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Development of abscesses of the right ileal area after appendectomy comes in connection with distribution of an infection from a shoot bed at its destructive change and insufficient drainage of an abdominal cavity more often. The abscess forms on 4 — the 6th days after appendectomy, passing an infiltrate stage. The following supervision can be an example.
Sick Sh.,37 of years, came to clinic of 24/VII 1967 g. Urgent appendectomy is carried out, the changed shoot is removed flegmonozno. The abdominal cavity is sewn up tightly. For the 5th days after operation the condition of the patient worsened. Evening temperature 38,6 °, pains in the right half of a stomach, not passage of flatus developed. Palpation: in the right ileal area defined painful dense infiltrate of 10Х10 cm. There are no symptoms of irritation of a peritoneum. Leukocytosis 12 400. Antibacterial and antiinflammatory therapy within 3 days is not effective.
2/VIII 1967 g vnebryushinno in the right ileal area abscess is opened. About 200 ml of dense pus with a collibacillary smell are evacuated. Recovery.
Developing of abscess of the right ileal area is possible not only in the absence of a drainage, but also at its early extraction. The wound of a front abdominal wall quickly sticks together, creating obstacles for free outflow of pus at local purulent peritonitis.
We observed development of intra belly complications including abscesses of the right ileal area, at technically wrong drainage of an abdominal cavity. It belongs to cases of infringement of a drainage in a wound when its function is broken and purulent complication develops.
The clinical picture of abscess of the right ileal area is rather characteristic. Usually in 4 — 7 days after appendectomy the condition of the patient worsens. There are complaints to feeling of weight and mild constant pains in the right ileal area, temperature, increases especially in the evenings, there can be oznoba and sweats. Sometimes the phenomena of dynamic intestinal impassability join. At research in the right ileal area sharply painful infiltrate which is difficult palpated in connection with a muscle tension of a front abdominal wall is found. Gektichesky temperature, a considerable leukocytosis, absence of effect of conservative therapy allow to distinguish correctly complication and to carry out differential diagnosis with infiltrate of ileal area.
Opening of abscess can be carried out by 2 ways. If it approaches a front abdominal wall in the field of a postoperative wound or a hem, then stupid cultivation of fabrics provides sufficient access to an abscess cavity. If abscess is deeply, it is necessary to use extra peritoneal access. The section is made on 1 — 1,5 cm medialny an upper horizontal awn of an ileal bone, zabryushinno approach a lateral surface of an abscess and open it. The abdominal cavity remains free.
The special attention is deserved by abscesses in a stump of a worm-shaped shoot. At a modern technique of its processing with immersion in a purse-string or Z-shaped seam the closed cavity is formed. P. I. Dyakonov (1902), Stich, Makkas (1928) indicated possibility of abscesses here. In modern literature only single descriptions of similar early complications of appendectomy meet (I. P. Dauderis, 1969; N. V. Chagaev, 1971; A. G. Sutyagin, 1973). By data A. G. Sutyagin (1973), it arose at 6 patients (0,1%) from 6236 operated. We observed this complication at 3 patients (0,06%) after 5100 appendectomies and at 2 patients who arrived from other medical institutions.
Complication develops usually on 7 — the 8th days after operation. In the beginning the postoperative period proceeds quietly. The subsequent break of an abscess in an abdominal cavity gives a bright picture of local or diffuse peritonitis concerning which relaparotomy is undertaken.
As an example we will refer to the following supervision.
Sick Ch., 34 years, is operated in clinic of 1/1 1971. The changed worm-shaped shoot is removed flegmonozno. Postoperative current smooth. For the 7th days seams, a wound repair by first intention, temperature normal are removed. By the evening sharp colicy pains on all stomach, not passage of flatus and a calla appeared. At survey the right half of a stomach does not participate in the act of breath, language is dryish. At a palpation here sharp morbidity and a muscle tension of a front abdominal wall, positive symptoms of irritation of a peritoneum. Pulse of 96 blows 1 minute, a leukocytosis 11 800 with shift of a formula to the left. At a survey X-ray analysis of abdominal organs Kloyber's bowls in the right ileal area are found.
Diagnosis: commissural intestinal impassability, peritonitis. Urgent lower median laparotomy. Commissural intestinal impassability at the level of an ileal gut which is soldered to the place of immersion of a stump of a shoot with formation of "double-barreled gun" is found. In this place the abscess opened in an abdominal cavity is found. The stump of a shoot is taken in by three rows of separate seams with additional sealing by MK-3 glue. A drainage in the right ileal area. Recovery.
In these cases only the urgent wide laparotomy with sanitation of an abdominal cavity and sewing up of a stump can rescue the patient.
At 2 patients abscess formed gradually and was well delimited from an abdominal cavity. Complication was not distinguished. "subgaleal abscess" was opened that considerably improved a condition of patients. The subsequent burrowing of a stump of a shoot allowed to estimate complication genesis retrospectively correctly.
A. G. Sutyagin (1973) for prevention of this complication considers important observance of all rules of processing of a stump of a worm-shaped shoot. It is possible to agree with it, but it should be noted that immersion of a stump in a purse-string seam is dangerous by developing of intramural abscess.
Interloopy abscesses after appendectomy meet now rather seldom. We observed 2 patients with such complications (0,04%). Development of abscess happens, as a rule, as formation of residual abscesses after diffuse peritonitis. It also defines his clinical picture. Usually it is about patients with destructive forms of an acute appendicitis and with a heavy postoperative current. After some improvement, stopping of the phenomena of diffuse peritonitis, dynamic intestinal impassability the state worsens, appears gektichesky fever, abdominal pains, not passage of flatus and a calla again, the picture of white blood worsens. At objective research of an abdominal cavity painful motionless infiltrate is defined. Antiinflammatory therapy is ineffective. Opening of an abscess leads to considerable improvement of a condition of the patient.
Patient I., 26 years, it is operated in clinic 22/02 1970 concerning phlegmonous appendicitis for the 2nd days from the beginning of a disease. Appendectomy under local anesthesia, drainage of an abdominal cavity. The postoperative period proceeded hard in connection with the phenomena of the expressed peritonitis. Powerful antibacterial therapy using reserve antibiotics, hemotransfusion and its components was led to considerable improvement of a state by 5th day after operation. For the 6th days the condition of the patient worsened, there were abdominal pains, a delay of gases, evening temperature rose to 38,7 °. Next day in the left mezogastralny area it was possible to propalpirovat painful infiltrate which is regarded as the forming interloopy abscess. For the 8th days after operation the abscess is opened. Recovery.
The similar course of process with an abscess adjunction directly to a front abdominal wall is optimum for diagnosis and operational treatment. At localization of process in the depth of an abdominal cavity diagnosis happens quite difficult. Opening of such abscesses is carried out through a free abdominal cavity which has to be carefully limited.