Preparation, indications and contraindications for surgery. Stages and tasks of preoperative preparation, indications and contraindications for surgery Contraindications for surgical treatment

Name surgery consists of the name of the organ on which it is performed and the term that denotes the surgical technique being performed.

The following terms are used:

Tomia– dissection, incision, opening;

ectomia– excision;

extirpatio– isolating, peeling;

resectio– partial excision;

amputatio– removal of the peripheral part of the organ;

stomia– creation of an artificial fistula;

centes- puncture

This is where the following names come from:

rumenotomy(rumen - scar, tomia - dissection) - dissection of the scar;
enterectomy(enteron - intestine, ectomia - excision) - excision of the intestine.
urethrostomy(urethra - urethra, stomia - creation of an artificial fistula) - creation of an artificial fistula of the urethra.

Indications and contraindications for operations

Each surgery preceded by a diagnosis based on clinical, laboratory or radiological examination.

After that surgery justified by relevant evidence. In all difficult and doubtful cases of determining the indications for surgery, it is necessary to resort to a consultation.

« A deftly performed surgical operation does not give the right to the title of an experienced clinician. Only a doctor with good clinical training can be a good surgeon».

Indications for surgery– these are those cases when surgical operations are necessary or can be performed.

Indications may be:

absolute(indicatio vitalis) – those cases in which there is no other way to cure the animal (malignant neoplasms, bleeding, suffocation, pneumothorax, rumen tympany, prolapse of internal organs);
relative– those cases in which surgery can be omitted without causing significant damage to the health and productivity of the animal, or when surgery is not the only method of treatment (benign tumor, non-strangulated hernia).

NB! You should not resort to surgery when the animal can be cured in an easier and safer way, but you should not neglect surgery when it is the only method of treatment.

Contraindications to surgery– these are those cases when the operation cannot or is undesirable to perform.

They are divided into:

Contraindications due to the severe condition of the animal:

In case of exhaustion, old age, exacerbation of the inflammatory process, fever, infectious disease, large volume of damage, the second half of pregnancy, sexual heat in females.

The exception is emergency operations (strangulated hernia, cellulitis, malignant tumor). In these cases, the full risk must be explained to the animal owner.

Contraindications due to economic and organizational factors:

when imposing quarantine due to an infectious disease characteristic of a given animal species (erysipelas, plague, horse washing, Siberian flu);
before moving and regrouping animals;
2 weeks before and within 2 weeks after preventive vaccination;
in the absence of appropriate sanitary conditions for postoperative keeping of animals.

The exception is emergency cases that require emergency intervention, in which the operation must be performed in compliance with all rules for self-protection and prevention of further spread of the disease.

Mass operations cannot be carried out on farms that do not have adequate conditions for post-operative housing of animals (calves cannot be castrated if they are kept knee-deep in slurry).

Any surgical operation involving a risk to the life of an animal must be performed only with the written consent of the legal owner of the animal or his representative (head of the farm, private owner of the animal).

If we are talking about an animal that is state property, then the doctor, who understands the necessity of the operation, must insist on its performance, and, if necessary, operate without waiting for consent.

Any surgical operation has a relative degree of risk.

Grade 1 – mild.

The risk is negligible. The existing disorders do not affect the general condition and do not cause disturbances in other organs and tissues. This group also includes planned operations.

2nd degree – moderate severity.

This applies to emergency operations that cannot be postponed, and the animal has moderate cardiac or respiratory failure.

Grade 3 – severe.

The sick animal had local lesions of vital organs (myocardial infarction, acute respiratory failure, diabetes).

Indications for surgery are divided into absolute and relative.

Absolute indications Diseases and conditions that pose a threat to the patient’s life and that can only be eliminated surgically are considered to be considered for surgery.

Absolute indications for emergency operations are otherwise called “vital”. This group of indications includes asphyxia, bleeding of any etiology, acute diseases of the abdominal organs (acute appendicitis, acute cholecystitis, acute pancreatitis, perforated ulcer of the stomach and duodenum, acute intestinal obstruction, strangulated hernia), acute purulent surgical diseases (abscess, phlegmon, osteomyelitis, mastitis, etc.).

In planned surgery, indications for surgery can also be absolute. In this case, urgent operations are usually performed without delaying them for more than 1-2 weeks.

The following diseases are considered absolute indications for elective surgery:

Malignant neoplasms (cancer of the lung, stomach, breast, thyroid gland, colon, etc.);

Stenosis of the esophagus, the outlet of the stomach;

Obstructive jaundice, etc.

