A condition perhaps a little less serious but always perplexing is that of gangrene of a limited area of cecum around a gangrenous appendix. To remove the appendix alone in this condition is to accomplish nothing, while to meet the indication may require the exsection of a small area of cecal wall or the resection of the entire cecum, or perhaps in cases of limited extent the enfolding of the gangrenous area and the suture of its edges in such a manner that when it sloughs it may slough into the bowel cavity.
When the surgeon sees a case of peri-appendicular (the old perityphlitic) abscess late, and after it is easily recognized, he should operate according to the local indication, making incision perhaps short and placing it at a point where pus will apparently be most easily reached and best drained. Most of these instances present rather on the side or even in the loin behind the colon, and here a posterior incision might be sufficient. This may here be more liberal, since there is little danger of postoperative hernia, while through it one may possibly expose the cecum freely and often reach even the appendix itself. In making this opening it is well, if possible, to separate the fibers of the transversalis by blunt dissection. Here, as in all of the other incisions made toward the outer side of the body, the opening should be made, if possible, obliquely and parallel to the branches of the iliohypogastric nerves, which are thereby avoided and loss of sensation thus prevented. In fact this posterior method is sometimes even more rapid, and preferable in exceedingly fat patients, while it will always cause less shock and abdominal distress than does an anterior section; moreover, drainage takes place in the most desirable direction.
Fecal fistula is sometimes the immediate and unavoidable, sometimes a more or less delayed and apparently inevitable, result or complication of some of these operations. In the former instance it will be because of more or less gangrene or the necessity for an immediate enterostomy. In the latter case it results from conditions which are concealed, but may be imagined, comprising the giving way of tissues already compromised or else being a continuation of the ulcerative or gangrenous process. These complications are always unpleasant and untoward, though they rarely reflect upon the method or judgment of the operator, being essentially inevitable. If only the fecal outflow escape externally the condition may be regarded as inconvenient and temporary. Only in those instances in which the peritoneal cavity is contaminated does septic peritonitis ensue. The majority of these fecal fistulas close spontaneously by granulation tissue. Sometimes closure is rapid, sometimes delayed, in which latter case it may be stimulated by the use of silver nitrate, as already indicated above. In a few instances the condition is so extensive or so permanent as to justify or require further operation, which may be in the nature of a curettement of the fistulous tract, a slight plastic procedure, including a buttonhole suture about the opening, or possibly a complete intestinal resection. I have seen small, fistulous tracts discharge occasionally, even for years, and then finally close spontaneously, and have far oftener seen some form of spontaneous closure than necessity for operative intervention. The danger of infection around any such fistulous tract is ever present, and when it has occurred the fact will be made known by increase of edematous granulations, with swelling and tendency to breaking down. In every such case active cauterization, or, better still, the use of the curette, will be required.
A tuberculous form of chronic appendicitis, as well as tuberculous infection of a subacute exudate, is possible, the case being converted into one of greater chronicity, with more or less mild but constant septic features (hectic). In any event, so soon as the tuberculous element can be recognized radical measures should be instituted.
Fig. 583
Omentum being gently lifted in order to uncover the appendix enclosed with its fold. (Lejars.)
Fig. 584
Appendix delivered from the abdominal cavity and brought to view. (Lejars.)