001. Diagnostic operations include:
1) appendectomy;
2) hernia repair;
3) lymph node biopsy;
4) reduction of shoulder dislocation;
5) opening of the panaritium.
002. Operations are classified according to urgency:
1) emergency, urgent, palliative;
2) planned, emergency, multi-stage;
3) emergency, urgent, planned;
4) radical, planned, palliative;
5) diagnostic, non-urgent, one-stage.
003. Emergency surgery is indicated for:
1) varicose veins lower limbs;
2) lipoma;
3) perforated gastric ulcer;
4) trophic ulcer;
5) liver cancer.
004. Planned surgical treatment is performed for:
1) acute appendicitis;
2) strangulated hernia;
3) bleeding from a damaged vessel;
4) asphyxia;
5) gallstone disease.
005. Prevention of thromboembolic complications after surgery includes:
1) bandaging the lower extremities with an elastic bandage;
2) use of anticoagulants;
3) use of antiplatelet agents;
4) getting up early;
5) all of the above.
006. Operation for vital indications is performed when:
1) ongoing bleeding;
2) benign tumor;
3) malignant tumor;
4) obliterating endarteritis;
5) varicose veins veins of the lower extremities.
007. In case of acute blood loss and stopped bleeding during surgery, a transfusion is performed:
2) intralipid;
3) hemodesis;
4) fibrinogen;
5) epsilonaminocaproic acid.
008. Radical surgery includes:
1) cholecystectomy;
2) gastrostomy for a wound of the esophagus;
3) bypass anastomosis for colon cancer;
4) biopsy;
5) puncture of the pleural cavity.
009. Preoperative measures to reduce the risk of infection surgical wound:
2) antibiotic therapy;
3) shaving skin;
4) cleansing gastrointestinal tract;
5) all of the above.
010. Specify an activity aimed at preventing pulmonary complications after surgery:
1) prescription of iron supplements;
2) inhalation of nitrous oxide;
3) gastric lavage;
5) cold on the stomach.
011. Bowel preparation in the preoperative period involves the appointment of:
1) expectorants;
2) slag-free diet;
3) tube feeding;
4) cleansing enemas;
5) cold on the stomach.
012. Changes in the general blood test characteristic of acute blood loss:
1) increase in ESR;
2) decrease in hemoglobin level;
3) eosinophilia;
4) leukocytosis;
5) increase in hematocrit.
013. For endogenous intoxication, the following is prescribed:
1) antispasmodics;
2) infusion therapy;
3) painkillers;
4) anticoagulants;
5) frequent change of dressings.
014. A study that helps in the diagnosis of pulmonary embolism:
1) biochemical analysis blood;
2) electrocardiography;
3) general urine analysis;
4) fibrobronchoscopy;
5) rheovasography.
015. Prevention of suppuration of a surgical wound:
1) frequent stitches on the wound;
2) absorbable sutures on the wound;
3) wound drainage;
4) physical therapy;
5) sealed bandage.
016. Preoperative preparation for appendectomy includes:
1) premedication;
2) cleansing enema;
3) shaving the skin of the abdominal wall;
4) psychological preparation;
5) emptying Bladder.
017. All factors contribute to the occurrence of thromboembolic complications in the postoperative period, except:
1) the presence of varicose veins of the lower extremities;
2) exhaustion;
3) obesity;
4) the presence of cancer;
5) old age.
018. Complications from a surgical wound include everything except:
1) bleeding;
2) hematomas;
3) infiltrate;
4) pain in the wound;
5) eventration.
019. The phase of tissue trauma during postoperative illness is characterized by:
1) catabolic type of metabolism
2) redistribution of water and electrolytes between “aqueous environments”
3) the excretion of total nitrogen in urine does not exceed 3 g per day
4) anabolic processes prevail over catabolic processes
5) preferential consumption of endogenous energy
Select a combination of answers
020. The anabolic phase of the course of postoperative illness is characterized by:
1) restoration of muscle mass
2) lysis of proteins and accumulation of their breakdown products
3) activation of the hormonal system
4) restoration of nitrogen balance
5) the supply of exogenous energy exceeds the body’s consumption
Select a combination of answers
1 – asymptomatic stage;
2 – stage of clinical manifestations;
3 – stage of complications.
(ultrasound) or fluorography.
Stage 3 of the disease is characterized by various complications, the most common of which is suppuration of cysts. Due to the presence of two cyst shells - chitinous and fibrous, infection of the cyst may not be clinically manifested for some time, and only as the fibrous capsule is destroyed, symptoms of general intoxication, hectic fever with chills, and a septic state appear.
No less dangerous is the development of obstructive jaundice, which develops as a result of compression of the main bile ducts by the cyst or due to the cyst breaking into the large bile ducts with blockage of their daughter bladders and the remnants of their membranes. The consequences of biliary hypertension can be biliary cirrhosis of the preserved liver parenchyma, purulent cholangitis.
1 – radical methods;
2 – organ-preserving methods.
1) roundworms;
2) Giardia;
3) actinomycetes;
4) cysticercoma;
5) pinworms.
1) trichinella;
2) pinworms;
3) actinomycetes;
4) alveococcus;
5) cysticercoma.
1) actinomycetes;
2) pinworms;
3) echinococcus;
4) cysticercoma;
5) Giardia.
1) cysticercosis;
2) giardiasis;
3) actinomycosis;
4) schistosomiasis;
005. Indicate the possible primary “host” of echinococcus:
1) man, monkey;
2) pig, sheep;
3) cow, deer;
4) horse, camel;
5) fox, dog.
006. Human infection with echinococcus occurs when:
1) consumption of smoked meat and fish;
2) consumption raw eggs and fish;
3) inhalation of the pathogen with dust;
4) fur dressing;
5) in all the above cases.
007. Echinococcus spreads in the human body through:
1) intestines;
2) interfascial spaces;
3) blood and lymphatic vessels;
4) urinary tract;
5) biliary tract.
008. Indicate the selective localization of echinococcus in the human body:
1) kidneys, adrenal glands, spinal cord;
2) gastrointestinal tract;
3) lungs, brain, liver;
4) subcutaneous tissue, bone marrow;
5) pancreas, spleen.
009. Specify the membranes of the echinococcal bladder:
1) intermediary, mesothelial;
2) pyogenic, intermediate;
3) membranous, serous;
4) germinal, chitinous;
5) epithelial, granulation.
010. It is not typical for the clinical manifestation of echinococcosis:
2) peritonitis;
3) pleurisy;
4) abscess formation;
011. In the diagnosis of echinococcosis, it is not essential:
1) anamnesis;
2) plain radiograph of the abdomen;
3) endoscopy;
4) Casoni reaction;
5) eosinophilia.
012. Treatment measures for echinococcosis include everything except:
1) therapy with mebendazole;
2) opening and draining the cavity;
3) enucleation;
4) organ resection;
5) opening and treating the cavity with formaldehyde.
013. Prevention of echinococcosis is:
1) taking antibiotics;
2) taking sulfonamides;
3) immunization of the rural population;
4) rehabilitation of domestic animals;
5) prevention of microtrauma.
014. The primary “host” of roundworm is:
1) dog;
2) horse;
3) pig;
5 people.
015. Human infection with roundworms occurs when:
1) violation of asepsis during injections;
2) accidental damage to the skin;
5) damage to the oral mucosa.
016. The maturation of roundworm eggs to the point of possible human infection occurs:
1) in the human intestine;
2) when fermenting vegetables;
3) when canning vegetables;
4) in the soil;
5) in raw milk.
017. What is not typical for the manifestation of ascariasis?
1) general intoxication;
2) hyperthermia;
3) intestinal obstruction;
4) cholecystocholangitis;
5) peritonitis.
018. Ascariasis can manifest itself in everything except:
1) general intoxication;
2) peritonitis;
3) leukocytosis;
4) cholecystocholangitis;
5) intestinal obstruction.
019. K surgical methods Treatment of complications of ascariasis include:
1) oxygen therapy;
2) chemotherapy;
3) venesection;
4) enterotomy, appendectomy;
020. Filariasis can manifest itself in everything except:
1) trophic ulcer;
2) phlegmon;
3) lymphadenitis;
4) anaphylaxis;
5) enteritis, pneumonia.
Lecture 31. ONCOLOGY
Oncology is the area medical science and practices aimed at studying tumor diseases (oncos - tumor, logos - science), as well as their prevention and treatment.
Clinical oncology deals with two types of neoplasms: benign and malignant tumors.
Based on the histological structure, epithelial, connective tissue, muscle, vascular, nervous and mixed tumors are distinguished.
When naming all benign tumors, the suffix - oma is added to the characteristics of the tissue from which they originated: lipoma, fibroma, myoma, chondroma, osteoma, angioma, neurinoma, fibromyoma, neurofibroma, etc.
All malignant neoplasms are divided into two groups - tumors of epithelial origin - cancer, and tumors of connective tissue origin - sarcoma.
Basic properties of tumors.
There are two main differences between a tumor and other cellular structures of the body:
Autonomous growth
Cell polymorphism and atypia.
Cells that have undergone tumor transformation begin to grow and divide without stopping, even after the factor that caused the tumor process is eliminated. In this case, the growth of tumor cells is not subject to the influence of any regulatory mechanisms, that is, it is not controlled by the body. This growth of tumor cells is called autonomous.
Cells that have undergone tumor transformation begin to multiply faster than the cells of the tissue from which they originated. At the same time, in varying degrees Cell differentiation may be impaired, which leads to their atypism - morphological difference from the cells of the tissue from which the tumor developed, and polymorphism - the appearance in the structure of the tumor of cells of different morphological characteristics. While maintaining sufficiently high differentiation, the tumor usually grows slowly, which is typical for benign tumors. Poorly differentiated or undifferentiated cells are characterized by rapid, aggressive growth, which is characteristic of malignant tumors.
The main advantageous differences between benign and malignant tumors are as follows:
Etiology and pathogenesis of tumors.
Currently, there is no single theory of the origin of tumors; let’s look at the main ones.
1. Virchow's theory of irritation.
Indeed, sometimes cancer develops in areas of the body or organ that are exposed to chronic irritation over a long period of time. For example, lip cancer in smokers, esophageal cancer at the level of physiological constrictions, stomach cancer along the lesser curvature, etc. However, Virchow’s theory cannot explain the development of tumors in areas of the body where there was no chronic irritation, it does not explain the development of congenital tumors, etc. .
2. Conheim's embryonic theory.
According to Conheim's theory, all tumors originate from excess, stray germ cells that remain out of touch with developing organs. These cells remain dormant for a long time and, under the influence of some endo- or exogenous factor, acquire activity. Less differentiated cells multiply and give rise to atypical growth - a tumor.
3. Viral theory.
The role of viruses (oncoviruses) in the development of certain types of tumors has now been clearly proven. The virus, entering the cell, acts at the gene level, disrupting the regulation of cell division.
4. Immunological theory.
According to this theory, various mutations constantly occur in the body, including tumor transformation of cells. But the immune system quickly identifies the "wrong" cells and destroys them. A disturbance in the immune system leads to the fact that some of the transformed cells are not destroyed and cause the development of a neoplasm.
None of the presented theories reflects the general pattern of oncogenesis. The mechanisms reflected in them are important only at a certain stage of tumor development.
5. Modern polyetiological theory.
The most common idea about the causes of tumor diseases is the so-called polyetiological theory, which assumes the possibility of tumor development under the influence of various tumor triggering factors. These factors are:
Mechanical factors: frequent, repeated tissue trauma with subsequent regeneration;
Chemical carcinogens. Already in 1964, a WHO special commission established that in almost 80% of human cancer cases it is caused by chemical carcinogens. They are found in atmospheric air, food products, etc. More than 800 are known chemical substances with carcinogenic properties, but only 34 of them were carcinogenic to humans;
Physical carcinogens: ultraviolet and ionizing radiation.
For a tumor to occur, there must also be internal causes: genetic predisposition and a certain state of the immune and neurohumoral systems.
Spread of tumors in the body.
Benign tumors grow unhindered on surfaces, in the lumens of hollow organs, and in tissues they grow equally expansively in all directions.
Local spread of malignant tumors can occur in a wide front or in the form of separate foci in all directions, penetrating into neighboring tissues and organs.
With lymphogenous spread, tumor cells disseminate to regional lymph nodes in the direction of the lymph flow, where they form a daughter tumor (metastasis).
Hematogenous spread occurs through direct penetration of tumor cells into the bloodstream. Hematogenous metastases occur most often in large organs with a widespread capillary adhesive surface.
Diagnostics.
The clinical picture of tumors is determined, on the one hand, by the nature of the tumor - benign or malignant, on the other hand - by the localization of the tumor, that is, the appearance of symptoms in those organs and tissues where they develop. Therefore, when diagnosing a disease, it is necessary to answer first of all the following questions:
1) whether the patient has a true tumor, or whether the swelling mistaken for a tumor is a symptom of another disease;
2) benign or malignant tumor, whether there are tumor metastases;
3) is this tumor operable?
Diagnosis of tumors should include the maximum number of activities aimed at early detection malignant neoplasms:
1. medical history,
2. clinical trial,
3. laboratory research,
4. X-ray examination,
6. biopsy,
7. cytological diagnosis,
8. radioisotope diagnostics,
10. ultrasound scanning,
11. computed tomography, etc.
With malignant tumors, cachexia often develops, which is expressed in a rapidly increasing decline in nutrition, anemia such as hypochromic anemia, loss of appetite, general weakness, etc.
The importance of early diagnosis in oncology should be emphasized.
Classification of tumors
The classification of benign tumors is simple. They are divided into types depending on the tissue from which they originated. For example: fibroma - connective tissue tumor, fibroid - tumor muscle tissue, fibroids, etc.
Currently, the international TNM classification and clinical classification of malignant tumors are generally accepted.
When classifying TNM, a certain characteristic of tumors is given according to the following parameters: T (tumor) - size and local spread of the tumor.
N (nodus) - presence and characteristics of metastases in regional lymph nodes.
M (metastasis) - the presence of distant metastases.
For tumors accessible to palpation, such as breast cancer, T1 means a tumor with a diameter of up to 2 cm, T2 means a tumor 2-5 cm, T3 means more than 5 cm.
For tumors that are inaccessible to palpation (for example, stomach cancer), size determination is carried out during laparotomy or on a removed specimen. In this case, T1 means that the cancer is localized within the mucous membrane, T2 - spreads to the serous membrane, T3 - the tumor grows into the serous membrane, T4 - infiltrates into neighboring organs.
