The appendix vermiformis is an integral part of the ileocecal angle, which is a morphological unity of the four parts of the intestine: the cecum, the terminal ileum, the initial part of the ascending colon, the colon and the appendix. All components of the ileocecal angle are in strict relationship, performing the function of an "internal analyzer" that coordinates the most important function of the intestine - carrying out chyme from small intestine into a thick one [Maksimenkov, 1972].

An important element of the ileocecal angle is the ileocecal (Bauginia) valve (valva ileocaecalis), which has a rather complex structure. The function of the ileocecal flap is to regulate the transition of intestinal contents into the cecum in separate portions and prevents its reverse movement from the cecum to the small intestine.

The ileocecal angle is located in the right iliac fossa. The bottom of the cecum is projected at a distance of 4-5 cm to the top from the middle of the inguinal ligament, and when the intestine is filled, its bottom is located directly above the middle of the inguinal ligament or even descends into the small pelvis. The large variability in the topographic and anatomical position of the cecum and the appendix largely explains the diversity of the clinical picture that is observed in acute appendicitis.

The most frequent and practically important deviations from the normal position of the cecum are the following [Kolesov, 1959]:

• 1. High or hepatic position, when the cecum with the appendix is \u200b\u200blocated high (- at the level of 1 lumbar vertebra), sometimes reaching the lower surface of the liver.
• 2. Low or pelvic position, when the cecum with the appendix is \u200b\u200blocated lower than usual (at the level of 2-3 sacral vertebrae), that is, it descends into the small pelvis.

More rarely, other options for the location of the cecum are found: its left-sided position, location along the midline of the abdomen, in the navel, in the left hypochondrium, in the hernial sac, etc.

According to F.I. Walker, there are some age changes in the position of the cecum with the appendix, which in small children are located relatively high, and in old age tend to go down below their usual position. In practice, it is very important to take into account the changes in the position of the cecum with the appendix associated with pregnancy. Starting from 4-5 months of pregnancy, the cecum with the appendix begins to gradually shift towards the lower surface of the liver. After childbirth, the ileocecal angle returns to its previous position, acquiring, however, greater mobility.

The cecum in 90-96% of cases is covered from all sides by the peritoneum, that is, it is located intraperitoneally, which determines its mobility.

The pockets of the peritoneum in the area of \u200b\u200bthe ileocecal angle are of great importance: recessus ileocaecalis superior et inferior, recessus retrocaecalis. In these pockets of the peritoneum, internal abdominal hernias can form, capable of simulating appendicitis.

The appendix in adults starts from the medial-posterior or medial side of the cecum and is a blindly ending segment of the intestinal tube. The appendix departs from the cecum at the confluence of the three taenia, 2-3 cm below the level of the ileum confluence into the cecum. In the overwhelming majority of cases, the process has a stem-like shape and is characterized by the same diameter throughout its entire length. Hence the name - worm-like. But there are also options. So, according to T.F. Lavrova (1960), the appendix narrows towards the apex in 17% of cases and resembles a cone in shape. In 15% of people, the so-called embryonic form is observed, when the process is, as it were, a direct continuation of the funnel-shaped narrowed cecum.

The dimensions of the appendix vary within a very wide range from 0.5 to 9 cm. However, cases of very short and very long (up to 50 cm) are described [Rostovtsev, 1968; Korning, 1939]. The thickness of the appendix is \u200b\u200bon average 0.5-1 cm. Moreover, its size largely depends on the age of the person. Largest dimensions observed between the ages of 10 and 30 years. In old and senile age, the appendix undergoes noticeable involutive changes.

In rare cases of reverse organ positioning abdominal the appendix together with the cecum is located in the left iliac region with all possible anatomical variants that occur in its right-sided position. It is also necessary to remember about the occasional anomalies, when, for example, the process departs from the outer wall of the cecum or from the ascending intestine. Interesting observation of I.I. Khomich (1970), in which the arcuate appendix with both ends opened into the lumen of the cecum. Doubling of the appendix is \u200b\u200balso possible, which, as a rule, is combined with other multiple malformations and deformities.

It is also necessary to remember about the possibility of a congenital absence of the appendix, which is extremely rare. P.I. Tikhonov cites literature data that the appendix is \u200b\u200babsent in 5 out of 1,000 people.

The appendix is \u200b\u200blocated intraperitoneally. It has its own mesentery - the mesenteriolum, which provides it with blood vessels and nerves.

The variability of the location of the cecum and the appendix itself is one of the factors that determine the different localization of pain and the variety of options for the clinical picture in the development of inflammation of the appendix, as well as sometimes difficulties in detecting it during surgery.

Blood supply to the ileocecal angle is provided by the superior mesenteric artery - a. ileocolica, which is divided into the anterior and posterior arteries of the cecum. From a. ileocolica or its branches its own artery of the appendix a. appendicularis, which has a loose, trunk or mixed structure. The artery of the appendix passes in the thickness of the mesentery of the appendix, along its free edge, to the end of the appendix. Despite the small caliber (from 1 to 3 mm), bleeding from a. appendicularis in postoperative period are extremely intense, requiring, as a rule, relaparotomy.

The veins of the cecum and the appendix are tributaries of the ileo-colonic vein v. ileocolica, flowing into the superior mesenteric (v. mesentericasuperior).

The innervation of the ileocecal angle is carried out by the superior mesenteric plexus, which has a connection with the solar plexus and takes part in the innervation of all digestive organs. The ileocecal angle is called the "nodal station" in the innervation of the abdominal organs. The impulses emanating from here affect the function of many organs. The peculiarity of the innervation of the appendix and the ileocecal angle explains the occurrence of epigastric pain in acute appendicitis and their spread throughout the abdomen.

Lymphatic drainage from the appendix and from the ileocecal angle as a whole is carried out into the lymph nodes located along the iliocolic artery. In total, along this artery, a chain of lymph nodes (10-20), which stretches to the central group of mesenteric lymph nodes... Topographic proximity of the mesenteric and iliac lymph nodes explains the generality of the clinical picture with inflammation of these nodes (acute mesoadenitis) and inflammation of the appendix.

In 3% of women, for the appendix and the right uterine appendages, there are common lymphatic (and sometimes blood) vessels and nerves. In such cases, inflammatory changes easily pass from one organ to another, and differential diagnosis between diseases of the appendix and female genital internal organs on the right is extremely difficult.

There are five main types of location of the appendix in relation to the cecum: descending (caudal); lateral (lateral); internal (medial); anterior (ventral); posterior (retrocecal).

With a descending, most frequent location, the appendix, heading towards the small pelvis, in one way or another comes into contact with its organs. When located laterally, the process lies outside of the cecum. Its apex is directed towards the pupar ligament. Medial location is also common. In these cases, it lies on the medial side of the cecum, located between the loops of the small intestine, which creates favorable conditions for the high prevalence of the inflammatory process in the abdominal cavity and the occurrence of ligitive abscesses. The anterior position of the appendix, when it lies in front of the cecum, is rare. This arrangement favors the appearance of anterior parietal abscesses. Some surgeons distinguish the ascending type of the location of the appendix. There are two possibilities here. Or the entire ileocecal angle is located high, under the liver, then the term is valid - the subhepatic location of the appendix. Or, which happens more often, the apex of the retrocecal appendix is \u200b\u200bdirected towards the liver. With a retrocecal arrangement of the appendix, which is observed in 2-5% of patients, two variants of its occurrence in relation to the peritoneum are characteristic: in some cases, the appendix, being covered by the peritoneum, lies behind the cecum in the iliac fossa, in others it is released from the peritoneal leaf and lies extraperitoneally. This location of the appendix is \u200b\u200bcalled retrocecal retroperitoneal. This option should be considered the most insidious, especially with purulent, destructive appendicitis, since in the absence of the peritoneal cover on the appendix inflammatory process spreads to the perineal tissue, causing deep retroperitoneal phlegmon.

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The above was considered clinical picture acute appendicitis with the most common typical variant of the anatomical location of the appendix in the right iliac fossa medially or immediately below the cecum. However, it can also occupy other positions in the abdominal cavity, which significantly affects the local clinical manifestations of the disease (Figure 13).

