Surgery To Remove Appendicitis - Preoperative, Operative And Postoperative Period

2024 Author: Josephine Shorter | [email protected]. Last modified: 2024-01-07 17:49

Surgery to remove appendicitis

Content:

• Fear of appendicitis
• Preoperative period for appendicitis
• The operating period for appendicitis
• Postoperative period
• Complications after removal of appendicitis
• Rehabilitation and recovery

Appendectomy in modern conditions is the only reliable method of treating most forms of inflammation of the appendix. Among people far from medicine, inflammation of the appendix is the cause of numerous justified and unfounded fears. The information presented below, available to a wide range of readers, can be used as a reminder before the operation to remove appendicitis.

Fear of appendicitis

The feeling of fear is a natural defensive reaction of a person, helping to avoid dangerous life situations. Fear is a bad counselor for painful illnesses. Pain is a signal that the body has ceased to cope with an internal problem on its own. Abdominal colic that persists for 3-4 hours is a sign of a serious health problem and one of the symptoms of appendicitis, as well as a reason for urgently contacting a hospital.

The causes of pain are always associated with:

• irritation of nerve endings with products of inflammation;
• squeezing (spasms), stretching and injury to nerve fibers.

Physical pain can usually be controlled with pharmaceutical drugs. However, without complex treatment, and sometimes radical surgical intervention, it is impossible to stop the pathological process - inflammation of the appendix. With the remaining focus of the disease, the pain will return sooner or later.

Other phobias (according to patient surveys) are associated with fears:

• trusting your life to surgeons;
• poor outcome of the operation;
• long-term consequences;
• correct diagnosis.

With regard to the first three phobias, the fears are justified to some extent, but late treatment to a medical institution only increases the risks. The operation from a common procedure turns into a complex manipulation.

As for doubts about the correctness of the diagnosis, indeed, the signs of appendicitis do not always correspond to the descriptions in the medical literature, and the symptomatology characteristic of appendicitis may be a manifestation of other dangerous diseases, for example:

• diseases of the gastrointestinal tract are stomach ulcers, duodenal ulcers, blockages of the small intestine, Meckel's diverticulum (blind outgrowth of the intestine, looks like an appendix), appendicular infiltration, periappendicular abscess, colon cancer or perforation, pancreatitis, cholecystitis;
• diseases of the genitourinary system - inflammation or obstruction of the ureters, inflammation of the appendages, pathological spasms during ovulatory cycles;
• infectious diseases - typhoid fever, dysentery and others.

Many casuistic diseases are disguised as appendicitis. There are diagnostic errors, but they are rarely fatal for the patient. With the introduction of laparoscopy into practice, the number of errors has decreased significantly.

Phobias associated with the peculiarities of the patient's physiological state and the difficulty of diagnosis during this period, namely:

• pregnancy - a natural fear for the life of the fetus, which is combined with a distorted compression of the internal organs of the clinical picture;
• old age - combined with the layering of various chronic diseases;
• childhood - for obvious reasons, phobias are typical for parents with hypertrophied fears for the health of their child.

Modern diagnostic techniques and surgical technologies make it possible to find the optimal, safe treatment suitable for each specific case at any age and in any physiological condition.

Appendectomy. Depending on the clinical situation, the operation is performed urgently or as planned.

Emergency operation. The indication is the acute stage or exacerbation of chronic inflammation. The operation is performed two to four hours after the patient is admitted to the clinic. The urgency is due to the rapid development of a dangerous condition (peritonitis, perforation of the walls of the appendix, outpouring of pus into the abdominal cavity).

Planned operation. If emergency intervention is prohibited, the operation is carried out after the threats have been eliminated. The time for a planned operation is determined based on the timing of palliative (eliminating threats) treatment and recovery.

Preoperative period for appendicitis

Appendectomy belongs to the category of operations performed urgently, so all the necessary procedures in the emergency room are carried out as quickly as possible.

Patient registration

Patient registration is a prerequisite for staying in a medical institution. To speed up, prepare the necessary documents in advance:

• passport of a citizen of the Russian Federation or a document replacing it (military ID);
• health insurance policy (compulsory or voluntary);
• individual personal account insurance number card (SNILS);
• an outpatient card, if any (usually it is in the clinic at the place of residence, but sometimes it is handed out).

Some problems with obtaining a free appendix removal may arise from persons who do not have citizenship of our country.

This does not mean that they will be denied emergency assistance, however, in order to rule out the problem, they should obtain an OMI (compulsory health insurance) policy in advance. To obtain a policy, contact the nearest insurance company with a good business reputation in the insurance market. A policy in the form of a plastic card is issued for a month, and a temporary policy is issued on the day of circulation.

