Recovery after laparoscopy

Recovery after appendicitis

Do not self-medicate.
You can consult a doctor now or make an appointment at the clinic on this page. Appendicitis is an inflammatory process of a small appendix of the blind part of the intestine. It is called the appendix, or vermiform appendix. This type of inflammation requires surgical treatment, which consists of removing the damaged intestinal process. The patient is operated on as an emergency. With timely treatment, this surgical intervention is successful with a minimal likelihood of any complications.

After the operation to remove appendicitis, experts recommend paying careful attention to the recovery period. If a patient after an appendectomy conscientiously and on time follows every doctor’s instructions, then the likelihood of complications is low and recovery occurs quickly. Otherwise, repeated surgical interventions will be required.

Preparing for surgery

Since laparoscopy for appendicitis is usually performed urgently, the patient and the doctor do not have enough time to undergo a thorough examination. However, a minimum of tests will still be done - blood and urine tests, coagulogram, ultrasound of the abdominal cavity, reactions to HIV, syphilis, hepatitis, and, if indicated, an ECG.

The preoperative examination is carried out in the emergency room and takes a minimum of time, after which the patient is sent to the surgical department, where an anesthesiologist and the attending surgeon talk with him. It is clear that in complicated forms the operation will be performed as quickly as possible. In cases where there are certain doubts about the diagnosis and the appropriateness of the operation, it can be delayed by prescribing observation or diagnostic laparoscopy.

The concept of the postoperative period

The postoperative period is the time from the end of the operation to the complete restoration of a person’s vital functions and lost ability to work.

Rehabilitation

After removal of appendicitis, the patient's body needs to adapt to the new anatomical and physiological relationships created by the operation. The completeness and duration of his recovery directly depends on this time. Rehabilitation is a very important and necessary moment that every patient must go through. The postoperative period is divided into early, when the patient is in the hospital, and late, when recovery occurs at home.

For a quick recovery, the patient after surgery to remove appendicitis needs to be under the dynamic supervision of a doctor and other medical professionals. This is carried out with the aim of timely detection and treatment of possible complications. For this purpose, the patient is immediately placed in a separate room after the operation, where he is monitored.

While the person undergoing surgery is in intensive care, visits to him are, as a rule, prohibited. There they monitor the condition of the skin, postoperative suture, consciousness and body temperature, as well as a number of specific indicators, such as: blood pressure, heart rate, respiratory rate, diuresis, blood test. Their study is carried out after surgery. In critical conditions, continuous recording of the electrocardiogram and hemodynamic monitoring are required.

In the first hours after appendectomy, a person comes out of anesthesia. At this time, adults and children experience a number of reactions that occur under the influence of narcotic drugs: the patient may sing, laugh, scream, cry. There is no need to be afraid of this, because subcortical structures are excited when the cortex is inhibited. This is an effect of the anesthesia medication and can also cause nausea and vomiting. Therefore, after surgery, place the patient so that the head is turned to one side.

In the late postoperative period, great efforts for rehabilitation are required on the part of the patient, because at this time his tissues are restored not under the supervision of qualified specialists, but under his personal supervision. It is mandatory to follow the doctor's recommendations. This will be the key to a speedy recovery. Failure to comply with these rules is the cause of complications and repeated visits to the hospital.

Diet and exercise

A prerequisite for a favorable outcome during the rehabilitation period is adherence to a special diet and standardized physical activity. This will reduce the load on the injured intestinal tract, improve digestion, blood circulation and metabolism.

Material and methods

In the department of surgery of the city multidisciplinary emergency hospital (Veliky Novgorod), from the beginning of 2007 to June 2017, 2096 patients with acute appendicitis were operated on: 1334 (63.6%) patients - laparoscopically and 762 (36.4%) - open access. The following clinical and morphological forms were observed in those operated by the laparoscopic method: simple appendicitis - in 12 (0.9%) patients, phlegmonous - in 844 (63.3%), gangrenous - in 376 (28.2%) and perforated - in 102 (7.6%). In 363 patients, complications of acute appendicitis were noted: local peritonitis - in 162 (12.1%) patients, widespread peritonitis - in 66 (4.9%), periappendicular infiltrate - in 86 (6.4%) and periappendiceal abscess - in 49 (3.7%) patients.