Figure 13. Variants of deviations from the typical location of the appendix: 1 - in the right lateral canal, 2 - behind the cecum, 3 - "retroperitoneal", 4 - subhepatic, 5 - in the small pelvis, 6 - medially, among the loops of the small intestine

Common Symptoms, of course, remain identical, regardless of the location of the appendix.An essential help in the diagnosis of an atypical location of the appendix is \u200b\u200bthe fact that regardless of its location, the onset of the disease retains the classic version, when pain begins in the epigastric, peri-umbilical region or throughout the entire abdomen, is worn permanent, aching character. Then, depending on the location of the process, the pain is localized, for example, in the lumbar or groin area.

With an atypical location of the appendix, the diagnosis can be significantly complicated, not only due to the non-characteristic localization of pain, but also due to the fact that the inflamed appendix can adhere to other organs and cause "contact" inflammation and the appearance of symptoms corresponding to the defeat of these organs (Figure 14).

Figure 14. Some positions of the appendix in the abdominal cavity, causing symptoms of damage to the corresponding adjacent organ: 1 - to the gallbladder; 2 - to the right kidney; 3 - to the mesentery of the small intestine; 4 - to the ileum; 5 - to the sigma about the colon; 6 - to the uterus; 7- to the bladder; 8 - to the inner groin ring and hernial sac

If the appendix occupies a lateral position, located between the cecum and the lateral surface abdominal wallThis is called the retrocecal position, since in this case the cecum covers the appendix. Due to the formed adhesions, the impression of a retroperitoneal location of the appendix may appear, since it practically does not contact the free abdominal cavity.

In this situation, the local clinical manifestations of the disease differ from the usual ones. Pain can be localized both in the right iliac and lumbar regions. At the same time, if there is a delimitation from the free abdominal cavity not only by the cecum, but also by adhesions, then palpation of the anterior abdominal wall almost does not increase pain, and there will be no muscle tension of the anterior abdominal wall, since the adjacent parietal peritoneum is not involved in inflammation. Thus, palpation of the anterior abdominal wall becomes little informative. The Bartomier-Michelson symptom can indicate the retrocecal position of the process. On palpation of the lumbar region, soreness can be detected, most pronounced in the projection of the Petit triangle (Yaure-Rozanov symptom). Its mechanism is due to the fact that due to the thinning in this area of \u200b\u200bthe posterior abdominal wall, during palpation, it is most possible to achieve mechanical irritation of the posterior layer of the peritoneum and the appendix adjacent to it.

Useful information for diagnosing the retrocecal location of the appendix can be obtained by compressing it between the posterior wall of the cecum and m. ileopsous, followed by a reduction in the latter. To do this, press with your hand on the abdominal wall in the projection of the cecum so that it with the appendix is \u200b\u200bfixed to the bottom of the iliac fossa. After this, the patient is asked to raise the straightened right leg. Due to the contact of the inflamed process with a moving mouse (m. Ileopsous), pain occurs in the iliac region (Obraztsov's symptom) (Figure 15).

Diagnosis of acute appendicitis with a retrocecal process can be extremely difficult, which can lead to diagnostic errors and, as a consequence, delayed surgery and severe complications. The adherence of the appendix to the ureter or kidney makes correct diagnosis difficult. Here is our observation as an example.

Figure 15. The appearance or intensification of pain in the right iliac region when raising the straightened right leg is caused by irritation of the posterior parietal peritoneum by the contracted psoas muscle. Typical for the retrocecal arrangement of the appendix.

Patient E., 79 years old, was admitted to the clinic with a referral diagnosis of acute cholecystopancreatitis on the 4th day from the onset of the disease. Upon admission, she complained about headache, nausea and repeated vomiting.

On admission, the condition was serious. Inhibited. In the lungs, hard breathing is carried out symmetrically, there is no wheezing. Pulse 80 per minute. BP - 140/80 mm Hg. Art. Tongue moist, coated with white bloom. The abdomen is significantly increased in volume due to adipose tissue. On palpation, it is soft, slightly painful in the lower parts. The liver is not enlarged Ortner's symptoms. Murphy, MeYo-Robson, Rovzing, Sitkovsky are negative. Peritoneal symptoms of her. Tumor formations in the abdominal cavity are not palpable. Pasternatsky's symptom is negative on both sides. No pathology was revealed during rectal and vaginal examinations. Blood leukocytes - 4.5x10 9 / l. IN general analysis urine single erythrocytes, leukocytes 5-7 in the field of view. Body temperature - 39.5 ° C.

Given the hyperthermia, the presence of indistinct pain in the lower abdomen on palpation, it was decided to perform diagnostic laparoscopy to exclude acute appendicitis. Under local anesthesia, the abdominal cavity was punctured along the lower contour of the navel, carboxyperitoneum was imposed, and a laparoscope was inserted. There is no effusion in the abdominal cavity. A large omentum of considerable size, fixed by planar adhesions to the peritoneum of the anterior abdominal wall and the right lateral canal. Inspection is available left lobe liver and proximal part the anterior wall of the stomach, separate loops of the small intestine in the left abdomen. The indicated bodies have not been changed. There is no effusion in the small pelvis, the peritoneum is not hyperemic. The uterus and its appendages are atrophic, without organic and inflammatory changes. An additional grocar was introduced in the left iliac region. Use the manipulator to displace the large oil seal and inspect gall bladder, the cecum and the appendix failed. The conclusion of the endoscopist: "Pronounced adhesive process." The patient was under dynamic observation. The patient is suspected of pyelonephritis. Uroseptic therapy was started. Body temperature returned to normal. The state of health has improved somewhat. However, after 2 days suddenly appeared severe pain in the lower abdomen, peritoneal symptoms appeared and the patient was urgently operated on. An average midline laparotomy was performed. In the lower abdominal floor, a small amount of turbid effusion with unpleasant odor... The right half of the abdominal cavity is covered with a large omentum, fixed by adhesions that are separated sharp way The cecum is deformed by adhesions and is fixed in the iliac fossa. The appendix was not found. The parietal peritoneum of the lateral canal was dissected, the cecum was mobilized, after which about 100 ml of thick fetid pus was released from the retrocecal space. It was found that an abscess was located behind the cecum, in the cavity of which there was a necrotic appendix. An appendectomy was performed, the abscess cavity was drained according to Penrose (rubber-gauze swab) through a counterperture. The postoperative period was complicated by anaerobic wound non-clostridial infection. Slow recovery.

In the described case, it was not possible to avoid a diagnostic error, despite laparoscopy. Complete delimitation of the appendix from the abdominal cavity led to the formation of a retrocecal abscess and, only after opening the abscess into the abdominal cavity, peritonitis was diagnosed.

With a retrocecal arrangement of the appendix, the infection may spread to the retroperitoneal tissue.

Patient P. 75 pet was admitted to the clinic with a diagnosis of peritonitis of unknown etiology. Contact with the patient is limited due to a previous violation of cerebral circulation. The condition is extremely serious. Moans from pain in the abdomen. According to accompanying relatives, he was ill for about 5 days, when he became restless in bed, refused to eat, and for the last 2 days he complained of abdominal pain. Examination revealed muscle tension in the anterior abdominal wall in all its sections, but more in the right half. Shchetkin's symptom is positive in all parts of the abdomen. In addition, there was severe soreness in the right lumbar region and some bulging of the lateral abdominal wall on the right with sharp pain on palpation. Rectal examination revealed no overhang and pain of the anterior rectal wall. The diagnosis of generalized peritonitis was not in doubt. It was assumed that perforation of the tumor of the ascending colon was the cause of peritonitis. After preoperative preparation in the intensive care unit, the patient was urgently operated on. Performed an average midline laparotomy. Fetid pus in all parts of the abdominal cavity. The intestinal loops are covered with fibrin. During the revision of the abdominal cavity, it was found that the blind and ascending colon are pushed anteriorly, the appendix is \u200b\u200babsent in the free abdominal cavity. Thick fetid pus comes from the retrocecal space. The peritoneum of the lateral canal is sharply infiltrated, with multiple foci of necrosis of a gray-green color, through which pus seeps out when pressed. The blind and ascending colon were mobilized by dissecting the peritoneum of the lateral canal. A huge cavity was opened, occupying the paracolic space. It contains sequesters of adipose tissue and a necrotic appendix located behind the colon. Further revision revealed that there is a spread of pus into the intermuscular spaces of the abdominal wall. Appendectomy performed, surgical debridement retroperitoneal space and abdominal wall on the right with necrsequestrectomy. The abdominal cavity is flushed with the removal of fibrinous overlays. The paracolic space on the right is widely drained through a counteropening in the lumbar region. In the postoperative period, one day after the operation, it was planned to revise the abdominal cavity. However, despite intensive treatment, the patient died 18 hours after the operation.