Attention! Foreign citizens temporarily or permanently residing in the territory of the Russian Federation are issued a compulsory medical insurance policy on the basis of Art. 10 of the Federal Law of the Russian Federation of November 29, 2010 N 326-FZ.

The presence of a temporary or permanent compulsory medical insurance policy is mandatory for all categories of citizens admitted to a medical institution.

Additionally, you must present:

• for a refugee - a refugee certificate or a copy of an application for this status (complaints about its deprivation);
• for a stateless person temporarily residing in the territory of our country - an identity card with a mark on permission to stay in the Russian Federation.
• for a foreign citizen temporarily staying in our country - a passport of the country of residence of a citizen with a mark from the migration service of the Russian Federation on temporary permission to stay in our country.
• for a foreign citizen permanently residing in our country - a passport of a foreign state and a residence permit in the Russian Federation.

The problem will be greatly simplified by contacting a clinic that provides paid services, including through voluntary health insurance (VHI).

Diagnosis of appendicitis

It is performed by a surgeon in a limited time period.

The indications for surgery may be the results of a clinical examination with vivid symptoms of an `` acute abdomen '' without confirmation of the focus of pathology in the appendix. This strategy is quite justified, since in addition to appendicitis, the causes of emergency surgery are diseases of the abdominal organs similar to appendicitis. During the operation, after examining the intestines and abdominal organs, the treatment tactics can be adjusted by the surgeon.

The sequence of diagnostic procedures:

• Patient interview;
• Examination: general - pay attention to the patient's posture, his gait, local - the condition of the abdominal wall (increase, decrease, symmetry of the sides);
• Palpation (feeling) - pay attention to pain in the place of application of force, and also take pain tests and apply internal palpation - rectal, vaginal;
• Percussion (tapping) - used to identify pain and tactile (to touch) sensitivity;
• Laboratory blood tests - counting the number of leukocytes, determining the ratio of different types of leukocytes in a stained smear and erythrocyte sedimentation rate, urine - general analysis. If indicated, other studies may be included, for example, a study on pregnancy in women. Unfortunately, standard laboratory tests only show an overall picture of inflammation.
• Instrumental methods - plain abdominal radiography, radiography or computed tomography with contrast, ultrasound and its modifications.
• Differential diagnostics. With an unclear, poorly expressed clinic and in the absence of clear indications for emergency appendectomy, the diagnosis is continued until the reasons are clarified. Laparoscopy is most often used as a method of differential diagnosis.

In preparation for the operation, the anesthesiologist conducts a study of the cardiovascular system and collects an allergic history in case of intolerance to pharmacological agents for anesthesia.

If necessary, intravenous drip infusion is carried out with an isotonic solution in order to maintain tone, relieve intoxication and prevent dehydration, as well as insert a probe into the stomach in order to evacuate the contents.

Due to the varying severity of the clinical condition of patients admitted for surgery, the sequence of diagnostic tests may partially change.

Preparation of the operating field for appendicitis

Preparation includes treatment of the abdominal skin, shaving the areas of hair growth, degreasing and disinfection of the skin in the area of the operating field.

If, before the operation, cases of allergy in the patient to solutions for skin disinfection, chemicals and medicines become known, the anesthesiologist corrects his actions.

The operating period for appendicitis

Before the operation, at the request of the patient and accompanying loved ones, it is possible to conduct a conversation about the upcoming manipulation with the provision of information about the essence of the operation, methods of pain relief and possible complications. But since the operation is urgent, this conversation is sometimes not carried out.

The operating period includes:

• the introduction of the patient into a state of anesthesia;
• layer-by-layer dissection of the abdominal wall;
• revision of the abdominal cavity and organs located in it, examination of the appendix and part of the intestine (approximately 50 cm before and the same amount after the place of its discharge);
• resection of the appendix, suturing of the edges of the removed process;
• tightening and suturing the peritoneum with absorbable sutures (sutures are not removed);
• tightening of the skin and the imposition of intermittent (removable) sutures.

In the presence of complications (effusion of the contents of the appendix into the abdominal cavity), the cavity is sanitized and temporary drainage is fixed in order to evacuate the products of inflammation outside the body. This drainage is removed before the surgical sutures are removed, immediately after the state of the body has stabilized.

The time of the operation. There are no standards, it can last from 40 minutes to 2-3 hours, depending on the severity of pathogenesis, physique, patient's age, location of the appendix in the abdominal cavity and many other factors.

Pain relief is an important step in the operation. The quality of anesthesia depends on the time of the operation, the rate of healing of the surgical wound, the likelihood of operational and postoperative complications.

