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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_725_Библиотеки_им_академика_М_И_Перельмана
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surgeonstoperformasplenectomyontheseexsanguinatingpatients—
inspiteofthefactthatJulesPéanofParishad performeda successful
splenectomy on a girl with a massive splenic cyst in 1867. Two
unsuccessful attempts to save life in splenic rupture were reported in
1892bySir Arbuthnot Lane of Guy’sHospital, London, and three more
fatal cases were recorded by Friedrich Trendelenburg in Leipzig the
followingyear.Thewordingofthesecasereportsstronglysuggeststhat
had blood transfusion been available, the patients might well have
survived.
ItfelltoOskarRiegnerinBreslautoperformthefirstsplenectomyfora
pulpedspleenwithsurvivalin1893.Thepatient,aladof14,wasfoundto
havethe spleencompletelysevered andthere was1.5Lofblood inthe
abdomen. Normal saline was given subcutaneously into all four limbs.
Hisrecoverywascomplicatedbygangreneoftheleftfoot,whichrequired
amputation,butheleftthehospital,completewithartificiallimb,5months
afterhissplenectomy.
Intestinalobstruction
Not surprisingly, early attempts to deal with large bowel obstruction
(usuallydue to aleft-sidedcolonic cancer) comprisedperformance of a
colostomy.The firstattempt to dothis wasmadeby PilloreofRouen in
1776.Heactuallycarriedoutacecostomyonawinemerchantwithgross
abdominal distension due to a rectosigmoid growth. The operation
produced great relief, but the patient died on the 28th day because of
necrosis of a loop of jejunum, brought about by the large amounts of
mercurygiveninthepre-operativeattemptstoovercometheobstruction.
Itremained forPierreFine ofGeneva, in1797,to performa successful
transverse colostomy. The patient, a lady of 63 with an obstructing
sigmoidgrowth,died14weekslaterwithascites.
Not until the introduction of anesthesia and antisepsis could routine
resection of bowel cancers be performed, the first success in this era
being reported by Vincent Czerny in Heidelberg in 1879. It was soon
realizedthatresectionoftheobstructedcolonwasverylikelytoresultin
afatalanastomoticleak.Exteriorizationofthegrowth,withformationofa
double-barrelledcolostomyanditssubsequentclosurewasintroducedby
FrankThomasPaulofLiverpoolin1895,andbyJohannesvonMikuliczRadecki of Breslau a little later. This procedure, the Paul-Mikulicz
operation,was shownby thelatter toreduce mortalityinhis owncases
from 43% with primary resection to 12.5% with the exteriorization
method.
With its vivid clinical features of intestinal obstruction in a baby,
passage of redcurrant jelly stools, a palpable abdominal mass and
sometimes a prolapsing mass to be felt per rectum or even seen to
protrudethroughtheanalverge,itisnotsurprisingthatintussusceptionin
children was one of the earliest specific pathologies of the acute
abdomen to be recognized. Treatment was expectant, with the use of
enemas or rectal bougies, in attempts to reduce the mass. Surgeons
were encouraged to dothis by very occasional reports of success and
still rarer accounts of recovery following the passage of the sloughed
gangrenousbowelperrectum.Thefirstoperativesuccesswasreported
bySirJonathanHutchinson,oftheLondonHospital,in1871.Hispatient,
agirl aged 2,hadher intussusceptionreducedthrough a shortmid-line
incision, the operation requiring just a few minutes. Hutchinson’s
meticulousreporttabulated 131previously recordedcases,whichmake
sadreadingindeed.
Therewasadownsidetothisnewabdominalsurgery.Itwasnot long
after this new era commenced that the first reports appeared of small
bowel obstruction due to postoperative adhesions. Thomas Bryant of
Guy’s Hospital recorded the first example in 1872 — a fatal case
following an ovariotomy. A second fatality, 4 years after removal of an
ovarianmass,wasreportedin1883byWilliamBattleofLondon.Today,
postoperative adhesions and bands account forsome three-quartersof
allcasesofsmallbowelobstructionsintheWesternWorld.
