阑尾切除术

nullnull阑尾切除术 Appendectomy主讲 刘栋才副教授nullSTRESSES AND DIFFICULTIES ●Local anatomy of appendix. ●Basic conception: McBurney point. ●Complications of acute appendicitis.null第一部分 阑尾的外科解剖 PartⅠ: Surgical anatomy of appendix null ◆General Conciderations. ◆ Anatomic Position of Appendix. ◆McBurney point. ◆Mesoappendix.null● positions of the appendix ● local anatomy of the appendixnull●vessels of the appendixnull● Essentials of Detecting Appendix: ①the Taeniae of the Colon converge at the Base of the Appendix. ②Approximately 2.5cm Below the ileocecal Valve. nullACUTE APPENDICTTIS: Essentials of Diagnosis: ●Abdomial pains. ●Anorexia, nausea and vomiting. ●Localized abdominal tenderness. ●Low-grade fever. ●Leukocytosis. nullDIFFERENTIAL DIAGNOSIS: ●Mesenteric Lymphadentitis. ●Ureteral or Renal Calculi. ●Female Pelvic Disorders: ＆A ruptured ovarian follicle. ＆pelvic inflammatory disease. ＆Twisted ovarian cyst. ＆Ectopic pregnancy. ●Other Acute Surgical Emergencies.null第二部分 阑尾切除术 Appendectomy ◆ Acute Simple Appendicitis. ◆ Acute Suppurative or Gangrenous appendicitis . ◆ Acute Perforating Appendicitis. ◆ Chronic Relapsing Appendicitis. ◆ Acute Simple Appendicitis. ◆ Acute Suppurative or Gangrenous appendicitis . ◆ Acute Perforating Appendicitis. ◆ Chronic Relapsing Appendicitis. Indicationsnull◆ Periappendiceal Abscess. ◆ Benign Tumor of the Appendix. ◆ Carcinid of the Appendix(<2cm)。 ◆ Appendicolithiasis.null●A history of more than 3 days’ duration. ●A right iliac swelling which is almost certainly an appendix abscess.Contra-indications ●B-US—Young woman. ●Fluid therapy. ●Intravenous Antibiotics. ●Nasogastric suction. ●B-US—Young woman. ●Fluid therapy. ●Intravenous Antibiotics. ●Nasogastric suction. Preoperative Management ●Local or General anaesthesia. Epidural Anaesthesia. ●Lie Supine. ●Local or General anaesthesia. Epidural Anaesthesia. ●Lie Supine.Anaesthesia and position of patientnullNormal appendixInflamed appendixnullChoice of incision: ＊Position of Inflamed Appendix— Maximum Tenderness. ＊Diagnosis. ＊Accompanied by Other Disease. ＊Diffuse Peritonitis. null◆Common Incision: McBurney 麦氏切口脐Advantages: ＊ no muscle-cutting, tendency to close up spontaneously. incisional hernial. ＊no injury to major vessels and nerves. ＊incision consistent with projection point of the appendix. ＊extend to midline ,and beneficial to remove pelvic appendix.nullDisadvantages： ＊the worse approach to retrocaecal appendix. ＊Disadvantageous to adequate exploration. ＊In the presence of peritonitis or dubious diagnosis. A right Midline or paramedian incision to be performed. ＊Incision across the skin-lines—discontent with cosmetic results. nullOther incisions: ＊Transverse Incision: the best approach to the inflamed appendix and the most satisfactory cosmetic. Especially to the retrocaecal appendix and fatty. ＊Right Paramedian Incision: adapt to the presence of peritonitis or dubious diagnosis, but wound infection can form easily incisional hernia. nullIncising the external oblique aponeurosis.2.Incising the internal oblique insertion.Technic of appendectomynull 3. Splitting internal oblique and transversus abdominis. Technic of appendectomy4. Incising the peritoneumnullTechnic of appendectomy5.the mesoappendix and vessels is divided. purse-string sture.null 7.Ligation and invagination of appendix stump. Technic of appendectomy``Operative Care＊When the Diagnosis is in Doubt: Abdominal Cavity Exploration. ①Peritoneal Cavity(gas, foods, bile etc.)— Stomach, Duodenum and Gollbladder. ②Female (Bloody Fluid in Peritoneal Cavity) Ovarian and Salpingion. ③Appendix is normal—Examining the Last 100cm of the Ileum.◆Activity in Early—Prevent Intestinal Adhesion. ◆Normal Intestinal Activity—Oral Fluids. ◆Perforated Appendicitis—According to Principals of Peritonitis. ◆Drain the Peritorium Cavity.◆Activity in Early—Prevent Intestinal Adhesion. ◆Normal Intestinal Activity—Oral Fluids. ◆Perforated Appendicitis—According to Principals of Peritonitis. ◆Drain the Peritorium Cavity.Postoperative managements: nullComplications of the Acute Appendicitis◆Perforation and Peritonitis:severe pain and high fever. About 50% of those under 10 or over age 50. Nearly all deaths occur in the latter group. ◆Appendiceal Abscess: Nonoperative management or drain the abscess. ◆Pylephlebitis: Chills,high fever, low-grade jaudice. ◆Hepatic Abscesses: Grave condition of pylephlebitis.nullOPERATIVE COMPLICATIONS※Injuries: Inferior epigastric vessels. Intestines. Right ureter and iliac artery. ※Excision : Right salpinx. Fatty appendices.※Hemorrhage. ※ Wound infection and dehiscence. ※ peritoneal cavity abscess. ※ Appendix-stump infection. ※ Adhesive ileus. ※ Intestinal fistula.※Hemorrhage. ※ Wound infection and dehiscence. ※ peritoneal cavity abscess. ※ Appendix-stump infection. ※ Adhesive ileus. ※ Intestinal fistula.null第三部分 逆行阑尾切除术 Retrograde AppendectomynullINDICATI0NS： ●Retrocaecal Appendix. ●Mesoappendix is Shorter. ●Adherent Inflamed Appendix is Difficult to Exposure. null1.从根部切断阑尾null2.包埋阑尾残端null3.必要时从侧腹膜游离盲肠null4.阑尾系膜较短时的逆行切除null