Is laparotomy a routine surgical operation or a dangerous procedure? Laparotomy - abdominal examination - exploratory laparotomy Stages of laparotomy.

A surgical method of operation such as laparotomy, often used in gynecology, is an open access to organs located in the pelvis, and is carried out through a small incision in the abdomen.

When is laparotomy used?

Laparotomy is used for:

ovarian cysts – cisectomy;
removal of myomatous nodes - myectomy;
surgical treatment of endometriosis;
caesarean section.

When performing laparotomy, quite often surgeons diagnose various kinds of pathological conditions, such as: inflammation of organs located in the pelvis, inflammation of the appendix (appendicitis), cancer of the ovaries and uterine appendages, the formation of adhesions in the pelvic area. Laparotomy is often used when a woman experiences this.

Species

There are several types of laparotomy:

The operation is performed through a lower midline incision. In this case, an incision is made along the line exactly between the navel and the pubic bone. This method of laparotomy is often used for tumor diseases, for example, uterine fibroids. The advantage of this method is that the surgeon can expand the incision at any time, thereby increasing access to organs and tissues.
Pfannenstiel laparotomy is the main method used in gynecology. The incision is made along the lower line of the abdomen, which allows it to be completely camouflaged and after healing, the remaining small scar is almost impossible to notice.

Main advantages

The main advantages of laparotomy are:

technical simplicity of the operation;
does not require complex tools;
convenient for the surgeon performing surgery.

Differences between laparotomy and laparoscopy

Many women often equate 2 different surgical methods: laparoscopy and laparotomy. The main differences between these two operations are that laparoscopy is performed mainly for diagnostic purposes, and laparotomy is already a method of direct surgical intervention, entailing the removal or excision of a pathological organ or tissue. Also, when performing laparotomy, a large incision is made on the woman’s body, after which a suture remains, and during laparoscopy, only small wounds remain, which heal after 1-1.5 weeks.

Depending on what is being performed - laparotomy or laparoscopy, the rehabilitation time is different. After laparotomy it ranges from several weeks to 1 month, and with laparoscopy the patient returns to normal life after 1-2 weeks.

Consequences of laparotomy and possible complications

When performing this type of surgery, such as laparotomy of the uterus, damage to adjacent pelvic organs is possible. In addition, the risk of adhesions after surgery increases. This happens because during the operation, surgical instruments come into contact with the peritoneum, as a result of which it becomes inflamed and adhesions are formed on it, which “glue” the organs together.

During laparotomy, complications such as bleeding may occur. It is caused by rupture or damage to organs (rupture of the fallopian tubes) during abdominal surgery. In this case, it is necessary to remove the entire organ, which will lead to infertility.

When can you plan a pregnancy after laparotomy?

Depending on which organ of the reproductive system underwent surgical intervention, the time frame after which you can become pregnant varies. In general, it is not recommended to plan a pregnancy earlier than six months after the laparotomy.

Laparotomy is a rather complex surgical operation that requires the specialist performing it to have special knowledge of anatomy and skills in using surgical instruments.

Types and features of holding

What is laparotomy in surgery? The following methods of transection are distinguished.

Median laparotomy, in turn, is divided into the following types:

Upper median laparotomy - features: the beginning of the section is from the urinary process of the sternum to the umbilical cavity. The surgeon gains access to organs/tissues located in the upper part of the peritoneum. The advantages of this method: speed, easy cutting/suturing, possibility of extending the incision line if necessary. Disadvantage: upper midline laparotomy involves cutting the tendons, and this is fraught with the formation of hernias;
Inferomedian laparotomy - the incision begins at the navel and ends near the symphysis pubis. The surgeon gets the opportunity to assess the condition and take measures to eliminate pathologies of the tissues and organs of the lower part of the peritoneum. The pros and cons of this method are similar to the upper median laparotomy;
What is central midline laparotomy in surgery? The incision begins at a distance of eight cm above the navel, then goes to it, goes around on the left side, and goes down 8 cm. This method is used when it is necessary to suturing internal organs for a more accurate diagnosis;
Total laparotomy is used in surgery quite rarely. Indication: multiple abdominal injuries. The line of dissection is from the urinary process to the symphysis pubis;

Oblique incision - the dissection is made from below along the edge of the rib arches or from above along the groin ligaments. It opens access to the appendix, spleen, gall bladder;

Transverse excision involves cutting the muscle fibers. Often used in gynecology. There is a risk of postoperative hernias due to weakening of the peritoneal wall;

Angular transection is prescribed if it is necessary to “get” to a specific organ: gallbladder ducts, liver.

The type of surgical intervention is prescribed by a specialist depending on the type of disease.

The role of laparotomy in the diagnosis of diseases of the abdominal cavity

Diagnostic laparotomy (explorative) is currently not so frequent and widespread in medicine. The reason is the presence in clinical practice of a sufficient number of high-precision research methods: ultrasound, computed tomography, x-rays, radiation diagnostics.

