Indications for surgical treatment. Contraindications for surgical treatment
Surgical interventions are divided into
▪ Life-saving surgery (eg, injuries complicated by internal or external bleeding; tracheostomy for upper airway obstruction; pericardial puncture for cardiac tamponade).
▪ Urgent (emergency) operations carried out within the shortest time from the moment of injury to prevent severe complications. To reduce operational risk, intensive preparation is prescribed before the operation. Depending on the nature of the pathology, the allowable time frame from the moment of admission to the clinic to the operation is, for example: - for embolism of the vessels of the extremities up to 2 hours; - with open fractures up to 2 hours. ▪ planned
Absolute readings to surgery ▪ Open injuries. ▪ Complicated fractures (damage to the main vessels and nerves). ▪ Risk of complications during closed reposition for fractures. ▪ Ineffectiveness of conservative methods of treatment. ▪ Soft tissue interposition. ▪ Avulsion fractures.
Relative readings. Planned interventions after injuries and previous surgical interventions (a preliminary outpatient examination of the patient is necessary).
For example: ▪ hip arthroplasty after a subcapital hip fracture; ▪ removal of metal structures.
When determining indications for surgical interventions, the following factors should be taken into account: - diagnosis of damage; - danger of damage; - prognosis without treatment, with conservative and surgical treatment; - the risk of surgery; - 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, the absolute and relative indications for surgery must be justified, and the intervention, c. on a case-by-case basis, may be delayed or rescinded.
Absolute contraindications:
- Severe general condition of the patient.
- Cardiovascular insufficiency.
- Infectious complications from 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, unresponsive hypertension, BCC deficiency);
- impaired renal function;
- metabolic disorders (eg, uncompensated diabetes mellitus);
- blood clotting disorders;
- allergies, skin diseases;
- pregnancy.
Without taking into account these risk factors, the implementation of 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 the choice of the method of anesthesia and the implementation of anesthesia (after agreement with the surgeon).
Surgery is the most important stage in the treatment of the 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 the treatment of a surgical patient are as follows:
Preoperative preparation;
Surgery;
Treatment in the postoperative period.
Preoperative preparation Purpose and objectives
The purpose of preoperative preparation is to reduce the risk of intra- and postoperative complications.
The beginning of the preoperative period usually coincides with the moment of admission of the patient to the surgical hospital. Although in rare cases, preoperative preparation begins much earlier (congenital pathology, first aid at the scene, etc.). Sometimes, when a patient is hospitalized, conservative treatment is planned, and the need for surgery arises suddenly with the development of any complication.
Thus, it is more correct to consider that preoperative preparation begins from the moment a diagnosis is made that requires surgery, and a decision is made to perform a surgical intervention. It ends with the delivery of the patient to the operating room.
The entire preoperative period is conditionally 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 state of the main organs and systems of the patient's body (identify concomitant diseases).
Psychologically prepare the patient.
Carry out general physical training.
Perform specific training as directed.
Directly prepare the patient for surgery.
The first two tasks are solved during the diagnostic stage. The third, fourth and fifth tasks are the components of the preparatory stage. Such a division is conditional, 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 tasks 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
Making an accurate surgical diagnosis is the key to a successful outcome of surgical treatment. It is precisely an accurate diagnosis with an indication of the stage, prevalence of the process and its features that makes it possible to choose the optimal type and volume 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 start of the operation, and during the intervention, only previously known facts are confirmed. Thus, even before the start of the operation, the surgeon knows what difficulties he may encounter during the intervention, clearly imagines the type and features of the upcoming operation.
Many examples can be cited to demonstrate the importance of a thorough preoperative examination. Here is just one of them.
Example.The patient was diagnosed with peptic ulcer, ulcer of the duodenal bulb. Conservative therapy for a long time does not give a positive effect, surgical treatment is indicated. But such a diagnosis is not enough for the operation. There are two main types of surgical interventions in the treatment of peptic ulcer: gastric resection and vagotomy. In addition, there are several varieties of gastric resection (according to Billroth-I, according to Billroth-II, in the modification of the Hofmeister-Finsterer, Roux, etc.) and vagotomy (stem, selective, proximal selective, with various types of draining the stomach operations and without them). What intervention to choose for this patient? It 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 these factors are not taken into account and a certain intervention is unreasonably performed, the effectiveness of treatment will significantly decrease. So, the patient may develop a recurrence of an 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 by weighing all the identified features of the disease, you can 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 the surgical method of treatment (indications for surgery).
Decision on the urgency of the operation
After the diagnosis is made, the surgeon must decide whether an emergency operation is indicated for the patient. If such indications are identified, you should immediately proceed to the preparatory stage, which, in case of emergency operations, takes from several minutes to 1-2 hours.
The main indications for emergency surgery are asphyxia, bleeding of any etiology, and acute inflammatory diseases.
The doctor must remember that the delay of the operation every minute worsens its result. With continued bleeding, for example, the sooner intervention is started and blood loss 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 the operation.
In cases where, in accordance with the nature of the disease, there is no need for an emergency operation, an appropriate entry is made 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 readings The operation considers diseases and conditions that pose a threat to the life of the patient, which can only be eliminated surgically.
Absolute indications for performing 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 gastric and duodenal ulcers, acute intestinal obstruction, strangulated hernia), acute
purulent surgical diseases (abscess, phlegmon, osteomyelitis, mastitis, etc.).
In elective surgery, indications for surgery can also be absolute. In this case, urgent operations are usually performed, not postponing them for more than 1-2 weeks.
The following diseases are considered absolute indications for a planned operation:
Malignant neoplasms (cancer of the lung, stomach, breast, thyroid, colon, etc.);
Stenosis of the esophagus, the output of the stomach;
Mechanical jaundice, etc.
Relative readings The operation includes two groups of diseases:
Diseases that can be cured only by surgery, but do not directly threaten the life of the patient (varicose saphenous veins of the lower extremities, uninjured hernia of the abdomen, benign tumors, cholelithiasis, etc.).
Diseases that are quite serious, the treatment of which can in principle be carried out both surgically and conservatively (ischemic 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 a surgical or conservative method in a particular patient. According to relative indications, operations are performed in a planned manner under optimal conditions.