With regard to the involvement of lymph nodes in breast cancer, No means that the axillary lymph nodes are not palpable, N1 - mobile axillary lymph nodes on the affected side are palpated, N2 - fixed lymph nodes are palpated, N3 - supraclavicular and subclavian lymph nodes are palpated.
The absence or presence of distant metastases is designated Mo and M1, respectively.
Distribution of cancer at stage 4 and by TNM system can be presented as follows: stage I - T1NoMo, stage II - T2N1Mo is operable, stage III - T3N2Mo - relatively operable, stage IY - T4N3M1 - inoperable.
Early diagnosis
In oncology, there is a concept of timely diagnosis. In this regard, early, timely and late diagnosis are distinguished.
ABOUT early diagnosis they say in cases where the diagnosis is made at stage I - the clinical stage of the disease. A timely diagnosis is made at stage II, and in some cases at stage III of the process; late is a diagnosis made at stages III – IY of the disease.
Precancerous diseases
Called precancerous chronic diseases, against the background of which the incidence of malignant tumors sharply increases. So, for the mammary gland, dyshormonal mastopathy is a precancerous disease, for the stomach - chronic ulcer, polyps, and some benign tumors are also precancerous.
Patients with precancerous diseases should be dispensary observation and timely sanitation.
General principles tumor treatment
Treatment of benign tumors is only surgical. In this case, the tumor must be removed entirely, and not in parts, and together with the capsule, if any. The excised tumor will necessarily undergo histological examination. Absolute indications for surgery are permanent trauma to the tumor, dysfunction of the organ, changes in tumor growth and suspicion of malignancy, and cosmetic defects.
Treatment of malignant tumors includes surgery, radiation therapy and chemotherapy. In this case, the main one, of course, is the surgical method.
The basic oncological principles of surgical treatment include:
1) radicality - complete removal of the tumor within healthy tissues, 2) ablasticity - removal of the tumor in a single block with regional lymphatic vessels and nodes,
3) antiblasticity - destruction during surgery of individual tumor cells that have separated from the main mass, which is achieved by using an electric knife, a laser scalpel, and treating the wound surface with 70 o alcohol.
Taking into account these principles, standard surgical schemes have been developed for various tumors, providing for maximum radicalism (for example, for stomach cancer, extirpation or subtotal resection of the stomach is performed with removal of the greater and lesser omentum).
For advanced tumors with distant metastases, radical surgery is not possible; in these cases, palliative surgeries are performed. In this case, the effect on the tumor itself is minimal or absent, but it alleviates or improves the patient’s condition and prolongs his life.
Radiation therapy. Main goal radiation therapy is the complete or partial destruction of tumor cells by affecting both the main focus and regional lymph nodes. Radiation treatment It is based on varying degrees sensitivity to ionizing radiation of malignant tumor cells and healthy tissue cells. The therapeutic effect is achieved, on the one hand, by the high sensitivity of malignant tumor cells, and on the other hand, by their lower ability to undergo reparative processes after damage. Ionizing radiation leads to metabolic disorders, destruction of the chromosome of tumor cells, the cell membrane of energy systems. Radiation therapy uses X-ray irradiation, gamma irradiation (isotopes of cobalt, cesium, iridium), beta therapy (radioactive gold, phosphorus), and flows of elementary particles (electrons and protons). Radiation therapy is often combined with surgical treatment.
Chemotherapy - different effects on the tumor pharmacological drugs. You need to know that so-called antitumor drugs act on both tumor and healthy cells (side effects).
The following groups of chemotherapeutic agents are distinguished:
1. Cytostatics - inhibit the proliferation of tumor cells, inhibiting their metabolic activity. Main drugs: 1) alkylating agents (cyclophosphamide, thioTEF), drugs of plant origin (vinblastine, vincrastine).
2. Antimetabolites - act on metabolic processes in tumor cells. Main drugs: metatrexate, 5-fluorouracil, phytorafur.
3. Antitumor antibiotics - mainly affect DNA chains. The main antibiotics are actinomycin, dactinomycin, sarcolysin, rubromycin, doxorubicin, carbinomycin, metamycin.
Immunotherapy used to activate and normalize the body's immunoprotective mechanisms in the postoperative period, after radiation and chemotherapy. Main drugs: levamisole, zymosan, prodegiosan, interferons, etc.
Hormone therapy used for the treatment of hormone-dependent tumors. For example, androgens (methyltestosterone, testosterone propionate) are used for breast cancer; estrogens (sinestrol, Androcur, etc.) are prescribed for the treatment of prostate cancer.
In the process of treating a patient, all three methods of treating malignant tumors can be combined. Indications for one or another treatment method or their combination are established depending on the stage of the tumor, its location and histological structure.
Tests for the section: Oncology.
001. Please specify clinical sign benign tumor:
1) rounded shape and lobed structure;
2) motionless and fused with surrounding tissues;
3) enlarged lymph nodes are palpated;
4) the tumor is painful on palpation;
5) fluctuation above the tumor.
002. Which of the following tumors is benign?
1) melanoma;
2) fibroadenoma;
3) adenocarcinoma;
4) lymphosarcoma;
5) fibrosarcoma.
003. Cancer develops from:
1) immature connective tissue;
2) glandular or integumentary epithelium;
3) blood vessels;
4) lymph nodes;
5) smooth or striated muscles.
004. Which tumor affecting connective tissue is malignant?
1) fibroma;
2) lipoma;
3) chondroma;
4) osteoma;
5) sarcoma.
005. What is characteristic of a benign tumor?
1) rapid growth;
2) infiltrating growth;
3) cachexia;
4) fatigue;
5) lack of adhesion to surrounding tissues.
006. What is characteristic of a benign tumor?
1) rapid growth;
2) infiltrating growth;
3) tendency to relapse after surgery;
4) lack of ability to metastasize;
5) a sharp effect on metabolism.
007. What is not typical for a malignant tumor?
1) the presence of a capsule;
2) structural atypia;
3) metastasis;
4) structural polymorphism;
5) relative autonomy of growth.
008. What feature is not typical for a malignant tumor?
1) spreads through lymphatic vessels;
2) it grows into neighboring tissues;
3) may exist throughout the patient’s life;
4) develops quickly and for no apparent reason;
5) after removal of the tumor, a relapse occurs.
009. All studies contribute to the detection of a tumor, except:
1) the patient’s medical history;
2) endoscopic studies;
3) laboratory data;
4) biopsy;
5) bacteriological culture.
010. What indication is necessary for radiotherapy?
1) low sensitivity of tumor cells;
2) high sensitivity of tumor cells;
3) the presence of necrotic ulcers in the irradiation zone;
4) appearance of symptoms radiation sickness;
5) the possibility of surgical treatment.
011. When is radiation therapy not used?
1) as an independent method of treatment;
2) as an auxiliary method of treatment after surgery;
3) as a method of preparation for surgery;
4) in combination with chemotherapy;
5) how individual method treatment.
012. What is not an absolute indication for surgical treatment for a benign tumor?
1) compression of a neighboring organ;
2) constant injury to the tumor by clothing;
3) accelerated tumor growth;
4) long-term existence of the tumor;
5) suspicion of malignant degeneration.
013. Indicate incorrectly. By ablastic we mean:
1) treating the wound with alcohol after tumor removal;
2) frequent change of instruments, linen, gloves during surgery;
3) repeated hand washing during the operation;
4) avoiding massage and biting the tumor during surgery;
5) tissue incision away from the tumor.
014. Antiblastics include everything except:
1) administration of antitumor antibiotics;
2) applications hormonal drugs;
3) use of chemotherapy drugs;
4) use of radiation therapy;
5) carrying out physical procedures.
015. Which route of tumor spread and metastasis is practically impossible?
1) lymphatic;
2) through blood vessels;
3) contact;
4) implantation from one patient to another.
016. What is not a complication of radiation therapy?
1) weakness;
2) nausea, vomiting;
3) sleep disturbance;
4) formation of metastases in distant organs;
5) leukopenia.
1) the tumor was completely removed;
2) no visible metastases were detected during surgery;
3) 5 years have passed since complex treatment;
4) no complaints are made;
5) all with the above.
018. Research methods are used to diagnose tumors:
1) clinical, laboratory and endoscopic;
2) diagnostic operations;
3) x-ray and radiological;
4) cyto- and morphological;
5) all of the above.
019. By oncological alertness of a doctor we mean:
1) suspicion of cancer;
2) careful collection of anamnesis;
3) use of general and special research methods;
4) analysis and synthesis of the obtained data;
5) all of the above.
020. The main complaints of a patient with malignant tumors are all except:
1) rapid fatigue;
2) loss of appetite, weight loss;
3) nausea in the morning;
4) apathy;
5) progressive intermittent claudication.
Lecture 32. INTRODUCTION TO TRANSPLANTOLOGY
Moral, ethical, legal and organizational provisions of transplantology.
Human-to-human organ transplantation is one of the most remarkable achievements modern medicine. Transplantology, as a science, has only in the last three decades moved from the experimental to the clinical stage of its development, but today the old dream of humanity about replacing damaged or diseased organs with new ones has left the realm of science fiction and is being developed in many industries. developed countries.
To date, there are more than one and a half thousand transplant centers in the world, which have performed about four hundred thousand kidney transplants, more than forty thousand heart transplants, over fifty thousand liver transplants, more than seventy thousand transplants bone marrow. Heart-lung transplants and pancreas transplants are also performed.
Naturally, the development of clinical transplantology, aimed at providing medical care to previously incurable patients, increases the need for donor organs, and their number is limited. At the same time, the number of patients waiting for an organ transplant is constantly increasing. For example, there are currently more than 700 patients on the kidney transplant waiting list (this is the name of the list of patients who need an organ transplant formed at the transplant center) of the Research Institute of Transplantology and Artificial Organs, and about 150 transplants are performed at the institute every year.
To ensure the legal basis for clinical transplantology in most countries of the world, on the basis of humanistic principles proclaimed by the world community, appropriate laws on organ and tissue transplantation have been adopted. These laws stipulate the rights of donors and recipients, restrictions on organ transplantation, and the responsibilities of health care institutions and medical personnel.
The main provisions of the current laws on organ transplantation are as follows:
1. Organ transplantation can only be used if other means cannot guarantee the life of the recipient.
2. Human organs cannot be the subject of purchase and sale. These actions or their advertising entail criminal liability.
3. Removal of organs is not permitted if they belong to a person suffering from a disease that poses a threat to the life of the recipient.
4. Removal of organs from a living donor is permitted only if the donor is over 18 years of age and is in a genetic relationship with the recipient.
5. Collection of human organs is permitted only in government health care institutions. Employees of these institutions are prohibited from disclosing information about the donor and recipient.
6. Removal of organs from a corpse is not allowed if the health care institution at the time of removal was informed that during life this person, or his close relatives, or his legal representative declared their disagreement with the removal of his organs after death for transplantation to another person.
7. A conclusion about a person’s death is given on the basis of brain death.
Biological death and the concept of “brain death”.
The main and fundamental issue in determining the possibility of obtaining an organ for transplantation is establishing the moment of death and maintaining the functional usefulness of the removed organs.
Biological death that is, the state of irreversible death of the organism as a whole with total death of the brain can be stated on the basis of:
1. Traditional criteria for cessation of cardiac activity and respiration.
2. Based on brain death, that is, the irreversible cessation of brain functions, including the functions of its stem structures.
Moreover, in both cases, the criteria for declaring biological death are the combination of the actual cessation of brain functions with evidence of the irreversibility of this cessation. Biological death, based on traditional criteria, is determined by a combination of the following signs:
1. Cessation of cardiac activity, that is, the disappearance of the pulse for carotid arteries, absence of heart contraction according to auscultation and ECG, or fibrillary oscillations on the ECG.
2. Termination of spontaneous breathing.
3. Disappearance of central functions nervous system(lack of spontaneous movements, lack of reactions to sound, pain, proprioceptive stimuli, maximum dilation of the pupils and lack of their reaction to light, as well as lack of corneal reflexes).
These criteria for biological death do not apply to cases of cardiac arrest due to deep cooling or drug intoxication.
Brain death concept was first proposed by French neurologists in 1959. Currently, the statement of “brain death” in Russian Federation is carried out in accordance with the Law of the Russian Federation “On Transplantation of Human Organs and (or) Tissues” and is regulated by Order of the Ministry of Health of the Russian Federation No. 189 dated August 10, 1993.
Various things can lead to “brain death.” pathological conditions, but many of them themselves become contraindications to organ removal - heart disease, tumors, infections, poisoning - that is, diseases that can pose a danger to the recipient when the latter receives an organ from a sick donor. Therefore, organ removal is possible in case of “brain death” caused either by traumatic brain injury, or vascular lesions of the brain, or other reasons that are not capable of providing negative impact on the recipient's body after transplantation.
Complex clinical criteria, the presence of which is mandatory to establish a diagnosis of “brain death”:
1. Complete and persistent lack of consciousness (coma).
2. Atony of all muscles.
3. Lack of response to strong painful stimuli.
4. Lack of reaction of the pupils to direct bright light while stationary eyeballs ah (it should be known that no medications that dilate the pupil were used).
5. Absence of corneal, oculocephalic, oculovestibular, pharyngeal and tracheal reflexes.
6. Lack of spontaneous breathing.
If necessary, additional instrumental diagnostic methods are performed: electroencephalographic monitoring (assessment of electrical activity of the brain) and transcranial Dopplerography (assessment of the presence of blood flow in the terminal arteries of the cerebral cortex and the presence of blood perfusion through brain structures).
The diagnosis of “brain death” is established by a commission of doctors consisting of a resuscitation specialist and a neurologist (with specialists with at least 5 years of experience).
The successes of modern transplantology and educational and information programs implemented in all developed countries with the participation of the media have led to the public understanding of the concept of “brain death”. In the USA and Western Europe, the number of refusals by relatives to remove organs from their deceased loved ones is decreasing every year, and the number of people who, during their lifetime, have documented their consent after death to allow the use of their organs for transplantation, is also increasing.
Selection criteria for potential organ donors, donor conditioning, organ retrieval.
Set out in the order of the Ministry of Health of the Russian Federation No. 189 of August 10, 1993, “Instructions for ascertaining brain death,” developed on the basis of the achievements of modern medical science, fully complies with international criteria and is used in a number of national transplant programs. To date, based on experimental and clinical experience, general criteria for identifying and selecting potential donors after a diagnosis of brain death have been optimized and standardized.