The diagnosis of peritonitis was established on the basis of clinical data, ultrasound results, laparoscopic examination of the abdominal cavity, bacteriological and histological studies.

Laparoscopic appendectomy was performed under endotracheal anesthesia using muscle relaxants. For prophylactic purposes, during laparoscopic surgery, cephalosporin antibiotics were administered intravenously in a dose of at least 1 g.

In most cases, three trocars were used, one of which (10 mm) was inserted at the upper paraumbilical point for the laparoscope, the second (5 mm) - in the right mesogastric region along the midclavicular line, and the third (5 mm) - in the left iliac region along the midclavicular line. In young women, the introduction of working trocars was used in both iliac regions. In case of anatomical features or technical difficulties, a 4th trocar was introduced, and the place of its insertion was selected in each case individually, depending on the surgical findings.

During the laparoscopic examination, the nature of the effusion was assessed, its distribution throughout the abdominal cavity, the severity of paresis of the small and large intestines, and the presence of adhesions were determined. After creating the desired exposure and assessing the nature of inflammatory changes in the ileocecal area, the adhesions were separated and pus or inflammatory exudate was aspirated. In the presence of purulent peritonitis, an important point in the operation is the primary sanitation of the abdominal cavity, aimed at preventing purulent exudate from entering the unaffected parts of the abdominal cavity.

In the case of inflammatory-infiltrative changes in the right iliac fossa, the separation of loose adhesions and isolation of the appendix was carried out using the tip of an aspirator-irrigator, which made it possible to quickly evacuate the purulent contents as a result of opening the periappendiceal abscess.

Antegrade mobilization of the appendix was performed in 854 (65.9%) patients. The mesentery of the appendix was in most cases transected using monopolar coagulation in small portions in the immediate vicinity of the appendix. For thickened, inflamed, infiltrated mesentery and the risk of intraoperative bleeding, the LigaSure device and an ultrasonic scalpel were used. Retrograde mobilization of the appendix was performed in 367 (28.3%) patients when it was impossible to visualize the entire appendix. In 75 (5.8%) patients, mobilization of the appendix was carried out using a combined approach, from the base to the apex and vice versa, most often in the case of gross infiltrative-inflammatory changes caused by destructive complicated appendicitis.

Treatment of the stump of the appendix was a critical stage of endovideosurgical intervention. It was performed using a ligature method using an intracorporeal knot at the base of the appendix in 842 (65.0%) patients, and a Roeder loop in 332 (25.6%). In 118 (9.1%) patients, combined ligation of the base of the process was performed by applying an intracorporeal node and a Raeder loop. This technique was used in the case of inflammatory-infiltrative changes in the proximal part of the appendix and the cecum. Regardless of the treatment method, mandatory demucosation of the stump was carried out by coagulating the mucous membrane with a spherical electrode. In 4 (0.3%) patients with self-amputation of the appendix and the inability to visualize and process the stump, the operation was limited to only removing the appendix and installing drainage.

After mobilization and cutting off the appendix in the left iliac region, a 5 mm trocar was removed and either a 10 mm trocar or a 20 mm evacuator was inserted, through which the drug was removed.

During laparoscopic operations for acute appendicitis, complicated by diffuse and diffuse peritonitis, up to 6-8 liters of antiseptic solution were used to sanitize the abdominal cavity. Methodical lavage of the small pelvis, the right and left lateral canal, both subdiaphragmatic and inter-loop spaces was carried out, periodically changing the position of the operating table in order to maximize aspiration of the rinsing fluid. Using the suction tip, we tried to remove loose fibrinous deposits on the parietal and visceral peritoneum. All patients with widespread peritonitis received a transnasal gastric tube to decompress the upper gastrointestinal tract.

