What incision is used for appendectomy. Appendectomy. Operations for appendicitis. How is the appendix removed? These include

This article will look at possible ways to remove appendicitis, as well as the recommended diet after appendicitis removal.
The only method of treating acute appendicitis that traditional medicine uses is removal of the appendix (appendectomy), which is performed surgically.

Before the operation to remove appendicitis, blood and urine tests, x-rays, ultrasound and tomography are possible, and only after having all the tests and images of the appendix, the surgeon proceeds with the appendectomy.

Methods (techniques) of appendectomy. Appendectomy techniques vary depending on the method of access to the appendix. The most commonly used method is the open access method according to Volkovich-Dyakonov. This method is also called the Volkovich-Dyakonov-McBurney method.

Removal of appendicitis using the open method.

With this method they do cut line, passing through a point called McBurney's point, which is located on the border between the outer and middle third of the line connecting the umbilicus to the anterior superior spine of the right ilium (shown on the left half of the picture).

The length of the incision depends on the thickness of the patient's subcutaneous fat and is usually 6-8 cm. In most cases, the dome of the cecum is located in this area. Using the index finger, the surgeon checks for the absence of adhesions that will interfere with the removal of the cecum. If there are no adhesions, then the cecum is very carefully pulled by its anterior wall and brought out into the surgical wound.
Sometimes it is difficult to detect the dome of the cecum, in which case the incision is widened. Next, there are two possible options for performing an appendectomy: antegrade (typical) appendectomy and retrograde.

Antegrade (typical) appendectomy performed when the appendix can be removed into the surgical wound. The mesentery of the appendix is ligated with a nylon thread, and the appendix is cut off. The stump of the appendix is immersed in the dome of the cecum and purse-string and Z-shaped seromuscular sutures are applied.

Retrograde appendectomy is performed if there is difficulty in removing the appendix into the surgical wound. This difficulty is possible with adhesions, as well as with the retrocecal and retroperitoneal location of the process. The vermiform appendix is cut off from the dome of the cecum, its stump is immersed in the dome, then a step-by-step isolation of the appendix is made, and its mesentery is ligated.
As a rule, the operation is performed under general anesthesia, sometimes epidural anesthesia is used.

Postoperative period.
After an appendectomy, the patient usually remains in the hospital for 6-7 days. In the first few days after surgery, pain in the postoperative wound and an increase in temperature up to 37.5 degrees are possible. Analgesics are prescribed for pain relief. After removal of destructive appendicitis, antibiotics are prescribed. In uncomplicated forms of appendicitis, dressings are done every other day, and in complicated forms, when drainage is left in the abdominal cavity, dressings are done every day.
Nutrition can be allowed after the appearance of the first stool. The presence of stool indicates normal intestinal motility. From the first days after surgery, the patient needs to move. First he makes movements in bed, then he can sit on the bed. Many patients can walk the very next day after surgery, and this significantly speeds up recovery time. The period of incapacity for work is up to 1 month. Complications after appendicitis removal occur in 5-7%.

Laparoscopic appendectomy.

Laparoscopic removal of appendicitis has recently become increasingly popular. This method was introduced into surgical practice in the 80s of the last century.
Laparoscopic appendectomy can be performed at any stage of appendicitis, with the exception of perforation of the appendix and the absence of signs of widespread peritonitis. Relative contraindications are the retrocecal position of the appendix (along the posterior wall of the cecum) and inflammation of the dome of the cecum (typhlitis), from where the appendix arises.
Laparoscopic appendectomy is performed under general anesthesia. An incision is made in the peri-umbilical area and a Veress needle is inserted, through which carbon dioxide is pumped into the abdominal cavity. This is done for better visualization of internal organs. Then, through this incision, a trocar with a diameter of 10 mm with a laparoscope is inserted into the abdominal cavity and a thorough examination of the abdominal organs is performed, for the presence of peritonitis (inflammation of the peritoneum), and the degree of its prevalence. The nature, shape and location of the appendix, morphological changes in the mesentery, base of the appendix, and dome of the cecum are also determined.
Based on the study, a decision is made on the possibility of performing laparoscopic appendectomy. If the contraindications described above are detected, the surgeon proceeds to perform an open operation.
If there are no contraindications, then incisions are made above the pubis and in the right hypochondrium ( shown on the right half of the picture) and 2 more trocars for instruments are introduced.
The appendix, which is under visual control, is fixed with a clamp at the apex and the mesentery, which is a connective tissue formation with the vessels of the appendix passing through it, is pulled out for inspection. Next, at the point where the appendix departs from the cecum (base of the appendix), a small hole is created in the mesentery, through which a ligature is passed (a ligature is called a thread for ligation or the ligation itself), and the mesentery with the vessels is ligated. Two ligatures are placed side by side at the base of the process and, at a distance of about 1.5 cm, a third ligature is applied.
Then the appendix is crossed between ligatures placed on the base and removed from the peritoneal cavity through a trocar. At the final stage of the operation, sanitation and, if necessary, drainage of the abdominal cavity are performed.
In case of perforation of the appendix and widespread peritonitis, switching to open surgery makes it possible to carry out high-quality sanitation of the abdominal cavity through a wide incision.
The duration of laparoscopic appendectomy is 40-90 minutes, after 24 hours you can eat. The length of hospital stay after surgery is 2-3 days. The period of incapacity for work is up to 1 month.

