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Immediate Complications Following Appendectomy
Immediate Complications Following Appendectomy JOHN L. MADDEN, M.D., F.A.C.S.*
The immediate postoperative complications following appendectomy may be considered under four headings: (1) pulmonary, (2) cardiovascular, (3) wound and (4) peritoneal.
POSTOPERATIVE PULMONARY COMPLICATIONS
Atelectasis
This is one of the most common of the pulmonary complications and affects patients of all age groups. The symptoms are usually manifest within the first 48 hours and in general are directly related to the extent of the atelectasis. This may vary from a small segmental area to a massive involvement of the whole of one or more lobes of the lung. Correspondingly the patient may have few or no symptoms or symptoms of grave severity characterized by dyspnea, orthopnea, cyanosis, chills and hyperpyrexia (103° to 105° F.). Roentgenograms of the chest show areas of radiodensity commensurate in size with the number of lung segments that are occluded. Also the degree of mediastinal displacement to the affected side varies with the extent of the lung area that is blocked. Atelectasis may occur as a complication of local, spinal or general anesthesia. However, it occurs more frequently when a general anesthesia is administered. Although the exact mechanism for the occurrence of atelectasis may be obscure, there are general precautionary measures which, if observed, are believed to lessen its incidence. These precautions begin with the duties and responsibilities of the anesthesiologist relative to (1) preoperative medication and (2) conduct of the anesthesia. Both the From the Department of Surgery, St. Clare's Hospital, New York, N. Y. Department of Surgery, St. Clare's Hospital; Clinical Professor of Surgery, New York Medical College, Flower and Fifth Avenue Hospitals
* Director,
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drugs and the anesthesia should be administered according to the individual requirements of the particular patient. Oversedation preoperatively and the use of excesses in anesthesia should be avoided, especially in the elderly. Upon completion of the operation a careful tracheobronchial toilet in conjunction with the establishment and maintenance of a patent airway are mandatory. Elderly patients and those who have pre-existing pulmonary disease are given antibiotics routinely as a prophylaxis. Deep breathing exercises and occasionally aerosol therapy with Alevaire are also prescribed. The position of the patient should be changed frequently and early ambulation is recommended. When atelectasis is established as a postoperative pulmonary complication, active treatment is required. Nasotracheal catheter suction, as recommended by Haight,3 is used as frequently as indicated. In some instances bronchoscopic aspiration may be necessary. Dornavac, 100,000 units (2 cc.) or Mucomyst 9 (5 cc. of a 20 per cent solution) may be used as an aerosol, with alternating positive and negative pressure, two to three times daily for one to seven days. If desired, a bronchodilator (Isuprel hydrochloride) and/or antibiotic may be added. Achromycin V, 250 mg. orally every six hours, is also prescribed. Mucomyst (1 cc. of a 10 per cent solution) or Dornavac (1 cc.) also may be instilled into the trachea through a percutaneous catheter every four hours, or more frequently as required. Since coughing should be encouraged, depressive sedation is avoided. The treatment should be continued as the needs of the patient require. Pneumonia Fortunately this complication now occurs infrequently. It is believed that the decreased incidence is in the maih attributable to the use of the prophylactic measures previously described. Whereas atelectasis usually occurs during the first 3 days postoperatively, pneumonia as a complication is most frequently observed 6 to 9 days after operation. The clinical manifestations are dependent upon whether the pneumonia is lobar or bronchial in type. In lobar pneumonia, chills, hyperpyrexia (103 0 to 104 0 F.), circumoral cyanosis, dyspnea with expiratory grunt, splinting of the chest wall with diminished respiratory excursion, the anxious facies, rusty sputum, dullness to percussion, and bronchial breathing on auscultation overlying the affected lung are classical symptoms. On roentgenographic examination of the chest, the typical lobar infiltration is demonstrable. In bronchopneumonia, hyperpyrexia, dyspnea and varying degrees of cyanosis are also present. However, the physical signs are indicative of a bilateral diffuse infiltration of the lungs, which is productive of a characteristic roentgenographic appearance. The treatment of pneumonia, whether lobar or bronchial, is essentially the same. This consists of: (1) the administration of antibiotics and chemotherapeutic drugs which are used in large doses and on a selective basis dependent upon culture and sensitivity studies; (2) continuous oxygen with intermittent positive pressure; (3) aerosol antibiotics; (4) sedation only as required; (5) general supportive and symptomatic care.
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There are two complications of pneumonia, particularly of the lobar type, which are of surgical significance, viz., pleural empyema and lung abscess. Postpneumonic pleural empyema is suspected when fever persists in association with fluid in the pleural cavity and is confirmed by thoracentesis. The initial treatment is by repeat aspirations and the daily instillations of specific antibiotics and Varidase (streptokinase 200,000 units and streptodornase 50,000 units). If symptoms persist, closed intercostal tube drainage, and next in order, rib resection with open drainage may be required for cure. Following open drainage, a large-tube drain is used initially and subsequently replaced by progressively smaller tubes as the cavity diIninishes in size. The last tube should not be removed until the capacity of the cavity is less than 5 cc.
Lung Abscess A lung abscess may occur as a complication of pneumonia or from aspiration during the recovery phase of anesthesia. When secondary to aspiration, it is most commonly located in the posterior segment of the right upper lobe. The next most common location is in the apical segment of the right lower lobe. Characteristically the patient expectorates increasing quantities of purulent material which mayor may not have a foul odor. When the infection is caused by an anaerobic organism, the odor is foul, befitting the phrase, "putrid (fetid) lung abscess." In the early stages of infection roentgenograms (postero-anterior and lateral) of the chest show one or more circumscribed densities within the segmental areas previously described. When communications are established between the abscess and the bronchial system, air fluid levels are present. The initial treatment prescribed is general supportive and symptomatic coupled with the use of antibiotic and chemotherapeutic drugs. When drainage into the bronchial system occurs, postural drainage is prescribed. This is performed as frequently and as long as it can be tolerated by the patient. Should this prove unsatisfactory, external drainage, lobectomy or pneumonectomy may be required. Segmental resection is rarely permissible.
CARDIOVASCULAR COMPLICATIONS Coronary artery thrombosis may occur as a complication following appendectomy, particularly in patients in the fifth decade and beyond. Precautionary measures during the operation are: (1) the maintenance of a normal and stable blood pressure; (2) the maintenance of a free respiratory exchange and the use of high concentrations of oxygen; (3) the production of minimal operative trauma; (4) absolute hemostasis. However, despite all precautions a coronary thrombosis may occur, the treatment of which is supervised completely by the attending cardiologist. The more prevalent cardiovascular complication is a thrombophlebitis of the deep venous system of the lower extremities. This complication may occur in patients of all age groups, the exact cause of which may be difficult
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to define. However, there are certain predisposing causes to the formation of a deep venous thrombosis. These are: (1) operation (being discussed); (2) parturition; (3) trauma; and (4) prolonged confinement in bed. In addition there are basic contributory factors that are commonly associated with these predisposing causes, namely: (1) circulatory stasis; (2) hemorrhage; (3) shock; (4) infection; (5) malnutrition; (6) anemia; (7) dehydration. Contrariwise, there are patients in whom a deep venous thrombosis occurs without any evident predisposing or contributory causes. Stasis in the peripheral venous circulation is considered one of the most important factors in the formation of a thrombus within a vein. The return of the venous blood to the right side of the heart is dependent upon five factors: (1) the vis a tergo or the force of the heart beat; (2) the contraction of the muscles in the extremities; (3) the aspiration action of the thorax; (4) the viscosity of the blood; and (5) the effect of gravity. Disturbances in one or more of these factors that may induce venous stasis are commonly associated with heart disease, malnutrition, hemorrhage, shock, trauma, dehydration, improper positioning of the patient in bed, and finally the use of constricting dressings. The symptoms of a deep venous thrombosis vary from patient to patient. Examination of the affected extremity may reveal: (1) tenderness along the plantar aspect of the foot; (2) pain in the calf on dorsiflexion of the foot (Homans' sign); (3) tenderness on manual compression of the calf, and on palpation a feeling of fullness or "heaviness" of the calf; (4) duskiness of the toes and distention of the superficial veins on dependency of the limb; (5) swelling of the ankle or leg. However, the first symptom may be a pulmonary embolus, the symptoms in the affected extremity not appearing until five to seven days later. The disturbing fact in such patients is that the initial infarct may prove immediately fatal. In some patients an acute fulminating thrombophlebitis, or phlegmasia cerulea dolens, may occur. In this type shock is frequently present and death may occur within 36 to 48 hours. Chills are frequent and the fever is high (1040 to 1060 F.). The involved extremity is massively swollen and tender. Cyanotic rubor with diffuse petechial hemorrhages are commonly present. The massive swelling of the extremity and the associated reflex arterial spasm may occlude the peripheral arterial pulsation and simulate an embolic arterial occlusion (pseudo-embolic thrombophlebitis). It is differentiated from a primary arterial blockage by the concomitant massive swelling. The treatment of thrombophlebitis is based on the symptoms manifest in the particular patient. Initially, absolute bed rest is prescribed and the affected extremity is elevated on a pillow. Heparin, the anticoagulant of choice, is administered intravenously for 14 days in a gradually decreasing dosage. For the first three days, the total daily dosage of heparin (5000 units per cc.) is 8 cc. (40,000 units), which is administered in divided doses at four-hour intervals (8 A.M., 12 noon; 4 P.M. and 8 P.M.). The respective
