Indications for surgical treatment. Contraindications to surgical treatment
Surgical interventions are divided into
▪ Emergency operations performed for life-saving reasons (eg, injuries complicated by internal or external bleeding; tracheostomy for obstruction of the upper respiratory tract; pericardial puncture for cardiac tamponade).
▪ Urgent (emergency) operations performed within the shortest possible time from the moment of injury to prevent severe complications. To reduce surgical risk, intensive preparation is prescribed before surgery. Depending on the nature of the pathology, the acceptable time frame from the moment of admission to the clinic to the operation is, for example: - for vascular embolism of the extremities, up to 2 hours; - for open fractures up to 2 hours. ▪ planned
Absolute readings for surgery ▪ Open injuries. ▪ Complicated fractures (damage to great vessels and nerves). ▪ The threat of complications when performing closed reduction for fractures. ▪ Ineffectiveness of conservative treatment methods. ▪ Soft tissue interposition. ▪ Avulsion fractures.
Relative indications. Planned interventions after injuries and previous surgical interventions (preliminary outpatient examination of the patient is required).
For example: ▪ hip replacement after a subcapital femoral fracture; ▪ removal of metal structures.
When determining indications for surgical interventions, the following factors should be taken into account: - diagnosis of injury; - danger of damage; - prognosis without treatment, with conservative and surgical treatment; - risk of surgical intervention; - risk on the part of the patient (general condition, medical history, concomitant diseases).
In addition to complicated fractures and other life-threatening injuries requiring surgical intervention, absolute and relative indications for surgery must be justified, and the intervention, c. In each specific case, it may be postponed or cancelled.
Absolute contraindications:
- Severe general condition of the patient.
- Cardiovascular failure.
- Infectious complications of the skin.
- Recent severe infectious diseases.
Relative contraindications may arise primarily due to the following risk factors:
- elderly age;
- premature baby;
- respiratory diseases (eg, bronchopneumonia);
- cardiovascular disorders (eg, untreatable hypertension, blood volume deficiency);
- renal dysfunction;
- metabolic disorders (eg, uncompensated diabetes mellitus);
- blood clotting disorders;
- allergies, skin diseases;
- pregnancy.
Without taking these risk factors into account, planned surgical interventions can lead to serious complications!
After the surgeon determines the indications for surgical treatment, the patient is examined by an anesthesiologist. The anesthesiologist prescribes additional studies to diagnose concomitant diseases and determines measures to stabilize impaired functions. The anesthesiologist is entirely responsible for choosing the method of anesthesia and administering anesthesia (after agreement with the surgeon).
Surgery is the most important stage in the treatment of a patient. However, in order for the effect of operations to be maximum, appropriate preoperative preparation and qualified treatment in the postoperative period are necessary. Thus, the main stages of treating a surgical patient are as follows:
Preoperative preparation;
Surgery;
Treatment in the postoperative period.
Preoperative preparation Goal and objectives
The goal of preoperative preparation is to reduce the risk of developing intra- and postoperative complications.
The beginning of the preoperative period usually coincides with the moment the patient enters the surgical hospital. Although in rare cases, preoperative preparation begins much earlier (congenital pathology, first aid at the scene of an accident, etc.). Sometimes, when a patient is hospitalized, conservative treatment is planned, but the need for surgery arises suddenly when a complication develops.
Thus, it is more correct to consider that preoperative preparation begins from the moment of making a diagnosis requiring surgery and making a decision to perform surgical intervention. It ends with the patient being taken to the operating room.
The entire preoperative period is conventionally divided into two stages: diagnostic and preparatory, during which they solve the main tasks of preoperative preparation (Fig. 9-1).
To achieve the goals of preoperative preparation, the surgeon must solve the following tasks:
Establish an accurate diagnosis of the underlying disease, determine the indications for surgery and the urgency of its implementation.
Rice. 9-1.Stages and tasks of preoperative preparation
Assess the condition of the patient’s main organs and systems (identify concomitant diseases).
Psychologically prepare the patient.
Conduct general somatic training.
Perform special training as indicated.
Directly prepare the patient for surgery.
The first two tasks are solved during the diagnostic stage. The third, fourth and fifth tasks are components of the preparatory stage. This division is arbitrary, since preparatory measures are often carried out against the background of performing diagnostic techniques.
Direct preparation is carried out before the operation itself.
Diagnostic stage
The objectives of the diagnostic stage are to establish an accurate diagnosis of the underlying disease and assess the condition of the main organs and systems of the patient’s body.
Establishing an accurate diagnosis
Establishing an accurate surgical diagnosis is the key to a successful outcome of surgical treatment. It is an accurate diagnosis indicating the stage, extent of the process and its features that allows you to choose the optimal type and extent of surgical intervention. There can be no trifles here; every feature of the course of the disease must be taken into account. In surgery of the 21st century, almost all diagnostic issues must be resolved before the operation, and during the intervention only previously known facts are confirmed. Thus, the surgeon, even before the operation begins, knows what difficulties he may encounter during the intervention, and clearly imagines the type and features of the upcoming operation.
There are many examples that demonstrate the importance of a thorough preoperative examination. Here is just one of them.
Example.The patient was diagnosed with peptic ulcer, duodenal bulb ulcer. Conservative therapy for a long time does not produce a positive effect; surgical treatment is indicated. But such a diagnosis is not enough for surgery. There are two main types of surgical interventions in the treatment of peptic ulcers: gastric resection and vagotomy. In addition, there are several types of both gastric resection (Billroth-I, Billroth-II, modified by Hofmeister-Finsterer, Roux, etc.) and vagotomy (trunk, selective, proximal selective, with various types of stomach drainage operations and without them). Which intervention should be chosen for this patient? This depends on many additional factors; they must be identified during the examination. You should know the nature of gastric secretion (basal and stimulated, nocturnal secretion), the exact localization of the ulcer (anterior or posterior wall), the presence or absence of deformation and narrowing of the gastric outlet, the functional state of the stomach and duodenum (are there any signs of duodenostasis), etc. If you do not take these factors into account and perform a certain intervention unreasonably, the effectiveness of treatment will significantly decrease. Thus, the patient may develop a relapse of the ulcer, dumping syndrome, afferent loop syndrome, gastric atony and other complications, sometimes leading the patient to disability and subsequently requiring complex reconstructive surgical interventions. Only after weighing all the identified features of the disease can you choose the right method of surgical treatment.
First of all, accurate diagnosis is necessary in order to resolve the issue of the urgency of the operation and the degree of need for surgical treatment (indications for surgery).
Resolving the issue of urgency of surgery
After making a diagnosis, the surgeon must decide whether emergency surgery is indicated for the patient. If such indications are identified, you should immediately begin the preparatory stage, which in case of emergency operations takes from several minutes to 1-2 hours.
The main indications for emergency surgery: asphyxia, bleeding of any etiology and acute inflammatory diseases.
The doctor must remember that delaying the operation worsens its result every minute. If bleeding continues, for example, the sooner intervention is started and blood loss is stopped, the greater the chance of saving the patient’s life.
At the same time, in some cases short-term preoperative preparation is necessary. Its nature is aimed at stabilizing the functions of the main systems of the body, primarily the cardiovascular system; such training is carried out individually. For example, in the presence of a purulent process complicated by sepsis with severe intoxication and arterial hypotension, it is advisable to carry out infusion and special therapy for 1-2 hours, and only then perform surgery.
In cases where, in accordance with the nature of the disease, there is no need for emergency surgery, an appropriate entry is made about this in the medical history. Then the indications for planned surgical treatment should be determined.
Indications for surgery
Indications for surgery are divided into absolute and relative.
Absolute indications Diseases and conditions that pose a threat to the patient’s life and that can only be eliminated surgically are considered to be considered for surgery.
Absolute indications for emergency operations are otherwise called “vital”. This group of indications includes asphyxia, bleeding of any etiology, acute diseases of the abdominal organs (acute appendicitis, acute cholecystitis, acute pancreatitis, perforated ulcer of the stomach and duodenum, acute intestinal obstruction, strangulated hernia), acute
purulent surgical diseases (abscess, phlegmon, osteomyelitis, mastitis, etc.).
In planned surgery, indications for surgery can also be absolute. In this case, urgent operations are usually performed without delaying them for more than 1-2 weeks.
The following diseases are considered absolute indications for elective surgery:
Malignant neoplasms (cancer of the lung, stomach, breast, thyroid, colon, etc.);
Stenosis of the esophagus, the outlet of the stomach;
Obstructive jaundice, etc.
Relative readings The operation includes two groups of diseases:
Diseases that can only be cured surgically, but do not directly threaten the patient’s life (varicose veins of the saphenous veins of the lower extremities, non-strangulated abdominal hernias, benign tumors, cholelithiasis, etc.).
Diseases that are quite serious, the treatment of which can, in principle, be carried out both surgically and conservatively (coronary heart disease, obliterating diseases of the vessels of the lower extremities, peptic ulcer of the stomach and duodenum, etc.). In this case, the choice is made on the basis of additional data, taking into account the possible effectiveness of the surgical or conservative method in a particular patient. According to relative indications, operations are performed as planned, subject to optimal conditions.
Assessment of the condition of the main organs and systems of the body
Treating the patient, not the disease, is one of the most important principles of medicine. It was most accurately stated by M.Ya. Mudrov: “We should not treat a disease by its name alone, but should treat the patient himself: his composition, his body, his strength.” Therefore, before surgery, one cannot limit oneself to examining only the damaged system or diseased organ. It is important to know the condition of the main vital systems. In this case, the doctor’s actions can be divided into four stages:
Preliminary estimate;
Standard minimum examination;
Additional examination;
Determination of contraindications for surgery.
Preliminary estimate
A preliminary assessment is carried out by the attending physician and an anesthesiologist based on complaints, a survey of organs and systems, and data from a physical examination of the patient. In this case, in addition to classical examination methods (inspection, palpation, percussion, auscultation, determination of organ boundaries), you can use the simplest tests for the compensatory capabilities of the body, for example, the Stange and Genche tests (the duration of maximum breath holding during inhalation and exhalation). When compensating the functions of the cardiovascular and respiratory systems, this duration should be at least 35 and 20 s, respectively.
Standard minimum examination
After a preliminary assessment, before any operation, regardless of concomitant diseases (even in their absence), it is necessary to conduct a minimum set of preoperative examinations:
Clinical blood test;
Biochemical blood test (content of total protein, bilirubin, transaminase activity, concentration of creatinine, sugar);
Blood clotting time;
Blood type and Rh factor;
General urine analysis;
Fluorography of the chest organs (not more than 1 year old);
Dentist's opinion on oral cavity sanitation;
ECG;
Examination by a therapist;
For women - examination by a gynecologist.
If results are obtained that fall within the normal range, surgery is possible. If any deviations are identified, it is necessary to find out their cause and then decide on the possibility of performing the intervention and the degree of its danger for the patient.