Advantages of laparoscopic appendectomy: less postoperative pain syndrome, faster restoration of intestinal motility (peristalsis), shorter hospital stay, earlier restoration of ability to work, better cosmetic effect. The top of the photo shows a scar from an open appendectomy, and the bottom of the photo shows scars from laparoscopic surgery.

Transluminal appendectomy method.

This is a minimally invasive method in which access to the operated object (in this case, the appendix) is carried out using flexible instruments inserted through the natural openings of the human body and then through a small incision in the wall of the internal organ.

When performing a transluminal appendectomy, two types of access are possible: transgastric appendectomy, in which instruments are inserted through a small hole in the wall of the stomach; transvaginal appendectomy, in which instruments are inserted through a small incision into the vagina. Advantages of transluminal surgery: faster recovery and reduced postoperative rehabilitation time; complete absence of cosmetic defects. Transluminal surgery in Russia is available in Moscow and St. Petersburg.

Diet after appendicitis removal.

The first meals should be in small quantities, and the food itself should be liquid. Kefir, yogurt, weak sweet tea, dried fruit compote (not very concentrated) are suitable for this.
If, after eating such food, the noise of intestinal peristalsis is heard, this means that intestinal function is beginning to recover and it will be possible to gradually add soft food to the diet.
After 3 days, you can add liquid stewed cereal porridge to your diet. You need to drink plenty of fluids throughout the day. Before meals, drink liquid half an hour before eating or no earlier than an hour after eating. The menu includes steamed vegetables and fruits, puree soups and light broths from lean meat, lean boiled fish and meat, unsalted butter, and fermented milk products.

You cannot eat borscht, okroshka, fish soup, soup with peas or beans, beans. Such products cause fermentation and gas formation. This does not promote rapid wound healing and increases postoperative pain. You should also not eat salads made from fresh fruits and vegetables. Moreover, you should not consume fatty broths, seasonings, spices, fried, smoked, salty foods, and carbonated drinks.

After 3 weeks of the diet, doctors usually allow you to switch to your usual diet. But for some time you should abstain from smoked, fried, fatty, salty foods.

type of service: Medicinal, service category: General surgical operations and manipulations

Clinics in St. Petersburg where this service is provided for adults (64)

Specialists providing this service (8)

Appendectomy is one of the most common operations in surgical practice. Indications for it include acute and chronic appendicitis, as well as tumors of the appendix.

It is advisable to divide the history of the formation of such an operation as appendectomy into four stages:

The first period lasted several centuries until 1884, and was characterized by the fact that surgeons limited themselves to opening the abscess in the right iliac region, without removing the process itself.

The second period was characterized by the fact that in the acute period of the disease they began to remove the appendix, but only when complications developed (peritonitis). This period lasted about 25 years.

The third stage was influenced by the theory that it is necessary to perform an appendectomy only in the first 24 to 48 hours from the onset of the disease; in all other cases, if there were no severe purulent complications, conservative treatment is possible. This period lasted until 1926.

And finally, the fourth stage. It continues to this day, and takes place under the dominance of the doctrine of surgical treatment of all forms of acute appendicitis, regardless of the duration of the disease.

The operation is performed under both local and general anesthesia.

Operation technique:

Appendectomy can be anterograde or retrograde.

Anterograde appendectomy.

An incision is made in the right iliac region, 4–5 cm long. After this, using a sharp and blunt method, cutting the ligaments and spreading the muscles, they reach the peritoneum. (Fig. 1, 2) After this, the peritoneum is lifted with clamps and carefully, so as not to damage the abdominal organs, it is opened with scissors .(Fig.3)

After this, they find the cecum and vermiform appendix and carefully remove it into the wound with tweezers.

The process is ligated at the base, and after dissecting the mesentery, it is cut off with a scalpel.