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doses are: 2.5 cc. (12,500 units); 1.5 cc. (7500 units); 1.5 cc. (7500 units) and 2.5 cc. (12,500 units). For the second three days the total daily dosage is reduced to 5 cc. (25,000 units) and is given in divided doses at six-hour intervals (2 cc. at 8 A.M., 1 cc. at 2 P.M. and 2 cc. at 8 P.M.). For the third three days, 1.5 cc. is given twice daily at 8 A.M. and 8 P.M. Subsequently, and up to 14 days, a daily injection of 2 cc. (10,000 units) is given at 8 P.M. After the fourteenth day, this daily domge may be maintained depending upon the response of the patient. An alternate route after the third day would be the use of heparin, 1 cc. (20,000 units per cc.), daily, either intramuscularly or subcutaneously, and continued for the succeeding five to seven days. The dosage is then reduced to 0.5 cc. (10,000 units) for an additional five to seven days. When the first indication of a deep venous thrombosis is a nonfatal pulmonary embolus the main goal of treatment is the prevention of recurrent thrombo-embolism. Accordingly, ligation of the inferior vena cava is recommended by many. Others prefer the use of anticoagulants initially and reserve vena cava ligation for recurrent thrombo-embolism. The main objection to this reasoning is that the recurrent embolus may prove immediately fatal. My own preference is ligation of the inferior vena cava (Figs. 1,2). Objections to the ligation of the superficial femoral vein, either unilateral or bilateral, are: (1) the site of ligation may not be sufficiently high to be safely above the thrombus; (2) the collateral circulation is limited and a persistent and disabling swelling of the extremity may occur; (3) a thrombus may form cephalad to the level of ligation and be the origin of a fatal thrombo-embolism. In the treatment of acute fulminating thrombophlebitis (phlegmasia cerulea dolens), conservative measures are believed interdicted. Immediate operative intervention is recommended, the efficacy of which has been emphasized previously.s The operative approach is dependent upon the clinical findings. If the thrombus has extended into the pelvis, as indicated by edema of the sacral region, the lower portion of the abdomen, and beginning swelling of the opposite extremity, exposure and thrombectomy of the inferior vena cava is prescribed (Fig. 3). When the thrombotic process is limited to the lower extremity, thrombect.omy and ligation of the superficial femoral vein is performed (Figs. 4, 5). Ligation is preferred to suture closure of the phlebotomy site. Although an apparent paradox, less postoperative edema is observed after ligation than after closure. In seven patients with phlegmasia cerulea dolens, three were treated by thrombectomy of the inferior vena cava, two by unilateral thrombectomy of the superficial femoral vein, and two by bilateral thrombectomy of the superficial femoral veins, and in all excellent results have been observed. Procrastination in treatment by the use of anticoagulants or repeated paravertebral and subarachnoid procaine "blocks" is believed a danger to both life and limb. The concept of mechanical blockage is supported by the excellent results obtained, both immediate and late, after removal of
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Figure 1. Preventive ligation of the inferior vena cava. The patient is placed in the supine position and the right side is elevated on a pillow to an angle of 25 degrees to the horizontal (A). A transverse skin incision (A) is employed and the underlying muscles are separated in the direction of their fibers (B-D) to expose the herniation of the retroperitoneal fat through an opening being made in the transversalis fascia (F), (Continued in Figure 2.)
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Figure 2. Preventive ligation of the inferior vena cava (continued). By digital dissection the peritoneum is displaced medially and anteriorly (G) and retracted (H) to show the close proximity of the ureter to the anterior surface of the vena 'cava (H). The vena cava is mobilized and doubly ligated in continuity as depicted (I-M).
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.Figure 3. Ligation of the inferior vena cava in the presence of a thrombotic occlusion. The vena cava is incised between encircling but untied ligatures and the clot is evacuated by "digital milking" motions (0, P). The vena cava is occluded, preferably in continuity (Q), or by transection and occlusion (R, S).
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Figure 4. Thrombectomy and ligation of the superficial femoral vein. The patient is placed in the supine position and the head is elevated to an angle of approximately 20 degrees from the horizontal (A). The incision (B) is deepened through the underlying fascia (C) and the sartorius muscle is retracted laterally to expose the femoral vessels encased in the femoral sheath (C). The sheath is opened and the femoral artery is retracted laterally to expose the superficial femoral vein which is being incised with scissors (F). (Continued in Figure 5.)
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Figure 5. Thrombectomy and ligation of the superficial femoral vein (continued). The venous thrombus is removed by suction (G) and digital "milking," both retrograde (H) and antegrade (I). The vein is doubly clamped between ligatures (J), severed, and the ends occluded with transfixion suture ligatures.
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the thrombi that occlude the inferior vena cava or the superficial femoral vein. Thrombectomy and ligation of the superficial femoral vein is also preferred in the treatment of acute thrombophlebitis of the femoral vein in which there is a diffuse swelling of the affected extremity although it is not as severe as in the acute fulminating form just described.
POSTOPERATIVE WOUND COMPLICATIONS
Wound Infection
The most common wound complication following appendectomy is infection. Wounds are classified relative to their potential for infection. When the appendix is acutely inflamed but grossly intact, the wound is classified as clean-contaminated. When the appendix is perforated and free pus is present within the peritoneal cavity, either local (abscess) or diffuse, the wound is classified as clean-infected. This classification enables one to determine the comparative incidence of actual wound infection in each group of patients. The wound infection may be due to the same organism as cultured from the inflamed appendix, or to extraneous organisms. Accordingly, strict surgical asepsis should prevail throughout the conduct of the operation to minimize the occurrence of a secondary or mixed infection. Before the peritoneal cavity is entered, the cut surfaces of the wound are protected with gauze pads moistened in warm saline. If preferred, impervious pads may be used. During the removal of the inflamed appendix it is handled solely with instruments and particular care is observed to prevent its contact with any portion of the wound. When pus is present, it is removed as completely as possible by suction siphonage before the appendectomy is performed. Upon completion of the appendectomy the surgical team wash their hands thoroughly and, if required, change their gloves. In the closure of the wound a second set of sterile instruments is used. Except on rare occasions, the wound is closed in layers without drainage. Following the closure of each layer, peritoneal and fascial, the wound is irrigated thoroughly with copious quantities of hot (112 0 F.) saline. This is believed to effect: (1) a mechanical cleansing of all loose wound debris; (2) dilution of any existing wound toxins; and (3) a bactericidal action. If preferred, a penicillin solution (50,000 units per cc.) may be used for the wound irrigations. In patients with frank and excessive soiling of the wound, delayed closure, as advocated by Coller and Valk2 is advised. Postoperatively, all patients in whom the wound is classified as cleaninfected are given antibiotics routinely. The dosage is dependent upon the extent of the infection and may vary from 600,000 to 4,000,000 or 6,000,000 units of penicillin intravenously every six hours.
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Wound Dehiscence Wound dehiscence as a complication of appendectomy is not a common occurrence. The two most commonly related factors which predispose to a wound disruption are abdominal distention and the excessive contractions of the abdominal muscles which occur with bouts of coughing and vomiting. There is no constant relation between the incidence of burst wounds and the method of wound closure. This complication occurs whether catgut, silk or wire sutures are used, and whether the sutures are interrupted or continuous. The nutritional status of the patient preoperatively and the presence of a malignant growth are repeatedly stressed as important predisposing factors to the occurrence of a wound dehiscence. However, it seems a paradox that disruption of a wound is seldom observed in those patients in whom a portacaval shunt is performed for intractable ascites. Admittedly, such patients do have severe nutritional deficits, yet primary wound healing is the rule. Furthermore, the abdominal wounds of patients with nonresectable malignant tumors and concomitant peritoneal metastases most commonly heal without incident. The preceding may be contrasted with the case of a 47 year old man, in apparent excellent health as determined by a thorough preoperative evaluation, who suffers a complete wound disruption 7 days after a cholecystectomy is performed for chronic cholecystitis and cholelithiasis. This contrast is used to emphasize our lack of knowledge of many of the vagaries underlying wound healing. The classical harbinger of a burst wound is the sudden discharge of a copious quantity of serosanguinous fluid from the wound 6 to 9 days after operation. However, it is believed that the diagnosis frequently may be made several days sooner. In fact, in some patients the disruption is initiated in the transfer of the patient from the operating table to the stretcher. It has been observed that patients who disrupt their wounds commonly have abdominal distention and associated discomfort during the first 3 or 4 days postoperatively. In such patients a careful examination of the wound may establish the diagnosis at this time. Admittedly, in many patients with such symptoms, primary wound healing occurs. It is also admitted that the postoperative convalescence may be entirely without incident and yet the wound disrupts. In the treatment of the burst wound, immediate secondary closure is the preferred method. Rarely, there may be extenuating circumstances which would indicate coaptation of the wound with strips of adhesive tape. In the performance of a secondary wound closure stainless steel wire sutures, swedged on large curved cutting edge needles, are used and incorporate the whole thickness of the abdominal wall. For patients with incomplete wound disruption with the skin margins intact, although each presents an individual problem, in general immediate secondary closure is preferred. It is believed that this method offers the best prophylaxis for other postoperative complications, both immediate and late.