Assessment of the state 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: “One should not treat a disease by its name alone, but should treat the patient himself: his composition, his body, his strength.” Therefore, before the operation, it is in no way possible to limit oneself to the study of only a damaged system or a diseased organ. It is important to know the state of the main vital systems. In this case, the actions of the doctor can be divided into four stages:
Preliminary estimate;
Standard minimum examination;
Additional examination;
Definition of contraindications to 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. At the same time, in addition to the classical methods of examination (inspection, palpation, percussion, auscultation, determination of the boundaries of organs), you can use the simplest tests for the compensatory capabilities of the body, for example, the Stange and Genche tests (the duration of the maximum breath holding on 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 if they are absent), it is necessary to conduct a minimum set of preoperative examinations:
Clinical blood test;
Biochemical blood test (total protein, bilirubin, transaminase activity, creatinine, sugar concentration);
Blood clotting time;
Blood type and Rh factor;
General urine analysis;
Fluorography of the chest (no more than 1 year old);
Conclusion of the dentist on the sanitation of the oral cavity;
ECG;
Therapist's examination;
For women - examination by a gynecologist.
Upon receipt of results that fit within the limits of the norm, the operation is possible. If any deviations are detected, it is necessary to find out their cause and then decide on the possibility of performing the intervention and the degree of its danger to the patient.
Additional examination
An additional examination is carried out if a patient has comorbidities or if the results deviate from the norm.
laboratory research. An additional examination is carried out to establish a complete diagnosis of concomitant diseases, as well as to control the effect of the ongoing preoperative preparation. In this case, methods of varying degrees of complexity can be used.
Definition of contraindications for surgery
As a result of the conducted studies, comorbidities 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 an acute stage of myocardial infarction or cerebrovascular accident (stroke). It should be noted that at present, if there are vital indications, it is possible to perform operations against the background of myocardial infarction or stroke, as well as in case of shock after stabilization of hemodynamics. Therefore, the allocation of absolute contraindications is currently not fundamentally decisive.
Relative contraindications include any concomitant disease. However, their impact 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, pulmonary 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 those situations where there are relative indications and relative contraindications, the issue is resolved 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
The operation is the most important event in the life of the patient. It is not easy to take such a step. Any person is afraid of surgery, as they are more or less aware of the possibility of adverse outcomes. In this regard, the psychological mood of the patient before the operation plays an important role. The attending physician should clearly explain to the patient the need for surgical intervention. It should, without delving into technical details, talk about what is planned to be done, and how the patient will live and feel after the operation, outline its possible consequences. At the same time, 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, make the patient his colleague in the fight against the disease and the difficulties of the postoperative period. A huge role in psychological preparation is played by the moral and psychological climate in the department.
For psychological preparation, pharmacological agents can be used. This is especially true for emotionally labile patients. Often used sedatives, tranquilizers, antidepressants.
Need to get patient consent to surgery. Doctors can do all operations only with the consent of the patient. At the same time, 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 norms, is usually pasted into the medical history.
It is possible to perform an operation without the consent of the patient if he is unconscious or incapacitated, which should be the conclusion of a psychiatrist. In such cases, they mean the operation according to absolute indications. If the patient refuses the operation when it is vital (for example, with continued bleeding), and dies as a result of this refusal, then legally the doctors are not guilty of this (with the appropriate registration of the refusal in the medical history). However, there is an unofficial rule in surgery: if the patient refused the operation, which was necessary for health reasons, then the attending physician is to blame. Why? Yes, because all people want to live, and the refusal of the operation 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 of the operating surgeon with the patient before the operation. The patient must know who is operating on him, to whom he trusts his life, to 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 should be of a confidential nature, because it is close people who can influence the mood of the patient and, in addition, provide him with purely practical assistance.
At the same time, we must not forget that in accordance with the law, it is possible to inform relatives of information about the patient's illness 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 disturbed as a result of the underlying and concomitant diseases, as well as to create a reserve in their functioning.
In preparation for the operation, the corresponding diseases are treated. So, in case of anemia, it is possible to carry out preoperative blood transfusion, in case of arterial hypertension - antihypertensive therapy, in case of a high risk of thromboembolic complications, treatment with antiplatelet agents and anticoagulants is carried out, the water and electrolyte balance is corrected, etc.
An important point of 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 preparation is preparation before operations on the colon. Special preparation is necessary in this case to reduce the bacterial contamination of the intestine and consists in a slag-free diet, performing enemas until “clean water” and prescribing antibacterial drugs.
In case of varicose disease of the lower extremities, complicated by the development of a trophic ulcer, special preparation is required in the preoperative period, aimed at destroying necrotic tissues 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, physiotherapy for 7-10 days, and then surgery is performed.
Before operations for purulent lung diseases (bronchiectasis), treatment is carried out to suppress infection in the bronchial tree, sometimes therapeutic sanation 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.
Immediate preparation of the patient for surgery
There comes a moment when the question of the operation is resolved, it is scheduled for a certain time. What should be done immediately before surgery in order to prevent at least some of the possible complications? There are basic principles that must be observed (Fig. 9-2). At the same time, there are differences in preparing for planned and emergency operations.
Rice. 9-2.The 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. Shaving should be mandatory 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 enough.
The situation is more complicated in case of an emergency operation. There is little time for preparation. How to proceed? 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
there was no involuntary defecation. 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 who are in critical condition. It is impossible to perform enema during emergency operations for acute diseases of the abdominal organs, since an increase in pressure inside the intestine can lead to a rupture of its wall, the mechanical strength of which can be reduced due to the inflammatory process.
Bladder emptying
Empty your bladder before any operation. For this, in the vast majority of cases, it is necessary for the patient to urinate on his own before the operation. The need for bladder catheterization is rare, 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 (surgery on the pelvic organs).
Premedication
Premedication - the introduction of drugs before surgery. It is necessary to prevent some 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 an emergency operation, only a narcotic analgesic and atropine are usually administered.
More details on premedication are set out in Chapter 7.
Preparation of the operating team
Not only the patient is preparing for the operation, but also the other side - the surgeon and the entire surgical team. First of all, you need to choose the members of the operating team, while, 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 theoretically prepare for the operation, 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 should always be ready for an emergency operation, the surgeon has been preparing for it all his 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, determining the forecast. Many factors influence the degree of risk of anesthesia and surgery: the age of the patient, his physical condition, the nature of the underlying disease, the presence and type of concomitant diseases, the trauma and duration of the operation, the qualifications of the surgeon and anesthetist, the method of anesthesia, the level of provision of surgical and anesthetic 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 operation
I degree of risk - practically healthy patients.
II degree of risk - mild diseases without functional impairment.
III degree of risk - severe diseases with dysfunction.
IV degree of risk - serious diseases, in combination with surgery or without it, threatening the life of the patient.
V degree of risk - you can expect the death of the patient within 24 hours after surgery or without it (moribund).
emergency operation
VI degree of risk - patients of the 1st-2nd categories, operated on an emergency basis.