The stump of the appendix is immersed in the cecum and fixed there with purse-string and Z-shaped sutures.

After this, the cecum is immersed back into the abdominal cavity and, after making sure that there is no bleeding, the abdominal cavity is sutured tightly in layers. In some cases, a thin tube is left in the abdominal cavity for later administration of antibiotics. If there was purulent effusion in the abdominal cavity, a rubber drainage may be placed.

Retrograde appendectomy.

All the main stages of the operation coincide with those of an anterograde appendectomy. The difference is that with anterograde removal of the process, it is first isolated from the surrounding tissues and then cut off from the cecum, and with retrograde, due to any difficulties in isolating the process, it is first intersected at the base and its stump is immersed in the cecum, and then it is released from surrounding tissues.

In the body of every person there is a small (about 7 mm) worm-like appendage of the cecum, which plays the role of protector of the intestinal microflora from harmful bacteria. This appendix is called the appendix. Due to a number of factors, the latter can become inflamed, causing acute pain in the abdominal cavity localized in the right iliac region.

Signs of acute appendicitis

According to the forms, chronic and acute appendicitis are distinguished. The first is very rare in nature, and due to certain factors, surgical intervention is unacceptable here.

In case of acute appendicitis, surgery is necessary. According to the structural features, this form of the disease in question is divided into:

catarrhal. There is a slight increase in the volume of the process. The upper ball becomes dull, visually we can talk about the expansion of the venous vessels. On palpation – tension in the right iliac region, slight pain. The patient's body temperature rises (up to 37.5 C, not higher), complaints of nausea and moderate pain in the abdominal cavity arise. One-time vomiting may occur. The catarrhal form of appendicitis lasts about 6 hours. It is difficult to diagnose appendicitis within this group - the symptoms are quite ambiguous and can indicate various diseases;

destructive. This group has several forms:

phlegmatic inflammation. With this form, all the balls of the appendix are absorbed by the process of inflammation. The walls of the process thicken, the diameter of its vessels increases. Purulent films form from inside the appendix, which explains the presence of pus when it is opened. In almost 50% of patients with this form of appendicitis, the formation of turbid fluid with the presence of protein in the abdominal cavity can be observed. In terms of duration, this form of destructive appendicitis lasts about 20 hours. During this time, the patient begins to complain of increased pain in the abdominal area; Due to the increase in temperature, regular dry mouth occurs.
gangrenous inflammation, abscess. Due to the huge number of blood clots that form in the vessels of the appendix, blood circulation is disrupted and necrosis of its tissue occurs. The rotting process is actively developing, which is accompanied by a sharp unpleasant odor. The process is soft to the touch, green in color, its tissue is damaged, resulting in bleeding. Options are also possible when there is not total necrosis, but the death of individual areas. Characteristic is the death of nerve cells, which is why the pain stops and the state of health improves. But due to the resulting intoxication, vomiting and nausea do not stop, the temperature remains at 38 C, and the heartbeat increases. With an abscess, the appendage changes its shape, turning into a ball or cylinder containing pus. The walls of such a ball/cylinder are very thin.
perforated form. The last and most dangerous form/stage of appendicitis. Surgical intervention here is not a guarantee of recovery. The purulent fluid of the appendix enters the abdominal cavity, causing infection of the latter. This happens due to a violation of the integrity of the walls of the appendix. The patient's condition changes dramatically: vomiting almost never stops; total weakness does not allow you to get out of bed; the temperature rises to 39 C. The pain is not concentrated only in the right side - the whole stomach begins to ache.

Two surgical techniques

Today, surgical treatment of appendicitis offers patients a choice of two methods:

Traditional appendectomy .

Duration of stages of this type of appendectomy:

30-60 minutes of the actual operation: depending on the patient’s age, body structure, stage of the disease, exacerbations;
7-8 days hospital stay. You can start working in a month.

Operation technique:

making an oblique incision in the area under the right rib, 6-7 cm long. If during this process a turbid liquid was detected, take a sample of it for examination;
searching for the appendage, removing it (together with the base of the cecum) through the hole made;
compression of the process, with fixation of the mesentery with tweezers;
suturing the cecum;
using medical thread to bandage the base of the process;
cutting off the shoot () slightly above the fixed thread. The remaining stump is disinfected, cauterized, hidden in the cecum, and the suture is tightened;
if there is no bleeding, the cecum is immersed in the abdominal cavity, the latter is dried, and the wound is sutured.

Laperoscopic appendectomy which includes 3 stages:

preoperative (2 hours): the operating area is prepared, the patient is given the necessary medications (antibiotics/sedatives);
the actual operation, which can last from 40 to 90 minutes;
postoperative. If no complications arise, then after 3 days the patient is discharged, and after 15 days he can start working.

