Appendix surrounded with ligature at its base, after its isolation from its mesentery. Purse-string suture in place. (Gosset.)
Fig. 588
Complete detachment of appendix. (Gosset.)
In the subsequent closure of the external wound drainage is not made, there having been no pus to call for it; while the more perfectly the wound layers be closed, each with a row of chromicized catgut sutures, the peritoneal incision being first carefully approximated and over it the muscle and aponeurotic layers, each by itself, the less the tendency to subsequent postoperative hernia. On general principles, also, the shorter the incision the less the danger of this undesirable event. Nevertheless other considerations should not be sacrificed to shortness and beauty of the cutaneous scar.
The essentials of after-treatment of these cases have been already summarized in the previous section, and to these little exception may be taken in cases such as those above described. Every precaution should be taken to prevent vomiting, as every muscular effort involved in the act tends to disturb a freshly sutured wound. While violent muscular efforts of defecation are also to be deprecated, there is perhaps as much or more to be dreaded from the abdominal distention which may result from inattention to free intestinal elimination. Until the bowels have been moved it is best to restrain the diet to the simplest fluid nourishment. So soon as elimination becomes free more liberality in diet may be allowed. There is the same liability to and danger from other possible complications, such as postanesthetic pneumonia, anuria, or lack of expulsive power of the bladder, which requires the use of the catheter, in these as in other abdominal cases. Principles of treatment, however, do not vary, and the reader is referred to the previous section already indicated.
Paratyphlitic abscesses are to be distinguished from perityphlitic or peri-appendicular abscesses in that they arise from a phlegmonous process in the cellular tissue around the colon not due to intra-appendicular infection. In consequence of such a cellulitis more or less considerable collections of pus may form, which are most likely to present either in the loin or just in front of the cecum, which may burrow either upward or downward, or appear elsewhere. They are mentioned here, not because they are to be differently treated or surgically regarded, but because it is worth while to remember that here about the cecum and ascending colon, as on the left side, such pericolic abscesses may form without reference to the appendix.