Fistula after appendicitis. Possible early postoperative complications in appendicitis

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

Mortality after appendectomy, due to diagnostic errors and loss of time, is 5.9% [I.L. Rotkov, 1988]. Causes of death after appendectomy mainly lie in purulent-septic complications [L.A. Zaitsev et al., 1977; V.F. Litvinov et al., 1979; IL. Rotkov, 1980 and others]. The cause of complications is usually destructive forms of inflammation of the HO, spreading to other parts of the abdominal cavity.

According to the literature, the reasons leading to the development of complications leading to repeated operations are as follows.
1. Late hospitalization of patients, insufficient qualifications medical workers, diagnostic errors due to the presence of atypical, difficult to diagnose forms of the disease, which is often found in elderly and senile people, in whom morphological and functional changes in various organs and systems worsen the severity of the disease, and sometimes come to the fore, masking the patient's existing acute appendicitis. Most patients cannot accurately name the onset of the disease, since at first they did not pay attention to mild persistent pain in the abdomen.
2. Delay of surgical intervention in the hospital due to errors in diagnosis, patient refusal or organizational issues.
3. Inaccurate assessment of the prevalence of the process during the operation, as a result - insufficient sanitation of the abdominal cavity, violation of the rules of drainage, lack of complex treatment in postoperative period.

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

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

Naturally, such errors reflect the well-known alertness of doctors in the pre-hospital network in relation to acute appendicitis and, in terms of their significance, cannot be compared with errors of the reverse order. Sometimes patients with appendicitis are either not hospitalized at all, or are not sent to a surgical hospital, which leads to the loss of precious time with all the ensuing consequences. Such errors due to the fault of the polyclinic amount to 0.9%, due to the fault of ambulance doctors - 0.7% in relation to all those operated on for this disease[V.N. Butsenko et al., 1983].

The problem of emergency diagnosis of acute appendicitis is very important, because in emergency surgery from timely diagnosis disease largely depends on the frequency of postoperative complications.

Often, diagnostic errors are observed in the differentiation of food poisoning, infectious diseases and acute appendicitis. Careful examination of patients, monitoring the dynamics of the disease, consultation with an infectious disease specialist, the use of all research methods available in a given situation will greatly help the doctor make the right decision.

It should be remembered that perforated appendicitis in some cases can be very similar in its manifestations to perforation of gastroduodenal ulcers.

Sharp pains in the abdomen, characteristic of perforation of gastroduodenal ulcers, are compared with pain from a dagger strike, they are called sudden, sharp, excruciating. Sometimes such pain can also be with perforated appendicitis, when patients often ask for emergency assistance, they can only move by bending over, the slightest movement causes increased pain in the abdomen.

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

First of all, in the event of an abdominal catastrophe, it is necessary to check for the presence of hepatic dullness both percussion and radiographically. An additional determination of free fluid in sloping areas of the abdomen, a digital examination of the PC will help the doctor establish the correct diagnosis. In all cases, when examining a patient who has severe pain in the abdomen, tension of the abdominal wall and other symptoms indicating the sharpest irritation of the peritoneum, along with perforation of the gastroduodenal ulcer, acute appendicitis should also be suspected, since perforated appendicitis often occurs under the "mask" of an abdominal catastrophe. .

Intra-abdominal postoperative complications are due to both the variety clinical forms acute appendicitis, a pathological process in the ChO, and the mistakes of surgeons of the organizational, diagnostic, tactical and technical plan. The frequency of complications leading to LC in acute appendicitis is 0.23-0.55% [P.A. Aleksandrovich, 1979; N.B. Batyan, 1982; K.S. Zhitnikova and S.N. Morshinin, 1987], and according to other authors [D.M. Krasilnikov et al., 1992] even 2.1%.

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

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

True postoperative peritonitis, which is not a consequence of purulent-destructive changes in the AO, usually develops as a result of tactical and technical errors made by surgeons. In this case, the insolvency of the fossa stump leads to the occurrence of postoperative peritonitis; through piercing of the SC when applying a purse-string suture; undiagnosed and unresolved capillary bleeding; gross violations of the principles of asepsis and antisepsis; leaving parts of the HO in the abdominal cavity, etc.