Technique for this type of appendectomy:

use of general anesthesia;
injection of carbon dioxide into the abdominal cavity through a special needle. The latter enters the body through a small incision made in the left anterior pubic region;
studying the condition of internal organs, the degree of infection of the latter; location, shape, consistency of the appendix, by inserting a telescope through a 5 mm incision in the navel, which is connected to the camera. If the surgeon detects exacerbations that do not allow the use of a laparoscope, the patient undergoes a traditional appendectomy. If the audit does not reveal the presence of complications, laparoscopic appendectomy is performed;
introduction of an additional 2 catheters: through incisions in the subcostal and suprapubic region;
fixation of the process using clamps, inspection;
in the place that connects the appendage to the cecum, a hole is made through which a medical thread is passed to ligate the mesentery. Three more threads are placed at the base of the appendix;
extraction of the appendage through a catheter with a diameter of 10 mm;
disinfection of the abdominal cavity; elimination of hemorrhages;
examination of the abdominal cavity with a laparoscope.

Possible complications

There are three groups of complications that can occur after an appendectomy:

Local: may arise as a result of insufficient sterility of equipment, poor disinfection of the wound, due to the individual characteristics of the body. These include:

hematomas that can form near the wound in the first days after surgery;
redness and swelling in the wound area, discharge of pus;
accumulation of atypical fluid in the suture area, mixed with red blood cells and lymph.

Intra-abdominal. They pose a considerable danger to the health of the person undergoing surgery. It can be:

abscesses inside the abdominal cavity, and more. We can talk about the formation of pelvic pustules in the presence of pain in the pelvic area, the prepubic area, and an increase in temperature. With an interintestinal abscess, the person operated on feels normal, but as the purulent bladder increases, intoxication develops, pain appears in the navel area (especially with muscle tension);
peritonitis;
inflammation of the venous trunk running from the stomach to the liver. It is rare, but often (about 85%) leads to death. Signs of this complication include fever, enlargement and abscess of the liver, severe intoxication, attacks of hysteria;
intestinal obstruction. The result of scars and adhesions.

System: diverse in nature and location. These include pneumonia, heart attacks, changes in the functioning of the genitourinary system, etc.

Patient status

Not all patients know what to do after appendicitis surgery, which causes an increase in rehabilitation time.

for 12 hours after appendectomy, do not get out of bed or eat;
After 12 hours, you can try to take a sitting position. If there is no nausea, water with lemon is allowed in small portions;
You can start walking 24 hours after surgery. If you have an appetite and no nausea, you can talk to your doctor about your allowed diet in the coming days. The standard menu at this time for such patients is liquid, low-fat food;
after 48 hours, protein foods are allowed to be introduced: boiled beef, chicken, fish, liquid broths;
on day 8 you can return to your usual diet;
You should refrain from heavy physical activity for 3-6 months, depending on how quickly the wound heals. But 2 months after discharge from the hospital, you can get exercise from running, swimming, and horse riding.

Rice. 12-186. Intussusception of the ileum.

Rice. 12-187. Disinvagination intestines.(From: Littmann I. Abdominal surgery. - Budapest, 1970.)

196 < ТОПОГРАФИЧЕСКАЯ АНАТОМИЯ И ОПЕРАТИВНАЯ ХИРУРГИЯ < Глава 12

The main access to the cecum is variable McBarney-Volkovich-Dyakonov(See “Oblique and transverse laparotomies”). Ett access has the following advantages:

Its projection corresponds to the position of the next

hollow intestine and appendix;

There is little damage to the nerves of the abdominal wall;

It gives a lower percentage of postoperative

ny hernias.

Technique. By cut McBarney-Volkovich-Dyakonov open the abdominal cavity and begin to search for the cecum. The cecum is distinguished from the small intestine by a wider lumen, the presence of ribbons and haustra, as well as a grayish color (the small intestine is pink). The difference between the cecum and the sigmoid and transverse colon is the absence of a mesentery and fatty pendants. If you have any difficulties, follow the free line (taenia libera), which always leads down to the base of the process. Usually the position of the cecum corresponds to the ileal fossa. With a long mesentery of the cecum, the latter can be found in any part of the abdominal cavity up to the left iliac fossa. In the most difficult cases, it can be found in the small intestine, gradually moving through it to the point of confluence.