Additional examination
Additional examination is carried out if concomitant diseases are detected in the patient or if the results deviate from the norm
laboratory research. Additional examination is carried out to establish a complete diagnosis of concomitant diseases, as well as to monitor the effect of the preoperative preparation. In this case, methods of varying degrees of complexity can be used.
Determination of contraindications for surgery
As a result of the studies, concomitant diseases can be identified that can, to one degree or another, become contraindications to the operation.
There is a classic division of contraindications into absolute and relative.
To absolute contraindications include a state of shock (except for hemorrhagic shock with ongoing bleeding), as well as the acute stage of myocardial infarction or cerebrovascular accident (stroke). It should be noted that currently, if there are vital indications, it is possible to perform operations against the background of myocardial infarction or stroke, as well as in shock after stabilization of hemodynamics. Therefore, the identification of absolute contraindications is not fundamentally important at present.
Relative contraindications include any concomitant disease. However, their influence on the tolerability of the operation is different. The greatest danger is the presence of the following diseases and conditions:
Cardiovascular system: hypertension, coronary heart disease, heart failure, arrhythmias, varicose veins, thrombosis.
Respiratory system: smoking, bronchial asthma, chronic bronchitis, emphysema, respiratory failure.
Kidneys: chronic pyelonephritis and glomerulonephritis, chronic renal failure, especially with a pronounced decrease in glomerular filtration.
Liver: acute and chronic hepatitis, liver cirrhosis, liver failure.
Blood system: anemia, leukemia, changes in the coagulation system.
Obesity.
Diabetes.
The presence of contraindications to surgery does not mean that the surgical method cannot be used. It all depends on the ratio of indications and contraindications. When identifying vital and absolute
indications, the operation should be performed almost always, with certain precautions. In situations where there are relative indications and relative contraindications, the issue is decided on an individual basis. Recently, the development of surgery, anesthesiology and resuscitation has led to the fact that the surgical method is used more and more often, including in the presence of a whole “bouquet” of concomitant diseases.
Preparatory stage
There are three main types of preoperative preparation:
Psychological;
General somatic;
Special.
Psychological preparation
An operation is the most important event in a patient’s life. Deciding to take such a step is not easy. Any person is afraid of surgery, because to one degree or another they are aware of the possibility of unfavorable outcomes. In this regard, the patient’s psychological mood before surgery plays an important role. The attending physician must clearly explain to the patient the need for surgical intervention. It is necessary, without going into technical details, to talk about what is planned to be done, how the patient will live and feel after the operation, and outline its possible consequences. In this case, in everything, of course, emphasis should be placed on confidence in a favorable outcome of treatment. The doctor must “infect” the patient with a certain optimism, making the patient his ally in the fight against the disease and the difficulties of the postoperative period. The moral and psychological climate in the department plays a huge role in psychological preparation.
Pharmacological agents can be used to conduct psychological preparation. This is especially true for emotionally labile patients. Sedatives, tranquilizers, and antidepressants are often used.
Need to get patient consent to surgery. Doctors can perform all operations only with the consent of the patient. In this case, the fact of consent is recorded by the attending physician in the medical history - in the preoperative epicrisis. In addition, it is now necessary for the patient to give written consent to the operation.
The corresponding form, drawn up in accordance with all legal standards, is usually pasted into the medical history.
It is possible to perform an operation without the patient’s consent if he is unconscious or incapacitated, which must be confirmed by a psychiatrist. In such cases, they mean surgery for absolute indications. If a patient refuses surgery in a case where it is vitally necessary (for example, with ongoing bleeding), and as a result of this refusal dies, then legally the doctors are not to blame for this (if the refusal is properly documented in the medical history). However, in surgery there is an unofficial rule: if a patient refuses an operation that was necessary for health reasons, then the attending physician is to blame. Why? Yes, because all people want to live, and refusal of surgery is due to the fact that the doctor could not find the right approach to the patient, find the right words in order to convince the patient of the need for surgical intervention.
In psychological preparation for surgery, an important point is the conversation between the operating surgeon and the patient before the operation. The patient must know who is operating on him, to whom he trusts his life, and make sure that the surgeon is in good physical and emotional condition.
The relationship between the surgeon and the patient’s relatives is of great importance. They must be of a trusting nature, because it is close people who can influence the patient’s mood and, in addition, provide him with purely practical assistance.
At the same time, we must not forget that in accordance with the law, information about a patient’s illness can be communicated to relatives only with the consent of the patient himself.
General somatic training
General somatic preparation is based on examination data and depends on the condition of the patient’s organs and systems. Its task is to achieve compensation for the functions of organs and systems impaired as a result of the main and concomitant diseases, as well as to create a reserve in their functioning.
In preparation for surgery, relevant diseases are treated. Thus, in case of anemia, preoperative blood transfusion is possible, in case of arterial hypertension - antihypertensive therapy, in case of a high risk of thromboembolic complications, treatment is carried out with disaggregants and anticoagulants, the water-electrolyte balance is corrected, etc.
An important point in general somatic preparation is the prevention of endogenous infection. This requires a complete examination to identify foci of endogenous infection and their sanitation in the preoperative period, as well as antibiotic prophylaxis (see Chapter 2).
Special training
Special training is not carried out for all surgical interventions. Its necessity is associated with the special properties of the organs on which the operation is performed, or with the peculiarities of changes in the functions of organs against the background of the course of the underlying disease.
An example of special training is preparation before colon surgery. Special preparation is necessary in this case to reduce bacterial contamination of the intestine and consists of a slag-free diet, performing enemas to “clean water” and prescribing antibacterial drugs.
For varicose veins of the lower extremities, complicated by the development of a trophic ulcer, special preparation is required in the preoperative period aimed at destroying necrotic tissue and bacteria at the bottom of the ulcer, as well as reducing tissue induration and inflammatory changes in them. Patients are prescribed a course of dressings with enzymes and antiseptics, physiotherapeutic procedures for 7-10 days, and then surgical intervention is performed.
Before operations for purulent lung diseases (bronchiectasis), treatment is carried out to suppress infection in the bronchial tree, and sometimes therapeutic bronchoscopy is performed.
There are many other examples of the use of special preparation of patients for surgery. The study of its features in various surgical diseases is the subject of private surgery.
Direct preparation of the patient for surgery
There comes a time when the question of the operation is decided, it is scheduled for a certain time. What needs to be done immediately before surgery to prevent at least some of the possible complications? There are basic principles that must be followed (Figure 9-2). However, there are differences in preparation for planned and emergency operations.
Rice. 9-2.Scheme of direct preparation of the patient for surgery
Preliminary preparation of the surgical field
Preliminary preparation of the surgical field is one of the ways to prevent contact infection.
Before a planned operation, it is necessary to carry out a complete sanitization. To do this, on the evening before the operation, the patient should take a shower or bathe, put on clean underwear; In addition, bed linen is changed. On the morning of the operation, the nurse shaves off the hairline in the area of the upcoming operation with a dry method. This is necessary, since the presence of hair greatly complicates the treatment of the skin with antiseptics and may contribute to the development of infectious postoperative complications. You should definitely shave on the day of surgery, and not before. This is due to the possibility of developing an infection in the area of minor skin damage (abrasions, scratches) formed during shaving.
When preparing for an emergency operation, they are usually limited to only shaving the hair in the area of the operation. If necessary (abundant contamination, presence of blood clots), partial sanitization can be performed.
"Empty Stomach"
With a full stomach after anesthesia, the contents from it can begin to passively flow into the esophagus, pharynx and oral cavity (regurgitation), and from there with breathing enter the larynx, trachea and bronchial tree (aspiration). Aspiration can cause asphyxia - blockage of the airways, which without urgent measures will lead to the death of the patient, or the most severe complication - aspiration pneumonia.
To prevent aspiration before a planned operation, the patient, having explained the reason, is told that in the morning on the day of the operation he does not eat or drink a single drop of liquid, and the day before he does not have a very hearty dinner at 5-6 o'clock in the evening. Such simple measures are usually quite sufficient.
The situation is more complicated during emergency surgery. There is little time for preparation here. What to do? If the patient claims that he last ate 6 hours ago or more, then in the absence of certain diseases (acute intestinal obstruction, peritonitis), there will be no food in the stomach and no special measures need to be taken. If the patient took food later, then before the operation it is necessary to wash the stomach with a thick gastric tube.
Bowel movement
Before a planned operation, patients need to do a cleansing enema, so that when the muscles relax on the operating table
no involuntary defecation occurred. In addition, bowel functions are often disturbed after surgery, especially if this is an intervention on the abdominal organs (intestinal paresis develops), and the presence of contents in the large intestine only exacerbates this phenomenon.
There is no need to do an enema before emergency operations - there is no time for this, and this procedure is difficult for patients in critical condition. It is impossible to perform an enema during emergency operations for acute diseases of the abdominal organs, since an increase in pressure inside the intestine can lead to rupture of its wall, the mechanical strength of which can be reduced due to the inflammatory process.
Emptying the Bladder
You should empty your bladder before any surgery. To do this, in the vast majority of cases, it is necessary for the patient to urinate independently before the operation. The need for bladder catheterization occurs rarely, mainly during emergency operations. This is necessary if the patient’s condition is severe, he is unconscious, or when performing special types of surgical interventions (surgeries on the pelvic organs).
Premedication
Premedication is the administration of medications before surgery. It is necessary to prevent certain complications and create the best conditions for anesthesia.
Premedication before a planned operation includes the administration of sedatives and hypnotics the night before the operation and the administration of narcotic analgesics 30-40 minutes before its start. Before emergency surgery, only a narcotic analgesic and atropine are usually administered.
Premedication issues are discussed in more detail in Chapter 7.
Preparation of the operating team
Not only the patient is preparing for the operation, but also the other party - the surgeon and the entire surgical team. First of all, you need to select members of the operating team, and in addition to high professionalism and normal physical condition, you should remember about coherence in work and psychological compatibility.
In some cases, even an experienced surgeon needs to prepare for the operation theoretically, remember some anatomical relationships, etc. It is important to prepare the appropriate technical means: devices, instruments, suture material. But all this is possible only with a planned operation. Everything must always be prepared for an emergency operation; the surgeon prepares for it his whole life.
The degree of risk of the operation
Determining the degree of risk of the upcoming operation for the patient’s life is mandatory. This is necessary for a real assessment of the situation and determination of the forecast. The degree of risk of anesthesia and surgery is influenced by many factors: the patient’s age, his physical condition, the nature of the underlying disease, the presence and type of concomitant diseases, the traumatic nature and duration of the operation, the qualifications of the surgeon and anesthesiologist, the method of pain relief, the level of surgical and anesthesiological services.
Abroad, the classification of the American Society of Anesthesiologists (ASA) is usually used, according to which the degree of risk is determined as follows.
Planned surgery
Risk degree I - practically healthy patients.