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

After appendectomy for complicated appendicitis, 0.35-0.8% of patients may develop intestinal fistulas [K.T. Ovnatanyan et al., 1970; V.V. Rodionov et al., 1976]. This complication causes death in 9.1-9.7% of patients [I.M. Matyashin et al., 1974]. The occurrence of intestinal fistulas is also closely related to the purulent-inflammatory process in the region of the ileocecal angle, in which the walls of the organs are infiltrated and easily injured. Especially dangerous is the forcible division of the appendicular infiltrate, as well as the removal of the appendix when an abscess has formed.

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

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

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

Of particular importance is the decrease in blood pressure during surgery. Against this background, VC from transected and bluntly separated adhesions stops, but in the postoperative period, when the pressure rises again, VC can resume, especially in the presence of atherosclerotic changes in the vessels. Errors in diagnosis are also sometimes the cause of unrecognized during surgery or postoperative VC [N.M. Zabolotsky and A.M. Semko, 1988]. This is most often observed in cases where the diagnosis of acute appendicitis in ovarian apoplexy in girls is made and an appendectomy is performed, and a small VC and its source go unnoticed. In the future, after such operations, severe VC may occur.

The so-called congenital and acquired hemorrhagic diatheses, such as hemophilia, Werlhof's disease, long-term jaundice, etc., are of great danger in terms of the occurrence of postoperative VC. Unrecognized in time or not taken into account during the operation, these diseases can play a fatal role. Keep in mind that some of them may simulate acute diseases abdominal organs [N.P. Batyan et al., 1976].

VC after appendectomy is very dangerous for the patient. The reasons for the complications are that, firstly, appendectomy is the most common operation in abdominal surgery, and secondly, it is often performed by inexperienced surgeons, while difficult situations during appendectomy are not uncommon. The reason in most cases - technical errors. The specific gravity of the VC after appendectomy is 0.02-0.07% [V.P. Radushkevich, I.M. Kudinov, 1967]. Some authors give even higher figures - 0.2%. Hundredths of a percent seem to be a very small amount, however, given a large number of performed appendectomies, this circumstance should seriously disturb surgeons.

VC often arise from the artery of the PR due to slipping of the ligature from the stump of his mesentery. This is facilitated by infiltration of the mesentery with novocaine and inflammatory changes in it. In cases where the mesentery is short, it must be bandaged piecemeal. Particularly significant difficulties in stopping bleeding arise when it is necessary to remove the CHO retrogradely. The process is mobilized in stages [I.F. Mazurin et al., 1975; YES. Dorogan et al., 1982].

Quite often there are VC from crossed or bluntly separated and unligated adhesions [I.M. Matyashin et al., 1974]. To prevent them, it is necessary to achieve an increase in blood pressure, if it decreased during the operation, to make a thorough check of hemostasis, to stop bleeding by capturing bleeding areas with hemostatic clamps, followed by stitching and dressing. Measures for the prevention of VC from the stump of the CJ are reliable bandaging of the stump, its immersion in a purse-string and Z-shaped sutures.

VC was also noted from deserized areas of the colon and small intestine[YES. Dorogan et al., 1982; AL. Gavura et al., 1985]. In all cases of bowel deserosis, peritonization of this area is necessary. This is a reliable measure to prevent such a complication. If, due to infiltration of the intestinal wall, serous-muscular sutures cannot be applied, the deserotic area should be peritonized by suturing a flap of the omentum on the leg. Sometimes VC arises from a puncture of the abdominal wall made to introduce a drain, so after passing it through the counter-opening, it is necessary to make sure that there is no VC.

An analysis of the causes of VC showed that in most cases they occur after non-standard operations, during which certain moments are noted that contribute to the occurrence of complications. These points, unfortunately, are not always easy to take into account, especially for young surgeons. There are situations when the surgeon foresees the possibility of postoperative VC, but the technical equipment is insufficient to prevent it. Such cases do not occur often. More often, VC are observed after operations performed by young surgeons who do not have sufficient experience [I.T. Zakishansky, I.D. Strugatsky, 1975].

