Appendectomy (traditional)

Appendectomy is used for the treatment of acute appendicitis. In general, surgery is easier, but sometimes it is difficult, such as ectopic tail. Therefore, appendicitis must not be considered a "small disease", and appendectomy is a "small surgery." It must be taken care of to improve the treatment effect, to avoid or reduce the occurrence of postoperative complications and sequelae. Acute appendicitis is a very common disease in surgery. Appendectomy is one of the most common and routine procedures, but sometimes it is difficult. Therefore, every operation must be taken seriously. Acute appendicitis is the most common acute abdomen in children. Because the pig's appendix wall is thin, the perforation rate is high; the abdominal cavity has poor ability to limit infection. Once perforation often causes diffuse peritonitis; at the same time, children are often unable to treat early due to diagnosis delay, so the clinical appendicitis is more serious. Therefore, once the diagnosis of appendicitis in children, surgery should be treated immediately. About 500 years ago, humans first recorded a medical literature that approximated the course of appendicitis. By 1875 Groves successfully completed the first appendectomy in Canada. In 1886, pathologist Fitz made it clear that inflammation around the cecum was caused by appendicitis. He coined the term "appendicitis" and predicted that the final treatment for appendicitis was a laparotomy. In the more than 100 years since then, appendectomy has become more and more perfect and is recognized as the most reliable and effective method for treating appendicitis. In the 1930s, due to the use of antibiotics, some appendicitis was also improved by antibiotic treatment. However, due to the residual inflammation of the appendix, there is still a recurrence. Therefore, the best treatment for recurrent appendicitis is still appendectomy. Treatment of diseases: acute appendicitis in children with acute appendicitis Indication The diagnosis of acute appendicitis is established, that is, surgery should be performed. 1. Suppurative or gangrenous appendicitis. 2. Perforation of appendicitis with diffuse peritonitis. 3. Recurrent appendicitis. 4. Chronic appendicitis. 5. Aphid appendicitis. 6. Elderly, pediatric, appendicitis during pregnancy. 7. Appendectomy abscess. 8. Most acute simple appendicitis. 9. Non-surgical treatment of abscess around the appendix. Contraindications The incidence of acute appendicitis in children more than 48h, the lower right abdomen touched the mass, considering the formation of appendicitis abscess, temporarily not surgery, active anti-infective treatment and close observation of changes in the condition. Preoperative preparation 1. For patients with severe disease, especially elderly patients with appendicitis in children, liquid should be added to correct water and electrolyte balance disorders. The sick child is generally in good condition and can be operated immediately. When the sick child is seriously poisoned and dehydrated, it should be prepared for several hours, including intravenous infusion, antibacterial application, high heat and temperature reduction, etc., which can make anesthesia and surgery safer. 2. gastrointestinal decompression with abdominal distension. 3. Infected patients, routine use of antibiotics before surgery. 4. Appropriate use of sedatives such as sedatives and progesterone for appendicitis during pregnancy. 5. Appendicitis with perforation, can not be enema before surgery. Surgical procedure Position Supine position. 12.2 2. Incision Need to choose according to the condition, the commonly used incisions are: (1) Right lower abdominal oblique incision (mc burney): right lower quadrant oblique incision, McBurney's incision. Make a skin incision perpendicular to the line through the umbilical hole and the middle 1/3 of the right anterior superior iliac spine (Macbeney point). The incision muscles cross, the healing is firmer, the incisional hernia is not easy to form, and it is close to the appendix, which is easy to find. The incision is generally 5 to 7 cm long. This incision is often used in patients who are confident in diagnosis. Some people advocate that the transverse skin incision is beneficial for healing. The method is to make a transverse incision through the McBernney point. 2/3 of the incision is outside the point, and the incision avoids the anterior superior iliac spine. The above two incisions are slightly higher, which is conducive to the exposure and operation of the appendix. After the skin and subcutaneous tissue were dissected, the external oblique muscle aponeurosis was cut in the direction of the external oblique muscle, and the intra-abdominal oblique muscle and the transverse abdominis muscle fibers were alternately separated by a vascular clamp to reveal the peritoneum. Use the vascular clamp to alternately clip and cut the peritoneum to avoid accidental injury to the intestine. The direction of the peritoneal incision can be oblique or horizontal. (2) Right lower abdomen transabdominal rectus incision: This incision facilitates the extension of the incision and the appendix. This incision is often used when the age is large, the diagnosis is not certain, or the adhesion is estimated to be difficult to handle. However, once infected, it is easy to form an incisional hernia. (3) Incision during pregnancy: Because the appendix is gradually enlarged upwards and outward with the uterus during pregnancy, the incision also needs to be offset upwards and outwards. 3. Looking for the tail After incision of the peritoneum, if there is exudate or pus overflow, it should be immediately removed, and the exudate should be taken for bacterial culture. Use the hook to pull the incision to the sides, looking for the appendix, first find the cecum. The color of the cecum is smaller than that of the intestine, with a colon band in front and fat on both sides. After finding the cecum, use the finger pad gauze to pinch the intestinal wall, and raise the cecum. The appendix can find the appendix. Sometimes you need to push the small intestine or omentum in front of you to find the cecum and appendix. If there is no adhesion around the appendix, use your fingers to push the tip of the appendix to the incision. Regardless of the severity of the inflammatory changes, the hemostatic forceps or tissue clamps should not be used to clamp the appendix itself to prevent infection spread. It can be clamped with a special appendical forceps or with a hemostatic forceps to clamp the mesentery at the tip of the appendix. At this time, due to the traction of the mesentery, the patient often feels abdominal discomfort, nausea, and vomiting, and can be closed with 1% procaine on the appendix. 