Indications for drainage of the abdominal cavity were doubts about the reliability of sealing the stump of the appendix, especially in destructive forms of appendicitis, opening the lumen of the appendix during dissection or removing it in parts, the presence of a periappendiceal abscess, local or widespread peritonitis. Drains were installed in the right lateral canal, and, if necessary, in the small pelvis and subdiaphragmatic space.

Duration of the recovery period

The duration of the postoperative period after appendicitis varies among patients, even with the same surgical method.

Influencing factors

The following signs influence the course of this time:

Severity of the disease;
Individual characteristics of the patient’s body (age, gender, weight and the presence of concomitant pathologies);
Method of surgical intervention;
Correctly following the instructions of the attending physician.

Nuances of abdominal surgery

Typically, recovery after this surgery lasts at least 2 weeks. The exact recovery time is determined only by the attending physician.

The abdominal method of surgery leads to a longer postoperative period. It usually lasts a month, and if complications arise, it lasts six months.

Features of laparoscopy

The operation is performed using laparoscopy if there are no contraindications to it. It refers to gentle and quick methods of medical intervention. There are a number of reasons for this:

Minor area of injury;
Minor pain;
The patient is allowed to roll over and move after 4-6 hours;
The operation is quick;
Discharge on 3-7 days.

Difficulties of recovery

The recovery period for children, overweight adults and the elderly is more difficult.

Advantages and disadvantages of laparoscopic appendectomy

The important advantages of laparoscopy over classical appendectomy are:

Excellent cosmetic result;
Lower incidence of complications, in particular adhesive disease;
Low trauma;
Short recovery period and rapid restoration of working capacity;
Possibility of a full examination of the abdominal organs and, if necessary, performing other surgical operations without widening the incision;
Economic benefits due to shorter hospitalization, less medication consumption and faster return to work.

The disadvantages of the method include the need for expensive equipment, staff training, and the inability to perform laparoscopy in patients with certain concomitant diseases.

Indications for laparoscopy of appendicitis:

Appendicitis;
Mucocele;
Benign tumor processes, cysts, parasitic lesions;
Carcinoid tumors.

As you can see, the reasons for laparoscopy are similar to those for open surgery, and the form of appendicitis and the presence of complications do not always serve as an obstacle to minimally invasive intervention.

Russian surgeons have identified groups of patients with concomitant diseases who, if possible, should undergo laparoscopy:

Diagnostically unclear cases when observation does not completely exclude an acute inflammatory process in the appendix (diagnostic laparoscopy turns into therapeutic);
Young women who do not exclude the possibility of becoming pregnant and giving birth to a child, in whom it is difficult to distinguish between acute appendicitis and gynecological pathology. In women, unjustified appendectomy reaches, according to some data, 47%, and subsequently it results in adhesions and secondary infertility;
Women of any age seeking the best cosmetic effect;
Patients with certain concomitant diseases that increase the risk of purulent complications - diabetes mellitus, obesity;
Children for whom laparoscopy is preferable due to the low likelihood of adhesions later.

An important reason for laparoscopic removal of appendicitis is the desire of the patient himself to undergo just such treatment. Of course, in this case, the latter should weigh all the pros and cons, and if there is insufficient trust in the surgeon or the absence of a highly qualified specialist, the desire will still have to be abandoned.

Contraindications to laparoscopy of the appendix are similar to those for other surgical diseases:

Severe concomitant diseases of the kidneys, liver, heart;
Long periods of pregnancy;
Severe coagulopathies and bleeding disorders.

Many surgeons consider pregnancy as a relative contraindication, because the negative effect of pneumoperitoneum on the fetus has not been proven, and impeccable surgical technique and minimally invasiveness make it possible to maintain pregnancy and speed up the recovery of the expectant mother.

Blood clotting disorders also have a dual meaning. On the one hand, they can lead to massive bleeding, on the other hand, such patients, if appendicitis occurs, one way or another need its treatment, so it is still better if the operation is less traumatic, and if replacement therapy is prescribed, laparoscopy for coagulopathies does not lead to greater blood loss than in people with normal coagulation.

