RU2196524C2 - Method for appendectomy at spreading of inflammatory process onto cecum's cupola - Google Patents

Abstract

FIELD: medicine, urgent surgery. SUBSTANCE: method deals with operative treatment of acute appendicitis. In case of spreading onto a cecum's cupola one should mobilize a vermiform appendix. One should resect and separate a serous-muscular cover of a cecum's cupola by two bordering sutures within intact tissues, separate sutures are applied onto a submucosal layer. It should be resected with a scalpel at the border of inflammatory process. Simultaneously, one should tighten the ligatures. Pirogov-Mateschuk's sutures are applied onto a serous-muscular membrane along the edge of a cecum's cupola. The method enables to prevent the failure of sutures applied. EFFECT: higher efficiency. 5 dwg, 1 ex

Description

 The invention relates to medicine, namely to urgent surgery, and relates to methods for appendectomy in the spread of the inflammatory process to the dome of the cecum.

 The literature describes a method of appendectomy with excision of the base of the appendix and subsequent layer-by-layer suturing of the wall of the cecum [1].

 At the same time, the use of this method of appendectomy is possible only in acute appendicitis, when the inflammatory process does not extend to the base of the appendix and the dome of the cecum [1].

 A known method of appendectomy when the inflammatory process spreads to the dome of the cecum by mobilizing and removing the vermiform appendix with immersion of its stump in the dome of the cecum with two purse-string gray-serous sutures [2].

 However, this method does not exclude the development in the postoperative period of inconsistency of sutures, deformation and development of adhesions in the area of the dome of the cecum [3].

 The objective of the invention is to prevent the development in the postoperative period of inconsistency of sutures, deformation and development of adhesions in the cecum after removal of the appendix during the spread of the inflammatory process to the dome of the cecum.

 The task is achieved by the fact that when implementing the appendectomy method when the inflammatory process spreads to the dome of the cecum, the vermiform process is mobilized, the serous-muscular membrane of the cecum dome is dissected and separated by two bordering sections, then separate sutures are placed on the submucous layer and excised with a scalpel at the border of the inflammatory process, while simultaneously tightening and tying the ligatures, then on the serous-muscular membrane separate edges of Pirogov-Mateshuk are placed along the edge of the section of the dome of the cecum.

 New in the proposed invention is that an appendectomy is performed when the inflammatory process spreads to the cecum dome, the serous-muscular membrane of the cecum dome is dissected and separated with two bordering sections, then separate sutures are placed on the submucosa, excised with a scalpel at the border inflammatory process, while simultaneously tightening and tying the ligatures, then separate seams of Pirogov-Mateshuk are applied to the serous-muscular membrane.

 This method can be successfully used in healthcare.

 Thus, the present invention meets the criteria of "novelty", "industrially applicable", "inventive step".

 The method is as follows.

 In a patient with a diagnosis of acute appendicitis, laparotomy is performed by Volkovich-Dyakonov access, and in the presence of clinical data for common peritonitis, the median lower laparotomy is performed.

 Mobilize the appendix. When the inflammatory process spreads to the base of the appendix and the dome of the cecum (Fig. 1), two sero-muscular membranes are cut with two bordering sections (Fig. 2) to the submucosal layer along the border of inflammatory infiltration within healthy tissues. Using a scalpel and tweezers, the sero-muscular membrane of the cecum dome is separated to the base of the appendix. Separate sutures are applied to the submucosal layer of the cecum dome (Fig. 3). A clamp is applied to the base of the appendix. At the border of the inflammatory process, the submucosal layer of the dome of the cecum is excised with a scalpel, while ligatures are tightened and tied (Fig. 4). Then, on the serous-muscular membrane along the edge of the incision of the dome of the cecum, separate Pirogov-Mateshuk sutures are applied (Fig. 5).

 The operation is completed by rehabilitation and drainage of the abdominal cavity.

 An example of a specific implementation of the method.

 Patient M., 54 years old, was admitted to the surgical ward after 50 hours from the onset of symptoms of acute appendicitis. I did not go to the doctor for help. I took baralgin and aspirin on my own with the goal of reducing abdominal pain and lowering the temperature.

 At the initial examination, the diagnosis of acute appendicitis, peritonitis widespread.

 After a comprehensive examination, the median lower laparotomy, appendectomy, debridement and drainage of the abdominal cavity were urgently performed. The operation was performed under endotracheal anesthesia. After tracheal intubation, a probe was installed to aspirate the gastric contents.

