Early and late complications of acute appendicitis. Complication of appendicitis

Early complications occur within two weeks of surgery. This group includes most complications from the postoperative wound (purulent-inflammatory processes, dehiscence of the edges of the wound; bleeding from the wound of the anterior abdominal wall) and all complications from the side of adjacent organs.

Bleeding from the vessels of the mesenteryarises as a result of technical errors during the operation or with an ongoing inflammatory / necrotic process leading to erosive bleeding. A feature of the clinic of postoperative bleeding is the presence of signs of acute blood loss and the rapid development of peritonitis. This complication requires immediate reoperation.

Stump failure appendix m / t develop in the first hours and days after appendectomy. It occurs most often in patients with destructive forms of appendicitis, when the cat is changed not only the appendix, but also the dome of the cecum, which complicates the processing of the appendix stump. With the development of this complication, fecal peritonitis develops rapidly, which requires immediate revision of the abdominal cavity.

20. Late complications after operations for acute appendicitis.

Late postoperative complications develop when the two-week postoperative period expires. These include complications from the postoperative wound- abscess, infiltration, postoperative hernia, ligature fistula, scar neuromas, keloid scars; acute inflammatory processes in the abdominal cavity- abscesses, infiltrates, cultitis; gastrointestinal complications- adhesive disease and mechanical acute intestinal obstruction.

Dynamic intestinal obstructionis caused by functional changes in the motility of the intestinal muscles without the presence of any mechanical disorders that impede the movement of intestinal contents. Most often it is paralytic. Intestinal motility ceases, bloating occurs with the termination of the absorption process and venous congestion in the intestinal wall. Clinic:the first symptom is i-i bloating of the intestines, not associated with pain. The increase in bloating is accompanied by vomiting, first by the contents of the stomach, then by bile, and in the later period by feces. Prolonged bloating of the intestine leads to damage to the intestinal wall, which is accompanied by the penetration of bacteria through it into the abdominal cavity. This leads to the appearance of symptoms of secondary peritonitis.

Postoperative infiltrationformed in the ileocecal angle as a result of the remaining inf-ii after the removal of the appendix. In this case, a tumor-like formation is determined in the right ileocecal region, painful on palpation. Treatment of postoperative infiltration is conservative: administration of broad-spectrum antibiotics, detoxification therapy, UHF, leeches.

Subphrenic abscessi-I complication of peritonitis and har-Xia accumulation of pus m / u diaphragm (top) and internal organs - liver, stomach, spleen, omentum, intestinal loops (bottom). An abscess can sometimes be located in the retroperitoneal space.

Douglas space abscessesare formed as a result of the flow of inflammatory exudate into the pelvic cavity. One of the early signs of a pelvic abscess is I-I dysuric phenomena, urge to defecate, tenesmus, dull pain in the lower abdomen, chills, high temperature. On rectal and vaginal examination, painful swelling in the Douglas space can be identified. In the center of the infiltrate, a fluctuation site is often probed, i.e. abscess. In the initial period of this complication, conservative treatment (antibiotics, enemas with chamomile infusion), and when the abscess is formed, it is opened.

Interintestinal abscesses. Clinic:abdominal pain, frequent loose stools, chills, general weakness. Then there are symptoms of peritoneal irritation, intestinal paresis. Palpation of the abdomen reveals a tumor-like formation in the abdominal cavity of different localization, more often in the middle of the abdomen.

Pylephlebitis- thrombosis of the mesenteric and portal veins. It develops as a result of necrotic processes and thrombosis of the mesenteric vessels with subsequent damage to the mesenteric vessels and the portal vein. The severity of the clinic is determined by the rate and prevalence of hepatic vein blockage. The complication often begins acutely, 1-2 days after appendectomy. The patient develops severe pains in the epigastric region or right hypochondrium, resembling in intensity attacks of hepatic colic. Pains are accompanied by nausea, often bloody vomiting, collapse. This complication is characterized by a temperature of a hectic nature, the appearance of yellowness of the sclera and skin as a result of toxic hepatitis. Soreness of the abdomen in the right hypochondrium, enlarged liver, ascites, hepatic-renal failure are noted. Serous effusion is often observed in the right pleural cavity. Sometimes an enlarged right thrombosed portal vein and edema of the hepato-duodenal ligament can cause compression of the common bile duct, followed by obstructive jaundice.

TELA.It occurs in the first 2 weeks after surgery. The clinic of PE depends on the size of the embolus and the degree of blockage of the arterial lumen. With complete blockage pulmonary artery death occurs instantly or within minutes after the onset of embolism. The main symptom of this complication is a sudden deterioration of the general condition, manifested by severe chest pain, severe shortness of breath, tense, intermittent, rapid breathing and almost instantaneous disappearance of the pulse. A sharp pallor of the skin is replaced by cyanosis of the face and upper half of the body. Acute failure of the right heart occurs, the patient loses consciousness and quickly dies.

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Despite great advances in the diagnosis and surgical treatment of appendicitis, this problem still does not fully satisfy surgeons. A high percentage of diagnostic errors (15-44.5%), stable, with no tendency to decrease mortality rates (0.2-0.3%) with a massive disease with acute appendicitis confirm what has been said [V.I. Kolesov, 1972; V.S. May, 1976; YL. Kulikov, 1980; V.N. Butsenko et al., 1983]

Mortality after appendectomy due to diagnostic errors and loss of time is 5.9% [I.L. Rotkov, 1988]. The causes of death after appendectomy mainly lie in purulentseptic complications [L.A. Zaitsev et al., 1977; V.F. Litvinov et al., 1979; IL. Rotkov, 1980, etc.]. The cause of complications is usually destructive forms of inflammation of the AO, spreading to other parts of the abdominal cavity.

According to the literature, the reasons leading to the development of complications leading to repeated operations are as follows.
1. Late hospitalization of patients, insufficient qualification of medical workers, diagnostic errors due to the presence of atypical, difficult to diagnose forms of the disease, which is often found in elderly and senile people, in whom morphological and functional changes in various organs and systems aggravate the severity of the disease, and sometimes come to the fore, masking the patient's acute appendicitis. Most patients cannot accurately name the onset of the disease, since at first they did not pay attention to mild persistent abdominal pain.
2. Delay of surgical intervention in a hospital due to errors in diagnosis, patient refusal or organizational issues.
3. Inaccurate assessment of the prevalence of the process during the operation, as a result, insufficient sanitation of the abdominal cavity, violation of the rules of drainage, lack of complex treatment in the postoperative period.

Unfortunately, late admission of patients with this pathology to the hospital is not yet a rarity. In addition, no matter how annoying it is to admit it, a large proportion of hospitalized and operated patients with delay are the result of diagnostic and tactical errors by doctors in the polyclinic network, ambulance and, finally, surgical departments.

