ACUTE APPENDIX Completed: Bogonina O.V. Associate Professor of the Department "Maxillofacial Surgery," k.m.s. - презентация

1 ACUTE APPENDIX Completed: Bogonina O.V. Associate Professor of the Department "Maxillofacial Surgery," k.m.s.

2 Definition and prevalence OA - inflammation of the worm-like process of the blind intestine, one of the most common surgical diseases. The incidence of acute apptraditiitis is 4-5 people per 1000 population. The most common acute appendix occurs between the ages of 20 and 40, women are ill 2-3 times more often than men. Lethality is %, postoperative complications - 5-9%.

3 History It is generally accepted that the first appendectomy was performed in 1884 by Kronlein. This date is noted in all the manuals and serves as a starting point for the historical review of the appendix. Only in 1953 it turned out that the first successful appendectomy was performed much earlier. In the works of the English scientist of the first half of the 18th century, Glaudis found an indication that in 1735 he operated on an 11- year-old boy for a scrotum hernia complicated by a fistula. He managed to establish that the fistula comes from a worm-like process, the breakdown of which is caused by a pin. He removed the process, leaving a long stump bandaged with ligature, and made hernioplasty with a successful outcome. Thus, 280 years have passed since the first appendectomy, undertaken, however, not by a reasonable diagnosis, but in connection with an accidental operational find.

4 Anatomy The worm-like process is a direct continuation of the blind intestine. It is located at the confluence of three longitudinal tapes (tendencies). Its length varies within very wide limits. On average, it is 7-10 cm. The appendix has its own mesentery, the same duplicate of the peritoneum in which the vessels and nerves pass. Blood supply of the blind intestine and the worm-like process is carried out by the ilium-colon artery, the final branch of the upper mesenteric artery.

5 Physiology Most researchers consider it a peculiar amygdala of the gastrointestinal tract, since it contains a large amount of lymphoid tissue in the mucosa. Lymphoid tissue is most developed in childhood, especially at years old. Since the age of 30, the number of follicles decreases significantly, and by the age of 60 they completely disappear.

6 Options for the location of the Allen appendix: pelvic in the right iliac fossa medial retrotsekalny

7 Options for the location of the Allen appendix: under terminal section of the ileum lateral

8 Appendix Layout Options In addition, they distinguish: Cervical - most often in pregnant women in the III trimester, but also occurs in other categories of patients Left-hand - situs viscerum inversus in Kartagerner syndrome

9 ETIOLOGY AND PATHOGENESIS The causes of acute apptraditiitis have not yet been fully studied. To explain the mechanisms for the development of inflammation in the worm-like process, many theories have been proposed. The main theories are: Infectious; Neurovascular; Contributing factors: Obturation (stone, worms, etc.) GI diseases

10 ETIOLOGY AND PATHOGENESIS Infectious theory: Proponents of infectious theory consider the main cause of acute inflammation of the worm-like process to be a polymicrobial infection living in a healthy intestine (E. coli, staphylococcus, streptococcus). At the same time, a significant place is given to predisposing moments, of which injuries to the mucosa of the process by foreign bodies, feces, pieces of solid food, intestinal parasites, as well as intestinal atonia, changes in body reactivity, etc. All this undeniably leads to violations of the barrier function of the epithelium of the mucosa of the worm-like process and the penetration of microorganisms into it.

11 ETIOLOGY AND PATHOGENESIS Neurovascular theory: Proponents of neurovascular theory believe that at first there is reflex disorders of regional blood flow in the process (vascular spasm, ischemia), and then thrombosis of feeding vessels, leading to trophic disorders in the wall of the process, up to necrosis. Some researchers attach importance to the allergic factor. This theory is supported by a significant amount of mucus and Charcot-Leiden crystals in the lumen of the worm-like process.