If the appendix is \u200b\u200blocated in the small pelvis, then the diagnostic difficulties and errors arising in connection with this, as a rule, are associated with the fact that palpation of the anterior abdominal wall is not very informative. The pains, which can be localized by the slope, in the right ilio-groin region, do not increase with palpation, there is no muscle tension and a symptom of peritoneal irritation. This is due to the fact. that the inflammation is localized in the small pelvis and the inflamed peritoneum and process are not palpable. Due to the fact that with the pelvic location of the appendix, it can adhere to the rectum, bladder, symptoms appear from these organs. In particular, when the inflamed vermiform appendix comes into contact with the rectum, patients may experience tenesmus (false urge to stool), and a rectal examination reveals a sharp soreness of the anterior rectal wall. With "interest" bladder frequent urination appears, while there may be cramps, and leukocytes appear in the analysis of urine (as a consequence of reactive inflammation) However, the greatest diagnostic difficulties arise in the differential diagnosis of the pelvic process and gynecological pathology... In the diagnosis of the pelvic location of the appendix, it is advisable to use laparoscopy.

The course of acute appendicitis is even more insidious when the appendix is \u200b\u200blocated in the subhepatic space. In this position, the process of pain is localized in the right hypochondrium. This leads to the fact that in the first place there is a suspicion that the patient has acute cholecystitis, exacerbations peptic ulcer 12-persistent intestine. The latter disease is relatively easy to exclude, since a characteristic history of peptic ulcer disease, as a rule, allows rejecting this disease.

Differential diagnosis with acute cholecystitis is extremely difficult, and sometimes impossible, without additional research methods. The whole trouble is that the local manifestations of the disease, when the appendix is \u200b\u200blocated in the immediate vicinity of the gallbladder, of course, will be absolutely identical to the symptoms of acute cholecystitis. The doctor should always remember about the possibility of such an arrangement of the appendix and critically evaluate any clinical situation that goes beyond the classical course of the disease. In particular, if y young man, without anamnestic data characteristic of gallstone disease, all the symptoms typical of destructive cholecystitis are found, one cannot finally stop on this diagnosis until it is obtained additional Information - in the described situation, the best option would be an ultrasound scan, which will confirm or reject the inflammation of the gallbladder. In the elderly, especially in women, in whom the likelihood of gallstone disease, and, accordingly, acute cholecystitis, is quite high, and the incidence of acute appendicitis is low, the subhepatic location of the appendix is \u200b\u200bextremely difficult to suspect. Error at differential diagnosis in such a situation, it leads to tragic consequences, since the active-expectant treatment tactics adopted in acute cholecystitis is unacceptable in acute appendicitis.

Patient Sh. 68 years old was admitted to the clinic on 15.04.88. diagnosed with acute cholecystitis. On admission she complained of pain in the right hypochondrium. Got sick 3 days ago when blunt aching pain in the right hypochondrium, which were accompanied by nausea, there was vomiting several times. Over the last 24 hours, the pain decreased somewhat, however, it persisted when walking. All days there was a subfebrile temperature. From the anamnesis it is known that over the past 8 years, pains in the right hypochondrium have repeatedly bothered; during the examination, stones in the gallbladder were found. General state the patient is regarded as moderate... Correct addition, increased nutrition. Skin covering and visible mucous membranes of normal color. In the lungs, hard breathing is carried out symmetrically, there is no shortness of breath. Pulse 88 beats per minute. BP - 150/80 mm Hg. Art. Tongue moist, coated with white bloom. The abdomen is of the correct shape, slightly enlarged due to fatty tissue. When breathing, the lag of the right half of the abdominal wall. On palpation, pronounced soreness in the right hypochondrium, muscle tension here, due to which it was not possible to carry out a deep palpation, to determine any tumor-like formations. Beating along the right costal arch is sharply painful (Ortner's symptom, characteristic of acute cholecystitis) Symptoms of Rovzing, Sitkovsky are negative. Rectal examination revealed no overhanging and painfulness of the anterior rectal wall; hemorrhoids Vaginal examination - painless, no organic pathology was revealed. Body temperature 37.8 ° C, blood leukocytes - 12x10 9 / l. Acute destructive cholecystitis was diagnosed. Conservative (antispasmodic, antibacterial, infusion) therapy was started. In a day, the patient's condition improved, independent abdominal pains decreased, the tension of the muscles of the anterior abdominal wall disappeared. In the right hypochondrium, a painful infiltration of large sizes, without clear contours, began to be determined. A persistent subfebrile fly remained. Clinical manifestations were regarded as the formation of a perivesical infiltrate caused by inflammation of the gallbladder. There were no signs of abscess formation. Conservative therapy continued. After 8 days from the onset of the disease and 5 days after admission to the hospital, the patient's condition deteriorated sharply. The pain in the right hypochondrium suddenly increased sharply and quickly spread throughout the abdomen. On examination, the abdomen did not participate in breathing; palpation revealed a pronounced tension of the muscles of the anterior abdominal wall in all sections. Positive symptoms of peritoneal irritation. Diagnosed with widespread peritonitis due to the opening of the perivesical abscess. The patient was urgently operated. During laparotomy, it was found that the subhepatic space was occupied by a large inflammatory infiltrate formed by the lower surface of the liver and the gallbladder, the cecum and the greater omentum. From under the omentum came thick, fetid brown pus. Purulent exudate spread along the right lateral canal to the small pelvis, a small amount of exudate was in between the loop spaces. Massive deposition of fibrin in the subhepatic space, in other parts of the abdomen there is no fibrin on the peritoneum. When dividing the infiltrate, it was found that the gallbladder was changed a second time, it contains large stones. In the subhepatic space, there was an abscess cavity 8x5x2cm, which opened into the abdominal cavity along the edge of the liver. In the abscess there was a worm-like process of gray-green color, in the area of \u200b\u200bthe base there was a perforated hole from which pus came. An appendectomy was performed. The abdominal cavity was washed with saline with dioxidine. A rubber-gauze tampon was inserted into the abscess cavity through a counterperture. The wound of the abdominal wall is sutured through all layers, the sutures are tied with "bows". In the postoperative period, sanitation and revisions of the abdominal cavity were carried out. It was not possible to avoid extensive suppuration of the surgical wound. Slow recovery

D.G. Krieger, A. V. Fedorov, P. K. Voskresensky, A. F. Dronov

Acute appendicitis and its complications

Purpose:Study of the pathogenesis, clinical picture, methods of diagnosis and treatment of acute appendicitis and its complications.

Need to know

General information.Anatomy of the anterior abdominal wall, cecum and appendix. Typical and atypical variants of the location of the appendix. The frequency and place of this pathology among other surgical diseases of the abdominal organs.

Classification(clinical and morphological) acute appendicitis.

Clinic and diagnostics.Characteristics of pain syndrome, dyspeptic symptoms, the sequence of their occurrence and dynamics of development. Kocher-Volkovich symptom. Inspection data, palpation of the abdomen. Signs of peritoneal irritation. Shchetkin-Blumberg symptom. Symptoms of Rovzing, Sitkovsky, Bartomier-Michelson and others. The importance of vaginal and rectal examinations. Laboratory and instrumental diagnostics. Features of the course of acute appendicitis, depending on the location of the appendix (subhepatic, pelvic, retrocecal, retroperitoneal, left-sided), during pregnancy, in children and elderly patients.

Differential diagnosis.Differential diagnostic signs (complaints, anamnesis, data of physical and instrumental examinations), allowing to distinguish acute appendicitis from the following groups of diseases:

1. Other surgical diseases of the abdominal organs: perforated ulcer; acute cholecystitis; acute pancreatitis; inflammation of Meckel's diverticulum; terminal ileitis (Crohn's disease), etc.

2. Acute urological diseases: renal colic, pyelonephritis.

3. Acute diseases of the pelvic organs - interrupted ectopic pregnancy, inflammatory diseases, etc.

4. Other diseases: enterocolitis; right-sided pleuropneumonia, etc.

Treatment.Surgical tactics for acute appendicitis. Anesthesia. Operational accesses. Appendectomy technique. Retrograde appendectomy. Laparoscopic appendectomy. Indications for revision of the terminal section of the small intestine and pelvic organs. Indications for drainage and tamponade of the abdominal cavity.

