For ectopic appendix, pathologically speaking, it is due to the patient's developmental malformation in the embryonic stage, abnormal colon rotation or insufficient descent after rotation, which can form an ectopic appendix.

Common ectopic appendices include extraperitoneal appendix, infrahepatic appendix, intramural appendix, left appendix and pelvic appendix. Some doctors have also encountered the appendix gradually shrinking and degenerating during the development process, resulting in congenital absence of the appendix.

This patient's condition is a typical subhepatic appendix.

If the subhepatic appendix is ​​searched using a conventional McLean incision, it will be difficult to find the lesion due to the limitation of the exposure range of the incision.

This time, Tanglou used ERAT to directly follow the colon from the inside and use the endoscope to enter the appendix cavity, which actually avoided the dilemma of not being able to find the appendix.

It's like a piece of intestine mixed in a bunch of intestines, and it's hard for you to tell which section is the end of the intestine.

But when you directly insert a tube into this section of intestine, no matter how curved the intestine is, as long as you push the tube along the wall to the head, you will definitely be able to touch the end of the intestine.

This is exactly what ERAT is, except that compared to a conventional appendix, the path of an ectopic appendix is ​​more tortuous, making it more difficult to enter the appendiceal cavity.

In the observation room, everyone was also curious about how Tanglou would complete such a difficult catheter insertion.

Tang Lou was seen controlling the LoopTip guidewire with one hand, while the other hand was placed on the patient's abdomen, calculating the path.

"What is he?"

In the observation room, everyone obviously did not expect that Tanglou would insert the guide wire in this way, relying solely on the direction of the subhepatic appendix to predict the insertion angle and strength of the guide wire.

Tanglou's hand wearing a transparent thin glove was seen starting to move toward the posterior peritoneum at the patient's right iliac fossa and right paracolic groove.

Use the tip of the index finger and the first knuckle of the thumb to move and gesture slightly on the patient's abdomen.

In the observation room, all the bosses were also staring intently.

"Smart! The ascending colon of the cecum of normal people is located in the right iliac fossa and the right paracolic groove, so in ordinary appendectomy, this is used as a mark. Now the patient has a subhepatic ectopic appendix, as long as it is along the right iliac fossa

The fossa and the right paracolic groove are located upward, and the protruding object is where the patient's cecum is."

Doctor Huang explained as he looked at Tanglou more and more. It was really a pity that this young man was in Hecheng No. 1 Hospital.

Sure enough, in the operating room, Tang Lou determined the direction of the ectopic appendix by positioning the index finger and thumb knuckles on the body surface.

The other hand controlled the guidewire and quickly passed through the cecum, covered by the ch’s valve, and entered the appendiceal cavity.

With the guidance of the guide wire, the subsequent catheter can naturally enter very smoothly.

The next step is to routinely aspirate the pus, then inject iohexol for angiography, and perform endoscopic retrograde appendicography (ERA).

"The X-ray showed the shape of the patient's appendix cavity. There was a fecal stone, confirming that the appendix was not perforated and gangrene. To confirm the diagnosis of acute appendicitis, remove the fecal stone and flush the appendiceal cavity."

Tanglou directly communicated the results with Ma En and others, and determined that ERAT could be continued, perforation and gangrene were ruled out, and traditional laparoscopic resection was avoided.

In the observation room, Professor Liu looked at Tanglou's operating procedures and this very typical case of ectopic appendicitis that was easily misdiagnosed, and said excitedly:

"This is what I said before, why we need to promote ERAT. For an ectopic appendix like this, it is very easy to be misdiagnosed as cholecystitis if conventional diagnosis is used, even with B-ultrasound, CT, magnetic resonance imaging (MRI) and other imaging modalities.

Examination methods. The diagnostic accuracy of CT for atypical appendicitis is 85%, and B-ultrasound is 82%. There is a very high possibility of misdiagnosis."

"And every misdiagnosis, especially for the elderly and children, if the diagnosis cannot be made within 36 to 48 hours of the onset of inflammation, the incidence of perforation will exceed 65%, so early diagnosis is very important."

"So, if ERAT is promoted, the purpose is not to perform ERAT in all cases, but to confirm the diagnosis first through endoscopic retrograde appendography ERA. If it is just simple acute appendicitis, then ERAT is performed directly, as is the case in Tanglou now.

situation. If it is diagnosed as perforation or gangrene, immediately switch to traditional laparoscopic appendectomy. Misdiagnosis can almost be avoided."

"That's why I think endoscopic retrograde appendography ERA will become the gold standard for the diagnosis of appendicitis."

With the perfect example of Tanglou in front of him, the credibility of Professor Liu's remarks is naturally greatly improved.

Several experts present nodded frequently. They were deeply impressed by the fact that Tanglou had neatly diagnosed a very difficult case of ectopic appendix.

The next step was naturally to remove the fecal stone very smoothly, rinse it, and finally insert the plastic stent.

Another ERAT was completed, and the time came to two o'clock noon.

In the following time, Tanglou naturally worked non-stop. Except for the preparation time between the two operations, he was operating and issuing instructions in an airtight manner.

By ten o'clock in the evening, Tanglou finally completed the last one, the sixteenth ERAT.

Among the 16 patients, 14 cases had purulent fur or pus and mucosal congestion and edema visible at the appendiceal fossa opening under endoscopy. Purulent secretions were seen in 2 cases during the intubation process, and in 2 cases only fecal stones were removed but not seen.

Pus.

The appendix cavity was intubated successfully with angiography catheters and guidewires in all cases. 9 cases were found to have filling defects (including massive and sludge-like filling defects) on angiography, which were successfully removed with a lithotomy balloon, followed by normal saline or metronidazole.

Plastic stents were routinely implanted in the remaining cases until the fluid outflow from the appendix cavity was clear with the injection and there was no filling defect after re-angiography.

...

Looking at the pile of data compiled simultaneously by the interns, all the experts were shocked.

Tanglou really successfully completed 16 cases of ERAT and one suspension type under their noses.

Moreover, there are many very rare cases such as pinworm appendicitis and ectopic appendix.

In the observation room, Cheng Jian lazily stood up and stretched his waist:

"Fortunately, everyone, is our hospital's development of ERAT okay?"

The expert group, having drunk a lot of bitter coffee at this moment, was really speechless.

Wen Dalong had lowered his head. He really couldn't understand why such a young doctor could have such strong surgical ability. Moreover, he was still looking energetic after having performed surgery for so long.

When Wen Dalong fell into isolation, Professor Liu stood up first, glanced around the observation room, and faced the tenement building on the screen.

"Bah bang bang!"

Hearing Professor Liu's applause, the other experts also reacted and stood up to applaud.

Wen Dalong dragged his numb feet, stood up shakily, and patted him a few times.

"Director Cheng, our inspection trip was very successful this time. Your hospital has shown us sufficient strength and confirmed that your hospital is capable of carrying out ERAT surgery. At the same time, I also believe that the general surgery department of your hospital is fully capable.

Build a provincial acute abdomen discipline point."
Chapter completed!