Is laparotomy a common surgical operation or a dangerous intervention? Laparotomy - abdominal examination - research laparotomy Stages of laparotomy.

Such a surgical method of operations as laparotomy, often used in gynecology, is an open access to the organs located in the small pelvis, and is carried out by a small incision in the abdomen.

When is a laparotomy used?

Laparotomy is used for:

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

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

Kinds

There are several types of laparotomy:

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

Main advantages

The main advantages of laparotomy are:

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

Differences between laparotomy and laparoscopy

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

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

Consequences of laparotomy and possible complications

When carrying out this kind of surgical intervention, such as laparotomy of the uterus, damage to neighboring organs of the small pelvis is possible. In addition, the risk of adhesions after surgery increases. This is because during the operation, surgical agents come into contact with the peritoneum, as a result of which it becomes inflamed, and adhesions form on it, which “glue” the organs to each other.

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

When can I plan pregnancy after laparotomy?

Depending on which organ from the reproductive system has undergone surgery, the terms after which you can become pregnant vary. In general, it is not recommended to plan a pregnancy earlier than six months after the laparotomy.

Laparotomy is a rather complicated surgical operation that requires special knowledge of anatomy and skills in using surgical instruments from the specialist who performs it.

Types and features of the conduct

What is laparotomy in surgery? Distinguish the following methods of abdominal dissection.

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

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

Oblique incision - a dissection is made from below along the edge of the arcs of the ribs or from above along the ligaments of the groin. It opens access to the appendix, spleen, gallbladder;

Transverse excision involves cutting the muscle fibers. Often used in gynecology. It is fraught with the risk of postoperative hernia due to the weakening of the peritoneal wall;

Angular abdominal surgery is prescribed if necessary to "get" to a certain organ: the ducts of the gallbladder, liver.

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

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

Diagnostic laparotomy (explorative) is currently a rare and widespread phenomenon in medicine. The reason is the presence in clinical practice of a sufficient number of high-precision research methods: ultrasound, computed tomography, x-rays, radiation diagnostics.

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

What pathologies are still assigned diagnostic laparotomy:

Perforation, injuries of the stomach, duodenum, colon, pancreas, ureter, kidneys, retroperitoneal vessels;
Ulcer in acute / chronic form;
Cancer in the stage of disintegration;
Tuberculosis;
Necrosis;
Fecal stones;
Internal hernias;
Peritonitis.

Diagnostic laparotomy can detect benign and malignant tumors, ulcers.

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

It is important to ensure during the operation the external breathing of the patient, to stabilize systolic pressure, to control urination with a catheter.

Requirements for a laparotomy

The risk of hernia formation is minimized; post-traumatic states, complications;
Muscles, nerve endings, blood vessels are intact;
The surgeon must have a place for excision, assessment of the state of organs, systems, tissues, manipulations, stitching the cut layers.

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

Fulfillment of all recommendations and prescriptions of the doctor;
Wearing shoes that reduce the risk of thrombosis;
Using a catheter while urinating;
The use of easily digestible food, vegetables, fruits, juices;
Most importantly, you can not touch a fresh wound, wet it, pick it with your fingers or sharp objects in order to avoid infection;
Intense physical activity and exercises are unacceptable after gluteal surgery;
Health monitoring: body temperature, timely urination, stool. You should immediately seek medical help in case of dizziness, nausea, fever, pain, bleeding in the wound area.

Transsection in gynecology: features, types, differences from laparoscopy

Laparotomy in gynecology is a fairly common phenomenon. It is assigned in the following cases:

ectopic pregnancy;
Cysts, purulent inflammation of the tubes of the uterus, ovaries;
Peritonitis;
Pathology of the ovaries;
Infertility;
Obstetrics (caesarean section).

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

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

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

Methods of abdominal dissection during gynecological operations:

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

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

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

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

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

Complications after gynecological surgery:

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

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

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

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

Access. The most commonly used incision is in the midline of the abdomen - median laparotomy.

At upper median laparotomy, t . e. incision along the midline above the navel, dissect the skin, subcutaneous tissue, aponeurosis (or white line of the abdomen), preperitoneal tissue and peritoneum. This incision provides access to the upper abdominal organs. Inferior median incisionalso passes along the white line, however, after dissection of the white line, which is very narrow below the navel, it is often necessary to use Farabef lamellar hooks to retract the edges of the rectus muscles. The incision provides access to the intestines and pelvic organs. At mid-medial laparotomy the incision starts above the navel, bypasses the navel on the left and ends below it by 3-4 cm. This access is intended for revision of the entire abdominal cavity: if necessary, it can be extended up or down.

