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Adhesive desease - 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

After the first appendectomies connected unsatisfactory results of this operation with development of an adhesive desease (D. D. Pletnev, 1905; L. E. Golubin, 1905; M. I. Rostovtsev, 1916; Korte, 1901). And though in the subsequent works (V. I. Efet, 1927; I. I. Grekov, 1927; S. Mauo, 1934) found out many other reasons of recurrence of pain after appendectomy, the adhesive desease by right is considered so far one of the most frequent complications of this operation (A. G. Zemlyana, 1971; L. A. Kozhura, 1971, etc.).
The statistical data reflecting the frequency of emergence of this complication are very contradictory. This results from the fact that neither clinical, nor even radiological data (Naegeli, 1919) concerning the frequency of finding of commissures at the operated patients cannot be considered as reliable. Moreover, as K. S. Simonyan (1966) specifies, even the visual diagnostic method at a chrevosecheniya in connection with a different approach and a certain subjectivity of researchers does not allow to obtain the unified data.
Most of researchers agree in opinion that the frequency of emergence of commissural intestinal impassability after appendectomy does not exceed 1%. G.Yu. Bakhur (1941) observed it at 0,1% of patients after appendectomy, B. A. Dmitriyev (1949) — at 1,05%, And. 3. Sverdlov (1966) — at 0,66%, V.P. Roy — at 0,6% of patients. These, apparently, small figures hide for themselves considerable number of patients with the adhesive desease which is quite often complicated by acute intestinal impassability. V.    I. Kazansky, L. G. Kharitonov (1958) specify that from 224 patients with commissural intestinal impassability at 24% with its initial reason the appendectomy made in the past served. There are instructions for higher percent — 48,3% (N. I. Blinova, L. V. Grigoriev) and even 53,1% (Flesch — Thebesins, 1920).
Under our supervision for 1964 — 1971 there were 286 patients with commissural intestinal impassability. At 92 of them appendectomy (32,1%) was the first operation. Most often this complication develops at women (74 patients). At 28 patients complication developed after operation on an occasion chronic, at 47 — an acute appendicitis. 17 patients had a phlegmonous form, gangrenous — at 13, appendicular infiltrate — at 4, simple appendicitis — at 13 patients, nature of changes in a shoot did not manage to be found out from 17 patients.
In literature development of an adhesive desease is connected most often with the appendectomies made concerning simple forms of appendicitis (D. A. Arapov et al., 1971; A. G. Zemlyana, 1971, etc.). N. I. Makhov and others (1971) noticed that destructive forms of appendicitis lead more often to development of early commissural impassability while the adhesive desease, as a rule, arises after simple and its even chronic forms. In other words, the adhesive desease can be considered as complication of a disease (appendicitis), but is a direct consequence of the postponed appendectomy.
Its development by attacks of intestinal impassability was most often observed within the first 2 years after appendectomy (87 patients). Only at 5 patients the disease developed in later terms. The maximum period between appendectomy and the first attack of commissural intestinal impassability, according to our data, was equal to 6 years. According to literature, also later development of this complication is possible. So, Piehl (1967) indicates its development through 10, Kaufman (1935) — 15, Mclver (1932) — 25 years after appendectomy.
What reasons of this complication? Why this operation most often is the intervention leading to development of an adhesive desease? The inflammatory nature of a disease, a mechanical injury, inevitable at any laparotomy, feature of a structure and function of ileocecal department of intestines — here the list of the main etiological moments.
The inflammatory nature of commissural process in an abdominal cavity is confirmed by daily surgical practice. This defense reaction of an organism which is expressed in fibroplastic process and often rescuing the person in certain conditions, can develop into the contrast with development of an adhesive desease. The mechanical injury of both a parietal, and visceral peritoneum, its drying at long intervention is of great importance. It is necessary to consider development of commissural process at hit of foreign bodys, including around ligatures and a suture material, tampons and drainages. Formation of commissures is promoted by hit in an abdominal cavity of talc (V. M. Glukhova, 1956;           V.P. Roy, 1966; Seeling, Verde, Kidd, 1943), antibiotics and streptocides in powder (S. I. Banaytis and soavt., 1949; K. S. Simonyan, 1966; M. E. Komakhidze, etc., 1971; Chesterman, 1945; Rathcke, 1962). This process is favored also by postoperative paresis of intestines (And. 3. Sverdlov, 1966; Schiff et al., 1949; Cone, 1959).
