IV. Table of contents of teaching

Before operation period – it is the period of time from the moment of hospitalization of patient in the separation to beginning of implementation to him operative interference. His duration relies on the character of illness (sharp or chronic), from the volume of future operation, from the state of patient and backlogs of his organism. Operations, that are executed in the sharp state which directly threatens to the life of patient, conduct after the minimum volume of before operation preparation. In the case of the planned operations a before operation period proceeds from a few o'clock (more frequent from one day) of to a few days, more liquid –tignya and quite rarely – weeks.

Basic tasks of before operation period:

1. to set a diagnosis

2. to define a testimony, urgency of implementation and character of operation

3. to prepare a patient to the operation.

Primary purpose of dooperatsiynogo period: to take to the minimum the risk of operative interference and possibility of development of complications after the operation.

From the medical and economic points of view a before operation period must be maximally brief: what a patient to the operation in the separation is less found, the less risk of infection by his internal-hospital infection. In the surgical separation it is needed to prevent the contact of sick, which expects operation with a festering infection. Therefore today greater plenitude of inspection and preparation of patient to the operation in ambulatory terms is important direction in the fight against an internal-hospital infection how possible.

On condition of comprehensive inspection and preparation of patient in ambulatory terms a before operation period is short. In this period in surgical permanent establishment a doctor meets with a patient and results of his inspection, conducts physical and auxiliary research in the moment of entry in the separation, ground diagnosis and testimony to the operation.

At every patient before the operation and above all things at those, who will operate under the local anaesthetizing (by novocaine anesthesia), it is needed to define a sensitiveness to novocaine by an internal-skin test. Do the same in relation to antibiotics, especially groups of penicillin.

After establishment of final diagnosis and conducting of necessary researches before operation preparation is conducted directly.

A volume and maintenance of before operation preparation is determined on the state the patient, his organs and systems and character actually operations. In the case of small after a volume operative interferences at patients without noticeable deviations from the norm of functions of their main systems and exchange of matters before operation preparation can be limited by psychological and sanitary-hygienic preparation. At patients which large operative interferences on internal organs are foreseen to, and at presence of considerable changes in an organism, related to illnesses and age, preparation to the operation must be more profile and considerably more difficult.

Before operation preparation of patients to the operation consists of general preparation (all patients without the exception need) and individual preparation of their organs and systems which different violations are exposed at. Last conduct by both current and specific (specific preparation) measures.

The volume of before operation preparation relies on the type of future operative interference after urgency of his implementation. Urgent operation – this operative interference, that is executed immediately or in a few hours from the moment of receipt of patient in permanent establishment (sharp appendicitis, jammed hernia, sharp intestinal impassability, perforate gastric ulcer and others like that). Urgent operation – this interference, that is executed in the nearest days after the receipt of patient in a clinic (mechanical icterus, malignant tumor and others like that). The planned operation is executed only after the detailed inspection of patient and careful before operation preparation of patient concerning chronic surgical pathology.

The inspection and preparation of patient to the urgent operation is individual and relies on weight of his state. At an asphyxia, wound of heart and large main vessels patients are operated off the hand practically. In other case the preparation of patients takes place in a brief volume. The main tasks of before operation period in such cases are establishment of diagnosis, determination of shows and contraindication, urgency and character of operation, determination of method of anaesthetizing, conducting of the hygienical and medical measures directed on the improvement of the broken functions of organs, accumulation of functional reserves of organism for the rise of his protective forces and prophylaxis of endogenous infection. Attention of doctor and hospital personnel is to be directed on creation of the protective mode for patients. From a moment the hospitalization of patient and to the operation all is to be directed on that not to injure his nervous system and psyche. It does not follow to send a just arriving patient in a chamber, where patients after heavy operative interferences are found, or those, that die. Expediently to place him in a chamber to the convalescent patients. The stay in such chamber well affects the newly arrived patients and infuses with a hope on the happy ending of future operation. The non-motivate change day of certain of operation, protracted its expectation, is impermissible.

Before the urgent operation it is necessary to execute a definite sequence at implementation of hygienical procedures: hygienical shower with a next change of linen, wide deleting of hair canopy in the area of the future operating field, treatment of skin by antiseptic, evacuation of maintenance of stomach, deleting of dentures, premedication, intravenous introduction of substitutes, transporting in an operating hall, catheterization of urinary bladder, preparation of the operating field.

