SURGICAL OPERATION
Mechanical motion on tissues and organs with medical or diagnostic function known as an operation.
For a lot of many years, an operation was a supply of insupportable ache and hazard of loss of life that pressured sufferers to refuse it, continuously even below direct menace to life. Completely different, even complicated, operations had been carried out way back, even earlier than the aseptic period and the applying of anaesthesia.
All operations are divided into bloody throughout which the integrity of the pores and skin and mucous membranes, muscle mass and different tissues, and in addition varied organs of the physique is damaged and cold throughout which the exterior integument isn’t broken. An instance of a cold operation is the repositioning of a dislocation. As well as, medical and diagnostic operations are distinguished.
Biopsy, punctures of pleural and stomach cavities, articulate, spinal and different endoscopic examinations (cystoscopy, bronchoscopy, esophagoscopy, gastroscopy, thoracoscopy, laparoscopy, and so on.) belong to diagnostic operations. The definition or specs of the prognosis with the assistance of this or that operative technique offers compulsory earlier utility of all different diagnostic strategies. Diagnostic laparotomy presents a sure threat, and used solely when there is no such thing as a different resort.
Medical operations could be radical, when injured organs or tissues are minimize or eliminated (abscess, appendectomy, abdomen resection, cholecystectomia, and so on.).
Radical operations could be prolonged and mixed. For instance, if a abdomen tumour has unfold onto the encompassing tissue, concurrently spleen removing, resection of part of the liver, and so on. are accomplished.
Palliative operations don’t liquidate the explanation of the sickness however facilitate the situation of the affected person. For instance, if a tumour closes a lumen of the intestines and there’s no alternative to radically take away it, they resort to bringing the intestinal loop onto the anterior wall of the abdomen with its following dissection.
Relying upon the urgency of efficiency the next operations are distinguished:
— emergency;
— pressing;
— elective.
Emergency operations are carried out instantly inside first 2 h after institution of the prognosis (appendicitis, perforation ulser abdomen, strangulated hernia, and intestinal obstruction). In some circumstances, operations are carried out throughout the nearest minutes due to important indications (acute bleeding, tracheostomy).
Pressing operations are carried out through the first days after being hospitalized in reference to the quick improvement of course of which may make the sufferers inoperable (malignant tumours, and so on.).
Elective operations are carried out at any time after a 2–3-day preparation.
Operations could be one, two- and multiple-staged. Most operations are carried out in a single stage (appendectomy, abdomen resection, and so on.). If the situation of the affected person is outlined as extreme, and the extent of the operation is massive and the diploma of threat will increase, the operation is split into two or extra levels. For instance, apendicular infiltrate, tumour of the big intestines with the intestinal obstruction, the Filatov’s graft.
Operations are divided into 4 teams:
clear;
conditionally clear (opening of the gastrointestinal tract (GIT));
contaminated (the coming into of the contents of cavitary organsinto the wound);
soiled, or primarily-infected.
The indications to an operation are absolute, relative and important. The latter are decided due to direct menace to the affected person’s life.
Absolute indications — if therapy of the illness is feasible by solely operative manner.
Relative indications have, for instance, elective operations, that are doable of briefly delaying with out hurt to the well being of the affected person. With the identical illness, relying on the urgency, the indications for the operation could be important, absolute or relative. For instance, with an advanced ulcer of the duodenal the indications for the operation could be important (profuse bleeding which doesn’t cease), or absolute (stenosis), or relative (in these circumstances, if not all strategies of conservative therapy have been used).
The surgeon is obliged to suppose over the plan of operation and make a pre-operational epicrisis during which the next is marked:
— justified prognosis;
— indication for the operation;
— plan of the operation;
— sort of anaesthesia.
In a surgery three primary levels are distinguished:
The preoperative interval and preparation of the affected person for theoperation.
Options of the operation course.
Intensive supervision and take care of the affected person within the post-operative interval.
If these necessities are stored the constructive impact of surgical intervention is assured.
The preoperative interval is the interval from the second of hospitalization of the affected person or go to to the polyclinic until the beginning of the operation.
The overall job of the preoperative interval is maximal discount of hazard from the operation. Throughout the preoperative preparation the surgeon can keep in mind all doable risks from the operation and use various preventive measures.