Of the other factors contributing to the development of postoperative VC, first of all, I would like to note the technical difficulties: extensive adhesions, the wrong choice of anesthesia method, insufficient online access, which complicates manipulations and increases technical difficulties, and sometimes even creates them.
Experience shows VC occur more often after operations performed at night [I.G. Zakishansky, I.L. Strugatsky, 1975 and others]. The explanation for this is that at night the surgeon is not always able to take advantage of the advice or help of an older comrade in difficult situations, as well as the fact that the surgeon's attention decreases at night.

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

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

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

Light bleeding is usually observed from small vessels that are damaged during separation of adhesions, isolation of the HO, with its retrocecal and retroperitoneal location, mobilization of the right flank of the large intestine, and in a number of other situations. These bleedings are the most secretive, hemodynamic and hematological parameters usually do not change significantly, therefore, in early dates these bleedings, unfortunately, are diagnosed very rarely.

One of the most severe complications of appendectomy is acute postoperative NK. According to the literature, it is 0.2-0.5% [MI. Matyashin, 1974]. In the development of this complication, adhesions that fix the ileum to the parental peritoneum at the entrance to the small pelvis are of particular importance. With an increase in paresis, intestinal loops located above the place of inflection, compression or infringement of the intestinal loop by adhesions overflow with liquid and gases, hang into the small pelvis, bending over adjacent, also stretched loops of the TC. A secondary torsion occurs [O.B. Milonov et al., 1990].

Postoperative NK is observed mainly in destructive forms of appendicitis. Its frequency is 0.6%. When appendicitis is complicated by local peritonitis, NK develops in 8.1% of patients, and when it is complicated by diffuse peritonitis, it develops in 18.7%. Gross trauma to the visceral peritoneum during surgery predisposes to the development of adhesions in the ileocecal angle.

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

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

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

The wound is expanded with forceps, injected into the abscess cavity drainage tube, fix it to the skin of the perineum and leave for 4-5 days. In women, when opening an abscess, the uterus is retracted anteriorly. The abscess is punctured and tissue is cut through the needle. The abscess cavity is drained with a rubber tube. After the opening of the abscess, the patient's condition quickly improves, after a few days the discharge of pus stops and recovery occurs.

Intestinal abscesses are rare. With the development long time after appendectomy, a high body temperature persists, leukocytosis with a shift is noted leukocyte formula to the left. On palpation of the abdomen, pain is not clearly expressed at the location of the infiltrate. Gradually increasing in size, it approaches the anterior abdominal wall and becomes accessible to palpation. In the initial stage, conservative treatment is usually carried out. When signs of abscess formation appear, it is drained.

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

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

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

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

Postoperative thrombophlebitis of the mesenteric veins usually occurs when conditions are created for direct contact of a virulent infection with the wall of a venous vessel. This complication is characterized by a progressive course and severity clinical manifestations. It begins acutely: from 1-2 days of the postoperative period, repeated stunning chills, fever with high temperature (39-40 ° C) appear. There is intense pain in the abdomen, more pronounced on the side of the lesion, progressive deterioration of the patient's condition, intestinal paresis, increasing intoxication. As the complication progresses, symptoms of mesenteric vein thrombosis (stool mixed with blood), signs of toxic hepatitis (pain in the right hypochondrium, jaundice), signs of PN, ascites appear.

Significant changes in laboratory parameters are noted: leukocytosis in the blood, a shift of the leukocyte formula to the left, toxic granularity of neutrophils, an increase in ESR, bilirubinemia, a decrease in the protein-forming and antitoxic function of the liver, protein in the urine, formed elements, etc. It is very difficult to make a diagnosis before surgery. Patients usually produce RL for "peritonitis", " intestinal obstruction» and other conditions.

When opening the abdominal cavity, the presence of a light exudate with a hemorrhagic tinge is noted. During revision of the abdominal cavity, an enlarged spotty color (due to the presence of multiple subcapsular abscesses) is found, a dense liver, a large spleen, a paretic cyanotic intestine with a congestive vascular pattern, dilated and tense mesentery veins, and often blood in the intestinal lumen. Thrombosed veins are palpated in the thickness of the hepatoduodenal ligament and mesacolon in the form of dense cord-like formations. Treatment of pylephlebitis is a difficult and complex task.

