Open wound management has long been the most common practice after appendectomy for perforated appendicitis. Primary closure, however, has recently been advocated to reduce sabiston textbook of surgery 20th edition pdf and morbidity.
Perforated appendicitis was the indication for appendectomy in 65 of these patients. The incision wounds in these 65 patients were closed primarily in 41 and left open at the end of the operation in 24. Open wound management may be preferable to primary wound closure for perforated appendicitis in adults because of a lower incidence of SWI and a shorter LOS. Randomized clinical trials, however, are needed to establish these findings.
However surgeons use the term primarily to denote reproducible muscle pain in the limbs that occurs during exercise and is caused by ischemia. Most patients describe the pain as cramping in character , and moderate in severity. It is intermittent in the sense that pain stops when the patient rests. Pain is reproducible within the same muscle groups, and goes away after 2-5 minutes of rest. In its most typical form the location of claudication is the calves during walking, but in the lower limb the site may depend on the level of arterial occlusion. Arterial lesions in the distal superficial femoral artery will usually cause claudication in the calf muscle area.
Atherosclerosis involving the aortoiliac area may cause thigh or buttock muscle claudication . As the disease progresses, the MWD shortens. Typically, when claudication occurs, the patient stops to rest, and the pain disappears. If arterial occlusion is minimal, the pain may actually be relieved if the patient continues to walk instead of resting. The pain of muscle ischemia does not radiate.
Boyd classified the severity of claudication in 1949. This probably has little significance today in terms of therapy , but is reproduced here for its historical interest. Type I: The blood supply and demand are equal. On continued walking the pain disappears.
The equilibrium is attained just below the threshold of pain, therefore if the patient is asked to walk more quickly, the pain returns. Type II: Most patients are in this group. The equilibrium is attained just above the threshold of pain. Type III: The blood supply is so low that equilibrium cannot be attained.
The pain is intolerable, and the patient must stop walking. One must differentiate arterial claudication from neurological claudication, a symptom common in lumbar spinal stenosis . In both neurological and vascular claudication, the patient develops pain on exercise. In vascular claudication, the patient gets relief on rest.