caecum by tightening of a purse-string seam. If necessary Z-in addition put a figurative stitch or serous and muscular noose sutures.

At an infiltrirovanny wall of a caecum in order to avoid heavy complications (peritonitis, intestinal fistula) it is necessary to immerse a stump of a shoot noose serous and muscular sutures.

In the presence of massive unions sometimes make retrograde And.: at first tie up and cross a worm-shaped shoot at the basis, and then gradually allocate (a part stupid, a part in the acute way) and delete all shoot.

The so-called alloyed method, at Krom the tied-up stump of a worm-shaped shoot remains not shipped in a tobacco pouch, in a crust, time is not applied because of danger of sliding of a ligature and development of peritonitis. The exception is allowed only at And. at children because their shoot is thinner and more gentle and the ligature tightened on it keeps stronger. Also that circumstance that at an alloyed technique the purse-string seam is excluded matters, at Krom the puncture of very thin wall of a caecum is possible.

In most cases ambassador A. the abdominal wall is sewn up tightly. At acute destructive appendicitis careful removal of an exudate from an abdominal cavity is obligatory.

The cavity of a stomach after evacuation of an exudate is irrigated with solution of antibiotics, active concerning gram-negative microflora (Kanamycinum, Monomycinum, streptomycin).

To the place of a remote shoot and the greatest accumulation of pus and fibrinny films bring thin drainage tubes for the subsequent introduction of antibiotics. The abdominal wall up to an aponeurosis is sewn up tightly. A skin wound leave open. Postoperative treatment is carried out, as at peritonitis (see).

Later on a skin wound put secondary stitches or its edges pull together with the help of an adhesive plaster. From this practical standard of mending of a stomach tightly the exception (leading of a drainage and tampon) is allowed to a caecum in the following cases: 1) a retrocecal retroperitoneal arrangement of a shoot at which the purulent inflammation of retroperitoneal cellulose is found; 2) in the presence of near shoot of the sacculated abscess delimited from a healthy abdominal cavity; 3) at not completely stopped bleeding, 4) at infiltration of a wall of a caecum and unreliable processing of a stump of a shoot, 5) during incomplete removal of a worm-shaped shoot.

The left tampon is taken after 7 — 9 days after operation. Earlier removal of a tampon is the mistake threatening with development of diffuse peritonitis. If the section was median, tampons and drainages remove through counteropening in the right ileal area.

From complications ambassador A. most often formation of abscesses in various departments of an abdominal cavity which are usually caused by insufficient removal of an exudate during operation meets. Abscess can be localized between loops of guts (interintestinal abscess), under a diaphragm (see. Subphrenic abscess ), but most often — in duglasovy space (see. Douglas abscess ). In these cases the patient has a fever of constant or gektichesky type, sometimes dull aches in a rectum and tenesmus. At the research per rectum the overhang and morbidity of a front wall of a rectum is found. Abscess of a duglasov of space shall be opened and trained through a front wall of a rectum. At a defective alloying of mesenteric vessels in the early postoperative period bleeding can develop in an abdominal cavity, at Krom relaparotomy is shown. In 2 — 3 hours after operation to the patient allow to turn in a bed. In the absence of peritonitis and suppuration in a wound, at a standard temperature of a body to the patient allow to rise on 2 — the 3rd days after operation. At the uncomplicated postoperative period of the patient it can be written out from a hospital on 8 — the 9th days after operation. A postoperative lethality — see Appendicitis. See also Postoperative period , Leaving (for the patient).

Features of appendectomy at children. At children of early age in view of a high arrangement of a caecum the slanting section is done slightly higher, than usually. If the basis of a worm-shaped shoot is not changed and if there is no peritonitis, make And. in the alloyed way. At children of early age the silk ligature on the basis of a shoot is imposed without its preliminary perezhimaniye. The alloyed way at children has a number of advantages: time of operation accelerates, danger of perforation of a thin wall of a caecum at annular pication decreases, the possibility of deformation of the bauginiyevy gate is excluded. When the basis of a shoot is changed by inflammatory process or there is peritonitis, immersion of a stump of a shoot a purse-string seam is necessary.

If destructive changes are not found in a worm-shaped shoot, some authors after bandaging of a mesenteriolum and its cutting off as it is possible closer to a shoot invaginate all worm-shaped shoot in a gleam of a caecum [Lilly and Randolf (R. Lilly, J. G. Randolph)]. For this purpose put previously purse-string stitch around the basis of a shoot, and then the bellied probe carefully invaginate it. The purse-string seam is tightened. Such technique allows not to open a cavity of a shoot. Further the worm-shaped shoot deprived of nerves and vessels is torn away in a gleam of a gut on 6 — the 10th day.

In the first 3 — 4 days after operation the sparing diet and the active mode are necessary. From postoperative complications most often to a vstra suppuration of a wound, infiltrate of a small pelvis is hoped, and children of early age have a pneumonia.

Bibliography: Volkovich H. M. K to a question of cuts of belly covers at a chrevosecheniya, the Doctor, t. 19, No. 5, page 123, 1898; Kolesov V. I. Clinic and treatment of an acute appendicitis, L., 1972, bibliogr.; Littmann I. Belly surgery, the lane with Wenger., page 324, Budapest, 1970; Bier A., Braun H. u. To ü m-m e 1 1 H. Chirurgische Operationslehre, Bd 4, Lpz., 1955; Lennander K. G. Über den Bauchschnitt durch eine Rectus-scheide mit Verschiebung des medialen oder lateralen Randes des Musculus rectus, Zbl. Chir., Bd 25, S. 90, 1898; McBurney C. The incision made in the abdominal wall in cases of appendicitis, with a description of a new method of operating, Ann. Surg., v. 20, p. 38, 1894.

B. A. Petrov; Yu. F. Isakov (ped.).