Overdiagnosis of acute appendicitis by doctors prehospital stage is fully justified, since it is dictated by the specifics of their work: short-term observation of patients, the absence of additional examination methods in most cases.

Naturally, such errors reflect the well-known wariness of prehospital network doctors in relation to acute appendicitis and cannot be compared in their importance with errors of the opposite order. Sometimes patients with appendicitis are either not hospitalized at all, or are not sent to a surgical hospital, which leads to the loss of precious time with all the ensuing consequences. Such errors due to the fault of the polyclinic are 0.9%, due to the fault of ambulance doctors - 0.7% in relation to all those operated on for this disease [V.N. Butsenko et al., 1983].

The problem of emergency diagnosis of acute appendicitis is very important, because in emergency surgery the frequency of the disease largely depends on the timely diagnosis of the disease postoperative complications.

Often, diagnostic errors are observed in the differentiation of food toxicoinfections, infectious diseases and acute appendicitis. Careful examination of patients, monitoring the dynamics of the disease, consultation with an infectious disease specialist, the use of all research methods available in this situation will greatly help the doctor make the right decision.

It should be remembered that perforated appendicitis in some cases in its manifestations can be very similar to perforation of gastroduodenal ulcers.

Sharp abdominal pains, characteristic of perforation of gastroduodenal ulcers, are compared to pain from a dagger strike, called sudden, sharp, painful. Sometimes such pain can also be with perforated appendicitis, when patients often ask for urgent help, they can only move bent over, the slightest movement causes an increase in abdominal pain.

It may also be deceiving that sometimes before the perforation of the OR, in some patients the pain subsides and the general condition improves for a certain period. In such cases, the surgeon sees in front of him a patient who has had a catastrophe in the abdomen, but diffuse soreness throughout the abdomen, tension in the muscles of the abdominal wall, a pronounced Blumberg-Shchetkin symptom - all this does not allow identifying the source of the catastrophe and making a confident diagnosis. But this does not mean that it is impossible to establish an accurate diagnosis. Studying the anamnesis of the disease, determining the characteristics of the initial period, identifying the nature of the acute pains that have arisen, their localization and prevalence makes it possible to more confidently differentiate the process.

First of all, when an abdominal catastrophe occurs, it is necessary to check for the presence of hepatic dullness both percussion and X-ray. Additional determination of free fluid in the sloping areas of the abdomen, digital examination of the PC will help the doctor establish the correct diagnosis. In all cases, examining a patient who has severe abdominal pain, tension of the abdominal wall and other symptoms indicating the sharpest irritation of the peritoneum, along with perforation of the gastroduodenal ulcer, acute appendicitis should also be suspected, since perforated appendicitis often proceeds under the "mask" of abdominal catastrophe ...

Intra-abdominal postoperative complications are caused both by the variety of clinical forms of acute appendicitis, by the pathological process in the emergency room, and by organizational, diagnostic, tactical and technical errors of surgeons. The incidence of complications leading to PC in acute appendicitis is 0.23-0.55% [P.A. Alexandrovich, 1979; N.B. Batyan, 1982; K.S. Zhitnikov and S.N. Morshinin, 1987], and according to other authors [D.M. Krasilnikov et al., 1992] even 2.1%.

Of the intra-abdominal complications after appendectomy, widespread and delimited peritonitis, intestinal fistulas, bleeding, and NK are relatively often observed. The vast majority of these complications after surgery are observed after destructive forms of acute appendicitis. Of the limited gaoinflammatory processes, pericultal abscess or, as it is mistakenly called, abscess of the stump of the CHO, delimited in the right iliac region, peritonitis, multiple (interintestinal, pelvic, subphrenic) abscesses, infected hematomas, as well as their breakthrough into the free abdominal cavity are often observed.

The reasons for the development of peritonitis are diagnostic, tactical and technical errors. When analyzing the case histories of patients who died from acute appendicitis, many medical errors... Doctors often ignore the principle of dynamic observation of patients who have abdominal pain, do not use the most basic laboratory and x-ray examination, neglect rectal examination, do not involve experienced specialists for consultation. Operations are usually performed by young, inexperienced surgeons. Often, with perforated appendicitis with symptoms of diffuse or diffuse peritonitis, appendectomy is performed from an oblique Volkovich incision, which does not allow completely sanitizing the abdominal cavity, determining the prevalence of peritonitis, and even more so making such necessary benefits as drainage of the abdominal cavity and intestinal intubation.

True postoperative peritonitis, which is not a consequence of purulent-destructive changes in the OR, usually develops as a result of tactical and technical errors made by surgeons. In this case, the failure of the stump of the CHO leads to the occurrence of postoperative peritonitis; through-piercing of the SC when applying a purse-string suture; undiagnosed and unrepaired capillary bleeding; gross violations of the principles of asepsis and antisepsis; leaving parts of the CHO in the abdominal cavity, etc.

Against the background of diffuse peritonitis, abscesses of the abdominal cavity can form, mainly as a result of its insufficiently thorough sanitation and inept use of peritoneal dialysis. After appendectomy, a pericultal abscess often develops. The reasons for this complication are often violations of the technique of applying a purse-string suture, when a puncture of the entire intestinal wall is allowed, the use of a Z-shaped suture in typhlitis instead of interrupted sutures, gross manipulation of tissues, deseroization of the intestinal wall, the failure of the stump of the OR, insufficient hemostasis, underestimation of the as a result, an unreasonable refusal to drain.

After appendectomy for complicated appendicitis in 0.35-0.8% of patients, intestinal fistulas may occur [K.T. Ovnatanyan et al., 1970; V.V. Rodionov et al., 1976]. This complication becomes the cause of death in 9.1-9.7% of patients [I.M. Matyashin et al., 1974]. The emergence of intestinal fistulas is also in close connection with the purulent-inflammatory process in the ileocecal angle, at which the walls of the organs are infiltrated and easily injured. Particularly dangerous is the violent division of the appendicular infiltrate, as well as the removal of the appendix when an abscess is formed.

Gauze tampons and drainage tubes that have been in the abdominal cavity for a long time, which can cause a pressure ulcer of the intestinal wall, can also cause intestinal fistulas. Also of great importance is the method of processing the stump of the CHO, its shelter under conditions of infiltration of the SC. When the stump of the appendix is \u200b\u200bimmersed in the inflammatory infiltrated wall of the SC by applying purse-string sutures, there is a risk of NK, failure of the appendix stump and the formation of an intestinal fistula.

In order to prevent this complication, it is recommended to cover the appendix stump with separate interrupted sutures using synthetic threads on an atraumatic needle and peritonize this area with a large omentum. In some patients, extraleritonization of the SC and even the imposition of a cecostomy is justified in order to prevent the development of peritonitis or the formation of a fistula.

After appendectomy, intra-abdominal bleeding (IV) from the mesenteric stump of the CHO is also possible. This complication can be unambiguously attributed to defects in surgical technique. It is observed in 0.03-0.2% of those operated.

