- After the patient is discharged from the hospital, a follow-up appointment is scheduled after 1, 3, 6, and 12 months to evaluate the long-term results of the aspiration method. The examination includes:
- Clinical examination of the old AXRT area to assess recurrence or stability after aspiration. Count white blood cells and erythrocyte sedimentation to assess time to return to normal.
- Ultrasound examination to monitor complete disappearance or persistence of abscess, evaluate the survey rate and image of remaining RT
e, Monitor the frequency of AXRT and VRT recurrence
All patients who had pus aspirated did not have RT surgery. Carefully advise about symptoms if they recur to return for a follow-up visit outside of the regular appointment. Evaluate the rate of recurrent VRT and RT abscess.
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1.4.3 Surgery
1.4.3.1 Laparoscopic appendectomy
* Indication
- AXRT in the abdomen (located in the middle of the abdominal cavity)
- AXRT is located in the pelvis
- AXRT in the right iliac fossa
* Contraindications
- Appendiceal mass
- Patient has history of multiple abdominal surgeries
- Patients with serious underlying diseases (heart disease, coronary artery disease and pulmonary tuberculosis)
* Prepare
- Performer: The performer is a general surgeon trained in laparoscopic surgery (with valid certificate).
- Vehicle:
+ Operating room fully equipped to perform laparoscopic surgery
+ Laparoscopy set: Monitor, camera, light source, CO2 source
+ Pump and lavage system for abdominal fluid
+ Bipolar and monopolar electric knife system, ultrasonic cutting and burning knife
+ Liver retractors, intestinal clamps, forceps, clamps, and specialized scissors for laparoscopic surgery
+ Commonly used abdominal surgery kit (prepared in case of open surgery)
- Patient
+ Basic tests (biochemistry, hematology, urine)
+ Lung X-ray, electrocardiogram (for people > 65 years old)
+ Last meal before surgery at least 6 hours away
- Medical records
+ Administrative procedures
+ Professional qualifications are fully completed according to regulations (detailed medical records, voluntary commitment to laparoscopic surgery, etc.)
* Steps to follow
* Anesthesia: Endotracheal anesthesia
* Technique:
- Posture:
+ Patient: Lie on your back, left arm along the body, head low
+ Surgical team: The operator stands on the left of the patient, assistant 1 stands on the left of the operator, assistant 2 stands on the right, and the instrument technician stands on the right of the patient.
- Perform abdominal inflation and trocar placement
+ There are 2 methods of abdominal inflation: Inflation with Veress needle or inflation by open method.
+ Trocar placement:
10mm trocar placed above or below the umbilicus. After inflation and under camera guidance, place the second trocar: 5mm trocar in the midline above the pubic bone; 3rd trocar: 10mm trocar in the left iliac fossa, 8-10cm from the second trocar. A fourth trocar can be placed in the right iliac fossa if necessary.
- Laparoscopic appendectomy technique:
+ Observe the entire abdomen to assess the abscess status: Aspirate secretions or pus (if any) in the free abdominal cavity, take fluid samples for bacterial testing and antibiotic sensitivity testing.
+ Dissect to enter the abscess. If pus flows out, it must be drained immediately to prevent it from overflowing into the abdominal cavity. Be careful not to damage the small intestine loops next to the abscess.
+ Find the inflamed appendix and remove it using laparoscopic surgery: In case of appendiceal abscess, the mesentery of the appendix is often edematous, making it difficult to dissect the appendiceal artery clearly. Hemostatic measures can be performed using a bipolar cautery knife, an ultrasonic knife, or clips at the base of the appendix.
+ Tie and cut the appendix close to the base (the appendix base can be cut with a laparoscopic intestinal stapler).
+ Drain and clean the abscess
+ Check the intestinal loops and the entire abdomen
+ Place a drain at the abscess site and Douglas pouch, remove after 3 days
+ Suture the abdominal wall at the trocar holes
* Postoperative monitoring and care
- Infusion on the first day after surgery
- Can drink water after 24 hours
- Combination treatment of two antibiotics
- Drainage removal on a case-by-case basis.
- Complications and treatment
* Complications of abdominal inflation
- Stimulates heart rate
- Pneumothorax: preperitoneal, subcutaneous, pleural cavity.
- Pulmonary embolism due to air
* Complications due to trocar puncture
- Injury to abdominal organs: conversion to open surgery
- Damage to blood vessels in the abdomen: conversion to open surgery
- Abdominal bleeding: hemostasis sutures
- Infection of trocar holes: remove stitches and change bandages daily.
* Complications during surgery
- Perforation or tearing of the small intestine during dissection into the abscess: conversion to open surgery
- Uncontrolled bleeding due to inflammation at the abscess: open surgery
* Postoperative complications
- Hematoma in the abdominal cavity, abdominal wall
- Abdominal wall abscess, intra-abdominal abscess: abscess drainage
- Hernia through trocar hole
- Postoperative intestinal obstruction
- Cecal fistula
- Inflammation of the remaining appendix
1.4.3.2 Open appendectomy [20]
* Indications for open surgery: Intra-abdominal appendiceal abscess does not meet the conditions for minimal intervention treatment.
* Prepare
- General surgeon, surgical team with assistant, surgical instruments
- Anesthesiologist and anesthesia assistant team.