Diagnostic laparotomy: causes - damage to the abdominal organs, acute surgical diseases, the inability to establish the disease using invasive methods and prescribe treatment methods.

For what pathologies is diagnostic laparotomy still prescribed:

Perforation, injuries of the stomach, duodenum, colon, pancreas, ureter, kidneys, vessels of the retroperitoneal space;
Ulcer in acute/chronic form;
A cancerous tumor is in the decay stage;
Tuberculosis;
Necrosis;
Fecal stones;
Internal hernias;
Peritonitis.

Diagnostic laparotomy allows you to detect benign and malignant tumors, ulcers.

Exploratory laparotomy is a manipulation that requires preliminary preparation. Specialists determine the plan and progress of work in advance, assess the risks, and take measures to reduce them. Its duration, as a rule, does not exceed two hours, with heavy bleeding - no more than twenty to thirty minutes.

It is important to ensure the patient’s external breathing during the operation, stabilize systolic pressure, and control urine output using a catheter.

Requirements for laparotomy

The risks of hernia formation are minimized; post-traumatic conditions, complications;
Muscles, nerve endings, blood vessels are intact;
The surgeon must have a place for excision, assessing the condition of organs, systems, tissues, performing manipulations, and stitching the cut layers.

The operation is performed using general anesthesia. Step one - the skin and subcutaneous fat are cut. The wound is dried using napkins attached to cleols or clamps along the edges, the vessels are clamped. Step two - the edges of the wound are spread apart using hooks, opening the view. Step three - dissection of the peritoneum with special scissors. Often at this stage, the liquid contained in the cavity splashes out. A special pump is used to suck it out. Step four - specialists carefully examine the opened organs, identify pathology, eliminate it, returning the organs and tissues to normal functioning, and if this is not possible, remove them. Step five – drains are installed, then the incised area of the peritoneum is sutured in layers. Diagnostic laparotomy is performed in a similar way.

Compliance with all recommendations and prescriptions of the doctor;
Wearing shoes that reduce the risk of blood clots;
Using a catheter when urinating;
Eating easily digestible foods, vegetables, fruits, juices;
The most important thing is that you should not touch a fresh wound, get it wet, or pick it with your fingers or sharp objects to avoid infections;
Intense physical activity and exercises are unacceptable after abdominal surgery;
Monitoring your health status: body temperature, timely urination, stool. You should immediately seek medical help in case of dizziness, nausea, fever, pain, or bleeding in the wound area.

Transsection in gynecology: features, types, differences from laparoscopy

Laparotomy in gynecology is a fairly common occurrence. It is prescribed in the following cases:

Ectopic pregnancy;
Cysts, purulent inflammation of the uterine tubes, ovaries;
Peritonitis;
Ovarian pathologies;
Infertility;
Obstetrics (caesarean section).

A similar procedure is also necessary when the patient requires complete removal for medical reasons - extirpation of the uterus and appendages.

Laparotomy is often confused with another surgical procedure – laparoscopy. How do they differ from each other?

Important: to perform the operation there is no need to cut the peritoneum - the surgeon makes several minor punctures through which manipulations are carried out, cameras and instruments are inserted.

Methods of abdominal dissection during gynecological operations:

Cherny dissection - an incision is made along the line between the navel and the pubic bone. Used for uterine fibroids.
Laparotomy according to Pfannenstiel with a transverse incision above the pubis, along the lower line of the abdomen.
Laparotomy according to Joel Cohen - transverse excision below the middle of the distance from the navel to the pubis by two to three cm.

Laparotomy of the female reproductive organs is an unsafe procedure, fraught with complications, functional disorders, and long tissue recovery. However, it is often the last chance for patients with malignant tumors and metastases. Laparotomy of the uterus is carried out after preliminary preparation and thorough studies, including ultrasound, histological studies, hysterocerviscopy, magnetic resonance and computed tomography. Laparotomy of an ovarian cyst is necessary in cases of formations of significant size in the deep tissues of the ovaries, purulent processes, torsion of neoplasms, adhesions in the pelvic organs, and the presence of cancer.

Recovery after laparotomy of an ovarian cyst is a process that requires adequate treatment and observation: hospital stay for four days from the day of surgery, regular medical examination, prescription and use of painkillers. During the month after surgery, intense physical activity and physical education are strictly contraindicated.

Does pregnancy occur after laparotomy? The chances of pregnancy and a successful delivery in patients who have undergone it are quite high. When can you get pregnant after surgery? The answer to this question will be given by a specialist under whose supervision the woman was. He will give recommendations on timing, based on the severity of the disease, the characteristics of the operation, the recovery period, and rehabilitation. It is recommended not to be sexually active for the first two months after surgery, and it is recommended to become pregnant after six months.

What to do if pregnancy does not occur after a year or more? Go to the hospital, undergo additional tests and prescribed treatments.