In addition to rational drainage of the primary focus of infections, it is recommended to recanalize the umbilical vein and cannulate the VV. When cannulating the portal vein, pus can be obtained from its lumen, which is aspirated until venous blood appears [M.G. Sachek and V.V. Anichkin, 1987]. Antibiotics, heparin, fibrolytic drugs, and agents that improve the rheological properties of blood are administered transumbilically.

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

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

To prevent purulent complications, massive antibiotic therapy is prescribed. Carry out oxygen therapy, including HBO therapy. To remove the products of protein breakdown (ammonia intoxication), gastric lavage (2-3 times a day), cleansing enemas, and stimulation of diuresis are recommended. If there are indications, hemo- and lymphosorption, peritoneal dialysis, hemodialysis, exchange blood transfusion, connection of allo- or xenogeneic liver are carried out. However, with this postoperative complication, the therapeutic measures taken are ineffective. Patients usually die from hepatic coma.

Other complications (diffuse purulent peritonitis, NK, adhesive disease) are described in the relevant sections.

Any of the listed postoperative complications can manifest itself in a variety of terms from the moment of the first operation. For example, an abscess or adhesive NK in some patients occurs in the first 5-7 days, in others - after 1-2, even 3 weeks after appendectomy. Our observations show that purulent complications are more often diagnosed at a later date (after 7 days). We also note that in terms of assessing the timeliness of the performed RL, it is not the time elapsed after the first operation that is of decisive importance, but the time since the first signs of a complication appeared.

Depending on the nature of the complications, their signs in some patients are expressed by local muscle tension with or without irritation of the peritoneum, in others by bloating and asymmetry of the abdomen or the presence of a palpable infiltrate without clear boundaries, local pain reaction.

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

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

Summarizing the above, we conclude that the main etiological factors in the development of complications after appendectomy are:
1) neglect of acute appendicitis due to late admission of patients to the hospital, most of whom have a destructive form of the pathological process, or due to diagnostic errors of doctors at the pre-hospital and hospital stages of treatment;
2) defects in surgical technique and tactical errors during appendectomy;
3) unforeseen situations associated with exacerbation of concomitant diseases.

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

For the treatment of postoperative peritonitis caused by the incompetence of the appendix stump after median laparotomy and its detection through the wound in the right iliac region, the dome of the SC should be removed along with the appendix stump and fixed to the parietal peritoneum at the level of the skin; make a thorough toilet of the abdominal cavity with its adequate drainage and fractional dialysis in order to prevent postoperative progressive peritonitis due to insufficiency of interintestinal anastomoses or sutured perforation of the intestine.

For this, it is recommended [V.V. Rodionov et al., 1982] apply subcutaneous removal of a segment of the intestine with sutures, especially in elderly and senile patients, in whom the development of suture failure is prognostically most likely. This is done as follows: through an additional counter-opening, a segment of the intestine with a line of sutures is removed subcutaneously and fixed to the hole in the aponeurosis. The skin wound is sutured with rare interrupted sutures. Pinpoint intestinal fistulas developing in the postoperative period are eliminated in a conservative way.

Our many years of experience show that common causes leading to RL after appendectomy are an inferior revision and sanitation, an incorrectly chosen method of drainage of the abdominal cavity. It is also noteworthy that quite often the surgical access during the first operation was small or displaced relative to the McBurney point, creating additional technical difficulties. It can also be considered a mistake to perform technically complex appendectomy under local anesthesia. Only anesthesia with sufficient access allows for a full revision and sanitation of the abdominal cavity.

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

With appendicular peritonitis late dates admission, even a wide median laparotomy under anesthesia with revision and radical treatment of all parts of the abdominal cavity with the participation of experienced surgeons cannot prevent the development of postoperative complications.

The reason for the development of complications is a violation of the principle of the expediency of combined antibiotic therapy, changing antibiotics during treatment, taking into account the sensitivity of the flora to them, and especially small doses.

