腹膜炎继发阑尾炎（图文演示）

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Control of the mesoappendix can be accomplished in 2 ways:
- electrocoagulation is carried out as close as possible to the appendicular wall. All branches of the appendicular artery are coagulated, starting from the apex and working towards the base (monopolar or bipolar hook). This technique has the advantage of reducing the appendicular volume, thus making extraction easier.
- dissection of the mesoappendix starts at its base and the appendicular artery is controlled using clips or ligatures.
In case of bleeding at the level of the mesoappendix (obese patient, inflammation of the mesoappendix), bipolar coagulation is very useful.

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1. Base of the appendix
2. Clip
Control of the appendicular stump is an essential step that may prove tricky due to the edema of the bowel wall.
Ligature of the base of the appendix is performed using slowly absorbable sutures with either a surgical loop, or with intracorporeal or extracorporeal knots. Two ligatures are generally placed.
A clip or a ligature can be applied across the base of the appendix once its contents have been pushed towards the distal end of the appendix. This manipulation, which prevents fecal contamination during the division of the base of the appendix, can be done either by moving the partially closed clip applier transversally or with atraumatic graspers.
The appendix is divided at its base and a peanut swab soaked with an antiseptic (iodine, for example) is applied to the appendicular stump.
In cases of necrosis of the base of the appendix, the use of a mechanical stapling device or a suture of the cecum may prove necessary.

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The extraction of the appendix must always be performed with protection so there is no direct contact between the appendix and the abdominal wall.
The techniques used depend on the size of the appendix:
- removal of the appendix through the 10/11 mm trocar (left iliac fossa) or the use of a 10/5 mm reducer sleeve through the same trocar if the diameter of the specimen does not exceed 10 mm;
- placing the appendix in an extraction bag or in a finger of a surgical glove (less expensive method), and their extraction after removing the 10/11 mm trocar from the left iliac fossa.

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Abdominal lavage is an essential part of the procedure. It begins right after the general exploration and aims to rapidly eliminate as much contaminated fluid as possible. It is continued after suturing the appendix.
Peritoneal lavage is performed with warm saline (4 to 6 L) using a pressured suction-irrigation device until a clear effluent is obtained. It is often necessary to change the tilt of the operating table and to moderately shake the patient to ensure good distribution of the saline throughout the entire peritoneal cavity. All residual fluids must be aspirated.
Routine drainage of the peritoneal cavity is performed with silicone drains (from 12 to 18 French). Generally, the drains are removed through the suprapubic and right subcostal trocar sites and are placed at the level of the rectouterine pouch and the right paracolic gutter.
Trocars are removed one by one and hemostasis of the trocar sites is carefully checked. The musculo-aponeurotic plane is closed only at the 10/11 mm trocar sites. The skin is closed using staples or sutures.
The drains are removed when flow is less than 100 mL per day, provided they are not draining feculent, bloody or purulent material.
Intravenous antibiotic therapy is maintained depending on the severity of the peritonitis and at least until a culture of the pus taken during the procedure is obtained. If the culture is positive, antibiotic therapy is continued either intravenously or orally for 10 days.

14. Reference
Peritonitis secondary to appendicitis is traditionally treated either by an enlarged McBurney’s incision to the flank and the right lower quadrant (in case of local peritonitis) or by a median incision (in case of general peritonitis). The laparoscopic approach makes it possible to avoid a large incision in the abdominal wall and almost eliminates the risk of wound infection.
For peritonitis, laparoscopy is an excellent approach with both diagnostic and therapeutic benefits.
Laparoscopic exploration leads to an accurate diagnosis of the origin of the peritonitis in 85% of cases, and permits a precise assessment of the pathologies (perforated appendix, location of purulent collections).
More than 80% of the cases of peritonitis from perforated appendices can be treated via laparoscopy. When conversion to laparotomy proves necessary, it is often possible to limit the size of the incision and to place it more accurately.
There are no complications specific to laparoscopy. However, caution must be exercised and certain technical rules must be observed.
There are 2 risks related to the creation of a pneumoperitoneum in the context of intra-abdominal sepsis:
- hypercapnia: carbon dioxide absorption is increased by peritoneal inflammation,
- bacteremia: bacterial dissemination through the blood may occur either via bacterial translocation or direct bacterial passage through the lymphatics of the diaphragm and the thoracic duct.