VII degree of risk - patients of the 3rd-5th categories, operated on an emergency basis.
The presented ASA classification 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, it evaluates both the general condition of the patient and the volume and nature of the surgical procedure.
Table 9-1.Classification of the degree of risk of surgery and anesthesia
intervention, as well as the type of anesthesia. Secondly, it provides for an objective scoring system.
There is an opinion among surgeons and anesthesiologists that the correct preoperative preparation can reduce the risk of surgery and anesthesia by one degree. Considering that the probability
the development of serious complications (up to death) progressively increases with an increase in the degree of operational risk, this once again emphasizes the importance of qualified preoperative preparation.
Preoperative epicrisis
All actions of the doctor in the preoperative period should be reflected in the preoperative epicrisis - one of the most important documents in the medical history.
The preoperative epicrisis should be drawn up in such a way that the indications and contraindications for the operation, the need for its implementation, the adequacy of the preoperative preparation and the optimal choice of both the type of operation and the method of anesthesia are absolutely clear. Such a document is necessary so that during a repeated synthetic review of the results of a clinical examination, for any doctor reading the medical history, and for the attending physician himself, indications and contraindications for surgery clearly emerge; the difficulties that may arise in its implementation; features of the course 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 for surgery;
Operation plan;
Type of anesthesia;
The degree of risk of surgery and anesthesia;
Blood type and Rh factor;
Consent of the patient to the operation;
Composition of the surgical team.
For clarity, below is an extract from the medical history with a preoperative epicrisis.
Patient P., aged 57, was prepared for surgery on February 3, 2005, with a diagnosis of left-sided acquired oblique reducible inguinal hernia. The diagnosis was made on the basis of:
The patient complains of pain in the left inguinal region and the appearance of a protrusion here at the slightest physical exertion, the protrusion disappears at rest;
Anamnesis data: for the first time, the protrusion appeared 4 years ago after lifting weights, since then there have been three episodes of infringement (the last one - a month ago);
Objective examination 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. Of the concomitant diseases, hypertension of the II degree was noted (in the anamnesis, rises in blood pressure up to 220/100 mm Hg).
Given the high risk of re-infringement of the hernia, it is necessary to perform a planned operation. The clinic conducted a course of antihypertensive therapy (pressure stabilized at 150-160/100 mm Hg).
It is planned to perform a radical operation 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 - 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 method of treatment
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 rather 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 following seems to be the most general.
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 refers to "ordinary", open operations. Somewhat apart are such special interventions as endovascular, endoscopic, etc.
The 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
In accordance with this classification, emergency, planned and urgent operations are distinguished.
emergency operations
Emergency operations are called operations performed almost immediately after the diagnosis is made, since they are delayed by several hours or
even minutes directly threatens the life of the patient or sharply worsens the prognosis. It is usually considered necessary to perform an emergency operation within 2 hours from the moment the patient enters the hospital.
Emergency operations are performed by an on-duty surgical team at any time of the day. The surgical service of the hospital should always be ready for this.
The peculiarity of emergency operations is that the existing threat to the patient's life does not allow for a complete examination and full preparation. The purpose of an emergency operation is primarily to save the life of the patient at the present time, while 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 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 stomach 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 is determined in advance, they are carried out by the most experienced surgeons in this field. Elective surgeries include radical surgeries 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 the planned ones, since they are performed during the daytime, after an adequate examination and the necessary preoperative preparation, they are carried out by specialists in this particular field. That is, surgical interventions are performed in the so-called "planned order". However, unlike elective 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 within 1-7 days from the moment the patient arrives or the disease is diagnosed.
So, a patient with stopped gastric bleeding can be operated on the next day after admission due to the risk of recurrent bleeding.
Intervention for obstructive jaundice cannot be postponed for a long time, as 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 the violation of the outflow of bile, exclusion of viral hepatitis, etc.).
Urgent operations include operations for malignant neoplasms (usually within 5-7 days from the date of admission, after the necessary examination). Prolonged postponing them can lead to the inability to perform a full-fledged operation due to the progression of the process (the appearance of metastases, tumor growth of vital organs, etc.).
Classification by purpose
According to the purpose of the performance, all operations are divided into two groups: diagnostic and therapeutic.
Diagnostic operations
The purpose of diagnostic operations is to clarify the diagnosis, 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, 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 takes a part of the organ (neoplasm) for subsequent histological examination in order to make the correct diagnosis. There are three types of biopsy:
1. Excisional biopsy. The whole formation is removed. It is the most informative, in some cases it can also have a therapeutic effect. Most often, excision of the lymph node is used (they find out the etiology of the process: specific or nonspecific inflammation, lymphogranulomatosis, tumor metastasis, etc.); excision of the formation of the mammary gland (for making a morphological diagnosis) - at the same time, if a malignant growth is detected, a medical operation is immediately performed after a biopsy, and if a benign tumor is found, 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, during the operation, an enlarged, dense pancreas was revealed, which resembles the picture of both its malignant lesion and indurative chronic pancreatitis. The tactics of the surgeon in 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 method of incisional biopsy 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 on a planned and emergency basis.
Sometimes operations for neoplasms become diagnostic. This happens if, during the revision of the organs during the operation, it is found out that the stage of the pathological process does not allow performing the required volume of the operation. The planned medical operation becomes diagnostic (the stage of the process is specified).
Example.The patient was scheduled for extirpation (removal) of the stomach for cancer. After laparotomy, multiple liver metastases were found. Performing extirpation of the stomach is considered inappropriate. The abdomen is sutured. The operation became diagnostic (stage IV of the malignant process was determined).
With the development of surgery, the improvement of methods for additional examination of patients, traditional surgical interventions for the purpose of diagnosis are performed less and less.
Medical operations
Medical operations are performed in order to improve the patient's condition. Depending on their influence on the pathological process
allocate radical, palliative and symptomatic medical operations.
radical operations. Radical operations are called operations performed with the aim of curing a disease. There are many such operations in surgery.
Example 1The patient has acute appendicitis: the surgeon performs an appendectomy (removes the appendix) and thus cures the patient (Fig. 9-3).
Example 2A 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 3The 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 surgery is 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 1A patient has a malignant tumor of the head of the pancreas with germination 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 the germination of the intestine by a tumor). Due to the prevalence of the process, a radical operation 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 main disease - a tumor of the pancreas - is not eliminated.
Example 2A patient has stomach cancer with distant metastases to the liver. The large size of the tumor is the cause of intoxication and frequent bleeding. The patient is operated on: a palliative resection of the stomach is performed, the tumor is removed, which significantly improves the patient's condition, but the operation is not aimed at curing the oncological disease, since multiple metastases remain, therefore the operation is considered palliative.
