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Diffuse peritonitis - appendectomy Complications

Table of contents
Appendectomy complications
Reasons of postoperative complications 2
Reasons of postoperative complications 3
Reasons of postoperative complications 4
Indications to appendectomy
Indications to appendectomy - appendicular infiltrate
Indications to appendectomy at not changed shoot
Indications to appendectomy at an appendicism
Indications to appendectomy - postoperative supervision
Complications from a wound
Complications from a wound, the choice of methods of treatment
Complications from a wound - the general treatment
Complications from a wound - eventration
Complications from a wound - use of antibiotics for prevention of early complications
Early complications from an abdominal cavity
Peritonitis
Diffuse peritonitis
Diffuse peritonitis - a peritoneal dialysis
Diffuse peritonitis - an intestines peristaltics
Infiltrates and abscesses of an abdominal cavity
Abscesses of an abdominal cavity
Abscesses interloopy and right ileal area
Subphrenic abscesses
Phlegmons of retroperitoneal cellulose
Acute intestinal impassability
Acute postoperative pancreatitis
Complications from cardiovascular system
Thromboembolism of a pulmonary artery
Myocardial infarction, pylephlebitis
Fibrinferments and embolisms of mesenteric vessels
Prevention of tromboembolic episodes
Complications from a respiratory organs
Complications from an urinary system
Late complications from an abdominal wall
Recognition of inflammatory "tumors" of a front abdominal wall
Origins of postoperative hernias
Late complications from an abdominal wall - keloid cicatrixes
Late complications from abdominal organs
Infiltrates and abscesses of an abdominal cavity
Inflammatory "tumors" of an abdominal cavity
Intestinal fistulas
Adhesive desease
The recommended literature