Near the apex of the appendix, a clamp is placed on its mesentery and pulled up. The mesentery of the appendix is ligated and dissected between sequentially applied clamps Kocher starting from the top to the base (Fig. 12-188). After this, a purse-string suture is placed around the base of the process stump. Following this, a crushing clamp is applied to the base of the process (Fig. 12-189, a) and along the formed groove it is bandaged with a catgut ligature and, distal to the ligation site, the process is again clamped with a clamp and cut off below it (Fig. 12-189, b).

The stump is lubricated with iodine and immersed into the lumen of the cecum while tightening the purse-string suture (Fig. 12-189, in, G). To strengthen the submerged infected stump of the appendicular process, a Z-shaped suture is usually placed over the purse-string suture.

After making sure that the sutures are completely sealed and that there is no bleeding from the mesentery, the cecum is lowered into the abdominal cavity and sutures are placed on the wound of the abdominal wall.

Rice. 12-188. Appendectomy. a - the vermiform appendix is lifted by its mesentery, which is then cut between clamps, b - ligation of blood vessels. (From: Littmann I. Abdominal surgery. - Budapest, 1970.)

RETROGRADE APPENDECTOMY

Often the apex of the appendix is fixed by adhesions to the posterior abdominal wall, which makes it difficult to remove it into the wound. In this case, appendectomy is performed in a retrograde manner (Fig. 12-190).

Technique. The cecum is brought out into the wound and the base of the vermiform appendix is found. At the base of the process, a dissector is passed through its mesentery, with which a thick thread-holder is inserted to extract the process from the depths. A purse-string suture is placed on the wall of the cecum, the process captured by the clamp is crossed, its ends are lubricated with

Operations on the anterior abdominal wall and abdominal organs ♦ 197

Rice. 12-190. Retrograde appendectomy. a - extraction of the appendix, b - intersection of the appendix after applying a purse-string suture to the cecum, c - the purse is tightened, the appendix is isolated, d - completion of the ligation of the mesentery after removal of the appendix. (From: Shabanov A.N., Kushkhabiev V.I., Veli-Zadv B.K. Operative surgery: Atlas. - M., 1977.)

house. The stump of the process is immersed with purse-string and Z-shaped sutures. After this, by pulling the clamp placed on the appendix, they find the mesentery and cross it step by step. To mobilize the appendix located retroperitoneally, the parietal peritoneum is dissected outward from the cecum, retracted inwards and the vermiform appendix is exposed.

LAPAROSCOPIC APPENDECTOMY

The patient is on the operating table in a supine position with the head down and the body turned to the left by 45%. Under general anesthesia, the abdominal cavity is punctured in the area of the umbilical ring or at a point 0.5 cm below the navel. In the abdomen

Operations on the anterior abdominal wall and abdominal organs ♦ 199

cavity under a pressure of 14-15 mm Hg. Art. insufflate 2-3 liters of carbon dioxide. After creating pneumoperitoneum, a visual inspection of the abdominal and pelvic organs is carried out, which is completed by examining the appendix.

After the diagnosis of acute appendicitis is established, the manipulator is removed and special forceps are inserted through the trocar in the right iliac region, with which the apex of the appendix is grasped. If the appendix was in a loose infiltrate, then to help isolate it, a trocar with a diameter of 10 mm is inserted into the abdominal cavity in the suprapubic region along the midline.

Mobilization of the appendix is carried out by gradual clamping of the mesentery with its subsequent intersection. Hemostasis from small vessels of the mesentery and other tissues is carried out by electrocoagulation. Then two ligatures are applied to the base of the mobilized vermiform appendix, between which it is crossed. The appendage is removed through the tube of the working trocar, and the mucous membrane of its stump is additionally coagulated. After this, a thorough examination of the operation area and monitoring of hemostasis is performed. If necessary, drain the abdominal cavity.

All materials on the site were prepared by specialists in the field of surgery, anatomy and specialized disciplines.
All recommendations are indicative in nature and are not applicable without consulting a doctor.

Appendectomy is one of the most common interventions on the abdominal organs. It involves removing the inflamed appendix, so appendicitis is the main indication for surgery. Inflammation of the appendix occurs in young people (mostly 20-40 years old) and in children.

Appendicitis is an acute surgical disease manifested by abdominal pain, symptoms of intoxication, fever, and vomiting. Despite the apparent simplicity of the diagnosis, sometimes it is quite difficult to confirm or refute the presence of this disease. Appendicitis is a “master of disguise”; it can simulate many other diseases and have a completely atypical course.

The vermiform appendix extends in the form of a narrow canal from the cecum. In early childhood, it participates in local immunity thanks to the lymphoid tissue in its wall, but with age this function is lost, and the process is a practically useless formation, the removal of which does not carry any consequences.

