After laparoscopic appendectomy (LA), the gastrointestinal tract is generally in a state of inhibition due to anesthesia and abdominal inflammation, and symptoms such as abdominal fullness and discomfort, warmth, vague pain and nausea often appear, and these patients have gastrointestinal motility disorders. For this reason, we applied the combination of rational gas and internal organs in the early post-LA period and obtained better results, which are reported as follows.
1. General information
A total of 64 patients, including 38 males and 26 females, aged 18-68 years, with an average age of 37.6 years, with 24 cases of simple appendicitis, 28 cases of suppurative appendicitis, and 12 cases of gangrenous or perforated appendicitis, underwent LA in Weifang Hospital of Traditional Chinese Medicine in Shandong Province and the First Affiliated Hospital of Guangzhou University of Traditional Chinese Medicine from September 2005 to December 2006.
The 64 appendicectomy patients were randomly divided into 32 cases each in the rational gas and internal organs combination treatment group and the blank control group, and the two groups were similarly distributed in terms of gender, age, appendicitis typing and length of operation time, which were comparable.
2. Anesthesia and surgical methods
Continuous epidural anesthesia was used in both patient groups. Before surgery, the patient was instructed to urinate, and no urinary catheter was required. A 10 mm curved incision was made at the infraumbilical margin, the abdominal wall on both sides was lifted with a scarf clamp, a pneumoperitoneum needle was inserted to test the water, and a pneumoperitoneum machine was connected after determining that the pneumoperitoneum needle was in the abdominal cavity, and the intra-abdominal pressure was maintained at 9-11 kpa, and a 10 mm trocar was removed and placed into the laparoscope to observe the whole abdominal cavity. mm trocar.
At this point, the patient is placed with a low head and foot, tilted 20° to the left, with the aim of allowing the intestinal canal and greater omentum to leave the right lower abdomen and fully expose the ileocecal region. The operator and assistant stand on the left side of the patient’s body head. The appendix is searched along the colonic band, and the adhesions around the appendix are separated with a separating forceps, or a small gauze block can be placed to expose the root of the appendix, and the tip of the appendix is grasped with a grasping forceps and lifted upward, and a certain tension is maintained, and the appendiceal tract is separated to the root in stages with an ultrasonic knife. After ligating the appendix with silk threads at about 5 mm and 10 mm from the cecum, the appendix was cut between the two threads. The mucosa of the appendiceal stump was electrocauterized by ultrasonic knife without embedding.
If the pus in the abdominal cavity is small, swabbing with a small sand block is sufficient. If the pus in the abdominal cavity is large, especially when the pus accumulates under the right diaphragm, the pus is first aspirated with an aspirator, then the local area is rinsed with saline, and an abdominal drainage tube is placed in the pelvis on the pubic symphysis.
3.Treatment method
In the treatment group, we started to take the combination of qi and internal organs (neem 15g, lycopodium 10g, mucuna pruriens 15g, citrus aurantium 10g, ocimum sanctum 10g, rhubarb 6g) orally on the first postoperative day and decocted it to 200ml in water. 100ml each time, twice a day, until the anal bowel movement was stopped. The control group did not use any postoperative drugs to promote gastrointestinal peristalsis, and was left to natural anal defecation. The postoperative rehydration and anti-inflammatory treatments were approximately the same in both groups. The time of anal exhaustion was calculated from the time of returning to the ward after surgery until the first obvious anal exhaustion, and the unit of measurement was in hours.
4.Results
All patients in both groups underwent successful laparoscopic appendectomy, no 1 case was converted to open abdomen, and no postoperative incision was infected. 56 patients were followed up for six months without 1 case of intestinal adhesion.
The postoperative anal venting of patients in the treatment group was compared with the control group by t-test, t=3.483, P<0.01, indicating that the time of venting in the treatment group was significantly shorter than that in the control group; the postoperative anal defecation of patients in the treatment group was compared with that in the control group by t-test, t=3.571, P<0.01, indicating that the time of defecation in the treatment group was also significantly shorter than that in the control group; for the correlation coefficient test between the two, r=0.71 for the treatment group and r=0.71 for the control group. The r=0.71, P<0.01 for the treatment group; r=0.74, P<0.01 for the treatment group, indicating that there was a positive correlation between exhaustion and defecation.