Relative indications for surgery include two groups of diseases:

Diseases that can only be cured surgically, but do not directly threaten the patient’s life (varicose veins of the saphenous veins of the lower extremities, non-strangulated abdominal hernias, benign tumors, cholelithiasis, etc.).

Diseases that are quite serious, the treatment of which can, in principle, be carried out both surgically and conservatively (coronary heart disease, obliterating diseases of the vessels of the lower extremities, peptic ulcer of the stomach and duodenum, etc.). In this case, the choice is made on the basis of additional data, taking into account the possible effectiveness of the surgical or conservative method in a particular patient. According to relative indications, operations are performed as planned, subject to optimal conditions.

There is a classic division of contraindications into absolute and relative.

To absolute contraindications include a state of shock (except for hemorrhagic shock with ongoing bleeding), as well as the acute stage of myocardial infarction or cerebrovascular accident (stroke). It should be noted that currently, if there are vital indications, it is possible to perform operations against the background of myocardial infarction or stroke, as well as in shock after stabilization of hemodynamics. Therefore, the identification of absolute contraindications is not fundamentally important at present.

Relative contraindications include any concomitant disease. However, their influence on the tolerability of the operation is different.

General anesthesia is the artificial immersion of the patient into sleep with a reversible decrease in all types of sensitivity through the use of pharmacological drugs. The drugs used in anesthesia are called anesthetics. Inhalation and non-inhalation anesthetics are used for anesthesia.

Inhalational anesthetics- these are drugs that are introduced into the patient’s body directly through the respiratory tract, through gas. Inhalational anesthetics are used as monoanesthesia, i.e. using gas alone, or in combination with other drugs. The most commonly used inhalational anesthetics are: nitrous oxide (NO), sevoflurane (Sevorane), isoflurane, halothane, desflurane.

Non-inhalational anesthetics- these are drugs administered directly to the patient into a vein (intravenously). Drugs used for non-inhalation anesthesia: a group of barbiturates (sodium thiopental and hexonal), ketamine, propofol (Pofol, Diprivan), a group of benzodiazepines (Dormikum). They can also be used as monoanesthesia, or as part of a combination (for example, propofol + sevoran).

Individually, each drug has its own spectrum of pharmacological effects.

When combining inhalational and non-inhalational anesthetics, anesthesia will be called general combined anesthesia.

General anesthesia is most often supplemented by two more important components - muscle relaxants and narcotic analgesics.

Muscle relaxants are pharmacological drugs administered intravenously that cause reversible relaxation of all muscle fibers, with a further inability to contract. This component of anesthesia is necessary when we are talking about a major operation, such as abdominal surgery, on the abdominal wall (stomach) and there is a need to perform tracheal intubation.

Tracheal intubation is a medical procedure necessary to maintain patency of the airway. A tube is inserted through the mouth into the trachea. After this, the cuff around the tube is inflated to create a sealed contour. The other end of the tube is connected through a system of circuits (hoses) to an artificial lung ventilation device (ventilator).

In such a situation, the patient must completely avoid independent muscle contractions.

Narcotic analgesics, such as fentanyl, are used as a component of anesthesia to completely relieve the patient's pain during surgery.

Indications for general anesthesia

Indications for general inhalation anesthesia (monoanesthesia): minimally invasive operations, i.e. operations with minimal damage to the skin, small access. Such operations include: removal of superficial structures and neoplasms; gynecological operations in the form of uterine curettage; traumatological operations - reduction of dislocations; also heavy dressings.

Indications for general non-inhalation anesthesia similar to monoanesthesia with gas. They are supplemented by various instrumental studies (gastroscopy, colonoscopy).

Indications for general combined anesthesia with tracheal intubation and mechanical ventilation: moderate surgical interventions, including operations in the area of the facial skull; ENT operations; some gynecological operations; amputation of segments of the upper and lower extremities; operations in the abdominal cavity (appendectomy, cholecystectomy, hernia repair, etc.); diagnostic laparotomy, laparoscopy; in the chest cavity in the form of diagnostic thoracotomies and thoracoscopies. Extensive surgical operations: extended operations in the abdominal and thoracic cavities; extended limb amputations; brain surgery. As well as operations on the heart, spinal cord, large vessels and other complex surgical interventions that require additional special conditions - the connection of a heart-lung machine (ACB) or the creation of hypothermia conditions.