It is necessary to consider features of a structure of ileocecal department of intestines where commissural process develops especially violently (K. S. Simonyan, 1966). In this area frequent formation of abnormal forms of an adhesive desease as an excess of an ileal gut of Lane or tyazhy Jeckson is noted.
The adhesive desease has no pathognomonic symptoms. Patients complain of a dull nagging pain in the right half of a stomach, the discomfort phenomenon in an abdominal cavity (abdominal distentions, rumblings, locks). Objective and laboratory researches do not give accurate instructions to the correct statement of the diagnosis. Only at X-ray inspection it is possible to receive reliable signs of a perityphlitis in some cases.
In this regard the diagnosis of an adhesive desease as late complication of appendectomy can be put after an exception of other diseases having a similar clinical picture with obligatory radiological confirmation.
Such strict approach to establishment of the diagnosis allowed to distinguish this complication only at 42 patients while 67 patients with an adhesive desease without attacks of intestinal impassability were sent to clinic. Among 25 patients at whom the diagnosis of an adhesive desease was removed at 10 — colitis, at 6 — a right-hand adnexitis, at 4 — diseases of a right kidney and an ureter, at 2 — a stenosis of the bauginiyevy gate, at 1 — postoperative hernia, at 1 — chronic pancreatitis is diagnosed, 1 patient has Shmorl's hernia.
We are supporters of conservative treatment of such patients, remembering that each new operative measure leads to a bigger development of commissural process. Only 7 people are operated. At the same time at 3 patients before operation the diagnosis of a tumor of a caecum was established and only during intervention true character of a disease is found; the section of unions is made. At 3 of 4 patients operated with a strong pain syndrome, the adhesiotomy was effective. At operations we were limited to their simple section, without complicating intervention by an additional plication of small intestinum across Nobl, Chayld — to Phillips, etc. In this respect we completely agree with D. A. Arapov, K. S. Simonyan and V. V. Umanska (1971), A. G. Zemlyany (1971) and others which frostily belong to operation of a plication of small intestinum as a little physiologic. The careful and accurate section (section) of commissures with sewing up of the arising deserozirovanny sites on pieces of intestines has essential value for achievement of the good long-term results.
At purpose of conservative therapy the great value has to be given to a rational diet with cellulose restriction, to a work-rest schedule. Except purpose of anti-inflammatory drugs, positive impact is exerted by physiotherapeutic methods, including paraffin applications, mud cure.
The clinical picture of the adhesive desease complicated by intestinal impassability (an acute form of an adhesive desease according to K. S. Simonyan) is characterized by the sudden beginning with the advent of colicy pains in a stomach, not passage of flatus and a calla, abdominal distention, repeated vomiting, sometimes with accession to the emetic mass of intestinal contents. Language dry, is laid over by a brown plaque. Pulse is frequent. At severe forms lowering of arterial pressure, reduction of daily amount of urine is noted.

Objective research: sometimes the asymmetry of a stomach seen approximately a peristaltics is found. At a palpation and percussion of a stomach it is possible to reveal the symptoms characteristic of this pathology: capotement, Wal, Kivul's symptoms. Skin and mucous membranes get a cyanotic shade. In blood the condensation with increase of quantity of erythrocytes is noted. Temperature, normal at the first stages, increases with accession of intoxication and the phenomenon of peritonitis. Deviations from the described picture, depending on the extent of disturbance of a passage, involvement in process of a mesentery accompanying and the previous diseases etc. are possible.
As big help in diagnosis serves the X-ray inspection revealing not only classical bowls of Kloyber, but also existence of arches, cross striation and transfusion of liquid from one loop in another (E. S. Geselevich, 1966; D. A. Arapov et al., 1971, etc.).