12 ETIOLOGY AND PATHOGENESIS Modern views: The process begins with functional disorders from the ileocecal angle (bauginospasm), the blind intestine and the worm-like process. Spastic phenomena are caused by digestive disorders (increased rotten processes in the intestine, atonia, etc.), as a result of which the colon and worm-like process are poorly emptied. Foreign bodies, rock stones, worms in the process can provoke spasm. Spasm of smooth muscle of the process also leads to regional vascular spasm and local violation of mucosal trophics (primary Aschoff effect).

13 ETIOLOGY AND PATHOGENESIS Modern views: Disruption of evacuation, stagnation of intestinal contents contribute to an increase in the virulence of the intestinal microflora, which, in the presence of a primary effect, easily penetrates the wall of the process and causes a typical inflammatory process in it. First, leukocytic impregnation of only the mucosa and submucous layer, and then all layers of the worm-like process, occurs. Infiltration is also accompanied by restructuring of lymphoid tissue (hyperplasia). The occurrence of ischemia and necrosis zones contributes to the formation of pathological enzymes (cytokinase, kallikrein, etc.) with high proteolytic activity, which leads to further destruction of the process wall, up to its perforation and the development of purulent peritonitis.

14 Classification The following forms of acute appendix are distinguished: 1) simple (cataral); 2) destructive: a) phlegmonous, b) gangrenous, c) gangrenous perforation; 3) OA complications: a) appendix infiltrate b) appendix abscess, c) purulent peritonite, d) other complications of acute appendix (sepsis, pileflebitis, etc.).

15 Acute simple (cataralic) appendix

16 Acute phlegmonotic appendix

17 Acute Gangrenous Appendi

18 Gangrene Perforation Appendix

19 CLINIC Acute appendix is characterized by a certain symptom complex, which depends on a number of causes: time elapsed from the moment of illness localization of process the nature of pathomorphological changes both in the process itself and in the abdominal cavity age of the patient the presence of concomitant pathology and physical state of the organism.

20 CLINIC The disease begins suddenly, among complete well- being, without a prodromal period. The most persistent symptom is abdominal pain, which is usually constant. The location of pain at the beginning of the disease is unstable. Most often, it appears immediately in the right iliac region, but can occur in epigastria (Koher's symptom) or in the parotid region (Kümmel's symptom) and only after a few hours move to the right iliac region. In some cases, the clinical picture of acute appendix develops very rapidly, the pain is not localized, but occurs immediately throughout the abdomen.

21 CLINIC Another important symptom is vomiting. It is observed in about 40% of patients and is reflex in the initial stages of the disease. Vomiting is more often a single. Nausea, as a rule, occurs after pain and is wave-like in nature. Sometimes there is stool delay, a decrease in appetite, but there may be a single diarrhea, which increases with the retrocecal or pelvic arrangement of the inflamed process and can serve as a pathognomonic symptom of atypical forms of the disease. Urinary disorders are rare and can be associated with unusual localization of the process (adjacent to the kidney, ureter, bladder). The temperature reaction depends on the form of the disease and the presence of complications (from subfebrile, febrile, rarely hektic).

22 CLINIC The main symptoms are: Mendel's symptom - soreness in the right iliac region when shaking a finger on the abdominal wall Markel symptom - increased soreness in the right iliac region with a sharp lowering of the patient from socks to heels

23 CLINIC Razdolsky symptom - with superficial palpation, it is possible to identify a zone of hyperesthesia in the right iliac region Rovzing symptom - the examining doctor with his left hand presses on the abdominal wall in the left iliac region according to the location of the descending colon; without taking away the left hand, the right one produces a short push on the anterior abdominal wall on the overlying section of the colon. With a positive symptom, the patient feels pain in the right iliac region.

24 CLINIC The main symptoms are: Voskresensky's symptom (or shirt symptom) - the doctor, located to the right of the patient, pulls his shirt with his left hand, and slips on it with his right fingertips from the substrate area towards the right iliac. At the end of sliding, the patient feels sharp pain (the symptom is considered positive). Sitkovsky-Patient symptom is laid on the left side. The increase or occurrence of pain in the right iliac region is characteristic of acute apptraditiitis.