Absolute contraindications to donation are:
2. Any malignant tumors (except primary brain tumors).
3. Infectious diseases (viral hepatitis, syphilis, tuberculosis, AIDS, cytomegalovirus disease).
4. History of diabetes mellitus, decompensated course of diseases of cardio-vascular system(hypertonic disease).
5. A long period of hypotension or asystole, leading to ischemic organ damage.
6. Systemic disease and metabolic diseases.
7. Intoxication (except carbon monoxide poisoning).
In recent years, the development of new methods for the preservation of cadaveric organs, advances in pharmacology and deepening of the understanding of the pathophysiology of transplants have made it possible to consider some contraindications to donation as relative. Among them are age over 50 years, uncomplicated hypertension, and some abnormalities of organ development.
One of the fundamental principles that guides transplantology is early notification of a potential donor to the transplant service, which allows for timely, adequate conditioning of the donor and ensures good and long-term function of the transplanted organ in the recipient’s body.
When a team of explantologists visits a potential organ donor, the decision on organ removal is made after documenting the occurrence of “brain death.” Before the explantology team arrives, the resuscitator provides mechanical ventilation (artificial pulmonary ventilation) and inotropic support with dopamine (adrenaline is not suitable for these purposes, as it impairs renal blood flow). If conditions allow, that is, the donor is hemodynamically stable, then a routine set of examinations is performed (blood type, Rh factor, general blood test, general urinalysis, biochemical blood test, if possible - blood electrolytes, ultrasound examination).
The trigger point for organ damage in the donor’s body in the terminal state of the latter is a violation of microcirculation, which manifests itself in a deterioration in the rheological properties of blood, vasospasm, and intravascular coagulation. All this leads to hypoxia, energy deficiency and acidosis. Thus, disturbances in organ microcirculation and disorders of intracellular metabolism cause cell damage and loss of function. This determines the main directions of medicinal effects on the donor’s body before organ removal for transplantation. Therefore, donor conditioning refers to the preliminary pharmacological protection of the graft in the donor's body.
Basic principles of donor conditioning:
1. Stabilization of hemodynamics (dopmin 1-2 mcg\kg\min, infusion of colloid and crystalloid solutions, albumin).
2. Providing the cell with a sufficient amount of oxygen and energy substrates (5% glucose solution, riboxin, cocarboxylase).
3. Prevention of vasoconstriction, cellular edema and electrolyte disturbances (droperidol, chimes, polyionic solutions).
4. Stabilization of the cell membrane and support of the adequacy of cellular metabolism (prednisolone, tocopherol acetate).
In itself, the removal of an organ for subsequent transplantation is a surgical intervention, the implementation of which is subject to the following requirements: strict asepsis and antiseptics, the shortest possible period of warm ischemia (that is, the time when the organ has already been switched off from the bloodstream, and its perfusion with a preservative solution has not yet begun ), inadmissibility of damage to the anatomical structures of the organ during removal.
There are several ways to preserve (preserve) donor organs for the period of time between removal and transplantation: cryopreservation - freezing, perfusion - constant washing of the organ with a special solution, and non-perfusion - the organ, after washing with a special solution, is preserved while in the same solution. Currently, the non-perfusion method of donor organ preservation is mainly used.
The solutions currently used for washing the organ after removal and preservation for the period before transplantation are EUROCOLLINS, CUSTODIOL, and VIASPAN solutions. They contain an optimal set of electrolytes, antioxidants and cell membrane stabilizers to preserve the viability of the donor organ. These solutions are intended for the preservation of various donor organs: kidney - EuroCollins, Custodiol; liver, heart – Viaspan. Preservation periods range from 24 to 72 hours at a temperature of +4 degrees Celsius.
Immunology in clinical transplantology.
Significant clinical experience in organ transplantation indicates the need to select donor-recipient pairs based on erythrocyte isoantigens (blood group) and histocompatibility antigens, since the transplantation antigenic barrier is the main factor determining the duration of the graft function in the recipient’s body, and sometimes the success of the transplantation itself. The system of transplantation antigens ensures the biological individuality of the body and takes part in the destruction of antigenically foreign substances, cells and tissues that penetrate into the body. Transplantation antigens are located on the surface of the membrane of all nucleated cells and are controlled by a group of genes called the major histocompatibility complex (HLA system, Human Leukocyte Antigen). The HLA system controls immune reactivity, including the rate and nature of transplant rejection, and the body’s predisposition to certain diseases. Currently, the structure of more than 160 antigens has been established.
Histocompatibility antigens are determined using serological methods using monoclonal antibodies, in particular the lymphocytotoxic test. This test is based on the ability of HLA antibodies in the presence of complement to cause the death of lymphocytes carrying the corresponding antigens on their surface membrane. After the reaction is performed, the number of dead cells is calculated and it is determined which antigens the cells of the organism under study contain, that is, immunological typing is performed.
For clinical immunological typing carried out as a pre-transplantation, the identification of antigens A, B, C and DR is of greatest importance.
When selecting donor-recipient pairs, it is also necessary to determine the presence in the recipient’s blood of antibodies to lymphocytes of a specific donor (specific cross-match) and determine the titer of pre-existing antibodies (antibodies to lymphocytes of randomly selected donors).
There must be a blood group match between the donor and recipient during transplantation (the matching scheme is similar to the scheme for blood transfusion).
Algorithm for immunological selection of a donor-recipient pair:
1. When selecting a recipient, patients who do not match or are incompatible in blood type are first excluded from the waiting list.
2. From these selected patients, more than 30% of lymphocytes die (positive cross-match) when performing a lymphocytotoxic test with donor lymphocytes.
3. From patients with a negative cross-match reaction, patients who match the donor according to the HLA system (A, B, C, DR antigens) are selected.
4. The last test in selection is the titer of pre-existing antibodies.
Surgical principles and stages of surgery on the recipient for kidney transplantation.
Preoperative examination and preparation of recipients for kidney transplantation are very important stages in the treatment of patients with end-stage chronic renal failure. The examination includes anamnestic analysis, clinical data and instrumental and laboratory tests:
1. Blood type and Rh factor.
2. Titer of pre-existing anti-leukocyte antibodies.
3. Liver tests.
4. Antibody titers to hepatitis B and C viruses, cytomegalovirus.
5. HBs antigen, Wasserman reaction, antibodies to HIV.
6. Radiography chest.
7. ECG, ultrasound of the heart.
8. FEGDS – fibroesophagogastroduodenoscopy.
9. Ultrasound of organs abdominal cavity.
10. Consultation with a dentist, ENT doctor, sanitation of the oral cavity.
When examining a candidate for kidney transplantation, absolute contraindications to surgery may be identified:
· disseminated tumor diseases
Chronic heart failure in the stage of decompensation
Chronic pulmonary insufficiency in the stage of decompensation
active hepatitis, liver cirrhosis
· mental disorders
· HIV infection.
While waiting for transplantation, patients are on program hemodialysis, they are corrected for metabolic disorders, and the course of arterial hypertension and anemia is monitored (recombinant erythropoietin is used to treat anemia in patients with chronic renal failure). The waiting period for a kidney transplant can range from several months to several years.
Kidney transplant surgery It is performed under endotracheal anesthesia or under epidural anesthesia.
In the vast majority of cases, the kidney graft is placed in the iliac region, retroperitoneally, in a heterotopic (contralateral to the donor kidney) position. Technically, the operation involves the creation of three anastomoses:
1) between the graft artery and the iliac artery (internal or external) of the recipient
2) between the graft vein and the recipient external iliac vein
3) between the graft ureter and bladder recipient.
The time that elapses between removal of the graft from the preservative solution until the graft is included in the bloodstream is called secondary warm ischemia time and should not exceed 30–40 minutes. During surgery, considerable attention is paid to careful lympho- and hemostasis, but neglect of this can lead to the development of postoperative hematomas and lymphoceles.
Post-transplantation period, methods of monitoring the condition of the patient and the transplant.
Immediately after kidney transplantation, the following course options are possible: postoperative period:
1. Fast recovery diuresis
2. Acute renal failure (ARF) of the transplant
3. Transplant rejection crisis
4. Combination of acute renal failure and rejection crisis.
From the first hours after surgery, immunosuppressive therapy begins, antibacterial therapy, prevention of complications from the cardiovascular, digestive and respiratory systems.
Immunosuppressive therapy includes the prescription in most cases of 3 components: cytostatics, corticosteroids, cyclosporine.
The main cytostatic drug is azathioprine (imuran). Azathioprine in the liver is converted into active metabolites, similar in structure to natural metabolites involved in the synthesis of purine and pyrimidine bases of DNA and RNA, displaces natural metabolites from cells and inhibits cell proliferation. These processes lead to a decrease in the number of T lymphocytes, disruption of the process of antigenic recognition and suppression of their cytotoxicity.
Of the corticosteroids, a constant component of post-transplant immunosuppression is prednisolone, which inhibits antibody formation, phagocytosis, and causes lymphocytolysis. A common disadvantage of cytostatics and corticosteroids is the non-selective nature of their effect on the immunobiological resistance of the body: the function of all immunocompetent cells is suppressed, which in turn causes the development of a significant number of infectious complications.
Therefore, the emergence of selective immunosuppressants (cyclosporine, poly- and monoclonal antilymphocyte antibodies) in the late 70s made it possible to significantly improve graft survival and reduce the incidence of infectious complications, which marked the beginning of a new stage in the development of clinical transplantology. Cyclosporine (Sandimmune, Neoral) suppresses the production of interleukin-2 by T helper cells, which disrupts the proliferation of cytotoxic lymphocytes - the main participants in the rejection reaction. Thus, unlike azathioprine and corticosteroids, cyclosporine does not interfere with the transplant patient's ability to fight infections.
In addition to immunosuppressants, in the post-transplantation period it is mandatory to prescribe drugs such as H 2 blockers (prevention of erosive and ulcerative lesions of the stomach and duodenum), antibiotics wide range(prevention of infection), disaggregants (prevention of thrombosis of vascular anastomoses and disseminated coagulation in graft vessels).
The condition of the kidney transplant is assessed based on general clinical, laboratory and instrumental data. Among laboratory methods, determining the level of cyclosporine in the patient’s blood is of greatest importance: an insufficient level can lead to the development of a rejection crisis and loss of the graft, and a significant increase in the level of cyclosporine in the blood is dangerous for the development of side effects. Of the instrumental techniques, it should be noted ultrasound of the transplant, supplemented by Doppler ultrasonography control of renal blood flow, as well as percutaneous fine-needle biopsy of the renal graft, performed under ultrasound control. Histological examination of a transplant biopsy is performed in cases where differential diagnosis between ischemic acute renal failure of the graft and a rejection crisis is necessary.
Lecture 33. PLASTIC (RESTORATIVE) SURGERY
Plastic surgery deals with the surgical restoration of the normal form or function of organs of the human body that are lost or damaged as a result of injury, disease, or developmental defects.
Very close to plastic surgery Cosmetic surgery deals with the correction of congenital or acquired defects in appearance and body shape.
Kinds plastic surgery
A distinction is made between free grafting, when the graft is completely separated from the maternal tissues, and tied (pedunculated) grafting, when the graft remains connected to the original bed.
Depending on the type of tissue transplanted, there are skin, muscle, tendon, nervous, vascular and organ tissues.
Depending on the source of transplanted tissues or organs, there are:
1) autogenous transplantation - the donor and recipient are the same person;
2) isogenic - the donor and recipient are identical twins;
3) syngeneic - the donor and recipient are first degree relatives;
4) allogeneic - the donor and recipient belong to the same species;
5) xenogeneic - the donor and recipient belong to different types;
6) prosthetics of organs and tissues, when used synthetic materials or inorganic substances.
Nowadays, autoplasty and prosthetics are most often used.
Depending on the type of free plastic surgery, there are:
1) transplantation of tissues and organs, when they are moved from one part of the body to another or from one organism (donor) to another (recipient);
2) replantation - when the affected tissues or organs are transplanted back to their original place;
3) implantation - when tissues or cells are transferred to a nearby area.
The first condition for a successful transplant is the general condition of the person: you cannot operate after a severe, debilitating illness, in weakened patients, etc.
It is very important what condition the tissue that is being transplanted is in (state of local blood circulation, etc.).
The reasons for unsuccessful transplantations are explained by tissue incompatibility.
There are a number of theories of tissue incompatibility:
1) Hematogenous theory: In connection with the existence of blood grouping, one can think that other tissues have similar biological properties.
2) Local reaction theory: The transplant reacts by releasing toxins with the subsequent development of local conflict, which leads to the death of the graft itself.
3) Immunological theory: It has now been proven that the basis of tissue incompatibility is the body’s immune reactions.
The transplants take root and live until the body becomes sensitized to foreign proteins of the transplanted tissues - then their life span ends, that is, they are rejected under the influence of antibodies.
The task of modern researchers is to find ways to overcome the antigenic nature of the transplant. Currently, these studies are being carried out in 2 ways: by reducing the immunological activity of the recipient (azathioprine, imuran, glucocorticoids, antilymphocyte serum, cyclosporine, radiation exposure) and by reducing the antigenic activity of the graft, which is achieved by preserving tissues or organs in solutions with antiseptics, at low temperatures, lyophilization, etc.
Types of tissue plastics.
Skin plastic surgery. There are free skin grafting and non-free (pedunculated):
1) Regional using surrounding skin and tissues;
2) Thiersch method;
3) Filatov’s method;
4) Douglas method;
5) dermatomal method.
The thinner the skin grafts (within 0.25–0.3 mm), the better they take root. Engraftment of free skin grafts occurs in stages. Literally from the first minutes, the graft adheres to the bottom of the bed, while fibrin falls out between the wound surfaces. Thin grafts are nourished by the diffusion of nutrient-rich tissue fluid, which maintains cellular metabolism at the proper level.
With free transplantation of thick skin grafts (0.75–1 mm), including the dermis layer, nutrition is provided only when tissue fluid enters the graft vessels. Revascularization, and with it their final engraftment, occurs within 2-4 days due to the growth of blood vessels and is completed by 7-8 days.
Muscle plastic surgery
Muscle transplantation on a pedicle is possible provided that blood circulation and innervation are maintained. The muscles on the feeding pedicle are often used for filling bronchial fistulas and sequestral cavities of long tubular bones.
Plastic surgery of tendons and fascia.
Tendon plastic surgery is widely used in traumatology and orthopedics. In cases of tendon rupture, a primary suture is applied,
MAIN TYPES OF SURGICAL OPERATIONS
Operation - performing special mechanical effects on organs or tissues for therapeutic or diagnostic purposes.
Classification of surgical operations
Surgical operations are usually divided according to the urgency of their implementation and the possibility of complete cure or alleviation of the patient’s condition.