Risk degree II - mild illness without impairment of function.
III degree of risk - severe diseases with impaired function.
IV degree of risk - severe diseases, in combination with or without surgery, threatening the patient’s life.
V degree of risk - the patient’s death can be expected within 24 hours after surgery or without it (moribund).
emergency operation
VI degree of risk - patients of categories 1-2, operated on as an emergency.
VII degree of risk - patients of categories 3-5, operated on as an emergency.
The ASA classification presented is convenient, but is based only on the severity of the patient's initial condition.
The most complete and clear classification of the degree of risk of surgery and anesthesia, recommended by the Moscow Society of Anesthesiologists and Reanimatologists (1989) (Table 9-1). This classification has two advantages. Firstly, it evaluates both the general condition of the patient and the volume and nature of the surgical procedure.
Table 9-1.Classification of the risk level of surgery and anesthesia
th intervention, as well as the type of anesthesia. Secondly, it provides an objective scoring system.
There is an opinion among surgeons and anesthesiologists that proper preoperative preparation can reduce the risk of surgery and anesthesia by one degree. Considering that the probability
the development of serious complications (including death) progressively increases with the degree of surgical risk, this once again emphasizes the importance of qualified preoperative preparation.
Preoperative epicrisis
All actions of the doctor in the preoperative period must be reflected in the preoperative epicrisis - one of the most important documents in the medical history.
The preoperative epicrisis must be drawn up in such a way that the indications and contraindications for the operation, the need to perform it, the adequacy of the preoperative preparation and the optimal choice of both the type of operation and the method of pain relief are absolutely clear. Such a document is necessary so that during a repeated synthetic review of the results of a clinical examination, the indications and contraindications for surgery are clearly outlined for any doctor reading the medical history, and even for the attending physician himself; difficulties possible in its implementation; features of the postoperative period and other important points. The preoperative epicrisis reflects the degree of readiness of the patient for surgery and the quality of the preoperative preparation.
The preoperative epicrisis contains the following sections:
Motivated diagnosis;
Indications for surgery;
Contraindications to surgery;
Operation plan;
Type of anesthesia;
Risk level of surgery and anesthesia;
Blood type and Rh factor;
The patient's consent to the operation;
Composition of the surgical team.
For clarity, below is an extract from the medical history with a preoperative epicrisis.
Patient P., 57 years old, was prepared for surgery on February 3, 2005, with a diagnosis of left-side acquired oblique reducible inguinal hernia. The diagnosis was made based on:
The patient complains of pain in the left groin area and the appearance of a protrusion here at the slightest physical exertion; at rest the protrusion disappears;
Anamnesis data: the protrusion first appeared 4 years ago after lifting heavy objects; over the past period there have been three episodes of pinching (the last one a month ago);
Objective research data: in the left inguinal region there is a protrusion measuring 4x5 cm, soft-elastic consistency, freely reducible into the abdominal cavity, located lateral to the spermatic cord, the external inguinal ring is moderately expanded (up to 2 cm).
The diagnosis is a relative indication for surgery. Among the concomitant diseases, stage II hypertension was noted (history of blood pressure rises to 220/100 mm Hg).
Given the high risk of repeated hernia strangulation, a planned operation is necessary. The clinic conducted a course of antihypertensive therapy (pressure stabilized at 150-160/100 mm Hg).
It is planned to perform radical surgery for a left-sided inguinal hernia using the Lichtenstein method under local anesthesia with elements of neuroleptanalgesia.
The degree of risk of surgery and anesthesia is II. Blood type 0(I) Rh(+) positive. The patient's consent was obtained.
Operated by: Surgeon...
assistant -...
Attending physician (signature)
Surgery
General provisions History
Archaeological excavations indicate that surgical operations were performed even before our era. Moreover, some patients then recovered after craniotomy, removal of stones from the bladder, amputations.
Like all sciences, surgery revived in the Renaissance, when, starting with the works of Andreas Vesalius, operative techniques began to develop rapidly. However, the modern appearance of the operating room, the attributes of surgical intervention were formed at the end of the 19th century after the appearance of asepsis with antiseptics and the development of anesthesiology.
Features of the surgical treatment method
An operation in surgery is the most important event for both the patient and the surgeon. In essence, it is the performance of surgery that distinguishes surgical specialties from others. During the operation, the surgeon, having exposed the diseased organ, can directly verify the presence of pathological changes with the help of sight and touch and quite quickly make a significant correction of the identified violations. It turns out that the treatment process is extremely concentrated in this most important event - a surgical operation. The patient is ill with acute appendicitis: the surgeon performs a laparotomy (opens the abdominal cavity) and removes the appendix, radically curing the disease. In a patient, bleeding is an immediate threat to life: the surgeon bandages the damaged vessel - and nothing threatens the patient's life. Surgery looks like magic, and very real: the diseased organ is removed, the bleeding is stopped, etc.
At present, it is rather difficult to give a clear definition of a surgical operation. The most general seems to be the following.
Surgery - mechanical impact on organs and tissues, usually accompanied by their separation in order to expose the diseased organ and perform therapeutic or diagnostic manipulations on it.
This definition primarily applies to “routine”, open transactions. Somewhat apart are such special interventions as endovascular, endoscopic, etc.
Main types of surgical interventions
There is a huge variety of surgical interventions. Their main types and types are presented below in classifications according to certain criteria.
Classification by urgency of implementation
In accordance with this classification, emergency, planned and urgent operations are distinguished.
Emergency operations
Emergency operations are those performed almost immediately after diagnosis, since they are delayed by several hours or
even minutes directly threatens the patient’s life or sharply worsens the prognosis. It is usually considered necessary to perform an emergency operation within 2 hours from the moment the patient is admitted to the hospital.
Emergency operations are performed by an on-duty surgical team at any time of the day. The hospital surgical service must always be prepared for this.
The peculiarity of emergency operations is that the existing threat to the patient’s life does not allow for a full examination and full preparation. The purpose of emergency surgery is primarily to save the patient's life at this time, but it does not necessarily lead to a complete recovery of the patient.
The main indications for emergency operations are bleeding of any etiology and asphyxia. Here a minute's delay can lead to the death of the patient.
The most common indication for emergency surgery is an acute inflammatory process in the abdominal cavity (acute appendicitis, acute cholecystitis, acute pancreatitis, perforated gastric ulcer, strangulated hernia, acute intestinal obstruction). With such diseases, there is no immediate threat to the life of the patient for several minutes, however, the later the operation is performed, the significantly worse the results of treatment. This is due to both the progression of endotoxicosis and the possibility of developing at any time the most severe complications, primarily peritonitis, which sharply worsens the prognosis. In such cases, short-term preoperative preparation is acceptable to eliminate adverse factors (correction of hemodynamics, water-electrolyte balance).
The indication for emergency surgery is all types of acute surgical infection (abscess, phlegmon, gangrene), which is also associated with the progression of intoxication, the risk of developing sepsis and other complications in the presence of an unsanitized purulent focus.
Planned operations
Planned operations are called operations, on the time of which the outcome of treatment practically does not depend. Before such interventions, the patient undergoes a complete examination, the operation is performed on the most favorable background in the absence of contraindications from other organs and systems, and in the presence of concomitant diseases - after reaching the stage of remission as a result of appropriate preoperative preparation. These
operations are performed in the morning, the day and time of the operation are determined in advance, and they are performed by the most experienced surgeons in the field. Planned operations include radical operations for hernia (not strangulated), varicose veins, cholelithiasis, uncomplicated gastric ulcer and many others.
Urgent operations
Urgent operations occupy an intermediate position between emergency and planned. In terms of surgical attributes, they are closer to planned ones, since they are performed during the daytime, after an adequate examination and the necessary preoperative preparation, and they are carried out by specialists in this particular field. That is, surgical interventions are performed in the so-called “planned order”. However, unlike planned operations, such interventions cannot be postponed for a significant period of time, as this can gradually lead the patient to death or significantly reduce the likelihood of recovery.
Urgent operations are usually performed 1-7 days after the patient’s admission or diagnosis of the disease.
Thus, a patient with stopped gastric bleeding can be operated on the next day after admission due to the risk of recurrent bleeding.
It is impossible to postpone intervention for obstructive jaundice for a long time, since it gradually leads to the development of irreversible changes in the patient’s body. In such cases, the intervention is usually performed within 3-4 days after a full examination (finding out the cause of impaired bile outflow, excluding viral hepatitis, etc.).
Urgent operations include operations for malignant neoplasms (usually within 5-7 days from the date of admission, after the necessary examination). Delaying them for a long time can lead to the inability to perform a full-fledged operation due to the progression of the process (the appearance of metastases, tumor invasion of vital organs, etc.).
Classification by purpose of execution
According to the purpose of execution, all operations are divided into two groups: diagnostic and therapeutic.
Diagnostic operations
The purpose of diagnostic operations is to clarify the diagnosis and determine the stage of the process. Diagnostic operations are resorted to only in cases where a clinical examination using additional methods does not allow an accurate diagnosis to be made, and the doctor cannot exclude the presence of a serious disease in the patient, the treatment tactics of which differ from the therapy being carried out.
Diagnostic operations include various types of biopsies, special diagnostic interventions and traditional surgical operations for diagnostic purposes.
Biopsy.During a biopsy, the surgeon removes a section of an organ (neoplasm) for subsequent histological examination in order to make a correct diagnosis. There are three types of biopsy:
1. Excisional biopsy. The entire formation is removed. It is the most informative, and in some cases it can also have a therapeutic effect. The most often used is excision of the lymph node (the etiology of the process is determined: specific or nonspecific inflammation, lymphogranulomatosis, tumor metastasis, etc.); excision of a mammary gland formation (to make a morphological diagnosis) - in this case, if a malignant growth is detected, after a biopsy a therapeutic operation is immediately performed, and if a benign tumor is discovered, the initial operation itself is of a therapeutic nature. There are other clinical examples.
2. Incisional biopsy. For histological examination, a part of the formation (organ) is excised. For example, an operation revealed an enlarged, dense pancreas, which resembles the picture of both its malignant lesion and indurative chronic pancreatitis. The surgeon's tactics for these diseases are different. To clarify the diagnosis, it is possible to excise a section of the gland for urgent morphological examination and, in accordance with its results, choose a specific method of treatment. The incisional biopsy method can be used in the differential diagnosis of ulcers and gastric cancer, trophic ulcers and specific lesions, and in many other situations. The most complete excision of an organ site at the border of pathologically altered and normal tissues. This is especially true for the diagnosis of malignant neoplasms.
3. Needle biopsy. It is more correct to attribute this manipulation not to operations, but to invasive research methods. Percutaneous puncture of the organ (formation) is performed, after which the remaining in the needle
a microcolumn, consisting of cells and tissues, is applied to the glass and sent for histological examination, it is also possible for a cytological examination of the punctate. The method is used to diagnose diseases of the mammary and thyroid glands, as well as the liver, kidneys, blood system (sternal puncture), etc. This biopsy method is the least accurate, but the simplest and most harmless to the patient.