A decrease in blood pressure during surgery is of certain importance. Against this background, VC from crossed and stupidly separated adhesions stops, but in the postoperative period, when the pressure rises again, VC may resume, especially in the presence of atherosclerotic changes in the vessels. Errors in diagnosis are also sometimes the cause of an unrecognized VC during the operation or in the postoperative period [N.M. Zabolotsky and A.M. Semko, 1988]. Most often this is observed in cases where acute appendicitis is diagnosed with ovarian apoplexy in girls and an appendectomy is performed, and a small VC and its source remain unnoticed. In the future, after such operations, severe VCs may occur.

The so-called congenital and acquired hemorrhagic diathesis - hemophilia, Werlhof's disease, long-standing jaundice, etc. - are of great danger in terms of the occurrence of postoperative VC. These diseases, which are not recognized in time or are not taken into account during the operation, can play a fatal role. It should be borne in mind that some of them can simulate acute diseases of the abdominal organs [N.P. Batyan et al, 1976].

VC after appendectomy is very dangerous for the patient. The reasons for the complications are that, firstly, appendectomy is the most common operation in abdominal surgery, and secondly, it is more often performed by inexperienced surgeons, while difficult situations during appendectomy are not uncommon. The reason in most cases is technical errors. The specific gravity of VC after appendectomy is 0.02-0.07% [V.P. Radushkevich, I.M. Kudinov, 1967]. Some authors cite even higher figures - 0.2%. Hundredths of a percent seem to be a very small figure, however, given the large number of appendectomies performed, this fact should seriously concern surgeons.

VCs more often arise from the artery of the CHO due to slipping of the ligature from the stump of its mesentery. This is facilitated by infiltration of the mesentery with novocaine and inflammatory changes in it. In cases where the mesentery is short, it must be bandaged in parts. Especially significant difficulties in stopping bleeding arise when it is necessary to retrogradely remove the CHO. The process is mobilized in stages [I.F. Mazurin et al., 1975; YES. Dorogan et al., 1982].

Often there are VC from crossed or stupidly separated and not tied up [I.M. Matyashin et al., 1974]. To prevent them, it is necessary to achieve an increase in blood pressure, if it decreased during the operation, to make a thorough check of hemostasis, to stop bleeding by capturing the bleeding areas with hemostatic clamps, followed by stitching and bandaging. Measures for the prevention of VC from the stump of the CHO are reliable ligation of the stump, immersing it in a purse string and Z-shaped sutures.

Also noted was VC from deserosed areas of the large and small intestines [D.A. Dorogan et al. 1982; AL. Gavura et al., 1985]. In all cases of intestinal deserosis, peritonization of this area is necessary. This is a reliable measure to prevent such a complication. If, due to infiltration of the intestinal wall, serous-muscular sutures cannot be applied, the deserosed area should be peritonized by suturing an omentum flap on the pedicle. Sometimes VC arises from a puncture of the abdominal wall made for the introduction of drainage, therefore, after passing it through a counter-opening, it is necessary to make sure that there is no VC.

Analysis of the causes of VC showed that in most cases they arise after non-standard operations, during the performance of which certain moments are noted that contribute to the occurrence of complications. Unfortunately, these points are not always easy to take into account, especially for young surgeons. There are situations when the surgeon foresees the possibility of a postoperative VC, but the technical equipment is insufficient to prevent it. Such cases are not common. More often, VC are observed after operations performed by young surgeons who do not have sufficient experience [I.T. Zakishansky, I.D. Strugatsky, 1975].

Of the other factors contributing to the development of postoperative VC, first of all, I would like to note technical difficulties: an extensive adhesion process, the wrong choice of anesthesia method, insufficient operative access, which complicates manipulations and increases technical difficulties, and sometimes creates them.
Experience shows VCs occur more often after operations performed at night [I.G. Zakishansky, IL. Strugatsky, 1975, etc.]. The explanation for this is that at night the surgeon cannot always take the advice or help of an older friend in difficult situations, and also that the surgeon's attention decreases at night.

VC can occur as a result of the melting of infected blood clots in the vessels of the mesentery of the OR or arrosion of the vessels [AI. Lenyushkin et al., 1964], with congenital or acquired hemorrhagic diathesis, but the main cause of VC should be considered defects in surgical technique. This is evidenced by the identified errors in RL: relaxation or slipping of the ligature from the stump of the mesentery of the appendix, unbound, dissected vessels in the adhesive tissues, poor hemostasis in the area of \u200b\u200bthe main wound of the abdominal wall.

VC can also take place from the wound channel of the counteropening. With technically complex appendectomies, VC can arise from damaged vessels of the retroperitoneal tissue and mesentery of the MC.

Intense VCs often stop spontaneously. Anemia can develop after several days, and often in these cases, due to the addition of infection, peritonitis develops. If infection does not occur, then the blood remaining in the abdominal cavity, gradually organizing, gives rise to the adhesion process.
To prevent the occurrence of bleeding after appendectomy, it is necessary to follow a number of principles, the main ones of which are careful pain relief during the operation, ensuring free access, respect for tissues and good hemostasis.

Light bleeding is usually observed from small vessels that are damaged during the separation of adhesions, the release of AE, with its retrocecal and retroperitoneal location, mobilization of the right flank of the large intestine, and in a number of other situations. These bleeding proceeds most secretly, hemodynamic and hematological parameters usually do not change significantly, therefore in early dates unfortunately, these bleeding is very rarely diagnosed.

One of the most severe complications of appendectomy is acute postoperative NC. According to the literature, it is 0.2-0.5% [MI. Matyashin, 1974]. In the process of development of this complication, adhesions that fix the ileum to the parietal peritoneum at the entrance to the small pelvis are of particular importance. With the growth of paresis, the intestinal loops, located above the place of inflection, compression or infringement of the intestinal loop by adhesion, overflow with fluid and gases, hang down into the small pelvis, bending over the adjacent, also stretched TC loops There is a kind of secondary volvulus [OB Milonov et al., 1990].

Postoperative NK is observed mainly in destructive forms of appendicitis. Its frequency is 0.6%. In case of complication of appendicitis by local peritonitis, NK develops in 8.1% of patients, and in case of its complication by diffuse peritonitis - in 18.7%. Gross trauma to the visceral peritoneum during surgery predisposes to the development of adhesions in the ileocecal angle.

The cause of complications can be diagnostic errors, when the appendix is \u200b\u200bremoved instead of a destructive process in the Meckel diverticulum. However, if we consider that allenectomy is performed in millions of patients [OB. Milonov et al., 1980], then this pathology is detected in hundreds and thousands of patients.