 Middle lower laparotomy. During the audit, up to 200 ml of purulent-fibrinous exudate was evacuated in the sloping places of the abdominal cavity. In the right ileal region, the dome of the cecum and adjacent loops of the small intestine are covered with fibrin. With the isolation and mobilization of the appendix, an abscess was revealed. The appendix is gangrenous. The inflammatory process extends to the base of the appendix and the dome of the cecum. Two bordering sections along the border of inflammatory infiltration of the dome of the cecum within healthy tissues dissected the serous-muscular membrane to the submucosal layer. Using a scalpel and tweezers, the sero-muscular membrane is separated to the base of the appendix for 5 mm. Separate U-shaped sutures were laid on the submucosal layer of the cecum dome. At the border between the clamp and the ligatures, the submucous layer of the cecum dome is excised with a scalpel, while the ligatures are simultaneously tightened and tied. Then on the serous-muscular membrane along the edge of the incision of the dome of the cecum individual seams of Pirogov-Mateshuk were applied.

 The operation is completed by abdominal sanitation, an enteral probe for intestinal decompression, and laparostomy.

 Over the next three days, the patient was twice sanitized and examined the seam of the dome of the cecum, after which the anterior abdominal wall was sutured tightly. On the fifth day after the operation, the enteral probe was removed, drug stimulation of the intestine was performed. On the seventh day after surgery, intestinal paresis was stopped. On the tenth day, the temperature returned to normal. On the fourteenth day, sutures were removed from the anterior abdominal wall.

 The patient was discharged from the hospital on the twenty-first day after the operation. According to the outpatient data, the patient began to work 46 days after the operation.

 Survey and examination results in a year.

 There are no complaints. The chair is regular - once a day, decorated. There is a scar on the anterior abdominal wall. The abdomen is symmetrical, participates in the act of breathing, with painless palpation in all departments. According to irrigoscopy, there is no deformation of the dome of the cecum; the haustration is preserved in all calving of the colon. According to fibrocolonoscopy, the colon was examined to the level of the blind. The mucous membrane of the colon in all departments is pink, shiny, vascular pattern is preserved, the tone of the intestinal wall is normal. On the medial wall of the dome of the cecum there is a fold. Visually, the mucous membrane in this area is not changed. There is no deformation of the cecum dome.

 The result of a clinical trial of the method of appendectomy with the spread of the inflammatory process to the dome of the cecum showed that after the operation, the patient did not have inconsistency of sutures, deformation and development of adhesions in the cecum after removal of the appendix.

 In the clinic, 42 patients were operated on using this technique. For acute phlegmonous appendicitis with the spread of the inflammatory process to the dome of the cecum, 17 operations were performed using this technique; for gangrenous appendicitis with the spread of the inflammatory process to the dome of the cecum, 25 operations were performed. Local peritonitis was detected in 19 patients, common - in 23.

 In all cases, a histological examination of the remote section of the cecum dome was performed. Microscopically, signs of an inflammatory process are noted - edema of the submucosa, swelling and homogenization of part of the collagen fibers. The vessels of the submucosal layer are dilated and full-blooded. In the muscle membrane there are also phenomena of edema and lymphogranulocyte infiltration.

 In the remote postoperative period, 18 patients were examined. According to the X-ray and endoscopic examination, no deformation of the cecum dome was found, there was no violation of the passage of barium in the area of the iocecal transition.

 Thus, the proposed method of appendectomy when the inflammatory process spreads to the bathe of the cecum allows you to radically excise the inflammatory tissue of the wall of the dome of the cecum, which are a source of infection and a productive inflammatory reaction, and layering stitches provides a wide contact of homogeneous tissue of the wall of the cecum (serous-muscular membrane and submucosal layer), which helps to prevent the development of suture insolvency, deformation and EVELOPMENT adhesions in the cecum.

Sources of information
1. A. p. 1362456 USSR, MKI 4 A 61 V 17/00. The method of appendectomy / A.S. Saidkhanov, G.Z. Karimov (USSR). - Announced on 11/19/85; Publ. 12.30.87 // Discoveries. Inventions - 1987.- N 48.P. 13.

 2. Korepanova M.V. Dangers and complications in the diagnosis and treatment of acute appendicitis. (REVIEW) // Vestn. chir. - 1997. - N 1. - S. 111.

 3. External and internal fistulas in a surgical clinic / Ed. E.N. Vantsyan. - M.: Medicine, 1990 .-- 224 p., Ill.

Claims (1)

 The appendectomy method when the inflammatory process spreads to the cecum dome, including mobilization of the appendix, characterized in that the sero-muscular membrane of the cecum dome is dissected and separated by two bordering incisions within the unchanged tissues, then separate sutures are placed on the submucosal layer and the scalp is excised the border of the inflammatory process, while simultaneously tightening and tying the ligatures, then on the serous-muscular membrane along the edge of the incision of the dome of the cecum impose individual seams Pirogov-Mateshuk.

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