When removing the appendix, three options for anesthesia are used:

• method of tight infiltration;
• conduction blockade;
• general anesthesia.

All methods, if performed correctly, have an adequate analgesic effect. The first two methods involve finding the operated person in consciousness during the period of the operation, in this regard, they are contraindicated for:

• young children - uncontrollable restlessness of a small child interferes with appendectomy;
• patients with peritonitis - a major operation involves the sanitation of the intestines, while reflex tension of the muscles of the abdominal wall is possible;
• patients who undergo laparoscopic surgery - manipulations inside the abdominal cavity with a medical instrument in a person who is conscious, cause a gag reflex and spasm of the muscles of the abdominal wall, and muscle relaxants to suppress these phenomena are not used without general anesthesia with controlled ventilation.
• patients with increased excitability, individual intolerance to novocaine and its derivatives.

Although considered outdated, local anesthetic methods have proven to be effective and safe when skillfully performed.

Tight creeping infiltration method

The goal is to provide painless layered cutting and stitching of the skin and abdominal wall.

The threshold of pain sensitivity of the intestine is much lower, for its anesthesia, a solution of novocaine is periodically added to the abdominal cavity, or other drugs are used.

The principle of the method is layer-by-layer under pressure created by a syringe, impregnation of layers of skin, muscles and tissues of the abdominal wall with a 0.25% solution of novocaine. As a result of the injection of the solution under pressure, an extensive novocaine layer is created under the operating field, which blocks the conduction of pain impulses. During the operation, you have to constantly repeat this procedure.

The practical value lies in the simplicity of execution and the ability to control the main physiological parameters of the operated without complex medical equipment. The operation can be successfully performed under primitive conditions.

Disadvantages - novocaine does not relieve the gag reflex; during the operation, you have to constantly inject a solution of novocaine.

Regional or local anesthesia

The goal is similar to the goal of the creeping infiltration method. The principle is based on blocking the conduction of nerve impulses through the nerve bundles that innervate the intestines by injecting anesthetic drugs into the space surrounding the nerve node from which the nerve bundles diverge. The technique is complex in comparison with tight infiltration. A good knowledge of the topographic landmarks of the needle insertion site and the location of the nerve nodes is required from the anesthesiologist.

Solutions of various concentrations (bupivacaine, lidocaine, ropivacaine) are used as anesthetics.

The advantages of the method:

• the speed of the onset of the effect;
• small doses of pain medication;
• reliable anesthesia, no need to constantly add anesthetic;
• the possibility of combining various techniques.

The disadvantage is the complexity of implementation.

General anesthesia is a modern method of pain relief

The patient is put into sleep and removed from the state of general anesthesia in stages. During the period of the narcotic state, the anesthesiologist monitors the cardiovascular and respiratory systems of the operated patient.

The stages of anesthesia consist of premedication, the introduction of drugs, the actual anesthesia and removal from this state:

• Premedication. Objectives - to increase the body's resistance before the operation, to ensure the stable functioning of the heart and lungs during the operation;
• Introductory anesthesia or induction. The goals are to gradually bring the operated person to the state of anesthesia, to adapt the heart and breathing to the conditions of anesthesia. At this time, if necessary, muscle relaxants are injected and tracheal intubation is performed for artificial ventilation of the lungs. The duration of the period is 10-15 minutes;
• Maintaining anesthesia. The goals are to maintain a stable level of basic body functions and the absence of pain sensitivity. The length of the period corresponds to the time of the operation. During the operation, fractional addition of drugs is allowed;
• Removal from anesthesia. Objectives - removal of metabolites of anesthesia, restoration of vital functions and the transition of the body to independent functioning.

Potent pharmaceuticals of limited availability are used as drugs for general anesthesia during appendectomy.

Possible complications of this stage are monitored by the anesthesiologist. The risk group includes patients with hypersensitivity and concomitant diseases that weaken the work of the heart and respiratory system.

Layer-by-layer dissection of the abdominal wall with appendicitis

General principles for performing an abdominal incision:

• The incision is made in layers. This allows you to control the process and, if necessary, in time to alloy the blood vessels, which reduces the risk of muscle injury and aponeuroses;
• The length of the incision is not strictly regulated; it must be sufficient for the surgeon to work. Too small an incision creates problems during the extraction and revision of internal organs, setting the omentum and bowel loops into the abdominal cavity, and too large - increases the time of tissue suturing and aggravates the risks during the wound healing period;
• The muscles, aponeuroses and the omentum are separated by a blunt method, that is, a small puncture is made, and then they are separated with tools and hands along the fibers.