Contraindications to general anesthesia

Contraindications for elective general anesthesia are:

From the cardiovascular system: recent (1-6 months) myocardial infarction, unstable angina or exertional angina of functional class 4, low blood pressure, increasing heart failure, severe heart valve disease, conduction and rhythm disturbances, failure of the contractile function of the heart.

From the nervous system: psychiatric illnesses, severe injuries and contusions of the brain (1-6 months).

From the respiratory system: bronchial asthma in the acute stage, pneumonia, severe bronchitis.

Anesthesia is not harmless or safe, but the potential danger of anesthesia is thousands of times less than the harm that the disease causes if surgical treatment is refused. Another thing is that the possible harm and danger of anesthesia can always be minimized; for this you just need to trust an anesthesiologist-resuscitator who firmly knows his job.

Please note that there are no contraindications for emergency surgery and emergency anesthesia, and in cases of progression of the cancer patient's disease. In such situations, the conversation is about saving the patient’s life, and not about assessing the patient’s contraindications.

Preparing the patient for the upcoming planned surgery under anesthesia

Most often, all preparation of the patient for a planned operation takes place immediately before the operation in the hospital. The day before, an anesthesiologist-resuscitator talks with the patient, collects anamnesis, talks about the upcoming anesthesia, fills out the necessary medical documentation, and takes written consent from the patient for anesthesia.

The doctor will definitely ask you if you are allergic to anything. Any allergies the patient has should be voiced, especially to medications. Food allergies are also important. For example: a non-inhalational anesthetic - propofol (hypnotic) is produced on the basis of egg lecithin. Accordingly, for patients with an allergy to egg yolk, this drug will be replaced with another hypnotic, for example sodium thiopental, but this is an extremely rare situation.

Any manifestation of an allergy must be recorded in the medical history and is strictly not allowed to be taken or administered to the patient.

If you have a pathology of any system and you are taking medications as prescribed by a specialist, then you must inform your anesthesiologist-resuscitator about this and then follow his instructions. The anesthesiologist-resuscitator either completely stops taking your medication and you resume it only after surgery, when you are allowed, or continue to take your medications according to the regimen that your specialist has developed.

The main preparation of the patient for the upcoming operation consists of strict compliance with all the requirements of the anesthesiologist-resuscitator.

They include: in the evening before bed and in the morning - a ban on taking any food or water. In the morning you are allowed to brush your teeth and rinse your mouth. Be sure to remove all jewelry: rings, earrings, chains, piercings, glasses. Remove removable dentures.

Another important component of preoperative preparation for the patient is premedication.

Premedication- This is the final stage of preoperative preparation. Premedication consists of taking pharmacological drugs to relieve psycho-emotional stress before surgery and improve the induction of general anesthesia. The drugs can be in the form of tablets for oral administration, or in the form of injections for intravenous or intramuscular administration. The main groups of drugs for premedication are tranquilizers. They help the patient fall asleep quickly the evening before surgery, reduce anxiety and stress. In the morning, these drugs are also prescribed for a softer and more comfortable introduction to anesthesia for the patient.

How is anesthesia done?

Let's look at the example of combined general anesthesia with tracheal intubation and mechanical ventilation.

After the planned preparation of the patient for the operation, compliance with all the requirements of morning premedication, the patient, lying on a gurney, accompanied by medical personnel, is transferred to the operating unit. In the operating room, the patient is transferred from the gurney to the operating table. An anesthesiology team consisting of a doctor and a nurse anesthetist is waiting for him there.

The mandatory, first manipulation with which it all begins is obtaining vascular (venous) access. This manipulation involves the percutaneous insertion of a sterile vascular catheter into a vein. Next, this catheter is fixed and a system for intravenous infusions with physiological sodium chloride solution is connected to it. This manipulation is necessary to ensure constant access for administering drugs intravenously.

After this, a blood pressure (BP) cuff is attached to the patient and electrode sensors are connected to the chest to continuously record an electrocardiogram (ECG). All parameters are displayed to the doctor directly on the monitor.

After this, the doctor instructs the nurse to draw up the medications. While the nurse is busy, the doctor begins preparing to put the patient under anesthesia.

The first stage of anesthesia is preoxygenation. Preoxygenation consists of the following: the anesthesiologist-resuscitator connects a face mask to the circuit system and sets parameters with a high oxygen supply on the ventilator monitor, after which he applies the mask to the patient’s face. At this moment, the patient needs to breathe as usual, take standard, normal vital inhalations and exhalations. This procedure lasts 3-5 minutes. Once the nurse and surgical team are ready, the patient is placed under anesthesia.

