SURGICAL OPERATION

Mechanical action on tissues and organs with medical or diagnostic purpose is called an operation.

For many decades, an operation was a source of intolerable pain and danger of death that forced patients to refuse it, frequently even under direct threat to life. Different, even complex, operations were performed long ago, even before the aseptic era and the application of anaesthesia.

All operations are divided into bloody during which the integrity of the skin and mucous membranes, muscles and other tissues, and also various organs of the body is broken and bloodless during which the external integument is not damaged. An example of a bloodless operation is the repositioning of a dislocation. In addition, medical and diagnostic operations are distinguished.

Biopsy, punctures of pleural and abdominal cavities, articulate, spinal and other endoscopic examinations (cystoscopy, bronchoscopy, esophagoscopy, gastroscopy, thoracoscopy, laparoscopy, etc.) belong to diagnostic operations. The definition or specifications of the diagnosis with the help of this or that operative method provides obligatory previous application of all other diagnostic methods. Diagnostic laparotomy offers a certain risk, and used only when there is no other resort.

Medical operations can be radical, when injured organs or tissues are cut or removed (abscess, appendectomy, stomach resection, cholecystectomia, etc.).

Radical operations can be extended and combined. For example, if a stomach tumour has spread onto the surrounding tissue, simultaneously spleen removal, resection of a part of the liver, etc. are done.

Palliative operations do not liquidate the reason of the illness but facilitate the condition of the patient. For example, if a tumour closes a lumen of the intestines and there is no opportunity to radically remove it, they resort to bringing the intestinal loop onto the anterior wall of the stomach with its following dissection.

Depending upon the urgency of performance the following operations are distinguished:

— emergency;

— urgent;

— elective.

Emergency operations are carried out immediately within first 2 h after establishment of the diagnosis (appendicitis, perforation ulser stomach, strangulated hernia, and intestinal obstruction). In some cases, operations are performed within the nearest minutes because of vital indications (acute bleeding, tracheostomy).

Urgent operations are carried out during the first days after being hospitalized in connection with the fast development of process which can make the patients inoperable (malignant tumours, etc.).

Elective operations are carried out at any time after a 2–3-day preparation.

Operations can be one, two- and multiple-staged. Most operations are carried out in one stage (appendectomy, stomach resection, etc.). If the condition of the patient is defined as severe, and the extent of the operation is big and the degree of risk increases, the operation is divided into two or more stages. For example, apendicular infiltrate, tumour of the large intestines with the intestinal obstruction, the Filatov’s graft.

Operations are divided into 4 groups:

clean;

conditionally clean (opening of the gastrointestinal tract (GIT));

contaminated (the entering of the contents of cavitary organsinto the wound);

dirty, or primarily-infected.

The indications to an operation are absolute, relative and vital. The latter are determined because of direct threat to the patient’s life.

Absolute indications — if treatment of the disease is possible by only operative way.

Relative indications have, for example, elective operations, which are possible of temporarily delaying without harm to the health of the patient. With the same disease, depending on the urgency, the indications for the operation can be vital, absolute or relative. For example, with a complicated ulcer of the duodenal the indications for the operation can be vital (profuse bleeding which does not stop), or absolute (stenosis), or relative (in these cases, if not all methods of conservative treatment have been used).

The surgeon is obliged to think over the plan of operation and make a pre-operational epicrisis in which the following is marked:

— justified diagnosis;

— indication for the operation;

— plan of the operation;

— type of anaesthesia.

In a surgical operation three main stages are distinguished:

The preoperative period and preparation of the patient for theoperation.

Features of the operation course.

Intensive supervision and care for the patient in the post-operative period.

If these requirements are kept the positive effect of surgical intervention is guaranteed.

The preoperative period is the interval from the moment of hospitalization of the patient or visit to the polyclinic till the start of the operation.

The general task of the preoperative period is maximal reduction of danger from the operation. During the preoperative preparation the surgeon can take into account all possible dangers from the operation and use a number of preventive measures.

