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Ростовский Государственный Медицинский Университет

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Медицина общая

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Openappendectomyisthetraditionalapproach,involvinganincisioninthelowerrightquadrantofthe abdomen.Thisapproachiscommonlyusedincasesofcomplicatedappendicitis,wheretheappendixhas ruptured,orthereisanabscess.

Procedure:

Incision:A2-3 inch(5-8 cm)incisionis madeintherightlowerquadrantatMcBurney’s

point(approximatelyone-third ofthedistance fromtheanteriorsuperior iliacspinetothe umbilicus).

Exposure:Themusclesandfasciaarecarefullydividedtoexposetheperitoneum,whichis thenincisedtoaccesstheabdominalcavity.

Identification and Removal of the Appendix: The appendix is identified, clamped, and dividedfromitsattachmenttothececum.Thebaseoftheappendixisligatedwithsuturesor staplerstopreventleakage.

Closure:Theabdominalwallisclosedinlayers,andtheskiniseithersuturedorstapled.

7.1.2.2LaparoscopicAppendectomy

Laparoscopicappendectomyisaminimallyinvasivetechniquethathasbecomethepreferredapproach

formostcasesofappendicitis.Itoffersseveraladvantages,includingsmallerincisions,reducedpain,and fasterrecovery.

Procedure:

Port Placement: Three small incisions are made to insert a laparoscope and surgical

instrumentsintotheabdomen.Oneportis placedattheumbilicusforthecamera,andtwo additionalportsareplacedinthelowerabdomen.

Appendix Identification: The appendix is identified and carefully dissected from surroundingstructuresusinglaparoscopicinstruments.

AppendixRemoval:Oncetheappendixisfreed,itisplacedinaretrievalbagandremoved throughoneofthesmallincisions.

Closure:Thesmallincisionsareclosedwithsuturesorsurgicalglue.

7.1.3PostoperativeCareandComplications

PostoperativeCare:

Recovery: Patients typically recover quickly after a laparoscopic appendectomy, often

being discharged within 24-48 hours. Open appendectomy may require a longer hospital stay,particularlyincomplicatedcases.

PainManagement:Painismanagedwithanalgesics,andearlymobilizationisencouraged topreventcomplicationssuchasdeepveinthrombosis(DVT).

Diet:Patientsareusuallystartedonaliquiddiet,advancingtoanormaldietastolerated.

Complications:

WoundInfection:Oneofthemostcommoncomplications,especiallyinopenappendectomy

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orcasesofperforatedappendicitis.

Intra-abdominal Abscess: Can occur in complicated appendicitis if infection spreads withintheabdomen.

BowelInjury:Rarebutpossibleduringdissectionoftheappendix.

7.2Cholecystectomy:LaparoscopicandOpenTechniques

7.2.1IndicationsforCholecystectomy

Acholecystectomyis thesurgical removal ofthegallbladder,typicallyperformedtotreatgallbladder diseasessuchascholelithiasis(gallstones), cholecystitis(inflammationofthegallbladder), andbiliary

dyskinesia(abnormalgallbladderfunction).Indicationsforcholecystectomyinclude:

SymptomaticGallstones:Patientsexperiencingbiliarycolic,nausea,vomiting,orjaundice

duetogallstones.

AcuteCholecystitis:Inflammationofthegallbladder,usuallycausedbyablockedbileduct duetogallstones.

Cholangitis:Infectionofthebileducts,aseriousconditionrequiringprompttreatment.

GallbladderPolypsorTumors:Evenbenignpolypsmayrequireremovaliftheyarelarger

than1cmduetotheriskofmalignancy.

7.2.2SurgicalTechniquesforCholecystectomy

As with appendectomy, cholecystectomy can be performed using either an open or laparoscopic technique,withthelaparoscopicmethodbeingthemostcommon.

7.2.2.1LaparoscopicCholecystectomy

Laparoscopic cholecystectomyis the standard ofcare for mostpatientsrequiringgallbladder removal. The procedure involves making small incisionsto insert a laparoscope and instrumentstoremovethe gallbladder.

Procedure:

Port Placement: Foursmall incisions are madeinthe abdomento insert thecamera and

instruments.Oneportisplacedattheumbilicus,twointheupperrightabdomen,andonein theepigastrium.

Dissection: The cystic duct and cystic artery are identified, clipped, and divided. The gallbladderisthencarefullyseparatedfromtheliverbed.

GallbladderRemoval: Thegallbladder is placed ina retrieval bagandremovedthrough oneoftheincisions.

Closure:Thesmallincisionsareclosedwithsuturesorsurgicalglue.