The first drug that is administered intravenously is narcotic analgesic. At this moment, the patient may feel a weak feeling in the form of dizziness and a slight unpleasant feeling in the form of a burning sensation in the vein.

After this, enter hypnotic drugs(non-inhalational anesthetic). The patient is warned that he will now begin to feel dizzy and will slowly fall asleep. There will be a feeling of heaviness in the head, facial muscles, a feeling of euphoria and fatigue. Time is counted in seconds. The patient falls asleep. The patient is sleeping.

The patient will not feel or remember further manipulations by the anesthesiological team.

The next drug administered intravenously is a muscle relaxant.

After its administration, the anesthesiologist-resuscitator performs tracheal intubation And connects the patient through a tube to the sealed circuit of the ventilator, turns on the supply of inhalational anesthetics through a special evaporator. After this, he checks the uniformity of the patient’s breathing using a phonendoscope (a medical device for listening to respiratory and heart sounds), fixes the endotracheal tube to the patient, and sets the necessary parameters on the ventilator. After the anesthesiologist-resuscitator is convinced of the patient’s complete safety and has checked everything, he gives the command to the surgical team to begin the operation.

With inhalation monoanesthesia, the scheme is simplified.

The duration of the operation is determined by the qualification level of the surgical team, the complexity of the surgical intervention and the anatomical characteristics of the patient.

Complications during general anesthesia

The main danger of any anesthesia is hypoxia (insufficient oxygen consumption by the patient) and hypercapnia (an increase in excess carbon dioxide in the body). The causes of these severe complications may be: malfunction of anesthesia equipment, obstruction of the airway, or excessive immersion of the patient in anesthesia sleep.

There are also complications of anesthesia in the form of:

Retraction of the tongue, which contributes to obstruction of the airway, most often this complication occurs when monoanesthesia is carried out only with inhalational anesthetics using gas supply through a face mask;

Laryngospasm - closure of the vocal cords of the larynx. This complication is associated with the body’s reflex reaction to excessive irritation of the mucous membranes of the larynx, or excessive painful effects on the body during surgery with too superficial medicinal sleep;

- obstruction of the airways by vomiting during regurgitation. Regurgitation is the entry of stomach contents into the oral cavity and possible entry into the respiratory tract;

- respiratory depression– a complication associated with the patient being immersed too deeply in anesthesia;

- changes in blood pressure and pulse in the form of tachycardia (increased heart rate) and bradycardia (decreased heart rate), which is directly related to surgery and the most painful stages of the operation.

Possible consequences of general anesthesia after surgery

The most common consequences are drowsiness, dizziness, weakness. They pass on their own. On average, after a planned, moderately severe operation without complications, patients return to a state of clear consciousness within 1-2 hours.

After general anesthesia, nausea and vomiting may occur. Treatment of this complication comes down to the use of antiemetic drugs, such as metoclopromide (Cerucal).

Headache (cephalgia) after anesthesia it manifests itself as a feeling of heaviness in the head and pressure in the temples. This consequence goes away on its own and does not require additional use of drugs. If the headache does not go away, your doctor will most likely prescribe you analgin.

Pain in a postoperative scar (wound)- the most pronounced, frequent consequence of the operation, when the effect of anesthesia ends. Pain in the wound will persist until the formation of the primary scar, because It is not the wound itself that hurts, but the skin itself that was cut. To prevent postoperative pain during moderate operations, the use of antispasmodic and painkillers is sufficient. In some cases, stronger opioid drugs (for example, promedol, tramadol) may be used. During major operations, anesthesiologists and resuscitators perform catheterization of the epidural space. This method involves inserting a catheter into the spine and providing prolonged pain relief by injecting local anesthetics into the catheter.

Increases or decreases in blood pressure (BP). A decrease in blood pressure is typical for patients who have undergone operations with extensive blood loss and blood transfusions (multiple injuries, operations associated with internal and external bleeding). The total volume of circulating blood is gradually restored and the patient feels better by the next day after surgery without additional medications. Increases in blood pressure are typical for patients after operations on the heart and large blood vessels. Most often, such patients are already receiving the necessary treatment and their blood pressure levels are under constant monitoring.