The progress of the laparotomy

1. Dissection of the skin and tissue. An incision is made in the skin and subcutaneous tissue, for which the surgeon is given a sharp abdominal scalpel. This scalpel becomes contaminated when the skin is cut, so the operating sister immediately throws it out with a forceps into the basin with the used instrument. When the incision is made, the wound must be dried - give the assistant a gauze ball (tupfer) on the forceps or clamp, the operating surgeon - hemostatic clamps one by one until all the bleeding vessels are captured.

After the bleeding stops, the sister gives 2 napkins to isolate the surgical wound from the skin - the napkins are placed along the edges of the incision and fixed at the corners with clamps. For large laparotomy, before laying the napkins, it is necessary to lubricate the skin around the wound with glue so that the napkins stick along the entire length of the incision and reliably isolate the skin. For better fixation, the skin must be wiped dry with a separate cloth before treatment with cleol. Hemostatic clamps placed in the subcutaneous tissue can be left until the end of a minor operation, but it is best to always aim for as few instruments as possible in the area of operation. For the final stop of bleeding, the vessels are tied up. To do this, the sister gives the assistant blunt-ended curved scissors for cutting the threads, and the surgeon successively - catgut ligatures No. 2, each 18-20 cm long. wiping them with a sterile napkin and thus clearing them of blood.

2. Dissection of the aponeurosis. With sharp hooks, the assistant spreads the edges of the skin wound. For dissection of the aponeurosis, the nurse gives a clean scalpel, with which the surgeon makes a small incision of the aponeurosis, and then curved scissors, with which the surgeon completes the dissection of the aponeurosis up and down. After dissection of the aponeurosis, the peritoneum covered with pre-peritoneal tissue is exposed in front of the surgeon. In order to clearly see the peritoneal sheet below the navel, it may be necessary to retract the edges of the rectus abdominis muscles with lamellar hooks.

3. Dissection of the peritoneum. To dissect the peritoneum, the sister gives the surgeon and assistant anatomical tweezers: with these tweezers, the peritoneum is taken into a fold and dissected with scissors. Once a small hole has been made in the peritoneum, two Mikulich forceps should be applied: one to the surgeon and one to the assistant. They capture the edges of the peritoneum and fix them to the edge of the side sheets. In this case, if there is a large amount of exudate or blood in the abdominal cavity, the contents under pressure can flow out, flooding the surgical field and contaminating the wound. Therefore, by the time of opening the abdominal cavity, the sister should have an electric suction pump or a sufficient number of large tampons on forceps ready.

As the peritoneum is cut with Cooper's scissors up and then down, the sister gives another 4-6 Mikulich clamps so that the edges of the peritoneum are securely fixed to the surgical linen throughout, covering the subcutaneous tissue. If, at the time of opening the abdominal cavity, the intestine interferes with the dissection of the peritoneum, the nurse, at the request of the assistant, gives a tupfer to remove the intestinal loops.

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

The sister should have at the ready saddle-shaped hooks for lifting the abdominal wall, liver and abdominal mirrors. To widen the edges of the wound and keep them in this position, the sister gives a retractor, most often of the Gosse type. Beforehand, she prepares two small napkins, which the surgeon places under the hooks of the retractor to reduce pressure on the tissues. These wipes must be well fixed and they must be remembered so that at the end of the operation one does not forget to throw them away after removing the retractor. Hot saline should always be available for any laparotomy. If there is an effusion in the abdominal cavity, the nurse gives the surgeon a small ball for sowing the contents on the microbial flora.

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

6. Installation of drains through the counter aperture. When indicated, the surgeon decides to leave a rubber drain in the abdominal cavity. Microirrigators for the administration of antibiotics are usually removed through the corners of the midline incision. In order to avoid infection of the median suture, the drains are removed through the counter-opening in the lateral part of the abdominal wall. To do this, the Mikulich clamps are shifted, freeing the edge of the sheet on the corresponding side and exposing the skin in the hypochondrium or iliac region. The sister gives a wand with an antiseptic for treatment and a pointed scalpel, with which the surgeon pierces the skin in the intended place. After that, the sister gives a pointed clamp, the assistant lifts the edge of the abdominal wall, and the surgeon, under the control of the eye, pierces all layers of the abdominal wall with a clamp from the outside to the inside. By this time, the sister should submit a rubber drainage prepared in advance with two to three holes at the end, the end should be rounded. If another type of drainage is needed, the surgeon himself prepares it in advance or explains in detail what exactly is needed.