Hemorrhage Hemorrhage is usually an early complication and may be either external or internal. The cause of external bleeding is frequently an unoccluded vessel or vessels just beneath the skin surface. The bleeding may be readily controlled by the removal of two or three of the adjacent skin sutures and the application of clamp and ligature to the bleeding vessel. The "blind" application of a reinforcing dressing is condemned. A wound
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that is bleeding should always be immediately and carefully inspected to determine both the cause and the choice of treatment. The diagnosis of internal or acute wound hemorrhage is usually made relatively late. A hematoma in a wound, particularly a contaminated wound, is an ideal nidus for a subsequent wound infection. When the hematoma is small and there are no local or systemic signs of expansion, the treatment is conservative. However, when the hematoma is large or expanding in size, surgical evacuation of the clot and the suture control of any actively bleeding vessel is practiced.
POSTOPERATIVE PERITONEAL COMPLICATIONS
Hemorrhage The complication of bleeding into the peritoneal cavity may occur· early or late. Shock within the first six to 12 hours after operation should be considered to be due to acute blood loss until proved otherwise. Clinically the symptoms are: hypotension, tachycardia and small pulse volume, pronounced pallor, dyspnea, free perspiration, apprehension and syncope. It is indeed most surprising how frequently the symptoms of postoperative hemorrhagic shock are unrecognized by experienced surgical personnel which unfortunately many times includes the resident surgical staff. The cause is most commonly an actively bleeding vessel within the severed and ligated mesoappendix. The treatment is fluid and blood replacement, concomitant with immediate reopening of the abdomen to control the source of bleeding. To minimize this complication, particular precaution is required in the severance and ligation of the mesoappendix. A technique which is believed to predispose to this complication is the inclusion of the mesoappendix in a single mass ligature. Although this technique is rapid and frequently successful, it is considered a potential danger and should not be practiced. The preferred method is to serially clamp and sever the mesoappendix and to include only a small segment of tissue in each of the clamps. Each clamp is in turn replaced by a suture ligature of 000 silk for hemostasis. This area is again carefully inspected to determine the completeness of hemostasis before the wound is closed. Ochsner and Lilly 8 have observed acute massive intestinal hemorrhage from a severed and unligated intramural branch of the appendicular artery. Hemorrhage from this vessel is precluded if the base of the appendix is ligated. However, it may occur when the stump is inverted without previous ligation, a technique recommended by these authors. To prevent this complication they have advised that in the insertion of the purse-string suture for inversion of the unligated appendiceal stump, a "loop" be
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incorporated on the mesentery side of the base of the appendix to insure occlusion of this intramural artery should it be present. Late hemorrhage, seven to ten days after operation, is usually associated with an infection and caused by a tissue slough. Fortunately this complication is now a rare occurrence. Unlike the acute postoperative hemorrhage, bleeding may subside spontaneously. However, recurrence is always a likelihood as long as the infection persists. Because of the associated and oftentimes extensive inflammatory reaction in the neighboring tissues, operation is deferred unless warranted by chronic recurrent or excessive blood loss.
Pelvic or Lumbar Abscess An abscess within the pelvic or lumbar region is a relatively frequent postoperative complication, particularly after the removal of an acutely suppurative, gangrenous or perforated appendix. The onset of "diarrhea," five to seven days after operation should make one immediately suspect a pelvic abscess. All too frequently antidiarrheal medications are routinely prescribed and a most important examination, a digital rectal, is omitted. The "diarrhea" is most commonly spurious, consisting of colored mucoid material caused by an irritative colitis secondary to the pelvic abscess. Similarly the sudden occurrence of a fever five to seven days postoperatively or a continuous fever since the day of operation should make one suspect an occult abscess. In addition to a digital rectal examination the operative wound and its surrounding area should be examined carefully for the presence of either a wound infection or an intra-abdominal mass (abscess). When the diagnosis of a pelvic or lumbar abscess is established, the immediate treatment is conservative. The indications for operation are: (1) persistent toxicity as indicated by anorexia, chills, fever, drenching sweats, weight loss, and anemia; (2) progressive increase in the size of either the abdominal or pelvic mass; (3) a combination of the preceding. In the drainage of an abdominal (lumbar) abscess, the incision is made over the summit of the swelling to enter the abscess cavity. The optimum time to drain a pelvic abscess presents more of a problem. Generally speaking, when one is in doubt, drainage should not be attempted. Similarly the presence of an indurated mass is not an indication. The optimum time to drain is indicated when, on digital rectal examination, the "bag of waters" feel is transmitted. The abscess should first be entered by transrectal aspiration. The syringe is then disconnected and, with the needle as a guide, a No. 11 bladed scalpel is inserted and the abscess is opened widely. The opening is enlarged by digital exploration and the abscess cavity is emptied. Two Penrose (cigarette) drains are inserted and a perineal "fluff" dressing is applied. The drains are usually expelled within 48 hours, subsequent to which sitz baths are prescribed twice daily for seven to ten days.
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Subphrenic Abscess
One of the most common causes of a subphrenic abscess is acute appendicitis. It may occur as a postoperative complication regardless of the nature of the local disease process in the appendix. It may occur in a patient in whom the immediate postoperative course has been uneventful or in one in whom the convalescence has been "stormy." Usually the symptoms are manifest 14 to 18 days after operation and characterized by chills, fever (103 0 to 1040 F.), sweats, and anorexia. Additional clinical findings that may be manifest are: (1) tenderness to percussion on deep pressure overlying the lower rib cage, anteriorly or posteriorly; (2) dullness to percussion and diminished or absent breath sounds in the lower lung field; (3) limitation of the respiratory excursion of the ipsilateral costal arch; (4) palpable mass. A roentgenogram of the chest frequently may show a pleural effusion secondary to the irritative reaction caused by the subphrenic collection of pus. The diagnosis of a subphrenic abscess oftentimes is not made because the possibility of its presence is not considered. In some patients the persistence of toxic symptoms may be its only indication and the diagnosis is ultimately established on surgical exploration. The treatment of a subphrenic abscess is surgical. Occasionally, and fortuitously, a spontaneous cure may occur by rupture through the diaphragm into the lung and drainage externally by way of the bronchus. The mortality without operation is 85 to 90 per cent. If a mass is present, it is drained by an incision overlying its summit. When the abscess is occult, the approach may be right side or left side and either anterior or posterior depending upon its location. A clear understanding of the anatomy of the subphrenic spaces, as so well discussed by Barnard,! is believed an absolute necessity for the proper surgical management of patients with subphrenic abscesses. There are 5 subphrenic spaces which may be divided into right and left; superior and inferior; and anterior and posterior. On the right side there are 2 spaces: (1) the superior between the dome of the right lobe of the liver and the right leaflet of the diaphragm; (2) the inferior or SUbhepatic space, also known as Morison's pouch or fossa. Some authors have further subdivided the superior space into anterior and posterior compartments, separated by the right triangular ligament. However, I am in complete agreement with Harley4 that this is in error and not justified on the basis of anatomic fact. On the left side there are 3 spaces: (1) the superior, and (2) the inferior, in relation to the left lobe of the liver. The left inferior space is separated by the gastrohepatic omentum into 2 spaces, anterior and posterior. The posterior space is the lesser omental bursa.
In the drainage of abscesses located superiorly or inferiorly on the right side, and superiorly and antero-inferiorly on the left side, a posterior extra peritoneal approach through the bed of the resected twelfth rib, as originally advocated by Nather and Ochsner,6, 7 may be employed. In this regard an isolated left subphrenic abscess occurred in one of our own
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patients as a postoperative complication of an acute gangrenous and perforated appendix. The abscess occupied both the superior and anteroinferior subphrenic spaces and was drained through a left posterior extraperitoneal approach. When the abscess presents anteriorly as a mass, it may be drained through an anterior extraperitoneal approach, employing an oblique subcostal curvilinear incision. When the abscess is located in the left inferior, posterior space (omental bursa), it is drained transperitoneally. In fact, this is the only location of a subphrenic abscess which must of anatomic necessity be drained by the transperitoneal route. One should not terminate this discussion of subphrenic abscess as a postoperative complication without stressing the importance of early diagnosis and early surgical drainage. These cannot be overemphasized.