5. Discussion
Acute appendicitis is the most common general surgery disease, and the need for trans-laparoscopic surgery is still debated. The earliest report of laparoscopic appendectomy in foreign countries was Semm, a famous German obstetrician and gynecologist, who performed the first laparoscopic appendectomy in the world in 1982 and believed that it could replace the traditional appendectomy, and the earlier report of laparoscopic appendectomy in China was Jiang Xue and Zheng Minghua in Ruijin Hospital in Shanghai in 1993.
According to the latest literature, the infection rate of traditional open appendectomy wound is between 4% and 7%. In recent years, with the maturation of laparoscopic technology, LA has gradually become a safer and more effective surgical approach because of its.
(1) Minimally invasive advantages of laparoscopic technology. less pain and faster recovery after LA, can get out of bed on the day of surgery, can eat and drink the next day, and can be discharged from the hospital in three days; no scars on the abdomen and beautiful appearance.
(2) Very few wound complications. One of the common complications after open surgery for appendicitis is wound infection and some of them lead to incisional hernia, but during laparoscopic surgery, there is no contact between the appendix and the surgical channel, so wound infection and incisional hernia almost never occur.
(3) Few abdominal adhesions. In contrast, there was no 1 case of infection and no intestinal adhesions occurred in this study. This indicates that LA can reduce incisional infection and abdominal adhesions.
Although LA has the advantage of rapid recovery, gastrointestinal dysfunction still exists after LA, which is a pathophysiological state resulting from the temporary suppression of gastrointestinal motor function. It is generally believed that intestinal motility suppression due to excessive activation of the postoperative intestinal sympathetic nervous system is the main reason for its occurrence, and secondary factors include the direct inhibitory effect of anesthetic drugs and postoperative electrolyte imbalance. Therefore, due to the inflammation of the appendix itself, anesthesia and disturbance of water-electrolyte balance, postoperative gastrointestinal function often takes 2 to 4 days to recover.
The early or late recovery of postoperative gastrointestinal function is not only directly related to the patient’s feeding, nutritional intake and recovery, but also important for the prevention and treatment of postoperative abdominal distension, loss of appetite and other symptoms as well as intestinal adhesion complications. Clinical observation also found that the earlier the patient defecates, the more stagnant stool is discharged, the faster the symptoms and signs of abdominal distension are relieved, the less endotoxin is absorbed, and the faster the patient recovers after surgery. Modern research believes that surgery can traumatize human vital energy and lead to stagnation of blood vessels, poor qi flow and stagnation of internal organs due to deficiency of qi and blood flow.
After laparoscopic appendectomy, patients often suffer from Qi blockage and internal Qi obstruction. Therefore, the formula uses neem as the ruler to regulate qi, ventilate the internal organs and relieve pain; together with lycopodium, mucuna pruriens and ocimum sanctum to promote qi and regulate the middle of the body as the subordinate herbs; then hedgehog is used to eliminate food and ventilate the internal organs, supplemented by rhubarb to relieve heat and ventilate the lower part of the body, and less into the blood to remove blood stasis as the adjuvant herbs; so that the internal qi can be lowered and finally achieve the treatment purpose of regulating qi and ventilating internal organs.
The main ingredient in the formula, Citrus aurantium, has an excitatory effect on the gastrointestinal tract and can strengthen the gastrointestinal peristalsis; Mu Xiang and Wu Yao can stimulate the gastrointestinal tract and enhance gastrointestinal peristalsis; Rhubarb has the effect of stimulating the intestinal wall, promoting gastrointestinal peristalsis, discharging gas and fluid in the digestive tract, eliminating gas and distension and protecting the gastric mucosa.
Therefore, we believe that Ruiqi Tongxiangxie is a kind of gastrointestinal motility promoter. The mechanism of its action is to be further clarified through pharmacological experiments in animals. Through the observation of clinical application, we have learned that Li-Qi-Tong-Qi Tang for the recovery of gastrointestinal function after LA has the advantages of good efficacy, small dosage and economic and practical, which is suitable for clinical application.