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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_907_Библиотеки_им_академика_М_И_Перельмана
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FIGURE 1B • Hand-assisted Laparoscopic Splenectomy (HALS) Port
Placement.
Postoperative Care
Postoperatively, the patient is allowed clear liquids orally
and ambulates the night of surgery. The Foley catheter is
removed the following morning. Pain is controlled with
intermittent parenteral narcotics until the patient is able to
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take oral pain medication. Diet is advanced on
postoperative day 1, and the patient is discharged when
oral intake is tolerated and pain is controlled with oral
analgesics usually on postoperative day 2.
Case Conclusion
The patient does very well after LS. Her platelet count
returns to the normal range before discharge from the
hospital. At 6- and 12-month follow-up, the patient has
no clinical evidence of thrombocytopenia and has
normal platelet counts.
LS has become the “gold standard” for removal of the
spleen in the setting of ITP Although the increase in
platelet number that defines a complete response to
splenectomy varies between studies, numerous
retrospective reviews and prospective nonrandomized
trials have determined that the response rates (80% to
89%) and long-term remission rates (50% to 70%) to
LS are comparable to those following open
splenectomy, despite initial concern about the accuracy
of accessory spleen identification using laparoscopy.
LS also provides patients with improved short-term
morbidity. Reductions in postoperative morbidity
characteristic of minimally invasive procedures such as
reduced length of hospital stay and reduced
postoperative ileus have been consistently
demonstrated in patients with ITP who undergo LS.
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TAKE HOME POINTS
Immune thrombocytopenic purpura (ITP) is the most
common indication for splenectomy excluding
trauma.
Splenectomy is indicated for treatment of ITP in
patients with episodes of severe bleeding related to
thrombocytopenia, patients who fail to respond to 4 to
6 weeks of medical therapy, patients who require
toxic doses of immunosuppressive medications to
achieve remission, or patients who relapse following
an initial response to steroids.
Laparoscopic splenectomy (LS) is the optimal
approach for removal of the spleen in the setting of
ITP. It is associated with a shorter hospital stay,
decreased postoperative pain, and earlier return to
regular activities.
Accessory spleens are found in 10% to 15% of
patients and if not removed at the time of
splenectomy will lead to recurrence of ITP.
LS for ITP is associated with short-term response
rates of 80% to 89% and complete long-term
remission rates of 50% to 70% that are compatible
with outcomes for open splenectomy.
SUGGESTED READINGS
Bresler L, Guerci A, Brunaud L, et al. Laparoscopic splenectomy for
idiopathic thrombocytopenic purpura: outcome and long-term results.
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World J Surg. 2002;26:111–114.
Brunt LM, Langer JC, Quasebarth MA, et al. Comparative analysis of
laparoscopic versus open splenectomy. Am J Surg. 1996;172:596–
599;discussion 599–601.
Friedman RL, Fallas MJ, Carroll BJ, et al. Laparoscopic splenectomy for
ITP. The gold standard. Surg Endosc. 1996;10:991–995.
Mikhael J, Northridge K, Lindquist K, et al. Short-term and long-term failure
of laparoscopic splenectomy in adult immune thrombocytopenic purpura
patients: a systematic review. Am J Hematol. 2009;84(11):743–748.
Rescorla FJ, Engum SA, West KW, et al. Laparoscopic splenectomy has
become the gold standard in children. Am Surg. 2002;68:297–
301;discussion 301–302.
Targarona EM, Espert JJ, Cerdan G, et al. Effect of spleen size on
splenectomy outcome. A comparison of open and laparoscopic surgery.
Surg Endosc. 1999;13:559–562.
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10
Acute Appendicitis
SARAH E. GREER and SAMUEL R.G.
FINLAYSON
Presentation
A 24-year-old woman presents to the emergency
department with abdominal pain, nausea, vomiting, and
anorexia that began the previous evening. She
describes her abdominal pain as initially periumbilical,
but now localized to the right lower quadrant (RLQ). Her
temperature is 37.9. Her vital signs are otherwise
normal. On abdominal exam, her abdomen is soft and
nondistended, but tender to palpation over McBurney’s
point. She has no signs of peritonitis.
Differential Diagnosis
In the United States, acute appendicitis is the most
common time-sensitive surgical problem. The signs and
symptoms of acute appendicitis are believed to develop as
a result of obstruction of the appendiceal lumen. This
obstruction leads to bacterial proliferation, which can result
in appendiceal necrosis and perforation.
While the classic symptoms of abdominal pain
migrating to the RLQ, nausea, and anorexia occur in a
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majority of patients with acute appendicitis, symptoms may
be less specific, requiring clinicians to consider a broad
differential diagnosis, including gastrointestinal, urologic,
and gynecologic pathology. Alternative gastrointestinal
diagnoses that must be considered include gastroenteritis,
colitis, ileitis, diverticulitis, and inflammatory bowel disease.