On the preoperating interval the surgeon is obliged to execute various duties, resembling:
Decide the prognosis, indications and contraindications forthe operation and select the optimum manner of surgical intervention and technique of anaesthesia.
Discover issues of the fundamental illness and accompanyingillnesses.
Decide the situation and diploma of infringement of respiratory, circulatory, liver, kidney capabilities.
Conduct a posh of medical actions which help to improvethe disturbed capabilities, lower the arterial strain, conduct oral cavity, and tonsils sanation for prevention of doable an infection.
Create useful reserves of an organism, enhance its immunological forces.
Conduct psychological preparation of the affected person so as toavoid of the nervous stress.
The period of the preoperative interval relies upon upon the character of the illness, common situation of the affected person, diploma of urgency of the operation and the extent of operative intervention. For emergency operations (bleeding, acute appendicitis, perforated abdomen ulcer, and so on.) the preoperative interval is diminished to a minimal and solely elementary actions are used.
On the preoperative interval the surgeon should count on issues, which may come up through the operative intervention for in time prevention. Throughout preparation for an operation the preventive actions towards issues are used, correction of exercise of the broken organs is carried out with the aim of accelerating their useful reserves.
In circumstances of elected operations the distant, nearest and speedy preoperative intervals are distinguished. For instance, on the distant interval the affected person preparation (sanatorium therapy) is carried out. Throughout the nearest interval (7–15 days) the overall situation of somatic techniques is normalized and through speedy affected person preparation, sanitary processing, and urinary bladder contents evacuation is carried out.
Direct preoperative actions are distinguished, that are essential for use within the preparatory interval (water baths, shaving hair, clyster, bladder emptying) and in addition particular measures for the preparation to operations of a sure type (evacuation of gastric contents with stenosis, colon lavage earlier than its resection, and so on.).
The next actions belong to preoperative preparation:
— normalization of the psychological situation of the affected person;
— stabilization of the overall somatic situations;
— native preparation.
Psychological preparation. The ability of the physician to take away and easy over psychological trauma assists within the preparation of the affected person for operation and the postoperative course. The medical workers is obliged to spare the nervous system of the affected person throughout the entire therapy interval. Within the postoperative interval the worth of contact between the physician and affected person specifically will increase. The flexibility of the physician to persuade the affected person of restoration and favorable outcomes of operation and therapy offers the affected person new forces. In case of extreme uncurable illnesses (malignant tumours) the physician deliberately hides the reality from the affected person, in any other case the affected person loses his final hope for restoration, and the illness begins to progress.
Normal somatic preparation. Within the preoperative interval particular consideration must be given to the modifications within the circulatory, respiratory techniques and in addition the exercise of parenchymatous organs with the aim of their correction.
Liquidation of anemia has a fantastic worth. Sufferers with haemoglobin quantity lower than the norm by 25–40% tolerate operation worse. In such circumstances, earlier than the operation, repeated haemotransfusions (250–500 ml) are carried out, haemopoietic organs are stimulated, full-value weight loss program and multi-vitamins are appointed. For preventive measures of thrombosis and embolism, the prothrombin index is decided, and if wanted anticoagulants are appointed.
Throughout 5–10% of all operations, specifically on the stomach and chest cavities, respiratory harm and pulmonary issues seem in sufferers who earlier than the operation already had pathological issues within the respiratory organs. Due to this fact earlier than the efficiency of elective operations it’s essential to liquidate irritation within the nasal cavities, acute and persistent bronchitis, pleuritis and pneumonia. Contraindications to an operation are acute rhinitis, bronchitis and in addition promoted lung emphysema. Throughout the preparation of the GIT lengthy hunger usually are not fascinating, in addition to the usage of laxatives and a repeated colon lavage, as a result of this brings acidosis and modifications within the acid-base situation, reduces the tone of the intestines and assists in stagnation of blood within the vessels of the mesentery. Consequently, extreme intoxications, vomiting, meteorism and oliguria can develop. Due to this fact, meals must be restricted solely the night earlier than the operation.
An essential position in affected person preparation is sanitation of the oral cavity, removing of carious enamel. The abdomen earlier than operation must be emptied.
