Appendicitis: removal, possible complications and consequences. Complications of appendectomy

On the topic " acute appendicitis"You can find several hundred thousand sites on the Internet. That's a lot. Search engines ask about almost everything. How it proceeds this pathology? How can I figure out whether I have appendicitis or not? What complications can occur after an appendectomy? How to treat them and generally recognize them?

In my opinion, the most requests arise for the last two questions. I am not saying this unfoundedly, because... I periodically conduct consultations on some resources on the Internet.

What do people read when they get to sites dedicated to acute appendicitis? And almost everywhere it’s the same: complaints, clinical picture, surgery, possible complications after her. Well, almost everything. It is written, in most cases, as in a textbook for students and doctors.

In this article I will not touch on the entire pathology - acute appendicitis, but will touch only on the main complications after appendectomy, but I will try to do this in a simple, accessible language.

Good day.

All complications of acute appendicitis, conditionally, can be divided into two groups:

What will happen if the operation is not performed?
Postoperative complications.

Let's talk today about complications after appendectomy.

They can also be divided into two large groups: early and late complications.

In the first hours after the operation, the bandage on the postoperative wound (where the stitches are) was wet with blood, either heavily or weakly.

Reason: this may happen when, in an already thrombosed vessel, when blood pressure rises, or when the patient coughs or actively moves, immediately after surgery, the blood clot “flies out”. Bleeding is eliminated by applying weight to the wound through a bandage (you can use a bag of sand or ice). If the bandage still gets wet, then the doctor, sometimes, right in the room, has to apply an additional suture to stop the bleeding. There is no need to be afraid in this situation. This happens.

Bleeding from the drain

In some patients, after surgery, tubular drainages of various diameters are left in the abdominal cavity through the wound, through which pathological effusion periodically occurs. There is no need to worry. The discharge, as a rule, is small and its color ranges from light yellowish to dark brown. The drainage is removed after a day or three.

If suddenly blood (liquid or with clots) began to be released from the drainage and, in addition, the blood pressure decreased blood pressure, weakness appeared, cold sweat, that is, a cause for concern.

Blood from the abdominal cavity can occur, most often, when a ligature (in simple terms, a thread with which an artery is tied) slips from the mesentery of the appendix.

There is only one way out of this situation - emergency surgical treatment to stop the bleeding.

Infiltrate, seroma, postoperative wound abscess

In the early postoperative period, usually on days 5-7, a thickening (infiltrate) in the area of the sutures and an increase in body temperature (from 37 to 38 degrees and above) may appear. Only a doctor can assess the situation visually, palpation, repeat general analysis blood, sometimes perform an ultrasound of the area of the sutures and surrounding tissues, the abdominal cavity for the presence of fluid accumulation in the subcutaneous fat layer, under the aponeurosis.

While dressing, the doctor can separate the edges of the wound, sometimes even remove some of the sutures and, using a probe (or other instrument), conduct an inspection of the subcutaneous fatty tissue, and possibly the subgaleal layer. The result of this manipulation can be:

A. absence of any foreign secretions. In this case, the doctor may strengthen conservative treatment change the antibiotic, refer for physiotherapeutic procedures, apply Vishnevsky ointment to the suture area (I sometimes use this method in my hospital with a good result).

b. during the audit postoperative wound the light will stand out, serous fluid(seroma). There's nothing wrong with that. The doctor may or may not put a rubber strip in the wound for drainage for 2-4 days, and if the discharge stops, it will be removed.

V. Sometimes, after phlegmonous, gangrenous, perforated, and abscess-forming variants of acute appendicitis, when the wound is examined, pus begins to be released. Everything is more serious here.

The patient should be transferred to a department for the treatment of patients with purulent complications. In addition to conservative treatment, the patient should undergo dressings with a 3% solution of hydrogen peroxide, iodinol, levomekol and other drugs from one to 2-3 times a day, physiotherapeutic procedures - ultraviolet irradiation on the area of the postoperative wound in combination with UHF and laser therapy.

If pus spreads under the aponeurosis, it is possible to open and inspect the abscess under anesthesia. Further treatment is carried out according to the same principles. But in the long-term postoperative period, after discharge from the hospital, this group of patients may develop a postoperative hernia at the site of the scar. And this, as a rule, in the future requires repeated surgical treatment - herniotomy.

Early adhesive intestinal obstruction

After any operation on the abdominal organs, adhesions form in the abdomen (some actively, some more slowly, and some have practically no adhesions). Increased adhesions in the early postoperative period after appendectomy can cause a serious complication - early adhesive intestinal obstruction.

It manifests itself as bloating, nausea, vomiting, cramping pain in the abdomen, lack of stool and gas.

In this situation, first conservative therapy, if unsuccessful, an operation is performed - laparotomy, revision of the abdominal cavity, and adhesions are dissected. In the postoperative period, early motor activity, the use of drugs that stimulate intestinal motility.

Abdominal abscess

The appearance of abdominal pain, an increase in body temperature to 38-40 degrees, chills, changes in blood tests on days 8-12 after surgery should alert the doctor to the possibility of an abdominal abscess.

An abscess can form in the right iliac fossa, in the small pelvis, and even be interintestinal.

The diagnosis is made according to ultrasound, CT ( computed tomography), radiography.

The causes of abscesses are different. This depends on the form of acute appendicitis, the presence of peritonitis, and the location of the appendix.

There is only one treatment for abdominal abscesses - surgery. For interintestinal abscesses, laparotomy is performed. If the abscess is in the right iliac region one must try to open it extraperitoneally (i.e., “without going” into the abdominal cavity). Pelvic abscesses can open through the vagina or rectum.

Intestinal fistula

The next serious complication of appendectomy is the formation of an intestinal fistula, usually a colonic fistula. This is easy to find out: intestinal contents (liquid feces) begin to leak from the wound.