Postoperative management... Prevention and diagnosis of postoperative complications.

Complications of acute appendicitis

Appendicular infiltration.Definition of the concept, mechanism of formation, time of onset from the onset of an acute attack. The dynamics of the development of symptoms of appendicitis before the formation of the infiltrate. Objective data when examining a patient. Differential diagnosis of appendicular infiltrate from cecum tumors. The course and possible outcomes of appendicular infiltrate, their clinical manifestations and diagnosis. Tactics and methods of treatment. Further treatment tactics for resorption of the infiltrate.

Periappendicular abscess.Clinical (general and local) manifestations. The nature of the temperature curve. Instrumental and laboratory diagnostics... Surgical tactics. Technique and scope of surgery. Further patient management.

Abdominal abscesses.Causes, localization, time of occurrence, clinical (general and local) signs. Instrumental and laboratory diagnostics. Pelvic (douglas space) abscess. Diagnostic value of vaginal and rectal examinations. Technique of opening a pelvic abscess. Subphrenic abscess... Diagnostic value of X-ray examination chest and the abdominal cavity. Technique of subphrenic abscess opening.

Pylephlebitis.Causes of occurrence. Clinical symptoms. Prevention measures.

Peritonitis.The clinical picture. Diagnostic and treatment methods.

You must be able to

1. Purposefully collect anamnesis in case of suspicion of an acute surgical disease of the abdominal organs, taking into account the main clinical symptoms of acute appendicitis, the characteristics of the course of the disease, the age and sex of the patient.

2. Conduct an examination of a patient with a suspected diagnosis of acute appendicitis with the identification of special symptoms characteristic of the disease (Shchetkin-Blumberg, Rovzing, Sitkovsky, Bartomier-Michelson).

3. Perform vaginal and rectal examinations and evaluate the findings.

4. Make a preliminary diagnosis.

5. Draw up a plan for the necessary instrumental and laboratory studies.

6. Arguably carry out a differential diagnosis based on anamnesis, complaints, examination of the patient, performed instrumental and laboratory research methods.

8. Formulate and substantiate the final detailed clinical diagnosis.

Definition.

Acute appendicitis is an acute destructive inflammation of the appendix of the cecum.

Epidemiology.

Acute appendicitis is one of the most common diseases in emergency surgery. The incidence of acute appendicitis is 4-5 cases per 1000 population per year. The most common acute appendicitis occurs at the age of 20-40 years (diagram 1). Women get sick 1.5-2 times more often.

Diagram 1. Frequency of occurrence of acute appendicitis

at different ages.

Mortality in acute appendicitis has stabilized over the past decades and averages 0.1-0.3%. Given the frequency of occurrence of this disease, even such a small probability of death turns into hundreds of lives annually.

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Above, the clinical picture of acute appendicitis was considered with the most common typical variant of the anatomical location of the appendix in the right iliac fossa medially or immediately below the cecum. However, it can also occupy other positions in the abdominal cavity, which significantly affects the local clinical manifestations of the disease (Figure 13).

Figure 13. Variants of deviations from the typical location of the appendix: 1 - in the right lateral canal, 2 - behind the cecum, 3 - "retroperitoneal", 4 - subhepatic, 5 - in the small pelvis, 6 - medially, among the loops of the small intestine

General symptoms, of course, remain identical, regardless of the location of the appendix.An essential help in the diagnosis of an atypical location of the appendix is \u200b\u200bthe fact that regardless of its location, the onset of the disease retains the classic version, when pain begins in the epigastric, peri-umbilical region or throughout the abdomen constant, aching character. Then, depending on the location of the process, the pain is localized, for example, in the lumbar or groin region.

With an atypical location of the appendix, the diagnosis can be significantly complicated, not only due to the non-characteristic localization of pain, but also due to the fact that the inflamed appendix can adhere to other organs and cause "contact" inflammation and the appearance of symptoms corresponding to the defeat of these organs (Figure 14).

Figure 14. Some positions of the appendix in the abdominal cavity, causing symptoms of damage to the corresponding adjacent organ: 1 - to the gallbladder; 2 - to the right kidney; 3 - to the mesentery of the small intestine; 4 - to the ileum; 5 - to the sigma about the colon; 6 - to the uterus; 7- to the bladder; 8 - to the inner groin ring and hernial sac

If the appendix occupies a lateral position, located between the cecum and the lateral surface of the abdominal wall, this is called a retrocecal position, since in this case the cecum covers the appendix. Due to the formed adhesions, the impression of a retroperitoneal location of the appendix may develop, since it practically does not contact with free abdominal cavity.

In this situation, the local clinical manifestations of the disease differ from the usual ones. Pain can be localized both in the right iliac and lumbar regions. At the same time, if there is a delimitation from the free abdominal cavity not only by the cecum, but also by adhesions, then palpation of the anterior abdominal wall almost does not increase pain, and there will be no muscle tension of the anterior abdominal wall, since the adjacent parietal peritoneum is not involved in inflammation. Thus, palpation of the anterior abdominal wall becomes little informative. The Bartomier-Michelson symptom can indicate the retrocecal position of the process. On palpation of the lumbar region, soreness can be detected, most pronounced in the projection of the Petit triangle (Yaure-Rozanov symptom). Its mechanism is due to the fact that due to the thinning in this area of \u200b\u200bthe posterior abdominal wall, during palpation, it is most possible to achieve mechanical irritation of the posterior layer of the peritoneum and the appendix adjacent to it.

Useful information for diagnosing the retrocecal location of the appendix can be obtained by compressing it between the posterior wall of the cecum and m. ileopsous, followed by a reduction in the latter. To do this, press with your hand on the abdominal wall in the projection of the cecum so that it with the appendix is \u200b\u200bfixed to the bottom of the iliac fossa. After this, the patient is asked to raise the straightened right leg. Due to the contact of the inflamed process with a moving mouse (m. Ileopsous), pain occurs in the iliac region (Obraztsov's symptom) (Figure 15).

Diagnosis of acute appendicitis with a retrocecal process can be extremely difficult, which can lead to diagnostic errors and, as a consequence, delayed surgery and severe complications. The adherence of the appendix to the ureter or kidney makes correct diagnosis difficult. Here is our observation as an example.

Figure 15. The appearance or intensification of pain in the right iliac region when raising the straightened right leg is caused by irritation of the posterior parietal peritoneum by the contracted psoas muscle. Typical for the retrocecal arrangement of the appendix.

Patient E., 79 years old, was admitted to the clinic with a referral diagnosis of acute cholecystopancreatitis on the 4th day from the onset of the disease. On admission she complained of headache, nausea and repeated vomiting.

On admission, the condition was serious. Inhibited. In the lungs, hard breathing is carried out symmetrically, there is no wheezing. Pulse 80 per minute. BP - 140/80 mm Hg. Art. Tongue moist, coated with white bloom. The abdomen is significantly increased in volume due to adipose tissue. On palpation, it is soft, slightly painful in the lower parts. The liver is not enlarged Ortner's symptoms. Murphy, MeYo-Robson, Rovzing, Sitkovsky are negative. Peritoneal symptoms of her. Tumor-like formations in the abdominal cavity are not palpable. Pasternatsky's symptom is negative on both sides. No pathology was revealed during rectal and vaginal examinations. Blood leukocytes - 4.5x10 9 / l. In the general analysis of urine, single erythrocytes, leukocytes 5-7 in the field of view. Body temperature - 39.5 ° C.