According to the urgency of implementation, they are distinguished:
1) emergency operations, they are performed immediately or within the next few hours from the moment the patient is admitted to the surgical department;
2) urgent operations are performed within the next few days after admission;
3) planned operations, they are performed as planned (the timing of their implementation is not limited).
There are radical and palliative operations.
Radicalconsider an operation in which, by removing a pathological formation, part or all of an organ, the return of the disease is excluded. The volume of surgical intervention, which determines its radicalism, is determined by the nature of the pathological process. For benign tumors (fibromas, lipomas, neuromas, polyps, etc.), their removal leads to a cure for the patient. In case of malignant tumors, radical intervention is not always achieved by removing part or all of the organ, taking into account the possibility of tumor metastasis. Therefore, radical oncological operations often, along with organ removal, include removal (or resection) of neighboring organs and regional lymph nodes. Thus, the radicalism of surgery for breast cancer is achieved by removing not only the entire mammary gland, but also the pectoralis major and minor muscles, fatty tissue along with lymph nodes axillary and subclavian areas. At inflammatory diseases the volume of intervention is determined
making the operation radical, it is limited to the removal of pathologically changed tissues: for example, they perform osteonecrectomy for chronic osteomyelitis or removal of a pathologically changed organ - appendectomy, cholecystectomy, etc.
Palliativeare operations performed to eliminate an immediate danger to the patient’s life or alleviate his condition. Thus, in case of disintegration and bleeding from a stomach tumor with metastases, when radical surgery is impossible due to the prevalence of the process, gastrectomy or wedge-shaped excision of the stomach with a tumor and a bleeding vessel is performed to save life. In case of a widespread neoplasm of the esophagus with metastases, when the tumor completely obstructs the lumen of the esophagus and it becomes impassable for food and even water, in order to prevent starvation, a palliative operation is performed - a fistula is placed on the stomach (gastrostomy), through which food is introduced into it. Palliative operations achieve stopping bleeding or the possibility of nutrition, but the disease itself is not eliminated, since tumor metastases or the tumor itself remain. For inflammatory or other diseases, palliative operations are also performed. For example, with paraosseous phlegmon complicating osteomyelitis, the phlegmon is opened, the wound is drained to eliminate intoxication, prevent the development of a general purulent infection, but the main focus of inflammation in the bone remains. In case of acute purulent cholecystitis in the elderly and people suffering from heart failure, the risk of radical surgery is high. To prevent the development of purulent peritonitis and severe intoxication, a palliative operation is performed - cholecystostomy: the application of a fistula to the gallbladder. Palliative operations can play the role of a certain stage in the treatment of patients, as in the examples given (opening of phlegmon in osteomyelitis or cholecystostomy in acute cholecystitis). Subsequently, when the general condition of the patient improves or local favorable conditions are created, a radical operation can be performed. In case of inoperable oncological diseases, when radical intervention is impossible due to the prevalence of the process, palliative surgery is the only benefit that can temporarily alleviate the patient’s condition.
Operations can be single-stage or multi-stage (two- or three-stage). At one-time All stages of the operation are carried out directly one after another without a break in time. Each of multi-moment operations consists of certain stages of chemical
surgical treatment of the patient, separated in time. As an example, we can cite multi-stage operations in orthopedics or oncology practice. For example, with a tumor of the colon that has caused intestinal obstruction, an anastomosis is first applied between the afferent and efferent loops of the intestine or a fistula on the afferent loop (1st stage), and then, after the patient’s condition improves, a resection of the intestine along with the tumor is performed (2nd stage) stage).
In modern conditions, with the development of pain management and intensive care, it has become possible to simultaneously perform two or more operations on a patient - simultaneous(simultaneous) operations. For example, a patient with inguinal hernia and varicose veins of the great saphenous vein, two operations can be performed in one step: hernia repair and phlebectomy. In a patient with a gastric ulcer and chronic calculous cholecystitis, gastric resection and cholecystectomy, if the patient is in good condition, can be performed simultaneously using one surgical approach.
In surgical practice, situations are possible when the question of the possibility of performing an operation is decided only during the surgical intervention itself. This concerns oncological diseases: if a tumor of a particular organ is diagnosed, a radical operation is expected; During the intervention, it turns out that the planned operation is impossible due to metastasis of the tumor to distant organs or germination into neighboring ones. This operation is called trial
Currently to diagnostic operations are rarely used due to the availability of highly informative diagnostic research methods. Nevertheless, there may be cases when surgery remains the last resort for establishing a diagnosis. If the diagnosis is confirmed, such an operation usually ends as a curative operation. Diagnostic operations include biopsy: taking a formation, organ or part thereof for histological examination. This diagnostic method plays important role V differential diagnosis between benign and malignant neoplasms, tumor and inflammatory process etc. Such studies help clarify the indications for surgery or choose its adequate volume, as, for example, in cancer or peptic ulcer stomach: in the first case, a gastrectomy is performed (removal of the entire stomach), in the second - gastrectomy (removal of part of it).
There are typical (standard) and atypical operations. Typical operations are performed according to clearly developed schemes and methods
surgical intervention. Atypical situations arise in the case of an unusual nature of the pathological process, which necessitates the need for surgical treatment. These include severe traumatic injuries, especially combined injuries, gunshot wounds. In these cases, operations may go beyond standard ones and require creative decisions from the surgeon when determining the volume of the operation, performing plastic elements, and performing simultaneous interventions on several organs: vessels, hollow organs, bones, joints, etc.
There are closed and open operations. TO closed include repositioning of bone fragments, some types of special operations (endoscopic), turning the fetus onto its stem in obstetrics, etc.
With the development of surgical technology, a number of special operations emerged.
Microsurgical operations are performed under magnification from 3 to 40 times using magnifying glasses or an operative microscope. In this case, special microsurgical instruments and the finest suture threads are used. Microsurgical operations are increasingly being introduced into the practice of vascular surgery and neurosurgery. With their help, replantation of limbs and fingers after traumatic amputation is successfully performed.
Endoscopic operations are carried out using endoscopic devices. Through an endoscope, polyps of the stomach, intestines, and bladder are removed, and bleeding from the mucous membrane of these organs is stopped by coagulating the bleeding vessel with a laser beam or closing its lumen with special glue. With the help of endoscopes, stones are removed from the bile ducts, bladder, foreign bodies from the bronchi, and esophagus.
Using endoscopic devices and television equipment, laparoscopic and thoracoscopic operations are performed (cholecystectomy, appendectomy, suturing of perforated ulcers, resection of the stomach, lung, suturing of bullae in the lung for bullous disease, hernia repair, etc.). So closed endoscopic operations have become basic for a number of diseases (for example, cholecystectomy, marginal lung resection) or are an alternative to open surgery. Taking into account the indications and contraindications, this type of operation is increasingly used in surgery.
Endovascular operations - a type of closed intravascular surgical interventions performed under x-ray control: expansion of the narrowed part of the vessel using special
catheters, artificial occlusion (embolization) of a bleeding vessel, removal of atherosclerotic plaques, etc.
Repeatedoperations can be planned (multi-stage operations) and forced - during development postoperative complications, the treatment of which is possible only surgically (for example, relaparotomy in case of failure of the sutures of the intestinal anastomosis with the development of peritonitis).
Stages of surgery
The surgical operation consists of the following main stages:
Surgical access;
The main stage of the operation (surgical procedure);
Suturing the wound.
Surgical approach
The requirements for surgical access are minimal trauma, ensuring a good angle of surgical activity, as well as conditions for carefully performing the main stage of the operation. Good access determines minimal tissue traumatization by hooks, provides a good overview of the surgical field and thorough hemostasis. For all existing typical operations, appropriate surgical approaches have been developed; only for atypical operations (for example, with extensive tissue damage due to trauma, gunshot wounds) it is necessary to choose a surgical approach taking into account the requirements stated above.
Surgical appointment
The basic techniques for performing an operation, the technique of specific surgical interventions are outlined in the course of operative surgery, the end of the main stage of the operation (before suturing the wound) necessarily includes a thorough check of hemostasis - stopping bleeding, which is an important point in the prevention of secondary bleeding.
Suturing the wound
The final stage of the operation is suturing the wound. It must be carried out carefully to avoid cutting through the seams, untying
ligatures, divergence of the edges of the surgical wound. Significant difficulties with wound suturing arise during atypical operations, when it is necessary to close the wound with displaced flaps of tissue, skin, or free skin grafts.
When performing all stages of the operation, an indispensable condition is careful handling of fabrics, Rough compression of tissues with instruments, their overstretching, and tears are unacceptable. Careful hemostasis is extremely important. Compliance with the above conditions makes it possible to prevent the development of complications after surgery - secondary bleeding, purulent-inflammatory complications that arise from endo- and exogenous infection of wounds.
Preventing wound infections during the operation - an indispensable condition for its implementation. Preventive measures consist of following the rules of asepsis (see. Asepsis) and special measures during surgery. Ensuring that the operation is performed aseptically begins with the treatment of the surgical field, which is performed after the patient is put under anesthesia or before local anesthesia. After preliminary washing of the skin with ammonia solution or diethyl ether, the surgical field is treated according to Grossikh-Filonchikov or another method. Recently, self-adhesive sterile films have been used to close the surgical field after treatment (they are glued to the skin). The surgical access site is isolated with sterile drapes when large operations or towels - for small ones. Sheets or towels are placed on the skin or on adhesive film. After this, the isolated area of skin is treated with an alcohol solution of iodine and chlorhexidine.
In cases where there is a source of possible contamination of the wound (purulent, intestinal fistulas, gangrene of the limb), it is first isolated: sterile napkins are applied, the foot with gangrene is wrapped in a towel, and sometimes the fistula is sutured.
During the operation, each of its participants - assistants (assistants to the surgeon), operating nurse - must clearly know their responsibilities. The surgeon’s orders are unquestioningly carried out by all participants in the operation.
After surgical access, the edges and walls of the surgical wound are covered with napkins or a towel to prevent the possibility of accidental infection of the wound by contact or air.
To prevent airborne infection, unnecessary conversations between the participants in the operation and walking in the operating room are prohibited;
The use of a mask is mandatory not only for those directly involved in the operation, but also for everyone in the operating room.
Prevention of contact and implantation infection is achieved by mandatory change of instruments when they become dirty. There are main stages that require changing all instruments, surgical needles, needle holders, delimiting napkins, and towels. In particular, this is a transition from an infected stage of the operation (for example, suturing the intestine) to a less infected stage (application of a second row of serous sutures, suturing the wound). When working on an infected organ (removal of the appendix, gall bladder when they purulent inflammation, opening a hollow organ, such as the colon), it is necessary to first isolate the surrounding tissues with gauze wipes and take precautions to avoid contact of the inflamed organ with the wound, to prevent the contents of the organs and pus from getting into the surrounding tissues.
After completing the main stage of the operation, all the napkins with which the tissues were isolated are removed, the instruments are changed, the skin is treated with iodine solution, iodine + potassium iodide, and then sutures are placed on the wound. The surgical wound must be sutured so that there are no pockets or closed cavities left in it; the edges of the wound should be well aligned with each other. The sutures are tightened until the walls and edges of the wound come into contact with moderate tension. Insufficiently tightened sutures can lead to divergence of the edges of the wound, and tightly tightened sutures can lead to necrosis (death) of the edges and walls of the wound.
Various methods of wound suturing have been developed depending on the nature of the operation, the treatment of the patient in the postoperative period, the condition of the tissues and the presence of inflammatory changes:
1) suturing the wound tightly;
2) drainage of the cavity, wound;
3) application of temporary sutures, taking into account repeated interventions;
4) leaving the wound open.
PREOPERATIVE PERIOD
Preoperative period - time from the patient’s admission to medical institution before the start of the operation. Its duration varies and depends on the nature of the disease, the severity of the patient’s condition, and the urgency of the operation.
Basic tasks preoperative period: 1) establish a diagnosis; 2) determine the indications, urgency and nature of the operation;
tions; 3) prepare the patient for surgery. Main target preoperative preparation of the patient - to minimize the risk of the upcoming operation and the possibility of developing postoperative complications.
Having established the diagnosis of a surgical disease, the following basic steps should be performed in a certain sequence to prepare the patient for surgery:
1) determine the indications and urgency of the operation, find out contraindications;
2) conduct additional clinical, laboratory and diagnostic studies in order to determine the condition of vital organs and systems;
3) determine the degree of anesthesiological and surgical risk;
4) conduct psychological preparation of the patient for surgery;
5) carry out preparation of organs, correction of violations of homeostasis systems;
6) carry out prevention of endogenous infection;
7) choose a method of pain relief, administer premedication;
8) carry out preliminary preparation of the surgical field;
9) transport the patient to the operating room;
10) place the patient on the operating table.
Determining the urgency of the operation
The timing of the operation is determined by indications, which can be vital, absolute and relative.
Vital indications to surgery arise in diseases in which the slightest delay in surgery threatens the patient’s life. Such operations are performed on an emergency basis. Vital indications for surgery arise in the following pathological conditions.
Continued bleeding due to rupture of an internal organ (liver, spleen, kidney, fallopian tube during pregnancy), injury to large vessels, stomach and duodenal ulcers. In these cases, if the ongoing bleeding is not immediately stopped during surgery, it can quickly lead to the death of the patient.
Acute inflammatory diseases of the abdominal organs - acute appendicitis, strangulated hernia, acute intestinal obstruction, thromboembolism. These diseases are fraught with the development of purulent peritonitis or gangrene of the organ due to thromboembolism, which pose a danger to the patient’s life.
Purulent-inflammatory diseases - abscess, phlegmon, purulent mastitis, acute osteomyelitis, etc. In these cases, delaying surgery can lead to the development of a general purulent infection in patients - sepsis.
Absolute readings to surgery arise in diseases in which failure to perform the operation or a long delay can lead to a condition that threatens the patient’s life. These operations are performed urgently, a few days or weeks after the patient’s admission to the surgical department. Such diseases include malignant neoplasms, pyloric stenosis, obstructive jaundice, chronic lung abscess, etc. Long-term delay of surgery can lead to tumor metastases, general exhaustion, liver failure and other serious complications.
Relative readings surgery may be necessary for diseases that do not pose a threat to the patient’s life (hernia, varicose veins of the superficial veins of the lower extremities, benign tumors). These operations are performed as planned.