Complications after gynecological surgery:

Excess weight;
Chronic diseases;
Bad habits: alcohol, drug addiction, smoking, non-compliance with the daily routine, nervous tension;
Diseases of the respiratory and cardiovascular systems;
Pathologies of the circulatory system (non-coagulability of blood, viscous, thick blood);
Repeated surgical procedures;
External and internal bleeding;
Tendency to form blood clots;
Hernias.

Where can I find out more about the operation? Modern specialized media, literature, and specialized websites provide complete and comprehensive information about this surgical procedure.

Laparotomy (chromectomy) – a mandatory stage of all operations on the abdominal organs. In some cases, it serves as access to a specific organ or pathological process, in others it is used to inspect the abdominal organs in order to exclude damage to internal organs or determine the possibility of surgery for a tumor process.

Anesthesia . For small laparotomies (Dyakonov-Volkovich access for appendectomy), local anesthesia is used. For midline laparotomy, oblique incisions in the hypochondrium, pararectal approaches, as well as for technically difficult appendectomy from a typical approach, modern endotracheal anesthesia with the use of muscle relaxants is preferable.

Accesses. Most often, an incision is used in the midline of the abdomen - median laparotomy.

At upper midline laparotomy, T . That is, an incision along the midline above the navel, dissects the skin, subcutaneous tissue, aponeurosis (or linea alba), preperitoneal tissue and peritoneum. This incision provides access to the organs of the upper abdominal cavity. Lower middle sectionalso runs along the linea alba, however, after dissecting the linea alba, which is very narrow below the navel, it is often necessary to use Farabeuf plate hooks to retract the edges of the rectus muscles. The incision provides access to the intestines and pelvic organs. At midmedian laparotomy the incision starts above the navel, goes around the navel on the left and ends 3-4 cm below it. This access is intended for revision of the entire abdominal cavity: if necessary, it can be extended up or down.

Progress of laparotomy operation

1. Dissection of skin and tissue. An incision is made into the skin and subcutaneous tissue, for which the surgeon is given a sharp abdominal scalpel. This scalpel becomes dirty when cutting the skin, so the operating nurse immediately throws it with a forceps into the basin with the used instrument. When the incision is made, the wound needs to be dried - give the assistant a gauze ball (tuffer) on a forceps or clamp, and the operating surgeon - hemostatic clamps one after another until all the bleeding vessels are captured.

After the bleeding has stopped, the nurse provides 2 napkins to isolate the surgical wound from the skin - the napkins are placed along the edges of the incision and secured at the corners with clamps. For large laparotomies, before placing napkins, it is necessary to lubricate the skin around the wound with cleol so that the napkins stick along the entire length of the incision and reliably isolate the skin. For better fixation, the skin must be wiped dry with a separate cloth before treatment with cleol. Hemostats placed in the subcutaneous tissue can be left until the end of a minor operation, but it is always best to aim for as few instruments as possible in the surgical area. To completely stop the bleeding, the vessels are ligated. To do this, the nurse gives the assistant blunt-ended curved scissors for cutting the threads, and the surgeon sequentially - ligatures made of catgut No. 2, each 18 - 20 cm long. The hemostatic clamps returned by the assistant (necessarily with a latched ratchet lock - the nurse must monitor this) can be used again, wiping them with a sterile napkin and thus clearing them of blood.

2. Dissection of the aponeurosis. The assistant uses sharp hooks to spread the edges of the skin wound. To dissect the aponeurosis, the nurse gives a clean scalpel, with which the surgeon makes a small incision in the aponeurosis, and then curved scissors, with which the surgeon finishes dissecting the aponeurosis up and down. After dissection of the aponeurosis, the peritoneum, covered with peritoneal tissue, is exposed to the surgeon. To clearly see the peritoneal layer below the umbilicus, it may be necessary to retract the edges of the rectus abdominis muscles with plate hooks.

3. Dissection of the peritoneum. To dissect the peritoneum, the nurse hands the surgeon and anatomical assistant tweezers: with these tweezers, the peritoneum is folded and cut with scissors. Once a small hole is made in the peritoneum, two Mikulicz forceps need to be applied: one to the surgeon and one to the assistant. They grab the edges of the peritoneum and fix them to the edge of the side sheets. Moreover, if there is a large amount of exudate or blood in the abdominal cavity, the contents under pressure can flow out, flooding the surgical field and contaminating the wound. Therefore, the nurse should have an electric suction device or a sufficient number of large tampons on forceps ready at the time of opening the abdominal cavity.

As the peritoneum is cut up and then down with Cooper scissors, the sister applies another 4-6 Mikulicz clamps so that the edges of the peritoneum along its entire length are securely fixed to the surgical linen, covering the subcutaneous tissue. If, at the time of opening the abdominal cavity, the intestines interfere with the dissection of the peritoneum, the nurse, at the request of the assistant, provides a tuffer to remove the intestinal loops.