Tactics of the surgeon at acute intestinal impassability is difficult. At supervision of each patient it is necessary to make the individual decision. Appointing operational treatment, it is necessary to consider that each intervention at this category of patients aggravates weight of commissural process. From 92 patients who arrived with the phenomena of intestinal impassability 4 people are operated at once. At all the heavy current with increase of intoxication, a fecal vomit, the expressed tachycardia and cyanosis was noted. These are the heaviest patients from whom 2 persons died of the developed peritonitis after an intestines resection.
At 85 patients attempts of the conservative therapy including a gastric lavage, purpose of spasmolysants, hypertensive and siphon enemas are made. At 24 sick these actions were inefficient in this connection an operative measure is undertaken. At 5 of them it was followed by an intestines resection, at the others was limited to an adhesiotomy.
Making an attempt of elimination of the phenomena of acute intestinal impassability conservative measures, we should not revaluate the achieved results and resort timely to operation in the shown cases. Concerning possible terms of carrying out conservative treatment, K. S. Simonyan considers that this issue has to be resolved within 2 hours. If the conservative therapy which is carried out at this time in full did not give due effect and the condition of the patient did not improve, it is necessary to resort to an urgent operative measure. It is unlikely this situation needs review. Prolongation under similar circumstances leads only to aggravation of weight of a condition of the patient. Meanwhile, approximately at a third of patients to resolve this issue in so limited period happens very difficult. The held conservative events quite often lead to improvement of their state. The pain syndrome decreases, activity of intestines up to a passage of flatus is recovered, blood indicators improve. But after several hours the acute pain, abdominal distention, not passage of flatus and a calla develop again. The surgeon can make a final decision only at dynamic supervision over the patient with attraction to the aid of additional diagnostic methods.
Discussion of a problem of an adhesive desease as complications of an acute appendicitis and appendectomy would be incomplete if in a few words not to stop on questions of its prevention.
According to literature, there is a huge number of warning facilities of development of commissural process in an abdominal cavity among which the leading place is taken by the drugs administered intraabdominalno. Recently for this purpose recommend a hydrocortisone, fibrinolysin, a lidaza (P. P. Kovalenko, N. M. Nikolaev, G. I. Chepurna, V. A. Budatova, V. G. Zubarin), the combined administration of fibrinolysin and polyvinylpirrolidone (T. P. Makarenko), oxygen (D. L. Rotenberg and R. G. Zelenetsky), proteolytic enzymes: chymotrypsin and ribonuclease (V. G. Morozov, G. A. Izmaylov). N. G. Gataullin with coauthors recommended to combine administration of oxygen and a hydrocortisone with a local hypothermia, and N. P. Batyan, I. B. Oleshkevich and M. N. Hapchenko used with the preventive purpose the "anticommissural mix" modified by them including novocaine, penicillin, streptomycin, a hydrocortisone and prozerin. From other prophylactics use the desensibilizing drugs (P. P. Kovalenko), intramuscular introduction of a pirrogenaza (M. E. Kochakhidzessoavt.), Thrombolytinum (A. M. Mezhenin), methyluracil (V. N. Chernov).
At the same time it is necessary to recognize that all specified means are ineffective for prevention of an adhesive desease. From our point of view, so-called specific prevention of an adhesive desease by means of intraabdominal administration of special medicinal substances at this pathology is unacceptable. It is explained by a large number of the made appendectomies, insufficient efficiency of the offered methods and the main thing that at appendicitis, especially at its acute forms, commissural process in an abdominal cavity limits distribution of process and saves life to the patient.
In this regard as the most important measures of prevention it is necessary to recognize a number of the organizational and tactical moments among which the main thing is the most strict and accurate definition of indications to operation at which the number of so-called vain appendectomies will be considerably reduced. Rather broad access to ileocecal area, a right choice of anesthesia, atraumatic operating, rational use of drainages also it has to be referred to number of the actions preventing development of an adhesive desease.
The organization of the postoperative period concerning recommendations of an early rising (in uncomplicated cases we recommend the active mode from the next day after operation), active purpose of food of patients, etc. has special value. All this promotes timely recovery of normal function of a digestive tract — the most essential moment of the prevention of an adhesive desease, as well as other early and late complications of appendectomy.

