RU2585736C1 - Method of appendectomy in distribution of inflammation to cecum dome - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: mobilization of the appendix is performed. Cleave and circularly separate serous-muscular layer from the base of the appendix to the dome of the cecum. Remove the process. Bandaged stump sprouts at the edge of the displaced serous-muscular layer. Over immersed in the dome of the cecal stump sprouts serous-muscular layer sutured.

EFFECT: method appendectomy during propagation of the inflammatory process of the dome cecum reduces the risk of septic complications: abscess of the appendix stump, insolvency joints by reducing the volume of operation.

1 cl, 4 dwg, 2 ex

Description

The invention relates to medicine, namely to surgery, and can be used in the treatment of acute appendicitis.

A known method of processing the stump of the appendix in appendectomy according to the RF patent No. 2428939 for the invention, comprising introducing the appendix stump into the lumen of the cecum, according to the invention, the stump of the appendix is stitched crosswise, the hollow tube with troughs at the end is inserted into it, the stump is invaginated with the tube lumen of the cecum, tighten the purse string suture around the tube, the stump cavity is washed with an antiseptic solution through the hollow tube, remove the tube and tighten the purse string suture.

The disadvantage of the method according to patent No. 2428939 is its complexity.

A known method of appendectomy for the spread of the inflammatory process to the dome of the cecum according to the patent of the Russian Federation No. 2196524 for the invention, comprising mobilizing the appendix, according to the invention, dissects and separates the sero-muscular membrane of the dome of the cecum within the unchanged tissues with two border sections, then separate sutures are made on the submucosa layer and excise it with a scalpel at the border of the inflammatory process, while simultaneously tightening and tying the ligatures, then on the serous-muscular individual sutures of Pirogov-Mateshuk are placed along the edge of the incision of the dome of the cecum.

The problem solved by the invention is to simplify the method of appendectomy with the spread (including significant) of the inflammatory process to the dome of the cecum and increase its reliability.

The technical result achieved by the invention is the simplification of the method of appendectomy with the spread of the inflammatory process to the dome of the cecum by reducing the volume of operation; ensuring the reliability of the method by reducing the risk of purulent complications: abscesses of the stump of the appendix, failure of sutures, postoperative peritonitis.

The claimed technical result is achieved by the fact that in the method of appendectomy with the spread of the inflammatory process to the dome of the cecum, including mobilization of the vermiform appendix, dissection and separation of the serous-muscular layer of the base of the vermiform process, removal of the vermiform process, according to the invention, dissection of the serous-muscular layer of the base of the vermis by a circular incision of the serous-muscular layer along the perimeter of the base of the appendix, separation the serous-muscular layer of the base of the appendix is carried out by displacing the serous-muscular layer from the base of the caecum, remaining connected with the dome of the caecum, to the dome of the caecum, the stump of the appendix is formed by ligating at the edge of the displaced serous-muscular layer of the muscularis and submucosal process with subsequent removal of the appendix, when the stump of the appendix is immersed in the dome of the cecum, shifted to the dome of the blind the intestine, the serous-muscular layer is sutured over the stump of the appendix, immersed in the dome of the cecum.

In case of severe inflammatory changes in the base of the appendix and the dome of the cecum (tiflitis), accompanied by severe rigidity of the wall (density and immobility), immerse the stump of the appendix (in the dome of the cecum) in the purse string suture or in separate nodular serous-muscular sutures due to the gap ligatures becomes quite a technically difficult task with a significant increase in the risk of suture failure with the subsequent development of intra-abdominal complications: paracecal abscesses, abs ssov appendicular stump and postoperative peritonitis.

The inventive method is performed when performing both antegrade and retrograde appendectomies from various surgical approaches (median or lateral).

In the inventive method, after mobilization of the appendix, i.e. its isolation from the surrounding appendix (from adhesions, from soldered loops of intestines, etc.), and dissection of its mesentery with an artery (excretion of the appendix, in which the appendix and dome of the cecum are completely accessible for examination and surgical operations, the base of the vermiform appendix make a circular incision (along the perimeter of the base of the vermiform appendix) to the submucosal layer (Fig. 1).

Further, part of the serous-muscular layer remaining connected with the cecum is displaced from the circular incision line towards the cecum, thus forming a muscular “sleeve” with a width of 5 to 7 mm. Moreover, the thicker the inflamed wall of the cecum dome, the easier it is to create a serous-muscular “sleeve”. In the future, this clutch will be used when applying sero-muscular sutures (Fig. 2).

The appendix is ligated with any suture material (ligature) at the edge of the muscular “sleeve” and is cut off. In this case, a stump of the appendix is formed, the size of which is no more than a “match head”, because only the submucosal and mucous layers of the appendix are ligated and dissected (Fig. 3).