At the preoperating period the surgeon is obliged to execute a number of tasks, such as:

Determine the diagnosis, indications and contraindications forthe operation and choose the optimum way of surgical intervention and method of anaesthesia.

Find complications of the basic disease and accompanyingillnesses.

Determine the condition and degree of infringement of respiratory, circulatory, liver, kidney functions.

Conduct a complex of medical actions which assist to improvethe disturbed functions, decrease the arterial pressure, conduct oral cavity, and tonsils sanation for prevention of possible infection.

Create functional reserves of an organism, increase its immunological forces.

Conduct psychological preparation of the patient in order toavoid of the nervous stress.

The duration of the preoperative period depends upon the character of the disease, general condition of the patient, degree of urgency of the operation and the extent of operative intervention. For emergency operations (bleeding, acute appendicitis, perforated stomach ulcer, etc.) the preoperative period is reduced to a minimum and only elementary actions are used.

At the preoperative period the surgeon must expect complications, which can arise during the operative intervention for in time prevention. During preparation for an operation the preventive actions against complications are used, correction of activity of the damaged organs is carried out with the purpose of increasing their functional reserves.

In cases of elected operations the remote, nearest and immediate preoperative periods are distinguished. For example, at the remote period the patient preparation (sanatorium treatment) is carried out. During the nearest period (7–15 days) the general condition of somatic systems is normalized and during immediate patient preparation, sanitary processing, and urinary bladder contents evacuation is carried out.

Direct preoperative actions are distinguished, which are necessary to be used in the preparatory period (water baths, shaving hair, clyster, bladder emptying) and also specific measures for the preparation to operations of a certain kind (evacuation of gastric contents with stenosis, colon lavage before its resection, etc.).

The following actions belong to preoperative preparation:

— normalization of the mental condition of the patient;

— stabilization of the general somatic conditions;

— local preparation.

Psychological preparation. The skill of the doctor to remove and smooth over mental trauma assists in the preparation of the patient for operation and the postoperative course. The medical staff is obliged to spare the nervous system of the patient during the whole treatment period. In the postoperative period the value of contact between the doctor and patient in particular increases. The ability of the doctor to convince the patient of recovery and favorable outcomes of operation and treatment gives the patient new forces. In case of severe uncurable diseases (malignant tumours) the doctor intentionally hides the truth from the patient, otherwise the patient loses his last hope for recovery, and the disease starts to progress.

General somatic preparation. In the preoperative period special attention should be given to the changes in the circulatory, respiratory systems and also the activity of parenchymatous organs with the purpose of their correction.

Liquidation of anemia has a great value. Patients with haemoglobin amount less than the norm by 25–40% tolerate operation worse. In such cases, before the operation, repeated haemotransfusions (250–500 ml) are carried out, haemopoietic organs are stimulated, full-value diet and multi-vitamins are appointed. For preventive measures of thrombosis and embolism, the prothrombin index is determined, and if needed anticoagulants are appointed.

During 5–10% of all operations, in particular on the abdominal and chest cavities, respiratory damage and pulmonary complications appear in patients who before the operation already had pathological disorders in the respiratory organs. Therefore before the performance of elective operations it is necessary to liquidate inflammation in the nasal cavities, acute and chronic bronchitis, pleuritis and pneumonia. Contraindications to an operation are acute rhinitis, bronchitis and also promoted lung emphysema. During the preparation of the GIT long starvation are not desirable, as well as the use of laxatives and a repeated colon lavage, because this brings acidosis and changes in the acid-base condition, reduces the tone of the intestines and assists in stagnation of blood in the vessels of the mesentery. As a result, severe intoxications, vomiting, meteorism and oliguria can develop. Therefore, food should be limited only the evening before the operation.

An important role in patient preparation is sanitation of the oral cavity, removal of carious teeth. The stomach before operation should be emptied.