Perforatedpepticulcer
Untreated, a perforated peptic ulcer nearly always results in fatal
peritonitis. Unsuccessful attempts at repair were made by MikuliczRadeckiin1884andbyCzernyin1885andsubsequentlybyanumberof
other surgeons. This depressing series came to an end under most
difficultcircumstances.In1892,LudwigHeusnerofWuppertal,Germany,
repairedaperforatedgastric ulcer high up on the lesser curve in a 41year-old businessman with a 16-hour history; the operation was
performedinthe middle of the night by candlelight! The convalescence
wascomplicatedbyaleft-sidedempyema,whichrequireddrainage.Two
yearslater,ThomasMorse,inNorwich,publishedthesuccessfulrepairof
aperforationnearthecardia in a girl of 20. With these two successes,
operationforthisconditionbecameroutine.Interestingly,gastriculcerat
theturnofthe20thcenturywasfarcommonerthanduodenalulcerand
wasespeciallyfoundinyoungwomen.
Rupturedectopicpregnancy
Until1883arupturedectopicpregnancywasadeathsentence.Thisis
surprisingbecause theearlypioneers ofabdominalsurgery, goingback
to pre-anesthetic era, were, in the main, concerned with removal of
ovarian masses. Indeed, the first elective abdominal operation for a
knownpathologywastheremovalofamassiveovariancystbyEphraim
McDowell in Danville, Kentucky, in 1809. Yet, for some inexplicable
reason,thesurgeonwouldstand helplesslybythebedsideandwatcha
young woman, in the most useful time of her existence, exsanguinate
fromherrupturedtube.Thefirstsurgeontoperformsuccessfulsurgeryin
this condition was Robert Lawson Tait, of Birmingham, whom we have
alreadymentionedperformingasuccessfulappendicectomyin1880.Tait
was asked to see a girl with a ruptured ectopic pregnancy by Dr.
Hallwright, a general practitioner. Hallwright suggested that Tait should
removetherupturedtube.Taitrecordedthefollowing:
Thesuggestionstaggered meandIamafraidI did notreceiveitfavourably.Ideclinedto act
andafurtherhaemorrhagekilledthepatient.Apost-mortemexaminationrevealedtheperfect
accuracyofthediagnosis.Icarefullyinspectedthespecimenthatwasremovedandfoundthat
ifIhad tied the broad ligamentandremovedthe tube I should havecompletelyarrestedthe
haemorrhage,andInowbelievethathadIdonethisthepatient’slifewouldhavebeensaved.
Eighteenmonthslater,Taitoperatedonaclearlydyingpatient,thefirst
occasion in which such an operation was performed. The patient, in
those pre-transfusion days, died of exsanguination. Finally, in March
1888, Tait performed a successful salpingectomy on such a case, who
survivedeven though,atoperation, theabdomen wasfullof clot.Years
later,he wasableto report39cases,withbuttwodeaths,includingthe
first.
Envoi
Eventoday,theacuteabdomenpresentsadiagnosticandtherapeutic
challenge to the surgeon. This is in spite of the fact that we have the
ancillary aids of radiology and other imaging, biochemical and
haematologicalstudiestohelpthediagnosisandbloodtransfusion,fluid
replacement, nasogastric suction, antibiotics and skilled anesthetists to
assistwiththerapy.
Thestudyofsurgicalhistoryshowsthat, occasionally,like thefrog —
wegoonestepforward,twostepsback…( Figure2.1).
Figure2.1.Greatadvanceinsurgery!
“Let us therefore look back with a mélange of
amazement, pride, and humility at the efforts of our
surgicalforefathers as they pavedthe wayforus in the
managementofthisfascinatinggroupofdiseases!”
HaroldEllis
PARTII
Beforetheoperation
Chapter3
Theacuteabdomen
MosheSchein,PaulN.Rogers,AriLeppäniemi,DannyRosinand
JonathanE.Efron
1
Fortheabdominalsurgeonitisafamiliarexperiencetosit,
ready scrubbed, and gowned, in a corner of the quiet
theatre,withtheclockpointingmidnight.…Inafewminutes
the patient will be wheeled in and another emergency
laparotomy will commence. This is the culmination of a
process which began a few hours previously with the
surgeonmeetingwithandexaminingthepatient,reachinga
diagnosis,andmakingaplanofaction.
PeterF.Jones
The general rule can be laid down that the majority of
severeabdominalpains whichensuein patientswhohave
been previously fairly well, and which last as long as six
hours,arecausedbyconditionsofsurgicalimport.