Given the hyperthermia, the presence of indistinct pain in the lower abdomen on palpation, it was decided to perform diagnostic laparoscopy to exclude acute appendicitis. Under local anesthesia, the abdominal cavity was punctured along the lower contour of the navel, carboxyperitoneum was imposed, and a laparoscope was inserted. There is no effusion in the abdominal cavity. A large omentum of considerable size, fixed by planar adhesions to the peritoneum of the anterior abdominal wall and the right lateral canal. Examination accessible to the left lobe of the liver and the proximal part of the anterior wall of the stomach, separate loops of the small intestine in the left abdomen. The indicated bodies have not been changed. There is no effusion in the small pelvis, the peritoneum is not hyperemic. The uterus and its appendages are atrophic, without organic and inflammatory changes. An additional grocar was introduced in the left iliac region. With the help of a manipulator, it was not possible to displace the great omentum and examine the gallbladder, cecum, and vermiform appendix. The conclusion of the endoscopist: "Pronounced adhesive process." The patient was under dynamic observation. The patient is suspected of pyelonephritis. Uroseptic therapy was started. Body temperature returned to normal. The state of health has improved somewhat. However, after 2 days, severe pains suddenly appeared in the lower abdomen, peritoneal symptoms appeared, and the patient was urgently operated on. An average midline laparotomy was performed. In the lower abdominal floor there is a small amount of turbid effusion with an unpleasant odor. The right half of the abdominal cavity is covered with a large omentum, fixed by adhesions, which are separated by an acute path. The cecum is deformed by adhesions and fixed in the iliac fossa. The appendix was not found. The parietal peritoneum of the lateral canal was dissected, the cecum was mobilized, after which about 100 ml of thick fetid pus was released from the retrocecal space. It was found that an abscess was located behind the cecum, in the cavity of which there was a necrotic appendix. An appendectomy was performed, the abscess cavity was drained according to Penrose (rubber-gauze swab) through a counterperture. The postoperative period was complicated by anaerobic wound non-clostridial infection. Slow recovery.

In the described case, it was not possible to avoid a diagnostic error, despite laparoscopy. Complete delimitation of the appendix from the abdominal cavity led to the formation of a retrocecal abscess and, only after opening the abscess into the abdominal cavity, peritonitis was diagnosed.

With a retrocecal arrangement of the appendix, the infection may spread to the retroperitoneal tissue.

Patient P. 75 pet was admitted to the clinic with a diagnosis of peritonitis of unknown etiology. Contact with the patient is limited due to a previous violation of cerebral circulation. The condition is extremely serious. Moans from pain in the abdomen. According to accompanying relatives, he was ill for about 5 days, when he became restless in bed, refused to eat, and for the last 2 days he complained of abdominal pain. Examination revealed muscle tension in the anterior abdominal wall in all its sections, but more in the right half. Shchetkin's symptom is positive in all parts of the abdomen. In addition, there was severe soreness in the right lumbar region and some bulging of the lateral abdominal wall on the right with sharp pain on palpation. At rectal examination, no overhanging and painfulness of the anterior rectal wall was found. The diagnosis of generalized peritonitis was not in doubt. It was assumed that perforation of the tumor of the ascending colon was the cause of peritonitis. After preoperative preparation in the intensive care unit, the patient was urgently operated on. Produced by an average midline laparotomy. Fetid pus in all parts of the abdominal cavity. The intestinal loops are covered with fibrin. During the revision of the abdominal cavity, it was found that the blind and ascending colon are pushed anteriorly, the appendix in the free abdominal cavity is absent. Thick fetid pus comes from the retrocecal space. The peritoneum of the lateral canal is sharply infiltrated, with multiple foci of necrosis of a gray-green color, through which pus seeps out when pressed. The blind and ascending colon were mobilized by dissecting the peritoneum of the lateral canal. A huge cavity was opened, occupying the paracolic space. It contains sequesters of adipose tissue and a necrotic appendix located behind the colon. Further revision revealed that there is a spread of pus into the intermuscular spaces of the abdominal wall. Made appendectomy, surgical treatment of the retroperitoneal space and abdominal wall on the right with necrsequestrectomy. The abdominal cavity is flushed with the removal of fibrinous overlays. The paracolic space on the right is widely drained through a counteropening in the lumbar region. In the postoperative period, one day after the operation, it was supposed to revise the abdominal cavity. However, despite intensive treatment, the patient died 18 hours after the operation.

If the appendix is \u200b\u200blocated in the small pelvis, then the diagnostic difficulties and errors arising in connection with this, as a rule, are associated with the fact that palpation of the anterior abdominal wall is not very informative. The pains, which can be localized by the nadlap, in the right ilio-groin region, do not increase with palpation, there is no muscle tension and a symptom of peritoneal irritation. This is due to the fact. that the inflammation is localized in the small pelvis and the inflamed peritoneum and process are not palpable. Due to the fact that with the pelvic location of the appendix, it can adhere to the rectum, bladder, symptoms appear from these organs. In particular, when the inflamed vermiform appendix comes into contact with the rectum, patients may experience tenesmus (false urge to stool), and a rectal examination reveals a sharp soreness of the anterior rectal wall. When the bladder is "interested", frequent urination appears, while there may be cramps, and leukocytes appear in the analysis of urine (as a result of reactive inflammation). However, the greatest diagnostic difficulties arise in the differential diagnosis of the pelvic process and gynecological pathology. In the diagnosis of the pelvic location of the appendix, it is advisable to use laparoscopy.

The course of acute appendicitis is even more insidious when the appendix is \u200b\u200blocated in the subhepatic space. In this position, the process of pain is localized in the right hypochondrium. This leads to the fact that, first of all, there is a suspicion of the presence of acute cholecystitis in the patient, exacerbation of peptic ulcer of the 12 intestine. The latter disease is relatively easy to exclude, since a characteristic history of peptic ulcer disease, as a rule, makes it possible to reject this disease.

Differential diagnosis with acute cholecystitis is extremely difficult, and sometimes impossible, without additional research methods. The whole trouble is that the local manifestations of the disease, when the appendix is \u200b\u200blocated in the immediate vicinity of the gallbladder, of course, will be absolutely identical to the symptoms of acute cholecystitis. The doctor should always remember about the possibility of such an arrangement of the appendix and critically evaluate any clinical situation that goes beyond the classical course of the disease. In particular, if a young person, without anamnestic data characteristic of cholelithiasis, has all the symptoms typical of destructive cholecystitis, one cannot finally dwell on this diagnosis until additional information is obtained - in the described situation, the best option would be an ultrasound scan, which allow you to confirm or reject gallbladder inflammation. In the elderly, especially in women, in whom the likelihood of gallstone disease, and, accordingly, acute cholecystitis, is quite high, and the incidence of acute appendicitis is low, the subhepatic location of the appendix is \u200b\u200bextremely difficult to suspect. An error in differential diagnosis in such a situation leads to tragic consequences, since the active-expectant treatment tactics adopted in acute cholecystitis is unacceptable in acute appendicitis.

Patient Sh. 68 years old was admitted to the clinic on 15.04.88. diagnosed with acute cholecystitis. On admission she complained of pain in the right hypochondrium. She fell ill 3 days ago, when there appeared dull aching pains in the right hypochondrium, which were accompanied by nausea, and vomiting several times. Over the last 24 hours, the pain decreased somewhat, however, it persisted when walking. All days there was a subfebrile temperature. From the anamnesis it is known that over the past 8 years, pains in the right hypochondrium have repeatedly bothered; during the examination, stones in the gallbladder were found. The general condition of the patient was assessed as moderate. Correct addition, increased nutrition. The skin and visible mucous membranes are of normal color. In the lungs, hard breathing is carried out symmetrically, there is no shortness of breath. Pulse 88 beats per minute. BP - 150/80 mm Hg. Art. Tongue moist, coated with white bloom. The abdomen is of the correct shape, slightly enlarged due to fatty tissue. When breathing, the lag of the right half of the abdominal wall. On palpation, pronounced soreness in the right hypochondrium, muscle tension here, due to which it was not possible to carry out a deep palpation, to determine any tumor-like formations. Beating along the right costal arch is sharply painful (Ortner's symptom, characteristic of acute cholecystitis) Symptoms of Rovzing, Sitkovsky are negative. Rectal examination revealed no overhanging and painfulness of the anterior rectal wall, there were collapsed hemorrhoids. Vaginal examination was painless, no organic pathology was revealed. Body temperature 37.8 ° C, blood leukocytes - 12x10 9 / l. Acute destructive cholecystitis was diagnosed. Conservative (antispasmodic, antibacterial, infusion) therapy was started. In a day, the patient's condition improved, independent abdominal pains decreased, the tension of the muscles of the anterior abdominal wall disappeared. In the right hypochondrium, a painful infiltration of large sizes, without clear contours, began to be determined. A persistent subfebrile fly remained. Clinical manifestations were regarded as the formation of a perivesical infiltrate caused by inflammation of the gallbladder. There were no signs of abscess formation. Conservative therapy continued. After 8 days from the onset of the disease and 5 days after admission to the hospital, the patient's condition deteriorated sharply. The pain in the right hypochondrium suddenly increased sharply and quickly spread throughout the abdomen. On examination, the abdomen did not participate in breathing; palpation revealed a pronounced tension of the muscles of the anterior abdominal wall in all sections. Positive symptoms of peritoneal irritation. Diagnosed with widespread peritonitis due to the opening of the perivesical abscess. The patient was urgently operated. During laparotomy, it was found that the subhepatic space was occupied by a large inflammatory infiltrate formed by the lower surface of the liver and the gallbladder, the cecum and the greater omentum. From under the omentum came thick, fetid brown pus. Purulent exudate spread along the right lateral canal to the small pelvis, a small amount of exudate was in between the loop spaces. Massive deposition of fibrin in the subhepatic space, in other parts of the abdomen there is no fibrin on the peritoneum. When dividing the infiltrate, it was found that the gallbladder was changed a second time, it contains large stones. In the subhepatic space, there was an abscess cavity 8x5x2cm, which opened into the abdominal cavity along the edge of the liver. In the abscess there was a worm-like process of gray-green color, in the area of \u200b\u200bthe base there was a perforated hole from which pus came. An appendectomy was performed. The abdominal cavity was washed with saline with dioxidine. A rubber-gauze tampon was inserted into the abscess cavity through a counterperture. The wound of the abdominal wall is sutured through all layers, the sutures are tied with "bows". In the postoperative period, sanitation and revisions of the abdominal cavity were carried out. It was not possible to avoid extensive suppuration of the surgical wound. Slow recovery