When determining the need for surgery, find out contraindications for its implementation: cardiac, respiratory and vascular failure (shock), myocardial infarction, stroke, hepatic-renal failure, thromboembolic disease, severe metabolic disorders (decompensation of diabetes mellitus, precomatose state, coma), severe anemia, severe cachexia. These changes in vital organs should be assessed individually, according to the volume and severity of the proposed operation. The patient’s condition is assessed jointly with relevant specialists (therapist, neurologist, endocrinologist). If there are relative indications for surgery and the presence of diseases that increase its risk, the intervention is postponed and appropriate specialists treat the diseases.
When performing an operation for life-saving reasons, when preoperative preparation is limited to several hours, the assessment of the patient’s condition and preparation for the operation is carried out jointly by the surgeon, anesthesiologist-resuscitator, and therapist. It is necessary to determine the extent of the operation, the method of pain relief, and the means for drug and transfusion therapy. The scope of the operation should be minimal, aimed at saving the patient’s life. For example, in a seriously ill patient with acute cholecystitis, surgery is limited to cholecystostomy; in a patient with acute intestinal obstruction caused by a tumor
leaking the colon, the operation consists of creating a colostomy (colon fistula), etc.
The choice of pain relief method in these patients should be strictly individual. Preference should be given to NLA.
For lung diseases, bronchial asthma Halothane anesthesia is indicated; in case of heart failure, some operations can be performed under local anesthesia.
Assessment of surgical and anesthetic risk
Surgery and anesthesia pose potential dangers to the patient. Therefore, an objective assessment of surgical and anesthetic risk is very important when determining the indications for surgery and choosing an anesthesia method. This allows you to reduce the risk of surgery due to adequate preoperative preparation, choosing a rational volume of surgical intervention and type of anesthesia. Typically, a score is used to assess the operational and anesthetic risk, which is carried out taking into account three factors: the general condition of the patient, the volume and nature of the operation, and the type of anesthesia.
I. Assessment of the patient’s general condition:
1) general satisfactory condition of a patient with localized surgical diseases in the absence of concomitant diseases and systemic disorders - 0.5 points;
2) moderate condition: patients with mild or moderate systemic disorders - 1 point;
3) severe condition: patients with severe systemic disorders associated with surgery or concomitant diseases - 2 points;
4) extremely severe condition: patients with extremely severe systemic disorders caused by a primary or concomitant disease that poses a threat to the patient’s life without surgical intervention or during its implementation - 4 points;
5) terminal condition: patients with decompensation of the functions of vital organs and systems that determine the likelihood of death during surgery and in the next few hours after it is performed - 6 points.
II. Assessment of the volume and nature of the operation:
1) operations on the body surface and minor purulent operations - 0.5 points;
2) more complex operations on the surface of the body, internal organs, spine, peripheral nerves and blood vessels - 1 point;
3) long and extensive operations on internal organs, in traumatology, urology, oncology, neurosurgery - 1.5 points;
4) complex operations on the heart, large vessels, extended operations in oncology, repeated and reconstructive operations - 2 points;
5) complex heart surgeries under artificial circulation (using a heart-lung machine - artificial blood circulation machine), transplantation internal organs- 2.5 points.
III. Assessment of the nature of anesthesia:
1) local potentiated anesthesia - 0.5 points;
2) regional, spinal, epidural, intravenous anesthesia, inhalation mask anesthesia with spontaneous breathing - 1 point;
3) standard combined endotracheal anesthesia - 1.5 points;
4) combined endotracheal anesthesia in combination with artificial hypothermia, controlled arterial hypotension, massive infusion therapy, cardiac pacing - 2 points;
5) combined endotracheal anesthesia in combination with artificial circulation (use of artificial blood circulation), hyperbaric oxygenation, using intensive care, resuscitation - 2.5 points.
Risk levelassessed by the sum of points: I degree (minor risk) - 1.5 points; II degree (moderate risk) - 2-3 points; III degree(significant risk) - 3.5-5 points; IV degree (high risk) - 8.5-11 points.
The resulting indicator allows us to reduce the risk of surgical intervention by reducing its volume, the right choice the nature of the operation and anesthesia with the lowest degree of risk.
Additional Research
A thorough examination helps to correctly assess the patient’s condition before surgery. During the period of preoperative preparation, there is a need to conduct additional studies.
From the anamnesis, it is necessary to find out the presence of thirst, the amount of fluid loss with vomiting, the amount of hematemesis and the approximate amount of blood loss due to external bleeding. Find out allergy and transfusion history: patient tolerance in the past
transfusion agents, as well as the presence of liver and kidney diseases, the amount of urine excreted in connection with the developed disease.
When examining the skin and mucous membranes, you should pay attention to their dryness, collapse of the superficial veins, which indicates dehydration and volemic disorders. Cyanosis of the fingertips and marbling of the skin indicate impaired microcirculation and respiratory failure.
It is mandatory to determine the frequency and nature of the pulse, blood pressure, and in seriously ill patients - central venous pressure (normally 50-150 mm water column), as well as an ECG study. The depth and frequency of breathing are determined, the presence of shortness of breath, noise and wheezing is noted during auscultation of the lungs.
To assess the excretory function of the kidneys, diuresis is determined - daily and hourly (normally 30-40 ml/h), and the relative density of urine.
In order to assess the state of homeostasis, the Hb concentration, hematocrit, acid-base status, the content of basic electrolytes (Na +, K +, Ca 2 +, Mg 2 +, C1 -), BCC and its components are periodically determined. Changes in homeostasis are not specific; they manifest themselves in various surgical diseases (trauma, bleeding, surgical infection).
In emergency situations, laboratory tests should be limited so as not to delay surgery. Once a diagnosis has been established, blood and urine tests (general tests) make it possible to determine the severity of inflammatory changes and blood loss (Hb content, hematocrit). By general analysis urine assess the state of kidney function. If possible, the electrolyte composition of the blood and bcc are examined using the express method. These data are important for transfusion therapy for both detoxification (for purulent inflammation) and replacement (for blood loss) purposes. The presence of chronic inflammatory diseases in the patient (inflammation of teeth, chronic tonsillitis, pharyngitis, pustular skin diseases, inflammation of the uterine appendages, prostate gland, etc.) is determined, and foci of chronic infection are sanitized. If the operation is performed according to relative indications, the patient can be discharged for the treatment of chronic inflammatory diseases.
The time to prepare for surgery is extremely limited during emergency interventions and is practically absent in extreme situations (heart injury, massive internal bleeding), when the patient is immediately taken to the operating room.
Preparing for surgery
Preparation for surgery begins before the patient enters the surgical department. At the first contact with the patient, the clinic or ambulance doctor determines the preliminary indications for surgery, conducts studies that make it possible to establish a diagnosis, conducts psychological preparation of the patient, explaining to him the need for the operation and convincing him of its favorable outcome. If the functions of vital organs are impaired, bleeding or shock occur, the doctor begins to carry out anti-shock measures, stop the bleeding, and use cardiac and vascular drugs. These actions continue when the patient is transported to the surgical department and are the beginning of preparing the patient for surgery.
Psychological preparation is aimed at calming the patient and instilling confidence in him in a favorable outcome of the operation. The patient is explained the inevitability of the operation and the need for its emergency performance, doing this in a gentle manner, in a calm voice, in order to instill confidence in the patient in the doctor. It is especially important to convince the patient if he refuses surgery, underestimating the severity of his condition. This applies to diseases and conditions such as acute appendicitis, strangulated hernia, perforation of a hollow organ (for example, with a stomach ulcer), intra-abdominal bleeding (with impaired ectopic pregnancy, rupture of the liver, spleen), penetrating injury to the abdomen, chest, when delay with surgery can lead to the progression of peritonitis, severe blood loss and irreparable consequences.
Preoperative preparation - an important stage in the surgical treatment of the patient. Even with an impeccably performed operation, if the dysfunctions of the organs and systems of the body are not taken into account and their correction is not carried out before, during and after the intervention, the success of treatment is questionable and the outcome of the operation may be unfavorable.
Preoperative preparation should be short-term, quickly effective and, in emergency situations, primarily aimed at reducing the degree of hypovolemia and tissue dehydration. In patients with hypovolemia, disturbances in water-electrolyte balance and acid-base status, infusion therapy is immediately started: dextran transfusion [cf. they say weight 50,000-70,000], albumin, protein, sodium bicarbonate solution for acidosis. To reduce metabolic acidosis, a concentrated solution of dextrose with insulin is administered. Cardiovascular drugs are used at the same time.
In case of acute blood loss and stopped bleeding, blood and dextran transfusions are performed [cf. they say weight 50,000-70,000], albumin, plasma. If bleeding continues, transfusion into several veins is started and the patient is immediately taken to the operating room, where an operation is performed to stop the bleeding under the cover of transfusion therapy, which is continued after the intervention.
When a patient is admitted in a state of shock (traumatic, toxic or hemorrhagic) and the bleeding has stopped, antishock therapy is carried out aimed at eliminating the shockogenic factor (eliminating pain during traumatic shock, stopping bleeding in hemorrhagic shock, detoxification therapy in toxic shock), restoration of blood volume (using transfusion therapy) and vascular tone (using vasoconstrictors).
Shock is considered a contraindication to surgery (with the exception of hemorrhagic shock with ongoing bleeding). The operation is performed when blood pressure is not lower than 90 mmHg. In case of hemorrhagic shock and ongoing internal bleeding, surgery is performed without waiting for the patient to recover from the state of shock, since the cause of shock - bleeding - can only be eliminated during surgery.
Preparation of organs and homeostasis systems should be comprehensive and include the following activities:
1) improvement of vascular activity, correction of microcirculation disorders with the help of cardiovascular drugs, drugs that improve microcirculation (dextran [average molecular weight 30,000-40,000]);
2) the fight against respiratory failure (oxygen therapy, normalization of blood circulation, in extreme cases - controlled ventilation);
3) detoxification therapy - administration of fluids, blood-substituting solutions with detoxification action, forced diuresis, use of special detoxification methods - hemosorption, lymphosorption, plasmapheresis, oxygen therapy;
4) correction of disturbances in the hemostatic system.
If a patient is diagnosed with one or another type of hypovolemia, disturbances in the water-electrolyte balance, or acid-base state, the urgency of complex transfusion therapy is determined, aimed at eliminating the disturbances with the help of agents that restore bcc, eliminate dehydration, and normalize the acid-base state and electrolyte balance. (see chapter 7).
Special preoperative preparation is carried out in accordance with the disease and is determined by the localization of the process and the patient’s condition. Thus, an upcoming operation on the colon requires special preparation of the intestines: a slag-free diet, taking laxatives, and cleansing enemas are prescribed a few days before the operation. 2-3 days before surgery, the patient is given broad-spectrum antibiotics orally to reduce bacterial contamination of the colon and thereby reduce the risk of infection of surrounding tissues and intestinal sutures in the postoperative period.
During surgery for stenosis of the antrum of the stomach caused by a peptic ulcer or tumor, the stagnant gastric contents are first removed with a probe for several days and the stomach is washed with light water with a solution of sodium bicarbonate, a weak solution of hydrochloric acid, or boiled water
For purulent lung diseases (abscess, bronchiectasis), in the preoperative period, comprehensive bronchial sanitation is carried out, using inhalation of antibiotics, antiseptics to combat microflora and proteolytic enzymes, mucolytic agents to liquefy and better remove purulent sputum; endotracheal and endobronchial administration are used medicinal substances, use therapeutic bronchoscopy to sanitize the bronchial tree and abscess cavity.
In order to sanitize the bone cavity and purulent fistulas in patients with chronic osteomyelitis, in the preoperative period, through catheters inserted into the fistula tracts, the bone cavity and fistula are washed for a long time with solutions of antibacterial drugs and proteolytic enzymes.
If the natural intake or passage of food is disrupted, the patient is immediately transferred to parenteral nutrition (see Chapter 7) or nutrition through a tube (passed below the narrowing of the esophagus or gastric outlet) or through a gastrostomy tube.
Particular attention is required in preparing for surgery patients whose surgical diseases or traumatic injuries occurred against the background of diabetes mellitus. Careful correction of the acid-base state (metabolic acidosis), disorders in the cardiovascular system, kidneys, and nervous system is necessary. Patients receiving long-acting forms of insulin are transferred to regular insulin before surgery.
These examples do not exhaust all possible options for special preoperative preparation - it has its own characteristics
at various diseases and is described in detail in the private surgery course.
During the preoperative preparation of the patient, the need arises to perform certain procedures aimed at preparing the patient’s organs and systems. If the patient has eaten the day before or has intestinal obstruction, gastric lavage is performed before surgery to prevent vomiting or regurgitation during anesthesia.
Length gastric lavage you need a gastric tube, a funnel, a basin, a rubber apron, gloves, a mug and a jug of boiled water. If the patient’s condition allows, he is seated on a chair, but more often this procedure is carried out with the patient lying down. The end of the probe is lubricated Vaseline oil, inserted into the oral cavity, then into the pharynx, forcing the patient to swallow, and slightly advance the probe along the esophagus. Reaching the first mark on the probe (50 cm) means that its end is in the cardiac part of the stomach. When the stomach is full, contents immediately begin to be released from the tube, which freely flows into the pelvis. When the spontaneous flow stops, a glass funnel is inserted into the outer end of the probe and the stomach is washed using a siphon. To do this, raise the funnel 20-25 cm above the level of the mouth and pour 0.5-1 liters of water into it, which passes into the stomach. To prevent air from entering the stomach, the stream must be continuous. When the liquid is completely released from the funnel, the latter is smoothly lowered to the patient’s knees (if he is sitting) or below the level of the bed (if he is in a horizontal position), and the bell of the funnel should be on top. The funnel begins to fill with liquid, and from the filled funnel it is poured into a bucket or basin. If less fluid comes out than was introduced into the stomach, the position of the probe is changed - it is inserted deeper or pulled up, and the funnel is smoothly raised and lowered again. The liquid released in this case is drained, after the release stops, a new one is poured in, and so on until the wash water is clean.
If the flow of liquid stops, you should use a Janet syringe to pour water under pressure into the probe several times and aspirate it. As a rule, stuck pieces of food can be removed, otherwise the probe is removed, cleaned and reinserted.
At the end of the rinsing, the probe is smoothly removed, covering it like a muff with a towel brought to the patient’s mouth.
Bladder catheterization before the operation it is performed for the purpose of emptying it, in case of urinary retention - to examine the bladder, if there is a suspicion of injury to the kidney or urinary tract.
For catheterization, you need a sterile rubber catheter, two sterile tweezers, sterile vaseline oil, cotton balls, a nitrofural solution 1:5000 or a 2% boric acid solution. All this is placed on a sterile tray. Hands are washed with running water and soap and treated with alcohol for 3 minutes.