Increased body temperature is the norm and most often indicates an operation has been performed. It is necessary to pay attention only to an increase in body temperature if it has reached low-grade levels (above 38.0 C), which most likely indicates an infectious complication of the operation. There is no need to panic in this situation. Your doctor will definitely prescribe you antibiotic therapy and eliminate the cause of the fever.

In foreign literature, there are reports of the negative consequences of anesthesia in children, in particular, that anesthesia can cause the development of cognitive disorders in a child - impairments in memory, attention, thinking and learning ability. In addition, it has been suggested that anesthesia suffered at an early age may be one of the reasons for the development of attention deficit hyperactivity disorder. This leads to recommendations to postpone the planned surgical treatment of a child until the age of four, under the clear condition that delaying the operation will not harm the child’s health.

The well-coordinated and professional work of the anesthesiological and surgical teams guarantees a safe, painless, comfortable performance of any operation without any medical complications. A patient who is psychologically attuned to general anesthesia will only help the anesthesiologist-resuscitator to work efficiently. Therefore, it is important to ask the specialist all your questions before the operation and strictly follow the prescribed recommendations.

Anesthesiologist - resuscitator Starostin D.O.

Indications for surgery for tetralogy of Fallot are actually absolute. All patients are subject to surgical treatment, especially in infants and patients with cyanosis. Cyanosis, severe hypertrophy of the right ventricle of the heart, continuously occurring changes in the anatomy of the right ventricle, its outlet section, and in the structure of the lungs - all this necessitates the need for possibly early surgical intervention, primarily in young children. If the defect occurs with pronounced cyanosis, frequent dyspnea-cyanotic attacks, or disturbances in general development, immediate surgery is indicated.

Contraindications to surgery are anoxic cachexia, severe cardiac decompensation, and severe concomitant diseases.

Surgical methods

In the surgical correction of tetralogy of Fallot, its radical correction is widely used, as well as palliative operations for certain indications.

The meaning of palliative operations (there are more than 30 types) lies in the creation of intersystem anastomoses to eliminate the deficiency of blood flow in the pulmonary circulation.

Palliative operations allow the patient to survive the critical period, eliminate total arterial hypoxemia, increase the cardiac index, and, under certain conditions, promote the growth of the trunk and branches of the pulmonary artery. Increased pulmonary blood flow increases

of course - diastolic pressure in the left ventricle, thereby promoting its development before radical correction of the defect.

Palliative bypass surgery improves the capacitance-elastic properties of the pulmonary arterial bed with increased elasticity of the pulmonary vessels.

Among bypass palliative operations, the most widespread are:

1. subclavian - pulmonary anastomosis according to Blelock - Taussig (l 945) (Nobel Prize in 1948). It is classic and most commonly used in the clinic. To apply it, synthetic linear prostheses Gore are used - Tech

2. anastomosis between the ascending aorta and the right branch of the pulmonary artery (CooGu - Waterston, 1962). This is an intrapericardial anastomosis between the posterior wall of the ascending aorta and the anterior wall of the right branch of the pulmonary artery

3. anastomosis between the trunk of the pulmonary artery and the aorta (Potts - Smith - Gibson, 1946)

When performing bypass operations, an important task is to create adequate sizes of the anastomosis, since the degree of reduction of arterial hypoxemia is proportional to the amount of pulmonary blood flow. Large anastomosis quickly leads to the development of pulmonary hypertension and. and small ones lead to rapid thrombosis, so the optimal size of the anastomosis is 3-4 mm in diameter.

Operations are performed on a beating heart, access is anterior-lateral left-sided thoracotomy in the 3rd - 4th intercostal space.

Currently, palliative operations are considered as a stage of surgical treatment of patients with severe forms of the defect. They are not only a necessary measure, but also prepare the patient for radical correction of the defect. However, the positive effect of palliative surgery is not permanent. With an increase in the duration of existence of intersystem anastomoses, a deterioration in the condition of patients was absolutely reliably noted. This is associated with the development of hypofunction or thrombosis of the anastomosis, with the development of deformation of the branch of the pulmonary artery on the side of the anastomosis, often with the occurrence of pulmonary hypertension, the possible manifestation of bacterial endocarditis, the progression of pulmonary stenosis up to the development of occlusion of the outflow tract from the right ventricle. This leads to increased cyanosis, worsening polycythemia and decreased arterial blood oxygen saturation. Over time, the question of repeated palliative surgery or radical intervention arises, and these manifestations are indications for their implementation.