Are palliative surgeries needed 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 of new methods that can cure the unresolved underlying disease;
There is a possibility of an error in the diagnosis, and the patient after palliative surgery can recover almost completely.
The last provision requires some comment. In the memory of any surgeon there are several cases when, after palliative operations, patients lived for many years. Such situations are inexplicable and incomprehensible, but they happen. Many years after the operation, having seen a living and healthy patient, the surgeon realizes that at one time he made a mistake in the main diagnosis, and thanks God for deciding to perform then a palliative intervention, thanks to which he managed 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.The patient has stomach cancer, gastric bleeding from the tumor. Performing a radical or palliative resection is impossible (the tumor grows into the pancreas and the root of the mesentery). The surgeon performs a symptomatic operation: bandaging the gastric vessels that supply the tumor with blood to stop the bleeding.
Single-stage, multi-stage and repeated operations
Surgical interventions can be one- and multi-stage (two-, three-stage), as well as repeated.
Single Operations
Simultaneous operations are called operations in which several successive stages are performed immediately in one intervention, the goal is complete recovery and rehabilitation of the patient. Such operations in surgery are most often performed, examples of which can be appendectomy, cholecystectomy, gastric resection, mastectomy, resection of the thyroid gland. In some cases, quite complex surgical interventions are performed in one stage.
Example.The patient has cancer of the esophagus. The surgeon performs the removal of the esophagus (Torek operation), after which he performs plastic surgery of the esophagus with the small intestine (Ru-Herzen-Yudin operation).
Multi-moment operations
One-time operations are certainly preferable, but in some cases their execution has to 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 initial state of the patient does not allow him to endure a complex, long and traumatic one-stage operation, or the risk of its complications in such a patient is much higher than usual.
Example.A patient has cancer of the esophagus with severe dysphagia, which led to the development of a sharp exhaustion of the body. It will not endure a complex one-step operation (see the example above). The patient undergoes a similar intervention, but in three stages, separated in time.
The imposition of a gastrostomy (for nutrition and normalization of the general condition).
After 1 month, the esophagus with the tumor is removed (Torek operation), after which food is continued through the gastrostomy.
5-6 months after the second stage, plastic surgery 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 the technical features of the method.
Example 1A patient has cancer of the sigmoid colon with the development of acute intestinal obstruction and peritonitis. It is impossible to immediately remove the tumor and restore intestinal patency, since the diameters of the adducting and efferent intestines differ significantly and the likelihood of developing a severe complication is especially high - the failure of the anastomosis sutures. In such cases, it is possible to perform the classic three-moment Schloffer operation.
The imposition 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, culminating in the creation of a sigmo-sigmoanastomosis (2-4 weeks after the first stage).
Closure of the cecostomy (2-4 weeks after the second stage). Example 2 The most striking example of the implementation of multi-stage
skin plastic surgery can serve as 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 qualification of the operating surgeon allows him to reliably perform only the first stage of treatment, and more complex stages can be performed later by other specialists.
Example.A patient has a large gastric ulcer with perforation. Shown resection of the stomach, but the surgeon does not know the technique of this operation. He sews up the ulcer, saving the patient from a complication - severe peritonitis, but not curing the peptic ulcer. After recovery, the patient routinely undergoes gastric resection in a specialized institution.
Reoperations
Repeated operations are those performed again on the same organ for the same pathology. Reoperations 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 the sanitation of the abdominal cavity with diffuse purulent peritonitis) and forced - with the development of complications (relaparotomy with gastroenteroanastomosis failure after gastric resection, with bleeding in the early postoperative period).
Combined and combined operations
Modern development of surgery allows to significantly expand the scope of surgical interventions. Combined and combined operations have become the norm of 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 absolute advantage of such operations: for one hospitalization, one operation, one anesthesia, the patient is cured of several pathological processes at once. However, a slight increase in the invasiveness of the intervention should be taken into account, which may be unacceptable for patients with comorbidities.
Example 1The patient has cholelithiasis and gastric ulcer. A combined operation is performed: cholecystectomy and resection of the stomach are performed simultaneously from one access.
Example 2The patient has varicose veins of the saphenous veins of the lower extremities and nodular non-toxic goiter. A combined operation is performed: Babcock-Narat phlebectomy and resection of the thyroid gland.
Combined operations
Combined surgeries are called surgeries in which, for the purpose of treating one disease, the intervention is performed on several organs.
Example.The patient has breast cancer. Perform a radical mastectomy and removal of the ovaries to change the hormonal background.
Classification of operations according to the 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 conditionally 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. Saveliev, 1997).
Operations with probable infection (conditionally aseptic)
This category includes operations with opening the lumen of organs in which the presence of microorganisms is possible (planned cholecystectomy, extirpation of the uterus, phlebectomy in the area of previous thrombophlebitis), repeated operations with a possible dormant infection (healing of previous wounds by secondary intention).
The frequency of infectious complications is 5-10%.
Operations with a high risk of infection (conditionally infected)
Such operations include interventions during which contact with the microflora is more significant (planned hemicolonectomy, appendectomy for phlegmonous appendicitis, cholecystectomy for phlegmonous or gangrenous cholecystitis).
The frequency 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 appendicular or subdiaphragmatic abscess, etc. (see Fig. 9-3).
The frequency 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, a typical resection of two-thirds of the stomach in the treatment of peptic ulcer, a typical hemicolonectomy. However, in some cases, the surgeon must apply certain creative abilities in order to modify the standard techniques during the operation in connection with the identified features of the pathological process. For example, during resection of the stomach, close the duodenal stump in a non-standard way due to the low location of the ulcer or expand the volume 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
The development of surgery has led to the emergence of minimally invasive surgery. Here, in operations, unlike traditional interventions, there is no typical dissection of tissues, a large wound surface, or exposure of the damaged organ; in addition, they use a special technical method for performing 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. For their implementation, special microsurgical instruments and the thinnest threads (10/0-2/0) are used. Interventions last long enough (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. So, with fibroesophagogastroduodenoscopy, you can remove a polyp from the stomach, dissect the nipple of Vater and remove the calculus from the common bile duct with obstructive jaundice; during bronchoscopy - mechanically or with a laser to remove small tumors of the trachea and bronchi; during cystoscopy - remove the calculus from the bladder or terminal ureter, perform resection of prostate adenoma.
Currently, interventions performed with the help of endovideo technology are widely used: 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 from a general nature, are extremely rare. Using a video camera and special instruments, it is possible to perform laparoscopic cholecystectomy, resection of a section of the intestine, removal of an ovarian cyst, suturing of a perforated stomach ulcer, and many other operations. A distinctive feature of endoscopic operations is their low trauma.