Other important points in the treatment of primary peritonitis are often neglected: correction of metabolic disorders and measures to restore the motor-evacuation function of the gastrointestinal tract.
So, we come to the conclusion that complications in the treatment of appendicitis are mainly due to untimely diagnosis, late hospitalization of patients, inadequate surgical access, incorrect assessment of the prevalence of the pathological process, technical difficulties and errors during the operation, unreliable processing of the stump of the AO and its mesentery, and defective toilet and drainage of the abdominal cavity.

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

Inflammation of appendicitis is acute or chronic. Forms of pathology differ in the severity of symptomatic signs of manifestation. Depending on the degree of damage to the mucous membrane of the process of the colon, the number of leukocytes in the epithelium is isolated, phlegmonous, perforative, type of disease.

Pronounced symptoms of the inflammatory process or exacerbation of chronic appendicitis are:

• severe spasms of an acute nature on the right side of the abdominal cavity;
• temperature rise;
• vomiting, nausea;
• allocation of frequent loose stools;
• dryness in the mouth;
• dyspnea.

The main symptom is pain, the intensity of which depends on the position of the body. The sudden cessation of sensation of spasms indicates a lack of functioning nerve cells due to tissue necrosis of the intestinal mucosa.

Holding an emergency surgical intervention after the diagnosis of acute appendicitis - the main way to treat inflammation.

Possible Complications

The progression of inflammation of the colon has several stages of development. The first stage of exacerbation of appendicitis lasts for several days. During this period, structural changes in the mucosal tissue are observed.

The development of appendicitis is associated with the ingress of leukocytes into the deep layers of the appendix, which leads to disruption of the colon, accompanied by severe pain. Failure to provide medical care in the first 5 days after observing spasms in the area of ​​the right inguinal fold leads to complications that pose a serious health hazard.

Preoperative period

The progression of the disease depends on individual characteristics organism. Inflammatory process can go to chronic form, characterized by the absence of symptomatic signs, and may worsen to a critical state.

Dangerous complications of appendicitis in the preoperative period are:

• peritonitis;
• abdominal abscess.

Complications of acute appendicitis occur when untimely treatment for medical care, the chronic nature of the pathology, as well as improper treatment of the disease.

Structural change in internal cells, rupture of the mucous membrane of the colon is observed 3 days after the appearance of symptomatic signs of exacerbation of appendicitis. Damage to the epithelium leads to the spread pathogenic bacteria, pus from the appendix to the abdominal cavity.

The main symptoms of complications of acute appendicitis are:

• pain in the abdomen, deep pelvis;
• high body temperature;
• feverish state;
• cardiopalmus;
• intoxication of the body: headache, weakness, change in the natural complexion;
• constipation.

If symptoms of complications of appendicitis are detected, a visual examination and palpation are performed. Emission of gases, detection of a sign of Shchetkin-Blumberg syndrome ( strong pain during a sharp pressure and release) when pressing on the right side of the abdominal cavity indicates the occurrence of peritonitis of appendicular origin. Untimely suspension of the process leads to the death of the patient.

The inflammatory process of the appendix leads to the spread of pathogenic microorganisms to adjacent processes of the blind, rectum, which are interconnected, forming an infiltrate with pronounced structural boundaries.

The resulting dense bump, located on the right side of the abdominal cavity, causes disturbing symptomatic signs:

• the temperature rises;
• severe spasms are observed at the site of formation of the appendicular infiltrate during palpation;
• rapid pulse;
• increased muscle tone of the abdominal wall;
• deterioration in general well-being.

The appearance of a dense neoplasm after 3-4 days prevents emergency appendectomy. Reason for postponing surgery possible removal connected loops of the caecum and rectum, which leads to serious complications after operation. For the treatment of infiltrate is prescribed drug therapy, after which a procedure is performed to remove the inflamed acute appendicitis.

The main drugs are:

• antibiotics;
• antispasmodics;
• anticoagulants.

Antibacterial agents relieve the inflammatory process, antispasmodics eliminate pain syndromes in the abdomen, anticoagulants thin the blood, preventing the formation of thrombosis.

Additional methods of treatment - diet therapy, including foods rich in coarse fiber, cold compresses, physiological procedures for resorption of a dense neoplasm. The complication of acute appendicitis in children requires the selection of methods of therapy, taking into account age-related characteristics.