4. Treatment of mesangium The operation of excising the appendix should be carried out outside the abdominal wall. If it is difficult to perform in the abdominal cavity, the gauze pad should be used to properly protect the layers of the abdominal wall to prevent contamination. Before the appendix is removed, the appendix mesentery and the appendix artery in it should be ligated and excised. If the mesentery is thin, the inflammation is not heavy, and the anatomical relationship is clear, a hemostatic forceps can be used to pierce a hole in the blood vessel at the root of the appendix, and the two No. 4 silk wires are pulled together. The mesangium is then cut. The proximal end is then ligated or sewed together. It is also possible to directly cut two hemostatic forceps side by side and then cut them, and then perform ligation and sewing. (4) proximal end plus stitching If the acute inflammation of the appendix is severe, and it is obviously shortened or edema, it is advisable to use a split clamp and a cutting method to bend the hemostat to cut the root of the appendix to the root of the appendix, and then suture the suture with a 4th wire. Mesangial. About half of the patients' appendix root is a mesenteric artery from the posterior cecal artery, which should be treated for ligation. 5. Protect the appendix and cecum Wrap the appendix with a small piece of dry gauze and clamp it with a pair of pliers or tissue clamps, then use saline gauze around the cecum at the base of the appendix to prevent intraoperative contamination. 6. purse stitching Lift the appendix, around the root of the appendix at the cecal wall 0.5 to 0.8 cm from the root of the appendix (the distance between the roots should be larger), make a purse-string suture, and do not tighten. Note that each needle should be deep and muscular, but do not penetrate into the intestine. 7. Ligation of the root of the appendix Use a straight hemostatic forceps to squeeze it 0.5 cm from the root of the appendix (use this contaminated straight pliers) to prevent the suture from slipping during ligation. Immediately, the 4th wire was ligated at the indentation, and the ligature was clamped by the hemostatic forceps against the appendix, and the pliers were used to cut the thread. Then use a straight hemostat to clamp the appendix at 0.4 cm distal to the ligature. 8. Cut off the tail After applying pure carbolic acid to the blade, the blade is up, close to the straight hemostat clamped by the root of the appendix, and the appendix is cut off, and the knife and the appendix are discarded. 9. Shanwei stump processing Use 3 straight hemostatic forceps with small cotton balls on the tip to pry the cotton balls with pure carbolic acid (or 5% iodonium), 75% alcohol and normal saline, rub them on the mucosal surface of the appendix stump, and then discard the cecum. Salt water gauze. 10. Embedding the tail of the appendix The assistant lifts the cecum wall on the opposite side of the purse-string suture with the left hand holding the fangs, and holds the hemostat of the knot with the right hand, and pushes the tail of the appendix into the cecal cavity. At the same time, the surgeon lifts and tightens the purse suture. The stump is buried in the purse mouth, and the thread is cut after ligation. Some people advocate that the residual strain should not be embedded, and only the root of the appendix can be ligated with silk thread. When using this method, it is better to use a needle to sew a little bit of the appendix serosa and then ligature the appendix to avoid slipping. This needle should not be sutured through the appendix cavity. When the cecal wall around the appendix is obviously edematous and brittle, it is not advisable to barely do the embedding of the residual strain, and it is safer to simply ligature. If you want to cover the appendix stump with surrounding tissue, you can use the appendix mesangial margin or nearby intestinal fat, do not pull the omentum and stump fixed. 11. Cover mesangial Reinforcement suture: use the 1-0 silk thread, 0.3cm at the outer circumference of the purse-string suture, and then suture the muscle layer 8 times, and fix the appendix mesenteric stump or fat droop colon to make the local surface smooth and prevent postoperative adhesion. . 12. Retrograde resection When the posterior appendix or appendix tip can not be revealed at the beginning of the cecum, the root of the appendix can be ligated according to the above method. After the residual strain is embedded, the vascular clamp clamps the distal end of the appendix, and the appendix is ligated successively until the appendix is removed. 13. Guan abdomen Before closing the abdomen, a small gauze group should be clamped in the oval, and the abdominal cavity should be inserted into the abdominal cavity. Check whether there is oozing or pus in the cecum, and whether there is bleeding at the ligation point. If it should be treated, suture the layers of the abdominal wall. Acute appendicitis perforation complicated with localized or diffuse peritonitis, infection and heavy pollution, when there is exudate or pus, the appendix residue treatment is not satisfactory, there may be stump cleft, when the retroperitoneal soft tissue is contaminated during operation After the abscess around the appendix is cut, the abdominal cavity must be drained. The most commonly used cigarette drainage is placed in the right axilla or pelvic cavity, and a small incision is made on the outside of the incision. Removed 2 to 3 days after surgery. If the incision is heavily polluted, the extraperitoneal space should be drained by a cigarette or by a hose. The layers of the abdominal wall are only loosely sutured for drainage. complication 1. Peritonitis and abdominal abscess. 2. Incision infection. 3. Intra-abdominal bleeding. 4. Abdominal residual abscess. 5. Intestinal obstruction. 6. Intestinal fistula. 7. Abdominal wall fistula or sinus.

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