Endovascular operations
These are intravascular operations performed under x-ray control. With the help of a puncture, usually of the femoral artery, special catheters and instruments are introduced into the vascular system, which, in the presence of a pinpoint surgical wound, allow embolization of a certain artery, expansion of the stenotic part of the vessel, and even valvular plasty. Like endoscopic, such operations are characterized by less trauma than traditional surgical interventions.
Stages of surgical intervention
The surgical operation consists of three stages:
Operational access.
Operational reception.
Completion of the operation.
The exception is special minimally invasive operations (endoscopic and endovascular), which are not fully characterized by the usual surgical attributes.
Online access Purpose
Online access is designed 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 greatly facilitated by giving the patient a special position on the operating table (Fig. 9-4). This needs to be given considerable attention.
online access requirements
Access is an important point of the operation. Its implementation sometimes takes much more time than the operational reception. The main requirements for online access are as follows.
Access must be wide enough to allow for convenient operative reception. The surgeon must sufficiently expose the organ to reliably perform basic manipulations under visual control. Reducing access should never be achieved at the cost of reducing the security of the intervention. This is well known by experienced surgeons who have encountered serious complications (the principle of "big surgeon - big incision").
Access must be gentle. When performing an access, the surgeon must remember that the injury caused by this must be
Rice. 9-4.Different positions of the patient on the operating table: a - during operations on the perineum; b - during operations on the organs of the neck; c - during operations on the kidneys and organs of the retroperitoneal space
Rice. 9-5.Types of longitudinal, transverse and oblique laparotomies: 1 - upper median; 2 - paramedial; 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-lower side section with a variable direction; 13 - Pfannenstiel section
the minimum possible. Due to the need to combine these provisions, there is a fairly large variety of accesses for performing surgical interventions. Particularly impressive is the number of proposed approaches for performing operations on the abdominal organs. Some of them are shown in Fig. 9-5.
Sparing access is one of the advantages of endovideosurgical operations, when the introduction of a laparoscope and instruments into the abdominal cavity is carried out 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 impossible (rough scars after previous operations, deformations, 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. So, despite the fact that the gallbladder is much closer when accessed in the right hypochondrium, it is currently rarely used, since in this case it is necessary to cross all the muscle layers of the anterior abdominal wall, damaging the vessels and nerves. When performing the upper median laparotomy, only the skin, subcutaneous tissue and the white line of the abdomen, which are practically devoid of nerves and blood 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 access in relation to the Langer lines matters.
Access must be physiological. When performing an 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 must be cosmetic. This requirement is currently not yet generally accepted. However, other things being equal, the incision should be made in the least noticeable places, along natural folds. An example of this approach is the predominant use of transverse Pfannenstiel laparotomy in operations on the pelvic organs.
Operational reception
Operative reception is the main stage of the operation, during which the necessary diagnostic or therapeutic effect is carried out. Before proceeding directly to its implementation, the surgeon performs an audit of the wound in order to confirm the diagnosis and in case of unexpected surgical findings.
According to the type of therapeutic effect performed, several types of surgical reception are distinguished:
Removal of an organ or pathological focus;
Removal of a 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 echinococcal cyst), etc.
Removing part of an organ
Such operations are called "resection": resection of the stomach, resection of the liver, resection of the ovary, resection of the thyroid gland.
It should be noted that all removed organs and their resected areas must be sent for a planned histological examination. After the removal of organs or their resection, it is necessary to restore the passage of food, blood, 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 it is necessary to correct previously artificially created structures - reconstructive.
This group of operations includes various types of prosthetics and vascular bypass, the imposition of biliodigestive anastomoses in case of obstructive jaundice, plasty of the esophageal opening of the diaphragm, plasty of the inguinal canal in case of hernia, nephropexy in case of nephroptosis, plasty of the ureter in case of its stenosis, etc.
Completion of the operation
The completion of the operation should be given no less attention than the first two stages. At the end of the operation, it is necessary, as far as possible, to restore the integrity of the tissues disturbed during access. In this case, it is necessary to use optimal methods of tissue connection, certain types of suture material, in order to ensure reliability, rapid healing, functional and cosmetic effect (Fig. 9-6).
Before proceeding directly to suturing the wound, the surgeon must control hemostasis, install control drains according to special indications, and during abdominal interventions check the number of used napkins, balls and surgical instruments (usually this is done by the operating sister).
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 according to 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 with drainage;
Partial stitching with tampons left;
Stitching the wound with the possibility of repeated planned revisions;
Leaving the wound unsutured, open.
The course of the postoperative period largely depends on how correctly the surgeon chooses the method for completing the operation.
Major 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 area of intervention.
Sufficient access to operate under visual control.
Operation in a "dry wound" (careful drying during the intervention, stopping minimal bleeding, which makes it difficult to distinguish formations in the wound).
The use of adequate methods of hemostasis (with vessels visible to the eye, give preference to mechanical methods of stopping bleeding - ligation and stitching).
Organ damage
To prevent intraoperative damage to organs, the same principles should be followed as in the prevention of bleeding. In addition, a careful, careful attitude to the tissues is necessary.
It is important to detect damage inflicted on the operating room table and adequately eliminate them. The most dangerous injuries are not recognized during the operation.
Intraoperative prevention of infectious complications
Prevention of infectious postoperative complications is mainly carried out on the operating table. In addition to the strictest observance of asepsis, it is necessary to pay attention to the following rules.
Reliable hemostasis
With the accumulation of even a small amount of blood in the wound cavity, the frequency of postoperative complications increases, which is associated with the rapid reproduction 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, tears lead to the formation of a large number of necrotic tissues in the wound, which serve as a substrate for the development of infection.
Changing tools and cleaning hands after infected stages
This measure serves to prevent contact and implantation infection. It is carried out after completion of contact with the skin, suturing of the cavities, completion of 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, a pathological focus. Limit contact with
him other fabrics. To do this, for example, the inflamed appendix is wrapped in a napkin. The anus during extirpation of the rectum is preliminarily sutured with a purse-string suture. When forming interintestinal anastomoses, before opening the internal lumen, the free abdominal cavity is carefully limited with napkins. Active vacuum suction is used to remove purulent exudate or contents flowing from the lumen of internal organs.
In addition to pathological foci, they necessarily limit the skin, since, despite repeated processing, it can become a source of microflora.