In the provided work we tried to light the most widespread complications of appendectomy, methods of their recognition and elimination. The statement would be incomplete if we did not stop on those enough often found postoperative states which are characterized by emergence of pain in operational area, or rather their resuming.
Patients in these cases claim that operation did not help them, they feel the same pain. Complexity of a situation is that the doctor usually does not manage to find some essential signs of postoperative complication, and at clarification of the anamnesis it turns out that operation and the postoperative period proceeded smoothly, and pain continues to disturb the patient. Most often such states arise after the operation undertaken in connection with slightly expressed inflammatory changes in a worm-shaped shoot is frequent concerning an appendicism.
We are inclined to consider that the organic changes expressed in a varying degree, which are quite often demanding surgical correction often are behind such states. Therefore this side of the problem is represented rather actual in this connection we found it possible to include this section in the part describing late complications of appendectomy.
It is necessary to specify that after the first operative measures surgeons noted that appendectomy is not always beneficial and sometimes arise persistent recurrence of pains (Vignard, 1899; Korte, 1901; Schwartz, 1902).
The subsequent research of this question revealed that the percent of the long-term unsatisfactory results is quite high and fluctuates from 3 to 90% (I. M. Topchibashev, A.S. Guseynov, 1970). It demanded identification of the reasons and elaboration of preventive and medical actions at these late complications. Among the first classifications by a causal relationship of recurrence of pain it is necessary to point to work of V. M. Mintz (1905) who established that unsuccessful cases are connected with herniation of a front abdominal wall and fecal fistula, the alternating infiltrates, so-called pseudoappendicites and relative impassability of guts.
I. I. Grekov (1927) offers the classification of the reasons of unsuccessful outcomes: recurrence owing to the extensive cicatricial unions around a caecum creating conditions to intestinal impassability and recurrence because of excesses of an ileal gut with partial intestinal obstruction, spasms of the bauginiyevy gate.
Studying of the reasons of unsatisfactory results shows that they can be divided into 3 groups. The first, the most numerous, the group is made by patients to whom appendectomy is mistakenly made, and the painful attack was caused by other disease. It is characteristic that most of these patients is operated apropos "chronic" or "acute simple" appendicitis. The number of wrong operations, apparently, is big. The big difference in selection of patients to operation in various medical institutions can testify to it. According to P.E. Beylin (1966), the percent of the rejected diagnoses of an acute appendicitis in various medical institutions fluctuates from 2,3 to 47%, and it is higher in more qualified establishments. According to Institute of Sklifosovsky, only thirds of the patients who arrived with the diagnosis of an acute appendicitis operation is made (D. A. Arapov, 1966). According to our data, only for 1971. at 43% of patients the diagnosis of an acute appendicitis was removed.
Laying aside many questions connected with this problem, discussed on pages of the medical and surgical press it would only be desirable to emphasize that the majority of "recurrence of pains" are connected not with an operative measure, and with the disease simulating appendicitis and which is timely not distinguished. Pointing to it, a number of authors provide convincing data that among patients with a disease of a right kidney and ureter from 20 (Ja. G. Gottlieb) to 43% (M. I. Kolomiychenko, 1966) made in the past appendectomy. Moreover, S. D. Goligorsky notes that often the hem after appendectomy is "symptom" of stones of the right ureter.
The complicated differential diagnosis with a right-hand adnexitis at women leads to diagnostic mistakes at 50 — 60% of patients (T. Ya. Aryev 1956). Data at infectious, internal diseases are not consolatory, a helminthic invasion etc.

Diagnostic mistakes are quite often made not only before operation, but also in the course of the intervention. Most often it occurs when the surgeon does not compare data of a clinical current with the pathological changes found during intervention. As N. I. Blinov (1966) fairly notices, lack of the expressed inflammatory changes in a worm-shaped shoot has to cause more careful audit of an abdominal cavity. If the surgeon at the same time is limited only to removal of the low-changed shoot, it makes a gross blunder.