D.G. Krieger, A. V. Fedorov, P. K. Voskresensky, A. F. Dronov

Appendix

The first description of the appendix of the cecum belongs to the Italian physician and anatomist Berengno Da Carpi (Berengano Da Carpi) in 1521. But the first image of the appendix was made by Leonardo Da Vinci in his anatomical drawings made in 1942.

Worm-like scion (processis vermiformis; appendix)

Hollow organ, an integral part of the gastrointestinal tract

It departs from the dome of the cecum in a place that is the place of convergence of three tendon bands of the colon (Valsalva bands): tenia libera, tenia tesocolica, tenia omentalis. This place is, on average, removed by 1.5-4.0 cm from the place where the ileum flows into the blind. The appendix is \u200b\u200blocated in the abdominal cavity intraperitoneally, has a mesentery. The length of the appendix is \u200b\u200bon average 7-10 cm, diameter 0.5-0.8 cm.In the literature, a vermiform appendix with a length of more than 23 cm is described (L, Morel, 1905) and as a casuistry 40 cm long, 8 cm wide, with a wall thickness 1.5 cm (M, I. Reznitsky, N. r. Rabinovich, 1968). In the structure of the appendix, there are: base, body and apex. The appendix serosa is smooth, pale pink in color.

Forms of the appendix (T, F. Lavrova, 1942): embryonic (as a continuation of the cecum); stem-shaped (the same thickness throughout); conical (the base of the appendix is \u200b\u200bnarrower than the apex).

In the lumen of the cecum, the appendix opens with an opening, which is called the opening of the appendix (ostiut appendicis). Here there is its own valve of the appendix (valva appepdicis), or Gerlach's valve (1, Ger1ach, 1847), a fold of the mucous membrane. The appendix valve becomes well pronounced only by the 9th year of life. From the side of the intestinal lumen, the mouth of the appendix is \u200b\u200blocated 24 cm below the ileocecal opening.

Types of discharge of the appendix from the cecum (E Treves, 1895):

the caecum, narrowing in a funnel shape, passes into the appendix;

the cecum passes into the appendix, sharply narrowing and curving;

the appendix departs from the dome of the cecum, but its base is displaced posteriorly;

departs posteriorly and below from the confluence of the ileum.

Location of the appendix in the abdominal cavity (relative to the cecum):

The projection of the appendix on the anterior abdominal wall of the abdomen is within the "appendicular triangle" of Scherren

The sides of the triangle are connected by the following anatomical structures: the navel, the right pubic tubercle and the antero-superior spine of the right iliac bone. Moreover, the line running from the navel to the anterosuperior spine of the right iliac bone (lipea spiпouтbilicalis) is called the Monro-Richter line (A. Monro, 1797; AGRichter, 1797), and the line connecting the anterosuperior spines of both iliac bones, the interosseous line / is) or Lanz's line (O. Lanz, 1902).

­

There are many topographic points of the projection of the appendix to the anterior abdominal wall of the abdomen:

· McBurney's point (CL, McBurney, 1889) is located on the border of the middle and lateral third of the line connecting the umbilicus and the anterosuperior spine of the right iliac bone.

Lanz's point (O, Lanz, 1902) is located on the border of the middle and right third of the interosseous line connecting the anterosuperior spines of both iliac bones,

Kummell's point (H, Kummell, 1890) is located below and to the right of the navel by 2 cm,

The rray point (T, C. Gray, 1971) is located 2.5 cm below and to the right of the navel.

Point 30nnenburra (E. Zonnenburg, 1894) is located at the intersection of Ppea bispina / is (the line connecting the anterosuperior spines of both iliac bones) and the outer edge of the right rectus abdominis muscle,

Morris point (R. T. Morris, 1904) is located at a distance of 4 cm from the navel along the line connecting the holes and the anteroposterior spine of the right iliac bone,

Point Munro (1. S. Munro, 1910) is located at the intersection of the outer OI "About the edge of the right rectus abdominis muscle and the line connecting the navel and the anterosuperior spine of the right iliac bone.

Lenzmann's point (R, Lenzmann, 1901) is located 5 cm medially from the anterosuperior spine of the right iliac bone along the interosseous line,

Abrazhanov's point (A.A. Abrazhanov, 1925) is located in the middle of the line connecting McBurney's point with the point obtained at the intersection of the interdivisional line and the white line of the abdomen.

The tuber point (M, M. tuberrits, 1927) is located immediately under the inguinal ligament in the Skarpovskoe treuolnik. Used for pelvic appendix.

Punin's point (B.V. Punin, 1927) is located to the right of the outer edge of the third LOYASNI4 vertebra. It is used to determine the projection of the retroperitoneal appendix,

Rotter's point O. Rotter, 1911) is determined by digital examination of the rectum, the point of maximum pain of the anterior rectal wall to the right of the midline.

BoykoPronin's point (fig. B, .N "!! 11), We have determined a point at the edge of the distal and middle third of the perpendicular, lowered from the navel to the inguinal ligament,

The literature contains many descriptions of the atypical, casuistic arrangement of the appendix: sternum (L, P. Semenova, E, A. Zinikhina, 1958); discharge of the appendix from the hepatic ulcer of the large intestine (N.S. Khaletskaya, 1955); intramesenteric (KL Bohan, 1987) and others, The facts of the presence of two appendixes are given (D, E, Robertson, 1940; B, E. Im nayshvili, R, R, Anakhasyan, 1968; c, r, Dzhioev, M. r : Revzis, 1980; M, M. Mypzanov, 1981, etc.), Described the left-sided arrangement of the appendix with situs viscerum ipversus (H, Hebblethwaite, 1908; M, A, Kaliner, 1962, etc.), as well as with left-sided placement cecum (N, Damianos, 1902; M. Sokolova, 1910, etc.),

In more than 70% of cases, the appendix is \u200b\u200bfree from adhesions throughout the entire ero length, in approximately 30% of cases it is fixed in a zip-like manner due to adhesions and adhesions

APPENDIX histotopography

1, Serous layer is a continuation of the general peritoneal layer, covering both the ileum and the cecum,.

2, Subserous layer is a loose tissue containing fat cells, where the subserous nerve plexus is located,

3, The outer muscle layer (solid longitudinal muscle tube), at the base of the process, is divided into three separate longitudinal muscle bands, which pass to the cecum, and some of the fibers of this layer pass into the muscles of the Baunian valve, Lockwood slits are located in the outer muscle layer (C, B, Lockwood, 1886) intermediate slits through which there is a constant connection of lymphoid accumulations opraHa,

4, Internal muscular layer (separate circular muscle BOlokna), Here the intermuscular nerve plexus of Auerbach (L, Auerbach, 1864) or Drasch (O, Drasch, 1886) is located.