The disappearance of the infiltrate is observed 1.5-2 months after the start of treatment. medicines. After successful treatment, surgical intervention is prescribed. As a result of the individual characteristics of the body, the tumor may begin to secrete pus, contributing to the development of an abdominal abscess. The inflammatory process, accompanied by hyperthermia, fever, painful palpation, develops into peritonitis.

A purulent abscess is formed when bacteria enter the process of the large intestine as a result of structural damage to the mucous membrane. A complication of appendicitis in the period before the operation is observed 1-1.5 weeks after the exacerbation.

Signs of an abscess bursting are:

• hyperthermia;
• chills, fever;
• weakness, increased fatigue;
• headache;
• increase in the number of leukocytes.

A complication of acute appendicitis can be observed in the iliac region on the right side of the bone, under the diaphragm, in the space behind abdominal wall. When an abscess occurs in the depression between the rectum and the gallbladder, the stomach swells, the urge to release loose stools becomes more frequent, and pain in the perineum, pelvic area. When pus gets under the right diaphragm, breathing difficulties, coughing, spasms are noted chest, intoxication.

Postoperative period

Complications after removal of appendicitis arise due to:

• untimely assistance in case of exacerbation;
• lack of diagnosing the nature of inflammation of the appendix;
• improper technique of surgical intervention;
• non-compliance with the rules during the rehabilitation period;
• acute form pathologies of the abdominal organs.

The classification of complications after surgery is based on the site of inflammation, the time of manifestation of symptoms of exacerbation. Dangerous Consequences surgical intervention can be observed in the area of ​​structural damage to the appendix, abdominal cavity, adjacent organs.

Postoperative complications of acute appendicitis appear 10-14 days after the removal procedure or after more than a few weeks.

Dangerous consequences of surgical intervention are:

• divergence of seams after suturing the wound;
• internal bleeding;
• pylephlebitis;
• damage to adjacent organs, tissues;
• development of intestinal fistulas;
• discharge of pus from the wound;
• blockage of the intestinal lumen;
• the formation of adhesions, hernias;
• abscesses respiratory system, abdominal cavity;
• nephritis, acute cystitis.

Removal of appendicitis can lead to pathologies in the functioning of the respiratory, circulatory, urinary systems, gastrointestinal tract, abdominal cavity, and small pelvis. The main symptoms of complications of the acute form of the disease are hyperthermia, indicating the spread purulent process, diarrhea and constipation due to disruption of the normal functioning of the digestive organs, pain and bloating after surgery.

Pylephlebitis

The spread of the purulent process to the liver leads to the development of a dangerous complication in appendicitis - pylephlebitis.

The main symptomatic signs that appear after a few days are:

• severe hyperthermia;
• feverish state, trembling in the body;
• abdominal cramps in the right hypochondrium with pain in the spine;
• enlargement of the liver, gallbladder;
• sepsis;
• the appearance of a yellow hue of the face is a symptom of Courvoisier.

Timely detection of a late complication, the correct technique of surgical intervention, reception antibacterial drugs and means for liquefaction blood clots save the lives of patients. The danger of the consequences of appendicitis is a sharp, rapid deterioration in the condition, leading to death.

Fistula development

Pathologies of the gastrointestinal tract occur due to the spread of inflammation with the wrong technique of intervention, the formation of bedsores due to the use of tight medical devices during the surgical procedure when draining the wound.

Signs of fistula development after appendix removal include:

• pain syndrome observed in the iliac region on the right side;
• discharge of intestinal contents from the surgical wound;
• the formation of an infiltrate as a result of pus entering the abdominal cavity.

The manifestation of signs of a complication of the removal of appendicitis after surgery occurs 7 days after surgery. Cutting out intestinal fistulas by performing an operation by hiding, cleaning, draining neoplasms.

Formation of adhesions, hernia

The detection of plexuses of the processes of the caecum and rectum is diagnosed after a minimally invasive therapy method, which involves the introduction of a device with an optical camera through a small hole in the abdominal cavity. Signs of the formation of adhesions include pain of a pulling nature in the abdomen. After removal of appendicitis, a tumor appears at the site of the surgical wound as a result of prolapse of the intestinal process into the depression between the muscles of the abdominal cavity.

