IV. Table of contents of teaching

The operation is an important link in the plan of medical treatment of surgical patient. However, only the operation provides success in surgical medical treatment. Success this relies on whole organokompleksa, that precedes operation and concerted actions of all operating brigade. That is why only learning all sections of general surgery, practical skills of work of student in an operating-room, grow into keen action.

The surgical operation is executed by an operating brigade in the complement of which enter:

• surgeon operating;

• surgeon – assistant (one or a few);

• operating sister (sisters);

• doctor – anaesthetist;

• anestezist;

• junior nurses.

Position of surgeon and his helpers in relation to sick and operating table must respond to the conditions of the best access to the wound and concerted co-operation of members of operating brigade. Placing of participants of operative interference is executed depending on the type of operation.

Operating table must be found at the level of elbow of the greatest member of operating brigade. It must not happen so that to who – nibud was to shut down through pain in the back. If at a surgeon the lowered sharpness of sight, he must carry glasses, that not to lean over table low.

The first assistant occupies position opposite a surgeon. The second assistant – on the left of surgeon and stands sideways, that not to interfere with a surgeon. He must well see the operating field and expressly manipulate retraktorami.

Attention of surgeon – operator and operating sister of sosredotachivaetsya on an operating wound. A surgeon gets instruments automatically, not paying attention, that to him pass. Thus only the right hand of surgeon is found afoot.

One bestenevaya lamp is found above a head, other – above the shoulder of surgeon. If an operating wound needs more intensive illumination (operation on a heart and dr.) a surgeon can use a frontal lamp. It is necessary to underline that sufficient operative access facilitates visibility and does not need strong restriktsii of edges of wound.

Trade of surgeon is based on a hand technique and is also provided by modern devices and equipment. For valuable surgical work it is necessary to have scientific knowledges and special materially – technical equipment, it is well to manage a surgical technique and use principles of surgical deontologii.

One of the basic requirements to high quality of surgical work is careful attitude toward fabrics. The presence of this quality allows to recognize the fitness of the given doctor to surgical activity. Opposite, careless attitude toward fabrics: pulling, mashing and digging up in fabrics characterizes a bad surgeon. In order to work quietly and it is sure, seriously and without vibrations in any meeting situation, a surgeon must have enough technical and psychological preparation which comes with experience. A surgeon must be able to execute the simple and difficult operations, he, in actual fact, never stops to study.

However, one theoretical knowledges to the surgeon it is not enough, if he did not acquire an operating technique in practice. It is known, that musicians and sportsmen, trade necessary for participation in a concert or sporting competition, acquire thanks to continuous exercises only. Most surgeons are sure, that the necessary training they will get at the conservative operations and, that they badly operate only because do it not enough often. Daily practice with the piece of fabric, needleholder, needle, stitch material, scissors and styptic clamp enables to acquire skills sufficient for implementation of operations.

Such practical exercises can be complicated, placing the piece of fabric on the bottom of box or kakoy– nibud other capacity.

A surgeon and all members of his brigade must have the good bodily condition, because can happen so, that to who – nibud will be to be engaged in the own health and samochuvstviem in place of that to work with a patient. Some surgeons strongly sweat during the operation. These complications can be decreased, if to limit the reception of liquid in the evening in eve the operation, and before the operation to draw on a little cap below than eyebrows and to heave up a mask till about the level of eyes. That, who carries glasses, for prevention of growing of glass misted it is necessary to rub them by dry soap, and then otpolirovivat by the piece of dry fabric.

Operation – it is work which is executed collectively. Success of operations relies on quality of work of all members of brigade, and not only from one surgeon.

Main duty of assistants – preparation of operating wound, so that during all operation a surgeon could easily distinguish all anatomic structures and clear see reproduced to them actions. Assistants must have the good review of the operating field. They must watch after that their instruments and hands did not cover the area of the operating field. They must work so that to give to the surgeon maximal freedom of actions in a wound.

A surgeon works in the center of operating wound, and the first assistant directly helps him. The second assistant, as a rule, works on peripheral areas. Assistants must well know all stages of operation and do all necessity, that the operation passed in accordance with established procedure. In spite of obstacles, efforts of all brigade must be directed on that to evade or overcome, any obstacles and to complete the operation of accordant drawn up a plan.

A surgeon must carry conviction in the actions, and an assistant must be able to be easily influenced. The best assistant is that at which only one purpose – to help a surgeon. Experience of the protracted compatible work of members of operating brigade allows to surmount any obstacles and successfully go out even from situations hopeless, on the face of it.