25 CLINIC The main symptoms are: The Bartomier-Michelson symptom is an increase in soreness during palpation of the right iliac region when the patient is on the left side. Krymov's symptom is soreness when examining the peritoneum with the tip of the finger through the outer opening of the right inguinal ring.

26 CLINIC * The main symptoms are: Dumbadze symptom - the appearance of soreness when examining the peritoneum with the tip of the finger through the navel. The symptom of Yaure-Rozanov is used to diagnose apptraditiitis in the retrocecal arrangement of the process: when pressed with a finger in the area of the lumbar triangle of Pty, soreness appears.

27 CLINIC The main symptoms are: Cope's symptom - when the appendix is located near the internal constipation muscle, the appearance of pain in the ileocecal area when the right thigh is unbended in the hip joint

28 Symptom of Cope

29 Psoas symptom (Obraztsov symptom)

30 CLINIC The main symptoms are: A rectal (in men) or vaginal (in women) study is important in the recognition of acute apptraditiitis. They should be produced by all patients and aim to determine the sensitivity of the pelvic peritoneum (Douglas cry) and the condition of other pelvic organs, especially in women. The Shchetkin-Blumberg symptom is caused by slow pressing of the fingers on the abdominal wall and rapid twitching of the hand. At the time of removal of the hand, acute localized pain appears due to irritation of the inflamed peritoneum.

31 Peculiarities of clinical course The following categories of patients are distinguished, in which clinical course features are observed: Children Elderly patients Pregnant women

32 PECULIARITIES OF ACUTE APPENDIX IN CHILDREN Acute appendix in children occurs at any age, and its current features are due to the reduced resistance of the peritoneum to infection, the small size of the gland, as well as the increased reactivity of the child's body. In this regard, acute appendix in children is severe, the disease develops faster than in adults, with a large percentage of destructive and perforating forms.

33 PECULIARITIES OF ACUTE APPENDIX IN CHILDREN rapid onset of disease; high temperature ° С; cramped abdominal pains; multiple vomiting, diarrhea; pulse frequency often does not correspond to T °C; rapid development of destructive changes in the worm-like process; pronounced symptoms of intoxication; frequent development of spilled peritonitis.

34 FEATURES OF ACUTE APPTRADITIITIS IN THE ELDERLY erased course of disease due to body areactivity and concomitant diseases; temperature is more often normal, its rise to 38 ° C and higher is observed in a small number of patients abdominal pain is insignificant; protective muscle stress is absent or weak; rapid development of destructive, changes in the worm- like process (due to vascular sclerosis), slight increase in blood leukocyte count, moderate leukocyte formula shift to the left even in destructive forms.

35 PECULIARITIES OF ACUTE APPENDIX IN PREGNANT WOMEN In the first half of pregnancy, manifestations of acute appendix do not differ from its usual manifestations

36 PECULIARITIES OF ACUTE APPENDIX IN PREGNANT WOMEN In the second half of pregnancy, the localization of pain and soreness changes (displacement of the blind intestine and the worm-like process with an enlarged uterus). The disease often begins suddenly with the appearance of acute abdominal pains that are constant, nausea and vomiting. Due to the change in the localization of the appendix, abdominal pain can be determined not only in the right iliac region, but also in the right lateral flange of the abdomen, the right undergrowth and even in the epigastric region. Muscle tension is not always detected, especially in the last third of pregnancy, due to pronounced overextension of the anterior abdominal wall. Of the pain symptoms, the most diagnostic value are the symptoms of Shchetkin-Blumberg, Voskresensky, Rozdolsky. Leukocytosis in acute appendix in pregnant women in most cases /L, often with a left shift.