4. Revision of the abdominal organs. The next important stage of laparotomy as an independent operation is a thorough examination of the entire abdominal cavity. At this stage, when the surgeon is focused on detecting pathology, the nurse must carefully ensure that during manipulations no napkins, balls or other foreign bodies are left in the abdominal cavity.

The nurse should have saddle-shaped hooks ready to lift the abdominal wall, liver and abdominal speculum. To widen the edges of the wound and hold them in this position, the nurse applies a retractor, most often the Gosse type. She first prepares two small napkins, which the surgeon places under the hooks of the retractor to reduce pressure on the tissue. These napkins must be well fixed and must be remembered so that at the end of the operation you do not forget to throw them away after removing the retractor. For any laparotomy, hot saline solution should always be available. If there is effusion in the abdominal cavity, the nurse gives the surgeon a small ball to culture the contents for microbial flora.

5. Mesenteric root block. Before suturing a wound of the anterior abdominal wall, in most cases it is necessary to perform a novocaine blockade of the root of the mesentery of the small intestine. To do this, you need to have a syringe with a capacity of 10 or 20 ml with a thin long needle and 150-200 ml of a 0.25% novocaine solution.

6. Installation of drains through a counter aperture. If indicated, the surgeon decides to leave a rubber drain in the abdominal cavity. Microirrigators for administering antibiotics are usually removed through the corners of the midline incision. To avoid infection of the median suture, drains are removed through a counter-aperture in the lateral part of the abdominal wall. To do this, shift the Mikulicz clamps, freeing the edge of the sheet on the corresponding side and exposing the skin in the hypochondrium or iliac region. The nurse provides a stick with an antiseptic for treatment and a pointed scalpel, with which the surgeon pierces the skin in the intended place. After this, the nurse applies a pointed clamp, the assistant lifts the edge of the abdominal wall and the surgeon, under eye control, pierces all layers of the abdominal wall from the outside inward with the clamp. At this point, the nurse should provide a rubber drainage prepared in advance with two to three holes at the end, the end should be rounded. If a different type of drainage is needed, the surgeon himself prepares it in advance or explains in detail what exactly is needed.

The surgeon fixes the drainage with jaws of the clamp and pulls it through the abdominal wall from the inside to the outside, leaving it in the abdominal cavity to the desired length. The nurse then delivers a needle holder with a cutting needle loaded with silk thread to secure the drainage to the skin. After this, the skin is carefully covered again with surgical linen and the surgeon begins to suture the wound of the anterior abdominal wall.

7. Suturing a wound of the anterior abdominal wall. First, the peritoneum is sewn with a continuous catgut suture. The surgeon shifts the Mikulicz clamps, freeing the side edges of the sheets. The sister feeds catgut No. 6 up to 50 cm long on a medium-sized cutting needle. After tying a continuous catgut thread, its ends are cut off.

The operating surgeon and the assistant, if necessary, treat the gloves with an antiseptic solution, the nurse changes the instruments and unfolds the towel lying on the patient with a clean side. Then interrupted silk sutures are applied to the aponeurosis. It is necessary to feed silk threads No. 6 or even No. 8 20-25 cm long on a large cutting needle. Sometimes suturing the peritoneum is difficult due to high tissue tension. In such cases, the surgeon can apply 3-4 interrupted silk sutures to the aponeurosis along with the peritoneum.

After suturing the aponeurosis, the nurse gives a stick with an antiseptic, the surgeon discards the napkins that isolate the skin and carefully treats the wounds with an antiseptic.

Sparse catgut (No. 2) sutures are usually placed on the subcutaneous tissue and superficial fascia. The nurse must take into account the thickness of the subcutaneous layer and apply the threads with a sufficiently long needle. The operation is completed by placing interrupted silk sutures on the skin using silk No. 4 on a strong cutting needle. When stitching the skin around the navel, the needle in the needle holder should be fixed further from the ear, since due to the high density of the skin in this area, the needles often break.

General information. The postoperative period can be divided into early and late. The first of these lasts about three to four days and generally ends by the time the intestines act; the second follows the first and ends after 12-20 days, that is, by the day of discharge. The period following discharge, ending with restoration of working capacity, can be called the period of convalescence; its duration varies.

In order to better monitor the wound (sometimes also the contraction of the uterus), after laparotomy it is better not to bandage the abdomen, but to apply a bandage of several layers of gauze reinforced with strips of adhesive plaster.

After the operation, the patient is placed in the postoperative ward under the supervision of an on-duty or specially designated nurse.

Postoperative wards should have one to three beds and be located close to the operating room and duty station. Only after minor gynecological operations can patients be placed in wards with four to six beds, which, however, are also intended for those who have recently undergone surgery.

The operated patient is placed on a previously prepared and warmed bed. If necessary, the patient is warmed with heating pads, cardiac supplements, glucose, saline, etc. are administered. An ice pack is placed on the abdomen after transection to reduce pain in the wound and to prevent hematoma. In case of vomiting after anesthesia, a basin, a mouth dilator, and a towel should be ready; the patient lies without a pillow, her head is turned to the side to avoid aspiration of vomit. For obese people, it is useful to wrap the abdomen over the bandage with a special towel with ties in the front (“gurita”).