Special diagnostic interventions. This group of diagnostic operations includes endoscopic examinations: laparo- and thoracoscopy (endoscopic examinations through natural openings - fibroesophagogastroscopy, cystoscopy, bronchoscopy - are classified as special research methods).
Laparo or thoracoscopy can be performed on an oncological patient to clarify the stage of the process (presence or absence of carcinomatosis of the serous membranes, metastases). These special interventions can be performed on an emergency basis if internal bleeding is suspected, the presence of an inflammatory process in the corresponding cavity.
Traditional surgical operations for diagnostic purposes. Such operations are carried out in cases where the examination does not make it possible to make an accurate diagnosis. The most commonly performed diagnostic laparotomy, it becomes the last diagnostic step. Such operations can be carried out both planned and emergency.
Sometimes operations for neoplasms become diagnostic. This happens if, during an audit of organs during surgery, it is determined that the stage of the pathological process does not allow the required volume of surgery to be performed. The planned medical operation becomes diagnostic (the stage of the process is specified).
Example.The patient was scheduled for gastric extirpation (removal) due to cancer. After laparotomy, multiple metastases were revealed in the liver. Performing gastric extirpation was considered inappropriate. The abdomen is sutured. The operation became diagnostic (stage IV of the malignant process was determined).
With the development of surgery and the improvement of methods for additional examination of patients, traditional surgical interventions for diagnostic purposes are performed less and less often.
Medical operations
Therapeutic operations are performed to improve the patient's condition. Depending on their influence on the pathological process
There are radical, palliative and symptomatic treatment operations.
Radical operations. Radical operations are those performed to cure a disease. The majority of such operations are performed in surgery.
Example 1.A patient has acute appendicitis: the surgeon performs an appendectomy (removes the appendix) and thus cures the patient (Fig. 9-3).
Example 2The patient has an acquired reducible umbilical hernia. The surgeon removes the hernia: the contents of the hernial sac are reduced into the abdominal cavity, the hernial sac is excised and the hernial orifice is repaired. After such an operation, the patient is cured of a hernia (such an operation was called in Russia “radical operation of an umbilical hernia”).
Example 3.The patient has stomach cancer, there are no distant metastases: in compliance with all oncological principles, a subtotal resection of the stomach is performed with the removal of the large and small omentums, aimed at the complete cure of the patient.
Palliative operations. Palliative operations are aimed at improving the patient's condition, but not at curing him of the disease. Most often, such operations are performed on cancer patients, when it is impossible to radically remove the tumor, but the patient's condition can be improved by eliminating a number of complications.
Example 1.The patient has a malignant tumor of the head of the pancreas with invasion of the hepatoduodenal ligament, complicated by obstructive jaundice (due to compression of the common bile duct) and the development of duodenal obstruction
Rice. 9-3.Typical appendectomy: a - mobilization of the appendix; b - removal of the process; c - immersion of the stump
(due to intestinal tumor growth). Due to the prevalence of the process, radical surgery cannot be performed. However, it is possible to alleviate the patient’s condition by eliminating the most severe syndromes for him: obstructive jaundice and intestinal obstruction. A palliative operation is performed: choledochojejunostomy and gastrojejunostomy (artificial bypasses are created for the passage of bile and food). In this case, the underlying disease - a pancreatic tumor - is not eliminated.
Example 2A patient has stomach cancer with distant metastases to the liver. Large tumor sizes cause intoxication and frequent bleeding. The patient is operated on: a palliative gastrectomy is performed, the tumor is removed, which significantly improves the patient’s condition, but the operation is not aimed at curing the cancer, since multiple metastases remain, so the operation is considered palliative.
Are palliative surgeries necessary that do not cure the patient of the underlying disease? - Of course, yes. This is due to the following circumstances:
Palliative operations increase the patient's life expectancy;
Palliative interventions improve quality of life;
After palliative surgery, conservative treatment may be more effective;
There is a possibility that new methods will emerge that can cure the underlying disease that has not been eliminated;
There is a possibility of an error in diagnosis, and the patient can recover almost completely after palliative surgery.
The last provision requires some comment. Any surgeon can remember several cases when patients lived for many years after performing palliative operations. Such situations are inexplicable and incomprehensible, but they do happen. Many years after the operation, seeing a living and healthy patient, the surgeon understands that at one time he was mistaken in the main diagnosis, and thanks God for deciding to perform a palliative intervention, thanks to which it was possible to save a human life.
Symptomatic operations. In general, symptomatic operations resemble palliative ones, but, unlike the latter, they are not aimed at improving the patient’s condition as a whole, but at eliminating one specific symptom.
Example.A patient has stomach cancer and gastric bleeding from the tumor. Radical or palliative resection is not possible (the tumor grows into the pancreas and the mesenteric root). The surgeon performs a symptomatic operation: ligates the gastric vessels supplying the tumor to stop bleeding.
Single-stage, multi-stage and repeated operations
Surgical interventions can be single- or multi-stage (two-, three-stage), as well as repeated.
One-step operations
One-stage operations are those in which several successive stages are performed at once in one intervention, the goal being complete recovery and rehabilitation of the patient. Such surgical operations are performed most often; examples of them include appendectomy, cholecystectomy, gastric resection, mastectomy, and thyroid resection. In some cases, quite complex surgical interventions are performed in one stage.
Example.A patient has esophageal cancer. The surgeon removes the esophagus (Torek's operation), after which he performs plastic surgery of the esophagus with the small intestine (Ru-Herzen-Yudin operation).
Multi-stage operations
Simultaneous operations are certainly preferable, but in some cases their implementation must be divided into separate stages. This may be due to three main reasons:
The severity of the patient's condition;
Lack of necessary objective conditions;
Insufficient qualification of the surgeon.
The severity of the patient's condition. In some cases, the patient’s initial condition does not allow him to undergo a complex, lengthy and traumatic one-stage operation, or the risk of its complications in such a patient is much higher than usual.
Example.The patient has esophageal cancer with severe dysphagia, which led to the development of severe exhaustion of the body. He will not tolerate a complex one-stage operation (see example above). The patient undergoes a similar intervention, but in three stages, separated in time.
Gastrostomy placement (for nutrition and normalization of general condition).
After 1 month, the esophagus with the tumor is removed (Torek's operation), after which nutrition is continued through a gastrostomy tube.
5-6 months after the second stage, plasty of the esophagus with the small intestine is performed (Ru-Herzen-Yudin operation).
Lack of necessary objective conditions. In some cases, the implementation of all stages at once is limited by the nature of the main process, its complications or technical features of the method.
Example 1.A patient has cancer of the sigmoid colon with the development of acute intestinal obstruction and peritonitis. It is impossible to remove the tumor and restore intestinal patency immediately, since the diameters of the afferent and efferent intestines differ significantly and the likelihood of developing a severe complication is particularly high - failure of the anastomotic sutures. In such cases, it is possible to perform the classic three-stage Schloffer operation.
Application of a cecostomy with sanitation and drainage of the abdominal cavity to eliminate intestinal obstruction and peritonitis.
Resection of the sigmoid colon with a tumor, ending with the creation of a sigmoid-sigmoid anastomosis (2-4 weeks after the first stage).
Closing the cecostoma (2-4 weeks after the second stage). Example 2. The most striking example of performing a multi-moment
This operation can be performed by skin grafting with a “walking” stem according to V.P. Filatov (see Chapter 14), its implementation in one stage is technically impossible.
Insufficient qualification of the surgeon. In some cases, the qualifications of the operating surgeon allow him to reliably perform only the first stage of treatment, and more complex stages can be performed subsequently by other specialists.
Example.A patient has a large stomach ulcer with perforation. Gastric resection is indicated, but the surgeon does not know the technique of this operation. He stitches up the ulcer, saving the patient from a complication - severe peritonitis, but not curing him from peptic ulcer disease. After recovery, the patient undergoes a gastric resection as planned in a specialized institution.
Repeated operations
Repeated operations are operations performed again on the same organ for the same pathology. Repeated operations performed during the immediate or early postoperative period
yes, they usually have the prefix “re” in the name: relaparotomy, rethoracotomy, etc. Repeated operations can be planned (planned relaparotomy for sanitation of the abdominal cavity in case of diffuse purulent peritonitis) and forced - in case of complications (relaparotomy in case of failure of gastroenteroanastomosis after gastrectomy, in case of bleeding in the early postoperative period).
Combined and combined operations
Modern developments in surgery make it possible to significantly expand the scope of surgical interventions. Combined and combined operations have become the norm in surgical activity.
Combined operations
Combined (simultaneous) are operations performed simultaneously on two or more organs for two or more different diseases. In this case, operations can be performed both from one and from different accesses.
The undoubted advantage of such operations: in one hospitalization, one operation, one anesthesia, the patient is cured of several pathological processes at once. However, one should take into account a slight increase in the invasiveness of the intervention, which may be unacceptable for patients with concomitant pathologies.
Example 1.The patient has cholelithiasis and gastric ulcer. A combined operation is performed: cholecystectomy and gastric resection are performed simultaneously from one access.
Example 2The patient has varicose veins of the saphenous veins of the lower extremities and nodular nontoxic goiter. A combined operation is performed: Babcock-Narat phlebectomy and resection of the thyroid gland.
Combined operations
Combined operations are operations in which, in order to treat one disease, an intervention is performed on several organs.
Example.The patient has breast cancer. A radical mastectomy and removal of the ovaries are performed to change hormonal levels.
Classification of operations by degree of infection
Classification according to the degree of infection is important both for determining the prognosis of purulent complications and for determining the method of completing the operation and the method of antibiotic prophylaxis. All operations are conventionally divided into four degrees of infection.
Clean (aseptic) operations
These operations include planned primary operations without opening the lumen of internal organs (for example, radical hernia surgery, removal of varicose veins, resection of the thyroid gland).
The frequency of infectious complications is 1-2% (hereinafter according to Yu.M. Lopukhin and V.S. Savelyev, 1997).
Operations with possible infection (conditionally aseptic)
This category includes operations with opening the lumen of organs in which the presence of microorganisms is possible (planned cholecystectomy, hysterectomy, phlebectomy in the area of previous thrombophlebitis), repeated operations with a possible dormant infection (healing of previous wounds by secondary intention).
The incidence of infectious complications is 5-10%.
Operations with a high risk of infection (conditionally infected)
Such operations include interventions during which there is more significant contact with microflora (planned hemicolonectomy, appendectomy for phlegmonous appendicitis, cholecystectomy for phlegmonous or gangrenous cholecystitis).
The incidence of infectious complications is 10-20%.
Operations with a very high risk of infection (infected)
Such operations include operations for purulent peritonitis, pleural empyema, perforation or damage to the colon, opening of an appendiceal or subphrenic abscess, etc. (see Fig. 9-3).