At discrepancy of a clinical picture to changes in a worm-shaped shoot the surgeon is obliged to study a condition of a caecum, mesenteric lymph nodes, an ileal gut (Mekkel's diverticulum). Recurrence of a pain syndrome is possible at not elimination of an abnormal form of the adhesive desease caused by unions around terminal department of an ileal gut (Lane, 1908, 1926) or the blind and ascending gut (Jekson, 1909).
It is necessary to investigate a condition of mobility of a caecum as caecum mobile is the frequent reason of recurrence of pain. The mobile gut has to be fixed by one of the accepted methods (Vilmsa, P. A. Grekov, G. A. Gomzyakov).
The majority of these diseases can be diagnosed during intervention. Usually they are not distinguished because of insufficient access to ileocecal department of intestines owing to use of small cuts. It does not allow the surgeon to study a condition of abdominal organs and conducts, sometimes, to tragic mistakes. At emergence of diagnostic difficulties, both in the presurgical period, and during intervention, the surgeon, first of all, has to make quick access, sufficient for audit of bodies, on condition of full anesthesia. Functional results of operations for an appendicism are especially adverse (Sh. D. Hakhutov, 1927; G. N. Keves, 1928; L. A. Divavin, 1929; I. M. Topchibashev, A. R. Guseynov, 1970; Melchior, 1927) where diagnostic mistakes because of defective inspection of patients in the presurgical period are most often made.
The second group of patients with recurrence of pain after appendectomy can be allocated conditionally. It is about the patients who transferred appendectomy and in the remote period of the patients with other diseases whose symptomatology is taken for recurrence of pains after appendectomy. The following supervision can be an example.
The patient At., 20 years, came to clinic of 20/X 1962 g with the diagnosis of abscess of the right ileal area. Complaints to severe constant pain in the right ileal area, without irradiation, appeared 18/X 1962 g 20/X nausea, vomiting, a fever joined it. Transferred appendectomy concerning phlegmonous appendicitis 6 months ago. At receipt temperature 37,8 °, language is laid over by a white plaque, is dryish. The stomach participates in breath, the right half lags behind a little. In the right ileal area a postoperative hem. At a superficial palpation the muscle tension of a front abdominal wall in right hypochondrium and mesogasters is defined. Here sharp morbidity, positive symptoms of irritation of a peritoneum. In blood a neutrophylic leukocytosis with shift to the left. At X-ray inspection of free gas and Kloyberg's bowls it is not revealed.
20/X 1962 g operation. The right pararectal section opened an abdominal cavity. Limited is found it is purulent - the fibrinous peritonitis caused by Mekkel's diverticulitis. The diverticulum is removed. Recovery.
At a number of patients emergence of pain after appendectomy is connected with development of late postoperative complications of functional or morphological character. Undoubtedly, at some part of them recurrence of pain can be explained not with appendectomy, and a consequence of a basic disease, but complexity of treatment of these concepts allows us to integrate these patients in one group. The adhesive desease among late complications occupies one of the leading places. Also is explained by it that doctors-surgeons of an out-patient link most often resort to this diagnosis at the corresponding complaints of the operated patients. Meanwhile this complication not the only thing among the pain reasons in the late postoperative period. We pointed to it at analysis of such complications as kultita, inflammatory "tumors", foreign bodys etc.
Can also lead to recurrence of pain the changes in ileocecal department of intestines arising later appendectomies. We are still insufficiently oriented in physiological features of this department of a digestive tract in general and changes after appendectomy in particular. According to the available data, muscles of a worm-shaped shoot and its innervation are closely connected with the bauginiyevy gate (Heil, 1914). Appendectomy can cause deep disorders of function of this department which have constant or intermittent character in some patients.
I. I. Grekov connected recurrence of pains with pathology of the bauginiyevy gate after appendectomy (1927). Having studied clinic of this disease, he came to a conclusion that at some patients with persistent spasms of the bauginiyevy gate the bauginoplastik needs to carry out. This operation executed by the author in clinic at 6 patients in 5 cases was followed by favorable results.