In recovery rooms, it is necessary to have oxygen available, which is used at the first signs of cyanosis, rapid or shallow breathing. Blood pressure is measured, as is pulse counting, several times during the first six to eight hours after surgery.

Already three to six hours after surgery, pain appears in the wound area. Pain can occur even after minor operations, for example, after colpoperineorrhaphy.

Postoperative pain must be eliminated, since, in addition to anxiety, insomnia and deterioration of the general condition, they can cause secondary complications: flatulence, urinary retention, etc. The negative effect of postoperative pain on the central nervous system has been proven; some surgeons see them as the cause of the development of shock and postoperative psychoses.

If pain occurs early, promedol 2% 1-2 ml subcutaneously is prescribed, and at night morphine 1% 1 ml or pantopon 2% 1 ml subcutaneously.

Some authors use aminazine for pain in the postoperative period. The drug can be prescribed intravenously or intramuscularly (2 ml of a 2.5% solution), as well as orally at 0.025, 1 tablet 3 times a day on the second day after surgery. After administration of chlorpromazine, blood pressure decreases for a short time.

Vomiting after anesthesia in operated patients is often observed and depends on irritation of the gastric mucosa by the narcotic substance. It is recommended not to prescribe anything internally; on the epigastric region - heating pads. In case of vomiting after spinal anesthesia, 1-2 ml of 10% caffeine is injected subcutaneously two to three times during the first day.

No later than 12 hours after surgery, it is necessary to achieve urination. If the patient cannot urinate herself (into a heated vessel), then the urine is released with a catheter in compliance with all the rules of asepsis. If urination is delayed in the following days, special measures are required.

Normal postoperative period. Nutrition. In the absence of contraindications - vomiting, post-anesthesia sleep, unconsciousness - a patient who has undergone surgery under general anesthesia is given something to drink within 3-4 hours (not earlier than 1-2 hours after the vomiting stops), preferably hot strong tea with lemon. After large blood loss, it is necessary to re-give fluids in large quantities: it should be noted that in these patients vomiting after anesthesia is observed less frequently, so they need to start giving fluids earlier. It is very important, soon after waking up from anesthesia, to force the operated patient to breathe deeply to remove residual ether from the lungs (“breathing exercises”).

Those who have undergone surgery under spinal or local anesthesia can be given a drink 15-20 minutes after the operation; this quenches thirst, regulates water metabolism and, in addition, has a positive effect on the psyche of patients.

To avoid acidosis, already on the day of surgery, you can start feeding patients, and their diet consists of a liquid and semi-liquid diet: sweet tea, broth, jelly, vitamins, milk; the next day in the morning - sweet tea, crackers; on the second and third days, add porridge (rice, semolina), crackers, bread, butter; sometimes, to stimulate the appetite of weak patients, from the fourth to fifth day it is useful to prescribe protein substances in small quantities - caviar, ham. After one or two bowel movements, patients are transferred to a common table.

From the first day of the operation, it is necessary to monitor the cleanliness of the mouth and tongue (rinsing with a weak solution of potassium permanganate, cleaning the tongue mechanically - with gauze wrapped on a spatula).

Bowel regulation. After laparotomy, if the intestinal action does not occur spontaneously, a hypertonic or glycerin enema is prescribed on the third day.

If the intestines do not work, a cleansing enema of 1 liter of water (with soap) is prescribed or a saline laxative is given.

After vaginal operations with suturing of the perineum, in order to prevent injury to the perineum, it is better to prescribe a laxative instead of an enema, but not earlier than four days after the operation.

Removing stitches. After laparotomy, the staples are removed on the seventh day, silk sutures on the eighth. The sutures on the perineum after plastic surgery are removed early - on the fifth day, since later removal of the sutures can cause them to cut through.

Postoperative complications. Shock (damage to the nervous system) occurs after gynecological operations more often than after obstetric operations, which is partly explained by the shorter duration of obstetric operations and anesthesia during them. In gynecological practice, shock can occur after major long-term operations (for example, after extended hysterectomy for cervical cancer). Collapse (damage to the vascular system, vasomotors) is more common in obstetric pathology and after obstetric operations, especially those associated with large blood loss.

Clinically, shock and collapse are very similar, but with shock consciousness is usually preserved, with collapse it is darkened; in case of shock, the color of the skin is pale yellow, matte; in case of collapse and blood loss, the skin is pale to a marble-shiny whiteness.