In gastric bleeding it is not recommended to empty the stomach before an operation. A cleansing oedema is necessary to use because of the absence of independent evacuation; an exception is made with operations on the large intestines and perineum.

It is very important to increase the reserves of glycogen in the liver for an increase of its function. The patient should use full-value food; he is given glucose, vitamin C, В₁₂, methionine, lipocain.

Local preparation. In the preoperative period it is necessary to carefully examine the patient’s skin. If inflammation is revealed on the site of the planned operation or nearby, the operative intervention is cancelled if there is no vital indications. Before an operation it is desirable to appoint a bath, change underclothes. At the day of the operation it is necessary to prepare the operational field — repeatedly wash it with soapy water and shave the hair.

The postoperative period is the time from the end of the operation to the moment when the patient’s work capacity is restored. The recovery period is no less important, than the surgical operation.

The postoperative period is divided into three phases:

1) Early phase — first 3–5 days after the operation;

2) Late phase — 2–3 weeks after the operation;

3) Remote phase — till a working ability is restored.

Smooth or normal postoperative period and postoperative period with complications are distinguished.

Changes which are observed in the postoperative period can normalize during several days. In 90% of the cases the patients that are operated on have infringement of the carbohydrate metabolism with hyperglycemia and glucosuria which disappear in 3–4 days.

In the postoperative period acidosis can occur as a result of violation of the acid-base balance in the blood. Preventive measures of acidosis are early feeding, introduction of glucose and insulin.

Violation of protein metabolism is accompanied by an increase in the blood of residual nitrogen hypoproteinemia, an increase in globulin fractions. The development of hypoproteinemia causes an increase in bleeding during the operation. It can be compensated for with a full-value diet with high contents of fiber, blood and plasma transfusions.

Violation of the water-electrolyte metabolism also is important in the postoperative period. The first days after the operation are characterised by a decrease in chlorides, which is compensated by the introduction of Ringer solutions, hypertonic solutions of sodium chloride and potassium.

Disorders of the water-electrolyte metabolism should be subject of individual correction within first postoperative days. About 2.5– 3 l of liquid a day should be given.

Changes of blood structure are noted at the postoperative period. In this case leukocytosis is the organism’s normal response to the protein disintegration products absorption. The reasons for anemia are blood loss during the operation, accelerated disintegration of erythrocytes after haemotransfusion, which is eliminated by haemotransfusion and erythrocyte mass. In 75% of patients the viscosity of blood increases, which in turn increases globulin fractions and dehydration of an organism, which makes danger of thromboses and embolism formation.

The intoxication which occurs in connection with pathology of the parenchymatous organs, GIT and endocrine systems is treated with different solutions (isotonic solution of sodium chloride, haemodesum, Ringer solution, 5–40% solution of glucose) are applied.

The activation of patients after operation is very important, in particular the elderly. It is done with respiratory exercises and physiotherapy exercises.

Violation of functions of vital organs and systems in the postoperative period are possible both in the early and late stages. As anesthetizing means 50% analgin, 1–2% promedol, omnopon, morphin, neuroleptics (droperidol, haloperidol), and medical narcosis are applied. If sleep disorders are observed the barbiturates are appointed.

Cardiovascular system disturbances manifest in heart attacks, acute cardiac and vascular failure, thrombosis, embolism can be observed. Cardiac glycosides (strophanthin, corglykon, digoxin), substances which tone up peripheral circulation (strychnine, caffeine, ephedrine, dopaminum), coronarolytics (nitroglycerine), diuretics (lasix), oxygenotherapy, for thromboses — anticoagulants are applied.

Respiratory complications include acute respiratory insufficiency — bronchitis, tracheitis, pneumonia, pleuritis, atelectasis, abscess of the lungs. Incomplete ventilation of the lungs has great value in the development of pneumonia. For prevention of respiratory complications it is necessary to avoid overcooling the patient in the operational hall, bath and other rooms. They give careful care to the patient, respiratory gymnastics, appoint antibiotics, mustard plasters, inhalations, etc.