The use of endovascular surgery (balloon angioplasty, stenting, bougienage of residual stenoses) has become of particular importance in preparing patients at all stages of surgical treatment of the defect, especially in recent years.

at the level of the anastomosis mouth, elimination of pulmonary valve stenosis, embolization of large aorto-pulmonary collateral anastomoses (BALKA).

Radical correction of TF, both initially and after palliative operations, is a complex but effective surgical intervention. Currently, the emphasis in the surgical treatment of TF is shifted towards radical surgical intervention at an earlier age, including the neonatal period, in connection with the development and improvement of methods for ensuring the safety of open-heart surgery (anesthesiology, cardiopulmonary bypass, cardioplegia, intensive care and resuscitation).

Radical correction of TF consists of eliminating stenosis or reconstructing the right ventricular outflow tract and closing the ventricular septal defect. In cases of previously imposed intersystemic anastomosis, its elimination at the very beginning of the operation before connecting the artificial circulation machine by isolating and ligating or suturing the anastomosis from the lumen of the corresponding pulmonary artery.

Radical surgery is performed under conditions of hypothermic artificial circulation (28-30 degrees), pharmacocold or blood cardioplegia.

Elimination of stenosis of the outflow tract from the right ventricle: in 90 - 95% of cases there is a need to expand the outflow tract of the right ventricle, and therefore longitudinal ventriculotomy is indicated. The infundibular stenosis of the right ventricle is inspected and the hypertrophied muscles are widely excised. Valvular stenosis is eliminated by dissecting the fused valves along the commissures. With a sharply changed valve, the elements of the latter are excised. To expand the exit section, xenopericardial patches with an implanted monocusp are used, the dimensions of which vary (No. 14 - No. 18) in each specific case.

Closure of the ventricular septal defect. In TF, perimembranous and less commonly subaortic VSD is more common, which is closed with a synthetic or xenopericardial patch, fixing it to the edges of the defect either with separate U-shaped sutures on Teflon pads or with a continuous suture.

How is the adequacy of defect correction assessed? For these purposes, pressure is measured in the inflow and outlet sections of the right ventricle, in the trunk and right pulmonary artery. The adequacy of the correction is assessed by the ratio of systolic pressure values in the right and left ventricles. It should be no more than 0.7. High residual pressure in the right ventricle dramatically increases postoperative mortality.

Adequately performed radical correction of the defect makes it possible to normalize intracardiac hemodynamics and increase physical

performance and already a year after surgery up to 75% - 80% of the norm for healthy children.

Recent studies indicate that even with good results in the long term, latent heart failure is revealed, caused by prolonged arterial hypoxemia, affecting fine structures in vital organs (in particular, cardiomyocytes). This leads to an important practical conclusion that children should be operated on at an early age, at least before two years of age. Unsatisfactory results of the operation are due to incomplete correction of the defect, recanalization of the VSD, and hypertension in the pulmonary artery system.

Assess the condition of the patient’s main organs and systems (identify concomitant diseases).

Psychologically prepare the patient.

Conduct general somatic training.

Perform special training as indicated.

Directly prepare the patient for surgery.

The first two tasks are solved during the diagnostic stage. The third, fourth and fifth tasks are components of the preparatory stage. This division is arbitrary, since preparatory measures are often carried out against the background of performing diagnostic techniques.

Direct preparation is carried out before the operation itself.

The objectives of the diagnostic stage are to establish an accurate diagnosis of the underlying disease and assess the condition of the main organs and systems of the patient’s body.

Establishing an accurate surgical diagnosis is the key to a successful outcome of surgical treatment. It is an accurate diagnosis indicating the stage, extent of the process and its features that allows you to choose the optimal type and extent of surgical intervention. There can be no trifles here; every feature of the course of the disease must be taken into account. In surgery of the 21st century, almost all diagnostic issues must be resolved before the operation, and during the intervention only previously known facts are confirmed. Thus, the surgeon, even before the operation begins, knows what difficulties he may encounter during the intervention, and clearly imagines the type and features of the upcoming operation. Stetsyuk V.G. A manual on surgical manipulations.-- M.: Medicine, 1996

There are many examples that demonstrate the importance of a thorough preoperative examination. Here's just one of them.