In case of shock and collapse, patients are placed with their heads slightly lowered and covered with heating pads; Cardiac drugs are injected under the skin or into a vein - camphor (subcutaneously), caffeine, strophanthin, strychnine. Adrenaline 1 is especially recommended: 1000-0.5 ml intramuscularly or into a vein; Due to the short action of adrenaline, it is necessary to re-administer it in 0.1-0.2 ml doses. Instead of adrenaline, pituitrin can be used subcutaneously. It tones blood vessels and has a longer lasting effect than adrenaline. To irritate the vasomotor center, it is recommended to inhale carbon dioxide, best in the form of a mixture (if you have a special apparatus) of 10% carbon dioxide, 50% oxygen and 40% air. Subsequently, glucose with adrenaline (intravenous drip) or some anti-shock liquid is administered. In case of significant blood loss and shock, a good remedy is blood transfusion (after restoration of proper blood circulation) in significant quantities (up to 1 liter), preferably in two doses.

Secondary bleeding into the abdominal cavity can be observed after laparotomy, less often after vaginal removal of the uterus, most often when the ligature slips off the vascular stump; They manifest themselves as symptoms of internal bleeding. The only correct therapy in these cases is urgent relaparotomy and ligation of bleeding vessels.

During vaginal surgery, secondary bleeding may also occur, usually through the vagina. In these cases, you can plug the latter with gauze. If this does not help, it is necessary to thoroughly expose the bleeding area with mirrors, find the bleeding vessel and ligate it.

Vomiting in the postoperative period can be of various origins, so its treatment depends on the cause that caused it.

Vomiting after inhalation anesthesia on the first day after surgery was discussed above. Vomiting that occurs later may be a sign of acute gastric dilatation, incipient peritonitis, or intestinal obstruction. The best treatment for vomiting is to rest the stomach; No food or medications should be administered through the stomach. Subcutaneous infusions or drip enemas are prescribed to combat dehydration. You can place a heating pad on the stomach area. If there is a large accumulation of mucus, the stomach is rinsed using a probe with a solution of soda mixed with a few drops of mint tincture, or a long-term lavage is prescribed according to Bukatko. When vomiting after spinal anesthesia, it is useful to inject 10% caffeine under the skin two to three times a day, 1 ml.

If vomiting is associated with failure to pass gases, you can first apply gastric lavage, inject a hypertonic NaCl solution (10% 50-100 ml) into a vein, and prescribe siphon enemas. In case of vomiting, depending on the onset of peritonitis, the stomach is washed out and penicillin is administered (150,000 IU intramuscularly after three hours). If there is no effect, in both cases they immediately move on to (repeated) transection.

The cause of flatulence after laparotomy is the exposure, cooling and trauma of internal organs associated with the operation, as well as the negative effect of general anesthesia. Quickly performed operations, especially without the use of general anesthesia, rarely produce postoperative intestinal paresis. In gynecology, postoperative flatulence is most often observed with intra-abdominal bleeding or with the flow of pus and the contents of cystic tumors into the abdominal cavity. By the beginning of the third day, flatulence usually passes.

Prevention of this painful complication for those operated on involves careful operation, according to surgical rules, with protection of the abdominal organs, especially the intestines, from pus, and careful handling of the peritoneum and intestinal loops. Preparing patients for laparotomy by prescribing laxatives is in most cases unnecessary, as they increase intestinal paresis.

The simplest remedy against flatulence is to insert a tube into the rectum (12-15 cm), which immediately eliminates one of the causes of flatulence - sphincter spasm. It is very good to combine the insertion of the tube with thermal procedures, for example, an electric light bath (recommended by Gelinsky). However, vigorous heat may be contraindicated if you are prone to uterine bleeding. To stimulate intestinal peristalsis, many surgeons and gynecologists use physostigmine subcutaneously, 0.5-1 ml of a 0.1% solution. You can administer it prophylactically while still on the operating table, and a day after surgery, prescribe a glycerin enema.

More often, physostigmine is prescribed under the skin once or twice a day in combination with a gas tube and a dry air bath. If this drug is not at hand, it can be successfully replaced with pituitrin. The action of pituitrin, in addition to stimulating intestinal peristalsis, is very useful in other respects: it raises blood pressure and promotes urination, which in most cases is desirable. Pituitrin is administered 0.5-1 ml twice a day under the skin.

As for enemas, they can be recommended 24 hours after surgery in the form of microenemas from a hypertonic solution of table salt (10% 100 ml) or, even better, in the form of glycerin enemas (one or two tablespoons of glycerin per 1/2 cup of water). Enemas made from pure, undiluted glycerin, recommended by some, are very irritating to the rectal mucosa. If hypertonic, glycerin or simple enemas do not have an effect, move on to siphon enemas, introducing a rubber tube above the internal sphincter; Siphon enemas from a hypertonic (10%) solution of table salt are also very effective.

Most often, postoperative pneumonia and bronchitis occur after laparotomy, especially long-term ones and performed under general inhalation anesthesia (aspiration lobular pneumonia). However, even vaginal operations performed without inhalation anesthesia can be complicated by bronchitis and pneumonia. To a greater extent, postoperative bronchitis and pneumonia can be caused by thrombosis of the pelvic veins after vaginal operations. Nevertheless, abstaining from inhalational anesthesia in favor of local or spinal anesthesia undoubtedly reduces the frequency and severity of postoperative complications in the lungs.