Some patients experience state of shock when you see this, but you shouldn’t be afraid in advance.

Yes, it's very unpleasant. But if there are no other complications, this intestinal fistula will slowly close on its own under the influence of conservative treatment and dressings. You have to resort to wearing a colostomy bag, while not forgetting to treat the skin around the fistula zinc ointment or Lassara paste. When the fistula closes, a postoperative ventral hernia may form.

Pylephlebitis

One of the most severe complications of acute appendicitis is pylephlebitis - purulent thrombophlebitis of the portal vein. It is usually detected early, 2-3 days and up to 2-3 weeks after surgery.

It develops rapidly: the patient’s condition is serious, pain in the right hypochondrium, weakness, tremendous chills, increased body temperature to 39-40 degrees, pouring sweat, yellowness of the sclera and skin. There is an enlargement of the liver, spleen, and sometimes ascites.

Conduct full examination. Powerful conservative therapy with antibiotics, fibrinolytics, and heparin is prescribed. The mortality rate for this pathology remains high.

Conclusions after reading the article

After reading this article, I hope you will draw appropriate conclusions for yourself. And they, oddly enough, are simple.

Do not self-diagnose or self-medicate if abdominal pain occurs. You just need to see a doctor. Only he, after examination and examination, can exclude or confirm the presence of acute surgical pathology in the abdominal cavity.
Carry out treatment at home on time and under the supervision of a doctor chronic diseases, especially purulent ones.
The most difficult people to endure surgical intervention are the elderly and old age, people who are obese, because, as a rule, both of them suffer from cardiovascular and pulmonary diseases.

The topic of “acute appendicitis”, like the topic of “acute abdomen”, is extensive. If you are interested in this topic, write about it in the comments.

Health to everyone. A. S. Podlipaev

Recommendations are given for informational purposes only and are of a preliminary informational nature. Based on the recommendations received, please consult a doctor, including to identify possible contraindications! Taking recommended medications is possible ONLY IF THEY ARE GOOD TOLERATED BY PATIENTS, TAKEN INTO ACCOUNT OF THEIR SIDE EFFECTS AND CONTRAINDICATIONS!

Rehabilitation after appendicitis lasts about two months, during which the patient must adhere to certain restrictions. Its duration depends on general condition the patient’s health, his age and the presence of complications before or after surgery.

The first days after appendectomy it is necessary bed rest

Young and middle-aged people who adhere to active image life. Children and overweight patients take longer to fully return to normal life.

First days after surgery

Upon completion, the patient is transported on a gurney to the ward, where he will be under close supervision of medical staff to monitor the process of recovery from anesthesia. In order to prevent suffocation in the event of vomiting, which may be caused side effect drug, the patient is turned on his healthy side. If there are no complications, then 8 hours after the operation the patient can sit up in bed and make careful movements. After appendicitis is removed, injectable painkillers are prescribed for several days, as well as antibiotics to prevent infectious complications.

If you follow all the doctor's recommendations, recovery after appendicitis surgery usually occurs without complications. The first day is the most difficult for the patient. The time spent in hospital, as a rule, does not exceed 10 days.

During this period the following is carried out:

daily monitoring of body temperature;
regular measurement of blood pressure levels;
control over the restoration of urination and defecation functions;
inspection and dressing of the postoperative suture;
monitoring the development of possible postoperative complications.

When removing appendicitis, the postoperative period, namely its duration, severity and the presence of complications, largely depends on the chosen method surgical intervention(laparoscopy or abdominal surgery).

Nutrition after surgery

Rehabilitation after appendicitis includes following a certain diet for at least two weeks. On the first postoperative day you cannot eat, you are only allowed to drink regular and mineral water without gas or kefir with 0% fat content. On the second day, you need to start eating to restore the gastrointestinal tract. You should eat foods and feel a feeling of heaviness in the intestines. The diet should be fractional: it is recommended to eat food in small portions, divided into 5 or 6 meals.

Recommendation: In the postoperative period, consumption of low-fat fermented milk products is beneficial. They will contribute to the rapid normalization of the gastrointestinal tract and the restoration of intestinal microflora disturbed after the use of antibiotics.

Low-fat fermented milk products have positive influence on the gastrointestinal tract in the postoperative period

Products allowed for consumption during the postoperative period

For the first three days after surgery, you need to eat easily digestible food with a jelly-like or liquid consistency. The following products are allowed:

liquid porridge;
liquid purees from potatoes, carrots, zucchini or pumpkin;
rice water;
low-fat kefir or yogurt;
pureed boiled chicken meat;
chicken broth;
jelly and jelly.

On the fourth day, you can add black or bran bread, baked apples, pureed soups with dill and parsley, hard cereals, boiled meat and lean fish. With each subsequent day, it will be possible to expand the list of products more and more, gradually returning to the patient’s usual diet. The diet used should be in mandatory agreed with the attending physician. Despite some restrictions, a complete diet rich in vitamins and minerals is necessary, since during the rehabilitation period the body needs additional support.

Drinks allowed include rosehip decoction, freshly squeezed diluted juices, compotes, still mineral water, herbal or weak black tea. The amount of liquid consumed per day should total 1.5–2 liters.

Products prohibited for consumption during the postoperative period

When discharged from the hospital, for another 14 days of the postoperative period after removal of appendicitis, it is not allowed to consume foods that lead to irritation of the mucous membrane, the formation of gases and fermentation processes in the intestines. First of all, the purpose of such a diet is to prevent rupture internal seams and reducing the food load on the body. The following rules must be followed:

limit the amount of salt;
do not add spices and seasonings when cooking, as well as ketchup and mayonnaise;
exclude legumes from the diet;
give up rich bakery products;
avoid eating vegetables such as tomatoes, peppers, cabbage and raw onions;
completely eliminate smoked meats, sausages, fatty meats and fish.