Example. The patient was diagnosed with peptic ulcer, duodenal bulb ulcer. Conservative therapy for a long time does not produce a positive effect; surgical treatment is indicated. But such a diagnosis is not enough for surgery. There are two main types of surgical interventions in the treatment of peptic ulcers: gastric resection and vagotomy. In addition, there are several types of both gastric resection (Billroth-I, Billroth-II, modified by Hofmeister-Finsterer, Roux, etc.) and vagotomy (trunk, selective, proximal selective, with various types of stomach drainage operations and without them). Which intervention should be chosen for this patient? This depends on many additional factors; they must be identified during the examination. You should know the nature of gastric secretion (basal and stimulated, nocturnal secretion), the exact localization of the ulcer (anterior or posterior wall), the presence or absence of deformation and narrowing of the outlet of the stomach, the functional state of the stomach and duodenum (are there any signs of duodenostasis), etc. If Not taking these factors into account and unreasonably performing a certain intervention will significantly reduce the effectiveness of treatment. Thus, the patient may develop a relapse of the ulcer, dumping syndrome, afferent loop syndrome, gastric atony and other complications, sometimes leading the patient to disability and subsequently requiring complex reconstructive surgical interventions. Only after weighing all the identified features of the disease can you choose the right method of surgical treatment.

First of all, accurate diagnosis is necessary in order to resolve the issue of the urgency of the operation and the degree of need for surgical treatment (indications for surgery).

After making a diagnosis, the surgeon must decide whether emergency surgery is indicated for the patient. If such indications are identified, you should immediately begin the preparatory stage, which in case of emergency operations takes from several minutes to 1-2 hours.

The main indications for emergency surgery: asphyxia, bleeding of any etiology and acute inflammatory diseases.

The doctor must remember that delaying the operation worsens its result every minute. If bleeding continues, for example, the sooner intervention is started and blood loss is stopped, the greater the chance of saving the patient’s life.

At the same time, in some cases short-term preoperative preparation is necessary. Its nature is aimed at stabilizing the functions of the main systems of the body, primarily the cardiovascular system; such training is carried out individually. For example, in the presence of a purulent process complicated by sepsis with severe intoxication and arterial hypotension, it is advisable to carry out infusion and special therapy for 1-2 hours, and only then perform surgery.

In cases where, in accordance with the nature of the disease, there is no need for emergency surgery, an appropriate entry is made about this in the medical history. Then the indications for planned surgical treatment should be determined.

Indications for surgery are divided into absolute and relative.

Absolute indications for surgery are diseases and conditions that pose a threat to the patient’s life and that can only be eliminated surgically.

In planned surgery, indications for surgery can also be absolute. In this case, urgent operations are usually performed without delaying them for more than 1-2 weeks.

The following diseases are considered absolute indications for elective surgery:

* malignant neoplasms (cancer of the lung, stomach, breast, thyroid gland, colon, etc.);

* stenosis of the esophagus, the outlet of the stomach;

* obstructive jaundice, etc.

Relative indications for surgery include two groups of diseases:

Treating the patient, not the disease, is one of the most important principles of medicine. It was most accurately stated by M.Ya. Mudrov: “We should not treat a disease by its name alone, but should treat the patient himself: his composition, his body, his strength.” Therefore, before surgery, one cannot limit oneself to examining only the damaged system or diseased organ. It is important to know the condition of the main vital systems. In this case, the doctor’s actions can be divided into four stages:

Preliminary assessment;

Standard minimum examination;

Additional examination;

Determination of contraindications for surgery.

Preliminary assessment

A preliminary assessment is carried out by the attending physician and an anesthesiologist based on complaints, a survey of organs and systems, and data from a physical examination of the patient. In this case, in addition to classical examination methods (inspection, palpation, percussion, auscultation, determination of organ boundaries), you can use the simplest tests for the compensatory capabilities of the body, for example, the Stange and Genche tests (the duration of maximum breath holding during inhalation and exhalation). When compensating the functions of the cardiovascular and respiratory systems, this duration should be at least 35 and 20 s, respectively.

After a preliminary assessment, before any operation, regardless of concomitant diseases (even in their absence), it is necessary to conduct a minimum set of preoperative examinations:

Clinical blood test;

Biochemical blood test (content of total protein, bilirubin, transaminase activity, concentration of creatinine, sugar);

Blood clotting time;

Blood type and Rh factor;

General urine test;

Fluorography of the chest organs (not more than 1 year old);

Dentist's opinion on oral cavity sanitation;

Examination by a therapist;

For women - examination by a gynecologist.

If results are obtained that fall within the normal range, surgery is possible. If any deviations are identified, it is necessary to find out their cause and then decide on the possibility of performing the intervention and the degree of its danger for the patient.