Pylephlebitis Fortunately, in the modern era of surgery, this dread and almost uniformly fatal complication is rarely seen. This is believed attributable to many factors, not the least important being the selective use of antibiotic and chemotherapeutic drugs. The symptoms are those of a rapidly progressive and fulminating systemic toxemia caused by a suppurative thrombophlebitis of the portal system and multiple intrahepatic abscesses. The occurrence of chills and high fever as associated symptoms of acute appendicitis was generally thought by older clinicians to augur well for the complication of pylephlebitis. The treatment is that of prevention since once it occurs, recovery is rare.
Ileus This is a common postoperative complication. Though more commonly present in patients with peritonitis, it may occur following an interval appendectomy. For convenience of discussion, ileus may be classified as early and late. Early or adynamic ileus occurs during the first 48 to 72 hours after operation and is a common accompaniment of peritonitis. The symptoms are those of progressive abdominal distention (tympanites), obstipation, and effortless vomiting. The abdomen is diffusely distended, tympanitic to percussion, and on auscultation bowel sounds are usually inaudible. Roentgenograms (scout films) of the abdomen characteristically show a gaseous distention throughout the small and large intestines. The immediate treatment is conservative. This consists of nasogastric intubation and suction siphonage, maintenance of a normal fluid and electrolyte balance, transfusions of fresh (less than 48 hours old), whole citrated blood, antibiotics, and warm rectal siphonage irrigations (Harris flush), using a warm soda bicarbonate solution. Many surgeons prefer intestinal intubation, which we ourselves have employed. Admittedly, there are many theoretic advantages to the use of the "long tube" for intestinal decompression. Unfortunately, however, it also has demonstrable disadvantages. Accordingly, nasogastric suction is the
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first preference. However, if after a suitable trial period, it is not effective, intestinal intubation may be prescribed. I am aware that many will take issue with this concept, in particular the staunch advocates of the "long tube." They may argue, and justifiably so, that by the preliminary use of nasogastric suction the "golden period" for the effectiveness of intestinal intubation may be lost. Indeed this may be true. These differences in opinion serve to emphasize the niceties of surgical judgment that are required in the successful management of patients with this complication. Late or dynamic ileus refers to the symptoms of obstruction which occur seven to ten days after operation. Although these symptoms may be secondary to an adynamic ileus, more frequently they are caused by mechanical factors. However, the differential diagnosis may be most difficult since an ileus which was initially adynamic in origin may prove to be a transient stage in the formation of a true mechanical obstruction. This difficulty in differential diagnosis is substantiated by the fact that patients with adynamic ileus have been operated upon for mechanical obstruction, and patients with dynamic ileus have been treated conservatively for prolonged periods on the basis of the diagnosis of an adynamic ileus. When the diagnosis of dynamic or mechanical ileus is reasonably established, the one danger is procrastination in treatment. Although the proponents of the "long tube" cite its advantages in relieving the obstruction due to fresh adhesions, it may cause a delay in surgical treatment which subsequently proves detrimental to the patient. There is an old adage in surgery, "mechanical obstruction necessitates mechanical intervention," which is believed particularly applicable to dynamic ileus. The sooner the mechanical factor is released, the better is the prognosis for the patient. Accordingly, it is firmly believed that early mechanical intervention (operation) is the prime treatment for dynamic or mechanical ileus.
Fecal Fistula A fecal fistula is another complication of appendectomy which is now seen infrequently. Its previous relatively high incidence was related to the associated high incidence of infection. Accordingly, the same factors previously mentioned which have been responsible for the lowered incidence of infection also are applicable to the decreased incidence of fecal fistula as a postoperative complication. This complication occurs 5 to 8 days after operation and is readily diagnosed. The immediate treatment is supportive and symptomatic. The wound is exposed to the room air by the use of a bed "cradle" to support the bedclothing. The application of copious wound dressings to absorb the discharge serves mostly as a "fecal poultice" which macerates and irritates the surrounding skin surface. Generally the fistula will close 9 to 12 days after its occurrence. This is often abrupt on the twelfth day. The persistence of a fecal fistula is usually related to the presence of (1) local infection, (2) obstruction in the bowel distal to the site of the fistula or (3) adherence of the bowel mucosa to the skin margins. Infection may act in a dual role and be a concomitant cause for the distal bowel obstruction. It should be treated by the selective use of antibiotics and chemotherapeutic drugs in combination with
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surgical drainage as indicated. Should the fistula persist, surgical exploration to determine the cause may be required. Tuberculosis, carcinoma of the cecum, regional enteritis, and foreign bodies, such as a gauze sponge or fecalith, are factors to consider. Barium enema roentgenograms are a diagnostic aid in determining the presence or absence of an associated obstructive lesion of the bowel. The persistence of a fecal fistula in excess of 2 months in association with roentgenographic evidence of bowel obstruction distal to the site of the fistula is believed an indication for operation. The type of operation performed would be dependent upon the local findings. The adherence of bowel mucosa to the skin margins is prima facie evidence that the fistula will not close spontaneously. Surgical closure is believed best accomplished by making an elliptical incision about the fistula and then dissecting the fistulous tract to its communication with the bowel lumen. At this site an ellipse of the bowel wall is excised and the opening closed in two layers using, preferably, interrupted sutures of 000 silk.
SUMMARY
Early postoperative complications after appendectomy occur regardless of the nature of the local disease process or the simplicity with which the operation is performed. Immediate thrombectomy of the superficial femoral vein or the inferior vena cava, dependent upon the extent of the thrombus, is the treatment of choice for acute fulminating thrombophlebitis (phlegmasia cerulea dolens). A "diarrhea" which occurs five to seven days postoperatively is frequently indicative of an occult pelvic abscess. In such patients a digital rectal examination should be performed before antidiarrheal medication is prescribed. The diagnosis of subphrenic abscess as a postoperative complication is frequently not made simply because the possibility of its presence is not considered. A thorough knowledge of the anatomy of the subphrenic spaces is a basic requirement and prime essential in the surgical treatment of a subphrenic abscess. The differential diagnosis between adynamic (nonmechanical) and dynamic (mechanical) ileus is oftentimes most difficult. When the diagnosis of dynamic or mechanical ileus is reasonably established, operation should be performed. Procrastination endangers the life of the patient. In the presence of a fecal fistula, the adherence of the bowel mucosa to the skin margins is prima facie evidence that the fistula will not close spontaneously. Accordingly, surgical closure is required. Eternal vigilance in the care of the patient is an absolute necessity for the early recognition of postoperative complications.
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DRUGS MENTIONED IN THE TEXT
Achromycin V (Tetracycline hydrochloride)
Lederle Laboratories Division American Cyanamid Company Pearl River, N.Y.
Alevaire (Superinone with 2 per cent soda bicarbonate and 5 per cent glycerin)
Winthrop Laboratories New York, N.Y.
Dornavac (Pancreatic Dornase)
Merck Sharp and Dohme Division of Merck & Co., Inc. West Point, Pa.
Heparin Sodium
The Upjohn Company Kalamazoo, Michigan
Isuprel Hydrochloride (Isoproterenol hydrochloride)
Winthrop Laboratories New York, N.Y.
Varidase (Streptokinase-Streptodornase)
Lederle Laboratories Division American Cyanamid Company Pearl River, N.Y.
Mucomyst (Acety lcysteine)
Mead Johnson Laboratories Evansville, Indiana
REFERENCES 1. Barnard, H. L.: Surgical aspects of subphrenic abscess. Lancet 1: 371-377; 429-436, 1908. 2. Coller, F. C. and Valk, W. L.: Delayed closure of contaminated wounds, a preliminary report. Ann. Surg. 112: 256-270, 1940. 3. Haight, C.: Intratracheal suction in management of postoperative pulmonary complications. Ann. Surg. 107: 218-228, 1938. 4. Harley, H. R. S.: Subphrenic Abscess. Springfield, Ill., Charles C Thomas, 1955, pp.4-7. 5. Madden, J. L.: Venous thrombosis and thromboembolism. Am. J. Surg. 87: 909916, 1954. 6. Nather, C. and Ochsner, A.: Retroperitoneal operation for subphrenic abscess. Surg. Gynec. & Obst. 37: 665-677, 1923. 7. Ochsner, A. and Graves, A. M.: Subphrenic abscess. Ann. Surg. 98: 961-990, 1933. 8. Ochsner, A. and Lilly, G.: Technique of appendectomy. Surgery 2: 532-554, 1937. 9. Webb, W. R.: Clinical evaluation of a new mucolytic agent, acetyl-cysteine. J. Thoracic & Cardiovasc. Surg. 44: 330, 1962.