Complications of urinary organs manifest by a delay in urination (ischuria), reduction in the amount of urine (oliguria, anuria), pyelitis or inflammation of the urinary bladder (cystitis). Postoperative oliguria and anuria have a neural-reflex origin or are connected to a damage of the renal parenchyma. A bilateral paranephral blockade, stimulation of diuresis (lasix, manitol, aminophyllin), haemodialysis and haemosorption are conducted. Ischuria occurs mostly after operations on the pelvic organs. Thus, the bladder is overfilled and the patient is recommended to drain it in a sitting or standing position. A hot-water bottle can be put on the urinary bladder, if necessary, catheterization is done. For the treatment of pyelitis and cystitis, antibiotics and means for disinfection of the urinary tract (urotropin, furodonin, furozolidon, nevigramon, etc.), and physical procedures are used.

In the postoperative period as a reaction to an operational trauma, shock, unconsciousness, collapse can occur. Mechanisms of their development and treatment in details are stated in the section “Traumatology”.

Terminal Conditions

Research concerning the revival of an organism was carried out in XVІІ century by the well-known anatomist and physiologist P. V. Postnikoff. Further Ye. Mukhin, M. Uspensky, and A. Philomafitsky (XVІІІ century) worked out this problem. For the last 40 years in the Research Laboratory on General Resuscitation under the management of prof. V. A. Negovsky the theoretical bases of the problem of terminal conditions were developed.

There are following terminal conditions:

Pre-agony condition.

Agony.

Clinical death.

In addition, shock of the ІІІ–IV degrees belongs to the terminal condition too.

The pre-agony condition is characterized by confused consciousness, paleness of the skin, acutely pronounced acrocyanosis.

Spasm of the peripheral vessels results in deep hypoxia, acidosis and metabolism disorder. Eye reflexes are kept, shallow breathing, threadlike pulse, ABP is not determined.

Agony is characterized by the absence of consciousness, areflexia, pronounced acrocyanosis. Pulse is hardly determined on the carotid arteries, tones of the heart are muffled, bradycardia. Breathing is rhythmic, shallow, and spasmodic. Pupils start to dilate; maximal dilatation occurs 90 s after the start of anoxia of the brain.

Clinical death: respiratory and cardiac activity is absent. The pupils are dilated and do not react to light. The organism passes into a condition of minimal vital ability which lasts 5–6 min, during this period cells of the CNS die. In 5–6 min clinical death passes into biological, during which biological processes in the organism completely stop.

Intensive therapy during terminal conditions should be directed on the restoration of functions of vital organs and reduction of hypoxia of tissue.

There are the following complex methods of treatment during terminal conditions:

Chest massage (direct and indirect).

Artificial lung ventilation.

Intra-arterial haemotransfusion.

Defibrillation of the heart.

Auxiliary artificial blood circulation.

Resuscitation departments are organized in all large hospitals. They are located near operation blocks, equipped with systems for the patients condition observation (monitoring systems) and also have an express-laboratory. The personnel in these departments are of high-skilled.

The primary goal of resuscitation and intensive therapy is mobilization of vital organs and normalization of their functions in patients with damages, acute blood loss in the early postoperative period after extensive traumatic operations. The bases of these violations are changes in haemodynamics, respiration, metabolism as well as the body temperature. In connection with this, special attention is given to diagnosis of circulatory insufficiency (monitoring systems, method of radionuclide researches, haemodilution, etc.), acute respiratory insufficiency (determined by change in the functions of external respiration, gas structure of the blood, acid-base status), violation of the water-electrolyte metabolism, function of the liver and kidneys, changes in the blood coagulation system. A differentiated approach to pathogenetic therapy of vital functions disturbances allows to decrease the incidence of complications and lethal outcomes in connection with surgical intervention and different critical states which arise in surgical patients.

Units of intensive therapy are intended for postoperative patients who demand intensive supervision for several hours and days before they are transferred to common wards.