In gastric bleeding it isn’t advisable to empty the abdomen earlier than an operation. A cleaning oedema is important to make use of due to the absence of impartial evacuation; an exception is made with operations on the big intestines and perineum.
It is vitally essential to extend the reserves of glycogen within the liver for a rise of its perform. The affected person ought to use full-value meals; he’s given glucose, vitamin C, В12, methionine, lipocain.
Native preparation. Within the preoperative interval it’s essential to fastidiously look at the affected person’s pores and skin. If irritation is revealed on the location of the deliberate operation or close by, the operative intervention is cancelled if there is no such thing as a important indications. Earlier than an operation it’s fascinating to nominate a shower, change undies. On the day of the operation it’s essential to organize the operational discipline — repeatedly wash it with soapy water and shave the hair.
The postoperative interval is the time from the tip of the operation to the second when the affected person’s work capability is restored. The restoration interval is not any much less essential, than the surgery.
The postoperative interval is split into three phases:
1) Early part — first 3–5 days after the operation;
2) Late part — 2–3 weeks after the operation;
3) Distant part — until a working potential is restored.
Easy or regular postoperative interval and postoperative interval with issues are distinguished.
Adjustments that are noticed within the postoperative interval can normalize throughout a number of days. In 90% of the circumstances the sufferers which can be operated on have infringement of the carbohydrate metabolism with hyperglycemia and glucosuria which disappear in 3–4 days.
Within the postoperative interval acidosis can happen because of violation of the acid-base steadiness within the blood. Preventive measures of acidosis are early feeding, introduction of glucose and insulin.
Violation of protein metabolism is accompanied by a rise within the blood of residual nitrogen hypoproteinemia, a rise in globulin fractions. The event of hypoproteinemia causes a rise in bleeding through the operation. It may be compensated for with a full-value weight loss program with excessive contents of fiber, blood and plasma transfusions.
Violation of the water-electrolyte metabolism is also essential within the postoperative interval. The primary days after the operation are characterised by a lower in chlorides, which is compensated by the introduction of Ringer options, hypertonic options of sodium chloride and potassium.
Issues of the water-electrolyte metabolism must be topic of particular person correction inside first postoperative days. About 2.5– 3 l of liquid a day must be given.
Adjustments of blood construction are famous on the postoperative interval. On this case leukocytosis is the organism’s regular response to the protein disintegration merchandise absorption. The explanations for anemia are blood loss through the operation, accelerated disintegration of erythrocytes after haemotransfusion, which is eradicated by haemotransfusion and erythrocyte mass. In 75% of sufferers the viscosity of blood will increase, which in flip will increase globulin fractions and dehydration of an organism, which makes hazard of thromboses and embolism formation.
The intoxication which happens in reference to pathology of the parenchymatous organs, GIT and endocrine techniques is handled with totally different options (isotonic resolution of sodium chloride, haemodesum, Ringer resolution, 5–40% resolution of glucose) are utilized.
The activation of sufferers after operation is essential, specifically the aged. It’s accomplished with respiratory workouts and physiotherapy workouts.
Violation of capabilities of important organs and techniques within the postoperative interval are doable each within the early and late levels. As anesthetizing means 50% analgin, 1–2% promedol, omnopon, morphin, neuroleptics (droperidol, haloperidol), and medical narcosis are utilized. If sleep issues are noticed the barbiturates are appointed.
Cardiovascular system disturbances manifest in coronary heart assaults, acute cardiac and vascular failure, thrombosis, embolism could be noticed. Cardiac glycosides (strophanthin, corglykon, digoxin), substances which tone up peripheral circulation (strychnine, caffeine, ephedrine, dopaminum), coronarolytics (nitroglycerine), diuretics (lasix), oxygenotherapy, for thromboses — anticoagulants are utilized.
Respiratory issues embody acute respiratory insufficiency — bronchitis, tracheitis, pneumonia, pleuritis, atelectasis, abscess of the lungs. Incomplete air flow of the lungs has nice worth within the improvement of pneumonia. For prevention of respiratory issues it’s essential to keep away from overcooling the affected person within the operational corridor, tub and different rooms. They offer cautious care to the affected person, respiratory gymnastics, appoint antibiotics, mustard plasters, inhalations, and so on.