Operating-room – it is a debating-society. Assistants can indicate to the surgeon on serious moments on which he could pass. However, they must operate so, only then, when it is absolutely needed – a surgeon could simply postpone on the set time the given manipulation and assistants must not hammer together him from the set way. It touches such situation, when more experimental surgeon comes forward as an assistant of beginner of surgeon. Small substantial details must be discussed to or after the operation.

A surgeon, assistants and anaesthetists, form “advice” which at the instance of surgeon considers all possibilities and awards common judgement in relation to subsequent actions. In some very much, the overloaded hospitals a surgeon can sometimes allow assistants to make off the operation since fabrics which it was necessary to delete, remote and gemostaz on basic areas is executed.

An operating sister to beginning of operation is under an obligation to prepare the workplace, that is put in supports and tie up necessary for the given operation biksi; to adjust a ceiling bestenevuyu operating lamp; to check up the presence of stitch material; sterile and disinfectant solutions, correct setting of operating table; to drive to working position electro-sucking for an abdominal region, vehicle the electro-knife and ultrasonic sterilizer.

An operating sister checks up correct position of patient on operating table, that squeezing of nerve, burns or other wounds did not happen. She must well know different stages of operation and operating technique. Only at these terms she will be able to prepare all necessary materials. During the operation, a sister must stand on one side with a surgeon, that she could clear see an operating wound, to give instruments directly in the right hand of surgeon and quickly take away at him after the use. A surgeon and assistants must do all from them dependent, that a sister always well saw the operating field, because only in this case she can give necessary instruments in good time. If an operating sister well sees the operating field, she is in a position to hold in a hand an instrument which will be needed to the following, for that to pass him to the surgeon without a hitch; if she does not see motion of operation, she has to expect, while a surgeon will not ask necessary instruments, and to lose time on their search on a dinner-wagon for instruments.

Surgeon which often changes the plans and requires that one, other instruments, hampers work to the operating sister. An operating sister must immediately adapt to different surprises which arise up during the operation, especially in the case of bleeding, and must quickly pass that to the surgeon, that he will need (vehicle for sucking of liquids, serviette, hot izotonicheskiy salt solution, stitch material and dr.). When difficult situation behind, she can recover the normal terms of the operating field, replacing the used serviettes, tampons and instruments on clean.

Before taking of cavity of body in an operating medical sister by a junior nurse must count clamps and serviettes withdrawn from a cavity. On ending of operation it is needed to disconnect all electrical equipment from a network, to wash prosterilizovat tips, attachments and to prepare an apparatus to a next operation.

The washed and dried out instruments, strictly upon a settlement, are mortgaged in biksi, or completed in the sets for the following avtoklavirovaniya.

A V Reference basis of action

Students present in an operating-room must be dressed after the proper form: hairs are tucked in under a little cap, to dress feet in bahili, the mask necessarily put on.

Students in predoperatsionnoy accept, from the hands of junior nurses of separation, katalku with a patient and transport her to operating table. Under the direction of operator they lay a patient on operating table. Piling must provide thus: position of body according to operative access; on the back, on a side, on a stomach or dr.: the reliable fixed position of separate parts of body: hands, feet, heads or dr.; not to violate action on the physiological and vitally important functions of organism of sick, not to squeeze vessels, nerves; not to cause disorder of circulation of blood and breathing.

1. Before the beginning of treatment of the operating field it is necessary to check up the hospital chart of patient. Check up absence of records about the allergic reactions of patient on solutions.

2. Out flowline of solution of antiseptikov under a patient or under turnstiles. These solutions can cause the irritations or burns.

3. Solution of antiseptika must not be cold, if the operation is executed under local anaesthesia.

4. The haste at treatment of the operating field is not needed.

Facing (isolation) of the operating field is executed by sterile sheets, made from linen fabrics (flax), or no tissue materials (paper sheets). Linen sheets and towels require elimination, piling and sterilization in the conditions of surgical permanent establishment. In addition, they do not push away water and easily moisten during the operation, creating terms for kontaminatsii of the operating field. Paper wares are intended for the non-permanent use, that considerably facilitates work of operating block. However, they inflexible and in the process of facing of the operating field there are difficulties, quite often which result in resterilizatsii.

Basic principles of technique of facing of the operating field follow from its setting – to warn kontaminatsiyu of hands of surgeon during the operation (“wide sleeves”) from unsterile parts of body of patient and located next to the articles of equipment of operating-room. Then from above towels small sheets which are sm of rectangles of material long to 100 are laid. And in durance vile use four sterile sheets which a surgeon consistently throws on a patient, not touching untilled parts of body of sick, clothes and operating table.