The cause of inflammation of the appendix has not yet been precisely determined; there are a lot of theories and hypotheses (infections, obstruction of the lumen, impaired trophism, etc.), but with its development there is always only one way out - surgery.

Based on the nature of changes in the appendix, destructive (phlegmonous, gangrenous) and non-destructive (catarrhal, superficial) forms of the disease are distinguished. Acute purulent appendicitis, when pus accumulates in the wall of the appendix and its lumen, as well as the gangrenous variant, a sign of which is necrosis (gangrene) of the appendix, are considered the most dangerous, since peritonitis and other dangerous complications are likely.

A special place belongs to chronic appendicitis, which occurs as a result of catarrhal disease that has not been operated on. This type of inflammation is accompanied by periodic exacerbations with pain, and an adhesive process develops in the abdominal cavity.

Appendiceal infiltrate is an inflammatory process in which the appendix merges with the surrounding areas of the intestine, peritoneum, and omentum. The infiltration is limited in nature and, as a rule, requires preliminary conservative treatment.

A special group of patients consists of children and pregnant women. In children, the disease practically does not occur until one year of age. The greatest diagnostic difficulties arise in young patients under 5-6 years of age, who have difficulty describing their complaints, and specific signs are less pronounced than in adults.

Pregnant women are more susceptible to inflammation of the appendix than others for a number of reasons: a tendency to constipation, displacement of abdominal organs by an enlarging uterus, decreased immunity due to changes in hormonal levels. Pregnant women are more prone to destructive forms that can lead to fetal death.

Indications and preparation for surgery

Appendectomy is one of the interventions that in most cases is performed as an emergency. Indication: acute appendicitis. A planned operation to remove the appendix is performed with appendiceal infiltrate after the inflammatory process has subsided, approximately 2-3 months from the onset of the disease. In case of increasing symptoms of intoxication, rupture of an abscess with peritonitis, the patient needs emergency surgical treatment.

There are no contraindications to appendectomy, except in cases of the patient's agonal state, when the operation is no longer advisable. If doctors have adopted a wait-and-see approach due to appendiceal infiltration, then severe decompensated diseases of the internal organs may be contraindications to surgery, but during conservative treatment the patient’s condition can be stabilized to such an extent that he can undergo the intervention.

The operation usually lasts about an hour, both general anesthesia and local anesthesia are possible. The choice of pain relief is determined by the patient’s condition, his age, and concomitant pathology. Thus, in children, people with excess body weight, which involves greater trauma when entering the abdominal cavity, with nervous overexcitation and mental illness, general anesthesia is preferable, and in thin young people, in some cases, it is possible to remove the appendix with local anesthesia. Pregnant women, due to the negative impact of general anesthesia on the fetus, are also operated on under local anesthesia.

The urgency of the intervention does not require sufficient time to prepare the patient, so the necessary minimum examinations are usually performed (general blood test, urine test, coagulogram, consultations with specialists, ultrasound, x-rays). To exclude acute pathology of the uterine appendages, women need to be examined by a gynecologist, possibly with an ultrasound examination. If there is a high risk of thrombosis of the veins of the extremities, the latter are bandaged before surgery with elastic bandages.

Before the operation, the bladder is catheterized, the contents are removed from the stomach if the patient ate later than 6 hours before the operation, and an enema is indicated for constipation. The preparatory stage should last no more than two hours.

When the diagnosis is beyond doubt, the patient is taken to the operating room, anesthesia is administered, and the surgical field is prepared (hair shaving, iodine treatment).

Progress of the operation

The classic operation to remove appendicitis is performed through an incision in the anterior abdominal wall in the right iliac region, through which the cecum with the appendix is removed, it is cut off, and the wound is sutured tightly. Depending on the location of the appendix, its length, and the nature of pathological changes, antegrade and retrograde appendectomy are distinguished.

The course of the operation includes several stages:

Formation of access to the affected area;
Removal of the cecum;
Severing the appendix;
Layer-by-layer suturing of the wound and control of hemostasis.

To “get” to the inflamed appendix, a standard incision about 7 cm long is made in the right iliac region. The reference point is McBurney's point. If you mentally draw a segment from the navel to the right upper iliac spine and divide it into three parts, then this point will lie between the outer and middle thirds. The cut passes at right angles to the resulting line through the indicated point, a third of it is located above, two thirds - below the specified landmark.

on the left – traditional open surgery, on the right – laparoscopic surgery

After the surgeon has cut through the skin and subcutaneous fat, he will have to penetrate the abdominal cavity. The fascia and aponeurosis of the oblique muscle are cut, and the muscles themselves are moved to the sides without incision. The last obstacle is the peritoneum, which is cut between the clamps, but first the doctor will make sure that the intestinal wall does not get into them.