The incidence of infectious complications is more than 50%.
Typical and atypical operations
In surgery, there are typical (standard) operations performed for certain diseases. For example, amputation of a limb in the lower third of the thigh, typical resection of two-thirds of the stomach in the treatment of peptic ulcer, typical hemicolectomy. However, in some cases, the surgeon must use certain creative abilities in order to modify standard techniques during the operation in connection with the identified features of the pathological process. For example, during gastrectomy, perform closure of the duodenal stump in a non-standard way due to the low location of the ulcer or expand the scope of hemicolonectomy due to the spread of tumor growth along the mesentery of the intestine. Atypical operations are rarely performed and usually indicate high creativity and skill of the surgeon.
Special Operations
Advances in surgery have led to the emergence of minimally invasive surgery. Here, during operations, unlike traditional interventions, there is no typical tissue dissection, large wound surface, or exposure of the damaged organ; in addition, they use a special technical method to perform the operation. Such surgical interventions are called special. These include microsurgical, endoscopic and endovascular operations. The listed types are currently considered the main ones, although there are also cryosurgery, laser surgery, etc. In the near future, technological progress will undoubtedly lead to the development of new types of special surgical interventions.
Microsurgical operations
Operations are performed under magnification from 3 to 40 times using magnifying glasses or an operating microscope. To carry them out, special microsurgical instruments and the finest threads (10/0-2/0) are used. The interventions last quite a long time (up to 10-12 hours). The use of the microsurgical method makes it possible to replant fingers and hands, restore the patency of the smallest vessels, and perform operations on lymphatic vessels and nerves.
Endoscopic operations
Interventions are performed using optical instruments - endoscopes. Thus, with fibroesophagogastroduodenoscopy, it is possible to remove a polyp from the stomach, dissect the Vater nipple and remove a calculus from the common bile duct in case of obstructive jaundice; during bronchoscopy - remove small tumors of the trachea and bronchi mechanically or using a laser; during cystoscopy - remove the stone from the bladder or terminal ureter, perform resection of the prostate adenoma.
Currently, interventions performed using endovideo technology are widespread: laparoscopic and thoracoscopic operations. They are not accompanied by large surgical wounds, patients recover quickly after treatment, and postoperative complications, both from the wound and of a general nature, are extremely rarely noted. Using a video camera and special instruments, cholecystectomy, resection of a section of intestine, removal of an ovarian cyst, suturing of a perforated gastric ulcer and many other operations can be performed laparoscopically. A distinctive feature of endoscopic operations is their low invasiveness.
Endovascular surgeries
These are intravascular operations performed under X-ray guidance. Using puncture of the femoral artery, special catheters and instruments are inserted into the vascular system, allowing, in the presence of a pinpoint surgical wound, to embolize a specific artery, expand the stenotic area of the vessel, and even perform heart valve repair. Like endoscopic operations, such operations are characterized by less trauma than traditional surgical interventions.
Stages of surgery
The surgical operation consists of three stages:
Online access.
Operational reception.
Completing the operation.
The exception is special minimally invasive operations (endoscopic and endovascular), which are not fully characterized by conventional surgical attributes.
Online access Purpose
Operative access is intended to expose the affected organ and create the necessary conditions for performing the planned manipulations.
It should be remembered that access to a certain organ can be significantly facilitated by giving the patient a special position on the operating table (Fig. 9-4). This needs to be given significant attention.
Requirements for online access
Access is an important aspect of the operation. Its implementation sometimes takes much more time than an operational procedure. The main requirements for operational access are as follows.
Access should be so wide as to ensure convenient execution of the surgical procedure. The surgeon must expose the organ sufficiently to reliably perform basic manipulations under visual control. Reducing access should never be achieved at the expense of reducing the reliability of the intervention. This is well known to experienced surgeons who have encountered serious complications (the principle of “big surgeon - big incision”).
Access must be gentle. When performing an approach, the surgeon must remember that the trauma caused must be
Rice. 9-4.Various positions of the patient on the operating table: a - during operations on the perineum; b - during operations on the neck organs; c - during operations on the kidneys and retroperitoneal organs
Rice. 9-5.Types of longitudinal, transverse and oblique laparotomies: 1 - upper middle; 2 - paramedian; 3 - transrectal; 4 - pararectal; 5 - along the semilunar line; 6 - lateral transmuscular; 7 - lower middle; 8 - paracostal (subcostal); 9 - upper transverse; 10 - upper side section with variable direction; 11 - lower transverse; 12 - mid-inferior side section with variable direction; 13 - Pfannenstiel section
minimum possible. Due to the need to combine these provisions, there is a fairly wide variety of approaches for performing surgical interventions. The number of proposed approaches for performing operations on the abdominal organs is especially impressive. Some of them are shown in Fig. 9-5.
Gentle access is one of the advantages of endovideosurgical operations, when the laparoscope and instruments are introduced into the abdominal cavity through punctures in the abdominal wall.
Currently, the number of possible accesses is reduced to a minimum. For each operation there is a typical access and one or two options in case the typical access is used
It is forbidden to undergo surgery (coarse scars from previous operations, deformities, etc.).
Access must be anatomical. When performing access, it is necessary to take into account the anatomical relationships and try to damage as few formations, vessels and nerves as possible. This speeds up access and reduces the number of postoperative complications. Thus, despite the fact that the gallbladder is much closer when accessed in the right hypochondrium, it is now rarely used, since this requires crossing all the muscular layers of the anterior abdominal wall, damaging the vessels and nerves. When performing an upper median laparotomy, only the skin, subcutaneous tissue and linea alba, practically devoid of nerves and vessels, are dissected, which makes this access the method of choice for operations on all organs of the upper abdominal cavity, including the gallbladder. In some cases, the location of the access in relation to the Langer lines matters.
Access must be physiological. When performing access, the surgeon must remember that the subsequently formed scar should not interfere with movements. This is especially true for operations on the limbs and joints.
Access should be cosmetic. This requirement is not yet generally accepted. However, other things being equal, the cut should be made in the least noticeable places, along natural folds. An example of this approach is the predominant use of transverse laparotomy according to Pfannenstiel during operations on the pelvic organs.
Operative procedure
Surgical appointment is the main stage of the operation, during which the necessary diagnostic or therapeutic effect is carried out. Before directly starting to perform it, the surgeon inspects the wound to confirm the diagnosis and in case of unexpected surgical findings.
Depending on the type of treatment performed, there are several types of surgical techniques:
Removal of an organ or pathological focus;
Removal of part of an organ;
Restoring broken relationships.
Removal of an organ or pathological focus
Such operations are usually called “ectomy”: appendectomy, cholecystectomy, gastrectomy, splenectomy, strumectomy (removal of goiter), echinococcectomy (removal of hydatid cyst), etc.
Removing part of an organ
Such operations are called “resection”: gastric resection, liver resection, ovarian resection, thyroid resection.
It should be noted that all removed organs and their resected areas are necessarily sent for routine histological examination. After removal of organs or their resection, it is necessary to restore the passage of food, blood, and bile. This part of the operation is usually longer than the removal itself and requires careful execution.
Restoring Broken Relationships
In some operations, the surgeon does not remove anything. Such interventions are sometimes called restorative, and if previously artificially created structures need to be corrected, reconstructive.
This group of operations includes various types of vascular prosthetics and bypass surgery, the application of biliodigestive anastomoses for obstructive jaundice, plasty of the esophageal opening of the diaphragm, plasty of the inguinal canal for hernia, nephropexy for nephroptosis, plasty of the ureter for stenosis, etc.
Completing the operation
The completion of the operation should be given no less attention than the first two stages. Upon completion of the operation, the integrity of the tissues damaged during access should be restored, as far as possible. In this case, it is necessary to use optimal methods for connecting tissues and certain types of suture material to ensure reliability, rapid healing, functional and cosmetic effect (Fig. 9-6).
Before directly starting to suture the wound, the surgeon must monitor hemostasis, install control drains for special indications, and for abdominal interventions, check the number of napkins, balls and surgical instruments used (usually this is done by the operating nurse).
Figure 9-6.Layer-by-layer suturing of the wound after appendectomy
Depending on the nature of the operation and, above all, on its type in terms of the degree of infection, the surgeon must choose one of the options for completing the operation:
Layer-by-layer suturing of the wound tightly (sometimes with a special cosmetic suture);
Layer-by-layer suturing of the wound, leaving drainage;
Partial suturing with tampons left in place;
Suturing the wound with the possibility of repeated planned revisions;
Leaving the wound unsutured and open.
The course of the postoperative period largely depends on how correctly the surgeon chooses the method of completing the operation.
Main intraoperative complications
The main intraoperative complications include bleeding and organ damage.
Bleeding
Prevention of bleeding on the operating table is as follows:
Good knowledge of topographic anatomy in the intervention area.
Sufficient access to allow surgery under visual control.
Surgery in a “dry wound” (thorough drying during the procedure, stopping minimal bleeding that makes it difficult to distinguish formations in the wound).
Use of adequate methods of hemostasis (in case of vessels visible to the eye, give preference to mechanical methods of stopping bleeding - ligation and suturing).
Organ damage
To prevent intraoperative organ damage, the same principles should be followed as for the prevention of bleeding. In addition, careful and careful handling of fabrics is necessary.
It is important to detect damage caused on the operating room and table and to adequately eliminate it. The most dangerous injuries are those that are not recognized during surgery.
Intraoperative prevention of infectious complications
Prevention of infectious postoperative complications is mainly carried out on the operating table. In addition to strict adherence to asepsis, attention must be paid to the following rules.
Reliable hemostasis
When even a small amount of blood accumulates in the wound cavity, the frequency of postoperative complications increases, which is associated with the rapid proliferation of microorganisms in a good nutrient medium.
Adequate drainage
The accumulation of any fluid in the surgical wound significantly increases the risk of infectious complications.
Careful handling of fabrics
Compression of tissues with instruments, their excessive stretching, and tears lead to the formation of a large amount of necrotic tissue in the wound, which serves as a substrate for the development of infection.
Changing instruments and cleaning hands after infected stages
This measure serves to prevent contact and implantation infection. It is carried out after completing contact with the skin, suturing the cavities, and completing the stages associated with opening the lumen of the internal organs.
Limitation of the pathological focus and evacuation of exudate
Some operations involve contact with an infected organ or pathological focus. It is necessary to limit contact with
him other fabrics. To do this, for example, the inflamed appendix is wrapped in a napkin. During rectal extirpation, the anus is first sutured with a purse-string suture. When forming interintestinal anastomoses, before opening the internal lumen, carefully limit the free abdominal cavity with napkins. To remove purulent exudate or contents flowing from the lumen of internal organs, active vacuum suction is used.
In addition to pathological foci, the skin must be limited, since, despite repeated treatment, it can become a source of microflora.