A sheet which separates the operating field from below and closes a pelvis and lower extremities is thrown at first. A sister must watch thus, that the lower edge of sterile sheet well closed the feet of patient, because in future she will have to work in a direct closeness to every end of operating table. Then throw prostinyu, separate the operating field from above and closing the breast of patient. For warning of contamination of the operating field and comfort of approach to the patient from the side of head (providing of the free breathing of sick, control after his state, introductions of anesthesia and dr.) this kick prostinyu about through the cross-beam of frame, fastened on operating table. Two other sheets limit the operating field on each side so that there was free their edge in the distance 8-10 sm. He will be needed in future, for fixing, dissected peritoneum.

At small cuts (appendektomiya, grigesechenie under local anaesthesia) sometimes it is possible to treat by two sheets, disposing them at right angles. Sheets were earlier used with cuts in the middle, here one prostin limited the operating field from every quarter. But at a necessity the expansion of volume of operation, expansion of access, this prostin was to cut. A surgeon, determines the character of operation and type of access, must independently insulate the operating field.

Preparation to the operation ends with fixing of all sheets, in the forced their position, by four linen clamps (tsapkami) on corners. To be farther conducted treatment of skin by antiseptikami on motion of credible cut, local anaesthesia and repeated treatment by antiseptikami.

When a surgeon and assistant conduct local anaesthesia, an operating sister has time finally to prepare to the operation.

The serve of instrument to the surgeon must be rapid, timely and technically correct. Speed is achieved by experience and skills. The timeliness of serve of instruments is achieved by knowledge of motion of operation and instruments. The technique of serve and by turn use of instruments are expounded in the special sections.

There are three methods of serve of instrument:

• in hands to the surgeon;

• on an instrumental dinner-wagon;

• combined.

Serve of instruments in hands to the surgeon – the most perfect method, because fully releases a surgeon from superfluous actions unconnected with work in the area of operative interference. This method is most tested, because an operating sister is easier to watch after an order and cleanness on instrumental table, but also the heaviest, because needs high speed, good organization of workplace and clear knowledge of motion of operation.

Necessary complete harmony in work with a surgeon and knowledge of all details of his technique, sequence what at different surgeons can be different.

The second method – most stand. An operating sister places the necessary set of instruments and materials on an instrumental dinner-wagon; a surgeon on motion of operation takes necessary instruments from table. A sister keeps order on table, gives ligature, tightens in the needles of filament. Attention of surgeon is diverted thus, the heap of time is lost, violations of rules of technique of asepsis are possible. This method is in right at the festering operations, in order to avoid contamination of large instrumental table.

The third method contains both described methods. In the less heavy and proper moments of operation, surgeon the beret those instruments which lie near at hand. Instruments, requiring preparations (syringes with solution, needleholder), are given by a sister. In tension the moments a sister gives all instruments in the hands of surgeon. This method is most widespread: than qualification of sister is higher, the she will be quick to pass to the first method of serve of instrument.

Instruments are given, as a rule, by a hand. A sister must not touch by a hand to that part of instrument, which will touch fabrics. It is necessary to use next receptions.

Serve of syringe. Solution in a syringe is collected by slow motions of piston, watching that solution was collected to the end and that in a syringe was not air.

Serve of scissors, clamps, hooks. Scissors are given in the closed kind by rings from itself. Just, by rings to the surgeon, all types of clamps are given, the locks of them must be closed thus.

Serve of needleholder. A needle for a nakladaniya stitch is stopped up in a needleholder. For this purpose a sister takes in a right hand the needleholder and takes needle by the ends of branshey, broadwise, nearer to the dull end. Sharp needles must be reverse to the left, vushko–vpravo, both ends are aimed upward. Needleholder give to the surgeon so that he could by the same hand take the long end of filament, or long end, a sister holds pincers, that he did not call round a needleholder.

Serve of scalpel. Give a scalpel to the surgeon by a handle, a sister holds him on a neck and blade by means little serviette, thus the edge of scalpel is turned to its palm. A serviette warns the hand of sister from an involuntary cut.

Sometimes instruments give korntsangom or, at the small operations, by pincers, if the hands of sister are not treated, from the danger of infitsirovaniya of her arms. Scalpel, take korntsangom for his middle – across pincers, for one with bransh. Scissors are given, sticking branshi korntsanga in the ring of scissors. Clamps are taken at the closed lock for one of rings.

Filaments without needles are given by pincers. To touch a filament by hands follows as few as possible in avoidances of infitsirovaniya. Length of her is determined by the type of stitch: for a continuous stitch a filament is taken long 40-45 sm., for superficial key stitches - 18-20 sm., for stitches, at back of operating wound – 15-20 sm. By the same length a filament is taken for a kissetnogo stitch. For measuring of length of filament it follows to use some permanent measurement, for example, length of own palm.