Relative contraindications may be old age, severe obesity, atypical location of the appendix, peritonitis, but in these cases the issue of surgical access is decided individually.

In addition to general pathology, local contraindications are also identified. These include:

Dense inflammatory infiltrate in and around the appendix;
Pronounced adhesive process;
Abscessing periappendicular process - when gas is pumped into the abdominal cavity, it can rupture and lead to peritonitis, and manipulation of such an abscess is fraught with damage to large vessels and the intestinal wall;
Advanced peritonitis with the formation of a large conglomerate of intestinal loops, massive fibrinous deposits, many foci of purulent inflammation (abscesses), which require open surgery, a full revision and lavage of the abdominal cavity.

Postoperative complications

Postoperative complications are newly emerging pathological processes that are not characteristic of the normal state in the postoperative period. They cause disruption of life and lead to death.

These problems arise when the doctor’s recommendations are not followed, prolonged physical inactivity, increased physical stress on the peritoneum and poor nutrition. It is important to remember that age and comorbidities also play an influential role.

Nutrition

Nutrition after discharge from the hospital is one of the very important issues. The diet requires a particularly careful and responsible approach. Unbalanced nutrition and improper diet cause bad consequences and even lead to death!

Menu selection

The menu after appendectomy is discussed with the attending physician. Self-selected improper nutrition will lead to rapid hardening of stool, gas formation, irritation of the mucous membrane, bloating, symptoms of malabsorption and maldigestion, and constipation.

Basic Rules

In the first days, it is better for the patient to refuse food. Afterwards, it is recommended to consume jelly-like and liquid foods. You should eat often, in small portions.

You need to consume the following: tea with a small amount of sugar added, a decoction of rice and rose hips, jelly, fat-free broths. The initial portion weight is 50 g. Gradually it is allowed to increase up to 300 g. The food should not be hot or cold. Warm, steamed food is allowed.

Be sure to drink about 2 liters of water daily without gases. After 4-6 days, the patient can eat soft food: porridge with boiled meat, dairy products with 0% fat, honey, grated eggs.

After eating, doctors recommend that patients sleep so that all the patient’s energy can be directed to digesting the food consumed.

Restrictions

There are also limitations. Hot seasonings, flour products, tomatoes, alcoholic beverages, hot peppers, green and onions, strong and very sweet tea, coffee, and canned food are prohibited. You should not eat foods that cause bloating - legumes, cabbage, carbonated drinks. Limiting the consumption of salt, spices and seasonings, ketchup, and mayonnaise is also a must. Excluding smoked meats, flour products, alcohol, fried foods, products with chemical additives, carbonated drinks, fish, tomatoes, cabbage, mushrooms and broths made from them will speed up the patient’s rehabilitation.

Rules of patient behavior

After removal of the inflamed appendix, the patient must correctly and responsibly follow the doctor’s recommendations. If postoperative complications are suspected, the assistance of a qualified specialist is required. To slow down the inflammatory process and reduce pain, a heating pad with cold water rather than warm water should be placed on the patient’s stomach. Heated water will only increase inflammation.

Painkillers

After surgery, you should not take large amounts of painkillers. This will make it difficult to diagnose possible complications. In these cases, the use of laxatives is also unsafe. But it is simply necessary to take vitamins, they will speed up treatment. If possible, it is better to take an antibiotic recommended by your doctor for an extra 1-2 days after surgery to prevent complications.

Swimming, bathing, sauna

You can't swim. Therefore, a trip to the sea should be postponed. The bathhouse is also prohibited during the postoperative period. Until the stitches are removed, bathing and showering are also prohibited. You should not wash while your whole body is in water. Doctors, if necessary, allow wiping the body with water, washing, washing feet and hands.

Self-massage

The seam area should not be touched, and especially not massaged or rubbed. It heals faster if you take proper care of it.

Smoking

Smoking cigarettes is strictly prohibited. Smoking will complicate the normal process of anesthesia and make the rehabilitation period problematic.