During catheterization in men, the patient is placed on his back with the hips and knees bent and legs apart. A vessel or tray is placed between his legs to collect urine. The head of the penis and the area of the external opening of the urethra are thoroughly wiped with a gauze ball moistened with an antiseptic solution. Use tweezers to take the catheter at a distance of 2-3 cm from its beak and lubricate it with petroleum jelly. With the left hand, between the third and fourth fingers, take the penis in the cervical area, and with the first and second fingers, push apart the external opening of the urethra and insert a catheter into it with tweezers. By moving the tweezers, the catheter is gradually advanced. A slight sensation of resistance when advancing the catheter is possible as it passes through the isthmic part of the urethra. The appearance of urine from the catheter confirms that it is in the bladder. When urine is excreted, its color, transparency, and quantity are noted. After urine is removed, the catheter is removed.
If an attempt to remove urine with a soft catheter fails, they resort to catheterization with a metal catheter, which requires certain skills (there is a risk of damage to the urethra).
Catheterization in women is technically easier to perform, since their urethra is short, straight and wide. It is performed with the patient lying on her back with her legs bent and spread. The patient lies on the ship. The external genitalia are washed with running water, the labia minora are separated with the fingers of the left hand and a cotton swab moistened with an antiseptic solution, and the area of the external opening of the urethra is wiped. Right hand a catheter is inserted into it using tweezers. You can use a female metal catheter, which is taken by the pavilion so that its beak is facing upward. The catheter is easily advanced until urine appears. After removing the urine, the catheter is removed.
For cleansing enema An Esmarch mug with a rubber tube, a tap or clamp and a glass or plastic tip is required. Take 1-1.5 liters of water into a mug, fill the tube so that the air comes out, and close it at the very tip with a tap or clamp. The tip is lubricated with Vaseline oil. The patient is placed on the left side (according to the location of the sigmoid colon) and the tip is inserted into the rectum to a depth of 10-15 cm. The clamp is removed
they wash or open the tap, lift the mug and slowly introduce water into the rectum, then the tip is removed, the patient is laid on his back on a bedpan (or, if his condition allows, he sits on the bedpan). It is recommended to retain water for as long as possible.
Siphon enemaused in cases where it is not possible to clear the intestines of feces with a regular enema (intestinal obstruction, fecal blockage). For a siphon, a rubber tube or probe is used, which is placed on a large glass funnel. The patient is placed on his left side on the edge of the bed, couch or trestle bed. The funnel is filled with water and, by opening the clamp on the tube, the air is forced out of it, after which the clamp is applied again. The end of a rubber tube or probe is inserted into the rectum 10-12 cm, the clamp is removed and, lifting the funnel, water is injected into the colon in a volume of 2-3 liters. Water is constantly added to the funnel so that there is no interruption in the flow of liquid and air does not enter the intestine. When there is an urge to stool, the funnel is lowered below the level of the bed, then, like a siphon, the liquid will fill the funnel, and with the liquid, gases will escape and feces. When the funnel is filled, the liquid is drained. The procedure of filling the intestine with water and removing it is repeated several times, spending 10-15 liters. Abundant discharge of feces and gases, disappearance of pain, reduction of bloating are favorable signs for intestinal obstruction.
On the eve of the operation, the patient is examined by an anesthesiologist and, in accordance with the proposed operation, the patient’s condition, and the method of pain relief, prescribes premedication (see Chapter 3).
Preliminary preparation of the surgical field
On the eve of the operation, the patient is given a cleansing enema, he takes a hygienic bath or shower, then his underwear and bed linen are changed. On the morning of the operation, the patient's hair in the area of the surgical field is shaved using a dry method.
If there is a wound, the preparation of the surgical field has its own characteristics. The bandage is removed, the wound is covered with a sterile cloth, the surrounding skin is wiped with diethyl ether and the hair is shaved dry. All movements - rubbing the skin, shaving hair - should be carried out in the direction away from the wound to reduce the degree of contamination. After shaving the hair, the napkin is removed, the skin around the wound is lubricated with a 5% alcohol solution of iodine, and the wound is covered with a sterile napkin. In the operating room, the wound is again treated with an alcohol solution of iodine and isolated with sterile surgical linen.
Delivery of the patient to the operating room
The patient is taken to the operating room on a gurney. In emergency cases, the infusion of certain medicinal solutions is continued, while mechanical ventilation is performed using an endotracheal tube (if there was tracheal intubation).
If the patient had external bleeding and a tourniquet was applied, the patient is transported to the operating room with a tourniquet, which is removed during the operation or immediately before it. Also, in case of open fractures, the patient is taken to the operating room with a bandage applied to the wound and with a transport splint, and patients with acute intestinal obstruction - with a probe inserted into the stomach. The patient is carefully transferred from the gurney to the operating table along with the transfusion system, tourniquet or transport splint and placed in the position necessary to perform the operation.
Prevention of postoperative infectious complications
The sources of microflora that cause postoperative inflammatory complications can be either outside the human body (exogenous infection) or in the body itself (endogenous infection). By reducing the number of bacteria on the wound surface, the frequency of complications is significantly reduced, although today the role of exogenous infection in the development of postoperative complications due to the use of modern aseptic methods does not seem to be so significant. Endogenous infection of a surgical wound occurs through contact, hematogenous and lymphogenous routes. Prevention of postoperative inflammatory complications in this case consists of sanitizing foci of infection, gentle surgical technique, creating an adequate concentration of antibacterial drugs in the blood and lymph, as well as influencing the inflammatory process in the surgical area in order to prevent the transition of aseptic inflammation to septic.
Targeted prophylactic use antibiotics for the sanitation of foci of surgical infection when preparing patients for surgery, it is determined by the localization of the focus of possible infection and the suspected pathogen. For chronic inflammatory diseases of the respiratory tract (chronic bronchitis, sinusitis, pharyngitis), the use of macrolides is indicated. For chronic infection
genital organs (adnexitis, colpitis, prostatitis), it is advisable to use fluoroquinolones. For the general prevention of postoperative infectious complications in modern conditions, the most justified prescription of cephalosporins and aminoglycosides. Rational antibiotic prophylaxis reduces the incidence of postoperative complications. In this case, the type of surgical intervention, the patient’s condition, the virulence and toxicity of the pathogen, the degree of infection of the surgical wound and other factors are of great importance.
The choice of means and methods of prevention depends on a reasonable assessment of the likelihood of developing a postoperative infection and the possible pathogen (or pathogens). There are four types of surgical interventions, differing in the degree of risk of postoperative inflammatory complications.
I. "Clean" operations. Non-traumatic elective surgeries, which do not affect the oropharynx, respiratory tract, gastrointestinal tract or genitourinary system, as well as orthopedic and operations such as mastectomy, strumectomy, hernia repair, phlebectomy, joint replacement, arthroplasty. At the same time, there are no signs of inflammation in the area of the surgical wound. The risk of postoperative infectious complications during these operations is less than 5%.
II. “Conditionally clean” operations.“Clean” operations with a risk of infectious complications: planned operations on the oropharynx, digestive tract, female genital organs, urological and pulmonological (without signs of concomitant infection), re-intervention through a “clean” wound within 7 days, emergency and emergency operations, operations for closed injuries. The risk of postoperative infectious complications in this group is about 10%.
III. “Contaminated” (contaminated) operations. Surgical wounds have signs of non-purulent inflammation. These are operations accompanied by opening of the gastrointestinal tract, interventions on the genitourinary system or biliary tract in the presence of infected urine or bile, respectively; the presence of granulating wounds before applying secondary sutures, operations for open traumatic injuries, penetrating wounds treated within 24 hours (early primary surgical treatment). The risk of postoperative infectious complications reaches 20%.
IV. "Dirty" operations. Surgical interventions on obviously infected organs and tissues in the presence of concomitant or previous infection, perforation of the stomach, intestines,
operations in the oropharynx, for purulent diseases of the biliary or respiratory tract, interventions for penetrating wounds and traumatic wounds in the case of delayed and late surgical treatment (after 24-48 hours). The risk of postoperative infectious complications in such situations reaches 30-40%.
Many risk factors the development of infection after surgery is associated with the condition of the patient himself. The development of infection in a wound begins under certain conditions, individual for each patient and consisting in a decrease in local and general reactivity of the body. The latter is especially characteristic of elderly patients or with concomitant diseases (anemia, diabetes mellitus etc.). This may also be associated with the underlying disease: malignant neoplasm, intestinal obstruction, peritonitis. Local reactivity may decrease as a result of a lengthy operation, excessive trauma to the wound, with overly developed subcutaneous fatty tissue, due to rough surgical technique, due to technical difficulties during surgery, violation of the rules of asepsis and antisepsis. Local and general factors reducing reactivity are closely interrelated.
The presence of a previous or latent infection also creates a risk of developing purulent complications in patients. In patients who are implanted with prostheses made from foreign material, infection of the implant can occur even if surgery is performed in another anatomical area, especially in non-sterile areas (for example, colon surgery).
The patient's age is directly correlated with the frequency of infectious complications. This can be explained by the fact that older people have a high predisposition to developing infectious complications due to concomitant diseases. A decrease in the body's defenses, structural features of the skin of the abdominal wall (flabbiness, dryness), often excessive development of subcutaneous fatty tissue, as well as less strict adherence to the sanitary and hygienic regime, which is of particular importance during emergency operations, also have an impact.
Risk factors caused by the pathogenicity of microorganisms are essential for antibacterial prophylaxis and therapy. Infection involves the presence of a significant number of microorganisms that can have a pathogenic effect. Their exact number is virtually impossible to determine; Apparently, it depends on the type of microorganism, as well as on risk factors,
due to the patient's condition. Risk factors associated with pathogenic microorganisms, such as virulence in particular, are difficult to study, as is their role in the multifactorial etiology of wound infection. However, risk factors associated with the patient’s condition, the characteristics of the surgical intervention, and the nature of the pathological process that served as the basis for the surgical operation are subject to objective assessment and should be taken into account when performing preventive measures (Table 4).
Measures to influence the site of surgical intervention, aimed at preventing infectious complications, can be divided into two groups: specific and nonspecific.
To non-specific measures These include means and methods aimed at increasing the overall reactivity of the body, its resistance to any adverse effects that increase the body’s susceptibility to infection, improving operating conditions, surgical techniques, etc. The tasks of nonspecific prevention are solved during the preoperative preparation of patients. These include:
Normalization of homeostasis and metabolism;
Replenishment of blood loss;
Table 4.Risk factors for suppuration of surgical wounds
Anti-shock measures;
Normalization of protein and electrolyte balance;
Improving surgical techniques, careful handling of tissues;
Thorough hemostasis, reducing operation time.
The incidence of wound infections is influenced by factors such as the patient’s age, exhaustion, obesity, irradiation of the surgical site, the qualifications of the surgeon performing the intervention, as well as concomitant conditions (diabetes mellitus, immunosuppression, chronic inflammation). However, strict adherence to the rules of asepsis and antisepsis during surgical operations in some cases is not enough.
Under specific measures should be understood different kinds and forms of influence on probable causative agents of bacterial complications, i.e. the use of means and methods of influencing the microbial flora, and above all, the prescription of antibiotics.
1. Forms of influence on the pathogen:
Sanitation of foci of infection;
Application antibacterial agents on routes of transmission of infection (intravenous, intramuscular, endolymphatic administration of antibiotics);
Maintaining a minimum inhibitory concentration (MIC) of antibacterial drugs in the surgical area - the site of tissue damage (antiseptic suture material, immobilized antibacterial drugs on implants, supplying antiseptics through microirrigators).
2. Immunocorrection and immunostimulation.
Postoperative infectious complications can be of different localization and nature, but the main ones are the following:
Wound suppuration;
Pneumonia;
Intracavitary complications (abdominal, pleural abscesses, empyema);
Inflammatory diseases of the urinary tract (pyelitis, pyelonephritis, cystitis, urethritis);
Sepsis.
The most common type of nosocomial infection is wound infection.
If there is a high probability of bacterial contamination of the wound, special preoperative preparation allows you to sanitize the source of infection or reduce the degree of bacterial contamination of the area
surgical intervention (colon, foci of infection in the oral cavity, pharynx, etc.). Intravenous infusion of antibiotics the day before, during and after surgery allows you to maintain the antibacterial activity of the blood due to the circulation of antibiotics. However, to achieve the required concentration in the surgical area (locus minoris resistentia) fails due to impaired local circulation, microcirculation disorder, tissue edema, aseptic inflammation.
It is possible to create the proper concentration only by using a depot of antibacterial agents by immobilizing antibiotics and introducing them into the structure of suture, plastic, and drainage materials.
The use of surgical antiseptic threads, plastic materials based on collagen and adhesive compositions, combined dressings and drainage materials containing chemical antiseptics and antibiotics ensures the maintenance of the antimicrobial effect in the surgical area for a long period, which prevents the development of purulent complications.
The use of various options for the immobilization of antibacterial agents by including them in the structure of dressings, sutures, and plastic materials, which ensures their slow release into the surrounding tissues and maintenance of therapeutic concentrations, is a promising direction in the prevention of purulent-inflammatory complications in surgery. The use of surgical antiseptic threads for anastomosis increases its mechanical strength by reducing the inflammatory and enhancing the reparative phase of wound healing. Osteoplastic materials based on collagen, containing antibiotics or chemical antiseptics for chronic osteomyelitis, are characterized by pronounced antibacterial activity and thereby have a positive effect on reparative processes in bone tissue.
It should be taken into account that during type I operations, antibacterial prophylaxis is impractical and is carried out only in cases where the possibility of tissue infection during surgery cannot be excluded (when performing prosthetics, installing a vascular shunt or artificial breast, the patient has an immunodeficiency state and reduced reactivity) . At the same time, during type III and IV operations, the use of antibacterial agents is mandatory and can be considered as preventive therapy for a nonspecific surgical infection, and in type IV surgical interventions, therapeutic courses are required rather than preventive ones.
Based on the above classification, the main emphasis in antibacterial prevention should be on “conditionally clean” and some “conditionally dirty” postoperative wounds. Without preoperative prophylaxis, such operations have a high incidence of infectious complications; the use of antibiotics reduces the number of purulent complications.
The antibiotic prophylaxis regimen is determined not only by the type of surgical intervention, but also by the presence of risk factors for the development of postoperative inflammatory complications.
Examples of antibiotic prophylaxis for various surgical interventions include the following.
