Appendectomy

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. Indication 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. 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 1. Position: supine position. 2. Incision: It depends on the condition. The commonly used incisions are: (1) Right lower abdominal oblique incision (mc burney): This incision muscle crosses, the healing is firmer, and it is not easy to form an incisional hernia; and it is close to the appendix for easy searching. The incision is generally 5 to 7 cm long. This incision is often used in patients who are confident in diagnosis. (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. Look for the appendix: After incision of the peritoneum, if there is exudate or pus overflow, it should be immediately removed. 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 spread of the infection; it can be clamped with a special appendicator 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 mesangial: 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. 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 appendix forceps or tissue forceps, and use saline gauze around the cecum at the base of the appendix to prevent intraoperative contamination. 6. Purse of the purse: Lift the appendix and surround 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), and make a purse-string suture, not tightening. 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 the appendix: After applying pure carbolic acid on the blade, the blade is up, close to the straight hemostat clamped at the root of the appendix, cut off the appendix, and discard the knife and the appendix. 9. Treatment of appendix stump: Use 3 straight hemostatic forceps with small cotton balls on the tip to pry the cotton ball to pure carbolic acid (or 5% iodine), 75% alcohol and normal saline, and then apply it to the mucosa of the appendix stump. Rub and then discard the saline gauze that protects the cecum. 10. Embed the tail of the appendix: the assistant lifts the cecum wall on the opposite side of the purse-string suture with the left hand-held fangs, and holds the hemostat of the knot with the right hand, and pushes the stump end of the appendix into the cecal cavity. And tighten the purse string, so that the stump is buried in the purse mouth, and the thread is cut after ligation. 1. Cover mesal: Reinforced suture: Use 1-0 silk thread, 0.3cm at the outer circumference of the purse suture, and then suture the muscle layer 8 times, and fix the appendix stump or fat droop colon to make the surface Smooth to prevent postoperative adhesions. 12. Acupuncture: Before closing the abdomen, a small gauze mass should be clamped in the oval to reach 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 abdominal wall. Each layer. Acute appendicitis perforation complicated with localized or diffuse peritonitis, infection and heavy pollution, with exudate or pus; unsatisfactory treatment of appendix residue, may occur when stump cleft; when 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: postoperative temperature does not drop, abdominal tenderness, rebound pain is not relieved, that is, the presence of peritonitis should be considered. In addition to continuing gastrointestinal decompression, infusion, correction of water and electrolyte imbalance, large doses of antibiotics and Chinese medicine should be given. If the symptoms of infection are still uncontrolled after 5-6 days, the intra-abdominal abscess may occur, most commonly in the pelvic, right axilla, underarm and intestine. Once diagnosed, drainage should be performed. 2. Incision infection: 3 to 4 days after surgery, the body temperature rises, the incision is painful, and incision infection or suppuration may occur. If the abdominal wall is red and swollen, and the tenderness is obvious, the needle stitch should be removed 1 to 2 stitches, and the incision should be removed. Wire knot, fully drained. Individual infirm patients may have incisional rupture after surgery, and should be sutured and sutured. Long-term unhealed sinus should be surgically removed. 3. Intra-abdominal hemorrhage: within 1 to 2 days after surgery, the patient suddenly appeared pale, rapid pulse, shortness of breath, cold sweat, individual patients with massive blood in the stool, hemoglobin decreased, and abdominal distension, should be considered intra-abdominal hemorrhage. After the test puncture confirmed that there was bleeding in the abdomen, surgery should be performed again to remove the blood, to find the bleeding point, and to sew.