Treatment of the wound during surgery with antiseptic solutions
In some cases, the mucous membrane is treated with antiseptics, in the presence of exudate, the abdominal cavity is washed with a solution of nitrofural, 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 the patient's blood plasma contains a bactericidal concentration of the antibiotic. Continued administration of the antibiotic in the future depends on the degree of infection.
Postoperative period Significance and main purpose
The value 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 the preoperative preparation and the operation itself appear in the form of 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 deal with emerging complications.
The postoperative period begins with the end of the surgical intervention and ends with the complete recovery of the patient or the acquisition of permanent disability. Unfortunately, not all operations lead to a complete recovery. If
a limb was amputated, a mammary gland was removed, a stomach was removed, etc., a person is largely limited in his abilities, then it is impossible to talk about his full recovery even with a favorable result of the operation itself. In such cases, the end of the postoperative period occurs when the wound process ends, and the state of all body systems stabilizes.
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 preoperative condition of the patient and the traumatic nature of the intervention performed. Catabolism intensifies in the body - fast delivery of the 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 a change 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 enzyme proteins. The loss of protein is very significant and in serious operations is 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).
Regression 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. Growing synthesis
glycogen and fats. Gradually, anabolic processes begin to prevail over catabolic ones.
Anabolic Phase
The anabolic phase is characterized by the active restoration of functions disturbed in the catabolic phase. The parasympathetic nervous system is activated, the activity of growth hormone and androgens increases, the synthesis of proteins and fats increases sharply, and glycogen stores are restored. Due to these changes, reparative processes, growth and development of connective tissue progress. The completion of the anabolic phase corresponds to the full recovery of the body after surgery. This usually happens after about 3-4 weeks.
Clinical Stages
In the clinic, the postoperative period is conventionally divided into three parts:
Early - 3-5 days;
Late - 2-3 weeks;
Remote (rehabilitation) - usually from 3 weeks to 2-3 months.
Features of the course of the late and remote stages of the postoperative period entirely depend 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. In essence, 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 one.
Features of the early postoperative period
The early postoperative period can be uncomplicated and complicated.
Uncomplicated postoperative period
In an uncomplicated postoperative period, a number of changes occur in the functioning of the main organs and systems in the body.
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 tissues in the area of the operation, the forced position of the patient, hypothermia, and eating disorders.
In a normal, uncomplicated course of the postoperative period, reactive changes that occur in the body are usually moderately expressed and last 2-3 days. At the same time, fever 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 in the uncomplicated postoperative period: correction of changes in the body, control of the functional state of the main organs and systems; taking measures to prevent possible complications.
Intensive care in the 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 deal with pain, since other measures are the lot of anesthesiologists-resuscitators.
To reduce the pain syndrome, both very simple and rather complex procedures are used.
Getting the right 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, Fowler's semi-sitting 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 (the angle is about 120?).
Wearing a bandage
Wearing a bandage significantly reduces the pain in the wound, especially when moving and coughing.
The 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.
The use of non-narcotic analgesics
It is necessary in the first 2-3 days after minor operations and starting from 3 days after traumatic interventions. Metamizole sodium injections are used. It is possible to use tablets.
The use of sedatives
Allows you to increase the threshold of pain sensitivity. diazepam, etc.
Epidural anesthesia
An important method of pain relief in the early postoperative period during operations on the abdominal organs, since, in addition to the method of pain relief, it serves as a powerful tool for the prevention and treatment of postoperative intestinal paresis.
Complicated postoperative period
Complications that can occur in the early postoperative period are divided according to the organs and systems in which they occur. Often complications are due to the presence of comorbidities in the patient. The scheme (Fig. 9-7) shows the most frequent complications of the early postoperative period.
Three main factors contribute to the development of complications:
The presence of a postoperative wound;
forced position;
Influence of surgical trauma and anesthesia.
The main complications of the early postoperative period
The most frequent 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 from the side of the wound, the following complications are possible:
Bleeding;
The development of an infection;
Divergence of seams.
In addition, the presence of a wound is associated with pain syndrome, which manifests itself in the first hours and days after surgery.
Bleeding
Bleeding is the most formidable complication, sometimes threatening the life of the patient and requiring a second operation. Prevention of bleeding is mainly carried out during surgery. In the postoperative period, to prevent bleeding, an ice pack or a load of sand is placed on the wound. For timely diagnosis, monitor the pulse, blood pressure, red blood counts. Bleeding after surgery can be of three types:
External (bleeding occurs in the surgical wound, which causes the dressing to get wet);
Bleeding through the drainage (blood begins to flow through the drainage left in the wound or some kind of cavity);
Internal bleeding (blood flows 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 the prevention of wound infection are laid on the operating table. After the operation, one should monitor the normal functioning of the drains, since the accumulation of non-evacuated fluid can become a good breeding ground for microorganisms and cause a suppuration process. In addition, it is necessary to carry out the prevention of secondary infection. For this, patients must be bandaged the next day after the operation in order to remove the dressing material, which is always wet with sanious wound discharge, treat the edges of the wound with an antiseptic and apply a protective aseptic bandage. After that, the bandage is changed every 3-4 days or, according to indications, more often (the bandage got wet, peeled off, etc.).
Divergence of seams
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 in 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. For the prevention of suture divergence during repeated operations and a high risk of developing
Rice. 9-8. Stitching of the wound of the anterior abdominal wall on the tubes
This complication is used for suturing the wound of the anterior abdominal wall with buttons or tubes (Fig. 9-8).
Complications from the cardiovascular system
In the postoperative period, myocardial infarction, arrhythmias, 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.
An important issue is the prevention of thromboembolic complications, the most common of which is pulmonary embolism - a severe complication, one of the common causes of deaths in the early postoperative period.
The development of thrombosis after surgery is due to a slowdown in blood flow (especially in the veins of the lower extremities and small pelvis), an increase in blood viscosity, a violation of the 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 of 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 antiplatelet agents and other means that improve the rheological properties of blood;
The use of anticoagulants (eg, 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 the most severe complication - acute respiratory failure, associated primarily with the consequences of anesthesia, much attention should be paid to the prevention of postoperative pneumonia - one of the most common causes of death of patients in the postoperative period.
Prevention principles:
Early activation of patients;
Antibiotic prophylaxis;
Adequate position in bed;
Breathing exercises, postural drainage;
Liquefaction of sputum and the use of expectorants;
Sanitation of the tracheobronchial tree in seriously ill patients (through an endotracheal tube with prolonged mechanical ventilation or through a specially applied microtracheostomy with spontaneous breathing);
Mustard plasters, banks;
Massage, physiotherapy.
Complications from the digestive organs
The development of anastomotic suture failure 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 the subject of consideration in private surgery.