Vascular operations. The incidence of infectious complications increases with the installation of vascular prostheses. In most cases (75%), the infection develops in the groin area. The causative agents are usually staphylococci. Infection of a vascular bypass can lead to the need for its removal and loss of the affected limb; infection of a coronary artery bypass can cause death. In this regard, despite the low risk of infectious complications during many vascular operations, the prophylactic use of cephalosporins of the I-II generation or (at high risk) - III-IV generation, as well as fluoroquinolones, is indicated, especially during bypass surgery, taking into account the possibility of severe infectious consequences.
Surgeries on the head and neck. The prophylactic use of antibiotics can halve the incidence of wound infections during certain surgical interventions in the oral cavity and oropharynx. The use of penicillins is not always sufficient due to the high risk of infection; the use of generation cephalosporins is more justified. Other surgical interventions, such as removal thyroid gland, do not require antibiotic prophylaxis, except in cases where it is due to the patient’s condition (presence of risk factors).
Operations on the upper gastrointestinal tract. Although the acidity of the contents of the upper gastrointestinal tract does not provide an adequate antibacterial effect, if it decreases due to the disease when taken medicines Proliferation of bacterial flora and increased incidence of wound infections may be observed. Most operations in these departments are considered “conditionally clean”, therefore prophylactic use of antibiotics is indicated for them. Preference should be given to I-II generation cephalosporins, if necessary, in combination with metronidazole.
Operations on the biliary tract. It is preferable to use an antibiotic that is excreted in bile. More often, infection after operations on the biliary tract develops in patients with previous infection and positive results of bacteriological examination of bile. Wound infections with negative cultures are usually caused by Staphylococcus aureus. For most interventions on the biliary tract (such as laparoscopic and open cholecystectomy), cefazolin, cefuroxime, cefoperazone, and metronidazole are widely used. When conducting studies such as endoscopic retrograde cholangiopancreatography (ERCP), ciprofloxacin is prescribed, which can penetrate into the bile even in the presence of bile duct obstruction.
Operations on the lower gastrointestinal tract. In case of appendicitis, prophylactic and, in severe cases, therapeutic use of antibiotics is justified. The most common finding with appendicitis is coli and bacteroides. In mild cases of appendicitis, the use of metronidazole in combination with one of the I-II generation cephalosporins is indicated.
During most operations on the colon and rectum (both planned and emergency), antibiotics are prescribed for prophylactic purposes - cefuroxime (or ceftriaxone), metronidazole, and in some cases the duration of courses of these drugs is increased. For interventions on the anorectal area (hemorrhoidectomy, removal of polyps, condylomas), the prophylactic use of antibiotics is not indicated.
Splenectomy.The absence of the spleen or impairment of its functions increases the risk of severe purulent complications, including sepsis after splenectomy. Most infectious complications develop in the first 2 years after splenectomy, although they may appear after more than 20 years. The risk of infection is higher in children and when splenectomy is performed not for injury, but for a malignant neoplasm. Antibiotic prophylaxis is recommended for all patients who have undergone splenectomy. The drugs of choice are generation cephalosporins. Phenoxymethylpenicillin is less effective; if you are allergic to penicillin, macrolides are indicated.
Antibiotic prophylaxis is not necessary in all cases, but sometimes it can be extremely beneficial both for the patient and from an economic point of view. The effectiveness of antibiotics should be determined by the surgeon based on the expected risk of postoperative infection. The choice of drug for prophylactic antibiotic therapy depends on the type of probable pathogens, the most
more often the cause of certain postoperative bacterial complications. However, infection can develop despite antibiotic prophylaxis, so the importance of other methods to prevent postoperative bacterial complications should not be underestimated.
Thus, prevention of postoperative complications is necessary at all stages of endo- and exogenous infection (impact on foci of infection, routes of transmission, surgical equipment, tissue in the surgical area), and the rules of asepsis and antisepsis should also be strictly observed.
POSTOPERATIVE PERIOD
Surgery and anesthesia are generally regarded as operational stress, and its consequences - how postoperative condition(postoperative illness).
Operational stress is caused by surgical trauma and occurs as a result of a complex of various influences on the patient: fear, excitement, pain, exposure to drugs, trauma, wound formation, abstinence from eating, the need to remain in bed, etc.
Various factors contribute to the appearance of a stressful state: 1) the general condition of the patient before and during surgery, due to the nature of the disease; 2) traumatism and duration of surgical intervention; 3) insufficient pain relief.
Postoperative period - the period of time from the end of the operation until the patient recovers or is transferred to disability. Distinguish early postoperative period- time from completion of the surgical operation to the patient’s discharge from the hospital - and late postoperative period- time from the moment the patient is discharged from the hospital until his recovery or transfer to disability.
Surgery and anesthesia lead to certain pathophysiological changes in the body of a general nature, which are a response to surgical trauma. The body mobilizes a system of protective factors and compensatory reactions aimed at eliminating the consequences of surgical trauma and restoring homeostasis. Under the influence of the operation, a new type of metabolism does not arise, but the intensity of individual processes changes - the ratio of catabolism and anabolism is disrupted.
Stages
In the postoperative state of the patient, three phases (stages) are distinguished: catabolic, reverse development and anabolic.
Catabolic phase
The duration of the phase is 3-7 days. It is more pronounced with serious changes in the body caused by the disease for which the operation was performed, as well as the severity of the operation. The catabolic phase is aggravated and prolonged by ongoing bleeding, the addition of postoperative (including purulent-inflammatory) complications, hypovolemia, changes in water-electrolyte and protein balance, as well as disturbances in the postoperative period (intractable pain, inadequate, unbalanced parenteral nutrition, hypoventilation of the lungs) .
The catabolic phase is a protective reaction of the body, the purpose of which is to increase its resistance through the rapid delivery of necessary energy and plastic materials.
It is characterized by certain neuroendocrine reactions: activation of the sympathetic-adrenal system, hypothalamus and pituitary gland, increased synthesis and entry into the blood of catecholamines, glucocorticoids, aldosterone, adrenocorticotropic hormone (ACTH). The concentration of dextrose in the blood increases and the insulin content decreases, and increased synthesis of angiotensin and renin occurs. Neurohumoral disorders lead to changes vascular tone(vasospasm) and blood circulation in tissues, microcirculation disorders, impaired tissue respiration, hypoxia, metabolic acidosis, which in turn causes disturbances in water and electrolyte balance, fluid leakage from the bloodstream into the interstitial spaces and cells, blood thickening and stasis of its formed elements . As a result, the degree of disruption in tissues of redox processes occurring under conditions of predominance (due to tissue hypoxia) of anaerobic glycolysis over aerobic one is aggravated. With such biochemical disorders and microcirculation disorders, the myocardium, liver and kidneys are primarily affected.
Increased protein breakdown is characteristic of the catabolic phase and represents the loss of not only muscle and connective tissue proteins, but, more importantly, enzyme proteins. The fastest breakdown of proteins occurs in the liver, plasma, gastrointestinal tract,
slower - proteins of striated muscles. Thus, when fasting for 24 hours, the amount of liver enzymes decreases by 50%. The total loss of protein in the postoperative period is significant. For example, after gastrectomy or gastrectomy, 10 days after surgery with an uncomplicated course and without parenteral nutrition, the patient loses 250-400 g of protein, which is 2 times the volume of plasma proteins and corresponds to a loss of 1700-2000 g of muscle mass. Protein loss increases significantly with blood loss and postoperative purulent complications; it is especially dangerous if the patient had hypoproteinemia before surgery.
Clinical manifestations The catabolic phase of the postoperative period has its own characteristics.
Nervous system. On the 1st day after surgery, due to the residual effect of narcotic and sedative substances, patients are lethargic, drowsy, and indifferent to the environment. Their behavior is calm in most cases. Starting from the 2nd day after the operation, as the effect of the narcotic drugs ceases and pain appears, manifestations of instability of mental activity are possible, which can be expressed in restless behavior, agitation, or, conversely, depression. Disorders of mental activity are caused by the addition of complications that increase hypoxia and disturbances in water and electrolyte balance.
The cardiovascular system. Pallor of the skin, increased heart rate by 20-30%, a moderate increase in blood pressure, and a slight decrease in stroke volume of the heart are noted.
Respiratory system. In patients, breathing becomes more frequent when its depth decreases. The vital capacity of the lungs is reduced by 30-50%. Shallow breathing may be caused by pain at the surgical site, high position of the diaphragm or limited mobility after surgery on the abdominal organs, or the development of gastrointestinal paresis.
Liver and kidney dysfunction manifested by an increase in dysproteinemia, a decrease in the synthesis of enzymes, as well as diuresis due to a decrease in renal blood flow and an increase in the content of aldosterone and antidiuretic hormone.
Reverse development phase
Its duration is 4-6 days. The transition from the catabolic phase to the anabolic phase does not occur immediately, but gradually. This period is characterized by a decrease in the activity of the sympathetic-adrenal system and catabolic processes, which
indicates a decrease in urinary nitrogen excretion to 5-8 g/day (instead of 15-20 g/day in the catabolic phase). The amount of nitrogen introduced is higher than that excreted in the urine. A positive nitrogen balance indicates normalization of protein metabolism and increased protein synthesis in the body. During this period, the excretion of potassium in the urine decreases and it accumulates in the body (participates in the synthesis of proteins and glycogen). Water-electrolyte balance is restored. The neurohumoral system is dominated by influences parasympathetic system. The level of somatotropic hormone (GH) insulin and androgens is increased.
In the transition phase, the increased consumption of energy and plastic materials (proteins, fats, carbohydrates) still continues, although to a lesser extent. Gradually it decreases, and active synthesis of proteins, glycogen, and then fats begins, which increases as the severity of catabolic processes decreases. The final predominance of anabolic processes over catabolic ones indicates the transition of the postoperative period to the anabolic phase.
In an uncomplicated course of the postoperative period, the phase of reverse development begins 3-7 days after surgery and lasts 4-6 days. Its signs are the disappearance of pain, normalization of body temperature, and the appearance of appetite. Patients become active, the skin acquires a normal color, breathing becomes deep, and the number of respiratory movements decreases. The heart rate is approaching the initial preoperative level. The activity of the gastrointestinal tract is restored: peristaltic bowel sounds appear, gases begin to escape.
Anabolic phase
This phase is characterized by increased synthesis of protein, glycogen, and fats consumed during surgery and in the catabolic phase of the postoperative period.
The neuroendocrine response consists of activating the parasympathetic autonomic nervous system and increasing the activity of anabolic hormones. Protein synthesis is stimulated by growth hormone and androgens, the activity of which increases significantly in the anabolic phase. STH activates the transport of amino acids from the intercellular spaces into the cell. Androgens actively influence protein synthesis in the liver, kidneys, and myocardium. Hormonal processes lead to an increase in the amount of proteins in the blood, organs, and also in the wound area, thereby ensuring reparative processes, growth and development of connective tissue.
In the anabolic phase of the postoperative period, glycogen reserves are restored due to the anti-insulin effect of GH.
Clinical signs characterize the anabolic phase as a period of recovery, restoration of impaired functions of the cardiovascular, respiratory, excretory systems, digestive organs, and nervous system. In this phase, the patient’s well-being and condition improve, appetite increases, heart rate and blood pressure normalize, and the activity of the gastrointestinal tract is restored: food passage, absorption processes in the intestines, and independent stool appears.
The duration of the anabolic phase is 2-5 weeks. Its duration depends on the severity of the operation, the initial condition of the patient, the severity and duration of the catabolic phase. This phase ends with an increase in body weight, which begins after 3-4 weeks and continues until complete recovery (sometimes several months). Restoring body weight depends on many factors: the degree of its loss in the preoperative period due to debilitating diseases, the volume and severity of the operation, postoperative complications, the severity and duration of the catabolic phase of the postoperative period. Within 3-6 months, the processes of reparative regeneration are finally completed - the maturation of connective tissue, the formation of a scar.
Monitoring patients
After the operation, patients are admitted to the intensive care unit or ward, which are specially organized for monitoring patients, conducting intensive care and providing, if necessary, emergency assistance. To monitor the patient’s condition, the departments have devices that allow them to constantly record pulse rate, rhythm, ECG and EEG. The express laboratory allows you to monitor the level of hemoglobin, hematocrit, electrolytes, blood proteins, blood volume, and acid-base status. The intensive care unit has everything necessary to provide emergency care: a set of medications and transfusion media, mechanical ventilation equipment, sterile sets for venesection and tracheostomy, a cardiac defibrillation apparatus, sterile catheters, probes, and an equipped dressing table.
A thorough examination of the patient is carried out using general clinical research methods (inspection, palpation, percussion, auscultation), and, if necessary, instrumental research (ECG,
EEG, radiography, etc.). Carry out constant monitoring of the patient's mental state (consciousness, behavior - excitement, depression, delirium, hallucinations), his skin (pallor, cyanosis, jaundice, dryness, sweating).
When examining the cardiovascular system, the pulse rate, filling, rhythm, blood pressure level and, if necessary, central venous pressure, the nature of heart sounds, and the presence of murmurs are determined. When examining the respiratory organs, the frequency, depth, and rhythm of breathing are assessed, and percussion and auscultation of the lungs are performed.
When examining the digestive organs, the condition of the tongue (dryness, the presence of plaque), the abdomen (bloating, participation in breathing, the presence of symptoms of peritoneal irritation: muscle tension in the abdominal wall, Shchetkin-Blumberg symptom, peristaltic bowel sounds) are determined, and the liver is palpated. Information is obtained from the patient about the passage of gases and the presence of stool.
The study of the urinary system includes determination of daily diuresis, urine flow rate through a permanent urinary catheter, and hourly diuresis.
Laboratory data are analyzed: hemoglobin content, hematocrit, indicators of acid-base status, bcc, blood electrolytes. Changes in laboratory parameters, along with clinical data, make it possible to correctly determine the composition and volume of transfusion therapy and select medications.
The patient is examined many times in order to compare the data obtained and promptly determine possible deterioration in his condition and identify early symptoms. possible complications and start treatment as quickly as possible.
Data from the examination and special studies are entered into a special card for monitoring the patient in the intensive care unit and noted in the medical history in the form of diary entries.
When monitoring a patient, one should focus on critical indicators of the activity of organs and systems, which should serve as the basis for determining the cause of the deterioration of the patient’s condition and providing emergency assistance.
1. Condition of the cardiovascular system: pulse more than 120 per minute, decrease in SBP to 80 mm Hg. and below and increasing it to 200 mmHg, cardiac arrhythmia, decreased central venous pressure below 50 mmHg. and increasing it to more than 110 mm water column.
2. Condition respiratory system: number of respirations more than 28 per minute, pronounced shortening of percussion sound, dull sound above the lungs
mi during percussion of the chest, absence of respiratory sounds in the dullness area.