During the postoperative period, it is also not allowed to drink carbonated drinks, juices from grapes and cabbage, and any drinks containing alcohol.

Physical activity in the postoperative period

During the rehabilitation process after appendectomy, it is necessary to adhere to certain restrictions on physical activity. This will speed up recovery and minimize the risk of possible complications. You are allowed to get out of bed and start walking three days after the operation. At first recovery period It is recommended to use a support bandage, especially for overweight patients.

Tip: to prevent the sutures from coming apart, it is recommended to hold your stomach when making sudden movements such as sneezing, coughing, or laughing.

A sedentary lifestyle during the rehabilitation process is no less dangerous than high physical activity. It can cause the formation of adhesions, poor circulation, or the development of muscle atrophy. In this regard, almost immediately after the operation, in agreement with the doctor in supine position it is recommended to do special complex Exercise therapy.

In the first two months physical activity should be limited to daily walking and therapeutic exercises. During this period, it is prohibited to carry or lift weights weighing more than 3 kg. After 14 days after surgery, if there are no contraindications, it is allowed to resume sex life. When the postoperative scar has completely healed, a visit to the pool is recommended.

You can learn more about nutrition rules after appendectomy from the video:

Removal of appendicitis has long been recognized as one of the safest and easiest operations, which can be easily tolerated by both adults and children. However, mistakes cannot be ruled out here either: during the surgical intervention itself and in the postoperative period. Therefore, it is so important to know all the rules and stages of treatment of acute appendicitis after surgery - this will help to avoid complications and return to normal routine as quickly as possible.

Treatment after surgery to cut out appendicitis (appendectomy) does not have a specific time frame - it is individual for each patient. How many days does recovery after an appendectomy last on average? Usually this is one and a half to four weeks; for children under 10 years of age, the elderly and obese people, the time increases. Young and slender patients return to their usual rhythm of life much faster.

If no complications arise in the first 3-7 days after excision of the appendix, the patient is discharged, explaining the basic rules for further behavior. It is on their strict adherence that it depends on how many days a person will be able to live a normal preoperative life.

Every day you need to go for a walk fresh air over short distances.
You can go to the pool and play sports only when a scar has formed after appendix removal (up to 2-6 months).
Lifting weights is prohibited for the first 2.5-3 months after appendicitis is removed.
Overweight patients and active sports people are recommended to wear a bandage for 3-7 days after surgery, and for several more months during any physical activity.
Sexual activity is allowed 2 weeks after surgery.

The first day after appendectomy

In the first 48 hours after surgery, patients are not given any special treatment - the main emphasis is on recovery measures: physical therapy, diet, and painkillers if necessary.

A standard operation to cut out the appendix takes 30-40 minutes, then the patient is transferred to the ward. How many days later can I go home? Official sick leave after an appendectomy usually does not exceed 2 weeks; after 3-4 days of hospitalization, the patient can be released for outpatient treatment.

The most important 24 hours in the rehabilitation process are immediately after an appendectomy. Surgical removal appendix is produced mainly under general anesthesia, and in the first hours after surgery it is especially important to ensure proper recovery from anesthesia. The biggest health hazard during this period is vomiting. To prevent vomit from getting into respiratory tract and did not provoke pneumonia or suffocation, the patient should be placed on the right side at the first urge.

For 12-24 hours after waking up, any food or drinking plenty of fluids. If there are no contraindications, you can give boiled, still mineral water or weak tea with sugar every 20-30 minutes - 2-3 teaspoons at a time.

Restrictions and prohibitions in the postoperative period

For the first 24 hours after surgery, patients must strictly adhere to strict bed rest. After how many hours can you move and walk? For 8-12 hours you need to lie motionless in bed, then you can sit up and turn around, after 24 hours you can get up and slowly move along the corridors (in consultation with the doctor!).

Eating is allowed every other day, provided that the patient does not experience bouts of vomiting. For the first 8 days it is important to follow strict postoperative diet, then you can gradually return to your usual diet.

Increased physical activity is strictly prohibited for several days, but physical inactivity is also very dangerous - it can provoke constipation, muscle atrophy, congestion in the lungs, and disturbances in blood and lymph flow. The ideal solution is special therapeutic exercises after acute appendicitis.

Sutures after appendectomy are removed on the 4-8th day, but only a couple of months after operational impact you can swim and do athletics (running, dancing, jumping, etc.). When 3-6 months have passed and the scar is fully formed, heavy physical activity is allowed.

Therapeutic exercises after appendicitis

A set of physical therapy exercises (PT) after acute appendicitis is recommended for patients of all ages - this is an excellent prevention of congestion, intestinal paresis, thrombophlebitis, pneumonia and intestinal adhesions. How many days does a physical therapy course last? It is necessary to do gymnastics after appendectomy for the first 3-4 days after the operation, while the patient is on bed rest, then in consultation with the attending physician.

All exercises are performed from the starting position “lying on your back”, the number of approaches is 5-6 times.

Legs lie straight on the bed, arms along the body. Bend and unbend ankle joint both legs.
Legs straight, arms bent at the elbows. Bend and straighten your fingers into a fist.
Legs bent at the knees, place one hand on the chest, the other on the surgical suture. As you inhale, pull your stomach in, and as you exhale, push it out.
Legs straight, hands raised to shoulders. Alternately perform circular movements shoulder joint- forward and backward.
Legs lie straight, hands on shoulders. Bend your knees and straighten them, your heel should slide along the bed.
Legs are together, the left arm is extended along the body, the right arm lies on the stomach, on the surgical suture. As you inhale, raise left hand up, exhale and lower.