Additional examination is carried out if concomitant diseases are identified in the patient or if the results of laboratory tests deviate from the norm. Additional examination is carried out to establish a complete diagnosis of concomitant diseases, as well as to monitor the effect of the preoperative preparation. In this case, methods of varying degrees of complexity can be used.

As a result of the studies, concomitant diseases can be identified that can, to one degree or another, become contraindications to the operation.

There is a classic division of contraindications into absolute and relative.

Absolute contraindications include a state of shock (except for hemorrhagic shock with ongoing bleeding), as well as the acute stage of myocardial infarction or cerebrovascular accident (stroke). It should be noted that currently, if there are vital indications, it is possible to perform operations against the background of myocardial infarction or stroke, as well as in shock after stabilization of hemodynamics. Therefore, the identification of absolute contraindications is not fundamentally important at present. Nurse's Handbook of Nursing / ed. N.R. Paleeva, - M., Alliance - V, 1999

Relative contraindications include any concomitant disease. However, their influence on the tolerability of the operation is different. The greatest danger is the presence of the following diseases and conditions:

Cardiovascular system: hypertension, coronary heart disease, heart failure, arrhythmias, varicose veins, thrombosis.

Respiratory system: smoking, bronchial asthma, chronic bronchitis, emphysema, respiratory failure.

Kidneys: chronic pyelonephritis and glomerulonephritis, chronic renal failure, especially with a pronounced decrease in glomerular filtration.

Liver: acute and chronic hepatitis, liver cirrhosis, liver failure.

Blood system: anemia, leukemia, changes in the coagulation system.

Obesity.

Diabetes mellitus.

The presence of contraindications to surgery does not mean that the surgical method cannot be used. It all depends on the ratio of indications and contraindications. When vital and absolute indications are identified, the operation should be performed almost always, with certain precautions. In situations where there are relative indications and relative contraindications, the issue is decided on an individual basis. Recently, the development of surgery, anesthesiology and resuscitation has led to the fact that the surgical method is used more and more often, including in the presence of a whole “bouquet” of concomitant diseases.

There are three main types of preoperative preparation:

Psychological;

General somatic;

Special.

An operation is the most important event in a patient’s life. Deciding to take such a step is not easy. Any person is afraid of surgery, because to one degree or another they are aware of the possibility of unfavorable outcomes. In this regard, the patient’s psychological mood before surgery plays an important role. The attending physician must clearly explain to the patient the need for surgical intervention. It is necessary, without going into technical details, to talk about what is planned to be done, how the patient will live and feel after the operation, and outline its possible consequences. In this case, in everything, of course, emphasis should be placed on confidence in a favorable outcome of treatment. The doctor must “infect” the patient with a certain optimism, making the patient his ally in the fight against the disease and the difficulties of the postoperative period. The moral and psychological climate in the department plays a huge role in psychological preparation.

Pharmacological agents can be used to conduct psychological preparation. This is especially true for emotionally labile patients. Sedatives, tranquilizers, and antidepressants are often used.

It is necessary to obtain the patient's consent for surgery. Doctors can perform all operations only with the consent of the patient. In this case, the fact of consent is recorded by the attending physician in the medical history - in the preoperative epicrisis. In addition, it is now necessary for the patient to give written consent to the operation. The corresponding form, drawn up in accordance with all legal standards, is usually pasted into the medical history.

An operation can be performed without the patient’s consent if he is unconscious or incapacitated, which must be confirmed by a psychiatrist. In such cases, they mean surgery for absolute indications. If a patient refuses surgery in a case where it is vitally necessary (for example, with ongoing bleeding), and as a result of this refusal dies, then legally the doctors are not to blame for this (if the refusal is properly recorded in the medical history). However, in surgery there is an unofficial rule: if a patient refuses an operation that was necessary for health reasons, then the attending physician is to blame. Why? Yes, because all people want to live, and refusal of surgery is due to the fact that the doctor could not find the right approach to the patient, find the right words in order to convince the patient of the need for surgical intervention.

In psychological preparation for surgery, an important point is the conversation between the operating surgeon and the patient before the operation. The patient must know who is operating on him, to whom he trusts his life, and make sure that the surgeon is in good physical and emotional condition.

The relationship between the surgeon and the patient’s relatives is of great importance. They must be of a trusting nature, because it is close people who can influence the patient’s mood and, moreover, provide him with purely practical assistance.

At the same time, we must not forget that in accordance with the law, information about a patient’s illness can be communicated to relatives only with the consent of the patient himself.