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Diffuse appendicular peritonitis

This video demonstrates an emergency appendectomy in a case of perforated gangrenous appendix with diffuse peritonitis. The surgeon demonstrates safe mobilization of bowel loops and identification of appendix before division of meso-appendix and resection of the appendix. The peritoneal cavity is thoroughly lavaged with saline and drains are inserted. This video demonstrates how to deal with a severe case of perforated appendicitis with diffuse purulent peritonitis.

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Diffuse   appendicular   peritonitis

作者群
B Navez
摘要
This video demonstrates an emergency appendectomy in a case of perforated gangrenous appendix with diffuse peritonitis. The surgeon demonstrates safe mobilization of bowel loops and identification of appendix before division of meso-appendix and resection of the appendix. The peritoneal cavity is thoroughly lavaged with saline and drains are inserted.
This video demonstrates how to deal with a severe case of perforated appendicitis with diffuse purulent peritonitis.
分類
complex cases
關鍵字
Perforated appendix, gangrenous, peritonitis, emergency,
媒體類型
期間
12'00''
刊物
2001-10
普通的
最愛
Favorites Media
音訊
en
副標題
en
數位出版
WeBSurg.com, Oct 2001;1(10).
URL: http://www.websurg.com/doi-vd01en1103e_1.htm

Diffuse   appendicular   peritonitis

1. Case presentation 00'14''
Laparoscopy can be very useful for the diagnosis and management of peritonitis. In fact, in addition to confirmed preoperative diagnosis of peritonitis, the laparoscopic approach has the advantage of avoiding laparotomy and its related risk of ventral hernias. The 1st step of the operation is the confirmation of diagnosis. In this case, as you can see, we have a diffuse peritonitis with pus in all abdominal quadrants and inflammatory adhesions between bowel loops. Peritoneal food needs to be evacuated to avoid formation of intra-abdominal abscess. In this case, inflammatory adhesions within caecum, omentum, and distal small bowel caused by acute appendicitis need to be carefully taken down. This is accomplished by the use of atraumatic fenestrated graspers and by gently using the irrigation suction cannula itself. However, extensive irrigation of the abdominal cavity is required. Irrigation and suction in fact reduces the contents of bacteria and toxin and fibrin and can possibly reduce the risk of bacterial translocation, which is a potential occurrence under the high abdominal pressure created by the pneumoperitoneum. We always perform bacteriological analysis on the peritoneal fluid. This is obtained by using a Veress needle percutaneously. Antibiotic therapy initially including first generation cephalosporins and metronidazole might be later modified according to the antibiograms. The inflammatory phlegmon must be separated from the abdominal wall in order to expose the appendix. The inflamed mesentery of the appendix can be attached posteriorly: this makes dissection difficult and delicate. In particular, care should be taken to avoid tearing the mesentery during this step. In this case, you can clearly see necrosis and perforation of the middle portion of the appendix. Dissection of the meso-appendix should be started at the tip of the organ and all small branches of the artery can be coagulated by electrocautery in close proximity to the wall of the appendix. The hook can be very useful for this step of the operation. Dissecting the mesentery of the appendix close to the wall of the organ has 2 potential benefits: the 1st is that it allows a bare extraction of the specimen and also it reduces the risk of significant bleeding since all the small distal branches of the artery can be injured. However, in case significant bleeding occurs, bipolar coagulation can be effectively used. It’s important to develop the plane between the caecum at the base of the appendix. Sometimes, the base of the appendix is located deep in the inflammatory thickened tissue. We use to place a ligature at the base of the appendix by using an Endoloop device. Caution must be taken at this point because the Endoloop may possibly cut through the bowel wall. If this occurs, intracorporeal suturing is required for fixation. The specimen is then extracted through an extraction tube. In this case, we prefer to divide the appendix in two: this allows easier extraction and helps to decrease the risk of abdominal wall contamination. After appendectomy is completed, a 2nd lavage is performed until the fluid comes clear. Six to 8 litres of saline solution can sometimes be necessary as shown in this case. The distal ileum is exposed in order to rule out the presence of a Meckel’s diverticulum. An additional lavage is now initiated. Extensive irrigation should be performed both in the left and right subphrenic spaces as well as in the pelvis. It is not necessary to remove all fibrin tissue since this may cause bleeding from the friable peritoneal surface. However, suction irrigation cannulas under aspiration may aid in removal of fibrin tissues that detach easily as shown here. At the end of the operation, the greater omentum is returned in its normal anatomic position over the small bowel. One or 2 silicone drains are introduced through the trocars and placed in the pouch of Douglas and in the right paracolic gutter. Drains are removed in 24 to 48 hours postoperatively.