Of the complications, intraperitoneal abscesses are relatively common (usually after 1-2 weeks) (Figure 5). In these patients, local signs of complications are indistinct. More often prevail general symptoms intoxication, septic conditions and multiple organ failure, which are not only alarming, but also alarming. With the pelvic location of the CHO, abscesses of the rectal-uterine or rectal-vesicular cavity occur. Clinically, these abscesses are manifested by a deterioration in the general condition, pain in the lower abdomen, high temperature body. A number of patients have frequent loose stools with mucus, frequent, difficult urination.

Figure 5. Scheme of the spread of abscesses in acute appendicitis (according to B.M. Khrov):
a - inside the peritoneal location of the process (front view): 1 - anterior or parietal abscess; 2 - intraperitoneal lateral abscess; 3 - iliac abscess; 4 - abscess in the pelvic cavity (abscess of the Douglas space); 5 - subphrenic abscess; 6 - podklechenny abscess; 7 - left-sided iliac abscess; 8 - interintestinal abscess; 9 - intraperitoneal abscess; b - retrocecal extraperitoneal location of the appendix (side view): 1 - purulent paracolitis; 2 - paranephritis, 3 - subphrenic (extraperitoneal) abscess; 4 - abscess or phlegmon of the iliac fossa; 5 - retroperitoneal phlegmon; 6 - pelvic phlegmon

A digital examination of the PC in the early stages reveals the pain of its anterior wall and the overhanging of the latter due to the formation of a dense infiltrate. With the formation of an abscess, the tone of the sphincter decreases and a softening area appears. In the initial stages, conservative treatment is prescribed (antibiotics, warm medicinal enemas, physiotherapy procedures). If the patient's condition does not improve, the abscess is opened through the PC in men, through the posterior fornix of the vagina in women. When opening an abscess through the PC after emptying bladder the sphincter of the ZP is stretched, the abscess is punctured and, having received pus, the intestinal wall is cut through the needle.

The wound is expanded with a forceps, a drainage tube is inserted into the abscess cavity, fixed to the skin of the perineum and left for 4-5 days. In women, when opening an abscess, the uterus is retracted anteriorly. The abscess is punctured and the tissue is dissected through the needle. The abscess cavity is drained with a rubber tube. After opening the abscess, the patient's condition quickly improves, after a few days, the discharge of pus stops and recovery occurs.

Interintestinal abscesses are rare. With development long time after appendectomy, high body temperature is maintained, leukocytosis with a shift is noted leukocyte formula to the left. On palpation of the abdomen, pain is indistinctly expressed at the location of the infiltrate. Gradually increasing in size, it approaches the anterior abdominal wall and becomes palpable. In the initial stage, conservative treatment is usually carried out. When signs of abscess formation appear, it is drained.

Subphrenic abscess after appendectomy is even less common. When it occurs, the patient's general condition worsens, the body temperature rises, pains appear on the right above or below the liver. Most often, in half of patients, the first symptom is pain. An abscess may appear suddenly or be masked by an obscure febrile condition, erased by onset. The diagnosis and treatment of subphrenic abscesses have been discussed above.

In another case, a purulent infection can spread to the entire peritoneum and develop diffuse peritonitis (Figure 6).

Figure 6. The spread of diffuse peritonitis of appendicular origin to the entire peritoneum (diagram)

A serious complication of acute destructive appendicitis is pylephlebitis - purulent thrombophlebitis of the veins of the portal system. Thrombophlebitis begins in the veins of the CHO and spreads to the IV through the ilio-colonic vein. Against the background of the complication of acute destructive appendicitis with pylephlebitis, multiple abscesses of the liver can form (Figure 7).

Figure 7. Development of multiple liver abscesses in acute destructive appendicitis complicated by pylephlebitis

VV thrombophlebitis, which occurs after alpendectomy and surgery on other organs of the gastrointestinal tract, is a formidable and rare complication. It is accompanied by a very high mortality rate. When the venous vessels of the mesentery are involved in the purulent-necrotic process with the subsequent formation of septic thrombophlebitis, the IV is usually also affected. This is due to the spread of the necrotic process of the OR to its mesentery and the venous vessels passing through it. In this regard, during the operation, it is recommended [M.G. Sachek and V.V. Anechkin, 1987] to excise the altered mesentery of the CHO to viable tissues.

Postoperative mesenteric thrombophlebitis usually occurs when conditions are created for direct contact of a virulent infection with the wall of a venous vessel. This complication is characterized by a progressive course and severity clinical manifestations... It begins acutely: from 1-2 days postoperative period repeated tremendous chills, fever with high temperature (39-40 ° C) appear. There is intense abdominal pain, more pronounced on the side of the lesion, progressive deterioration of the patient's condition, intestinal paresis, and increasing intoxication. As the complication progresses, symptoms of mesenteric vein thrombosis (stool with an admixture of blood) appear, signs toxic hepatitis (soreness in the right hypochondrium, jaundice), signs of PN, ascites.

There are marked changes in laboratory parameters: leukocytosis in the blood, a shift in the leukocyte formula to the left, toxic granularity of neutrophils, an increase in ESR, bilirubinemia, a decrease in protein-forming and antitoxic liver function, protein in urine, corpuscles, etc. It is very difficult to make a diagnosis before surgery. Patients usually undergo RL for "peritonitis", "intestinal obstruction" and other conditions.

When the abdominal cavity is opened, a light exudate with a hemorrhagic shade is noted. When revising the abdominal cavity, an enlarged spotty color (due to the presence of multiple subcapsular abscesses) is found, a dense liver, a large spleen, a paretic cyanotic intestine with a stagnant vascular pattern, dilated and tense mesenteric veins, often blood in the intestinal lumen. Thrombosed veins are palpable in the thickness of the hepato-duodenal ligament and mesacolon in the form of dense cord-like formations. Treating pylephlebitis is a difficult and challenging task.

In addition to rational drainage of the primary focus of infections, it is recommended to recanalize the umbilical vein and canalize the IV. When cannulating the portal vein, pus can be obtained from its lumen, which is aspirated until venous blood appears [M.G. Sachek and V.V. Anichkin, 1987]. Antibiotics, heparin, fibronolytic drugs, agents that improve the rheological properties of blood are injected transumbilically.

At the same time, correction of metabolic disorders caused by developing PN is carried out. In metabolic acidosis accompanying PN, a 4% sodium bicarbonate solution is injected, the loss of body fluid is controlled, intravenous administration of solutions of glucose, albumin, rheopolyglucin, hemodez is carried out - the total volume is up to 3-3.5 liters. Large losses of potassium ions are compensated by the introduction of an adequate amount of 1-2% potassium chloride solution.