The most important diet rules after appendix removal

Treatment after appendix removal primarily involves following a gentle diet. A special treatment menu will reduce the burden on a weakened body, restore and give strength, and also prevent problems with stool and other complications.

To make recovery after acute appendicitis as easy as possible, it is important to follow the rules of the postoperative diet.

You need to eat fractionally: in modest portions 5-6 times a day. This will reduce the load on the intestines, and the patient simply will not have time to get hungry.
For the first 2-3 days after acute appendicitis, no solid food: only liquids, porridge, jelly and puree.
Food should not be ice cold or very hot - this irritates the already weakened intestines.
The basis of the menu is drinks, pureed and steamed food.

All patients are concerned with the question: after how many days can they again eat sweets, fried foods, salty foods, smoked foods and alcohol, and add their favorite spices to food? Doctors definitely recommend abstaining completely from junk food and drinks for 2-3 weeks, and then gradually introduce them into the diet - up to 2 months.

Features of the diet after acute appendicitis

How many days should the therapeutic diet last? It is necessary to return to a normal diet in stages: for the first day after surgery you will have to do without food at all. On the 2-3rd day, the basis of the hospital diet should be liquid porridge, chicken broth, pureed vegetable purees and jelly, rosehip infusion and rice infusion.

Then you can add bread, steamed chicken cutlets, light vegetable soups, steamed omelette, low-fat sour milk, after 4-5 days - fruit.

The first three days after removal of the appendix, any solid food, milk, pea and bean soups, potatoes, grapes, fresh cabbage, products with increased content fiber.

For 2-3 weeks you will have to completely forget about alcohol, sausages, sweets and cakes, fatty and smoked dishes. Any homemade preparations, marinades and canned goods will also have to be hidden away. It is necessary to give up strong tea, coffee and soda - they are replaced by still mineral water, weak tea, herbal infusions, jelly, fruit and vegetable fresh juices.

After 2-2.5 months, you can completely return to the pre-operative menu and favorite dishes.

Possible complications after surgery

Typically, an appendectomy is quick and without serious consequences for the patient, but there are exceptions. Complications, as a rule, arise after surgery with advanced appendicitis with peritonitis, non-compliance with rehabilitation rules in the first days and weak immunity of the patient.

Acute appendicitis can cause the following complications:
Wound infection – pus, formation of inflammatory infiltrate, abdominal wall abscess.
Large blood loss, resulting in interruptions in work cardiovascular system.
Peritonitis (inflammation of the peritoneum).
Intestinal adhesions and postoperative hernia.
Respiratory system disorders - bronchitis and pneumonia.
Constipation, bloating, gas and urinary retention.
Intestinal fistula is a hole in the wall of the intestine through which its contents (bile, feces, undigested food) are thrown out.

Fever after appendectomy

An increase in temperature to 38º is a very common occurrence after an appendectomy. She might be natural reaction body or signal possible complications - it all depends on how many days the temperature lasts.

The main causes of fever after acute appendix:

Infection due to non-compliance with sanitary rules.
Damage internal organs during appendectomy and the development of inflammation.
A sharp decrease in immunity.
Severe blood loss.
Reaction to the installation of a drainage tube.

The norm is to preserve elevated temperature body up to 3 days if the fever lasts longer and is accompanied by severe chills and increased sweating, additional treatment is prescribed.

A course of antibiotics (depending on the causative agent of the postoperative infection).
Antipyretic drugs (aspirin, paracetamol, etc.).
Anti-inflammatory drugs (ibuprofen, etc.).
In emergency cases, additional surgical intervention is required.

Treatment of complications

Serious complications after acute appendicitis occur in 5-10% of all cases and require serious complex treatment. How many days after surgery do such dangerous consequences appear?

Suppuration of the wound, the appearance of infiltrate and abscess usually make themselves felt on the 3-4th day after removal of the appendix. The main symptoms are pain, fever, problems with bowel movements, noticeable swelling in the scar area). Treatment involves novocaine blockades, antibiotics, and physiotherapeutic procedures. At favorable outcome after 2-3 days the inflammatory process stops.

For pulmonary and cardiovascular complications therapeutic exercises, antibiotics, inhalations are necessary. For intestinal fistulas, conservative treatment is also used; vacuum therapy is also effective.

The most dangerous consequence acute appendicitis is peritonitis. It occurs quite rarely and only in destructive forms of the disease. The main symptom is persistent pain after surgery, followed by nausea and vomiting, dry mouth, gas and bloating, and constipation. There is only one treatment in such cases - repeated surgery.

Acute appendicitis is a fairly common disease. If you contact a surgeon in time and follow all medical recommendations in the postoperative period, the recovery process will go as quickly as possible. However, in advanced cases, the disease can cause complications, and how many days the recovery will last will depend only on the correct and complete treatment after surgery.

In the postoperative period special treatment not performed on patients. Only physical therapy and painkillers at night (if necessary) are prescribed. For special indications, give cardiovascular and other medicines. Essential has physical therapy, which should be carried out for all patients. The next day after surgery, patients can walk. Permission to get up and walk must be taken into account the individual characteristics and condition of the patient.

As noted, an indispensable condition is the use of methyluracil in the postoperative period: the postoperative period in patients is easier, the number of complications becomes insignificant. Sutures are removed 4-5 days after surgery. Over the past 8 years, there have been no deaths due to acute appendicitis in our clinic.

Postoperative complications

After an appendectomy, complications most often develop in the wound and in the abdominal cavity. However, complications from the respiratory, cardiovascular and genitourinary systems may occur.