By consideration of peritonitis of an appendicular origin it must be kept in mind that it always is secondary. Inflammatory process, having initially arisen in a worm-shaped shoot, extends to nearby departments of an abdominal cavity. At appendicitis, in view of the accruing destruction in it and small readiness of a peritoneum for fight against an inflammation, process is seldom limited only to a caecum zone therefore limited peritonitises are rather rare and, on the contrary, danger of development of the general diffuse peritonitis is quite real.
The concept "diffuse purulent peritonitis" demands more exact definition. Many authors instead of "diffuse peritonitis" use expression "the general or free peritonitis". Giving definition "diffuse peritonitis", Sprengel (1912) specified that accumulation of pus has no limited character so both definitions are synonyms (A. M. Zabludowsky, 1922). It is important to note that such names can be given only to the peritonitises taking the most part of an abdominal cavity. "the general peritonitis" we avoid expression as this concept not clinical, but is more pathoanatomical. Nature of transition of inflammatory process to all peritoneum has the defining value for the further course of peritonitis.
At appendicitis peritonitis develops gradually, gradually involving all new sites of a peritoneum, and by the time of identification of accurate signs of this terrible complication duration of inflammatory process turns out quite big and is followed by a number of profound changes in important bodies and systems.
Development of peritonitis involves receipt in blood of huge mass of bacterial toxins. The factor promoting increase of their absorption is paralytic expansion of a capillary and vascular network of all surface of a peritoneum. It is followed by decrease in the general vascular tone (collapse) and accumulation of transudate in an abdominal cavity which quickly turns into exudate.
Further influence of endotoxins double, first of all on extensive receptor fields of a peritoneum. It is followed by development of paralytic intestinal impassability, and then reflex influence on a number of bodies and systems, including a cardiovascular, central nervous system and system a hypothalamus — a hypophysis — adrenal glands.
Toxic influence through blood is reflected in functional activity of a liver and kidneys that leads to development of acute hepatonephric insufficiency.
The general intoxication and sharp shifts of exchange processes aggravate functional impassability of intestines. In its gleam putrilages and fermentations collect that becomes a source of additional intoxication due to absorption of toxins through an intestinal wall, and also direct action through chemo - and baroreceptors of sharply ektazirovanny intestinal tube.
The vicious circle becomes isolated. The accruing intoxication leads to development of acute cardiovascular insufficiency at the expense of a hypoxia, toxic impact on a vasomotor center and a cardiac muscle. It comes to an end with a cardioplegia and death of the patient.
The clinical picture of purulent peritonitis is represented quite characteristic and depends on speed of development of process: the quicker development, the clinical manifestations grozny, more brightly and more sharply.
It should be noted that there is no one symptom characterizing all diverse clinic of acute purulent diffuse peritonitis. Moreover, as V. Ya. Shlapobersky (1958) noted, now owing to broad use of antibiotics often it is necessary to deal with the so-called erased forms of peritonitises. Damage of a peritoneum and receipt in an abdominal cavity of contents of its bodies causes her sharp irritation that is characterized by a pain syndrome. Except a megalgia on all stomach and a positive symptom of Shchetkin — Blyumberg who is holding down the patient in motionless forced situation right at the beginning there is a number of the adverse remote and local reflexes. The reflex contracture of an abdominal wall protects an abdominal cavity from harmful external effects (defanse musculaire) and promotes necessary rest of the inflamed peritoneum. At the same time all front abdominal wall and a diaphragm does not participate in breath: breath is at a loss and, getting exclusively costal type, becomes superficial and speeded up.
Powerful pain stimulations cause reflex reduction of blood vessels of a peritoneum. The period of a spasm is replaced by the period of an active hyperemia. There is an overflow of vessels of an abdominal cavity and thereof there is so unprofitable redistribution of blood that "the organism can bleed profusely in not opened vessels of own abdominal cavity" 1. The strengthened intake of liquid in an abdominal cavity by transudation leads to fluidifying of the toxic products which got here and relative decrease in their toxicity.
Defeat of independent nervous devices of a digestive tract together with inflammatory treatment of their wall leads to frustration motor evakuatornoy functions. Advance of gastro intestinal contents stops, there is a delay of a chair and gases, abdominal distention. Under the influence of the strengthened processes of rotting and fermentation contents of a small bowel and a stomach gain toxic properties. Absorption of these products aggravates intoxication of hepatic cells, at the same time disintoxication function of a liver decreases, bilirubin accrues, protein level in blood decreases, the adynamia accrues, drowsiness, yellowness of scleras and skin, a hyperthermia — symptoms of a liver failure appear.
There is a vicious circle. Sharply secretion of free hydrochloric acid decreases, there is no reflex short circuit of the gatekeeper. Bile and intestinal contents gets into a stomach, vomitings gain fecal character that is a desolate predictive sign.
Because of the accruing meteorism high standing of a diaphragm develops that considerably worsens already weakened breath and cordial activity. It conducts to cyanosis and short wind: auxiliary muscles of a neck come into effect, breath becomes frequent even more.
Owing to loss of a large amount of liquid with intraperitoneal exudation, plentiful transudation in a digestive tract and emetic masses the organism is quickly dehydrated: painful thirst joins initial dryness of language; turgor of skin goes down, features — fades Hippocratica are pointed. It is a characteristic picture for far come peritonitis. The consciousness is clear. Almost till the end of the patient feels concern from sufferings and only in a final stage there comes the short phase of calm, the patient does not realize weight of the situation (euphoria). After this, already before the death, the consciousness dies away.
In a terminal phase there comes acute falling of the arterial pressure before supported at the certain level; pulse becomes frequent, small, threadlike. There comes the final collapse and death at paralysis of a vasomotor center and breath.
Apparently, the picture of an illness consists of the local and general symptoms which are developing as a result of difficult influences on an organism and closely weaved among themselves.
Diffuse peritonitis is the heaviest complication of appendectomy, and in pathophysiological aspect it should be considered as complex defeat of many functional systems of an organism at which the inflammation of a peritoneum is the main, but not the only link of a disease.
In this regard the problem of treatment of diffuse peritonitis includes a number of tasks: 1) oppression and elimination of an infection of an abdominal cavity; 2) recovery of activity of intestines; 3) fight against intoxication; 4) prevention and elimination of acute liver and hepatonephric failure; 5) correction of proteinaceous, water-salt and vitamin exchanges; 6) completion of globular and plasma deficit in blood; 7) prevention of cardiopulmonary complications.
Treatment of diffuse peritonitis begins with elimination. primary center of an infection. Now at anybody need of this action at acute surgical diseases does not raise doubts. After elimination of the center of an inflammation the main efforts have to be directed to elimination of an inflammation of a peritoneum. It is one of the main links in treatment of peritonitis.
We were the principles stated in 1902 to Rehn the basis for topical treatment of peritonitis: 1) broad opening of an abdominal cavity; 2) elimination of a source of peritonitis; 3) removal of pus from an abdominal cavity; 4) its drainage.
Important action is elimination of exudate from an abdominal cavity which can be single-step and systematic. During single-step removal of exudate only certain surgeons do not resort to drainage of an abdominal cavity (K. I. Pikin, B. A. Chumak, 1967). Concerning character of drainages surgeons express various opinions. So, A. V. Kirilenko (1962), N. S. Makokh (1967) are used by gauze turundas; D. E. Baking, B. P. Sandomirsky (1966) bring to the peritonitis center thin tubes for introduction of antibiotics. At the same time A. A. Olypanetsky, 3. I. Stukalo (1967) is considered that drainages from thin tubes and plastic capillaries do not provide sufficient outflow and do not promote restriction of peritonitis.
At the peritonitis phenomena we drain an abdominal cavity combined glove and gauze drenazhy S. I. Spasokukotsky. The number of complications and a lethality at this way of drainage in comparison with others is much lower. Drainages have to be entered through counteropenings on a sidewall of an abdominal cavity, pushing aside intestines aside. For the best outflow from an abdominal cavity through the trained small pelvis we raise the head end of a bed.
Important link in treatment of peritonitis is a rational antibioticotherapia which provides use of antibiotics taking into account sensitivity to them microbic flora or use from the first hours of a disease of antibiotics of a reserve (Sigmamycinum, Kanamycinum, Neomycinum — 2,5 mg/ml). In some cases at unsuccessfulness of an antibioticotherapia we used an antiseptic agent the dimethyl sulfoxide which is on approbation in clinic (I. I. Moroz, F. A. Spector, etc., 1972).
Respect for some methodical features of introduction of antibiotics is of great importance. At local peritonitis we drain a small pelvis, and we bring a gauze tampon to a bed of a shoot. Antibiotics in solution of novocaine enter into the trained small pelvis from where they extend towards a shoot bed due to hygroscopicity of a tampon or the replaced bandage (in the first 2 days). In this case at patients liquid current not from the center in an abdominal cavity, and from an abdominal cavity to the center is created.



 
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