ZacharyCope
Simplystated,theterm‘acuteabdomen’referstoabdominalpain
of short duration that requires a decision regarding whether an
urgent intervention is necessary. This clinical problem is the most
common cause for you to be called upon to provide a surgical
consultation in the emergency room, and serves as a convenient
gateway for a discussion of the approach to abdominal surgical
emergencies.
Itisasmuchanintellectualexercisetotackletheproblems
ofbellyacheastoworkonthehumangenome.
HughDudley
Theproblem
Most major textbookscontain a long list of possible causes of acute
abdominalpain. These ‘biglists’usuallygo from perforatedpeptic ulcer
downtosuchesotericcausesasporphyriaandblackwidowspiderbites.
The lists are popular with medical students and residents in internal
medicine,butareuselessforpracticalguyslikeyou.
The experienced surgeon called upon to consult a patient with acute
abdominal pain in theemergency room(ER) in the middle ofthe night
simply doesn’t workthis way. Heor she doesn’tconsider the 50 or so
‘mostlikely’causesofacuteabdominal pain from the list, attemptingto
rule them out one by one. Instead, the intelligent surgeon tries to
identify a clinical pattern, and to decide upon a course of action
from a limited menu of management options. Below we will
demonstratehowthemultipleetiologiesforacuteabdominalpainactually
converge into a small number of easily recognizable clinical patterns.
Once recognized, each of these patterns dictates a specific course of
action.
The acute abdomen: management menus and clinical
patterns
Themanagementoptions
SeeingapatientwithanacuteabdomenintheER( Figure3.1),you
have only a few management options to choose from the following
menu.
Immediateoperation
(“surgerynow…now…bynowImeannow!”).
Emergencyoperation
(“surgerywithin2-3hours…noneedtorun!”).
Urgent operation
(“Let us take some time and optimize the patient and
operatetomorrowmorning”).
Invasivenon-surgicaltreatments
(“Let’sembolizethebleeder”).
Conservativetreatment—intheICUifnecessary
(“I plan to
admitandtreatwithintravenousfluids,antibiotics,possiblyimageagain.Imaystill
decidetooperatelater…TheICUisthebestplaceforasickpatientwhodoesnot
needsurgerynowbuthasorgandysfunction”).
Dischargehome
.
Figure3.1.“Whichofthemhasan‘acuteabdomen’?”
Theclinicalpatterns
Theacuteabdomenusuallypresentsasoneofthewell-definedclinical
patternslistedbelow.
Abdominalpainandshock.
Generalizedperitonitis.
Localizedperitonitis(confinedtoonequadrantoftheabdomen).
Intestinalobstruction.
Wastebasket(‘non-specific’abdominalpainordueto‘medicalcauses’).
Gynecological.
Trauma.
The last two patterns (gynecological and trauma) are addresed
elsewhere in this book. Occasionally a mixed picture of
obstruction/peritonitismaypresent.Foreachoftheseclinicalpatterns
you have to choose a management option from the aforementioned
menu—butyourfirsttaskistoidentifythespecificpatterninorder
toknowhowtoproceed.
Abdominalpainandshock
This is the most dramatic and least common clinical pattern of the
acute abdomen. The patient typically presents pale and diaphoretic, in
severe abdominal pain and with hypotension, the so-calledabdominal
apoplexy.Thetwomostcommonetiologiesofthisclinicalpatternarea
ruptured abdominal aortic aneurysm and a ruptured ectopic
pregnancy( Chapters34and35).Herethe onlymanagement option
is immediate surgery NOW! No timeshould be wastedon ‘preparation’
andonancillaryinvestigations.Losingapatientwithabdominalapoplexy
intheCTscannerisacardinal,andunfortunatelynottoorare,sin.
Notehoweverthatotherabdominalemergenciesmayalsopresentwith
abdominal pain and shock due to fluid loss into the ‘third space’. This
may occur for example in patients with intestinal obstruction (
Chapter21),orsevereacutepancreatitis( Chapter19)—particularly
if neglected or superimposed on a deficient cardiovascular system. In
manyofthesesituationsan emergencyoperation isnot necessary;and
— as we will be nagging you over and over again — operatingon a
poorlyresuscitatedpatientislikeskatingonthinice.
Generalizedperitonitis
Theclinicalpictureofgeneralizedperitonitisconsistsofdiffuse,severe
abdominalpaininapatientwholookssickandtoxic.Thepatienttypically
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