Violations of the protein-forming function of the liver are corrected by the introduction of a 5% or 10% solution of albumin, native plasma, amino acid mixtures, alvezin, aminosterilhepa (aminocrovin). For detoxification, hemodez solution (400 ml) is used. Patients are transferred to a protein-free diet, concentrated (10-20%) glucose solutions with an adequate amount of insulin are administered intravenously. Apply hormonal drugs: prednisone (10 mg / kg body weight per day), hydrocortisone (40 mg / kg body weight per day). With an increase in the activity of proteolytic enzymes, it is advisable to intravenously administer counterkal (50-100 thousand units). To stabilize the blood coagulation system, vikasol, calcium chloride, epsilonaminocaproic acid are administered. To stimulate tissue metabolism, B vitamins (B1, B6, B12) are used, ascorbic acid, liver extracts (sirepar, campolon, vitohepat).

For the prevention of purulent complications, massive antibiotic therapy is prescribed. Oxygen therapy is performed, including HBO therapy. To remove protein breakdown products (ammonia intoxication), gastric lavage (2-3 times a day), cleansing enemas, stimulation of diuresis are recommended. If indicated, hemo- and lymphatic sorption, peritoneal dialysis, hemodialysis, exchange transfusion, connection of an allo- or xenogenic liver are performed. However, with this postoperative complication, therapeutic measures are ineffective. Patients usually die from hepatic coma.

Other complications (diffuse purulent peritonitis, NK, adhesive disease) are described in the relevant sections.

Any of the following postoperative complications can occur in the most different terms from the moment of the first operation. For example, an abscess or adhesive NK in some patients occurs in the first 5-7 days, in others - after 1-2, even 3 weeks after appendectomy. Our observations show that purulent deposits are more often diagnosed at a later date (later than 7 days). We also note that in terms of assessing the timeliness of the performed radar test, it is not the time elapsed after the first operation that is decisive, but the time since the first signs of complication appear.

Depending on the nature of complications, their signs in some patients are expressed by local muscle tension with or without irritation of the peritoneum, in others - by bloating and asymmetry of the abdomen or by the presence of a palpable infiltrate without clear boundaries by a local pain reaction.

The leading symptoms in toyo-inflammatory complications that develop after alendectomine are pain syndrome, moderate and then increasing muscle tension and symptoms of peritoneal irritation. The temperature in this bowl is subfebrile and can reach 38-39 ° C. On the part of the blood, there is an increase in the number of leukocytes up to 12-19 thousand units with a shift of the formula to the left.

The choice of surgical tactics during reoperation depends on the identified pathomorphic findings.

Summarizing the above, we come to the conclusion that the main etiological factors in the development of complications after appendectomy are:
1) neglect of acute appendicitis due to late admission of patients to the hospital, most of whom have a destructive form of the pathological process, or due to diagnostic errors of doctors at the prehospital and hospital stages of treatment;
2) defects in surgical technique and tactical errors during appendectomy;
3) unforeseen situations associated with exacerbation of concomitant diseases.

In the event of complications after appendectomy, the urgency of RL is determined depending on its nature. Urgent RL are performed (in the first 72 hours after the initial intervention) for VC, incompetence of the stump of the appendix, adhesive NK. The clinical picture of complications in these patients is growing rapidly and is manifested by symptoms of an acute abdomen. There is usually no doubt about the indications for RL in such patients. The so-called delayed RL (in the period of 4-7 days) are performed for single abscesses, partial adhesions, less often in individual cases of progression of peritonitis. In these patients, the indications for RL are based more on local abdominal symptoms that predominate over general reaction organism.

For the treatment of postoperative peritonitis caused by incompetence of the appendix stump after a midline laparotomy and its detection through a wound in the right iliac region, the dome of the SC should be withdrawn together with the stump of the appendix and fixed to the parietal peritoneum at the skin level; make a thorough toilet of the abdominal cavity with its adequate drainage and conducting fractional dialysis in order to prevent postoperative progressive peritonitis due to insufficiency of interintestinal anastomoses or sutured bowel perforation.

For this it is recommended [V.V. Rodionov et al, 1982] to use subcutaneous excretion of the intestinal segment with sutures, especially in elderly and senile patients, in whom the development of suture incompetence is most likely prognostically. This is done as follows: through an additional counter-opening, a segment of the intestine with a suture line is brought out subcutaneously and fixed to the opening in the aponeurosis. The skin wound is sutured with rare interrupted sutures. Point intestinal fistulas that develop in the postoperative period are eliminated in a conservative way.

Our many years of experience show that frequent reasonsInadequate revision and debridement, an incorrectly chosen method of draining the abdominal cavity, which lead to RL after uplendectomy. It is also noteworthy that quite often the surgical access during the first operation was small or was displaced relative to the McBurney point, creating additional technical difficulties. Performing technically difficult appendectomy under local anesthesia can also be considered a mistake. Only anesthesia with sufficient access allows for a full revision and sanitation of the abdominal cavity.

The unfavorable factors contributing to the development of complications include the lack of preoperative preparation for appendicular peritonitis, non-observance of the principles of pathogenetic treatment of peritonitis after the first operation, the presence of severe chronic concomitant diseases, elderly and old age... The progression of peritonitis, the formation of abscesses, and necrosis of the SC wall in these patients are due to a decrease in the general resistance of the organism, disorders of central and peripheral hemodynamics, and immunological changes. The immediate cause of death is the progression of peritonitis and acute CV failure.

In case of late admission aplendicular peritonitis, even a wide midline laparotomy under anesthesia with revision and radical treatment of all parts of the abdominal cavity with the participation of experienced surgeons cannot prevent the development of postoperative complications.

The reason for the development of complications is the violation of the principle of the expediency of combined antibiotic therapy, the change of antibiotics in the course of treatment, taking into account the sensitivity of the flora to them, and especially small doses.

Often neglected are other important points in the treatment of primary peritonitis: correction of metabolic disorders and measures to restore the motor-evacuation function of the gastrointestinal tract.
So, we come to the conclusion that complications in the treatment of appendicitis are mainly due to untimely diagnosis, late hospitalization of patients, inadequate surgical access, incorrect assessment of the prevalence of the pathological process, technical difficulties and errors during the operation, unreliable processing of the stump of the OR and its mesentery, and inadequate toilet and drainage of the abdominal cavity.

Based on the literature data and our own experience, we believe that the main way to reduce the incidence of postoperative complications, and, consequently, postoperative mortality in acute appendicitis, is to reduce the diagnostic, tactical and technical errors of operating surgeons.

Appendicitis is acute inflammation appendix (appendix). With appendicitis, in almost 100 percent of cases, an urgent surgeryand the earlier it is done, the better.

In acute appendicitis, the disease can be roughly divided into several stages. The first stage is. It lasts about 48 hours and is characterized by catarrhal changes in the walls of the appendix. There are usually no dangerous complications during this period.

Complications of appendicitis, which can lead to serious consequences and even death, appear with the second stage. It is called phlegmonous. It lasts from 2 to 5 days and is characterized by purulent fusion of the walls of the appendix. The phlegmonous stage passes into the gangrenous one. If during this time urgent surgical measures are not taken, then a lethal outcome becomes more and more likely. Spilled peritonitis with appendicitis occurs on the 5th day. At the same time, pylephlebitis and appendicular infiltration may appear. Appendicitis, in which the appendix ruptures, is called perforation.