Having opened the abdominal cavity, the surgeon determines the presence of obstacles in the form of adhesions and adhesions. When they are loose, they are simply separated with a finger, and when they are dense, connective tissue, they are cut with a scalpel or scissors. This is followed by the removal of a section of the cecum with the appendix, for which the surgeon carefully pulls the wall of the organ, removing it out. Upon penetration into the abdomen, inflammatory exudate may be detected there, which is removed with wipes or an electric suction.

appendectomy: progress of the operation

The appendix is removed antegrade (typically) and retrogradely (less commonly). Antegrade removal involves ligation of the vessels of the mesentery, then a clamp is applied to the base of the appendix, the appendix is sutured and cut off. The stump is immersed in the cecum, and the surgeon remains to apply stitches. The condition for antegrade removal of the appendix is the possibility of its unhindered removal into the wound.

Retrograde appendectomy is performed in a different sequence: first, the appendix is cut off, the stump of which is immersed in the intestine, sutures are applied, and then the vessels of the mesentery are gradually sutured and it is cut off. The need for such an operation arises when the appendix is localized behind the cecum or retroperitoneally, with a pronounced adhesive process that makes it difficult to remove the appendix into the surgical field.

After the appendix is removed, stitches are applied, the abdominal cavity is examined, and the abdominal wall is sutured layer-by-layer. Usually the suture is blind and does not imply drainage, but only in cases where there are no signs of the inflammatory process spreading to the peritoneum, and no exudate is found in the abdomen.

In some cases, it becomes necessary to install drains, indications for which are:

Development of peritonitis;
Possibility of incomplete removal of the appendix and insufficient hemostasis;
Inflammation of the retroperitoneal tissue and the presence of abscesses in the abdominal cavity.

When it comes to peritonitis, 2 drainages are needed - into the area of the removed process and the right lateral canal of the abdomen. In the postoperative period, the doctor carefully monitors the discharge from the abdominal cavity, and if necessary, a repeat operation is possible.

Suspect peritonitis(inflammation of the peritoneum) is possible even at the stage of examining the patient. In this case, an incision in the midline of the abdomen would be preferable, providing a good view of the abdominal cavity and the possibility of lavage (washing with saline or antiseptics).

Laparoscopic appendectomy

Recently, with the development of technical capabilities in medicine, minimally invasive techniques, also used in the surgery of abdominal diseases, are becoming increasingly popular. Laparoscopic appendectomy is a worthy alternative to classical surgery, but for a number of reasons it cannot be performed on every patient.

Laparoscopic removal of the appendix is considered a more gentle method of treatment, which has a number of advantages:

Low morbidity compared to abdominal surgery;
Possibility of local anesthesia in most patients;
Shorter recovery period;
The best result for severe diseases of internal organs, diabetes, obesity, etc.;
Good cosmetic effect;
Minimum complications.

However, laparoscopic appendectomy also has some disadvantages. For example, an operation requires the availability of appropriate expensive equipment and a trained surgeon at any time of the day, because the patient can be taken to the hospital at night. Laparoscopy does not allow a detailed examination of the entire volume of the abdominal cavity, adequate sanitation and removal of exudate in common forms of the inflammatory process. In severe cases, with peritonitis, it is impractical and even dangerous.

Through many years of discussions, doctors determined the indications and contraindications for laparoscopic removal of the appendix.

The following are considered indications:

If there are no risks, the patient’s condition is stable, and the inflammation has not spread beyond the appendix, then laparoscopic appendectomy can be considered the method of choice.

Contraindications to minimally invasive treatment:

More than a day from the onset of the disease, when the likelihood of complications is high (perforation of the appendix, abscess).
Peritonitis and the transition of inflammation to the cecum.
Contraindications for a number of other diseases - myocardial infarction, decompensated heart failure, bronchopulmonary pathology, etc.

In order for laparoscopic appendectomy to be a safe and effective treatment procedure, the surgeon will always weigh the pros and cons, and in the absence of contraindications to the procedure, it will be a low-traumatic treatment method with minimal risk of complications and a short postoperative period.

The course of laparoscopic appendectomy includes:

Laparoscopic surgery for appendicitis lasts up to one and a half hours, and the postoperative period takes only 3-4 days. Scars after such an intervention are barely noticeable, and after some time has passed for final healing, they can be difficult to find.

The suture after open surgery is removed after 7-10 days. A scar will remain at the site of the incision, which will thicken and fade over time. The scar formation process takes several weeks.