Treating the wound during surgery with antiseptic solutions
In some cases, the mucous membrane is treated with antiseptics, if there is exudate, the abdominal cavity is washed with a solution of nitrofural, and the wounds are treated with povidone-iodine before suturing.
Antibiotic prophylaxis
To reduce the risk of infectious postoperative complications, it is necessary that during the operation there is a bactericidal concentration of the antibiotic in the patient’s blood plasma. Continuation of antibiotic administration in the future depends on the degree of infection.
Postoperative period Meaning and main purpose
The significance of the postoperative period is quite large. It is at this time that the patient needs maximum attention and care. It is at this time that all defects in preoperative preparation and the operation itself manifest themselves as complications.
The main goal of the postoperative period is to promote the processes of regeneration and adaptation occurring in the patient’s body, as well as to prevent, promptly identify and combat emerging complications.
The postoperative period begins with the end of the surgical intervention and ends with the patient’s complete recovery or permanent disability. Unfortunately, not all operations lead to a complete recovery. If
If a limb is amputated, the mammary gland is removed, the stomach is removed, etc., the person is largely limited in his capabilities, then it is impossible to talk about his complete recovery even with a favorable result of the operation itself. In such cases, the end of the postoperative period occurs when the wound process is completed and the condition of all body systems is stabilized.
Physiological phases
In the postoperative period, physiological changes occur in the patient's body, usually divided into three phases: catabolic, reverse development and anabolic.
Catabolic phase
The catabolic phase usually lasts 5-7 days. Its severity depends on the severity of the patient’s preoperative condition and the traumatic nature of the intervention performed. Catabolism increases in the body - rapid delivery of necessary energy and plastic materials. At the same time, activation of the sympathoadrenal system is noted, the flow of catecholamines, glucocorticoids, and aldosterone into the blood increases. Neurohumoral processes lead to changes in vascular tone, which ultimately causes disturbances in microcirculation and redox processes in tissues. Tissue acidosis develops; due to hypoxia, anaerobic glycolysis predominates.
The catabolic phase is characterized by increased protein breakdown, which reduces not only the protein content in muscles and connective tissue, but also enzymatic proteins. The loss of protein is very significant and during major operations amounts to up to 30-40 g per day.
The course of the catabolic phase is significantly aggravated by the addition of early postoperative complications (bleeding, inflammation, pneumonia).
Reverse development phase
This phase becomes transitional from catabolic to anabolic. Its duration is 3-5 days. The activity of the sympathoadrenal system decreases. Protein metabolism is normalized, which is manifested by a positive nitrogen balance. At the same time, the breakdown of proteins continues, but an increase in their synthesis is also noted. Synthesis is growing
glycogen and fats. Gradually, anabolic processes begin to prevail over catabolic ones.
Anabolic phase
The anabolic phase is characterized by active restoration of functions impaired in the catabolic phase. The parasympathetic nervous system is activated, the activity of somatotropic hormone and androgens increases, the synthesis of proteins and fats sharply increases, and glycogen reserves are restored. Thanks to these changes, reparative processes, growth and development of connective tissue progress. The completion of the anabolic phase corresponds to the complete recovery of the body after surgery. This usually happens after about 3-4 weeks.
Clinical stages
In the clinic, the postoperative period is divided into three parts:
Early - 3-5 days;
Late - 2-3 weeks;
Long-term (rehabilitation) - usually from 3 weeks to 2-3 months.
Features of the course of the late and remote stages of the postoperative period depend entirely on the nature of the underlying disease; this is the subject of private surgery.
The early postoperative period is the time when the patient’s body is primarily affected by surgical trauma, the effects of anesthesia and the forced position of the patient. Essentially, the course of the early postoperative period is typical and does not particularly depend on the type of operation and the nature of the underlying disease.
In general, the early postoperative period corresponds to the catabolic phase of the postoperative period, and the late one corresponds to the anabolic phase.
Features of the early postoperative period
The early postoperative period can be uncomplicated or complicated.
Uncomplicated postoperative period
During an uncomplicated postoperative period, a number of changes occur in the body in the functioning of the main organs and systems.
stem. This is due to the influence of factors such as psychological stress, anesthesia, pain in the area of the surgical wound, the presence of necrosis and injured tissue in the operation area, the forced position of the patient, hypothermia, and nutritional disturbances.
In a normal, uncomplicated course of the postoperative period, the reactive changes that occur in the body are usually moderate and last 2-3 days. In this case, a fever of up to 37.0-37.5? C is noted. Observe the inhibition of processes in the central nervous system. The composition of peripheral blood changes: moderate leukocytosis, anemia and thrombocytopenia, blood viscosity increases.
The main tasks during an uncomplicated postoperative period: correction of changes in the body, monitoring the functional state of the main organs and systems; taking measures to prevent possible complications.
Intensive therapy for an uncomplicated postoperative period is as follows:
Fighting pain;
Restoration of the functions of the cardiovascular system and microcirculation;
Prevention and treatment of respiratory failure;
Correction of water and electrolyte balance;
Detoxification therapy;
Balanced diet;
Control of the functions of the excretory system.
Let us dwell in detail on ways to combat pain, since other measures are the lot of anesthesiologists and resuscitators.
To reduce pain, both very simple and quite complex procedures are used.
Getting the correct position in bed
It is necessary to relax the muscles in the area of the surgical wound as much as possible. After operations on the organs of the abdominal and thoracic cavities, the semi-sitting Fowler position is used for this: the head end of the bed is raised by 50 cm, the lower limbs are bent at the hip and knee joints (an angle of about 120?).
Wearing a bandage
Wearing a bandage significantly reduces pain in the wound, especially when moving and coughing.
Use of narcotic analgesics
It is necessary in the first 2-3 days after extensive abdominal operations. Trimeperidine, morphine + narcotine + papaverine + codeine + thebaine, morphine are used.
Use of non-narcotic analgesics
It is necessary in the first 2-3 days after minor operations and starting from the 3rd day after traumatic interventions. Metamizole sodium injections are used. It is possible to use tablet drugs.
Use of sedatives
Allows you to increase the threshold of pain sensitivity. Diazepam and others are used.
Epidural anesthesia
An important method of pain relief in the early postoperative period during operations on the abdominal organs, since, in addition to a method of pain relief, it serves as a powerful means of preventing and treating postoperative intestinal paresis.
Complicated postoperative period
Complications that can arise in the early postoperative period are divided according to the organs and systems in which they occur. Often complications are caused by the presence of concomitant pathology in the patient. The diagram (Fig. 9-7) shows the most common complications of the early postoperative period.
Three main factors contribute to the development of complications:
Presence of a postoperative wound;
Forced position;
The influence of surgical trauma and anesthesia.
Main complications of the early postoperative period
The most common and dangerous complications in the early postoperative period are complications from the wound, cardiovascular, respiratory, digestive and urinary systems, as well as the development of bedsores.
Rice. 9-7.Complications of the early postoperative period (by organs and systems)
Complications from the wound
In the early postoperative period, the following complications are possible from the wound:
Bleeding;
Development of infection;
Seams coming apart.
In addition, the presence of a wound is associated with pain, which manifests itself in the first hours and days after surgery.
Bleeding
Bleeding is the most serious complication, sometimes threatening the patient’s life and requiring repeated surgery. Prevention of bleeding is mainly carried out during surgery. In the postoperative period, to prevent bleeding, place an ice pack or a load of sand on the wound. For timely diagnosis, monitor pulse, blood pressure, and red blood counts. Bleeding after surgery can be of three types:
External (bleeding occurs into the surgical wound, which causes the bandage to become wet);
Bleeding through the drainage (blood begins to flow through the drainage left in the wound or some kind of cavity);
Internal bleeding (blood pours into the internal cavities of the body without entering the external environment), the diagnosis of internal bleeding is especially difficult and is based on special symptoms and signs.
Development of infection
The foundations for preventing wound infections are laid on the operating table. After the operation, you should monitor the normal functioning of the drainages, since the accumulation of unevacuated fluid can become a good breeding ground for microorganisms and cause a suppurative process. In addition, it is necessary to prevent secondary infection. To do this, patients must be bandaged the next day after surgery in order to remove the dressing material, which is always wet with sanguineous wound discharge, treat the edges of the wound with an antiseptic and apply a protective aseptic bandage. After this, the bandage is changed every 3-4 days or more often if indicated (the bandage is wet, has come off, etc.).
Seam divergence
The divergence of the seams is especially dangerous after operations on the abdominal cavity. This state is called eventration. It may be associated with technical errors when suturing the wound, as well as with a significant increase in intra-abdominal pressure (with intestinal paresis, peritonitis, pneumonia with severe cough syndrome) or the development of infection in the wound. To prevent suture dehiscence during repeated operations and a high risk of developing
Rice. 9-8. Suturing a wound of the anterior abdominal wall on tubes
For this complication, suturing the wound of the anterior abdominal wall with buttons or tubes is used (Fig. 9-8).
Complications from the cardiovascular system
In the postoperative period, myocardial infarction, arrhythmia, and acute cardiovascular failure may occur. The development of these complications is usually associated with concomitant diseases, so their prevention largely depends on the treatment of concomitant pathology.
The issue of preventing thromboembolic complications is important, the most common of which is pulmonary embolism - a serious complication, one of the common causes of death in the early postoperative period.
The development of thrombosis after surgery is caused by a slowdown in blood flow (especially in the veins of the lower extremities and pelvis), increased blood viscosity, impaired water and electrolyte balance, unstable hemodynamics and activation of the coagulation system due to intraoperative tissue damage. The risk of pulmonary embolism is especially high in elderly obese patients with concomitant pathology of the cardiovascular system, the presence of varicose veins of the lower extremities and a history of thrombophlebitis.
Principles for the prevention of thromboembolic complications:
Early activation of patients;
Impact on a possible source (for example, treatment of thrombophlebitis);
Ensuring stable hemodynamics;
Correction of water and electrolyte balance with a tendency to hemodilution;
The use of disaggregants and other agents that improve the rheological properties of blood;
The use of anticoagulants (for example, heparin sodium, nadroparin calcium, enoxaparin sodium) in patients with an increased risk of thromboembolic complications.
Complications from the respiratory system
In addition to the development of a severe complication - acute respiratory failure, associated primarily with the consequences of anesthesia, great attention should be paid to the prevention of postoperative pneumonia - one of the most common causes of death in patients in the postoperative period.
Principles of prevention:
Early activation of patients;
Antibiotic prophylaxis;
Adequate position in bed;
Breathing exercises, postural drainage;
Thinning sputum and using expectorants;
Sanitation of the tracheobronchial tree in seriously ill patients (through an endotracheal tube during prolonged mechanical ventilation or through a specially applied microtracheostomy during spontaneous breathing);
Mustard plasters, jars;
Massage, physiotherapy.