Issues of urinary organs manifest by a delay in urination (ischuria), discount within the quantity of urine (oliguria, anuria), pyelitis or irritation of the urinary bladder (cystitis). Postoperative oliguria and anuria have a neural-reflex origin or are linked to a harm of the renal parenchyma. A bilateral paranephral blockade, stimulation of diuresis (lasix, manitol, aminophyllin), haemodialysis and haemosorption are carried out. Ischuria happens largely after operations on the pelvic organs. Thus, the bladder is overfilled and the affected person is advisable to empty it in a sitting or standing place. A hot-water bottle could be placed on the urinary bladder, if essential, catheterization is finished. For the therapy of pyelitis and cystitis, antibiotics and means for disinfection of the urinary tract (urotropin, furodonin, furozolidon, nevigramon, and so on.), and bodily procedures are used.
Within the postoperative interval as a response to an operational trauma, shock, unconsciousness, collapse can happen. Mechanisms of their improvement and therapy in particulars are acknowledged within the part “Traumatology”.
Terminal Situations
Analysis regarding the revival of an organism was carried out in XVІІ century by the well-known anatomist and physiologist P. V. Postnikoff. Additional Ye. Mukhin, M. Uspensky, and A. Philomafitsky (XVІІІ century) labored out this drawback. For the final 40 years within the Analysis Laboratory on Normal Resuscitation below the administration of prof. V. A. Negovsky the theoretical bases of the issue of terminal situations had been developed.
There are following terminal situations:
Pre-agony situation.
Agony.
Scientific loss of life.
As well as, shock of the ІІІ–IV levels belongs to the terminal situation too.
The pre-agony situation is characterised by confused consciousness, paleness of the pores and skin, acutely pronounced acrocyanosis.
Spasm of the peripheral vessels ends in deep hypoxia, acidosis and metabolism dysfunction. Eye reflexes are stored, shallow respiratory, threadlike pulse, ABP isn’t decided.
Agony is characterised by the absence of consciousness, areflexia, pronounced acrocyanosis. Pulse is hardly decided on the carotid arteries, tones of the guts are muffled, bradycardia. Respiration is rhythmic, shallow, and spasmodic. Pupils begin to dilate; maximal dilatation happens 90 s after the beginning of anoxia of the mind.
Scientific loss of life: respiratory and cardiac exercise is absent. The pupils are dilated and don’t react to gentle. The organism passes right into a situation of minimal important potential which lasts 5–6 min, throughout this era cells of the CNS die. In 5–6 min medical loss of life passes into organic, throughout which organic processes within the organism fully cease.
Intensive remedy throughout terminal situations must be directed on the restoration of capabilities of important organs and discount of hypoxia of tissue.
There are the next complicated strategies of therapy throughout terminal situations:
Chest therapeutic massage (direct and oblique).
Synthetic lung air flow.
Intra-arterial haemotransfusion.
Defibrillation of the guts.
Auxiliary synthetic blood circulation.
Resuscitation departments are organized in all massive hospitals. They’re positioned close to operation blocks, geared up with techniques for the sufferers situation statement (monitoring techniques) and now have an express-laboratory. The personnel in these departments are of high-skilled.
The first aim of resuscitation and intensive remedy is mobilization of important organs and normalization of their capabilities in sufferers with damages, acute blood loss within the early postoperative interval after in depth traumatic operations. The bases of those violations are modifications in haemodynamics, respiration, metabolism in addition to the physique temperature. In reference to this, particular consideration is given to prognosis of circulatory insufficiency (monitoring techniques, technique of radionuclide researches, haemodilution, and so on.), acute respiratory insufficiency (decided by change within the capabilities of exterior respiration, gasoline construction of the blood, acid-base standing), violation of the water-electrolyte metabolism, perform of the liver and kidneys, modifications within the blood coagulation system. A differentiated strategy to pathogenetic remedy of important capabilities disturbances permits to lower the incidence of issues and deadly outcomes in reference to surgical intervention and totally different crucial states which come up in surgical sufferers.
Models of intensive remedy are meant for postoperative sufferers who demand intensive supervision for a number of hours and days earlier than they’re transferred to widespread wards.