The incidence of complications ranges from 2 to 19-20%. According to V.P. Radushkevich et al. (1969), complications are 4.6%. The greatest number of complications arise from destructive forms of appendicitis. G.G. Karavanov et al. (1969) reported that after appendectomy for catarrhal appendicitis, complications developed in 0.74% of patients, for phlegmonous - in 3.02%, for gangrenous - in 9.37%, for perforated - in 25.66% ; the most common complications are wound suppuration (6.72%), peritonitis (1.99%) and pneumonia (1.9%) - Appendectomy can be complicated by intestinal fistulas, which form in 0.05-0.02% of patients. B.A. Vitsin (1969) notes in recent years increase in the number of intestinal fistulas.
M.I. Kolomiychenko et al. (1971) give detailed analysis reasons for the formation of intestinal fistulas after appendectomy.

The most important measure in the treatment of intestinal fistula is the suction of intestinal contents using a vacuum device until the fistula forms. Abscesses of the wall of the cecum in the area of the stump of the appendix are rare (0.1% - according to A. G. Sutyagin, 1973), they require relaparotomy. Untimely intervention can lead to the formation of phlegmon, breakthrough of an abscess into the abdominal cavity, or the formation of an infiltrate.

Complications of the wound process

The most common complication is the formation of an inflammatory infiltrate and wound suppuration. In the first two days, the patient’s condition does not cause concern, but on the third day, after a short subsidence of postoperative pain in the wound, they reappear and soon acquire a pulsating character. By this time, the temperature, which has dropped after the operation, rises again to 38-38.5°. The activity of patients is reduced, they spare the stomach when moving and prefer to lie down. Upon removal of the bandage, swelling of the tissues in the wound area, threads cut into the skin and hyperemia of the skin are detected. Skin is hot. Even a light touch causes severe pain. Upon palpation, a dense painful infiltrate is determined, located in the subcutaneous tissue, deep in the abdominal wall or covering its entire thickness.

Infiltrates vary in prevalence.

If appropriate measures are not taken, then with increasing pain, persistence of high temperature, increased toxic changes in the blood and urine for several days, signs of abscess formation of the infiltrate appear (decreased density, clearer boundaries, ripples). Subsequently, the abscess becomes chronic course, and along with the stable general condition of the patient or its gradual deterioration (emaciation, pallor, bad dream, loss of appetite, stool retention) the inflammatory process involves the skin in the process and opens up on its own. With subcutaneous abscesses, the process resolves in a shorter time.

Recognition of infiltrates and abscesses of the abdominal wall in the wound area is clear from the above clinical picture.

An alarming moment, definitely indicating an unfavorable course of the wound process, is the appearance or intensification of pain on the 3-4th day after surgery and an increase in temperature. Pain in the wound area and determination of infiltrate on palpation complete the diagnosis. Blood testing is of undoubted importance in diagnosis and, moreover, late stages, urine,. The earliest recognition of inflammatory complications is very important. It was previously noted that if treatment is started at a time when the inflammatory process is in the infiltration stage, it is possible to reverse its development with timely targeted treatment.

Treatment should begin with the immediate implementation of a bilateral lumbar novocaine blockade. The therapy is complemented by antibiotics, cold on the abdomen, UHF, and other physiotherapeutic procedures, the nature of which is determined by the attending physician together with a physiotherapy specialist. Timely treatment measures eliminate the acute inflammatory process within 2-3 days, and the patient recovers.

If conservative treatment does not have an effect and signs of abscess formation appear, you should turn to surgical treatment. In case of subcutaneous suppuration, the sutures are removed, the edges of the wound are spread wide, the purulent-necrotic masses are removed and the cavity is tamponed with tampons moistened with a 0.5% solution of chloramine or a solution of furatsiln 1:5000. In cases of localization of the abscess in the thickness of the abdominal wall, especially when abscess formation is recognized 8-9 days after surgery, it is necessary to local anesthesia or under anesthesia, dissect the tissue layer by layer and open the purulent cavity. After surgery, the wounds heal, gradually filling with granulations. After cleansing the wounds from purulent-necrotic masses, ointment dressings are used, then secondary sutures are applied.

In the vast majority of patients, the described complications end without a trace, however, with significant destruction of the muscles and aponeurosis, hernias may subsequently develop. Postoperative hernias in the area of the scar after appendectomy are not very rare.

Hematoma. Insufficient hemostasis can lead to hematoma formation. Most often, hematomas are localized in the subcutaneous fatty tissue, less often in the muscles. The next day the patient complains of a feeling of pressure or dull pain in the wound area. There is noticeable swelling in the right iliac region, moderate uniform pain.

Sometimes swaying is detected.

Treatment consists of partial removal of sutures and removal of hematoma (blood, blood clots). After this, the wound is sutured and pressure bandage and cold. If the hematoma is represented by uncoagulated blood, then it can be evacuated by puncture with a thick needle (after skin anesthesia). Treatment should begin immediately after recognition of the hematoma. Otherwise, the hematoma may fester or cause extensive scarring of the abdominal wall.

Dehiscence of wound edges. The apparently smooth course of the postoperative period is sometimes complicated by the divergence of wound edges without visible signs of inflammation. Dehiscence of the wound edges occurs immediately after the sutures are removed. The occurrence of this complication is associated with a decrease in regenerative processes, vitamin deficiencies, and a general decrease in the body’s defense reactions. Dehiscence of the wound edges often occurs when the sutures are removed (with the usual management of the postoperative period) in the early stages - 4-5 days after surgery. It should be noted that without the use of regeneration stimulants, sutures can be removed after 7 days, because only by this time a scar begins to form (the maturation of connective tissue is microscopically detected). With the use of methyluracil and inert suture material, we remove the sutures after 4-5 days and never* get dehiscence of the wound edges. Morphological and physical methods studies carried out in our laboratory and in many other institutions show that maturation of connective tissue during treatment with methyluracil occurs 2-3 days earlier than in control observations.