Preparation of patient to the planned operation includes the following measures:

• Psychological preparation.

• Preparation of the cardio-vessels system.

• Preparation of organs of breathing.

• Preparation of gastric-intestinal highway.

• Improvement of the functional state of liver and buds.

Preparation of the nervous system and psyche of patient consists in attentive attitude toward his complaints, removal of fear before the operation, all, that irritates, flusters a patient. Fear of pain, violation of sleep, doubts related to the future operation, blow up forces of patient and diminish opirnist of his organism. Sometimes enough a few words of doctor, or the trained nurses, that to blow about the heavy doubts and difficult experiencing of patient.

Term of implementation of operation are determined by testimonies, which can be vital, absolute, relative.

Vital testimonies arise up at such diseases, when laying of operation on time threatens to the life of patient. Such operations are executed in an urgent order. Vital testimonies arise up at the following pathological states:

• proceeding bleeding at the break of parenchimatosis organs or at the wound of large vessels – death.

• at the sharp diseases of organs of abdominal region – sharp appendicitis, sharp intestinal impassability – development of peritonitis or gangrene of organ goes.

• festering-inflammatory diseases – absce6ss, phlegmon, sharp osteomielitis – the removal of operation conduces to complications, expressed intoxication, sepsis.

At implementation of operation after vital testimonies the volume of her is to be minimum, directed on the rescue the life of sick.

Absolute testimonies to the operation arise up at such diseases, at which the protracted postponement can result in the state which threatens to the life of patient. These operations are executed in an urgent order in a few days after the receipt of patient in the surgical separation. Malignant new formations of a different localization, mechanical icterus, belong before such diseases, stenosis of pylori part of stomach.

Relative testimonies to implementation of operation can be at the diseases which do not present a threat for the life of sick (hernia, of high quality tumors). These operations are executed in the planned order.

Before contra-indications for conducting of operations belong: cardiac, respiratory and vascular to insufficiency (shock), heart attack of myocardium, stroke, hepatic-kidney insufficiency, tromboembolic illness, heavy metabolic disturbances (saccharine diabetes: comma), heavy anemia, considerable cachexy.

The indicated changes are determined strictly individually and according to a volume and weight of operation, that is planned. At relative testimonies to implementation of operation and presence of diseases which multiply the risk of operation, put aside her on the set time and conduct correction of concomitant disease.

The second measure – conducting of additional inspections.

From anamnesis it is necessary to find out the presence of thirst, vomits (his volume), allergist and transfusion anamnesis, and also presence of diseases of liver and kidney. The special attention is spared to the review of skin: its dryness, color. Necessarily to define frequency and character of pulse, arterial pressure, and in heavy patients and central vein pressure (which in a norm is evened 50-150 mm of waters. item), electrocardiography research of heart is conducted. A depth and breathing frequency is determined, presence of stuffiness, made to noise, wheezed at auscultation of lights. For determination of secretion function of kidney day's and for hour diuresis (30-40 ml/god)is measured, specific gravity of urine.

With the purpose of estimation of the state of homeostasis it is necessary to conduct periodic control determinations to the level Hb, Ht, the acid-alkali state, basic electrolytes, VCB and his components. In the urgent case the laboratory inspections must be limited, that not to detain the operation.

All this am very important during conducting of transfusion therapy.

Psychological preparation of patient to the operation is directed on calming of patient, it is necessary to infuse with at him a confidence in the success operation. Especially this am important at the attempt of patient to give up the operation, when he does not realize the state and consequences of disease.

Before operation preparation – important stage of surgical medical treatment of sick. Even during the ideally executed operation, if not the conducted adequate correction of violations of function of other organs and systems – expect a misfortune!!!

Before operation preparation must be short on time and high effective.

At sharp loss blood and stopped bleeding blood transfusion and substitutions is conducted. At the proceeding bleeding conduct hemotransfusion in a few veins simultaneously and execute the operation directed on the stop of bleeding.

At the receipt of patient in a hospital in a state of shock – conduct contra-shock therapy. Shock – is contra-indication to conducting of operation (except for hemorrhagic at bleeding which proceeds and can not be stopped without operative interference), therefore the operation is executed at arterial pressure not below by 90 mm of rt. item.