Next, the formed stump of the appendix is immersed in the dome of the cecum and covered with a muscular sleeve on top, the edges of which are fastened by applying two or three separate nodular serous-muscular sutures, while providing reliable shelter of the appendix stump in the dome of the cecum. The line of sutures on the muscle sleeve does not need additional methods of strengthening or isolation (Fig. 4). In fact, the stump of the appendix due to its small size itself plunges into the dome of the cecum when the muscular sleeve is closed over the stump.

The main difference between the proposed method and the known ones is that in the known methods all altered (inflamed) tissues of the base of the appendix and the dome of the cecum are completely excised, which significantly increases the volume of surgery, and in the inventive method, the altered (inflamed) tissues of the base of the appendix and the dome the cecum is not removed (excised), but rather, used to form muscle clutch. Those. in the claimed method, surgical intervention is deliberately carried out precisely within the most pathologically altered inflammatory process tissues.

At the same time, changes in tissues of the cecum dome of the vermiform appendix (thickening, densification) present during inflammation are useful, since it is more convenient to form a muscle “clutch” from such altered tissues.

In the claimed method, it is not required to completely remove the altered (inflamed) tissues of the base of the appendix and the dome of the cecum, since after removing the focus of inflammation (the appendix) as the cause of pathological changes in the wall of the cecum and the appendix, regression of inflammatory changes in the formed muscle “sleeve” and dome of the cecum.

Thus, due to a significant reduction in the volume of surgical procedures, there is a simplification of the appendectomy method when the inflammatory process spreads to the cecum dome.

The reliability of the proposed method is ensured by the fact that in the claimed method, a stump of the vermiform appendix is formed of minimal size, since the stump is formed only from the submucous and mucous layers of the appendix. The small size of the stump of the vermiform process allows you to reliably immerse it in the dome of the cecum, and then provide reliable shelter of the stump with tissues of the formed muscle sleeve.

The inventive method minimizes the events of insolvency of sutures and postoperative intra-abdominal purulent complications to a minimum.

Earlier it was believed that reliable healing occurs exclusively within healthy, unchanged tissue inflammatory processes. The present method proves that the immersion of the stump of the appendix within the changed tissues leads to reliable healing and does not require a precision technique.

Using the proposed method in the surgical department of the city hospital of Krasnoturinsk, more than 75 appedectomies were performed for destructive appendicitis with severe tiflitis. In no case of intra-abdominal complications were recorded.

The inventive method is less traumatic, minimal in volume and time, easy to implement and does not give complications. But the most important thing is that after removal of the focus of inflammation (the appendix) as the cause of pathological changes, there is always a regression of inflammatory changes in the altered tissues.

In FIG. 1 shows a circular incision at the base of the appendix.

In FIG. 2 shows a formed serous-muscular “sleeve”.

In FIG. 3 shows the formation of the stump of the appendix.

In FIG. 4 shows the immersion of the stump of the appendix in the dome of the cecum and its shelter formed by the serous-muscular coupling.

The inventive method is illustrated by the following examples.

Example 1. Patient M., aged 42, was admitted to the surgical department 47 hours after the onset of symptoms of acute appendicitis. I didn’t immediately seek help, I took no-shpa and analgin on my own in order to reduce abdominal pain. At the initial examination by the surgeon, the diagnosis of destructive appendicitis with local peritonitis was established. Appendectomy, abdominal sanitation, and active drainage of the postoperative wound were performed urgently under spinal anesthesia. The access of Volkovich-Dyakonov revealed the abdominal cavity. A small amount of purulent effusion stood out. Crops on microflora and sensitivity to antibiotics were taken. In the right ileal region, the dome of the cecum and the underlying loops of the ileum are moderately hyperemic and covered with fibrin. The appendix is sharply thickened, tense, covered with fibrin and hyperemic. The inflammatory process extends to the base of the appendix and the dome of the cecum for a considerable extent with a sharp thickening, infiltration and rigidity of the wall of the cecum. It is not possible to perform an appendectomy by immersing the stump of the vermiform appendix in the dome of the cecum by applying a purse string suture or by simply applying individual nodular serous-muscular sutures. The mesentery of the appendix is clamped in stages, stitched, and bandaged. Using a scalpel at the base of the appendix, a circular incision was made up to the submucosal layer and separation and displacement of the serous-muscular layer toward the cecum with the formation of a “sleeve” up to 0.5 cm high. The worm-shaped process is tied with a ligature along the upper edge of the serous-muscular “sleeve”, clipped and deleted. The size of the stump of the appendix is 3 × 2 mm. After processing the stump of the appendix with iodine, the stump is immersed in the dome of the cecum using three nodular sero-muscular sutures, applied to the entire height of the formed serous-muscular “sleeve”. The iliac region is washed with antiseptic solutions, drained. Layered sutures on the wound before active drainage into the subcutaneous adipose tissue. Diagnosis after surgery: acute phlegmonous appendicitis, tiflitis, local unlimited peritonitis. The postoperative period is smooth. An independent chair on the third day. Within five days received antibiotic therapy. Active drainage of the wound is removed on the third day. Sutures were removed on the seventh day. Primary healing. Discharged in satisfactory condition under the supervision of an outpatient surgeon. He started to work 21 days after the operation.