Postoperative complications of acute appendicitis are associated with late appendectomy (consequences of delayed diagnosis). They can also be associated with the surgeon's mistakes during the appendectomy. Factors that increase the likelihood of complications - the patient has chronic diseases, old age, non-compliance with medical recommendations after surgery.

Retroperitoneal appendicitis can also be considered a complication. it clinical form acute appendicitis when the appendix is \u200b\u200bin the retroperitoneal space. In this situation, the greatest difficulty is the diagnosis of the disease. They occur in 1-2 percent of cases.

Early complications of acute appendicitis occur more quickly in children than in adults. The reason for this is the more rapid course of the disease. Appendicitis and peritonitis in children is especially difficult to diagnose before the age of three.

Preoperative complications

Destructive forms begin to appear in the appendix approximately 3 days after inflammation. This can result in melting of the walls and perforation (the common name is a rupture of appendicitis). Ultimately, this ends with peritonitis. Appendicitis with peritonitis is when the contents of the appendix, containing a large amount of pus and bacteria, flow into the abdominal cavity. Appendicular peritonitis is inflammation of the peritoneum, which is the membrane that lines the abdominal cavity.

Perforation can be identified by the following symptoms:

• Pain is felt in all areas of the abdomen;
• Tachycardia;
• Increased anxiety;
• Unhealthy earthy skin color;
• Facial features become sharpened;
• High body temperature;
• Stool retention.

Palpation shows positive Shchetkin-Bloomberg syndrome and distention. If peritonitis develops, an urgent operation is required. Before her, the patient is prescribed anti-shock and antibacterial drugs.

If suppuration occurs, the cause of which is a limited pathological process with peritonitis or the formation of an infiltrate, then an abscess is likely. If we talk about the preoperative period, then the abscess occurs approximately on the 10th day. Postoperative abscess is a consequence of limited peritonitis. An abscess requires compulsory treatment. Otherwise, it is opened and the abdominal cavity is filled with pus. The following symptoms indicate that the abscess has opened:

• An increase in the number of leukocytes in the blood;
• Intoxication;
• Fever;
• Deterioration of the general condition.

We list the areas where the likelihood of appendicular abscess is high. This is the Douglas pocket, the space between the intestinal loops, the right iliac fossa. If the place of detection of an abscess is a Douglas pocket, then several more are added to the symptoms described above. The already existing pain radiates to the perineum and rectum. Defecation becomes more frequent, which becomes painful. To clarify the diagnosis, it is necessary to conduct a rectal examination (in women, vaginal). Treatment of an abscess is surgical, that is, an opening and drainage is performed. Antibiotics are used during the treatment.

Appendicular infiltration

The appendix is \u200b\u200bsurrounded by other tissues and organs. The inflammatory processes taking place in it may well go beyond it and spread to the loops of the cecum, small intestine, oil seal and so on. As a result, mutual adhesion of all these structures occurs, which leads to the formation of an appendicular infiltrate. This education differs in density and soreness. Soreness is moderate, it is felt in the lower right abdomen. An appendicular infiltrate develops approximately on the third day after the first attack. This complication has 2 stages of development, on which the symptoms depend.

On early stage irritation of the peritoneum, intoxication, pain is characteristic. The late stage is also characterized by moderate pain, high fever, and mild leukocytosis. Palpation shows a solid swelling. There is pain on palpation, but not severe.

The operation to remove the appendix, if an appendicular infiltrate is found in the patient, cannot be done immediately, it must be postponed. Appendectomy with this complication is fraught with damage to the mesentery, omentum, bowel loop, since they are in adhesion with the appendix. If this happens, then the patient may die.

For the treatment of appendicular infiltrate, conservative methods are used and this is done in a hospital setting. This uses:

• Antibiotics that reduce inflammation;
• Anticoagulants that fight blood clots due to their blood-thinning action
• Physiotherapy;
• Pain relievers, including bilateral novocaine blockade;
• Cold is used to prevent further expansion of inflammation.

The patient needs compulsory bed rest and diet. The diet is to reduce the intake of food containing coarse fiber.

The further course of appendicular infiltration can have different manifestations. In the event of a favorable development of events, it can completely dissolve in a month and a half. Otherwise, additional complications occur - suppuration and abscess. In this case, the following symptoms are observed:

• Tenderness to palpation;
• Chills, tachycardia;
• Further development of intoxication;
• Body temperature can go beyond 38.

The most unfavorable development of events is when an abscess breaks into the abdominal cavity and causes appendicular peritonitis. But in 80 percent of cases, therapy is successful, the infiltrate resolves. An appendectomy can be done 2 months after that. It may also happen that the operation has already begun and the presence of an infiltrate is revealed. In this situation, the appendix is \u200b\u200bnot removed, but drainage is done, after which the wound is sutured.

Appendicular infiltration, as one of the types of complications of acute appendicitis in children, is most dangerous at a young age. In particular, this applies to conservative treatment methods, when using which you need to be very careful.

Complications after removal of appendicitis

Complication of acute appendicitis, which occurs after surgery, becomes the cause of the pathology internal organs and the wound itself. On these grounds, postoperative complications are divided into:

• Acute appendicitis is a complication of the organs of the urinary system. This concerns urinary retention, acute nephritis and cystitis are also possible;
• Complications affecting the respiratory system, heart and blood vessels. These are pulmonary abscess, pylephlebitis, thrombophlebitis, pulmonary embolism, pneumonia;
• From the gastrointestinal tract. After appendectomy, fistulas may form in the intestines, bleeding may appear. It is also possible to develop intestinal obstruction;
• Complications arising in the abdominal cavity. In this case, abscesses and infiltrates may form in various places of the abdominal cavity. In addition, in the postoperative period, the development of peritonitis, both local in nature and general, may occur;
• Late complications related to the postoperative wound. It can be a fistula, bleeding, infiltration, suppuration, dehiscence, hematoma.

If you strictly follow all medical recommendations, then most complications can be avoided. For example, if you avoid physical activity and do not follow a diet, then there is a high risk of intestinal obstruction. Wearing compression underwear is the prevention of thrombophlebitis. Thrombophlebitis is also prevented by the use of anticoagulants.

The most common complications of appendicitis are wound complications. At the same time, they represent the least danger. The fact that the wound does not heal, as it should be, is indicated by an increase in temperature and the appearance of a seal. Pus appears from the seam. In this case, the wound is treated again, drainage is used and antibiotics are prescribed.

Now we will describe the most dangerous complications of appendectomy.

Intestinal fistulas

Reasons for the appearance of intestinal fistulas after appendectomy:

• Pressure sores. Appear from the use of drains and tight tampons;
• Technical mistakes made during the operation;
• Inflammation passing to the intestinal loops with their subsequent destruction.