St. Clare's Hospital 415 West 51st Street New York, N. Y. 10019
The immediate postoperative complications following appendectomy may be considered under four headings: (1) pulmonary, (2) cardiovascular, (3) wound and (4) peritoneal.
POSTOPERATIVE PULMONARY COMPLICATIONS
Atelectasis
This is one of the most common of the pulmonary complications and affects patients of all age groups. The symptoms are usually manifest within the first 48 hours and in general are directly related to the extent of the atelectasis. This may vary from a small segmental area to a massive involvement of the whole of one or more lobes of the lung. Correspondingly the patient may have few or no symptoms or symptoms of grave severity characterized by dyspnea, orthopnea, cyanosis, chills and hyperpyrexia (103° to 105° F.). Roentgenograms of the chest show areas of radiodensity commensurate in size with the number of lung segments that are occluded. Also the degree of mediastinal displacement to the affected side varies with the extent of the lung area that is blocked. Atelectasis may occur as a complication of local, spinal or general anesthesia. However, it occurs more frequently when a general anesthesia is administered. Although the exact mechanism for the occurrence of atelectasis may be obscure, there are general precautionary measures which, if observed, are believed to lessen its incidence. These precautions begin with the duties and responsibilities of the anesthesiologist relative to (1) preoperative medication and (2) conduct of the anesthesia. Both the From the Department of Surgery, St. Clare's Hospital, New York, N. Y. Department of Surgery, St. Clare's Hospital; Clinical Professor of Surgery, New York Medical College, Flower and Fifth Avenue Hospitals
* Director,
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drugs and the anesthesia should be administered according to the individual requirements of the particular patient. Oversedation preoperatively and the use of excesses in anesthesia should be avoided, especially in the elderly. Upon completion of the operation a careful tracheobronchial toilet in conjunction with the establishment and maintenance of a patent airway are mandatory. Elderly patients and those who have pre-existing pulmonary disease are given antibiotics routinely as a prophylaxis. Deep breathing exercises and occasionally aerosol therapy with Alevaire are also prescribed. The position of the patient should be changed frequently and early ambulation is recommended. When atelectasis is established as a postoperative pulmonary complication, active treatment is required. Nasotracheal catheter suction, as recommended by Haight,3 is used as frequently as indicated. In some instances bronchoscopic aspiration may be necessary. Dornavac, 100,000 units (2 cc.) or Mucomyst 9 (5 cc. of a 20 per cent solution) may be used as an aerosol, with alternating positive and negative pressure, two to three times daily for one to seven days. If desired, a bronchodilator (Isuprel hydrochloride) and/or antibiotic may be added. Achromycin V, 250 mg. orally every six hours, is also prescribed. Mucomyst (1 cc. of a 10 per cent solution) or Dornavac (1 cc.) also may be instilled into the trachea through a percutaneous catheter every four hours, or more frequently as required. Since coughing should be encouraged, depressive sedation is avoided. The treatment should be continued as the needs of the patient require. Pneumonia Fortunately this complication now occurs infrequently. It is believed that the decreased incidence is in the maih attributable to the use of the prophylactic measures previously described. Whereas atelectasis usually occurs during the first 3 days postoperatively, pneumonia as a complication is most frequently observed 6 to 9 days after operation. The clinical manifestations are dependent upon whether the pneumonia is lobar or bronchial in type. In lobar pneumonia, chills, hyperpyrexia (103 0 to 104 0 F.), circumoral cyanosis, dyspnea with expiratory grunt, splinting of the chest wall with diminished respiratory excursion, the anxious facies, rusty sputum, dullness to percussion, and bronchial breathing on auscultation overlying the affected lung are classical symptoms. On roentgenographic examination of the chest, the typical lobar infiltration is demonstrable. In bronchopneumonia, hyperpyrexia, dyspnea and varying degrees of cyanosis are also present. However, the physical signs are indicative of a bilateral diffuse infiltration of the lungs, which is productive of a characteristic roentgenographic appearance. The treatment of pneumonia, whether lobar or bronchial, is essentially the same. This consists of: (1) the administration of antibiotics and chemotherapeutic drugs which are used in large doses and on a selective basis dependent upon culture and sensitivity studies; (2) continuous oxygen with intermittent positive pressure; (3) aerosol antibiotics; (4) sedation only as required; (5) general supportive and symptomatic care.
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There are two complications of pneumonia, particularly of the lobar type, which are of surgical significance, viz., pleural empyema and lung abscess. Postpneumonic pleural empyema is suspected when fever persists in association with fluid in the pleural cavity and is confirmed by thoracentesis. The initial treatment is by repeat aspirations and the daily instillations of specific antibiotics and Varidase (streptokinase 200,000 units and streptodornase 50,000 units). If symptoms persist, closed intercostal tube drainage, and next in order, rib resection with open drainage may be required for cure. Following open drainage, a large-tube drain is used initially and subsequently replaced by progressively smaller tubes as the cavity diIninishes in size. The last tube should not be removed until the capacity of the cavity is less than 5 cc.
Lung Abscess A lung abscess may occur as a complication of pneumonia or from aspiration during the recovery phase of anesthesia. When secondary to aspiration, it is most commonly located in the posterior segment of the right upper lobe. The next most common location is in the apical segment of the right lower lobe. Characteristically the patient expectorates increasing quantities of purulent material which mayor may not have a foul odor. When the infection is caused by an anaerobic organism, the odor is foul, befitting the phrase, "putrid (fetid) lung abscess." In the early stages of infection roentgenograms (postero-anterior and lateral) of the chest show one or more circumscribed densities within the segmental areas previously described. When communications are established between the abscess and the bronchial system, air fluid levels are present. The initial treatment prescribed is general supportive and symptomatic coupled with the use of antibiotic and chemotherapeutic drugs. When drainage into the bronchial system occurs, postural drainage is prescribed. This is performed as frequently and as long as it can be tolerated by the patient. Should this prove unsatisfactory, external drainage, lobectomy or pneumonectomy may be required. Segmental resection is rarely permissible.
CARDIOVASCULAR COMPLICATIONS Coronary artery thrombosis may occur as a complication following appendectomy, particularly in patients in the fifth decade and beyond. Precautionary measures during the operation are: (1) the maintenance of a normal and stable blood pressure; (2) the maintenance of a free respiratory exchange and the use of high concentrations of oxygen; (3) the production of minimal operative trauma; (4) absolute hemostasis. However, despite all precautions a coronary thrombosis may occur, the treatment of which is supervised completely by the attending cardiologist. The more prevalent cardiovascular complication is a thrombophlebitis of the deep venous system of the lower extremities. This complication may occur in patients of all age groups, the exact cause of which may be difficult
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to define. However, there are certain predisposing causes to the formation of a deep venous thrombosis. These are: (1) operation (being discussed); (2) parturition; (3) trauma; and (4) prolonged confinement in bed. In addition there are basic contributory factors that are commonly associated with these predisposing causes, namely: (1) circulatory stasis; (2) hemorrhage; (3) shock; (4) infection; (5) malnutrition; (6) anemia; (7) dehydration. Contrariwise, there are patients in whom a deep venous thrombosis occurs without any evident predisposing or contributory causes. Stasis in the peripheral venous circulation is considered one of the most important factors in the formation of a thrombus within a vein. The return of the venous blood to the right side of the heart is dependent upon five factors: (1) the vis a tergo or the force of the heart beat; (2) the contraction of the muscles in the extremities; (3) the aspiration action of the thorax; (4) the viscosity of the blood; and (5) the effect of gravity. Disturbances in one or more of these factors that may induce venous stasis are commonly associated with heart disease, malnutrition, hemorrhage, shock, trauma, dehydration, improper positioning of the patient in bed, and finally the use of constricting dressings. The symptoms of a deep venous thrombosis vary from patient to patient. Examination of the affected extremity may reveal: (1) tenderness along the plantar aspect of the foot; (2) pain in the calf on dorsiflexion of the foot (Homans' sign); (3) tenderness on manual compression of the calf, and on palpation a feeling of fullness or "heaviness" of the calf; (4) duskiness of the toes and distention of the superficial veins on dependency of the limb; (5) swelling of the ankle or leg. However, the first symptom may be a pulmonary embolus, the symptoms in the affected extremity not appearing until five to seven days later. The disturbing fact in such patients is that the initial infarct may prove immediately fatal. In some patients an acute fulminating thrombophlebitis, or phlegmasia cerulea dolens, may occur. In this type shock is frequently present and death may occur within 36 to 48 hours. Chills are frequent and the fever is high (1040 to 1060 F.). The involved extremity is massively swollen and tender. Cyanotic rubor with diffuse petechial hemorrhages are commonly present. The massive swelling of the extremity and the associated reflex arterial spasm may occlude the peripheral arterial pulsation and simulate an embolic arterial occlusion (pseudo-embolic thrombophlebitis). It is differentiated from a primary arterial blockage by the concomitant massive swelling. The treatment of thrombophlebitis is based on the symptoms manifest in the particular patient. Initially, absolute bed rest is prescribed and the affected extremity is elevated on a pillow. Heparin, the anticoagulant of choice, is administered intravenously for 14 days in a gradually decreasing dosage. For the first three days, the total daily dosage of heparin (5000 units per cc.) is 8 cc. (40,000 units), which is administered in divided doses at four-hour intervals (8 A.M., 12 noon; 4 P.M. and 8 P.M.). The respective