Preparation of organs and systems to operative interference must be complex and include at itself:

1. Improvement of cardio-vessels activity, correction of violations of microcirculation by means cardio-vessels preparations, antiaggregates.

2. Fight against respiratory insufficiency (oxygenotherapy, normalization of circulation of blood, at heavy - cases artificial ventilation of lights).

3. Desintoxication therapy – introduction of liquid, substitutes, forced diuresis, the use of the special methods of detoxication – plasmosorbtion, hemosorbtion, lymphosorbtion, oxygenotherapy, lasers.

4. Correction of violations in the system to hemostasis.

Depending on the disease and localization of pathological process the special before sterilization preparation is conducted. So at the operations on a stomach, washing of stomach during a few days is conducted, a special diet, purgative preparations, cleansing enemas, antibiotics, is appointed.

The special attention is spared to the patients with mellitus diabetes. Patients before the operation are translated into simple insulin.

Prophylaxis of endogenous infection. A doctor must find out or it is not at the patient of chronic inflammatory processes (tonsillitis, pharyngitis, abscess diseases of skin) and conducts sanation of hearths of infection. If the operation is executed in the planned order, a patient can be written out for conducting of medical treatment of chronic infection in ambulatory terms.

Preparation of the operating field.

In eve the operation to the patient a cleansing enema is executed. A patient takes a hygienical bath or shower. In the morning, in the day of operation, to the patient, shaving of hair is conducted in the area of the operating field.

At presence of wound the treatment of the operating field has the features. Bandage take off, a wound is covered by a sterile napkin, and wipe a skin round a wound by ether and shave off a hair round by a dry method. All motions are conducted from a wound, that to decrease the degree of its contamination. After it napkin is taken off, and process a skin 5 % by alcoholic solution of iodine and cover a wound by a sterile napkin.

In an operating-room a patient is delivered on wheel-stretcher. In the heavy case continue transfusion medications and a patient can be found on artificial ventilation of lights. At bleeding with the imposed plait a patient is delivered in an operating-room with a plait.

From wheel-stretcher a patient translated into operating table in comfortable for implementation of operation of position.

Operation – this implementation of the special mechanical action on organs and fabrics with a medical purpose.

The surgical operations are divided depending on the term of their implementation, and depending on the complete curing or facilitation of the state of sick.

On a term the implementations divide the operations on:

- emergency – operations which are executed immediately or in the nearest time from the moment of receipt of patient in the surgical separation;

- urgent – operations which are executed in the first days after the receipt of patient in the surgical separation;

- the planned operations which are executed in the planned order (the term of their implementation is unlimited).

Depending on the medical effect of operation are divided on:

1. radical;

2. palliative.

Radical operations – it is the operations after implementation of which, convalescence of sick comes by deleting of pathological education, part or all organ.

Volume of operative medical treatment, which determines radicalism of operation relies on the character of pathological process. So at the of high quality tumors (lipoma, fibroma, polyps) of deleting of tumor results in convalescence of sick. At malignant tumors the radicalism of operation consists not only in deleting of part or whole organ, but also in deleting of neighboring organ, which a tumor germinates in, surrounding cellulose, lymphatic knots. So at the cancer of stomach, deleting of stomach with large and small stuffing-boxes is executed.

At the inflammatory diseases the volume of interference is limited by deleting of the pathologically changed fabrics or organ (at osteomielitis – osteonecrectomy; at sharp appendicitis - appendectomy).

The second group of operations – palliative operations. They are executed with the purpose of removal of danger for the life of sick, or improvement of his state.

So at the large tumor of gullet, which germinates in the organs of mediastinum, to the patient the palliative operation is executed - imposition of fistulas on a stomach, that a patient no die of hunger. At a tumor to the intestine, which blocks the road clearance of the last, and is metastases in a liver, and the common state of patient heavy from intestinal impassability - to the patient the operation of imposition of artificial anus is executed (that is an intestine is opened on a front abdominal wall, and a tumor remains).

More frequent all the palliative operations are executed at oncology patients, in the neglected case, when radical operation impossible from distribution of process, and even temporally to improve the purpose of palliative operation the state of patient.

Depending on the stages of operation they are one-stage – appendectomy, cholecystectomy, when all stages follow after each other and many-stages: double-stage – at the adenoma of prostate (the first stage – imposition of fistula of urinary bladder and after some time the second stage – deleting of adenoma).