At this stage, bleeding is dangerous, which is not noticed when the blood vessels of the abdominal wall are severed. With insufficient anesthesia, intra-abdominal pressure reflexively increases, possibly uncontrolled prolapse of the omentum and intestinal loops. All these risks are taken into account by the surgeon.

Revision of the abdominal cavity with appendicitis

After the abdominal wall is disconnected, the omentum is removed and the internal organs are examined. If necessary, the bowel loops are removed outside the abdomen. In parallel, an inflamed appendix is found.

When examining the appendix, internal organs and intestinal loops, attention is paid to visible morphological defects of the walls of the peritoneum and the organs under study. If changes are detected, the surgeon acts in accordance with the instructions and his own intuition. With uncomplicated appendicitis, the operation goes into the final stage. In case of complications, the algorithm of actions is different.

When examining the internal organs under local anesthesia, one should beware of the gag reflex in response to tightening the intestinal loops. The danger lies in uncontrolled prolapse of intestinal loops, spontaneous rupture of the appendix and infection of the abdominal cavity. These risks are considered by the surgeon and the anesthesiologist.

Resection of the appendix

The appendix is pulled up to the edge of the surgical wound and removed outside of it. Isolation of the appendix from the abdominal cavity is provided, the technique is described in detail in textbooks and manuals. Catgut or synthetic spontaneously absorbable sutures are used as suture material.

The principle of imposing a submerged purse-string suture on the stump of the appendix consists in tightening the appendix so that the edges of the wound plunge into the stump, and the outer side of the appendix is connected by serous membranes to the center. This method of suturing allows you to expect the fastest possible healing and sealing of the appendix.

The risks are associated with possible contamination of the abdominal cavity, instruments and surgical linen due to inaccurate separation of tissues, as well as with the failure of surgical sutures and knots.

Suturing the surgical wound after appendectomy

The connection of the abdominal wall is made with threads that absorb after a while, and the stitching of the skin is made with intermittent sutures (on average, 7-10 stitches are performed). Strong silk or synthetic threads are used as suture material. The stitches on the skin are removed after 7-10 days. Potential risks are associated with rupture of threads and knots.

Find out more: Do's and don'ts after appendicitis surgery?

Postoperative period

The recovery period lasts from the end of the operation to the removal of the stitches on the skin. The duration of the period increases with complex appendectomy. The sequence of actions of the medical staff for uncomplicated appendicitis is quite simple.

In the early postoperative period (first day):

• carry out (if necessary) detoxification of the patient's body;
• monitor for signs of possible postoperative bleeding, bowel and / or bladder paresis.

In the middle and late postoperative period (on the second - tenth day):

• monitor the restoration of the functions of the patient's physiological functions (defecation, urination), if necessary, take measures;
• monitor the possible development of postoperative complications (control of body temperature, appetite, the state of postoperative sutures, the presence of pain).

How long do they stay in the hospital after appendicitis is removed?

After an uncomplicated operation, the patient is in the hospital for no more than ten days. You can get up after surgery with the permission of your doctor, usually on the third or fourth day (individual recommendation!). Sometimes you should wear a bandage or tie a towel around your abdomen to prevent suture divergence. Drink is given on the first day after the operation. From the second day, nutrition is shown according to the diet recommended by a dietitian.

Inform your doctor promptly if:

• impossibility of defecation and / or urination without strong straining;
• pain in the abdomen and in the area of the seams;
• wet seams and discomfort when moving.

When are stitches removed after appendicitis removal?

They are removed after filling the surgical wound with healthy granulation (crust). Under normal conditions, this is the seventh, sometimes tenth day. The stitches are removed in the treatment room. The patient is discharged only after removing the stitches. Attention! A few days after discharge from the hospital, you should be careful with physical exertion - even in a well-healed surgical wound, the edges may come apart.

What to do if the suture has split after appendicitis removal?

The reason is non-compliance with the regimen after discharge from the hospital. Both internal and external seams can disperse.

1. It is possible to determine the rupture of the internal seams (on the abdominal wall) by the following criteria:

• protrusion (hernia) of the skin in the area of the surgical wound, while the skin is not damaged;
• with light pressure on the bulging site of the abdominal wall, a jelly-like or slightly harder formation is felt - this is an omentum;
• pain that provokes vomiting is a sign of intestinal loops protruding under the skin, but usually the omentum prevents intestinal prolapse.

Patient actions:

• Call an ambulance;
• Take a horizontal position on a solid surface;
• If, after taking a horizontal position, the protrusion has gone inward, tie a towel around the stomach;
• Calmly wait for the doctor: anxiety and straining only aggravate the dehiscence of the wound.