Movement

After 6-10 hours, the patient should work with proper turning over and the ability to sit. At first, he needs the help of loved ones and medical personnel. Experts recommend walking and getting up after 20-24 hours.

Technical features of laparoscopic appendectomy

To perform laparoscopic appendix removal, special tools are required:

A laparoscope, which allows you to examine the cavity from the inside;
Video camera and monitor;
Light source;
An insufflator that injects carbon dioxide;
Electrosurgical equipment or laser for cutting tissue and coagulating blood vessels;
Irrigator-aspirator, removing effusion, blood, pus, etc. from the abdominal cavity.

In addition to the main equipment, the surgeon uses many surgical instruments - a Veress needle for the safe introduction of gas into the body cavity, scissors, forceps, clamps, four trocars of different diameters, devices for suturing or clips.

The optimal method of anesthesia is considered to be general anesthesia with tracheal intubation and artificial ventilation, as it makes it possible to administer muscle relaxants that relax the muscles and facilitate the introduction of gas into the abdominal cavity. If there are contraindications to such anesthesia, epidural and intravenous anesthesia is possible, but in these cases the operation will be technically more difficult to perform due to the inability to relax the muscles of the abdominal wall.

During laparoscopic appendectomy, the patient is placed on his back, and the operating table is tilted slightly to the left, which facilitates access to the right iliac region by retracting the omentum and intestinal loops to the side.

After treating the skin with an antiseptic, the first small incision is made in the umbilical area, through which a Veress needle is inserted and carbon dioxide is injected. Then the first trocar for the laparoscope is placed in the same hole. A second trocar inserted in the left iliac region or along the midline below the umbilicus helps to examine the area of interest.

After a thorough examination of the area where the appendix is located and making a decision to continue the operation laparoscopically, the surgeon inserts another trocar near the navel or under the right costal arch, and in case of an atypical location of the appendix, adhesions, or inflammation of the peritoneum, a fourth trocar may be needed, the insertion point of which determined individually for each patient.

When all the instruments are installed, the surgeon examines in detail the internal organs - the liver with the gall bladder, intestinal loops, omentum, the surface of the peritoneum, the ovary and the fallopian tube with the uterus in women. It is very important to assess the condition of the appendix: if even in one fragment obvious inflammatory signs are found, then the diagnosis can be considered confirmed and the organ should be removed, however, the absence of visible signs of inflammation does not allow us to reject acute appendicitis, catarrhal and superficial forms of which also require surgical treatment .

Laparoscopic appendectomy itself includes several stages:

Traction of the process, which is fixed by the mesentery or end and rises to the abdominal wall;
Crossing the mesentery using a coagulator, applying a ligature, clip or hardware suture;
Treatment of the appendix stump - suturing, immersing the sutured stump into the cecum with fixation with sutures, applying metal staples (clips) and removing the appendix out;
Control examination of the abdominal cavity, ligation or coagulation of bleeding vessels, in the presence of effusion, peritonitis, complicated forms, drainage is performed at the end of the operation;
Suturing the skin incisions and completing the intervention.

After crossing the appendix, its mesentery, coagulation or suturing of the vessels, the surgeon removes the inflamed appendix out through any of the available trocars, preventing the appendix from coming into contact with other organs and the peritoneum. When the appendix is removed from the abdominal cavity, it is placed in a special container and then sent for pathohistological examination.

After completing the main stage of the operation, the doctor once again examines the abdominal cavity for bleeding, rinses the surface of the peritoneum with chlorhexidine or furatsilin, removes all pathological impurities (blood, pus, fibrin protein), and aspirates the liquid contents.

Drainage after laparoscopy of appendicitis is not always carried out, but only if there are indications - peritonitis, abscess around the appendix, while drains are placed in the pelvis, iliac zone, area of the removed appendix.

On average, laparoscopy of appendicitis for uncomplicated forms of pathology takes half an hour, but can be longer in case of complications, and the stages can change their sequence. For example, with peritonitis, the surgeon will first try to eliminate the effusion fluid, and then begin manipulations on the appendix itself.