Prevention of pneumonia and bronchitis involves protecting patients from cooling, for example during sanitation. It is better to operate patients with bronchitis, emphysema, and pulmonary tuberculosis not under ether anesthesia, but under local anesthesia or thiopental-sodium intravenous drip anesthesia. To reduce the secretion of mucus from the respiratory tract, it is advisable to inject 1 ml of atropine under the skin before surgery under anesthesia.

After waking up, the patient is asked to take deep breaths (“breathing exercises”), prescribed (prophylactically) circular cupping on the chest, cardiac medications under the skin, high position of the upper body (in the absence of contraindications - anemia - and only four to six hours after surgery) . From the first day, operated patients should be turned from one side to the other and should not be allowed to lie on their back for a long time.

Modern treatment of already developed pneumonia is carried out according to general schemes using sulfonamide drugs in large doses, penicillin and streptomycin.

Urinary retention can occur both after laparotomy and after vaginal surgery. Postoperative urinary retention cannot be explained by separation of the bladder if it was performed during surgery, since urinary retention is observed without this factor. Often the cause of urinary retention is fear of pain while straining to urinate. As mentioned above, it is recommended to teach patients to urinate while lying down before surgery, which is very useful.

To treat already developed urinary retention, you need to start with the simplest measures; heating pad on the bladder area, hot microenemas, suctioning. The vessel must be served warm, in order to avoid a reflex spasm of the sphincter from contact with a cold object; For this purpose, a little hot water is poured into the vessel.

Medicines used include injection into the bladder of 20 ml of a warm solution of 1-2% collargol or 20 ml of 2% boric acid with the addition of one third of glycerin. You can prescribe intravenous administration of 5-10 ml of 40% methenamine, which often gives a positive result. Sometimes subcutaneous injection of 3-5 ml of 25% magnesium sulfate has a beneficial effect. Finally, as with intestinal paresis, a good remedy against urinary retention is the injection of repeated small doses (0.5 ml) of pituitrin under the skin.

If the medications do not have an effect, then catheterization is resorted to. To prevent cystitis, catheterization must be carried out strictly aseptically.

In the postoperative period, pyelitis develops in those operated on by the ascending route from the bladder and the lymphatic route from the intestines, especially with constipation. Bact is found as a pathogen in 90% of cases. coli; in this case, right-sided pyelitis is more often observed due to the transfer of infection through the lymphatic vessels from the hepatic curvature or another part of the colon to the pelvis of the right kidney.

Therapy consists of prescribing a dairy-vegetable diet, alkaline waters, heating pads on the lower back; Lying on the left side is recommended (for right-sided pyelitis); Antibiotics and sulfodimezine are used among medicinal substances.

Postoperative anuria, which develops in rare cases (in persons with renal failure, after long-term anesthesia in severely exsanguinated patients) is usually a serious complication and quickly leads to uremia and death.

Minor suppuration of the abdominal wound after laparotomy is treated, as in surgery, by removing the sutures and spreading the edges of the wound to the width necessary for the free outflow of pus. A good method of treating suppurating surgical wounds is to irradiate them with a quartz lamp with a gradual increase in the dosage of ultraviolet rays.

If suppuration is not eliminated after a few days and there is a festering fistula, then this indicates an infection in the area of the non-absorbable silk ligature (ligature fistula). In these cases, it is necessary to remove the ligature under local anesthesia, after which the fistula quickly closes.

When treating a wound, it is better not to resort to packing. In case of extensive suppuration, but not affecting the aponeurosis, the wound is opened, widely and loosely tamponed. When the wound is clean and the granulation culture is sterile, a secondary suture can be applied. This applies not only to wounds after laparotomy, but also to perineal wounds that have ruptured due to suppuration.

With deep suppuration of the subcutaneous tissue with divergence of the aponeurosis (after laparotomy), the uterus and intestinal loops may emerge into the wound. Treatment is the application of a secondary suture.

Stump infiltrates when using catgut instead of poorly absorbable silk are observed after gynecological operations relatively rarely. If infiltrates develop, then there is a danger of infection spreading to the parametrium and peritoneum.

Complete divergence of the abdominal wall wound with the release of the viscera - eventration - is an extremely rare complication. In 80% of cases, the cause of this severe complication is cachexia, intoxication, severe anemia, severe metabolic disorders (vitaminosis, diabetes). The reasons for the onset of eventration are coughing and straining. intestinal atony. Eventration usually occurs between the 6th and 12th day after surgery, most often on the eighth day when the sutures are removed. The type of anesthesia and material for sutures do not matter in the origin of eventration.