37 DIAGNOSTICS Carefully collect, detail patient complaints and history of the disease. Identification of symptoms characteristic of acute apptraditiitis (palpation, abdominal percussion). Rectal and vaginal studies. Laboratory research. Exclusion of diseases simulating acute abdominal pathology

38 Laboratory studies Minimal laboratory studies suggesting a diagnosis of acute apptraditiitis include: general blood test general urine analysis determination of neutrophil-leukocyte coefficient (nf/lc) Calf-Kalif leukocyte intoxication index.

39 Laboratory studies Leukocytosis is characteristic of all forms of acute appendix and is of no pathognomonic importance, since it is also observed in other inflammatory diseases. It should only be considered and interpreted together with clinical manifestations of the disease. A more significant diagnostic value is the assessment of the leukocyte formula (the presence of NF shift - the appearance of young forms, an increase in the nf/lc coefficient of more than 4 indicates a destructive process). During the development of the destructive process, a (sometimes very significant) decrease in the number of white blood cells can be observed compared to the norm with the predominance of PJ NF and other young forms. This indicates a pronounced strain on the hematopoietic system. This phenomenon is called "leukocytosis of consumption."

40 Rectal study

41 Instrumental research RG OBP ULTRASONOGRAPHY KT Laparoscopy NB! These methods are used only in questionable cases, including for differential diagnosis and exclusion of other diseases that simulate acute apptraditiitis

42 Instrumental diagnostics The radiography of OBP makes it possible in some cases to diagnose OA and exclude other acute surgical diseases.

43 USE

44 CT

45 DIFFERENTIAL DIAGNOSIS Acute appendix should be differentiated with acute surgical pathology of abdominal organs and retroperitoneum. This is caused by the significant variability in the location of the worm-like process in the peritoneum cavity, often by the absence of a typical clinical picture of the disease.

46 DIFFERENTIAL DIAGNOSIS Acute pancreatitis Acute cholecystitis Gastric or duodenal perforation Acute intestinal obstruction Impaired ectopic pregnancy Twisted cyst or ovarian rupture Acute adnexite Crohn's Disease Meckel diverticul perforation or Meckel diverticullite. Lerner's developing hernia Right-handed renal colic Food toxicoinfection Acute mesenteric lymphadenitis Acute pleuropnevonia Myocardial infarction (abdominal form)

47 SURGICAL TREATMENT All patients with an established diagnosis of acute apptraditiitis, regardless of the time elapsed from the onset of the disease, are subject to surgical treatment. A significant delay in surgery, even with a relatively mild course of the disease, poses a danger of developing severe complications, up to death.

48 Preoperative preparation Preoperative training in most patients with acute apptraditiitis should be minimal. It comes down to the exclusion of writing and water through the mouth before surgery, as well as shaving the anterior abdominal wall and pubis. All patients with suspected acute apptraditiitis are forbidden to prescribe laxatives, Donbass and hot belly. In destructive appendicytes with peritonitis phenomena, expressed intoxication, hypovolemia, impaired water-electrolyte balance and hemodynamics, complex intensive therapy is shown, the volume and character of which are individual in each particular case. It should be continued during the operation and in the postoperative period until the patient is completely removed from the serious condition.

49 SURGICAL TREATMENT Operative treatment is not indicated in two categories of patients: with a well-delimited appendicular infiltrate having no tendency to abscedise; with weakly expressed appendix, the so-called "appendix colic." In this case, if there is a normal body temperature, normal white blood cell content, the patient is observed for 4- 6 hours with the necessary research methods (laboratory, radiological, instrumental, etc.).

50 SURGICAL TREATMENT Accesses: Oblique variable incision in the right iliac region (according to McBurney, according to Volkovich-Dyakonov) Lennander Paramedic Laparoscopic Median-median laparotomy

51 SURGICAL TREATMENT Methods of interventions: Typical appendectomy Retrograde appendectomy

52 The incision is made perpendicular to the line drawn from the anterior iliac bone (SIAS) to the umbilical cord, through the outer third.