- The patient must be fasted for at least 6 hours before surgery if endotracheal anesthesia and complete abdominal lavage are required.
- Basic tests, chest X-ray and electrocardiogram.
* Steps to follow
- Position: the patient lies on his back and is catheterized.
- Anesthesia by spinal anesthesia or endotracheal anesthesia, laryngeal mask anesthesia depending on the expected level of intervention, can be combined with spinal epidural anesthesia to reduce postoperative pain.
- Technique:
+ Skin incision: along the normal appendectomy line (Mc Burney's line) if the appendix is inflamed without other abnormalities, or along the right white line, or the extended middle white line depending on surgical requirements. Remove adhesions or follow the loops of ileum to the base of the appendix at the base of the cecum, it is essential to find and identify the base of the appendix. If there is an abscess in the abdomen due to the appendix, it must be removed by suction, cleaning and removing all inflammatory tissue. If the abscess is too tightly adherent, it may not be removed but must be drained. Try to clean the right iliac fossa, pelvis, and abdomen as much as possible by washing with isotonic saline, wiping, cleaning, and draining to the right abdominal wall.
+ Appendectomy: is the most important technique. Clearly expose the appendix from the tip of the appendix to the base where the three longitudinal muscle bands of the cecum end. Expose the mesentery of the appendix, including the appendiceal artery. Clamp the appendix close to the base and tie it with thread or other materials such as clips. Clamp the mesentery of the appendix by tying it with thread or clips or other instruments. If the base of the appendix is inflamed, necrotic, or has pus, it must be cut, cleaned, and then sutured in two layers.
+ Close the abdomen by layers of muscle and skin or close the abdomen in one layer with a separate stitch if the abdominal cavity has severe peritonitis.
* Monitoring and handling of complications
- Monitoring care and treatment of common complications:
Complications of residual abscess in the peritoneal cavity due to incomplete treatment of the right iliac fossa, complications at the base of the appendix, and cecal fistula. Inter-intestinal abscess, pelvic abscess, especially in cases of postoperative generalized peritonitis, require close monitoring.
- If there is an infection in the abdomen, antibiotics must be used, drainage must be aspirated, the surgical wound must be separated and drained, or surgery must be performed to remove the cause.
- Surgical site infection complications, causing the surgical site to swell, become hot, red, painful, and have pus. The stitches must be removed, the surgical site must be cleaned, and antibiotics must be administered. When the abdominal drainage stops draining fluid, an abdominal ultrasound should be performed or the drainage should be removed based on a good clinical examination.
* Postoperative care
- Postoperative pain relief requires effective oral analgesics, injections or continuous infusions into the epidural anesthetic line, and controlled-dose intravenous autoinjections.
- Feed the patient early if bowel movements return to normal.
- If there are no signs of infectious complications, the patient can be discharged early.
CHAPTER II: RESEARCH SUBJECTS AND METHODS
2.1 SUBJECTS OF RESEARCH
Including all patients diagnosed with: Appendiceal abscess and treated at the Department of Emergency Digestive Surgery at Viet Duc Friendship Hospital from September 2020 to April 2022.
2.1.1 Patient selection criteria
- All patients were diagnosed with appendiceal abscess.
- Patients treated for appendiceal abscess with medical methods or surgical intervention
- These patients had complete records of preoperative diagnosis, treatment, follow-up and treatment
2.1.2 Patient exclusion criteria
- Preoperative diagnosis was appendiceal abscess but postoperative diagnosis was not appendiceal abscess
- Patient with appendiceal mass
- Medical records do not provide enough necessary information
- Patients under 15 years old
2.1.3 Diagnostic criteria for appendiceal abscess
- Systemic symptoms: high fever, fluctuating, rapid pulse.
- Abdominal examination: there is a painful mass in the right iliac fossa, the inner edge is relatively clear, the outer edge is unclear, continuous with the abdominal wall of the iliac fossa, the remaining areas are soft and painless.
- Rectal examination: the lower pole of the mass can be felt and is very painful.
- Ultrasound: found heterogeneous fluid mass in the right iliac fossa.
- CT scan confirmed appendiceal abscess
- Pathological lesions:
* In general:
+ Abdominal cavity with pus and pseudomembrane: pus, foul odor, pseudomembrane can be in the right iliac fossa, Douglas, covered by omentum to form a mass.
+ Appendicitis: purulent inflammation, ruptured necrosis.
* Microscopic:
+ Appendicitis with pus, necrosis, localized peritonitis.
2.2 RESEARCH METHODS
2.2.1 Research method
- Retrospective study (Retrospective from September 2020 to April 2022): collect data through medical records stored at the Viet Duc Friendship Hospital's records storage room, record full information according to selection criteria in the sample medical record.
2.2.2 Sample size
- Select a convenient sample according to the research purpose
- In our study, there were n = 30 patients meeting the above criteria.
2.3 RESEARCH VARIABLES AND INDICATORS
Patients were recorded in their medical records from admission to discharge according to the same research medical record form (appendix).
2.3.1 Study on some clinical and paraclinical characteristics of appendiceal abscess
a, General criteria
- Age: 15 – 19; 20 – 30; 31 – 44; 45 – 59; 60 -74; ≥75
- Gender: Male; female
- Geography: Urban, rural, mountainous b, Clinical