Digestive complications
The development of anastomotic suture leakage and peritonitis after surgery is usually associated with the technical features of the operation and the condition of the stomach or intestines due to the underlying disease; this is a subject for consideration in private surgery.
After operations on the abdominal organs, to varying degrees, the development of paralytic obstruction (intestinal paresis) is possible. Intestinal paresis significantly disrupts the digestive processes. An increase in intra-abdominal pressure leads to a high standing of the diaphragm, impaired ventilation of the lungs and heart activity. In addition, there is a redistribution of fluid in the body and the absorption of toxic substances from the intestinal lumen.
The foundations for the prevention of intestinal paresis are laid during surgery (careful attitude towards tissues, minimal infection).
abdominal cavity, careful hemostasis, novocaine blockade of the mesenteric root at the end of the intervention).
Principles of prevention and control of intestinal paresis after surgery:
Early activation of patients;
Rational diet;
Gastric drainage;
Epidural blockade (or pararenal novocaine blockade);
Introduction of a gas outlet tube;
Hypertensive enema;
Administration of motor stimulation agents (eg, hypertonic solution, neostigmine methyl sulfate);
Physiotherapeutic procedures (diadynamic therapy).
Complications from the urinary system
In the postoperative period, the development of acute renal failure, impaired renal function due to inadequate systemic hemodynamics, and the occurrence of inflammatory diseases (pyelonephritis, cystitis, urethritis, etc.) are possible. After surgery, it is necessary to carefully monitor diuresis, not only during the day, but also hourly diuresis.
The development of inflammatory and some other complications is facilitated by urinary retention, often observed after surgery. Impaired urination, which sometimes leads to acute urinary retention, is of a reflex nature and occurs as a result of a reaction to pain in the wound, reflex tension of the abdominal muscles, and the effects of anesthesia.
If urination is impaired, simple measures are first taken: the patient is allowed to stand up, he can be taken to the toilet to restore the usual environment for urination, analgesics and antispasmodics are administered, a warm heating pad is placed on the suprapubic area. If these measures are ineffective, it is necessary to perform catheterization of the bladder.
If the patient cannot urinate, it is necessary to release urine with a catheter at least once every 12 hours. During catheterization, it is necessary to carefully observe the rules of asepsis. In cases where the patient’s condition is severe and constant monitoring of diuresis is necessary, the catheter is left in the bladder for the entire period of early postoperative treatment.
ration period. In this case, the bladder is washed twice a day with an antiseptic (nitrofural) to prevent ascending infection.
Prevention and treatment of bedsores
Bedsores are aseptic necrosis of the skin and deeper tissues due to impaired microcirculation due to prolonged compression.
After surgery, bedsores usually form in seriously elderly patients who have been in a forced position (lying on their back) for a long time.
Most often, bedsores occur on the sacrum, in the area of the shoulder blades, on the back of the head, the back of the elbow joint, and the heels. It is in these areas that the bone tissue is located quite close and there is pronounced compression of the skin and subcutaneous tissue.
Prevention
Prevention of bedsores involves the following measures:
Early activation (if possible, stand, seat patients, or at least turn from side to side);
Clean dry linen;
Rubber circles (placed in the areas of the most common locations of bedsores to change the nature of pressure on the tissue);
Anti-decubitus mattress (mattress with constantly changing pressure in separate sections);
Massage;
Treatment of skin with antiseptics.
Stages of development
There are three stages in the development of bedsores:
Ischemia stage: tissues become pale, sensitivity is impaired.
Stage of superficial necrosis: swelling and hyperemia appear, and areas of black or brown necrosis form in the center.
Stage of purulent melting: an infection occurs, inflammatory changes progress, purulent discharge appears, the process spreads deeper, even to damage the muscles and bones.
Treatment
When treating bedsores, it is necessary to comply with all measures related to prevention, since they are, to one degree or another, aimed at eliminating the etiological factor.
Local treatment of pressure ulcers depends on the stage of the process.
Ischemia stage - the skin is treated with camphor alcohol, which causes vasodilation and improves blood flow in the skin.
Stage of superficial necrosis - the affected area is treated with a 5% solution of potassium permanganate or a 1% alcohol solution of brilliant green. These substances have a tanning effect and create a scab that prevents infection.
Stage of purulent melting - Treatment is carried out according to the principle of treating a purulent wound. It should be noted that it is much easier to prevent bedsores than to treat them.
Absolute – shock (serious condition of the body, close to terminal), except hemorrhagic with ongoing bleeding; acute stage of myocardial infarction or cerebrovascular accident (stroke), except for methods of surgical correction of these conditions, and the presence of absolute indications (perforating duodenal ulcer, acute appendicitis, strangulated hernia)
Relative - the presence of concomitant diseases, primarily the cardiovascular system, respiratory, kidney, liver, blood system, obesity, diabetes.
Preliminary preparation of the surgical field
One of the ways to prevent contact infection.
Before a planned operation, it is necessary to carry out complete sanitization. To do this, on the evening before the operation, the patient should take a shower or bathe, put on clean underwear; In addition, bed linen is changed. On the morning of the operation, the nurse shaves off the hairline in the area of the upcoming operation with a dry method. This is necessary, since the presence of hair makes it much more difficult to treat the skin with antiseptics and can contribute to the development of infectious postoperative complications. You should definitely shave on the day of surgery, and not before. When preparing for emergency surgery, they usually limit themselves to shaving the hair in the surgical area.
"Empty Stomach"
When the stomach is full, after induction of anesthesia, the contents from it can begin to passively flow into the esophagus, pharynx and oral cavity (regurgitation), and from there, with breathing, enter the larynx, trachea and bronchial tree (aspiration). Aspiration can cause asphyxia - blockage of the airways, which without urgent measures will lead to the death of the patient, or the most severe complication - aspiration pneumonia.
Bowel movement
Before a planned operation, patients need to do a cleansing enema so that when the muscles relax on the operating table, involuntary bowel movements do not occur. Before emergency operations, there is no need to do an enema - there is no time for this, and this procedure is difficult for patients in critical condition. It is impossible to perform an enema during emergency operations for acute diseases of the abdominal organs, since an increase in pressure inside the intestine can lead to rupture of its wall, the mechanical strength of which can be reduced due to the inflammatory process.
Emptying the Bladder
To do this, the patient urinated on his own before the operation. The need for bladder catheterization occurs rarely, mainly during emergency operations. This is necessary if the patient’s condition is severe, he is unconscious, or when performing special types of surgical interventions (surgeries on the pelvic organs).
Premedication- administration of medications before surgery. It is necessary to prevent certain complications and create the best conditions for anesthesia. Premedication before a planned operation includes the introduction of sedatives and hypnotics on the night before the operation and the introduction of narcotic analgesics 30-40 minutes before it starts. Before emergency surgery, only a narcotic analgesic and atropine are usually administered.
The degree of risk of the operation
Abroad, the classification of the American Society of Anesthesiologists (ASA) is usually used, according to which the degree of risk is determined as follows.
Planned surgery
Risk degree I - practically healthy patients.
Risk degree II - mild illness without impairment of function.
III degree of risk - severe diseases with impaired function.
IV degree of risk - severe diseases, in combination with or without surgery, threatening the patient’s life.
V degree of risk - the patient’s death can be expected within 24 hours after surgery or without it (moribund).
emergency operation
VI degree of risk - patients of categories 1-2, operated on as an emergency.
VII degree of risk - patients of categories 3-5, operated on as an emergency.
The ASA classification presented is convenient, but is based only on the severity of the patient's initial condition.
The classification of the degree of risk of surgery and anesthesia recommended by the Moscow Society of Anesthesiologists and Resuscitators (1989) seems to be the most complete and clear (Table 9-1). This classification has two advantages. Firstly, she evaluates both the general condition of the patient and the volume, nature of the surgical intervention, as well as the type of anesthesia. Secondly, it provides an objective scoring system.
There is an opinion among surgeons and anesthesiologists that proper preoperative preparation can reduce the risk of surgery and anesthesia by one degree. Considering that the likelihood of developing serious complications (including death) progressively increases with the degree of surgical risk, this once again emphasizes the importance of qualified preoperative preparation.
Indications. There are vital indications (absolute) and relative. When indicating the indications for an operation, it is necessary to reflect the order in which it is performed - emergency, urgent or planned. Emergency: appendicitis, o. surgical diseases of the abdominal organs, traumatic injuries, thrombosis and embolism, after resuscitation.
Contraindications. There are absolute and relative contraindications to surgical treatment. The range of absolute contraindications is currently sharply limited, they include only the agonal state of the patient. In the presence of absolute contraindications, the operation is not performed even according to absolute indications. So, in a patient with hemorrhagic shock and internal bleeding, the operation should be started in parallel with anti-shock measures - with continued bleeding, shock cannot be stopped, only hemostasis will allow the patient to be taken out of shock.
196. Degree of surgical and anesthetic risk. Choosing pain relief and preparing for it. Preparing for an emergency ny operations. Legal and legal bases for conducting examinations and surgical interventions.