After operations on the organs of the abdominal cavity, to one degree or another, the development of paralytic obstruction (intestinal paresis) is possible. Intestinal paresis significantly disrupts the processes of digestion. An increase in intra-abdominal pressure leads to a high standing of the diaphragm, impaired lung ventilation and heart activity. In addition, there is a redistribution of fluid in the body, the absorption of toxic substances from the intestinal lumen.
The foundations for the prevention of intestinal paresis are laid during the operation (careful attitude to 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;
Drainage of the stomach;
Epidural blockade (or pararenal novocaine blockade);
Introduction of a gas outlet tube;
Hypertonic enema;
Administration of motility stimulants (eg, hypertonic saline, neostigmine methyl sulfate);
Physiotherapeutic procedures (diadynamic therapy).
Complications from the urinary system
In the postoperative period, it is possible to develop acute renal failure, impaired renal function due to inadequate systemic hemodynamics, and the occurrence of inflammatory diseases (pyelonephritis, cystitis, urethritis, etc.). After the operation, it is necessary to carefully monitor diuresis, and not only during the day, but also for hourly diuresis.
The development of inflammatory and some other complications is facilitated by urinary retention, which is often observed after surgery. Violation of urination, sometimes leading to acute urinary retention, is reflex in nature and occurs as a result of a reaction to pain in the wound, reflex tension of the abdominal muscles, and the action of anesthesia.
In case of violation of urination, simple measures are first taken: the patient is allowed to stand up, he can be taken to the toilet to restore the situation familiar to the act of urination, analgesics and antispasmodics are administered, a warm heating pad is placed on the suprapubic region. With the ineffectiveness of these measures, it is necessary to carry out 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, aseptic rules must be carefully observed. In cases where the condition of patients is severe and constant monitoring of diuresis is necessary, the catheter is left in the bladder for the entire time of early postoperative
rational period. At the same time, the bladder is washed twice a day with an antiseptic (nitrofural) to prevent ascending infection.
Prevention and treatment of bedsores
Bedsores - aseptic necrosis of the skin and deeper tissues due to impaired microcirculation due to their prolonged compression.
After surgery, bedsores usually form in severe elderly patients who have been in a forced position for a long time (lying on their backs).
Most often, bedsores occur on the sacrum, in the area of the shoulder blades, on the back of the head, on the back of the elbow joint, and on the heels. It is in these areas that the bone tissue is located quite close and there is a pronounced compression of the skin and subcutaneous tissue.
Prevention
Prevention of bedsores consists of the following activities:
Early activation (if possible, put, seat patients, or at least turn from side to side);
Clean dry linen;
Rubber circles (placed in the area of the most frequent localizations of bedsores to change the nature of the pressure on the tissue);
Anti-decubitus mattress (mattress with constantly changing pressure in separate sections);
Massage;
Skin treatment with antiseptics.
Stages of development
There are three stages in the development of bedsores:
Stage of ischemia: tissues become pale, sensitivity is disturbed.
Stage of superficial necrosis: swelling, hyperemia appear, in the center areas of necrosis of black or brown color are formed.
Stage of purulent fusion: an infection joins, inflammatory changes progress, a purulent discharge appears, the process spreads deep into, up to damage to muscles and bones.
Treatment
In the treatment of bedsores, it is imperative 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 bedsores depends on the stage of the process.
Stage of ischemia - 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, create a scab that prevents the infection from joining.
Stage of purulent fusion - treatment is carried out according to the principle of treatment of a purulent wound. It should be noted that it is much easier to prevent bedsores than to treat them.
Absolute - shock (a serious condition of the body, close to terminal), except for hemorrhagic with continued bleeding; acute stage of myocardial infarction or cerebrovascular accident (stroke), except for the methods of surgical correction of these conditions, and the presence of absolute indications (perforated duodenal ulcer, acute appendicitis, strangulated hernia)
Relative - the presence of concomitant diseases, primarily the cardiovascular system, respiratory, kidney, liver, blood system, obesity, diabetes mellitus.
Preliminary preparation of the surgical field
One way 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. Shaving should be mandatory on the day of surgery, and not before. When preparing for an emergency operation, they are usually limited to only shaving the hair in the area of the operation.
"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.
Bowel movement
Before a planned operation, patients need to do a cleansing enema so that when the muscles relax on the operating table, involuntary defecation does not occur. 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 enema during emergency operations for acute diseases of the abdominal organs, since an increase in pressure inside the intestine can lead to a rupture of its wall, the mechanical strength of which can be reduced due to the inflammatory process.
Bladder emptying
For this, the patient urinated on his own before the operation. The need for bladder catheterization is rare, 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 (surgery on the pelvic organs).
Premedication- the introduction of drugs before surgery. It is necessary to prevent some 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 an emergency operation, 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 operation
I degree of risk - practically healthy patients.
II degree of risk - mild diseases without functional impairment.
III degree of risk - severe diseases with dysfunction.
IV degree of risk - serious diseases, in combination with surgery or without it, threatening the life of the patient.
V degree of risk - you can expect the death of the patient within 24 hours after surgery or without it (moribund).
emergency operation
VI degree of risk - patients of the 1st-2nd categories, operated on an emergency basis.
VII degree of risk - patients of the 3rd-5th categories, operated on an emergency basis.
The presented ASA classification 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 for an objective scoring system.
There is an opinion among surgeons and anesthesiologists that the correct preoperative preparation can reduce the risk of surgery and anesthesia by one degree. Considering that the probability of developing serious complications (up to death) progressively increases with an increase in the degree of operational risk, this once again emphasizes the importance of qualified preoperative preparation.