The surgeon fixes the drainage with the jaws of the clamp and pulls it through the abdominal wall from the inside to the outside, leaving it in the abdominal cavity to the desired length. Then the nurse gives a needle holder with a cutting needle loaded with silk thread to fix the drainage to the skin. After that, the skin is again carefully closed with surgical linen, and the surgeon proceeds to suture the wound of the anterior abdominal wall.

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

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

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

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

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

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

After the operation, the patient is placed in the postoperative ward under the supervision of a nurse on duty or a specially assigned nurse.

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

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

In the postoperative wards, it is necessary to have oxygen at the ready, which is used at the first sign of cyanosis, increased frequency or shallow breathing. Measurement of blood pressure is carried out, as well as counting the pulse, several times during the first six to eight hours after the operation.

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

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

With the early onset of pain, promedol 2% 1-2 ml subcutaneously is prescribed, and at night morphine 1% 1 ml or pantopon 2% 1 ml subcutaneously.

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

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

Urination must be achieved no later than 12 hours after the operation. If the patient cannot urinate herself (into a heated vessel), then urine is released by a catheter in compliance with all asepsis rules. With urinary retention in the following days, special measures are required.

Normal postoperative period. Food. In the absence of contraindications - vomiting, post-anesthetic sleep, unconsciousness - a patient who has undergone surgery under general anesthesia is allowed to drink after 3-4 hours (not earlier than 1-2 hours after vomiting has stopped), hot strong tea with lemon is best. After a large blood loss, it is necessary to re-give liquid in large quantities: it should be noted that in these patients vomiting after anesthesia is less common, so they need to start drinking earlier. It is very important to force the operated woman to breathe deeply soon after waking up from anesthesia to remove the remnants of ether from the lungs ("breathing exercises").

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

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

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

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

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

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

Removal of stitches. After laparotomy, the brackets are removed on the seventh day, silk sutures - on the eighth. The sutures on the perineum after plastic surgery are removed early - on the fifth day, since later removal of the sutures can cause their eruption.

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

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

In shock and collapse, patients are laid down with their heads slightly lowered, they are covered with heating pads; cardiac agents are injected under the skin or into a vein - camphor (subcutaneously), caffeine, strophanthin, strychnine. Especially recommend adrenaline 1: 1000-0.5 ml intramuscularly or into a vein; due to the short action of adrenaline, it is necessary to re-introduce it in 0.1-0.2 ml. Subcutaneous pituitrin can be used instead of epinephrine. It tones the blood vessels and has a longer effect than adrenaline. To irritate the vasomotor center, carbon dioxide inhalation is recommended, preferably in the form of a mixture (if a special apparatus is available) of 10% carbon dioxide, 50% oxygen and 40% air. Subsequently, glucose with adrenaline is administered (by intravenous drip) or some kind of anti-shock liquid. With significant blood loss and shock, a good remedy is blood transfusion (after the restoration of proper blood circulation) in significant quantities (up to 1 liter), preferably in two doses.

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

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

Vomiting in the postoperative period is of various origins, and therefore its treatment depends on the cause that caused it.

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

If vomiting is associated with non-excretion of gases, you can first apply gastric lavage, inject a hypertonic solution of NaCl (10% 50-100 ml) into a vein, prescribe siphon enemas. With vomiting, depending on the onset of peritonitis, the stomach is washed, penicillin is administered (intramuscularly at 150,000 IU every three hours). If there is no effect, in both cases immediately go to the (re-) abdominal surgery.

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

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

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

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

As for enemas, they can be recommended after a day after the operation in the form of microclysters from a hypertonic saline solution (10% 100 ml) or even better in the form of glycerin enemas (one to two tablespoons of glycerin per 1/2 cup of water). The enemas of pure, undiluted glycerin recommended by some are very irritating to the rectal mucosa. If hypertonic, glycerin, or simple enemas fail, proceed to siphon enemas by inserting a rubber tube above the internal sphincter; siphon enemas from hypertonic (10%) saline solution are also very effective.

Most often, postoperative pneumonia and bronchitis occur after laparotomy, especially prolonged and performed under general inhalation anesthesia (aspiration lobular pneumonia). However, even vaginal operations performed without inhalation anesthesia can be complicated by bronchitis and pneumonia. To a greater extent, postoperative bronchitis and pneumonia can contribute to pelvic vein thrombosis after vaginal surgery. Nevertheless, refraining from inhalation anesthesia in favor of local or spinal anesthesia undoubtedly reduces the frequency and severity of postoperative complications in the lungs.