With development of the common anesthesia and intensive therapy all more frequent in surgery two and more operations are executed simultaneously – so rank of simultaneity operation. For example, at a gastric ulcer and chronic calculus cholecystitis - resection of stomach and cholecystectomy. At the adenoma of prostate and hernia of inguinal ring – deleting of adenoma of prostate gland and herniotomy with the plastic arts of hernia gates.

There are also trial operations – it is the operations, which it appears during, that the radical operation is impossible. Especially often it meets in oncology, when from the germination of tumor in neighbouring organs a surgeon becomes unstrong before the disease.

There are such cases, when the operation is the last method for diagnostics of disease. Such operations are named diagnostic.

Distinguish also typical and atypical operations.

The typical operations are executed on to the expressly developed charts, to the methods of operative interference. The atypical operations arise up in the case of unusual thing of pathological process which resulted in operative interference. The heavy traumatic damages, gunshot wounds, belong here. In these case the operation can take place on a few organs: vessels, bones, joints, hollow organs.

The blood and bloodless operations are distinguished also (reposition of bone wreckages, turn of fruit up and about).

With development of surgical technique the row of the special operations is selected:

• microsurgery – the operations are executed at the increase from 3 to 40 times for the help to the microscope – vascular surgery, ophthalmology, orthopedics, neurosurgery;

• endoscopy – with the use of endoscopy devices – deleting of polyps of stomach, urinary bladder, deleting of stone with choledochus, strange bodies. The laparoscopy operations belong here;

• endovessels – the closed intravessels operations which are executed under the rentgenologic control.

The surgical operation consists of basic stages:

1. surgical access;

2. basic stage of operation (surgical reception);

3. put suture of wound.

The basic requirements to operating access:

• minimum trauma;

• providing of good review of pathological process and terms of implementation of surgical reception.

For all typical operations the development the proper surgical accesses, and at untypical - a surgeon follows foregoing criteria.

Ending of basic stage of operation includes at itself the careful control of stop of bleeding – hemostasis.

Final stage of operation – put suture of wound. It must be executed carefully, that ligatures did not get untied and divide not edges of wound.

At implementation of all stages of operation basic condition – this thrifty attitude toward fabrics, impermissible rough compression of fabrics by instruments, over distension, tears of fabrics. These moments are important for the prophylaxis of complications about which a language will go later.

Warning of infection of wound is the above all task during the operation, that is observance of rules of asepsis and special measures during the operation.

All is begun with treatment of the operating field, which is conducted after introduction of patient to anesthesia or before the local anaesthetizing.

After the previous washing of skin by solution of liquid ammonia, by medical ether process the operating field after a method Grossich-Filonchicov or other method. The place of surgical access is insulated by operating sterile sheets. After it the isolated area of skin is processed by alcoholic solution of Jodonate or Chlorhexidine.

In the case when there is the source of possible contamination of wound – intestinal fistula, gangrene of extremity - he preliminary is insulated.

During the operation each of its participants must expressly know the duties. The orders of surgeon execute all without vibrations.

After implementation of access edges and walls of wound are closed by sterile serviettes for warning of infection of wound.

After implementation of basic stage the operations delete all serviettes, instruments are changed, process a skin by r-nom of Jodonate and then impose stitches on a wound. An operating wound must be sewn up, that in her there were no pockets, reserved cavities; the edges of wound must be well comparison, without tention.

After operation period – it is a period from the moment of ending of operation to convalescence of patient or transference of him on disability.

3 Periods distinguish in a pislyaoperatsiynomou period: early (from the moment of ending of operation of a to 4-5 day after her), late (from a 6-7 day after the operation to excerption of patient from a hospital), remote (since excerption from a hospital to renewal of capacity).

Normal motion of after operation period is distinguished, when absent heavy violations of functions of organs and systems, and is complicated, when the reaction on an operative trauma is sharply expressed and considerable functional violations develop.

The surgical operation and anesthesia cause pathophysiology changes of patient in an organism, that carry a general character and are an answer for an operating trauma. An organism mobilizes the system of protective factors and compensate reactions directed on the removal of consequences of operating trauma and renewal of homeostasis. Under action of operation there is a no new type of exchange of matters, and intensity of separate processes changes – accordance of catabolism and anabolism is violated.

