Fig. 585
Separation of the meso-appendix. (Gosset.)
Operation for Chronic or Recurring Appendicitis; Internal Operations.
—Other things being equal the most favorable time at which to remove the appendix is that when pathological processes are least active. If, therefore, there be a choice the interval of quiescence rather than the stage of active infection would be chosen. Interval operations, so called, are usually comparatively simple, both in principle and technique. There are times, however, when it is difficult to find a partially obliterated appendix which has been covered up in thickened peritoneum or partially organized exudate. In such a case considerable blunt dissection or separation may have to be done before it can be removed. In those instances is this particularly true where it had originally a retroperitoneal location, and at no time a free or movable position. When difficult of recognition we may be unerringly led to it if we but follow the bands of white fibrous tissue on either side of the cecum to their junction.
The opening by which the appendix should, under these circumstances, be reached may again be made at the point of election, and should best be located over the area of greatest tenderness. Whatever incision is selected we should endeavor to separate muscle bundles as much and incise as little as possible. The appendix being delivered through the wound, either before or after ligation of its mesentery, and being thus completely isolated, is removed close to the large intestine, its base being tied and its structure being seized within the blades of a forceps in such a way that none of its contents may escape. The scissors with which it is divided are contaminated by its contents and should not be used again until cleansed. The stump on the proximal side may be touched with the actual cautery, or scraped and then cauterized with pure carbolic acid or formalin solution in order to thoroughly disinfect it. Subsequent treatment of this stump differs with different operators. Some are satisfied to leave it thus cauterized, while others cover it with the adjoining peritoneum, which is brought together over the stump end by either a purse-string or a continuous suture. Yet others have been satisfied to invert the ends of the stump into the cecum and thus leave it with or without further protection. It seems to make really very little difference how the stump is treated, providing only it be disinfected and prevented from leaking. Nevertheless it would appear preferable to give it at least a peritoneal covering to prevent adhesions ([Figs. 583] to [588]).
Fig. 586
The base of the appendix is tied with silk. The meso-appendix is being tied in sections with the Cleveland needle. (Richardson.)
Fig. 587