Page 4 of 43
Features are represented also by an anesthesia technique (when operation is made under local anesthesia). The infiltration anesthesia of a front abdominal wall should be made carefully, with obligatory control of own feelings, especially at the time of subgaleal administration of novocaine. The unexperienced surgeon did not develop at himself yet feelings of passing of separate fabric layers therefore when carrying out a needle danger of damage of an adjacent caecum deep into is not excluded. Its insignificant puncture can remain unnoticed, but in the subsequent to become a peritonitis source. Dangerously also carrying out needle n. ileo-ingvinalis, lateralny for an infiltration of a zone of branching. Very important reception when performing this moment of anesthesia is the constant feeling of a wing of an ileal bone and an indispensable predposylaniye to a novocaine stream needle. The surgeon who is not possessing sufficient experience should recommend carrying out layer-by-layer anesthesia.
In the course of carrying out an intra belly stage of interventions traumatic manipulations with a caecum and a small intestine are the reason of postoperative complications. Negligent extraction of a caecum in a wound is followed by its deserozirovaniye on separate sites. It can lead to intraparietal thrombosis with formation of heart attacks in all thickness of a gut, especially if tampons are entered into an abdominal cavity. With a caecum as on the explicit reason of postoperative intestinal fistulas point I. I. Kalchenko and F. P. Nechiporenko (1969), M. I. Kolomiychenko with coauthors (1971) to rough manipulations and other authors.
Extra care has to be shown at removal in a wound of a worm-shaped shoot. At the same time the surgeon should not show any efforts: allocation of a shoot has to be carried out extremely carefully: friable commissures are taken stupidly away, stronger — are sharply dissect taking into account blood supply of a shoot. At more persistent removal of a worm-shaped shoot there is a danger of its opening, release of virulent pus in a free abdominal cavity with the subsequent development of peritonitis, also danger of a separation and leaving of a top of a worm-shaped shoot in an abdominal cavity is real. Searches of the come-off top in the conditions of the inflamed, sharply infiltrirovanny fabrics represents extreme difficulty, is more often an impracticable task, and its leaving in an abdominal cavity is very dangerous. Calculation on independent rejection of this sequester (a worm-shaped shoot) most often is insolvent.
We had to observe the patient who came to surgical separation by the end of second day from the beginning of a disease and operated concerning gangrenous appendicitis with the phenomena of limited peritonitis. In very difficult conditions the shoot was removed, but at macroscopic research of drug it was established that its top remained in an abdominal cavity. Attempt of its removal was unsuccessful, in an abdominal cavity the tampon counting upon independent rejection of a top was brought to a bed of a shoot. The postoperative period proceeded very hard, was complicated by development of peritonitis, and then interloopback abscesses. The patient spent more than 2 years in hospital and died from a septicopyemia.
The possibility of such tragic outcome dictates need of careful attitude to a destructive worm-shaped shoot. At difficulties of removal of a shoot in a belly wound it is necessary to make its retrograde allocation. In these cases the worm-shaped shoot is cut from a caecum in the beginning, by usual rules process his stump, and then the surgeon starts allocation of a shoot. This part of operation is laborious and has to be executed with special care, can be even with some loss of time. It is less traumatic and it is dangerous, than attempts of a violent vyvikhivaniye of the destroyed friable worm-shaped shoot which is strongly fixed in an abdominal cavity.
Danger warns the surgeon at allocation of a worm-shaped shoot, especially at allocations of its mesentery. Sliding of a ligature from a shoot mesentery is the most frequent reason of postoperative intra belly bleedings. It occurs at unsteadily imposed ligature, especially on a wide and fat mesentery (N. I. Makhov, etc., 1972). The promoting moment is preliminary administration of novocaine in thickness of a mesentery. In several hours the ligature on a mesentery weakens and slides off.
Due to the danger of sliding of a ligature from a mesentery and intra belly bleeding its bandaging has to be recognized as very responsible moment of intervention. We recommend to use in these cases only silk, imposing ligatures No. 4 or No. 5. Strong imposing of this ligature is reliable, it is necessary only to aim to advance it whenever possible more deeply to the mesentery basis — it guarantees it against sliding. At a short mesentery it should be tied up in 2 — 3 portions. The small bleeding vessel at the basis of a worm-shaped shoot is alloyed when overlaying a purse-string seam directly on a caecum wall in a shoot stump circle.
It is necessary to cut a worm-shaped shoot only after its full allocation to the basis, at the same time the stump has to be minimum. Leaving of a long stump is fraught with repeated emergence of an inflammation in a gleam, one may say, repeated appendicitis (Williams and sotr., 1970, etc.). This mistake is often made by the beginning surgeons, especially at a considerable periappendicitis and a perityphlitis. Special difficulties arise at a so-called intraparietal arrangement of a worm-shaped shoot when even experienced surgeons cannot find it; in certain cases operation does not come to the end with appendectomy because of the specified difficulties. As an example we will refer to own supervision.
