Retrograde appendectomy

The appendix is an intraperitoneal organ with a length of about 5 to 7 cm, a few less than 2 cm or as long as 20 cm, and a diameter of about 0.5 to 0.8 cm. The appendix is a blind tube whose root is located in the end of the cecum and where the three colonic confluences meet and communicate with the cecum. The tip is free and can be extended in any direction. Common sites include anterior or posterior ileum, lower cecum, posterior cecum, and lateral cecum (Fig.1.7.1.2-0-1). Therefore, in the appendectomy, the cecum should be found first, and the colon should be looked down. At the confluence of the three colonic bands, the root of the appendix can be found. There are appendix arteries and veins in the appendix. The appendix artery originates from the ileal artery and is a terminal branch. Once the blood circulation is blocked, the appendix gangrene is very likely to occur; the appendix vein passes through the ileal vein to the superior mesenteric vein. Therefore, in the appendicitis, it may lead to portal inflammation or liver abscess. Treatment of diseases: appendicitis, acute appendicitis Indication Appendectomy for appendectomy is applicable to: 1. Appendicitis after cecum. 2. The appendix is too short. 3. The appendix is not easy to make an incision due to inflammatory adhesions. Contraindications 1. The incidence of acute appendicitis has been more than 72h, or the formation of masses, the local inflammatory edema of the appendix is obvious, this period is not suitable for surgical treatment. 2. If the abscess around the appendix is treated without symptoms, it is not necessary to force the appendectomy. Preoperative preparation 1. Acute appendicitis generally does not require special preparation; for those who cannot eat or vomit seriously, appropriate rehydration should be done according to the situation. 2. Acute appendicitis with peritonitis should be treated with antibiotics. In order to prevent anaerobic bacterium infection, in addition to the general antibiotics, oral metronidazole 0.4g 1 h before surgery, or 1 g of metronidazole rectal suppository. 3. Pregnancy appendicitis should be intramuscularly injected with progesterone 30mg in order to reduce uterine contractions to prevent miscarriage or premature birth. Surgical procedure 1. The right lower abdomen McBurney, that is, from the umbilical hole to the middle and outer 1/3 junction of the anterior superior iliac spine, make a vertical incision perpendicular to the line. The length of the slit is 5 to 6 cm. If the diagnosis is not clear or the operation is complicated, the right lower abdomen can be incision through the rectus abdominis. The advantage is that the incision can be extended upwards and downwards at will. Cut the skin and subcutaneous tissue. The ventral external oblique aponeurosis was cut in the direction of the aponeurotic fibers. 2. Use the retractor to retract the external oblique aponeurosis to the sides to reveal the intra-abdominal oblique muscle. The sarcolemma was firstly cut along the direction of the intra-abdominal oblique muscle fibers. Then the surgeon and the assistant each held a straight hemostasis, interlaced into the intra-oblique oblique muscle and the transverse abdominis muscle, and separated the muscle fibers until the peritoneum. 3. Use two thyroid retractors to open the muscles, then change the appendix retractor, push open the extraperitoneal fat, and fully reveal the peritoneum. 4. The surgeon and the first assistant use the tissue to lift the peritoneum. In order to avoid clamping the abdominal organs, the peritoneum is cut when the incision is made, and the forceps can be alternately relaxed one time, which proves that when the abdominal organs are not caught, Lift the peritoneum and cut the peritoneum between the two scorpions. 5. Use two curved hemostats to clamp the incision of the peritoneal edge and cut the peritoneum in the direction of the skin incision. If pus overflows, it should be exhausted in time. The incision is protected with a saline gauze pad. 6. Lift the cecum first and reveal the root of the appendix. 7. Use a curved hemostatic forceps to pass through the appendix membrane at the base of the appendix near the appendix, and then ligature the root of the appendix with an absorbable or non-absorbent line. At the distal end of the ligature, 0.5 cm, the appendix was clamped with a straight hemostatic forceps, and the appendix was cut between the ligature and the hemostat. 8. After the two ends of the appendix are treated with pure carbolic acid, ethanol and saline, the purse of the cecum wall at the root of the appendix is sutured, and the appendage stump is buried. 9. Then step by step with a curved hemostat clamp and cut the appendix mesangium, suture with silk suture until the entire appendix is removed. 10. If the appendix is located behind the cecum, the lateral peritoneum of the cecum should be cut open, the posterior wall of the cecum should be separated, the cecum should be turned to the inside, and the appendix should be revealed. It should be removed according to conventional methods or retrograde methods. complication Postoperative bleeding There are intra-abdominal hemorrhage, retroperitoneal hemorrhage and intestinal bleeding. Intra-abdominal hemorrhage is more common, due to the shedding of the appendix ligament. Retroperitoneal and mesenteric hemorrhage caused by retraction of the appendix artery, severe cases of right abdomen mass, hemorrhagic shock, and even ileocecal necrosis. Intra-intestinal hemorrhage is caused by the purulent suture buried without the ligation of the appendix. 2. Surgical wound infection More common in the appendix with suppuration, gangrene or perforation. After the incision is infected, it should be opened, the knot removed, and fully drained. 3. Abdominal residual abscess Most occur in the perforation of the appendix caused by peritonitis. The abscess in the abdominal cavity can be confined to the rectum of the bladder, the intestine gap, the right axilla, and even the underarm abscess. There were still abdominal pain, elevated body temperature, fast pulse, increased white blood cells and local tenderness. With B-mode ultrasound, the diagnosis can be confirmed early. After the diagnosis is confirmed, the abscess is treated according to different parts. 4. Adhesive intestinal obstruction Most occur in the perforation of the appendix and peritonitis. Generally manifested as incomplete intestinal obstruction, caused by inflammatory edema, adhesions. With active anti-infective treatment and systemic support therapy, obstruction can be alleviated. If it does not turn well, when it develops into complete intestinal obstruction, it needs to be operated again. 5. Feces Most occur in gangrenous appendicitis, perforation of the appendix root or severe cecal lesions. Often within a few days after surgery, the fecal odor secretions are removed from the incision, as can be seen by seeing food debris or mites. Fecal fistula is often confined around the appendix and rarely contaminates the free abdominal cavity. If the distal intestine has no obstruction, it can be closed by itself after dressing change. If it is still not closed after 2 to 3 months, it needs to be treated again.