7.2.2.2OpenCholecystectomy

Anopencholecystectomyis performed whenlaparoscopic surgery is notfeasible, suchas in cases of

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severe inflammation,scarringfromprevioussurgeries,orifthepatientisnotacandidateforminimally invasivesurgery.

Procedure:

Incision: A 4-6 inch(10-15 cm) incisionis made in theright upper quadrant, below the

ribcage.

GallbladderRemoval:Thegallbladderisdissectedfromtheliverbedafterthecysticduct andarteryareligatedanddivided.

Closure:Theabdominalwallisclosedinlayers,andtheskinissuturedorstapled.

7.2.3PostoperativeCareandComplications

PostoperativeCare:

Recovery:Mostpatientsundergoinglaparoscopiccholecystectomyaredischargedthesame

dayorthefollowingday.Opencholecystectomyrequiresalongerhospitalstay.

Diet:Patientsareadvisedtofollowalow-fatdietforseveralweeksaftersurgery.

PainManagement:Painismanagedwithanalgesics,andpatientsareencouragedtomove

aroundassoonaspossibletopreventcomplications.

Complications:

BileDuctInjury:Oneofthemostseriouscomplications,potentiallyleadingtobileleakage

andrequiringfurthersurgery.

Bleeding:Canoccurfromthecysticarteryorliverbedduringtheprocedure.

Infection:Woundorintra-abdominalinfectionsarepossibleaftersurgery.

7.3HerniaRepair:Inguinal,Femoral,andVentral

7.3.1TypesofHernias

Aherniaoccurs whenan organor tissue protrudesthrougha weak spot inthe surrounding muscle or fascia. Hernias are classified based on their location, with the most common types being inguinal,

femoral,andventralhernias.

InguinalHernia:Occursinthegroinarea,wheretheintestinespushthroughaweakspotin

theabdominalwall.

FemoralHernia:Similartoaninguinalherniabutoccurslowerinthegroinarea,nearthe thigh.

Ventral Hernia: A hernia that occurs in the abdominal wall, typically at the site of a previoussurgicalincision.

7.3.2SurgicalTechniquesforHerniaRepair

Herniarepaircanbeperformedusingopenorlaparoscopictechniques,withthegoalofreinforcingthe

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weakenedareaandpreventingtheherniafromrecurring.

7.3.2.1OpenHerniaRepair

Procedure:

Incision:Asmallincisionis made over thehernia site,andtheherniatedtissueis pushed

backintotheabdominalcavity.

MeshPlacement:Asyntheticmeshisplacedovertheweakareatoreinforcetheabdominal wallandpreventrecurrence.

Closure:Theincisionisclosedwithsutures,andthepatientismonitoredforrecovery.

7.3.2.2LaparoscopicHerniaRepair

Procedure:

PortPlacement:Smallincisionsaremadetoinsertalaparoscopeandinstruments.

HerniaReduction: Theherniated tissue is pushed backinto theabdomen, anda mesh is

placedtoreinforcetheweakenedarea.

Closure:Thesmallincisionsareclosedwithsuturesorglue.

7.3.3PostoperativeCareandComplications

PostoperativeCare:

Recovery:Patientsundergoinglaparoscopicrepairtypicallyhaveafasterrecoveryandless

postoperativepaincomparedtoopenrepair.

Activity Restrictions: Patientsare advised to avoid heavylifting for several weeksafter surgery.

Complications:

Recurrence: Despite repair, hernias can recur, particularly if the repair is not properly

reinforced.

Infection:Aswithanysurgicalprocedure,infectionattheincisionsiteisarisk.

Chronic Pain: Some patients may experience chronic pain atthe repair site, particularly

withmeshplacement.

7.4BowelResectionandAnastomosis

7.4.1IndicationsforBowelResection

Abowelresectioninvolvesremovingadiseasedportionoftheintestine,oftenduetoconditionssuchas:

ColonCancer:Removalofthecanceroussegmentofthecolon.

Diverticulitis: Inflammation of the diverticula in the colon that can lead to infection or

perforation.

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Crohn’s Disease: A chronic inflammatory bowel disease that may require resection of diseasedbowelsegments.

IschemicBowel: When the blood supplyto the bowel is compromised, leading to tissue death.

7.4.2SurgicalTechniquesforBowelResection

Bowelresectioncanbeperformedusingopenorlaparoscopictechniques,withthegoalofremovingthe diseasedsegmentandreattachingthehealthyendsofthebowel.

7.4.2.1OpenBowelResection

Procedure:

Incision:Alargeincisionismadeintheabdomentoaccessthebowel.

Resection:Thediseasedsegmentofthebowelisidentifiedandremoved.

Anastomosis:Thetwohealthyendsofthebowelarereconnectedtorestorecontinuity.