The development of intestinal fistulas is indicated by increased pain in the right iliac region. This manifests itself after a week (approximately) after the appendectomy. The development of intestinal obstruction is possible. In case of incomplete closure of the wound, the contents of the intestine may be released through the suture. If the wound is well sutured, then the intestinal contents enter the abdominal cavity, which causes purulent inflammation... To combat intestinal fistulas, there is only one method - surgical.

Pylephlebitis

One of the most unpleasant and dangerous consequences appendicitis is pylephlebitis. Pylephlebitis is the spread of purulent processes from the appendix to the portal vein of the liver. Since this vein has branches, ulcers appear in large numbers. This complication can occur both before and after appendectomy. In most cases, pylephlebitis is a postoperative complication. The timing of the onset of symptoms can also vary greatly. They can occur both on the third day after the operation, and one and a half months after it.

Pylephlebitis is manifested by the following symptoms:

• Enlargement of the spleen and liver;
• Pulse weakens, stops quickening;
• A sharp rise in temperature, fever;
• Pain radiating to the lower back and scapula in the right hypochondrium;
• The skin becomes pale, the face becomes jaundiced.

With the development of such a complication as pylephlebitis, the mortality rate is very high. The patient manages to save his life in rare cases. This is possible only if pylephlebitis is detected at an early stage. For pylephlebitis, anticoagulants and antibiotics are used, but the main method of treatment is surgery. Each abscess is opened and drained.

If complications have occurred with appendicitis, then the patient needs careful diagnosis and immediate treatment. Very often the patient's life depends only on the timeliness of the operation. To protect himself from the development of various complications, the patient should consult a doctor as early as possible.

Do's and don'ts after appendicitis

After appendectomy, a gentle exercise regimen must be observed. You should refrain from heavy loads for 3 months. If uncomplicated appendicitis has been operated on, then you can start walking 5 hours after the operation, and not only is it possible, but also necessary. It is also necessary to avoid getting water on the postoperative wound. You can swim completely only when the stitches are removed. After an appendectomy, it is best to abstain from sex for about a week.

Refers to diseases of the abdominal organs, characterized by a tendency to develop all kinds of complications. It is their presence that determines the unfavorable outcomes of appendectomies.

Complications are subdivided into preoperative and postoperative by periods of occurrence. Preoperative complications include appendicular infiltration, appendicular abscess, retroperitoneal cellulitis, peritonitis. Postoperative complications of acute appendicitis are classified according to the clinical and anatomical principle.

In terms of development, postoperative complications of acute appendicitis are divided into early and late. Early complications occur within two weeks of the date. This group includes most complications from the postoperative wound (purulent-inflammatory processes, dehiscence of the edges of the wound without or with eventration; bleeding from the wound of the anterior abdominal wall) and all complications from adjacent organs.

Late postoperative complications of acute appendicitis are diseases that develop after a two-week postoperative period. Among them, the most common are:

• From complications from the postoperative wound - infiltration, abscess, ligature fistula, postoperative, keloid scars, scar neuromas.
• From acute inflammatory processes in the abdominal cavity - infiltrates, abscesses, cultitis.
• From complications from the gastrointestinal tract - acute mechanical,.

The causes of postoperative complications of acute appendicitis are:

• Untimely treatment of patients for medical care.
• Late diagnosis of acute appendicitis (due to the atypical course of the disease, misinterpretation of the available clinical data typical for inflammation of the appendix).
• Tactical errors (lack of dynamic monitoring of patients with a dubious diagnosis of acute appendicitis, underestimation of the prevalence of the inflammatory process in the abdominal cavity, incorrect determination of indications for the abdominal cavity).
• Errors in the technique of the operation (tissue injury, unreliable vascular ligation, incomplete removal of the appendix, poor drainage of the abdominal).
• The progression of chronic or the emergence of acute diseases of adjacent organs.

The article was prepared and edited by: surgeon

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Developing acute appendicitis almost always requires an emergency surgical intervention, during which the inflamed vermiform appendix is \u200b\u200bremoved. Surgeons resort to surgery even if the diagnosis is in doubt. This treatment is explained by the fact that complications of acute appendicitis are sometimes so serious that they can be fatal. Operation - appendectomy minimizes the risk of some of the dangerous consequences of appendicitis for humans.

When complications can occur with appendicitis

Acute inflammation of the vermiform appendix in humans passes in several stages. Initially, catarrhal changes occur in the walls of the processes, usually they last for 48 hours. At this time, there are almost never serious complications. After the catarrhal stage, destructive changes follow, appendicitis from catarrhal can become phlegmonous, and then gangrenous. This stage lasts from two to five days. During this time, purulent melting of the walls of the appendix occurs and a number of dangerous complications may develop, this is perforation followed by peritonitis, infiltration and a number of other pathologies. If during this period there is no surgery, then there are other complications of appendicitis, which can be fatal. In the late period of appendicitis, which occurs on the fifth day from the onset of inflammation of the appendix, diffuse peritonitis develops, appendicular abscess and pylephlebitis are often detected.

Various complications are possible after the operation. The causes of postoperative complications are associated with an untimely operation, late diagnosis of acute appendicitis, and surgeon's mistakes. More often, pathological disorders after surgery develop in people of age, with a history of chronic diseases. Some complications can also be caused by non-compliance with the doctor's recommendations in the postoperative period.

Thus, complications in patients with acute appendicitis can be divided into two groups. These are those that develop in the preoperative period and develop after the operation. Treatment of complications depends on their type, the patient's condition and always requires a very careful attention of the surgeon.

Complications of appendicitis in the preoperative period

The development of complications before the operation in most cases is associated with the untimely treatment of a person in medical institution... Less often, pathological changes in the appendix itself and the structures surrounding it develop as a result of improperly selected tactics of managing and treating a patient by a doctor. The most dangerous complications that develop before surgery include diffuse peritonitis, appendicular infiltrate, inflammation of the portal vein - pylephlebitis, abscess in different parts of the abdominal cavity.

Appendicular infiltration

An appendicular infiltrate occurs due to the spread of developing inflammation to organs and tissues located next to the appendix, this is the omentum, loops of the small and cecum. As a result of inflammation, all these structures are soldered together, and an infiltrate is formed, which is a dense formation with moderate pain in the lower, right part of the abdomen. A similar complication usually occurs 3-4 days after the onset of an attack, its main symptoms depend on the stage of development. At an early stage, the infiltration is similar in signs to destructive forms of appendicitis, that is, the patient has pain, symptoms of intoxication, signs of irritation of the peritoneum. After an early stage, a late one comes, it is manifested by moderate soreness, slight leukocytosis, an increase in temperature to 37-38 degrees. On palpation in the lower abdomen, a dense tumor is determined, which is not distinguished by severe pain.