2. Determine the discrepancy of the external (skin) seams by the following signs:

• a red (scarlet) wound is gaping at the site of the gap - this is the abdominal wall, there is a seam on it that prevents intestinal prolapse;
• the wound site is bleeding, or the wound is dry.

Patient actions:

• Take a horizontal position, call an ambulance;
• Cover the wound with a sterile napkin, you cannot press on it, in contrast to the situation with the discrepancy of the internal seams.

Related article: diet after surgery to remove appendicitis

Complications after removal of appendicitis

Complications after appendectomy are divided into early and late. We will focus on the main manifestations of complications that sometimes bother patients after removal of the appendix.

Fever after appendicitis surgery

Subfebrile fever is a frequent companion of inflammation of the appendix and one of the symptoms of the disease. An increase in temperature is a signal of the presence of an inflammation focus. At the first stage of the disease, this is a useful signal - it means that the body resists. A short-term increase in temperature after removal of appendicitis does not pose a danger, it passes on its own or after several medical procedures.

The danger is hyperthermia after the removal of appendicitis (within a month), if it proceeds against the background:

• vomiting;
• constipation or diarrhea;
• pain in the abdomen;
• disturbances of consciousness;
• increased sweating.

In some cases, the temperature after the removal of appendicitis lasts a very long time, sometimes up to three to six months. In this case, it is necessary to conduct an in-depth examination. Perhaps the reason is a reflex violation of thermoregulation.

Pain after appendicitis surgery

Pain is the result of suture inflammation, adhesion formation, or incipient peritonitis. It is possible that pain persists from concomitant pathology that was not eliminated during appendectomy.

You need to contact the surgeon at the local polyclinic, or to the surgeon who performed the operation.

Adhesions after appendicitis surgery

Adhesions are fibrous-fibrous tissue, the result of adherent inflammation. They lead to a connection between the serous membranes of different intestinal loops. The causes of adhesive inflammation are unpredictable, sometimes the pathology is provoked by microorganisms trapped in the abdominal cavity during the operation, but it is believed that adhesions occur in sedentary people, as well as in old age.

Adhesions formed on the intestines after appendicitis are manifested by increased soreness when the intestines are overfilled with food and gases, as well as with increased peristaltic contractions of the intestines. Treating adhesions is difficult because the fibrous tissue of the adhesions is penetrated by blood vessels and nerves.

Peritonitis after appendicitis

Peritonitis results from perforation of the appendix. Accordingly, the operation to remove appendicitis is carried out taking into account the severity of the pathogenesis, while the intestines are sanitized, drainage is applied, a constant outflow of inflammatory exudate is maintained, and complex treatment is prescribed in the postoperative period.

Peritonitis after appendectomy is a phenomenon predicted in persons:

• old age;
• with chronic pathologies;
• with a history of a severe preoperative condition.

Symptoms of peritonitis are high fever, soreness and hardness of the abdominal wall, large-scale intoxication.

Postoperative hernia after appendicitis

Postoperative hernia is the result of a rupture of the abdominal wall at the site of the surgical incision some time after the operation. A hernia is the result of a combination of the following factors: poor fusion of the edges of the surgical wound, strong straining or blunt trauma of the abdomen in the area of the surgical wound. It manifests itself as a protrusion of the abdominal wall at the site of the postoperative suture. The actions of a person who has a hernia after appendicitis are similar to those recommended for patients with internal suture dehiscence (see above).

Rehabilitation and recovery after removal of appendicitis

With uncomplicated appendectomy surgery, the period from surgery to going to work is on average three weeks, with the first week spent in the surgical department.

There are no general recommendations on how to behave after an operation to remove appendicitis. Some patients get up and begin to move the very next day after the intervention, others need several days for this. Recovery is faster in young and thin people.

General recommendations relevant to all categories of convalescents from uncomplicated appendectomy:

• take short walks;
• consult your doctor in what cases it is necessary to wear a postoperative bandage (usually it is indicated for obese people or for long movements);
• do moderate exercise, swim (immersion in water is possible after the formation of a scar - a seal at the site of the skin incision);
• sex is possible two weeks after the removal of appendicitis;
• the diet for the first month after surgery should consist of easily digestible food.

Rehabilitation for complications after appendectomy is carried out based on the individual characteristics of the pathology and the patient.

The author of the article: Volkov Dmitry Sergeevich | c. m. n. surgeon, phlebologist

Education: Moscow State University of Medicine and Dentistry (1996). In 2003 he received a diploma from the Educational and Scientific Medical Center of the Presidential Administration of the Russian Federation.