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doses are: 2.5 cc. (12,500 units); 1.5 cc. (7500 units); 1.5 cc. (7500 units) and 2.5 cc. (12,500 units). For the second three days the total daily dosage is reduced to 5 cc. (25,000 units) and is given in divided doses at six-hour intervals (2 cc. at 8 A.M., 1 cc. at 2 P.M. and 2 cc. at 8 P.M.). For the third three days, 1.5 cc. is given twice daily at 8 A.M. and 8 P.M. Subsequently, and up to 14 days, a daily injection of 2 cc. (10,000 units) is given at 8 P.M. After the fourteenth day, this daily domge may be maintained depending upon the response of the patient. An alternate route after the third day would be the use of heparin, 1 cc. (20,000 units per cc.), daily, either intramuscularly or subcutaneously, and continued for the succeeding five to seven days. The dosage is then reduced to 0.5 cc. (10,000 units) for an additional five to seven days. When the first indication of a deep venous thrombosis is a nonfatal pulmonary embolus the main goal of treatment is the prevention of recurrent thrombo-embolism. Accordingly, ligation of the inferior vena cava is recommended by many. Others prefer the use of anticoagulants initially and reserve vena cava ligation for recurrent thrombo-embolism. The main objection to this reasoning is that the recurrent embolus may prove immediately fatal. My own preference is ligation of the inferior vena cava (Figs. 1,2). Objections to the ligation of the superficial femoral vein, either unilateral or bilateral, are: (1) the site of ligation may not be sufficiently high to be safely above the thrombus; (2) the collateral circulation is limited and a persistent and disabling swelling of the extremity may occur; (3) a thrombus may form cephalad to the level of ligation and be the origin of a fatal thrombo-embolism. In the treatment of acute fulminating thrombophlebitis (phlegmasia cerulea dolens), conservative measures are believed interdicted. Immediate operative intervention is recommended, the efficacy of which has been emphasized previously.s The operative approach is dependent upon the clinical findings. If the thrombus has extended into the pelvis, as indicated by edema of the sacral region, the lower portion of the abdomen, and beginning swelling of the opposite extremity, exposure and thrombectomy of the inferior vena cava is prescribed (Fig. 3). When the thrombotic process is limited to the lower extremity, thrombect.omy and ligation of the superficial femoral vein is performed (Figs. 4, 5). Ligation is preferred to suture closure of the phlebotomy site. Although an apparent paradox, less postoperative edema is observed after ligation than after closure. In seven patients with phlegmasia cerulea dolens, three were treated by thrombectomy of the inferior vena cava, two by unilateral thrombectomy of the superficial femoral vein, and two by bilateral thrombectomy of the superficial femoral veins, and in all excellent results have been observed. Procrastination in treatment by the use of anticoagulants or repeated paravertebral and subarachnoid procaine "blocks" is believed a danger to both life and limb. The concept of mechanical blockage is supported by the excellent results obtained, both immediate and late, after removal of
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Figure 1. Preventive ligation of the inferior vena cava. The patient is placed in the supine position and the right side is elevated on a pillow to an angle of 25 degrees to the horizontal (A). A transverse skin incision (A) is employed and the underlying muscles are separated in the direction of their fibers (B-D) to expose the herniation of the retroperitoneal fat through an opening being made in the transversalis fascia (F), (Continued in Figure 2.)
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Figure 2. Preventive ligation of the inferior vena cava (continued). By digital dissection the peritoneum is displaced medially and anteriorly (G) and retracted (H) to show the close proximity of the ureter to the anterior surface of the vena 'cava (H). The vena cava is mobilized and doubly ligated in continuity as depicted (I-M).
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.Figure 3. Ligation of the inferior vena cava in the presence of a thrombotic occlusion. The vena cava is incised between encircling but untied ligatures and the clot is evacuated by "digital milking" motions (0, P). The vena cava is occluded, preferably in continuity (Q), or by transection and occlusion (R, S).
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Figure 4. Thrombectomy and ligation of the superficial femoral vein. The patient is placed in the supine position and the head is elevated to an angle of approximately 20 degrees from the horizontal (A). The incision (B) is deepened through the underlying fascia (C) and the sartorius muscle is retracted laterally to expose the femoral vessels encased in the femoral sheath (C). The sheath is opened and the femoral artery is retracted laterally to expose the superficial femoral vein which is being incised with scissors (F). (Continued in Figure 5.)
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Figure 5. Thrombectomy and ligation of the superficial femoral vein (continued). The venous thrombus is removed by suction (G) and digital "milking," both retrograde (H) and antegrade (I). The vein is doubly clamped between ligatures (J), severed, and the ends occluded with transfixion suture ligatures.
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the thrombi that occlude the inferior vena cava or the superficial femoral vein. Thrombectomy and ligation of the superficial femoral vein is also preferred in the treatment of acute thrombophlebitis of the femoral vein in which there is a diffuse swelling of the affected extremity although it is not as severe as in the acute fulminating form just described.
POSTOPERATIVE WOUND COMPLICATIONS
Wound Infection
The most common wound complication following appendectomy is infection. Wounds are classified relative to their potential for infection. When the appendix is acutely inflamed but grossly intact, the wound is classified as clean-contaminated. When the appendix is perforated and free pus is present within the peritoneal cavity, either local (abscess) or diffuse, the wound is classified as clean-infected. This classification enables one to determine the comparative incidence of actual wound infection in each group of patients. The wound infection may be due to the same organism as cultured from the inflamed appendix, or to extraneous organisms. Accordingly, strict surgical asepsis should prevail throughout the conduct of the operation to minimize the occurrence of a secondary or mixed infection. Before the peritoneal cavity is entered, the cut surfaces of the wound are protected with gauze pads moistened in warm saline. If preferred, impervious pads may be used. During the removal of the inflamed appendix it is handled solely with instruments and particular care is observed to prevent its contact with any portion of the wound. When pus is present, it is removed as completely as possible by suction siphonage before the appendectomy is performed. Upon completion of the appendectomy the surgical team wash their hands thoroughly and, if required, change their gloves. In the closure of the wound a second set of sterile instruments is used. Except on rare occasions, the wound is closed in layers without drainage. Following the closure of each layer, peritoneal and fascial, the wound is irrigated thoroughly with copious quantities of hot (112 0 F.) saline. This is believed to effect: (1) a mechanical cleansing of all loose wound debris; (2) dilution of any existing wound toxins; and (3) a bactericidal action. If preferred, a penicillin solution (50,000 units per cc.) may be used for the wound irrigations. In patients with frank and excessive soiling of the wound, delayed closure, as advocated by Coller and Valk2 is advised. Postoperatively, all patients in whom the wound is classified as cleaninfected are given antibiotics routinely. The dosage is dependent upon the extent of the infection and may vary from 600,000 to 4,000,000 or 6,000,000 units of penicillin intravenously every six hours.
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Wound Dehiscence Wound dehiscence as a complication of appendectomy is not a common occurrence. The two most commonly related factors which predispose to a wound disruption are abdominal distention and the excessive contractions of the abdominal muscles which occur with bouts of coughing and vomiting. There is no constant relation between the incidence of burst wounds and the method of wound closure. This complication occurs whether catgut, silk or wire sutures are used, and whether the sutures are interrupted or continuous. The nutritional status of the patient preoperatively and the presence of a malignant growth are repeatedly stressed as important predisposing factors to the occurrence of a wound dehiscence. However, it seems a paradox that disruption of a wound is seldom observed in those patients in whom a portacaval shunt is performed for intractable ascites. Admittedly, such patients do have severe nutritional deficits, yet primary wound healing is the rule. Furthermore, the abdominal wounds of patients with nonresectable malignant tumors and concomitant peritoneal metastases most commonly heal without incident. The preceding may be contrasted with the case of a 47 year old man, in apparent excellent health as determined by a thorough preoperative evaluation, who suffers a complete wound disruption 7 days after a cholecystectomy is performed for chronic cholecystitis and cholelithiasis. This contrast is used to emphasize our lack of knowledge of many of the vagaries underlying wound healing. The classical harbinger of a burst wound is the sudden discharge of a copious quantity of serosanguinous fluid from the wound 6 to 9 days after operation. However, it is believed that the diagnosis frequently may be made several days sooner. In fact, in some patients the disruption is initiated in the transfer of the patient from the operating table to the stretcher. It has been observed that patients who disrupt their wounds commonly have abdominal distention and associated discomfort during the first 3 or 4 days postoperatively. In such patients a careful examination of the wound may establish the diagnosis at this time. Admittedly, in many patients with such symptoms, primary wound healing occurs. It is also admitted that the postoperative convalescence may be entirely without incident and yet the wound disrupts. In the treatment of the burst wound, immediate secondary closure is the preferred method. Rarely, there may be extenuating circumstances which would indicate coaptation of the wound with strips of adhesive tape. In the performance of a secondary wound closure stainless steel wire sutures, swedged on large curved cutting edge needles, are used and incorporate the whole thickness of the abdominal wall. For patients with incomplete wound disruption with the skin margins intact, although each presents an individual problem, in general immediate secondary closure is preferred. It is believed that this method offers the best prophylaxis for other postoperative complications, both immediate and late.