If the patient has an appendicular infiltrate, the appendectomy is postponed. This approach to treatment is explained by the fact that when removing the inflamed appendix, the intestinal loops, omentum, mesentery soldered to it can be damaged. And this, in turn, leads to the development of postoperative complications that are life-threatening to the patient. Appendicular infiltrate is treated in a hospital conservative methods, they include:

• Antibacterial drugs. Antibiotics are essential to reduce inflammation.
• Using cold to limit the spread of inflammation.
• Pain medications or bilateral blockade with novocaine.
• Anticoagulants are drugs that thin the blood and prevent blood clots.
• Physiotherapy with absorbing effect.

Throughout the treatment, patients must follow strict bed rest and diet. It is recommended to consume less foods with coarse fiber.

Appendicular infiltration can further manifest itself in different ways. With a favorable variant of its course, it dissolves within a month and a half, with an unfavorable one, it suppurates and is complicated by an abscess. In this case, the patient has the following symptoms:

• An increase in body temperature to 38 degrees and above.
• The increase in symptoms of intoxication.
• Tachycardia, chills.
• The infiltration becomes painful on palpation of the abdomen.

An abscess can break into the abdominal cavity with the development of peritonitis. In almost 80% of cases, the appendicular infiltrate resolves under the influence of therapy, and after that the planned removal of the appendix is \u200b\u200bshown after about two months. It also happens that infiltration is detected when an operation is performed for acute appendicitis. In this case, the appendix is \u200b\u200bnot removed, but drainage is performed and the wound is sutured.

Abscess

Appendicular abscesses occur as a result of suppuration of an already formed infiltrate or when the pathological process is limited in peritonitis. In the latter case, an abscess most often occurs after surgery. A preoperative abscess is formed about 10 days after the onset of the inflammatory reaction in the appendix. Without treatment, the abscess may open, and the purulent contents are released into the abdominal cavity. The following symptoms indicate the opening of the abscess:

• Rapid deterioration in general health.
• Feverish syndrome - fever, periodic chills.
• Signs of intoxication.
• In the blood, the growth of leukocytes.

An appendicular abscess can be found in the right iliac fossa, between the intestinal loops, retroperitoneally, in the Douglas pocket (rectal-vesical cavity), in the subphrenic space. If the abscess is in the Douglas pocket, then symptoms such as painful, frequent stools, irradiation of pain into the rectum and perineum join the general signs. To clarify the diagnosis, rectal and vaginal examinations in women are also carried out, as a result of which an abscess can be found - an infiltrate with incipient softening.

Abscess is treated surgically, it is opened, drained and further antibiotics are used.

Perforation

On 3-4 days from the onset of inflammation in the appendix, its destructive forms develop, leading to melting of the walls or to perforation. As a result, the purulent contents, along with a huge number of bacteria, enter the abdominal cavity and peritonitis develops. Symptoms of this complication include:

• The spread of pain in all parts of the abdomen.
• The temperature rises to 39 degrees.
• Tachycardia over 120 beats per minute.
• Outward signs are sharpening of facial features, sallow skin tone, anxiety.
• Retention of gas and stool.

On palpation, swelling is detected, the Shchetkin-Blumberg symptom is positive in all departments. With peritonitis, an emergency operation is indicated; before the surgical intervention, the patient is prepared by the introduction antibacterial agents and anti-shock drugs.

Postoperative complications in patients with acute appendicitis

Postoperative complicated appendicitis leads to the development of pathologies from the wound and internal organs. Adopted complications after surgery are divided into several groups, these include:

• Complications identified from the sutured wound. These are hematoma, infiltration, suppuration, dehiscence of the edges of the wound, bleeding, fistula.
• Acute inflammatory reactions from the abdominal cavity. Most often these are infiltrates and abscesses that form in different parts of the abdominal cavity. Also, after surgery, local or general peritonitis may develop.
• Complications affecting the digestive tract. Appendectomy can lead to intestinal obstruction, bleeding, fistula formation in different parts of the intestine.
• Complications from the heart, blood vessels and the respiratory system. In the postoperative period, some patients develop thrombophlebitis, pylephlebitis, pulmonary embolism, pneumonia, abscesses in the lungs.
• Complications from the urinary system - acute cystitis and nephritis, urinary retention.

Most of the complications of the postoperative period are prevented by following the doctor's recommendations. For example, intestinal obstruction can occur if the diet is not followed and under the influence of insufficient physical activity. Thrombophlebitis is prevented by the use of compression garments before and after surgery, the introduction of anticoagulants.

Complications of acute appendicitis from the wound are considered the most frequent, but at the same time the safest. The development of pathology is judged by the appearance of a seal in the wound area, an increase in the general and local temperature, and the release of pus from the seam. Treatment consists in re-treatment of the wound, in the introduction of drainage, the use of antibiotics.

The most severe complications after surgery include pylephlebitis and intestinal fistulas.

Pylephlebitis

Pylephlebitis is one of the most severe complications of acute appendicitis. With pylephlebitis, a purulent process from the appendix extends to the portal vein of the liver and its branches, as a result of which numerous abscesses form in the organ. The disease develops rapidly, it may be the result of untreated acute appendicitis. But in most patients it is a complication of appendectomy. Symptoms of the disease can appear both 3-4 days after the operation, and after a month and a half. The most obvious signs of pylephlebitis include:

• A sharp jump in body temperature, chills.
• The pulse is fast and weak.
• Pain in the right hypochondrium. They can radiate to the scapula, lower back.
• Enlargement of the liver and spleen.
• The skin is pale, the face is sunken with an icteric color.

With pylephlebitis, a very high mortality rate, rarely the patient can be saved. The outcome depends on how time this complication is detected and the operation is performed. During surgery, abscesses are opened, drained, and antibiotics and anticoagulants are administered.

Intestinal fistulas

Intestinal fistulas in patients with appendectomy occur for several reasons. This is most often:

• Inflammation spreading to the intestinal loops and their destruction.
• Non-observance of the operation technique.
• Pressure ulcers that develop under pressure from tight tampons and drains used during surgery.

The development of intestinal fistulas can be judged by increased pain in the right iliac region about a week after removal of the inflamed appendix. There may be signs of intestinal obstruction. If the wound is not completely sutured, then intestinal contents are released through the seam. It is much more difficult for patients to endure the formation of a fistula with a sutured wound - the contents of the intestine penetrate into the abdominal cavity, where purulent inflammation develops. The resulting fistulas are removed surgically.

Complicated appendicitis requires careful diagnosis, detection of pathological changes and prompt treatment. Sometimes the patient's life depends only on a timely emergency operation. Experienced surgeons can already assume the risk of complications after appendectomy based on the age of the patient, whether he has a history of chronic diseases, such as diabetes... Adverse changes often occur in obese patients. All these factors are taken into account both in the preoperative and postoperative period.

It is possible to minimize the possible number of complications only through timely access to a doctor. Early surgery is prevention of a group of the most serious complications and shortens the recovery period.