Indications. Allocate vital indications (absolute) and relative. Indicating the indications for the operation, it is necessary to reflect the order of its implementation - emergency, urgent or planned. Emergency: o.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. The degree of operational and anesthetic risk. The choice of anesthesia and preparation for it. Preparing for emergency 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)- small operations on the surface of the body and abdominal organs (removal of superficially located and localized tumors, opening of small abscesses, amputation of fingers and toes, ligation and removal of hemorrhoids, uncomplicated appendectomy and herniotomy); 2 (2 points)- operations of moderate severity (removal of superficially located malignant tumors requiring extended intervention; opening of abscesses located in cavities; amputation of segments of the upper and lower extremities; operations on peripheral vessels; complicated appendectomy and herniotomy requiring extended 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 operations on the organs of the breast; 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 marked in the medical history, the numerator indicates the risk by the severity of the condition, and the denominator - by the volume and nature of the surgical intervention. Classification of operational and anesthetic risk. MNOAR-89. In 1989, the Moscow Scientific Society of Anesthesiologists and Resuscitators adopted and recommended for use a classification that provides for a quantitative (in points) assessment of operational and anesthetic risk according to three main criteria: - general condition of the patient; - the volume and nature of the surgical operation; - the nature of anesthesia. Assessment of the general condition of the patient. Satisfactory (0.5 points): somatically healthy patients with localized surgical disease or not associated with the underlying surgical disease. Moderate severity (1 point): Patients with mild or moderate systemic disorders associated or not associated with the underlying surgical disease. Severe (2 points): patients with severe systemic disorders that are associated or not associated with 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 life of the patient without surgery or during surgery. Terminal (6 points): patients in a terminal state with severe 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. Estimation of 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 IR), as well as extended and reconstructive operations in surgery of various areas (2 points). Complex operations on the heart and great vessels with the use of IR and transplantation of internal organs (2.5 points). Assessment of the nature of anesthesia. Different kinds local potentiated anesthesia (0.5 points). Regional, epidural, spinal, intravenous or inhalation anesthesia with spontaneous breathing or with short-term assisted ventilation of the lungs through the mask of the anesthesia machine (1 point). Usual standard options for general combined anesthesia with tracheal intubation using inhaled, non-inhaled or non-drug anesthesia (1.5 points). Combined endotracheal anesthesia with the use of inhaled non-inhaled anesthetics and their combinations with methods of regional anesthesia, as well as special methods of anesthesia and corrective intensive care (artificial hypothermia, infusion-transfusion therapy, controlled hypotension, circulatory support, pacing, etc.) (2 points). Combined endotracheal anesthesia with the use of inhalation and non-inhalation anesthetics under conditions of 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. With emergency anesthesia, a risk increase of 1 point is acceptable.
Preparing for emergency operations
The amount of preparation of the patient for an emergency operation 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 sanitization, shaving of 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 tube. With low blood pressure, if it is not caused by bleeding, intravenous administration of blood substitutes of hemodynamic action, glucose, prednisolone (90 mg) should increase blood pressure to a level of 90-100 mm Hg. Art.
Preparing for emergency surgery. In conditions that threaten the life of the patient (wound, life-threatening blood loss, etc.), no preparation is carried out, the patient is urgently taken to the operating room without even taking off his clothes. In such cases, the operation begins simultaneously with anesthesia and resuscitation (resuscitation) without any preparation.
Before other emergency operations, preparations for them are still being carried out, albeit in a significantly reduced volume. After deciding on the need for surgery, preoperative preparation is carried out in parallel with the continuation of the examination of the patient by the surgeon and anesthesiologist. Thus, the preparation of the oral cavity is limited to rinsing or wiping. Preparation of the gastrointestinal tract may include evacuation of gastric contents and even leaving a gastric nasal tube (for example, in intestinal obstruction) for the duration of the operation. An enema is rarely given, only a siphon enema is allowed when trying to conservatively treat intestinal obstruction. In all other acute surgical diseases of the abdominal cavity, an enema is contraindicated.
The hygienic water procedure is carried out in an abbreviated form - a shower or washing the patient. However, the 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 should receive clear instructions from the doctor on how much and by what time she must fulfill her duties.
197. Preparation of the patient for surgery. Training goals. Deontological preparation. Medical 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 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, surgery 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 - Failed Back Surgery Syndrome "), 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.
Consider the indications for surgical treatment of clinical manifestations caused by a herniated disc, which are published by leading experts in the field of neurology, veterinary neurology and manual therapy.
In the article of the professor, d.m.s. O.S. Levina (Department of Neurology of the Russian Medical Academy of Postgraduate Education, Moscow) "Diagnosis and treatment of vertebrogenic lumbosacral radiculopathy" in relation to the problem we are considering, the following is indicated:
Recent large-scale studies have shown that although early surgical treatment undoubtedly leads to faster pain relief, after six months, a year and two, it does not have advantages in the main indicators of pain syndrome and the degree of disability over conservative therapy and does not reduce the risk of chronic pain.
It turned out that the timing of the surgical intervention 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. Preservation of intense radicular pain syndrome, severe limitation of mobility, 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 foot paresis, anesthesia of the anogenital region, dysfunction of the pelvic organs. An indication for surgery may also be an increase in neurological symptoms, such as muscle weakness. As for other cases, questions about the appropriateness, optimal time and method of surgical treatment remain the subject of discussion.
In recent years, along with traditional discectomy, more sparing methods of surgical intervention 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 disc while maintaining the integrity of the fibrous ring, its bulging 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. Minimally invasive intervention expands the range of indications for it. Nevertheless, the principle remains unchanged: the surgical intervention should be preceded by optimal conservative therapy for at least 6 weeks.
Regarding the use of sparing methods for the treatment of a herniated disc, there is also the following recommendation (which can be found in more detail in the article: “Neuropathic pain syndrome in back pain” by A.N. Barinov, First Moscow State Medical University named after I.M. Sechenov):
If there is a non-sequestered lateral (foraminal) disc herniation, less than 7 mm, and the short-term effectiveness of foraminal blockades and / or poor tolerance of 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 a 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 (published in the article "Lumbar pain: etiology, clinic, diagnosis and treatment") indications for surgical treatment of clinical manifestations caused by a herniated 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, a pronounced radicular pain syndrome that does not decrease despite the treatment.
The development of radiculomyeloishemia 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 in the course of treatment and rehabilitation measures, the process regresses within approximately 6 months. The same terms of regression are observed in delayed operations.
Relative indications include the ineffectiveness of conservative treatment, recurrent sciatica. Conservative therapy in duration should not exceed 3 months and last at least 6 weeks.
It is assumed that the surgical approach in case of acute radicular syndrome and the failure of conservative treatment is justified during the first 3 months after the onset of pain to prevent chronic pathological changes in the root. Relative indications are cases of extremely pronounced pain syndrome, when there is a change in the pain component with an increase in neurological deficit.
As a conclusion, so to speak, summing up the above, one should list the indications for surgical treatment of a herniated disc, adapted for their correct perception by patients and doctors who are 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 an operation necessary? (read full article ->):
“According to the results of many years of observations and the results of surgical and conservative methods of treatment, 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 you need to agree to an operation out of captivity, otherwise it will be worse.
But in the following cases, you need to go for an operation only of your own free will, carefully weighing your decision:
. ineffectiveness of conservative treatment for 3 months or more;
. paralysis of limbs and segments;
. signs of muscle atrophy against the background of the absence of functional activity of the spine.
These are relative readings, i.e. about a person's ability to endure pain, the need to go to work, and the ability to self-care."