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

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

Modern treatment of already developed pneumonia is carried out according to general schemes with the use of sulfanilamide drugs in large doses, penicillin and streptomycin.

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

For the treatment of urinary retention that has already developed, it is necessary to start with the simplest measures; heating pad on the bladder area, hot microclysters, planting. The vessel must be served warm, in order to avoid reflex spasm of the sphincter from contact with a cold object; for this purpose, a little hot water is poured into the vessel.

Of the drugs, the introduction into the bladder of 20 ml of a warm solution of 1-2% collargol or 20 ml of 2% boric acid with the addition of one third of glycerol. You can prescribe intravenous administration of 5-10 ml of 40% urotropin, which often gives a positive result. Sometimes subcutaneous administration of 3-5 ml of 25% magnesium sulfate works favorably. Finally, as in paresis of the intestines, a good remedy for urinary retention is the introduction under the skin of repeated small doses (0.5 ml) of pituitrin.

If drugs do not have an effect, then resort to catheterization. For the prevention of cystitis, catheterization must be carried out strictly aseptically.

In the postoperative period, pyelitis develops in those operated on by the ascending path from the bladder and by the lymphatic path from the intestines, especially with constipation. As a causative agent in 90% of cases, bact occurs. coli; at the same time, right-sided pyelitis is more often observed due to the transfer of infection through the lymphatic vessels from the hepatic curvature or other part of the colon to the pelvis of the right kidney.

The therapy consists in the appointment of a milk-vegetable diet, alkaline waters, heating pads for the lower back; recommend lying on the left side (with right-sided pyelitis); from medicinal substances antibiotics are used, as well as sulfodimesin.

Postoperative anuria that develops in rare cases (in persons with kidney failure, after prolonged anesthesia in sharply bled patients) is usually a formidable complication and leads quickly to uremia and death.

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

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

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

With deep suppuration of the subcutaneous tissue with a divergence of the aponeurosis (after laparotomy), the uterus and intestinal loops can enter the wound. Treatment - the imposition of a secondary suture.

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

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

Almost all obstetricians-gynecologists impose a deaf suture when the eventration has taken place, capturing the skin, fiber and aponeurosis; it is best to use nodal, not thin silk ligatures. With peritoneal phenomena or local suppuration, penicillin should be injected into the wound. You should never refresh the edges of the wound during eventration and separate the intestinal loops soldered to the parietal peritoneum.

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

thromboembolic disease. According to V.P. Mikhailov and A.A. Terekhova, physicochemical changes in blood plasma colloids play an important role in the pathogenesis of thromboembolic disease, causing a violation of its stabilization and an increase in coagulability. This disease is often found in the postoperative period, especially in patients with saphenous vein dilation, a history of thrombophlebitis, with an increase in blood prothrombin, obesity, etc. The use of fibrinolytics and anticoagulants (heparin, dicoumarin, neodicumarin, pelentan) is now possible to prevent and therapy for thromboembolic disease. Anticoagulants should be used under the control of determining the level of prothrombin in the blood; its level should be at least 30% when using pelentan or at least 50% when treated with dicoumarin (Mikhailov and Terekhova). Early recognition of the clinical manifestations of thromboembolism is important for the success of prevention and treatment with anticoagulants. Many cases of pneumonia and pleurisy in the postoperative period should be attributed to embolic processes in the lungs such as infarction. Prophylaxis with anticoagulants should be combined with early active movements in bed; active behavior and discharge of patients can only be allowed if the ESR is below 20 mm and if the blood viscosity is not higher than 5.

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

According to M.V. Elkin, physiotherapy exercises in the postoperative period have the following tasks: to restore normal breathing, to facilitate the work of the heart, to prevent intestinal paresis, postoperative acidosis, ischuria, as well as adhesions and adhesions due to improved blood circulation in the surgical area.

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

Usually, in the first three or four days after the operation, the exercises should be simple (breathing, raising the arms, squeezing and unclenching the fingers with flexion and extension of the feet, etc.); Tightening the abdominal muscles is not yet allowed. In the following days (before getting up on the 5th-7th day), the exercises become more difficult. After permission to stand up, the patient conducts exercises while sitting on a chair.

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

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

Indications

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

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

General characteristics of the procedure

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

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

Contraindications

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

Possible Complications

Laparotomy can be complicated by certain pathological conditions:

Bleeding in the surgical area.
Suppuration of a postoperative wound on the skin.
Vascular damage.
Damage to adjacent organs during surgery (ureters, bladder, intestines).
The formation of adhesions with the development of adhesive disease, etc.

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