Example 2. Patient R., 49 years old, was admitted to the surgical department after 78 hours from the onset of symptoms of acute appendicitis. He did not immediately seek help, he independently took no-shpa, analgin and tablet antibiotics in order to reduce abdominal pain and lower body temperature. At the initial examination, the surgeon diagnosed destructive appendicitis in the infiltrate with diffuse peritonitis. After a comprehensive examination and preoperative preparation, an emergency appodectomy was performed under mid-access under endotracheal anesthesia, sanitation of the abdominal cavity with suturing of the laparotomy wound on ventrophils. Middle and lower middle laparotomy. In the abdominal cavity up to 350 ml of purulent effusion with fibrin. Crops on microflora and sensitivity to antibiotics were taken. Signs of peritonitis in the middle and lower floors of the abdominal cavity. Loops of the small intestines are brightly hyperemic with plaque of fibrin, moderately inflated. Less pronounced changes in the colon. In the right ileal fossa, the infiltrate formed by the dome of the cecum, omentum, terminal ileum, parietal peritoneum with massive overlays of fibrin. When the infiltrate was divided, an abscess opened. Stand out up to 20 ml of pus. In the center of the infiltrate lies a gangrenous altered vermiform appendix with a medial location. Inflammatory changes extend to the entire dome of the cecum with severe infiltration and rigidity of its wall. The mobilization of the appendix is made. Using a scalpel at the base of the appendix, a circular incision was made up to the submucosal layer and separation and displacement of the serous-muscular layer toward the cecum with the formation of a “sleeve” up to 0.5 cm high. The worm-shaped process is tied with a ligature along the upper edge of the serous-muscular “sleeve”, clipped and deleted. The size of the stump of the appendix is 3 × 2 mm. After processing the stump of the appendix with iodine, the stump is immersed in the dome of the cecum using two nodular serous-muscular sutures, applied to the entire height of the formed serous-muscular “sleeve”. The abdominal cavity is washed with antiseptic solutions to clean water (7 liters), drained. In the mesentery of the small intestine, up to 120 ml of a 0.25% solution of novocaine is introduced. The laparotomic wound is sutured on ventrophiles for subsequent programmatic sanitation of the abdominal cavity. On the second day, the programmed sanitation of the abdominal cavity under endotracheal anesthesia was performed. The laparotomy wound is diluted. In the abdominal cavity, a moderate amount of clear effusion. The serous membrane of the small intestines is brilliant, active peristalsis, the amount of fibrin in the area of infiltrate, tissue hyperemia decreased significantly. The seams on the dome of the cecum are completely consistent. The abdominal cavity is washed with antiseptic solutions to clean water (4 liters), drained and drained by 4 drainage tubes: into the small pelvis, to the infiltrate, and into the subphrenic spaces on the right and left. The laparotomy wound is sutured in layers. The patient was treated in the department of anesthesiology and intensive care for 4 days, followed by transfer to the surgical department. Received complex infusion and antibiotic therapy. Drainage tubes are removed on the second day after program reorganization. Stool on the fifth day after appendectomy. Sutures from the wound were removed on the 14th day, primary healing. Duration of stay in the surgical department is 19 days. Discharged home in satisfactory condition under the supervision of an outpatient surgeon. He started to work 52 days after the operation.

Claims (1)

The appendectomy method for spreading the inflammatory process to the dome of the cecum, including mobilization of the vermiform appendix, dissection and separation of the serous-muscular layer of the base of the vermiform appendix, removal of the vermiform process, characterized in that the dissection of the serous-muscular layer of the base of the vermiform appendix is made by circular circular layer along the perimeter of the base of the appendix, separation of the serous-muscular layer of the base of the appendix and carried out by displacing the serous-muscular layer to the dome of the cecum from the base of the appendix, which remains connected with the dome of the cecum, the stump of the appendix is formed by ligating at the edge level of the displaced serous-muscular layer of the submucosal and mucous layers of the vermiform appendix , when the stump of the appendix is immersed in the dome of the cecum, the serous-muscular layer displaced to the dome of the cecum is sutured over the immersed in the floor of the cecum of the stumps of the appendix.

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