5. I10 MUCOSA LAYER the interweaving of elastic and muscular BOlokones. Closely related to muscle layerIt contains the submucous nerve plexus of Remak (R, Remak, 1847) or Meissner (G, Meissner, 1863). This layer also contains follicles that first appear on the first [ode to life, but atrophy by old age, Their number varies dramatically in all age groups. Fullicle function is poorly understood,

6. The mucous membrane of numerous crypts, Covered with a single-row high prismatic epithelium, which, in turn, is covered with a cuticle. The layer contains the glandular secretion apparatus; cells of Kulchitsko (N.K. Kulchitsky, 1882) argeptaffipocyti iptestipa / es, which produce biologically active substances. L, Ashoff (L. Ashoff, 1908) called them “ birthmarks mucous membrane of the appendix ".

BLOOD SUPPLY OF THE WORM-ABOUT PROCESS

Types of blood supply to the appendix (H, A. Kel1y, E. Hurdon, 1905):

1, A single vessel (o. appediculoris) feeds the entire process without the adjacent part of the cecum, This type occurs in 50% of cases,

2, The appendix is \u200b\u200bsupplied by more than one vessel. [the lava vessel (a. appepdicularis) feeds only the distal 4/5 of the process, the proximal 1/5 of the process is supplied with blood by the branches of the posterior cecum aptery (a, caecalis posterior). This type is observed in 25% of cases.

3, The appendix and the adjacent cecum are supplied to the BMeste from the posterior cecum artery. This type is identified in 2S% of cases.

4, Loop forming type is extremely rare,

This classification is of great practical importance. Thus, in the case of the third type of blood supply, lining of the mesentery in the proximal part entails necrosis of the caecum area and incompetence of the purse-string "O suture with POL" cutting of the appendix stump. The main artery, IIIIII, may participate in the blood supply to the appendix, is a, appendicularis in the amount of 13. The average diameter is 1 mm. Departs: directly from the OCHoBHoro trunk a, i / eocolica (85%); from the iliac artery or "vascular island of Didkovsko" (14%); from anastomoses or other branches (1%). Passes a. appendicularis more often Bcero behind the ileum at a distance of up to 3 cm from the ileocecal ul "la. Branching types a, appendicularis (B. V, OrHeB, 1925):

1. Main. It occurs in 55% of cases. This type of xapaKTeren is for a low and maximally mobile appendix. The main trunk runs along the free edge of the mesentery of the appendix and gives off branches perpendicular to the process. The number of these branches is from 4 to 10. Their circular arrangement along the process indicates the cerMeHTapHOM nature of the ero blood supply (cerMeHTa length 8-12 mm).

2. Looped. It is observed in 15% of cases. This type is characteristic of a fixed, highly located process.

3, Loose. It is noted in 30% of cases. Inherent in the wide mesentery of the appendix. As a rule, with this type of branching, there is always an additional source of blood supply (branches of the posterior cecintestinal artery),

4. The mixed type is rare.

APPENDIX LYMPHATIC SYSTEM

Intra-oral lymphatic vessels are located in all layers of the process. The main ones among them are the submucosal and pserosal layers of capillaries, which form 25 lymphatic vessels, passing into the ero mesentery next to the appendicularis. They fall into the main group of lymph nodes located in a chain along a. ileoco / ica, From there they flow into the central l "RUPPU of the mesenteric lymph nodes. It should be remembered that the regional lymph nodes for the distal 1/3 of the process are located in the mesentery of the process. And the regional lymph nodes for the proximal 2/3 of the process are located at the base of the appendix and along the cecum and the ascending colon.This is extremely important to remember when determining the scope of the operation for malignant tumor appendix with metastases to regional lymph nodes,

INERVATION OF THE WORM-SHAPED PROCESS

Sources of sympathetic innervation: superior mesenteric plexus, cecum plexus (located 1 cm above and inward from the ileocecal ulcer), inferior mesenteric plexus, aortic plexus. More often Bcero nerves accompany the same names blood vessels.

physiology of the WORM-SHAPED PROCESS

There are several points of view on the nature of the appendix. The appendix is \u200b\u200ba phylogenetically new and morphological, actively functioning formation, but it does not perform vital functions (A.I. Tarenetsky, 1883; S.M. Rubashov, 1928; M.S. Kondrat'ev, 1941; B.M. Khromov, 1978; A, A. Pykakov et al., 1990, etc.).

The appendix is \u200b\u200ba rudiment, devoid of any useful functions (II Mechnikov, 1904; A. A. Bobrov, 1904; V. P. Vorobiev, 1936; A. r. Brzhozovsky, 1906; B, P, Braitsev, 1946; V., I. Kolesov, 1972, etc.).

Functions of the appendix

1. The contractile function of the appendix is \u200b\u200bvery poorly developed for a definite rhythm and strength of contractions. However, different layers of the muscles of the appendix can contract tonically and periodically.

2. Secretory function The fact that the appendix secretes a secret consisting of juice and mucus was first described by J. Lieberkuhn (J, Lieberkuhn) in 1739 r. The total amount of secretion BbJ released per day is 35 ml, ero pH is 8.38.9 (alkaline medium). The secret contains biologically active substances.

3. Lymphocytic function, Research by EI Sinelnikov (1948) found that 1 sq. Cm of the mucous membrane of the appendix contains about 200 lymphatic follicles. On average, the process contains 6,000 lymphatic follicles. In one minute, a miration from 18000 to 36000 leukocytes per 1 sq. M. Occurs in the lumen of the appendix. cm of the surface of the mucous membrane "; lKI. This function is most developed at the age of 11-16. In connection with the above, EI Sinelnikov introduced in the 19th century the concept of" amygdala-like appendix ". Although H. Sahli (N. SahIi, 1895) said that appendicitis is "anina worm-like" O process. Lymphocyte migration into venous capillaries was also noted. V, I, Kolesov (J 972) believes that lymphatic follicles ALROPHY with l odes and by 60 odes are extremely rare, and the wall of the appendix undergoes sclerotic changes, degenerative changes develop in muscle and There is an opinion that under extreme circumstances, when lymphatic tissue in other opl "aHax" and parts of the body is destroyed, the appendix can take on a protective role and is, as it were, a reserve apparatus, which is inactive for the time being.

4, Antibody production. Kawanishi (N. Kawanichi, 1987) believes that the lymphoid tissue of the appendix is \u200b\u200bone of the important links in the B-lymphocyte system, which provides the production of antibodies. A. V. Rusakov et al. (1990) note that the main function of the appendix is \u200b\u200bthe ability to control according to the principle feedback completeness of enzymatic breakdown of food products by assessing the degree of antigenicity of chyme. In addition, B, M. Khromov (1979) believes that the appendix may be responsible for the incompatibility reaction in opraHoB transplantation.

5. Endocrine function. This function was attributed to the secretion of the appendix to P. I. Dyakonov (1927). B.M., Khromov (1978) emphasized that the mucous membrane secretes a number of enzymes that affect the digestion process and affect the activity of other opl aHoB in the abdominal cavity. There is an assumption that the endocrine role is played by Kulchitsko's cells.

6, Digestive function. In, DeBush (W. DeBusch, 1814) believed that the appendix is \u200b\u200binvolved in the digestion of fiber, he even introduced the terms "second salivary gland" and "second pancreas". O. Funke (Oh, Funke, 1858) proved that the secret of the appendix can break down starch.

7, Maintaining a normal microbial background, K. H. Di-bi (K. N. Digy, 1923) and H. Kawanishi (H., Kawanichi, 1987) noted that the secret of the appendix promotes the transition of microbial toxins to a neutral state and delays the reproduction of bacteria the initial sections of the large intestine,

8. Valve function. A.N. Maksimenkov (1972) believes that with the IIPower of the appendix, the valve function is carried out in the ileocecal region.

9. Influence on intestinal motility. V. McEven (W, McEven, 1904) believed that the secret of the appendix promotes increased peristalsis and prevention of coprostasis in the cecum. It is believed that this secret is produced by Kulchitsko's cells.