Prevention of complications

Complicated appendicitis is observed when the rules are not followed in the preoperative and rehabilitation period.

• seeking medical help if symptoms of acute appendicitis are detected;
• adherence to the rules of dietary nutrition:
• regular consumption of foods rich in fiber: fruits, baked vegetables;
• refusal of greens, semi-finished products, fatty, salty, smoked foods;
• bed rest for the period prescribed by the doctor;
• you can not sleep on your stomach;
• lack of physical activity after surgery for 90 days;
• compliance hygiene procedures avoiding water and soap on the wound;
• abstaining from sexual intercourse for 7 days.

A complication of appendicitis occurs when due attention is not paid to the symptomatic signs of the disease. Untimely assistance in case of deformation of the appendix leads to death.

The information on our website is provided by qualified doctors and is for informational purposes only. Do not self-medicate! Be sure to contact a specialist!

Gastroenterologist, professor, doctor of medical sciences. Prescribes diagnostics and conducts treatment. Study Group Expert inflammatory diseases. Author of more than 300 scientific papers.

Acute appendicitis may be accompanied by severe life threatening complications. These include appendicular infiltrate (abscess), intraperitoneal 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 Blumberg-Shchetkin symptom may persist for several days. The temperature is increased to 37-38°C, moderate leukocytosis in the blood with a shift to the left.

It's believed that appendicular infiltrate is one of the forms of limited peritonitis, its outcomes are very variable. The infiltrate is a wolf in sheep's clothing” (L. G. Brzhozovsky). With a favorable course, it undergoes resorption in most patients. However, in some cases, its suppuration may occur, which is manifested by increased pain in the abdomen, 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 borders, sometimes fluctuations and severe symptoms of peritoneal irritation.

Peritonitis is one of the most dangerous complications acute appendicitis and is one of the leading 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, suppuration, 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 its elimination. Suppuration of the wound - the most frequent complication operations. There are also 1-6% of cases, depending on the form of appendicitis. The treatment of suppuration consists in the removal of sutures, dilution of the edges of the wound, the use of dressings with antibacterial agents and enzymes, immunotherapy in accordance with the phases of the wound process.
With inflammatory infiltrates prescribe antibiotics and physiotherapeutic procedures (quartz, UHF, electrophoresis, etc.).

Complications from the abdominal cavity are classified as severe and life-threatening and include intra-abdominal abscesses (pelvic, subphrenic, inter-intestinal, retroperitoneal), limited and diffuse peritonitis, peliflebitis, 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 7-12th day after the operation, the temperature rises again and leukocytosis increases, pains appear above the womb or in the depths of the pelvis.

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

Subdiaphragmatic abscess observed in 0.1-0.5% of cases and occurs with high fever, severe intoxication, shortness of breath, chest pain on the side of the lesion when inhaling. Diagnosis is relatively difficult. Treatment consists of opening the abscess, preferably by extraperitoneal or extrapleural access. Interintestinal abscesses and the period of provenation forms are characterized by poor clinical picture, however, in the future, with an increase in the abscess, signs of purulent intoxication appear and a painful formation is determined most often in the navel or to the left of it with muscle tension, positive symptom Blumberg - Shchetkin. Treatment - opening and drainage of the abscess.

Rare but very dangerous complications include pylephlebitis, or ascending portal vein thrombophlebitis with pyemia 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 is 90-98%. Treatment consists in the introduction of large doses of antibiotics and the appointment of anticoagulants. In the presence of liver abscesses, their opening is indicated. Adhesions after appendectomy can cause intestinal obstruction in the near and long term. Systemic complications include thromboembolic complications, pneumonia, acute myocardial infarction, disorders of the urinary system, etc.

More than 1 mln. appendectomy with a lethality of about 0.2%. The main cause of mortality is the complications of acute appendicitis described above. They are associated with late diagnosis, belated surgery and its complications. The highest percentage of complications and mortality is observed among children and elderly and senile people.

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