We observed 3 patients with a stenosis of the bauginiyevy gate. At one of them pathological changes were connected with imposing of the wide purse-string seam which led to sharp deformation is thin - colic transition. The executed reconstructive operation led to recovery. Emergence of a stenosis of this department of intestines was caused in the second patient by chronic inflammatory process.
Sick L., 29 years, came to clinic of 28/01 1971 with complaints to periodically arising acute colicy pain in a stomach, existence of fistula with purulent separated in the right ileal area. In October, 1969 it is operated concerning an acute appendicitis. During intervention appendicular infiltrate is found in view of what the shoot was not removed, surgeons were limited to drainage of an abdominal cavity. Appendectomy is made in December, 1969. In 2 weeks fistula with purulent separated in an operational zone developed. Attempt of its sewing up was unsuccessful. In August, 1970 abscess of a front abdominal wall was opened. In clinic fistula of a stump of a worm-shaped shoot is diagnosed for the patient. 9/02 1971 it is operated. During operation it is revealed that fistula proceeds from a shoot stump; in a wall of a caecum infiltrate of 3X3 cm of Infiltrirovannaya is defined the wall of a gut is resected and removed in one block with the fistular course. The sharp stenosis of the bauginiyevy gate is at the same time established: diameter of a gleam is up to 0,5 cm. The terminal department of an ileal gut is sharply expanded to 5 — 6 cm in the diameter. The bauginoplastika is made. Recovery.
At 2 patients we could not connect emergence of a spasm of Bauhin's valve with errors of technology of intervention or accession of complications of inflammatory character. The made bauginoplastika had the expressed medical effect.
At one patient the made bauginoplastika did not lead to desirable result. Obviously, indications to reconstructive operation were overestimated. On clinical signs at it it was established astheno - a vegetative syndrome. The therapy which is carried out in the subsequent was followed by some improvement of its state.
B. N. Rozanov (1924), I. V. Yurasov (1927) recurrence of pain, on the contrary, connected with insufficiency of the bauginiyevy gate. According to their supervision, contents of a caecum can be thrown in terminal department ileal, at the same time there are spasms leading to a hypertrophy of a muscular layer and unions.
Many researchers connect the reason of recurrence of pain with disturbance of an innervation of abdominal organs. L. F. Hermann (1927), G. I. Gimmelfarb (1927) in these cases speak about neurosises of an abdominal cavity, A. G. Radziyevsky (1929) — about Simpatici abdominalis neuralgia, described visceral neurosises after a splenectomy also Ya. M. Pavlovsky (1929).
Development of a chronic inflammation in a mesentery of a worm-shaped shoot can be a pain source in the late postoperative period. M. K. Komissarov (1934), M. O. Vulfovich (1935) in this connection they did not recommend to peritonize a shoot stump a mesentery according to Brown pointed to it.
At 13 patients any diseases which could explain development of a pain syndrome in the remote terms after appendectomy are not revealed. In this regard the theory of Pribram (1930) which published an interesting explanation of recurrence of pain after appendectomy draws attention. He established that the good long-term results were much more often at the patients operated during the acute period at the rough phenomena of an inflammation in a shoot wall (gangrene, an empyema or phlegmon of a shoot). At operations in an interval between attacks without the expressed inflammatory changes in body recurrence was observed in 10 — 15% and a thicket. The author considers that the major role in an origin of recurrence of pain after appendectomy belongs to a mezenterialny limfangiit and lymphadenitis. This point of view is supported M. O. Vulfovich (1935) and I. M. Talman (1963).
Thus, recurrence of pains after operation for appendicitis is observed at considerable group of patients. In most cases it is connected with inaccuracy of diagnosis, errors in technology of intervention less often with effects actually of appendectomy. Improvement of quality of diagnosis, strict implementation of requirements of the developed surgical tactics at acute and an appendicism, careful execution of all stages of appendectomy can improve considerably the long-term results of this eurysynusic intervention.
At emergence of pain in the late period after appendectomy careful clinical trial of the patient is necessary for detection of the most verified diagnosis of complication and definition pathogenetic of reasonable medical tactics.



 
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