Bleeding. A rare but serious complication is bleeding from the stump of the mesentery of the appendix when the ligature slips. In the first hours, bleeding is asymptomatic, and only with significant blood loss do signs of acute blood loss appear and very mild pain all over the belly. If the bleeding is moderate, then the general condition of the patient is satisfactory. Pain in the abdomen, initially weak or moderate, gradually increases in strength, and when the blood is infected, it becomes severe, accompanied by nausea, repeated vomiting, bloating, retention of stool and gases, i.e. symptoms of increasing diffuse peritonitis appear.

During an objective examination, the patient's anxiety, pallor, rapid pulse, and coated tongue are noteworthy. At first, the abdomen has the correct shape, moderately painful, with signs of peritoneal irritation. In sloping areas of the abdomen, it is sometimes possible to determine the presence of free fluid. Intestinal peristalsis sounds are reduced. When examining with a finger through the rectum, pain is noted pelvic peritoneum. In case of blood infection, symptoms characteristic of peritonitis appear.

Careful observation of the patient after surgery and a thoughtful explanation of each symptom of trouble will allow a timely diagnosis of intra-abdominal bleeding. Diagnosis is often hampered by the doctor's attempts to explain abdominal pain, signs of anemia, peritoneal irritation and other symptoms to the diagnosis. surgical intervention And hypersensitivity sick. It should be emphasized that irritation of the peritoneum in the presence of blood in the abdominal cavity in the first days is weak and may be completely absent. In doubtful cases, the issue must be resolved in favor of relaparotomy - re-opening the abdomen. An important role in diagnosis is hourly observation of the patient with the indispensable recording of the following indicators:

1) the patient’s condition (better, worse), 2) pulse, 3) the condition of the abdomen, including the severity of the Shchetkin-Blumberg symptom. Such observation will allow the most short term resolve doubts in diagnosis.

It is clear that the only method of treatment is relaparotomy, during which a revision is performed, the bleeding is stopped and the blood and its clots are removed. Before suturing, it is advisable to inject a solution of methyluracil with antibiotics into the abdominal cavity.

Infiltrates and abscesses. Most often, infiltrates are formed in the right iliac region, near the cecum, after operations for destructive appendicitis in the presence of effusion, fibrinous-purulent deposits and involvement of nearby organs in the process. The formation of infiltrates is facilitated by remaining pieces of dead tissue, contents that have fallen out of the appendix, and thick silk or catgut ligatures. Sometimes infiltrates form without visible reasons. In such cases, one must think about the high virulence of the infection and the decrease in the body’s defenses.

Postoperative infiltrates appear 5-6 days after surgery. From the first days, patients have noticeably more severe course postoperative period: they are pale, the pain almost does not disappear, and after three days it becomes quite severe, the temperature rises to 38-39°, the pulse is frequent, stool is retained. By the 5-6th day, a dense, painful formation is detected in the abdominal cavity. Treatment tactics are the same as for appendiceal infiltrates formed before surgery: bilateral lumbar novocaine blockade, antibiotics, cold on the stomach, rest. Subsequently - thermal procedures.

Infiltrates and abscesses can be localized in other parts of the abdominal cavity: in the pelvis, between the loops small intestine, under the diaphragm, under the liver. Quite often, infiltrates form in the pouch of Douglas, in women, and between the rectum and bladder in men. This pocket of the pelvic peritoneum is quite deep and narrow, overlapped from above by loops of the small intestine and partially by the cecum and sigmoid colon, which contributes to the accumulation and retention of effusion and pus here, and consequently, the formation of infiltrates and abscesses. Most often, infiltrates and abscesses of the pouch of Douglas are formed with destructive appendicitis and a low position of the cecum. In such cases, exudate accumulates in the pelvic recess of the peritoneum and becomes the cause of an abscess if it is not completely removed during surgery. In the space of Douglas it can be delimited purulent exudate, formed during diffuse or limited peritonitis.

An infiltrate forms in the pelvic cavity, involving adjacent organs in the inflammatory process: loops of the small intestine, rectum, cecum, uterus, etc. appendages in women, bladder, pelvic walls. When abscess formation occurs, a cavity is formed here containing different quantity pus: from 100-150 to 1000 or more milliliters.

The clinical picture of abscesses in the pouch of Douglas in many patients is quite expressive. 4-6 days after the operation, sometimes against the background of a fairly favorable course, the patient develops or intensifies pain in the lower abdomen, a feeling of discomfort in the anus, an increase in temperature to high numbers, which subsequently acquires a hectic character. Soon a frequent urge to nag follows. defecation, tenesmus, mucus discharge from the rectum, as well as frequent painful urination. .These disorders are explained by the involvement in the inflammatory process of the nerve elements that innervate pelvic organs, And mechanical pressure formed infiltrate.

The patient's general condition worsens, pallor and weakness increase, the patient noticeably loses weight and refuses food. The abdomen is somewhat protruded above the pubis or above the Pupart's ligament, and is painful. Large infiltrates are determined by palpation of the abdomen. Infiltrates located deep in the pelvis are inaccessible to palpation from the abdominal wall, which in such cases has regular form and may be involved in respiration. Of great importance in recognizing inflammatory infiltrates of the pouch of Douglas is examination with a finger through the rectum in men and children and through the vagina in women.

The writing of the anterior wall of the rectum or the posterior wall of the vagina (posterior fornix) and a dense painful infiltrate, which sometimes sharply deforms the hollow organs of the small pelvis (compresses them), are determined. When the infiltrate abscesses, an area of softening is detected - ripple (fluctuation) (Fig. 91).

We must remember the need for digital examination of the rectum in all patients in the postoperative period with an unexplained increase in temperature, abdominal pain and other symptoms indicating trouble in the abdominal cavity.