The cosmetic effect is largely determined by the efforts and skill of the surgeon. If the doctor treats the wound suturing conscientiously, the scar will be almost invisible. If complications develop, if it is necessary to increase the length of the incision, the surgeon will be forced to sacrifice the cosmetic side of the issue in favor of preserving the health and life of the patient.

Postoperative period

In cases of uncomplicated forms of appendicitis and a favorable course of the operation, the patient can be immediately taken to the surgical department, in other cases - to the postoperative ward or intensive care unit.

During the rehabilitation period, wound care and early activation of the patient are of great importance, allowing the intestines to “turn on” in time and avoid complications. Dressings are carried out every other day, if there are drainages - daily.

On the first day after the intervention, the patient may experience pain and increased body temperature. Pain is a natural phenomenon, because both the inflammation itself and the need for incisions imply tissue damage. Usually the pain is localized to the site of the surgical wound, it is quite tolerable, and the patient is prescribed analgesics if necessary.

Antibacterial therapy is indicated for complicated forms of appendicitis. Fever may be a consequence of surgery and a natural reaction during the recovery period, but it must be carefully monitored, since an increase in temperature to significant levels is a sign of serious complications. The temperature should not exceed 37.5 degrees during the normal course of the postoperative period.

Many patients prefer to lie in bed, citing weakness and pain. This is wrong, because the sooner the patient gets up and starts moving, the faster intestinal function will be restored and the lower the risk of dangerous complications, in particular thrombosis. In the very first days after the operation, you need to gather your courage and at least walk around the ward.

A very important role in interventions on the abdominal organs is given to diet and nutrition. On the one hand, the patient must get the calories he needs, on the other hand, he must not harm the intestines with an abundance of food, which during this period can cause adverse consequences.

You can start eating after the appearance of intestinal peristalsis, as evidenced by the first independent stool. The patient should be informed what can be eaten after surgery and what is better to avoid.

Patients who have suffered acute appendicitis are assigned to table No. 5. Safe to consume compotes and tea, lean meats, light soups and cereals, white bread. Fermented milk products, stewed vegetables, and fruits that do not contribute to gas formation are useful.

During the recovery period can't eat fatty meat and fish, legumes, fried and smoked foods, spices, alcohol, coffee, baked goods and sweets, carbonated drinks should be excluded.

On average, after surgery, the patient remains in the hospital for about a week in uncomplicated forms of the disease, otherwise longer. After laparoscopic appendectomy, discharge is possible already on the third day after the operation. You can return to work after a month with open operations, with laparoscopy - after 10-14 days. A sick leave certificate is issued depending on the treatment performed and the presence or absence of complications for a month or more.

Video: what should be the diet after appendicitis removal?

Complications

After surgery to remove the appendix, some complications may develop, so the patient needs constant monitoring. The operation itself usually proceeds well, but some technical difficulties may be caused by the unusual location of the appendix in the abdominal cavity.

The most common complication in the postoperative period is considered suppuration in the area of the incision, which in case of purulent types of appendicitis can be diagnosed in every fifth patient. Other options for unfavorable developments - peritonitis, bleeding into the abdominal cavity with insufficient hemostasis or sutures slipping off the vessels, seam dehiscence, thromboembolism, adhesive disease in the late postoperative period.

Considered a very dangerous consequence sepsis when purulent inflammation becomes systemic, as well as the formation of ulcers (abscesses) in the abdomen. These conditions are facilitated by rupture of the appendix with the development of diffuse peritonitis.

Appendectomy is an operation that is performed for emergency reasons, and its absence can cost the patient’s life, so it would be illogical to talk about the cost of such treatment. All appendectomies are performed free of charge, regardless of the patient’s age, social status, or citizenship. This procedure has been established in all countries, because any acute surgical pathology requiring urgent measures can occur anywhere and anytime.

Doctors will save the patient by performing an operation on him, but subsequent treatment and observation during a period when nothing threatens life may require some costs. For example, a general blood or urine test in Russia will cost an average of 300-500 rubles, and consultations with specialists - up to one and a half thousand. Post-surgery costs associated with continued treatment may be covered by insurance.

Since interventions like appendectomy are carried out urgently and unplanned for the patient himself, reviews of the treatment received will vary greatly. If the disease was limited in nature, the treatment was carried out quickly and efficiently, the feedback will be positive. Laparoscopic surgery can leave a particularly good impression when, just a few days after a life-threatening pathology, the patient finds himself at home and feeling well. Complicated forms that require long-term treatment and subsequent rehabilitation are much worse tolerated, and therefore the negative impressions of patients remain for life.