In a after operation period three phases are distinguished: catabolic, reverse development, anabolic.

A catabolic phase proceeds 3-7 days. She is more expressed at patients with the heavy diseases, that carried heavy operative interferences. A catabolic phase is substantially prolonged by after operation complications. In lengthening of duration of catabolic phase act part bleeding, that proceeds, joining of festering-inflammatory complications, hypovolemy, changes of water-electrolyte and albumin’s balances, violation in the conduct of after operation period (take off pain, inferior and unbalanced parenteral feed, hypoventilation lights).

The clinical displays of catabolic phase from the side of the nervous system are: blurring sleeping, somnolence. Beginning with the second day after the operation, on the measure of stopping of action of narcotic facilities and appearance of pain, possible show excitation or oppression, unsteady psychical activity. Violations of psychical activity can be conditioned by joining of complications, that strengthen hypoxia, violation of water-electrolyte balance. From the side of the cardio-vessels system – pallor of skin, acceleration of pulse, moderate rise of arterial pressure. From the side of the respiratory system – increase of frequency of breathing, reduction of depth of breathing, the shallow breathing can be the conditioned pain, high standing of diaphragm, by development of paresis to the intestine. From the side of liver and buds – growth of disproteinemia, decline of synthesis of enzymes, reduction of diuresis.

The phase of reverse development proceeds 4-6 days. She comes at the uncomplicated motion of after operation period. It is characterized by normalization of albumin’s exchange, by the increased synthesis of albumens, glycogen, grew fat, by the decline of selection of ions to potassium with urine, renewal of water-electrolyte exchange, by predomination of the parasimpatic nervous system.

The clinical displays of this phase are: to reduction of pain, normalization of temperature of body, appearance of appetite, rise of activity of patient, normalization of colouring of skin, deepening of breathing, reduction of frequency of breathing, normalization of frequency of cardiac abbreviations, renewal of function of gastric-intestinal highway – renewal of peristalsis, departure of gases.

The Anabolic phase is characterized by the increased synthesis of albumen, glycogen, grew fat, that was lost during the operation and in the catabolic phase of after operation period. In this phase there is the subsequent activating of the parasimpatic nervous system and rise of activity of anabolic processes. It proceeds 2-5 weeks.

Clinical signs characterize an anabolic phase as period of convalescence, renewal of functions of the cardio-vessels, respiratory, secretion systems, organs of digestion, nervous system. The feel and state of patient gets better, an appetite rises, frequency of cardiac abbreviations, arterial pressure, is normalized, activity of digestive highway recommences: arcade of meal, processes of suction in an intestine, appearance of independent chair.

Duration of anabolic phase relies on weight of operation, initial state of sick, expressiveness and duration of catabolic phase.

After operative interference the patients go back into the surgical separation or in the chamber of intensive therapy, which are specially organized for the supervision after a patient, conducting of the proper intensive therapy and grant of urgent help, if herein there is a necessity. To the patient the permanent monitoring is conducted on the state life functions, after the indexes of homeostasis.

During the supervision after a patient it is needed to be oriented on the critical performance indicators of organs and systems which must serve by a basis for finding of reason of worsening of the state of patient and grant of condition out.

• The state of the cardio-vessels system: frequency of pulse more than 120 /min, decline of arterial pressure to 80 mm rt. pr. and below or rise to 200 mm rt. pr., violation of cardiac rhythm, decline or rise of central vein pressure.

• The state of the respiratory system: breathing frequency more than 28 for a 1 minute, absence of respiratory noises above the areas of lights.

• The state of skin and visible mucus shells: the expressed pallor, acrocianosis, sticky death-damp.

• The state of the system urinary excretion: reduction of urination (quantity of urine less than 10 ml/hour), absence of urination (anuria).

• The state of organs of gastric-intestinal highway: sharp tension of muscles of front abdominal wall, black excrement, presence of blood in an excrement, expressed swelling of stomach, absence of output of gases, absence of peristalsis.

• The state of the central nervous system: loss of consciousness, delirium, hallucination, excitation, put state on the brakes.

• The state of after operation wound: the expressed soaking of bandage of blood, divergence of edges of wound, go out of organs of abdominal region in a wound (eventeration), abundant soaking of bandage by a pus, intestinal maintenance.