3. Condition of the skin and visible mucous membranes: severe pallor, acrocyanosis, cold sticky sweat.
4. Condition of the excretory system: decreased urination (urine amount less than 10 ml/h), anuria.
5. Condition of the gastrointestinal tract organs: sharp tension in the muscles of the anterior abdominal wall, black feces (admixture of blood), sharply positive Shchetkin-Blumberg symptom, severe bloating, non-passage of gases, absence of peristaltic bowel sounds for more than 3 days.
6. State of the central nervous system: loss of consciousness, delirium, hallucinations, motor and speech agitation, lethargy.
7. Condition of the surgical wound: abundant soaking of the dressing with blood, separation of the edges of the wound, protrusion of abdominal organs into the wound (eventration), abundant soaking of the dressing with pus, intestinal contents, bile, and urine.
Treatment
Measures are taken to compensate for metabolic disorders, restore impaired organ functions, normalize redox processes in tissues (oxygen delivery, removal of under-oxidized metabolic products, carbon dioxide, replenishment of increased energy costs).
An important point in maintaining and improving protein and electrolyte metabolism is parenteral and, if possible, enteral nutrition of the patient. Natural introduction of fluids and nutrients should be preferred and used as early as possible.
Key points of intensive care in the postoperative period:
1) pain control with the help of painkillers, electroanalgesia, epidural anesthesia, etc.;
2) restoration of cardiovascular activity, elimination of microcirculation disorders (cardiovascular drugs, dextran [average molecular weight 30,000-40,000]);
3) prevention and treatment of respiratory failure (oxygen therapy, breathing exercises, controlled pulmonary ventilation);
4) detoxification therapy (see Chapter 7);
5) correction of metabolic disorders (water-electrolyte balance, acid-base status, protein synthesis) (see Chapter 7);
6) balanced parenteral nutrition (see Chapter 7);
7) restoration of the functions of the excretory system;
8) restoration of the functions of organs whose activity is impaired due to surgery (intestinal paresis during operations on the abdominal organs, hypoventilation, atelectasis during operations on the lungs, etc.).
Complications
In the early postoperative period complications can arise at different times. In the first 2 days after surgery, complications such as bleeding (internal or external), acute vascular failure (shock), acute heart failure, asphyxia, respiratory failure, complications from anesthesia, water-electrolyte imbalance, decreased urination (oliguria, anuria), paresis of the stomach, intestines.
In the following days after surgery (3-8 days), the development of cardiovascular failure, pneumonia, thrombophlebitis, thromboembolism, acute hepatic-renal failure, and wound suppuration is possible.
A patient who has undergone surgery and anesthesia may experience complications in the postoperative period due to disruption of the basic functions of the body. The causes of postoperative complications may be related to the underlying disease for which the surgery was performed, the anesthesia and surgery suffered, and exacerbation of concomitant diseases. All complications can be divided into early and late.
Early complications
Early complications can arise in the first hours and days after surgery; they are associated with the inhibitory effect of narcotic substances on breathing and blood circulation, and with uncompensated water and electrolyte disturbances. Drugs that are not eliminated from the body and muscle relaxants that are not destroyed lead to respiratory depression, until it stops. This is manifested by hypoventilation (rare shallow breathing, tongue retraction), and apnea may develop.
Breathing disorders can also be caused by vomiting and regurgitation in a patient who has not completely recovered from the state of narcotic sleep. Therefore, monitoring the patient in the early postoperative period is very important. If breathing is impaired, it is necessary to immediately establish Ventilation bag Ambu, if the tongue is retracted, use air ducts that restore airway patency. In case of respiratory depression caused by the ongoing effect of narcotic substances, respiratory analeptics (nalorphine, bemegride) can be used.
Bleeding -the most serious complication of the postoperative period. It can be external (from a wound) or internal - hemorrhage in the cavity (thoracic, abdominal) tissue. Common signs of bleeding are pale skin, weak, rapid pulse, and decreased blood pressure. When bleeding from a wound, the bandage is soaked with blood, and bleeding from drains inserted into body cavities and tissue is possible. The increase in clinical and laboratory signs with slowly progressing internal bleeding allows us to clarify the diagnosis. Methods to stop bleeding are described in Chapter 5. If conservative measures are unsuccessful, wound revision and repeated surgery - relaparotomy, rethoracotomy - are indicated.
In the first days after surgery, patients may have disturbances in water-electrolyte balance, caused by an underlying disease in which there is loss of water and electrolytes (intestinal obstruction), or blood loss. Clinical signs of water-electrolyte imbalance are dry skin, increased skin temperature, decreased skin turgor, dry tongue, severe thirst, soft eyeballs, decreased central venous pressure and hematocrit, decreased diuresis, and tachycardia. It is necessary to immediately correct the deficiency of water and electrolytes by transfusion of appropriate solutions (Ringer-Locke solutions, potassium chloride, Sodium acetate + Sodium chloride, Sodium acetate + Sodium chloride + Potassium chloride). Transfusion must be carried out under the control of central venous pressure, the amount of urine produced and the level of blood electrolytes. Fluid and electrolyte disorders can also occur in the late period after surgery, especially in patients with intestinal fistulas. In this case, constant correction of the electrolyte balance and transfer of the patient to parenteral nutrition are necessary.
In the early postoperative period, there may be respiratory disorders, associated with pulmonary atelectasis, pneumonia, bronchitis; These complications are especially common in elderly patients. To prevent respiratory complications, early activation of
tion of the patient, adequate pain relief after surgery, therapeutic exercises, percussion and vacuum chest massage, aerosol steam inhalations, inflation of rubber chambers. All these measures contribute to the opening of collapsed alveoli and improve the drainage function of the bronchi.
Complications from the cardiovascular system often occur against the background of uncompensated blood loss, disturbed water-electrolyte balance and require adequate correction. In elderly patients with concomitant pathology of the cardiovascular system, against the background of the underlying surgical disease, anesthesia and surgery in the postoperative period, episodes of acute cardiovascular failure (tachycardia, rhythm disturbances), as well as an increase in central venous pressure, which serves as a symptom of left ventricular failure and pulmonary edema, may occur. Treatment is individual in each specific case (cardiac glycosides, antiarrhythmics, coronary dilators). For pulmonary edema, ganglion blockers, diuretics, and inhalation of oxygen moistened with alcohol are used.
During operations on the gastrointestinal tract, one of the complications may be intestinal paresis(dynamic intestinal obstruction). It usually develops in the first 2-3 days after surgery. Its main signs: bloating, absence of peristaltic bowel sounds. For the prevention and treatment of paresis, intubation of the stomach and intestines, early activation of the patient, anesthesia, epidural anesthesia, perirenal blockades, intestinal stimulants (neostigmine methyl sulfate, diadynamic currents, etc.) are used.
Urinary dysfunction in the postoperative period may be due to a change in the excretory function of the kidneys or the addition of inflammatory diseases - cystitis, urethritis, pyelonephritis. Urinary retention can also be of a reflex nature - caused by pain, spastic contraction of the abdominal muscles, pelvis, and bladder sphincters.
For seriously ill patients after long-term traumatic operations, a permanent catheter is installed in the bladder, which allows systematic monitoring of diuresis. In case of urinary retention, painkillers and antispastic agents are administered; A warm heating pad is placed on the bladder area above the pubis. If the patient's condition allows, men are allowed to stand up to try to urinate while standing. If it fails, urine is removed with a soft catheter; if this fails, with a hard (metal) catheter. As a last resort, when attempts at catheterization
bladder are ineffective (with benign prostatic hyperplasia), a suprapubic bladder fistula is applied.
Thromboembolic complications in the postoperative period they are rare and mainly develop in the elderly and seriously ill. The source of embolism is most often the veins of the lower extremities and pelvis. Slowing blood flow and changing the rheological properties of blood can lead to thrombosis. Prevention includes activation of patients, treatment of thrombophlebitis, bandaging of the lower extremities, correction of the blood coagulation system, which includes the use of sodium heparin, administration of agents that reduce the aggregation of blood cells (for example, dextran [average molecular weight 30,000-40,000], acetylsalicylic acid ), daily fluid transfusion to create moderate hemodilution.
Development wound infection most often occurs on the 3-10th day of the postoperative period. Pain in the wound, increased body temperature, tissue compaction, inflammatory infiltrate, hyperemia of the skin around the wound are indications for its revision, partial or complete removal of sutures. Subsequent treatment is carried out according to the principle of treating a purulent wound.
In exhausted patients who are in bed for a long time in a forced position, it is possible to develop bedsores in places of tissue compression. More often, bedsores appear in the area of the sacrum, less often - in the area of the shoulder blades, heels, etc. In this case, the places of compression are treated with camphor alcohol, the patients are placed on special rubber circles, an anti-bedsore mattress, and a 5% solution of potassium permanganate is used. When necrosis has developed, necrectomy is resorted to, and treatment is carried out according to the principle of treating a purulent wound. To prevent bedsores, early activation of the patient, turning him in bed, treating the skin with antiseptics, using rubber circles and mattresses, and clean, dry linen are necessary.
Pain syndrome in the postoperative period. The absence of pain after surgery largely determines the normal course of the postoperative period. In addition to psycho-emotional perception, pain syndrome leads to respiratory depression, reduces the cough impulse, promotes the release of catecholamines into the blood, against this background tachycardia occurs, and blood pressure increases.
To relieve pain, you can use narcotic drugs that do not depress respiration and cardiac activity (for example, fentanyl), non-narcotic analgesics (metamizole sodium), transcutaneous electroanalgesia, long-term epidural anesthesia,
acupuncture. The latter methods in combination with analgesics are especially indicated for the elderly. Pain relief allows the patient to cough up mucus well, breathe deeply, and be active, which determines a favorable course of the postoperative period and prevents the development of complications.
Classification of surgical operations
Surgical operations are usually divided according to the urgency of their implementation and the possibility of complete cure or alleviation of the patient’s condition.
According to the urgency of implementation, they are distinguished:
- 1) emergency operations, they are performed immediately or within the next few hours from the moment the patient is admitted to the surgical department;
- 2) urgent operations are performed within the next few days after admission;
- 3) planned operations, they are performed as planned (the timing of their implementation is not limited).
There are radical and palliative operations.
Radical consider an operation in which, by removing a pathological formation, part or all of an organ, the return of the disease is excluded. The volume of surgical intervention, which determines its radicalism, is determined by the nature of the pathological process. For benign tumors (fibromas, lipomas, neuromas, polyps, etc.), their removal leads to a cure for the patient. In case of malignant tumors, radical intervention is not always achieved by removing part or all of the organ, taking into account the possibility of tumor metastasis. Therefore, radical oncological operations often, along with organ removal, include removal (or resection) of neighboring organs and regional lymph nodes. Thus, the radicalism of surgery for breast cancer is achieved by removing not only the entire mammary gland, but also the large and small pectoral muscles, fatty tissue along with the lymph nodes of the axillary and subclavian regions. In inflammatory diseases, the scope of intervention, which determines the radicality of the operation, is limited to the removal of pathologically changed tissues: for example, osteonecrectomy is performed for chronic osteomyelitis or removal of a pathologically changed organ - appendectomy, cholecystectomy, etc.
Palliative are operations performed to eliminate an immediate danger to the patient’s life or alleviate his condition. Thus, in case of disintegration and bleeding from a stomach tumor with metastases, when radical surgery is impossible due to the prevalence of the process, gastric resection or wedge-shaped excision of the stomach with a tumor and a bleeding vessel is performed to save life. In case of a widespread neoplasm of the esophagus with metastases, when the tumor completely obstructs the lumen of the esophagus, and it becomes impassable for food and even water, in order to prevent starvation, a palliative operation is performed - the placement of a fistula on the stomach (gastrostomy), through which food is introduced into it. Palliative operations achieve stopping bleeding or the possibility of nutrition, but the disease itself is not eliminated, since tumor metastases or the tumor itself remain. For inflammatory or other diseases, palliative operations are also performed. For example, with paraosseous phlegmon complicating osteomyelitis, the phlegmon is opened, the wound is drained to eliminate intoxication, prevent the development of a general purulent infection, but the main focus of inflammation in the bone remains. In case of acute purulent cholecystitis in the elderly and people suffering from heart failure, the risk of radical surgery is high. To prevent the development of purulent peritonitis and severe intoxication, a palliative operation is performed - cholecystostomy: the application of a fistula to gallbladder. Palliative operations can play the role of a certain stage in the treatment of patients, as in the examples given (opening of phlegmon in osteomyelitis or cholecystostomy in acute cholecystitis). Subsequently, when the general condition of the patient improves or local favorable conditions are created, a radical operation can be performed. In case of inoperable oncological diseases, when radical intervention is impossible due to the prevalence of the process, palliative surgery is the only benefit that can temporarily alleviate the patient’s condition.
Radical operation (o. radicalis) O., through which a complete cure of the patient can be achieved.
Large medical dictionary. 2000 .
See what a “radical operation” is in other dictionaries:
OPERATION RADICAL- (commando operation) basic operation to remove a malignant tumor of the head and neck. The extensive excision performed during this operation (often affecting facial tissues) requires further reconstruction to restore lost... ... Explanatory dictionary of medicine
Major surgery to remove a malignant tumor of the head and neck. The extensive excision performed during this operation (often affecting facial tissue) requires further reconstruction to restore lost functions, as well as... ... Medical terms
Surgeons during an operation A surgical operation, surgical intervention or surgical intervention (from the Latin operatic work, action) a complex of effects on human tissues or organs carried out by a doctor for the purpose of treatment, diagnosis, ... ... Wikipedia
See Radical surgery on the maxillary cavity... Large medical dictionary
See Radical ear surgery... Large medical dictionary
- (syn. O. on the maxillary cavity combined) a type of maxillary sinus in which resection of the anterior (facial) wall of the maxillary sinus and its nasal wall in the area of the middle and lower nasal passages is performed... Large medical dictionary
- (syn. O. on the ear, general cavity) O., in which the cavities of the middle ear are widely opened and pathologically altered tissues are removed, combining the cave into a common cavity, tympanic cavity and ear canal; produced in chronic purulent inflammation... Large medical dictionary
This term has other meanings, see Operation. Surgeons during an operation Surgical operation, surgical intervention or surgical intervention (about ... Wikipedia
- (L. Stacke, 1859 1918, German otorhinolaryngologist) radical surgery on the middle ear for chronic purulent otitis media with bone caries or cholesteatoma; consists of opening the middle ear cavity by removing the lateral wall... ... Large medical dictionary
Books
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