CLASSIFICATION OF APPENDIX PATHOLOGY

International classification of diseases 10th revision (ICD-10)

Class XI. Diseases of the digestive system (K00-K93)

	[hide]Diseases of the appendix (appendix)
		Acute appendicitis
			Acute appendicitis with generalized peritonitis acute appendicitis with perforation, peritonitis (swollen), rupture
			Acute appendicitis with peritoneal abscess appendix abscess
			Acute appendicitis, unspecified acute appendicitis without perforation, peritoneal abscess, peritonitis, rupture
		Other forms of appendicitis chronic and recurrent appendicitis:
		Appendicitis, unspecified
		Other diseases of the appendix
			Hyperplasia of the appendix
			Appendicular stones fecal stone of appendix
			Appendix diverticulum
			Appendix fistula
			Other specified diseases of appendix invagination of the appendix
			Unspecified appendix disease

Classification of pathologic appendix (Pronin, Boyko)

1. Inflammation of the appendix:

a) nonspecific inflammation;

b) specific inflammation,

2. Tumors of the appendix:

a) benign;

b) malignant;

c) metastatic.

3. Volvulus of the appendix

4. Infringement of the appendix in the nephritis

5. Injury of the appendix

6, Endometriosis of the appendix

7, Diverticula of the appendix

8. Appendix cysts

9. Pneumatosis of the appendix

10. Invasion of the appendix

11. Foreign bodies of the appendix

12, Changes in the appendix in diseases of related opraHoB

Appendicitis

Acute appendicitis is an acute (often nonspecific) inflammation of the appendix.

Currently, acute appendicitis is one of the most widespread diseases, accounting for 25-30% of all surgical diseases (its frequency is 1 case per 150-200 people). Acute appendicitis can develop at any age, but the peak incidence occurs in the period 20-40 years. It develops more often in urban residents. In civilized countries, 6-12% of people have an attack of acute appendicitis during their lives. Usually it causes only temporary disability, but late diagnosis may lead to disability or even death. Mortality in acute appendicitis has practically not changed over the past 20 years and is 0.05-0.3% (in the Republic of Belarus 0.15-02%). Diagnostic errors in this disease occur in 12-31% of cases. Complications of acute appendicitis occur on average in 10% of patients, their frequency sharply increases in children and the elderly and old age and has no tendency to decline. Among acute surgical diseases of the abdominal cavity, acute appendicitis accounts for 89.1%, ranking first among them.

History of appendectomy

The history of appendicitis and appendectomy goes back more than two centuries and can be divided into two main periods.

First period: accidental opening of appendicular abscesses with or without removal of the appendix. The first reliable appendectomy was performed in 1735 in London by the royal surgeon, founder of St. George's Hospital Claudius Amyand. He operated on an 11-year-old boy with an inguinal-scrotal hernia complicated by a fecal fistula. During the operation, Amyand discovered in the contents of the hernia a double-folded process with a perforation and a pin inlaid with salts in it. The process was removed, the hernia was sutured. The whole operation lasted half an hour, and the child recovered. Before this operation, only the opening of the "abscesses" of the iliac fossa was performed. The attention of surgeons is increasingly attracting cases of inflammation in the right iliac region, but they were interpreted as muscle inflammation ("psoit") or postpartum complications ("uterine abscesses") and, as a rule, were treated conservatively. At this time, the first mentions of cases of perforated appendicitis and the formation of abscesses of the iliac fossa appear in the literature, however, the role of the appendix in the occurrence of intraperitoneal abscesses was ignored, and the disease was explained by the primary lesion of the cecum (typhlitis) due to injuries from foreign bodies or bedsore by feces.

The second period: recognition of the role of the appendix in inflammation of the area of \u200b\u200bthe right iliac fossa and the allocation of "appendicitis" into an independent nosological form.

In 1839. British surgeons Bright and Addison in their work "Elements of Practical Medicine" described in detail the clinic of acute appendicitis and provided evidence of the existence of this disease and its primacy in relation to inflammation of the intestine (earlier the idea of \u200b\u200bthe independence of inflammation of the appendix in the 1920s was put forward by the French Louis Fillerme and François Miller, however, then the theory was not accepted). Despite this, the treatment of acute appendicitis, peritonitis and intra-abdominal abscesses was in the hands of therapists. The treatment consisted of observing rest, diet, gastric lavage, enemas and giving opium tincture, the antiperistaltic and analgesic effect of which did not so much allow localizing the abscess as allowed the patient to die peacefully.

However, with the beginning of the era of pain relief (Marton 1846) and antiseptics (Lister 1867), a new milestone began in the treatment of appendicitis. In 1886, at the Congress of the American Medical Association, Reginal Fitz, an American surgeon, professor at Harvard University made a report in which he proposed the term "appendicitis", emphasized that the root cause of abscesses in the right iliac fossa is the appendix, clearly described the clinic of the disease, and called for a surgical removal of the appendix. From that moment on, the surgical treatment of appendicitis began to be adopted everywhere, the technique of the operation was improved, but it was not finally standardized. A significant number of operational access, however, some of them did not give a comfortable exposure, while others led to muscle denervation and formation ventral hernias... One of the most successful was the oblique variable incision of McBurney (1894), a little later the same approach was offered by Russian surgeons N.M. Volkovich and P.I.Dyakonov. In 1933, at the All-Russian conference on acute appendicitis, it was decided on a unified tactics for treating acute appendicitis, which boiled down to the earliest possible placement of the patient in a surgical hospital and urgent surgery at any time from the onset of the disease.

With the passage of time, methods of diagnostics and approaches to treatment have improved. In 1901. A Russian obstetrician-gynecologist, using mirrors and a forehead reflector, examined the abdominal cavity through an incision in the posterior fornix of the vagina. In the same year, Kelling performed an endoscopic examination of the abdominal cavity using a cystoscope. This was the beginning of endoscopic surgery. In 1982, the German gynecologist Kurt Semm performed the first laparoscopic appendectomy.

Appendectomy

Classification of appendectomies:

Appendectomy classification:

1. Appendectomy from laparotomic access:

Typical (antegrade) - first, the ligation is performed and the cut-off-mesentery of the appendix is \u200b\u200bperformed, and then the cut-off of the appendix itself and treatments) of the stump;

Atypical (retrograde) - first, the appendix is \u200b\u200bcut off and its stump is treated, and then the mesentery of the appendix is \u200b\u200bligated and cut off.

2. Laparoscopic appendectomy.

3. Appendectomy from an extraperitoneal approach with a retroperitoneal process.

There are many operative approaches to the vermiform, we will consider carrying out a laparotomic appendectomy using an oblique variable incision according to Volkovich-Dyakonov (McBurney)

The incision is made perpendicular to the line connecting the navel and the upper anterior iliac spine, at the border of the middle and outer third of this line. One third of the incision is located upwards, 2/3 downwards. The incision is from 4 to 10-15 cm, depending on the thickness of the anterior abdominal wall. After dissection of the skin, subcutaneous fat, superficial fascia, the aponeurosis of the external oblique muscle of the abdomen is exposed and a small hole is made in it along the fibers with a scalpel. Scissors are inserted into the resulting hole and stratified along the fibers, first down, then up. At the same time, the muscle fibers of the external oblique muscle are also disconnected to the corners of the skin wound. After the edges of the aponeurosis and the external oblique abdominal muscle are diluted, the internal oblique muscle of the abdomen opens. Its perimisium is dissected, after which the muscle is bluntly stratified with two closed forceps together with the transverse abdominal muscle. The muscles are stretched with Farabef hooks, the transverse fascia is grasped and incised. The parietal peritoneum is exposed in the preperitoneal tissue. The peritoneum is gently grasped into the fold with anatomical tweezers, carefully isolated from the wound canal with gauze napkins, lifted, folded through the branch of the Kupffer scissors, making sure that only the peritoneum is captured (the branch should be visible). The peritoneum is carefully incised, its edges are grasped with clamps, the edges of the wound are bred in the longitudinal direction and the revision of the abdominal cavity is started. After opening the abdominal cavity, the caecum usually bulges into the wound, characterized by a bluish-purple color compared to the pink loops of the small intestine. If the loops of the small intestine or the greater omentum are adjacent to the wound, they are pushed back medially. With a low position of the cecum, it is pulled upward, sorting out the ascending colon from top to bottom along the free muscle tape using anatomical tweezers or fingers, after which the base of the appendix becomes visible. Thus, the dome of the cecum and the appendix are removed into the wound. The distal edge of the mesentery of the appendix is \u200b\u200bcaptured at its apex and the appendix is \u200b\u200braised. At the very base of the process, its mesentery is bluntly perforated with a clamp, which then squeezes the mesentery, it is crossed at the very base and tied with an absorbable thread. A clamp is applied to the base of the appendix and bandaged in the formed groove. Around the base of the appendix, retreating 10-15 mm from it, a purse-string serous-muscular suture is applied.