53 Retrograde appendectomy technique

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57 Laparoscopic appendectomy

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61 NOTES – Natural Orifice Translumenal Endoscopic Surgery Endoscopic transluminal surgery through natural holes Transgastralny Transvaginal Transrectal Chrezmochepuzyrny Combined

62 Surgical system daVinci

63 Postoperative period bedding is prescribed for hours, cold is applied to the wound, painkillers are prescribed for 1-2 days. In the absence of complications in the abdomen, the peristalsis of the intestine is restored on day 2-3. Drinking and liquid writing are allowed after 8-12 hours in the absence of dyspeptic disorders with a gradual expansion of the diet by the 7th-10th day. Antibiotics are administered for complications, most often for destructive forms.

64 PERITONITIS

65 Frequency per 100,000 Complicates % of all acute surgical and gynecological diseases Lethality %

66 Peritoneum cavity

67 Peritoneum Cavity Sections Верхний этаж Нижний этаж Полость малого таза Right Subphragmic Space Undercarriage space Left Subphragmic Space Gland bag Right side channel Left side channel Right mesenteric sine Left mesenteric sine

68 Etiological classification Primary (bacterial) Hematogenic Metastatic Cryptogene Secondary Bacterial (nonspecific) Bacterial (specific) Aseptic (chemical) Acute peritonitis

69 Classification by nature of exudate Serous peritonitis Fibrinose peritonitis Purulent peritonitis

70 Classification by prevalence 1. Local peritonitis Limited (inflammatory infiltrate, abscess) Unlimited 1. Common peritonitis Diffuse (more than 2, less than 5 regions) Poured

71 Phases of peritonite flow 1. Reactive 2. Toxic 3. Terminal

72 Major pathogenetic syndromes in peritonitis Water-Electrolyte Disorders and KOS Disorders Syndrome Protein disorder syndrome Endogenous intoxication syndrome Enteral insufficiency syndrome

73 Causes of protein disorders 1. Activating a catabolism-biased exchange 2. Peritoneum losses 3. Intestinal lumen loss 4. Ensuring reparative processes 5. Urine loss

74 Major pathogenetic syndromes in peritonitis Water-Electrolyte Disorders and KOS Disorders Syndrome Protein disorder syndrome Endogenous intoxication syndrome Enteral insufficiency syndrome

75 Phases of peritonite flow 1. Reactive 2. Toxic 3. Terminal

76 Secondary peritonite flow types Peritonitis during perforation of hollow organ Peritonitis in acute inflammatory abdominal disease Bile peritonitis Postoperative peritonitis

77 Significance of peritonitis symptoms Pain100% Abdominal wall stress85% Tachycardia76,5% Hyperthermia75% Blumberg-Shchetkin symptom66% Dry language55% Vomiting54% Meteorizm22% Thoracic breathing typ21% Hiccups10%

78 Principles of peritonitis treatment Early hospitalization; Early operation including: elimination of peritonitis sources; thorough abdominal rehabilitation; abdominal drainage; readings - decompression of small intestine; Comprehensive intensive postoperative therapy comprising: rational antibacterial therapy; detoxification therapy; correction of homeostasis disorders; treatment and prevention of enteral insufficiency.

79 Steps of peritonitis operation Operational access; Elimination of peritonite source; Evacuation of exudate and abdominal toilet; Blind wound suturing or introduction of drains or tampons into the abdominal cavity.

80 Abdominal drainage options

81

82 Indications for small intestine drainage Bowel paresis; Resection of the intestine or suturing of the opening in its wall under conditions of paresis and spilled peritonitis; Postoperative or progressive peritonitis; Toxic phase of peritonitis

83 Laparostomy readings Late relaparotomies in postoperative peritonitis; Eventration in advanced peritonitis through purulent wound; Common peritonitis in late stage disease; Common peritonitis, accompanied by necrosis of the abdominal organs and retroperitoneal space; Anaerobic peritonitis.

84 " Without many worries and troubles, it is impossible to cure the patient with spilled peritonitis" И.И.Греков