Almost all obstetrician-gynecologists apply a blind suture when eventration is complete, capturing the skin, tissue and aponeurosis; It is best to use knotted, not thin silk ligatures. In case of peritoneal phenomena or local suppuration, penicillin should be injected into the wound. During eventration, you should never refresh the edges of the wound and separate the intestinal loops soldered to the parietal peritoneum.

Sleep therapy is recommended to combat postoperative complications. According to the observations of E.M. Kaplun, with sleep therapy the need for catheterization decreased tenfold; the need for an enema, a gas outlet tube, as a means of combating flatulence, decreased by 2.5-3 times; the strength of the patients was restored much faster,

Thromboembolic disease. According to V.P. Mikhailov and A.A. Terekhova, in the pathogenesis of thromboembolic disease, physicochemical changes in blood plasma colloids play an important role, causing a violation of its stabilization and increased coagulability. This disease often occurs in the postoperative period, especially in patients with dilated saphenous veins, a history of thrombophlebitis, with increased blood prothrombin, obesity, etc. With the current use of fibrinolytics and anticoagulants (heparin, dicoumarin, neodicoumarin, pelentan), prevention and therapy for thromboembolic disease. Anticoagulants should be used under the supervision of determining the level of prothrombin in the blood; its level should be no lower than 30% when using pelentan or no lower than 50% when treating with dicoumarin (Mikhailov and Terekhova). For the success of prevention and treatment with anticoagulants, early recognition of the clinical manifestations of thromboembolism is important. Many cases of pneumonia and pleurisy in the postoperative period must be attributed to embolic processes in the lungs such as infarction. Prevention with anticoagulants should be combined with early active movement in bed; active behavior and discharge of patients can be allowed only when ROE is below 20 mm and when blood viscosity is not higher than 5.

Therapeutic exercise in the postoperative period. The use of rational physical education in operated patients is of great importance for the prevention of postoperative complications.

According to M.V. Elkin, physical therapy in the postoperative period has the following objectives: to restore normal breathing, ease the work of the heart, prevent intestinal paresis, postoperative acidosis, ischuria, as well as adhesions and adhesions due to improved blood circulation in the surgical area.

The exercise therapy regimens for operated patients proposed by various authors should be considered only exemplary, since in practice certain exercises are prescribed strictly individually, depending on the patient’s condition and the goals pursued by exercise therapy in this case; The attending physician must give appropriate instructions to the exercise therapy methodologist conducting classes with patients.

Typically, in the first three to four days after surgery, the exercises should be simple (breathing, raising your arms, squeezing and unclenching your fingers with flexion and extension of your feet, etc.); It is not yet allowed to strain your abdominal muscles. In the following days (before getting up on days 5-7), the exercises become more complicated. After permission to stand up, the patient performs the exercises while sitting on a chair.

Complexes of therapeutic exercises for postoperative gynecological patients are given in various manuals, including in “Gynecology” by prof. M. S. Malinovsky. We prescribe similar exercises, choosing, together with the methodologist, individually for each patient or for two to four patients, 3-8 required exercises.

Laparotomy - what is it?? This is a type of surgical treatment that involves making an incision on the anterior abdominal wall to provide surgical access. Subsequently, this incision is either sutured or special staples are applied to it.

Indications

Laparotomy– what is it when it is shown? The main indications are:

Rupture of an ovarian cyst.
Ectopic pregnancy.
Tubal-peritoneal infertility.
Ovarian cyst without clinical symptoms of acute abdomen.
Pyosalpinx is a purulent inflammation of the fallopian tube.
Pyovar is a purulent inflammation of the ovary.
Apoplexy of the ovary.
Tuboovarian tumors are purulent inflammatory lesions of the fallopian tubes, ovaries and underlying structures.
Peritonitis is inflammation of the peritoneum.
Tumors of the reproductive organs (uterine fibroids, endometriosis, ovarian tumors, malignant tumors, etc.).

General characteristics of the procedure

Laparotomy - what is it, how is it produced? This operation consists of several stages:

Anesthesia, which can be either general or local.
Making an incision on the anterior abdominal wall. This can be either an inferomedian incision (from the umbilicus to the pubis along the midline) or a Pfannenstiel incision (performed in the transverse direction 2 fingers above the upper edge of the pubic symphysis).
Opening the abdominal cavity, which is performed layer by layer.
The main stage of the operation, which depends on the pathological process.
Layer-by-layer restoration of the anterior abdominal wall followed by application of an aseptic dressing.

Contraindications

Laparotomy, which is performed urgently, has no contraindications. Planned operations require treatment of inflammatory processes, which can lead to various complications in the postoperative period.

Possible complications

Laparotomy can be complicated by certain pathological conditions:

Bleeding in the surgical area.
Suppuration of a postoperative wound on the skin.
Damage to blood vessels.
Damage to nearby organs during surgery (ureters, bladder, intestines).
Formation of adhesions with the development of adhesive disease, etc.

In conclusion, it should be noted that laparotomy - what it is, will allow a woman to navigate the main types