Closure:Theabdominalwallisclosedwithsuturesorstaples.

7.4.2.2LaparoscopicBowelResection

Procedure:

PortPlacement:Smallincisionsaremadetoinsertalaparoscopeandinstruments.

Resection:Thediseasedsegmentofthebowelisremovedusinglaparoscopicinstruments.

Anastomosis:Thehealthyendsofthebowelarereconnected.

Closure:Thesmallincisionsareclosedwithsuturesorglue.

7.4.3PostoperativeCareandComplications

PostoperativeCare:

Diet: Patients are initiallystarted ona liquiddiet, graduallyadvancingtosolid foods as

bowelfunctionreturns.

PainManagement:Painismanagedwithanalgesics,andearlymobilizationisencouraged.

Complications:

AnastomoticLeak:Aseriouscomplicationwhere theconnectionbetweenthetwo bowel

endsfails,leadingtoleakageofbowelcontentsintotheabdomen.

Infection:Woundinfectionsorintra-abdominalinfectionsarepossible.

BowelObstruction:Scartissuefromthesurgerycanleadtobowelobstruction,requiring

furthertreatment.

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Conclusion

General surgery procedures are critical in the management of a variety of abdominal and soft tissue conditions.Whetherperforminganappendectomy,cholecystectomy,herniarepair,orbowelresection,the surgeonmusthaveathoroughunderstandingoftheindications,techniques,andpotentialcomplicationsof eachprocedure.Masteryofthesetechniquesensuresoptimalpatientoutcomesandminimizestheriskof postoperative complications. In all cases, careful patient selection, meticulous surgical technique, and vigilantpostoperativecareareessentialtosuccessfulsurgery.

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CHAPTEREIGHT

SpecializedSurgicalProcedures

Surgery has evolved to encompass highly specialized procedures, each requiring unique expertise, techniques,andtechnologies.Thesespecializedsurgicalfieldsallowsurgeonstofocusonspecificparts ofthebodyorparticulardiseases,improvingpatientoutcomesthroughtargetedtreatments.Inthissection, we will discuss five major areas of specialized surgery: Cardiothoracic Surgery, Neurosurgery, OrthopedicSurgery,UrologicalSurgery,andPlasticandReconstructiveSurgery.

8.1CardiothoracicSurgery:CoronaryArteryBypassGrafting(CABG)

8.1.1IndicationsforCABG

CoronaryArteryBypassGrafting(CABG)isasurgicalprocedureperformedtoimprovebloodflow to theheart.Itisprimarilyindicatedforpatientswithcoronaryarterydisease(CAD),wherethearteries supplyingbloodtotheheartmusclebecomenarrowedorblocked.IndicationsforCABGinclude:

Severe coronary artery blockage: Particularly when multiple arteries are involved or whentheleftmaincoronaryarteryissignificantlynarrowed.

Refractoryangina:Chestpainthatcannotbecontrolledwithmedicationsorlessinvasive procedures.

Heartfailure with coronaryarterydisease: CABGis sometimes performed toimprove heartfunctioninpatientswithheartfailure.

8.1.2SurgicalTechniquesforCABG

Coronaryarterybypassgraftinginvolvestakingabloodvesselfromanotherpartofthebodyandusingit

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tobypasstheblockedornarrowedcoronaryartery,restoringnormalbloodflowtotheheartmuscle.

8.1.2.1Traditional(On-Pump)CABG

On-pumpCABGisperformedwiththeaidofaheart-lungmachine,whichtakesoverthefunctionsofthe

heartandlungsduringthesurgery.Thistechniqueallowsthesurgeontooperateonastillheart.

Procedure:

Incision: A midline incision is made along the sternum to provide access to the heart

(sternotomy).

CardiopulmonaryBypass(CPB):Thepatientisconnectedtoaheart-lungmachine,which circulatesandoxygenatesthebloodwhiletheheartisstopped.

Harvesting Grafts: Grafts are typically taken from the saphenous vein in the leg, the internalmammaryartery,ortheradialarteryinthearm.

GraftPlacement:Thegraftissewnaboveandbelowtheblockage,creatinganewroutefor bloodflowtotheheartmuscle.

RestartingtheHeart:Oncethegraftsareinplace,theheartisrestarted,andthepatientis graduallyweanedofftheheart-lungmachine.

Closure:Thesternumisclosedwithwires,andtheincisionissutured.

8.1.2.2Off-PumpCABG

Off-pumpCABGisperformedonabeatingheart,withouttheuseoftheheart-lungmachine.Thismethod

reducestherisksassociatedwithcardiopulmonarybypassbutrequiresadvancedsurgicalskills.