Ketgutovuyu ligature needs to be taken a bit more of silk filament, because a catgut slides at stringing. Filaments for stitches are used a different thickness depending on necessary durability of stitch, features of the fabric taken in and dr.

Silk №9 use for the stitch of vessels and nerves №1–2 – for an intestinal stitch №a 4–6 –dlya stitch of aponevroza. A skin is sewn by silk №3–4. Muscles, as a rule, sew by a catgut. Before the serve of ligatures it is necessary to check up durability of filaments on a break. The hanks of a secret is easily breaking filaments are removed.

Bandaging material is given by an instrument. Marbles hold on an instrumental dinner-wagon or give in hands one by one: to lay marbles grouped on prostinyu, covering a patient, dangerously, because a marble by a chance can get in a wound. For drying of the operating field give tupferi – the convolute by a roller little serviettes clutched on length in branshah korntsanga. For osushivaniya at back of wound the tampons are applied (on their end here are naladivayut clamps).

The size of marble, serviette or tampon must answer the size of wound, to the quantity of liquid which it follows to dry. In the case of appearance of drops of content at dissection of stomach or bowel, the “beauty-spot” underlay so-called – very little marbles. At presence of krovotochivosti, for osushivaniya, it follows to give so nazvaemie magnificent tupferi – clutched in the korntsang convolute middle serviettes of appeals.

Internal organs, during the operation, with the purpose of warning of their drying out close moist, moistened by warm izotonicheskim solution of sodium of chloride, large serviettes or towels.

Instruments during the operation can be used one time or repeatedly. At the non-permanent use at once throw down an instrument after the use or he, being imposed on fabric, remains to the end of operation. Those instruments which are needed during all operation are repeatedly used (scalpels, scissors, some types of clamps). This so-called, instruments, that return.

It is necessary to watch after that every used and already unnecessary presently instrument was again placed on an instrumental dinner-wagon. It is impossible to assume accumulation of such instruments on sheets, round an operating wound. Every instrument which return must be at the same time carefully wiped by a gauze, otherwise bacteria from air can settle on the bloodstained surface of metal, a blood will dry up and to delete her will be uneasily. Instruments which are covered by a sohshey blood, must be are either thrown out in a pelvis, or cleared by a moist serviette and treated by antiseptikom.

A sister must watch not only after the cleanness of instruments which return, but also after their good condition. Especially attentively it is needed to check needleholders and watch that a needle came back together with him.

A personnel in an operating-room, dressed in sterile clothes, must be found in the area of the sterile mode. Members of operating brigade, which are dressed in sterile clothes (shirt, pantaloons, dressing-gown, little cap, mask, tapochki) must not abandon the area of the sterile mode.

Talks in the area of the sterile mode need to be taken to the minimum. During the talk of mouth of man, which speaks, the sparks of saliva take off, that leads to distribution the bacteria in mid air. A loud talk and laughter in an operating-room create the terms of kontaminatsii of operating wound (hit of microorganisms).

Motion of personnel during the operation is taken to the minimum. At walking on an operating-room a blast is created, that moves, which microorganisms can move together with.

The personnel of operating block, not dressed in sterile clothes, must not be found above sterile table.

The members of operating brigade must be found to the persons to each other. The members of operating brigade go by each other by only the back. Never turn the back to the sterile surface (instrumental dinner-wagon, operating table and others).

Equipment which use during the operation, it is needed to sterilize to the operation.

The personnel dressed in sterile clothes touches to the sterile equipment only.

If sterility of operating brigade is subject to the doubt, a brigade is considered unsterile.

Sterile materials and surgical instruments are considered sterile only on sterile table.

An operating dressing-gown is accepted to consider sterile at the front from the line of arm-pits, and the sleeves of dressing-gown on 3 sm are higher than elbow.

The edge of container, that contains sterile material, is unsterile.

Careful gemostaz due to the methods of final stop of bleeding is ending of basic stage of operation.

Taking of wound is the eventual stage of operation in. She is executed layer with intimate comparison of homogeneous fabrics and without abandonment of cavities. This one of terms of primary cicatrization of wound. The edges of wound are compared without the pull.

And before taking in, and after, both the edges of wound and line of stitches the next time are processed by an alcohol–iodine. The posleoperatsionnaya wound taken in by dreniruetsya rubber ribbons and on her are laid on moistened by antiseptikom row of serviettes, and over him another row, but already dry serviettes. All it is fastened kleolovoy or bandage bandage.

Students look after after the stage of “awakening” of patient and transition him on the spontaneous breathing. After it under the control the teacher they shift him on katalku and escorted by anaesthetist transport in a posleoperatsionnuyu chamber.