Infectious causes, such as mesenteric adenitis, urinary tract
infection, and pyelonephritis, should also be considered. In
women, it is important to include Mittleschmirz, salpingitis,
tuboovarian abscess, ovarian torsion, and ruptured ovarian
cyst in the differential diagnosis.
Workup
A full history and physical exam must be performed to help
establish the diagnosis. In addition to eliciting a history of
symptoms and their temporal evolution, the surgeon should
ask the patient about any family history of inflammatory
bowel disease and a complete menstrual and pregnancy
history in women.
On physical exam, pain over McBurney’s point (onethird the distance from the anterior superior iliac spine to
the umbilicus) is a classic presenting sign of acute
appendicitis. Additional physical exam findings may
suggest appendicitis as a diagnosis.
Rovsing’s sign
is
pain in the RLQ when pressure is applied in the left lower
quadrant (LLQ); an obturator sign is pain with passive
rotation of the flexed right hip; and a psoas sign describes
pain on extension of the right hip, the latter commonly
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present in patients with a retrocecal appendix that lies in
contact with the iliopsoas muscle. A pelvic exam in women
of childbearing age must not be omitted, as it may reveal
gynecologic conditions to which the patient’s symptoms
can be attributed.
Laboratory tests that should be obtained include a
complete blood count, which will typically reveal a lowgrade leukocytosis. Other laboratory tests that should be
ordered include a coagulation profile, type and screen (if an
operation is anticipated), and a urinalysis to exclude urinary
pathology. A pregnancy test should also be performed in
women of childbearing age.
In the patient above, pelvic exam reveals no adnexal
mass or cervical motion tenderness. Laboratory evaluation
reveals a leukocytosis of 16,000. The patient is otherwise
healthy, with no history of previous abdominal surgery and
no pertinent family history.
Diagnostic Imaging
In young males with symptoms and signs consistent with
acute appendicitis, imaging studies to confirm the
diagnosis are generally unnecessary prior to proceeding to
surgery. In many cases, however, when the diagnosis is not
clear after thorough history taking and physical
examination, imaging may be helpful in making the
decision whether or not to proceed with surgery. Many
clinicians are more liberal in the use of imaging in young
female patients, both because of the presence of
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gynecologic conditions in the differential diagnosis and
because of the risk of infertility associated with ruptured
appendicitis that might result from a delay in diagnosis.
The two most common imaging modalities used in the
diagnosis of appendicitis are ultrasound and computed
tomography (CT). CT has demonstrated significantly higher
sensitivity for the diagnosis of appendicitis, 94% versus
83% to 88%. However, because CT scans expose patients
to ionizing radiation, this modality should be used
judiciously, especially in children.
Although CT scans are an expensive technology, a
focused contrast CT scan limited to the appendix may
actually be cost saving. A study by Rao et al. found that
routine appendix-focused CT in patients with suspected
appendicitis prevented unnecessary appendectomies as
well as unnecessary hospitalization for observation, with a
net reduction in use of hospital resources and cost per
patient.
In the patient in this case, a CT scan was performed
that demonstrates a dilated, thickened appendix with
surrounding inflammatory changes, consistent with acute
appendicitis (Figure 1).
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FIGURE 1 • CT radiograph showing appendiceal dilation, wall thickening,
and periappendiceal fat stranding consistent with acute appendicitis.
Diagnosis and Treatment
Although a few studies in the surgical literature support
nonoperative management of nonperforated acute
appendicitis, surgical appendectomy represents the
standard of care in the United States. Management of the
15% to 30% of patients who present with perforated
appendicitis is controversial. Perforated appendicitis with
abscess can be treated initially with antibiotics and imageguided percutaneous drainage, with interval appendectomy
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6 to 12 weeks later to prevent recurrence. This approach
has been advocated to decrease complication and
reoperation rates associated with immediate
appendectomy for perforated appendicitis. However,
others have argued that an immediate operative approach
to perforated appendicitis may improve long-term
outcomes and consume fewer healthcare resources.
Surgical Approach
The technique for open appendectomy was described by
McBurney in 1894 and has been used with little
modification throughout the 20th century. In 1983, Semm
introduced the option of laparoscopic appendectomy.
Since then, there has been much debate regarding the
superiority of one approach versus the other. Advantages
of laparoscopic appendectomy include the ability to
perform diagnostic laparoscopy if the appendix is found to
be normal. Laparoscopic appendectomy is also
associated with less postoperative pain, faster recovery,
and lower wound infection rates. In contrast, open
appendectomy has been found to be less costly and less
time-consuming.
Open Appendectomy
Following administration of preoperative antibiotics and
induction of general anesthesia, with the patient in a supine
position, an incision is made in an oblique or transverse
direction overlying McBurney’s point. The subcutaneous fat
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