Procedure:

Incision:Asinon-pumpCABG,amidlinesternotomyisperformed.

Stabilization: Specialized instruments are used to stabilize the area of the heart being

operatedon,allowingthesurgeontosewthegraftwhiletheheartcontinuestobeat.

GraftPlacement:Thegraftissewninplacewithoutstoppingtheheart.

Closure:Thesternumiswiredclosed,andtheincisionissutured.

8.1.3PostoperativeCareandComplications

PostoperativeCare:

ICUMonitoring:PatientsarecloselymonitoredintheICUforthefirst24-48hours,witha

focusonheartrhythm,bloodpressure,andoxygenation.

PainManagement:Painismanagedwithanalgesics,andearlyambulationisencouragedto preventcomplications.

DietandLifestyleChanges: Patientsare advised toadopta heart-healthydietandavoid smokingtopreventfuturecoronaryarterydisease.

Complications:

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Infection:Particularlyatthesternotomysiteorwhereveinswereharvested.

Arrhythmias:Abnormalheartrhythms,suchasatrialfibrillation,arecommonafterCABG.

GraftFailure:Overtime,thegraftedvesselsmaybecomeblockedornarrowed.

8.2Neurosurgery:CraniotomyandSpinalSurgery

8.2.1Craniotomy:IndicationsandTechniques

Acraniotomyisasurgicalprocedureinwhichaportionoftheskullistemporarilyremovedtoaccessthe brain.Indicationsforcraniotomyinclude:

Brain Tumors: Both benign and malignant tumors may require craniotomy for biopsy or removal.

Aneurysms:Acraniotomymaybenecessarytocliporrepairabrainaneurysm.

TraumaticBrainInjury:Craniotomyisoftenperformedtorelievepressurefrombleeding

orswellinginthebrain.

EpilepsySurgery:Toremovethepartofthebraincausingseizures.

8.2.2SurgicalTechniquesforCraniotomy

Procedure:

Incision:Ascalp incisionismadeover theareaoftheskull whereaccess to thebrain is

needed.

BoneFlapRemoval:Asectionoftheskull(boneflap)isremovedusingaspecializeddrill.

BrainExposure:Thedura(outerlayerofthebrain)iscarefullyopenedtoexposethebrain

tissue.

Treatment: The neurosurgeon performs the necessary treatment, whether it’s removing a tumor,repairingananeurysm,oraddressingatraumaticinjury.

Closure:Aftertheprocedure,theboneflapisreplacedandsecuredwithplatesandscrews. Thescalpissuturedclosed.

8.2.3SpinalSurgery:IndicationsandTechniques

Spinal surgery is often performed to address issues such as herniated discs, spinal fractures, or

degenerativespinalconditionslikespinalstenosis.

Indicationsforspinalsurgeryinclude:

HerniatedDisc:Causingcompressionofthespinalcordornerves.

SpinalStenosis:Narrowingofthespinalcanalleadingtonervecompression.

SpinalFractures:Causedbytraumaorosteoporosis.

SpinalTumors:Bothbenignandmalignanttumorsmayrequireremoval.

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8.2.3.1Laminectomy

Alaminectomyis performed torelieve pressure onthespinalcord or nerves byremovingpart ofthe vertebracalledthelamina.

Procedure:

Incision:Asmallincisionismadeovertheaffectedareaofthespine.

LaminaRemoval:Thesurgeonremovespartofthelaminatodecompressthespinalcordor

nerves.

Closure:Themusclesandskinaresuturedclosed.

8.2.3.2SpinalFusion

Spinalfusioninvolvesfusingtwoormorevertebraetogethertostabilizethespine.Itisoftenusedtotreat

conditionslikedegenerativediscdiseaseorspinalfractures.

Procedure:

BoneGraftPlacement:Abonegraft,takenfromthepatient’spelvisoradonor,isplaced

betweenthevertebrae.

Stabilization: Screws and rods are used to hold the vertebrae together while the fusion occurs.

Closure:Theincisionissuturedclosed,andthepatientismonitoredforrecovery.

8.3OrthopedicSurgery:JointReplacementandFractureFixation

8.3.1JointReplacement:IndicationsandTechniques

Joint replacement surgery, particularly hip and knee replacements, is one of the most common orthopedic procedures.Itis primarilyperformed torelieve painandimprovemobilityinpatientswith

arthritisorjointdamage.

Indicationsforjointreplacementinclude:

Osteoarthritis:Wear-and-teararthritisthatleadstojointpainandstiffness.

Rheumatoid Arthritis: An autoimmune condition that causes joint inflammation and

damage.

Trauma:Jointreplacementmayberequiredfollowingsignificantjointinjuries.

8.3.1.1HipReplacement

Procedure:

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