As in all patients with suppurative complications in the postoperative period, with infiltrates and abscesses of the pouch of Douglas there are changes in the blood: leukocytosis, a shift in the white blood count to the left, accelerated ROE, etc.

If you do not intervene in a timely manner during the infiltration, it will abscess, the suppurative process will progress and can break into the abdominal cavity - a lightning-fast general purulent peritonitis ending in the death of the patient. A prolonged purulent process, accompanied by hectic temperature and severe intoxication, causes dystrophic changes in vital organs, disrupts metabolic processes, which sharply reduces defensive reactions body. Therefore, the breakthrough of the abscess and the occurrence of severe peritonitis is the last link in this tragic situation. Even immediate recognition of an abscess breaking into the abdominal cavity and the operation undertaken are useless in such cases - the patient dies in the next few hours.

Less commonly, ulcers break out through abdominal wall, into the small or large intestine, and then recovery can occur. A case of emptying of a huge abscess (about two liters of pus) of the pouch of Douglas through the fallopian tube, uterus and vagina is described, which ended with the patient’s recovery. But one cannot count on such outcomes. We need to intervene in inflammatory process first, conservative, and then, when indicated, surgical methods of treatment.

Treatment of infiltrates of the pouch of Douglas is the same as for infiltrates of other localizations. Additional measures include: warm enemas with furatsilin, enemas with novocaine, hot douching in women.

Unfortunately, infiltrates of the pouch of Douglas rarely resolve. They abscess and require surgery. The operation is performed on the rectal side in men, and on the vaginal side in women. It is best to operate under anesthesia. The rectum is opened wide with hooks and thoroughly treated with a 2% solution of chloramine and iodine. In the midline of the rectum at the site of the greatest protrusion (where softening is determined), a puncture is made with a thick needle and, having obtained pus, the tissues are bluntly separated through the needle and the abscess is emptied. The cavity is treated with a 2% chloramine solution and drained with a rubber or polyethylene tube, the end of which is removed through anus out. It is even better to insert two tubes, which will allow you to rinse the cavity 2-3 times a day with an antiseptic liquid or antibiotics, to which the flora in this patient is sensitive. A similar operation is performed in women, but the hyoid is opened from the vaginal side, cutting its posterior fornix. The purulent cavity, freed from purulent masses, decreases in size and gradually heals. Immediately after surgery the temperature drops to normal numbers, and literally before our eyes the patient gets better, quickly freeing himself from all the symptoms of his former purulent process.

The clinical picture, diagnosis and treatment of infiltrates and abscesses in other areas of the abdomen are similar to those described.

The only difference is the localization of the process, which affects the clinical course and the choice of surgical treatment method (approach). So, subphrenic abscesses are accompanied by pain when breathing, dry cough (Troyanov's symptom), expansion, protrusion and sharp pain of the lower intercostal spaces (Kryukov's symptom) and require special approaches during surgery, of which extrapleural and extraperitoneal ones should be considered the best. Each infiltrate and abscess of the abdominal cavity must be studied in depth and a treatment method must be thoughtfully chosen, taking into account topographic and anatomical data and the individual characteristics of the patient.

Peritonitis

The most serious complication after appendectomy is peritonitis- inflammation of the peritoneum. Peritonitis after surgery for appendicitis occurs rarely and, as a rule, in patients with destructive forms diseases. Peritonitis after appendectomy is especially alarming. This danger, this anxiety is due to the fact that symptoms of peritonitis appear in a patient in the postoperative period. The doctor, to a certain extent, has reason to associate the patient’s pain, anxiety and deterioration in condition with the characteristics of the postoperative period, with the instability of the patient’s neuropsychic status.

How does peritonitis manifest in patients after appendectomy? The leading symptom of peritonitis is pain, which gradually intensifies, instead of disappearing 1-2 days after surgery. The pain is constant, severe, causing the patient to moan and behave restlessly. Nausea and repeated vomiting, which does not provide relief, soon follow.

Postoperative peritonitis is often accompanied by hiccups, which indicates the spread of inflammation to the diaphragmatic peritoneum. The patient's condition worsens, the pulse becomes frequent (does not correspond to the temperature), facial features sharpen, the tongue becomes dry and coated with a brownish coating, stool is retained, gases do not pass away, the abdomen is initially tense and then becomes swollen. During auscultation, rare weak peristaltic sounds are detected, then disappearing altogether. Symptoms of peritoneal irritation are clearly expressed. The blood picture worsens and changes dramatically biochemical parameters. The daily amount of urine decreases.

The above symptoms, even if they are mild, dictate the need for immediate surgical intervention.

It is necessary to do a relaparotomy. There can be no explanation for refusing surgical intervention in the presence of symptoms of peritonitis, and if this rule is well remembered and felt, then errors in the surgeon’s tactics in the treatment of peritonitis, both preoperative and postoperative, will be extremely rare.

The operation consists of opening the abdominal cavity, revision, eliminating the cause of peritonitis and drainage. With limited peritonitis in the right iliac region, the abdominal cavity can be opened by removing the sutures from the wound and spreading its edges. Generalized peritonitis requires midline laparotomy. The operation is best performed under general anesthesia. More detailed information about peritonitis will be given in the corresponding chapter.

Other complications

In the postoperative period, complications from other organs and systems are possible. In spring and autumn, bronchitis and pneumonia often occur. The most important prophylactic These complications are treated with therapeutic exercises, which should be started from the first day after surgery. In the first hours after the operation, the patient is recommended to bend and straighten his legs, do breathing exercises, turn on your side. In the following days, the methodologist conducts gymnastics according to a special scheme and gives tasks to the patients for the whole day. If there is no methodologist in the department, physical therapy classes are assigned nurse. Therapeutic exercise in the vast majority of patients, even the elderly and weakened, by providing good ventilation of the lungs and maintaining normal tone of the cardiovascular system, it prevents pulmonary complications.