RISK ASSESSMENT OF ANESTHESIA AND SURGERY The degree of risk of surgery can be determined based on the patient's condition, the volume and nature of the surgical intervention, adopted by the American Society of Anesthesiologists - ASA. According to the severity of the somatic condition: I (1 point)- patients in whom the disease is localized and does not cause systemic disorders (virtually healthy); II (2 points)- patients with mild or moderate disorders that to a small extent disrupt the vital activity of the body without pronounced shifts in homeostasis; III (3 points)- patients with severe systemic disorders that significantly disrupt the vital activity of the body, but do not lead to disability; IV (4 points)- patients with severe systemic disorders that pose a serious danger to life and lead to disability; V (5 points)- patients whose condition is so severe that they can be expected to die within 24 hours. According to the volume and nature of the surgical intervention: I (1 point)- minor operations on the surface of the body and abdominal organs (removal of superficial and localized tumors, opening of small ulcers, amputation of fingers and toes, ligation and removal of hemorrhoids, uncomplicated appendectomies and hernia repairs); 2 (2 points)- operations of moderate severity (removal of superficially located malignant tumors requiring extensive intervention; opening of ulcers located in cavities; amputation of segments of the upper and lower extremities; operations on peripheral vessels; complicated appendectomies and hernia repairs requiring extensive intervention; trial laparotomy and thoracotomy; other similar by complexity and volume of intervention; 3 (3 points)- extensive surgical interventions: radical operations on the abdominal organs (except those listed above); radical surgery on the breast organs; extended limb amputations - transiliosacral amputation of the lower limb, etc., brain surgery; 4 (4 points)- operations on the heart, large vessels and other complex interventions performed under special conditions - artificial circulation, hypothermia, etc. The gradation of emergency operations is carried out in the same way as planned ones. However, they are designated with the index "E" (emergency). When noted in the medical history, the numerator indicates the risk according to the severity of the condition, and the denominator - according to the volume and nature of the surgical intervention. Classification of surgical and anesthetic risk. MNOAR-89. In 1989, the Moscow Scientific Society of Anesthesiologists and Reanimatologists adopted and recommended for use a classification that provides for a quantitative (in points) assessment of surgical and anesthesiological risk according to three main criteria: - the general condition of the patient; - volume and nature of the surgical operation; - the nature of anesthesia. Assessment of the patient's general condition. Satisfactory (0.5 points): somatically healthy patients with localized surgical diseases or not related to the underlying surgical disease. Moderate severity (1 point): Patients with mild or moderate systemic disorders, related or not related to the underlying surgical disease. Severe (2 points): patients with severe systemic disorders that are associated or not associated with a surgical disease. Extremely severe (4 points): patients with extremely severe systemic disorders that are associated or not associated with a surgical disease and pose a danger to the patient’s life without surgery or during surgery. Terminal (6 points): patients in a terminal condition with pronounced symptoms of decompensation of the functions of vital organs and systems, in which death can be expected during surgery or in the next few hours without it. Assessing the volume and nature of the operation. Minor abdominal or minor surgeries on body surfaces (0.5 points). More complex and lengthy operations on the surface of the body, spine, nervous system and operations on internal organs (1 point). Major or lengthy surgeries in various fields of surgery, neurosurgery, urology, traumatology, oncology (1.5 points). Complex and lengthy operations on the heart and large vessels (without the use of infrared), as well as extended and reconstructive operations in surgery in various areas (2 points). Complex operations on the heart and great vessels using IR and internal organ transplant surgery (2.5 points). Assessment of the nature of anesthesia. Different kinds local potentiated anesthesia (0.5 points). Regional, epidural, spinal, intravenous or inhalational anesthesia with preservation of spontaneous breathing or with short-term assisted ventilation through a mask of an anesthesia machine (1 point). Common standard options for general combined anesthesia with tracheal intubation using inhalation, non-inhalation or non-drug anesthesia (1.5 points). Combined endotracheal anesthesia with the use of inhalational non-inhalational anesthetics and their combinations with methods of regional anesthesia, as well as special methods of anesthesia and corrective intensive therapy (artificial hypothermia, infusion-transfusion therapy, controlled hypotension, assisted circulation, cardiac pacing, etc.) (2 points). Combined endotracheal anesthesia using inhalation and non-inhalation anesthetics under IR, HBO, etc. with the complex use of special anesthesia methods, intensive care and resuscitation (2.5 points). Risk degree: I degree(minor) - 1.5 points; II degree(moderate) -2-3 points; III degree(significant) - 3.5-5 points; IV degree(high) - 5.5-8 points; V degree(extremely high) - 8.5-11 points. In case of emergency anesthesia, an increase in risk by 1 point is acceptable.
Preparing for emergency operations
The scope of preparing a patient for emergency surgery is determined by the urgency of the intervention and the severity of the patient’s condition. Minimal preparation is performed in case of bleeding, shock (partial sanitary treatment, shaving the skin in the area of the surgical field). Patients with peritonitis require preparation aimed at correcting water and electrolyte metabolism. If the operation is supposed to be under anesthesia, the stomach is emptied using a thick probe. In case of low blood pressure, if the cause is not bleeding, intravenous administration of hemodynamic blood substitutes, glucose, prednisolone (90 mg) should be used to increase blood pressure to a level of 90-100 mm Hg. Art.
Preparing for emergency surgery. In conditions that threaten the patient’s life (wound, life-threatening loss of blood, etc.), no preparation is carried out; the patient is urgently taken to the operating room without even removing his clothes. In such cases, the operation begins simultaneously with anesthesia and revival (reanimation) without any preparation.
Before other emergency operations, preparations for them are still carried out, although to a significantly reduced extent. After a decision is made about the need for surgery, preoperative preparation is carried out in parallel with the continued examination of the patient by the surgeon and anesthesiologist. Thus, preparation of the oral cavity is limited to rinsing or wiping. Gastrointestinal preparation may include pumping out gastric contents and even leaving a gastric nasal tube (for example, for intestinal obstruction) during surgery. An enema is rarely given; only a siphon enema is allowed when attempting conservative treatment of intestinal obstruction. For all other acute surgical diseases of the abdominal organs, an enema is contraindicated.
The hygienic water procedure is carried out in an abbreviated form - a shower or washing the patient. However, preparation of the surgical field is carried out in full. If it is necessary to prepare patients who came from production or from the street, whose skin is heavily contaminated, the preparation of the patient's skin begins with mechanical cleaning of the surgical field, which in these cases should be at least 2 times larger than the intended incision. The skin is cleaned with a sterile gauze swab moistened with one of the following liquids: ethyl ether, 0.5% ammonia solution, pure ethyl alcohol. After cleaning the skin, the hair is shaved and the surgical field is further prepared.
In all cases, the nurse must receive clear instructions from the doctor about to what extent and by what time she must fulfill her duties.
197. Preparing the patient for surgery. Training goals. Deontological training. Medication and physical preparation of the patient. The role of physical training in the prevention of postoperative infectious complications. Preparation of the oral cavity, preparation of the gastrointestinal tract, skin.
The issue of surgical treatment of clinical manifestations that are caused by a herniated intervertebral disc requires a qualified decision (after a thorough examination) with the participation of a neurologist, neurosurgeon, therapist (and in some cases with the participation of an orthopedist and/or rheumatologist).
Unfortunately, surgical intervention is often performed in the absence of proper indications (which will be discussed in this article), which is fraught with the formation of chronic post-discectomy pain syndrome or Failed Back Surgery Syndrome (FBSS), which is caused by many factors, for example , violation of the biomechanics of movement in the operated segment of the spine, adhesions, chronic epiduritis, etc.
Let's consider the indications for surgical treatment of clinical manifestations caused by a herniated intervertebral disc, which were published by leading experts in the field of neurology, veterinary neurology and manual therapy.
In the article by Professor, Doctor of Medical Sciences. O.S. Levina (Department of Neurology of the Russian Medical Academy of Postgraduate Education, Moscow) “Diagnostics and treatment of vertebrogenic lumbosacral radiculopathy” in relation to the problem we are considering, the following is stated:
Recent large-scale studies have shown that although early surgical treatment undoubtedly leads to faster pain relief, after six months, a year or two it has no advantages in terms of the main indicators of pain syndrome and degree of disability over conservative therapy and does not reduce the risk of chronic pain.
It turned out that the timing of surgery in general does not affect its effectiveness. In this regard, in uncomplicated cases of vertebrogenic radiculopathy, the decision on surgical treatment can be delayed for 6-8 weeks, during which adequate (!) conservative therapy should be carried out. The persistence of intense radicular pain syndrome, severe limitation of mobility, and resistance to conservative measures during these periods may be indications for surgical intervention.
Absolute indications for surgical treatment are compression of the roots of the cauda equina with paresis of the foot, anesthesia of the anogenital area, and dysfunction of the pelvic organs. An increase in neurological symptoms, such as muscle weakness, may also be an indication for surgery. As for other cases, questions about the feasibility, optimal time and method of surgical treatment remain the subject of debate.
In recent years, along with traditional discectomy, more gentle surgical techniques have been used; microdiscectomy, laser decompression (vaporization) of the intervertebral disc, high-frequency disc ablation, etc. For example, laser vaporization is potentially effective in radiculopathy associated with a herniated intervertebral disc while maintaining the integrity of the fibrous ring, its protrusion by no more than 1/3 of the sagittal size of the spinal canal (about 6 mm) and in the absence of movement disorders or symptoms of root compression in the patient horse tail. The minimally invasive nature of the intervention expands the range of indications for it. However, the principle remains unchanged: surgery should be preceded by optimal conservative therapy for at least 6 weeks.
Regarding the use of gentle methods for treating intervertebral disc herniation, there is also the following recommendation (which can be found in more detail in the article: “Neuropathic pain syndrome for back pain” A.N. Barinov, First Moscow State Medical University named after I.M. Sechenov):
Provided there is a non-sequestrated lateral (foraminal) disc herniation of less than 7 mm, and short-term effectiveness of foraminal blockades and/or poor tolerance to glucocorticoids, a minimally invasive procedure of laser vaporization (or its modification - foraminoplasty), cold plasma ablation or intradiscal electrothermal annuloplasty is performed, which is effective in 50-65% of patients. If this minimally invasive procedure does not lead to pain regression, then microdiscectomy is performed.
According to the recommendations of L.S. Manvelova, V.M. Tyurnikova, Scientific Center of Neurology of the Russian Academy of Medical Sciences, Moscow (which are published in the article “Lumbar pain: etiology, clinical picture, diagnosis and treatment”), indications for surgical treatment of clinical manifestations caused by a herniated intervertebral disc are divided into relative and absolute:
The absolute indication for surgical treatment is the development of caudal syndrome, the presence of a sequestered herniated intervertebral disc, severe radicular pain syndrome that does not decrease despite the treatment.
The development of radiculomyeloischemia also requires emergency surgical intervention, however, after the first 12-24 hours, the indications for surgery in such cases become relative, firstly, due to the formation of irreversible changes in the roots, and secondly, because in most cases in During treatment and rehabilitation measures, the process regresses within approximately 6 months. The same regression periods are observed with delayed operations.
Relative indications include the ineffectiveness of conservative treatment, recurrent sciatica. Conservative therapy should not exceed 3 months in duration and last at least 6 weeks.
It is assumed that a surgical approach in case of acute radicular syndrome and failure of conservative treatment is justified within the first 3 months after the onset of pain to prevent chronic pathological changes in the root. A relative indication is cases of extremely severe pain syndrome, when the pain component is replaced by an increase in neurological deficit.
As a conclusion, so to speak, summing up the above, we should list the indications for surgical treatment of intervertebral disc herniation, adapted for their correct perception by patients and doctors not related to neurology and neurosurgery, and published in the article F.P. Stupina(doctor of the highest category, candidate of medical sciences, associate professor of the course of restorative medicine at the Department of Physical Rehabilitation and Sports Medicine of the Russian Medical Academy of Postgraduate Education) “Intervertebral hernia. Is surgery necessary? (read the full article ->):
“Based on the results of many years of observations and the results of surgical and conservative treatment methods, we noted that the indications for surgery are:
. paresis and paralysis of the sphincters of the rectum and bladder;
. the severity and persistence of radicular pain, and the absence of a tendency to their disappearance within 2 weeks, especially when the size of the hernial protrusion is over 7 mm, especially with sequestration.
These are urgent indications, when the operation must be agreed to involuntarily, otherwise it will be worse.
But in the following cases, you need to undergo surgery only of your own free will, carefully weighing your decision:
. failure of conservative treatment for 3 months or more;
. paralysis of limbs and segments;
. signs of muscle atrophy against the background of lack of functional activity of the root.
These are relative indications, i.e. regarding a person’s ability to withstand pain, the need to go to work and the ability to self-care.”