Hemorrhage Hemorrhage is usually an early complication and may be either external or internal. The cause of external bleeding is frequently an unoccluded vessel or vessels just beneath the skin surface. The bleeding may be readily controlled by the removal of two or three of the adjacent skin sutures and the application of clamp and ligature to the bleeding vessel. The "blind" application of a reinforcing dressing is condemned. A wound
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that is bleeding should always be immediately and carefully inspected to determine both the cause and the choice of treatment. The diagnosis of internal or acute wound hemorrhage is usually made relatively late. A hematoma in a wound, particularly a contaminated wound, is an ideal nidus for a subsequent wound infection. When the hematoma is small and there are no local or systemic signs of expansion, the treatment is conservative. However, when the hematoma is large or expanding in size, surgical evacuation of the clot and the suture control of any actively bleeding vessel is practiced.
POSTOPERATIVE PERITONEAL COMPLICATIONS
Hemorrhage The complication of bleeding into the peritoneal cavity may occur· early or late. Shock within the first six to 12 hours after operation should be considered to be due to acute blood loss until proved otherwise. Clinically the symptoms are: hypotension, tachycardia and small pulse volume, pronounced pallor, dyspnea, free perspiration, apprehension and syncope. It is indeed most surprising how frequently the symptoms of postoperative hemorrhagic shock are unrecognized by experienced surgical personnel which unfortunately many times includes the resident surgical staff. The cause is most commonly an actively bleeding vessel within the severed and ligated mesoappendix. The treatment is fluid and blood replacement, concomitant with immediate reopening of the abdomen to control the source of bleeding. To minimize this complication, particular precaution is required in the severance and ligation of the mesoappendix. A technique which is believed to predispose to this complication is the inclusion of the mesoappendix in a single mass ligature. Although this technique is rapid and frequently successful, it is considered a potential danger and should not be practiced. The preferred method is to serially clamp and sever the mesoappendix and to include only a small segment of tissue in each of the clamps. Each clamp is in turn replaced by a suture ligature of 000 silk for hemostasis. This area is again carefully inspected to determine the completeness of hemostasis before the wound is closed. Ochsner and Lilly 8 have observed acute massive intestinal hemorrhage from a severed and unligated intramural branch of the appendicular artery. Hemorrhage from this vessel is precluded if the base of the appendix is ligated. However, it may occur when the stump is inverted without previous ligation, a technique recommended by these authors. To prevent this complication they have advised that in the insertion of the purse-string suture for inversion of the unligated appendiceal stump, a "loop" be
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incorporated on the mesentery side of the base of the appendix to insure occlusion of this intramural artery should it be present. Late hemorrhage, seven to ten days after operation, is usually associated with an infection and caused by a tissue slough. Fortunately this complication is now a rare occurrence. Unlike the acute postoperative hemorrhage, bleeding may subside spontaneously. However, recurrence is always a likelihood as long as the infection persists. Because of the associated and oftentimes extensive inflammatory reaction in the neighboring tissues, operation is deferred unless warranted by chronic recurrent or excessive blood loss.
Pelvic or Lumbar Abscess An abscess within the pelvic or lumbar region is a relatively frequent postoperative complication, particularly after the removal of an acutely suppurative, gangrenous or perforated appendix. The onset of "diarrhea," five to seven days after operation should make one immediately suspect a pelvic abscess. All too frequently antidiarrheal medications are routinely prescribed and a most important examination, a digital rectal, is omitted. The "diarrhea" is most commonly spurious, consisting of colored mucoid material caused by an irritative colitis secondary to the pelvic abscess. Similarly the sudden occurrence of a fever five to seven days postoperatively or a continuous fever since the day of operation should make one suspect an occult abscess. In addition to a digital rectal examination the operative wound and its surrounding area should be examined carefully for the presence of either a wound infection or an intra-abdominal mass (abscess). When the diagnosis of a pelvic or lumbar abscess is established, the immediate treatment is conservative. The indications for operation are: (1) persistent toxicity as indicated by anorexia, chills, fever, drenching sweats, weight loss, and anemia; (2) progressive increase in the size of either the abdominal or pelvic mass; (3) a combination of the preceding. In the drainage of an abdominal (lumbar) abscess, the incision is made over the summit of the swelling to enter the abscess cavity. The optimum time to drain a pelvic abscess presents more of a problem. Generally speaking, when one is in doubt, drainage should not be attempted. Similarly the presence of an indurated mass is not an indication. The optimum time to drain is indicated when, on digital rectal examination, the "bag of waters" feel is transmitted. The abscess should first be entered by transrectal aspiration. The syringe is then disconnected and, with the needle as a guide, a No. 11 bladed scalpel is inserted and the abscess is opened widely. The opening is enlarged by digital exploration and the abscess cavity is emptied. Two Penrose (cigarette) drains are inserted and a perineal "fluff" dressing is applied. The drains are usually expelled within 48 hours, subsequent to which sitz baths are prescribed twice daily for seven to ten days.
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Subphrenic Abscess
One of the most common causes of a subphrenic abscess is acute appendicitis. It may occur as a postoperative complication regardless of the nature of the local disease process in the appendix. It may occur in a patient in whom the immediate postoperative course has been uneventful or in one in whom the convalescence has been "stormy." Usually the symptoms are manifest 14 to 18 days after operation and characterized by chills, fever (103 0 to 1040 F.), sweats, and anorexia. Additional clinical findings that may be manifest are: (1) tenderness to percussion on deep pressure overlying the lower rib cage, anteriorly or posteriorly; (2) dullness to percussion and diminished or absent breath sounds in the lower lung field; (3) limitation of the respiratory excursion of the ipsilateral costal arch; (4) palpable mass. A roentgenogram of the chest frequently may show a pleural effusion secondary to the irritative reaction caused by the subphrenic collection of pus. The diagnosis of a subphrenic abscess oftentimes is not made because the possibility of its presence is not considered. In some patients the persistence of toxic symptoms may be its only indication and the diagnosis is ultimately established on surgical exploration. The treatment of a subphrenic abscess is surgical. Occasionally, and fortuitously, a spontaneous cure may occur by rupture through the diaphragm into the lung and drainage externally by way of the bronchus. The mortality without operation is 85 to 90 per cent. If a mass is present, it is drained by an incision overlying its summit. When the abscess is occult, the approach may be right side or left side and either anterior or posterior depending upon its location. A clear understanding of the anatomy of the subphrenic spaces, as so well discussed by Barnard,! is believed an absolute necessity for the proper surgical management of patients with subphrenic abscesses. There are 5 subphrenic spaces which may be divided into right and left; superior and inferior; and anterior and posterior. On the right side there are 2 spaces: (1) the superior between the dome of the right lobe of the liver and the right leaflet of the diaphragm; (2) the inferior or SUbhepatic space, also known as Morison's pouch or fossa. Some authors have further subdivided the superior space into anterior and posterior compartments, separated by the right triangular ligament. However, I am in complete agreement with Harley4 that this is in error and not justified on the basis of anatomic fact. On the left side there are 3 spaces: (1) the superior, and (2) the inferior, in relation to the left lobe of the liver. The left inferior space is separated by the gastrohepatic omentum into 2 spaces, anterior and posterior. The posterior space is the lesser omental bursa.
In the drainage of abscesses located superiorly or inferiorly on the right side, and superiorly and antero-inferiorly on the left side, a posterior extra peritoneal approach through the bed of the resected twelfth rib, as originally advocated by Nather and Ochsner,6, 7 may be employed. In this regard an isolated left subphrenic abscess occurred in one of our own
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patients as a postoperative complication of an acute gangrenous and perforated appendix. The abscess occupied both the superior and anteroinferior subphrenic spaces and was drained through a left posterior extraperitoneal approach. When the abscess presents anteriorly as a mass, it may be drained through an anterior extraperitoneal approach, employing an oblique subcostal curvilinear incision. When the abscess is located in the left inferior, posterior space (omental bursa), it is drained transperitoneally. In fact, this is the only location of a subphrenic abscess which must of anatomic necessity be drained by the transperitoneal route. One should not terminate this discussion of subphrenic abscess as a postoperative complication without stressing the importance of early diagnosis and early surgical drainage. These cannot be overemphasized.