Sick M., 48 years, came to clinic of 8/IX 1969 g with complaints to pains in the right ileal area where tumorous education, temperature increase in the evenings to subfebrile, a periodic delay of a chair and gases is defined the considerable sizes. The patient within 3 months when pains in the right ileal area for the first time developed considers himself and there was a temperature increase to 37,5 °. The conservative treatment undertaken in regional hospital improved its state a little, but in several days of pain renewed again in this connection the laparotomy was made. During operation the worm-shaped shoot did not manage to be found as it was located retrotsekalno and it was immured in the right flank. The abdominal cavity was sewn up, the drainage is inserted. Under the influence of conservative treatment (cold locally, intravenous administration of Calcium chloratum, after UVCh) "tumor" decreased, the patient felt well. But in 3 months recurrence of pains, emergence of "tumour", temperature increase is again noted.
During stay in clinic under the influence of physiotherapeutic treatment "tumor" periodically decreased, but was left dense, without clear boundary. At a blood analysis, except acceleration of ROE to 36 mm/hour, shifts it is not found. Irrigoskopiya: changes from a mucous membrane of a caecum are not revealed. The palpated education is located lateralny and below a caecum.
Operation; the anesthesia is endotracheal. At a laparotomy the dense infiltrate in an abdominal cavity proceeding from a lateral wall of a caecum and which is densely soldered to a sidewall of an abdominal cavity is found. Searches of a worm-shaped shoot presented great difficulties. After stratification of dense fabrics of infiltrate, on a back wall of a caecum, the worm-shaped shoot which is allocated subserozno after a longitudinal section of its bed is intramuralno found. The shoot is removed. Recovery.
Processing of a stump of a worm-shaped shoot has several options. Bandaging of a stump of a shoot directly at the basis a catgut ligature is the most accepted. The remained stump has to be minimum short. In essence and all operation can be only conditionally called "appendectomy". "Ektomiya" — is supposed full removal of body, at the existing technique when remains, let the small sizes, a shoot stump, with the big basis it is possible to speak about a resection of a worm-shaped shoot. In this regard the task consists in whenever possible to reduce harmful effects of such technique by reduction of the sizes of a stump. For this purpose the stump is alloyed by a catgut ligature which in several days is torn away in a caecum gleam, and in a stump the closed cavity is not formed. By the standard technique the stump plunges into a caecum wall a double purse-string seam or purse-string and Z-shaped seams.
Interestingly in this respect offer Yu. A. Ratner who recommends not to cross a shoot and to delete it together with a caecum dome when involving it in inflammatory process.
For the prevention of development of an abscess in the closed shoot stump cavity P. I. Dyakonov recommended not to tie up it, and to immerse in a gut gleam, previously having pressed the shoot basis. We prefer this technique more, than offered
M. A. Kimbarovsky (1966) and the technique of an alloying of a worm-shaped shoot supported by a number of surgeons a strong silk ligature without its immersion, a so-called alloyed way (A. I. Lenyushkin, 1960, 1964; V. F. Kurasov, 1961; G. A. Kolpakov, 1971, etc.). Leaving of a stump of a worm-shaped shoot in the abdominal cavity which is not covered with a peritoneum not only is dangerous concerning its insolvency, but also can lead to development of commissural impassability.
It is necessary to tell that the technique of processing of a stump of a shoot, despite the considerable experience of surgeons which is saved up concerning appendectomy remains still completely unresolved question. Of course, the site of immersion of a stump always remains the dangerous place, the outstanding center of an infection. Danger of insolvency of a stump with formation of fistulas, and at worst with development of diffuse peritonitis remains also rather real.
At annular pication on a caecum there is a danger of a puncture of an intestinal wall which, having remained unnoticed, can promote development of diffuse peritonitis. In order to avoid such complication in practice of children's surgery apply vascular atraumatic needles.
Serious danger to development of postoperative complications is constituted by leaving of foreign bodys in an abdominal cavity. Literature abounds with examples, sometimes the most fantastic, however, at appendectomy foreign bodys in an abdominal cavity are left extremely seldom.
We completely make common cause with all authors pointing to extremely harmful effects of such negligence.
Finishing the section on sources of postoperative complications at appendectomy, it is necessary to stop on quite big group of so-called "vain appendectomies". We put this term in quotes as absolutely vain it is impossible to call them. At histologic research certain pathomorphologic changes, in certain cases even considerable come to light, up to destruction of a wall of a shoot. Nevertheless appendicitis at these patients is not a basic disease, and accompanies not less serious defeat of other abdominal organs.
It is possible to agree with the views existing in this respect stated by a number of surgeons in literature completely (tsit. according to V. I. Struchkov, 1966): "The excessive and meaningless interest in early operation, sometimes thoughtless approach to questions of diagnosis of an acute appendicitis, leads to the fact that appendectomy is made when it is not necessary at all, and it is possible and is harmful (B. V. Petrovsky, D. A. Arapov, V. I. Kazansky, L. G. Kharitonov)". It speaks not only the fact that during removal of not changed worm-shaped shoot it is possible to pass another, sometimes a serious illness, but also that operation leads quite often to the serious consequences revealed later in the form of late complications of appendectomy.