Nowadays, pulmonary complications are rare. When they appear, antibiotics, sulfa drugs, cupping, cardiovascular and expectorant medications, and inhalations are prescribed. Pulmonary complications are of greatest concern in the elderly. Treatment is best done together with a therapist.

After appendectomy, urinary retention may occur, which is caused by reflex effects from the surgical wound or the patient’s inability to urinate in a supine position. Timid, shy people sometimes do not talk about urinary retention and suffer seriously. They complain of pain in the lower abdomen and behave restlessly. An objective examination can reveal bloating, sharp pain on palpation, muscle tension, and even the Shchetkin-Blumberg symptom. After urine evacuation, all alarming symptoms disappear, the patient calms down. From this we can conclude: it is imperative that every patient in the postoperative period be asked about urination. For urinary retention, use the most simple methods: warm heating pad on the lower abdomen, gentle diuretics, methenamine (0.25), irrigation of the external genitalia with warm water. Good effect gives a conditioned reflex effect: the patient is taken on a gurney to the dressing room and the water tap is turned on, or in the ward a thin stream of water is poured from a jug into a basin. The murmuring stream of water has a reflex effect on the function bladder. Sometimes, to eliminate urinary retention, it is enough to raise the patient to his feet. If listed. the measures do not have an effect, then they resort to catheterization of the bladder. This procedure must be carried out under strictly aseptic conditions.

Acute appendicitis may be accompanied by severe, often life-threatening complications. These include appendiceal infiltrate (abscess), intra-abdominal ulcers, peritonitis and pylephlebitis. Appendicular infiltrate usually develops on the 2-4th day of the disease and is expressed in the appearance in the right iliac region, less often in other places, of a limited, painful, dense and immobile formation of various sizes. On palpation, local pain is determined. The Bloomberg-Shchetkin symptom can persist for several days. The temperature is increased to 37-38°C, the blood shows moderate leukocytosis with a shift to the left.

It is believed that appendicular infiltrate is one of the forms of limited peritonitis, its outcomes are very variable. Infiltration is a wolf in sheep's clothing"(L. G. Brzhozovsky). With a favorable course, it undergoes resorption in most patients. However, in a number of cases, its suppuration may occur, which is manifested by increased abdominal pain, a further increase in temperature, an increase in leukocytosis, a deterioration in the general condition, an increase in the size of the infiltration, the appearance of blurring of its boundaries, sometimes fluctuations and severe symptoms peritoneal irritation.

Peritonitis is one of the most dangerous complications acute appendicitis and is one of the main causes of death. His clinic and treatment are described in a special chapter.

Complications of appendectomy can be from the side of the wound (local), intra-abdominal and systemic. Local include hematomas, suppurations, inflammatory infiltrates and ligature fistulas. Hematomas occur in the first days after surgery. There is pain and swelling in the suture area. Emptying the hematoma is the main method of eliminating it. Wound suppuration is the most common complication operations. It also occurs in 1-6% of cases, depending on the form of appendicitis. Treatment of suppuration consists of removing sutures, spreading the edges of the wound, applying bandages with antibacterial agents and enzymes, immunotherapy in accordance with the phases of the wound process.
With inflammatory infiltrates antibiotics and physiotherapeutic procedures (quartz, UHF, electrophoresis, etc.) are prescribed.

Complications from the abdominal cavity are classified as severe and life-threatening and include intra-abdominal abscesses (pelvic, subdiaphragmatic, interintestinal, retroperitoneal), limited and diffuse peritonitis, pelyphlebitis, intestinal obstruction, intra-abdominal bleeding and intestinal fistulas. Abscesses after acute appendicitis account for 19% of intra-abdominal abscesses. Pelvic abscesses occur when destructive appendicitis is localized in the small pelvis or in cases where exudate descends into it from other parts of the abdomen. Usually, on the 7th to 12th day after surgery, the temperature rises again and leukocytosis increases, pain appears above the womb or in the depths of the pelvis.

Often dysuric disorders are observed, as well as pain during defecation, tenesmus. A rectal or vaginal examination reveals a painful overhanging infiltrate, often with softening. Treatment consists of opening the abscess through the rectum in men and through the posterior fornix in women.

Subphrenic abscess observed in 0.1-0.5% of cases and occurs with high temperature, severe intoxication, shortness of breath, chest pain on the affected side when inhaling. Diagnosis is relatively difficult. Treatment consists of opening the abscess, preferably through an extraperitoneal or extrapleural approach. Interintestinal abscesses and the period of forms of provania are characterized by poor clinical picture, however, later, as the abscess enlarges, signs of purulent intoxication appear and a painful formation is determined, most often in the navel area or to the left of it with muscle tension, positive symptom Bloomberg - Shchetkin. Treatment is opening and draining the abscess.

Rare but very dangerous complications include pylephlebitis, or ascending thrombophlebitis of the portal vein with pyaemia and multiple liver abscesses. It is characterized by an extremely severe purulent-septic course, rapidly increasing intoxication, high fever, icterus, liver enlargement, tachycardia and hypotension. The prognosis is serious, mortality 90-98%. Treatment consists of administering large doses of antibiotics and prescribing anticoagulants. In the presence of liver abscesses, their opening is indicated. Adhesive process after appendectomy may cause intestinal obstruction in the near future and long term. Systemic complications include thromboembolic complications, pneumonia, acute myocardial infarction, disorders urinary system etc.

More than 1 million are produced annually in Russia. appendectomy with a mortality rate of about 0.2%. The main cause of mortality is the complications of acute appendicitis described above. They are associated with late diagnosis, delayed surgery and its complications. The highest percentage of complications and mortality is observed among children and the elderly.