Pylephlebitis Fortunately, in the modern era of surgery, this dread and almost uniformly fatal complication is rarely seen. This is believed attributable to many factors, not the least important being the selective use of antibiotic and chemotherapeutic drugs. The symptoms are those of a rapidly progressive and fulminating systemic toxemia caused by a suppurative thrombophlebitis of the portal system and multiple intrahepatic abscesses. The occurrence of chills and high fever as associated symptoms of acute appendicitis was generally thought by older clinicians to augur well for the complication of pylephlebitis. The treatment is that of prevention since once it occurs, recovery is rare.
Ileus This is a common postoperative complication. Though more commonly present in patients with peritonitis, it may occur following an interval appendectomy. For convenience of discussion, ileus may be classified as early and late. Early or adynamic ileus occurs during the first 48 to 72 hours after operation and is a common accompaniment of peritonitis. The symptoms are those of progressive abdominal distention (tympanites), obstipation, and effortless vomiting. The abdomen is diffusely distended, tympanitic to percussion, and on auscultation bowel sounds are usually inaudible. Roentgenograms (scout films) of the abdomen characteristically show a gaseous distention throughout the small and large intestines. The immediate treatment is conservative. This consists of nasogastric intubation and suction siphonage, maintenance of a normal fluid and electrolyte balance, transfusions of fresh (less than 48 hours old), whole citrated blood, antibiotics, and warm rectal siphonage irrigations (Harris flush), using a warm soda bicarbonate solution. Many surgeons prefer intestinal intubation, which we ourselves have employed. Admittedly, there are many theoretic advantages to the use of the "long tube" for intestinal decompression. Unfortunately, however, it also has demonstrable disadvantages. Accordingly, nasogastric suction is the
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first preference. However, if after a suitable trial period, it is not effective, intestinal intubation may be prescribed. I am aware that many will take issue with this concept, in particular the staunch advocates of the "long tube." They may argue, and justifiably so, that by the preliminary use of nasogastric suction the "golden period" for the effectiveness of intestinal intubation may be lost. Indeed this may be true. These differences in opinion serve to emphasize the niceties of surgical judgment that are required in the successful management of patients with this complication. Late or dynamic ileus refers to the symptoms of obstruction which occur seven to ten days after operation. Although these symptoms may be secondary to an adynamic ileus, more frequently they are caused by mechanical factors. However, the differential diagnosis may be most difficult since an ileus which was initially adynamic in origin may prove to be a transient stage in the formation of a true mechanical obstruction. This difficulty in differential diagnosis is substantiated by the fact that patients with adynamic ileus have been operated upon for mechanical obstruction, and patients with dynamic ileus have been treated conservatively for prolonged periods on the basis of the diagnosis of an adynamic ileus. When the diagnosis of dynamic or mechanical ileus is reasonably established, the one danger is procrastination in treatment. Although the proponents of the "long tube" cite its advantages in relieving the obstruction due to fresh adhesions, it may cause a delay in surgical treatment which subsequently proves detrimental to the patient. There is an old adage in surgery, "mechanical obstruction necessitates mechanical intervention," which is believed particularly applicable to dynamic ileus. The sooner the mechanical factor is released, the better is the prognosis for the patient. Accordingly, it is firmly believed that early mechanical intervention (operation) is the prime treatment for dynamic or mechanical ileus.
Fecal Fistula A fecal fistula is another complication of appendectomy which is now seen infrequently. Its previous relatively high incidence was related to the associated high incidence of infection. Accordingly, the same factors previously mentioned which have been responsible for the lowered incidence of infection also are applicable to the decreased incidence of fecal fistula as a postoperative complication. This complication occurs 5 to 8 days after operation and is readily diagnosed. The immediate treatment is supportive and symptomatic. The wound is exposed to the room air by the use of a bed "cradle" to support the bedclothing. The application of copious wound dressings to absorb the discharge serves mostly as a "fecal poultice" which macerates and irritates the surrounding skin surface. Generally the fistula will close 9 to 12 days after its occurrence. This is often abrupt on the twelfth day. The persistence of a fecal fistula is usually related to the presence of (1) local infection, (2) obstruction in the bowel distal to the site of the fistula or (3) adherence of the bowel mucosa to the skin margins. Infection may act in a dual role and be a concomitant cause for the distal bowel obstruction. It should be treated by the selective use of antibiotics and chemotherapeutic drugs in combination with
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surgical drainage as indicated. Should the fistula persist, surgical exploration to determine the cause may be required. Tuberculosis, carcinoma of the cecum, regional enteritis, and foreign bodies, such as a gauze sponge or fecalith, are factors to consider. Barium enema roentgenograms are a diagnostic aid in determining the presence or absence of an associated obstructive lesion of the bowel. The persistence of a fecal fistula in excess of 2 months in association with roentgenographic evidence of bowel obstruction distal to the site of the fistula is believed an indication for operation. The type of operation performed would be dependent upon the local findings. The adherence of bowel mucosa to the skin margins is prima facie evidence that the fistula will not close spontaneously. Surgical closure is believed best accomplished by making an elliptical incision about the fistula and then dissecting the fistulous tract to its communication with the bowel lumen. At this site an ellipse of the bowel wall is excised and the opening closed in two layers using, preferably, interrupted sutures of 000 silk.
SUMMARY
Early postoperative complications after appendectomy occur regardless of the nature of the local disease process or the simplicity with which the operation is performed. Immediate thrombectomy of the superficial femoral vein or the inferior vena cava, dependent upon the extent of the thrombus, is the treatment of choice for acute fulminating thrombophlebitis (phlegmasia cerulea dolens). A "diarrhea" which occurs five to seven days postoperatively is frequently indicative of an occult pelvic abscess. In such patients a digital rectal examination should be performed before antidiarrheal medication is prescribed. The diagnosis of subphrenic abscess as a postoperative complication is frequently not made simply because the possibility of its presence is not considered. A thorough knowledge of the anatomy of the subphrenic spaces is a basic requirement and prime essential in the surgical treatment of a subphrenic abscess. The differential diagnosis between adynamic (nonmechanical) and dynamic (mechanical) ileus is oftentimes most difficult. When the diagnosis of dynamic or mechanical ileus is reasonably established, operation should be performed. Procrastination endangers the life of the patient. In the presence of a fecal fistula, the adherence of the bowel mucosa to the skin margins is prima facie evidence that the fistula will not close spontaneously. Accordingly, surgical closure is required. Eternal vigilance in the care of the patient is an absolute necessity for the early recognition of postoperative complications.
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DRUGS MENTIONED IN THE TEXT
Achromycin V (Tetracycline hydrochloride)
Lederle Laboratories Division American Cyanamid Company Pearl River, N.Y.
Alevaire (Superinone with 2 per cent soda bicarbonate and 5 per cent glycerin)
Winthrop Laboratories New York, N.Y.
Dornavac (Pancreatic Dornase)
Merck Sharp and Dohme Division of Merck & Co., Inc. West Point, Pa.
Heparin Sodium
The Upjohn Company Kalamazoo, Michigan
Isuprel Hydrochloride (Isoproterenol hydrochloride)
Winthrop Laboratories New York, N.Y.
Varidase (Streptokinase-Streptodornase)
Lederle Laboratories Division American Cyanamid Company Pearl River, N.Y.
Mucomyst (Acety lcysteine)
Mead Johnson Laboratories Evansville, Indiana
REFERENCES 1. Barnard, H. L.: Surgical aspects of subphrenic abscess. Lancet 1: 371-377; 429-436, 1908. 2. Coller, F. C. and Valk, W. L.: Delayed closure of contaminated wounds, a preliminary report. Ann. Surg. 112: 256-270, 1940. 3. Haight, C.: Intratracheal suction in management of postoperative pulmonary complications. Ann. Surg. 107: 218-228, 1938. 4. Harley, H. R. S.: Subphrenic Abscess. Springfield, Ill., Charles C Thomas, 1955, pp.4-7. 5. Madden, J. L.: Venous thrombosis and thromboembolism. Am. J. Surg. 87: 909916, 1954. 6. Nather, C. and Ochsner, A.: Retroperitoneal operation for subphrenic abscess. Surg. Gynec. & Obst. 37: 665-677, 1923. 7. Ochsner, A. and Graves, A. M.: Subphrenic abscess. Ann. Surg. 98: 961-990, 1933. 8. Ochsner, A. and Lilly, G.: Technique of appendectomy. Surgery 2: 532-554, 1937. 9. Webb, W. R.: Clinical evaluation of a new mucolytic agent, acetyl-cysteine. J. Thoracic & Cardiovasc. Surg. 44: 330, 1962.
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