Indications and contraindications for surgery.
| Parameter name | Meaning |
| Article topic: | Indications and contraindications for surgery. |
| Rubric (thematic category) | Education |
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 “life-saving”. 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 elective surgery, indications for surgery are also 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, mammary gland, thyroid gland, colon, etc.);
‣‣‣ stenosis of the esophagus, the outlet of the stomach;
‣‣‣ obstructive jaundice, etc.
Relative readings The operation includes 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 hemodynamic stabilization. For this reason, the identification of absolute contraindications is not of fundamental importance at present.
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.
Indications and contraindications for surgery. - concept and types. Classification and features of the category "Indications and contraindications for surgery." 2017, 2018.
Contraindications to surgical treatment.
According to vital and absolute indications, operations should be performed in all cases, with the exception of the preagonal and agonal state of the patient who is in the terminal stage of a long-term disease that inevitably leads to death (for example, oncopathology, cirrhosis of the liver, etc.). Such patients, by decision of the council, undergo conservative syndromic therapy.
For relative indications, the risk of surgery and the planned effect of it should be individually weighed against the background of concomitant pathology and the patient’s age. If the risk of surgical intervention exceeds the desired result, it is necessary to refrain from surgery (for example, removal of a benign formation that does not compress vital organs in a patient with severe allergies.
126. Preparation of organs and systems of patients at the stage of preoperative preparation.
There are two types of preoperative preparation: general somatic Skye And special .
General somatic training It is performed for patients with common surgical diseases that have little effect on the condition of the body.
Skin should be examined in every patient. Rash, purulent-inflammatory rashes exclude the possibility of performing a planned operation. Plays an important role oral sanitation . Carious teeth can cause diseases that seriously affect the postoperative patient. Sanitation of the oral cavity and regular teeth cleaning are very advisable to prevent postoperative mumps, gingivitis, and glossitis.
Body temperature should be normal before elective surgery. Its increase is explained in the very nature of the disease (purulent disease, cancer in the decay stage, etc.). In all patients hospitalized routinely, the cause of the fever should be found. Until it is detected and measures are taken to normalize it, elective surgery should be postponed.
The cardiovascular system should be studied especially carefully. If blood circulation is compensated, then there is no need to improve it. The average blood pressure level is 120/80 mm. rt. Art., can fluctuate between 130-140/90-100 mm. rt. Art., which does not require special treatment. Hypotension, if it is normal for a given subject, also does not require treatment. If there is a suspicion of an organic disease (arterial hypertension, circulatory failure and cardiac rhythm and conduction disturbances), the patient should be consulted with a cardiologist and the issue of surgery will be decided after special studies.
For prevention thrombosis and embolism the prothombin index is determined and, if necessary, anticoagulants are prescribed (heparin, phenylin, clexane, fraxiparin). In patients with varicose veins and thrombophlebitis, elastic bandaging of the legs is performed before surgery.
Preparation gastrointestinal tract patients before surgery on other areas of the body is simple. Eating should be limited only the evening before surgery and the morning before surgery. Prolonged fasting, the use of laxatives and repeated lavage of the gastrointestinal tract should be carried out according to strict indications, as they cause acidosis, reduce intestinal tone and promote stagnation of blood in the mesenteric vessels.
Before planned operations, it is necessary to determine the condition respiratory system , according to indications, eliminate inflammation of the paranasal cavities, acute and chronic bronchitis, pneumonia. Pain and the forced state of the patient after surgery contribute to a decrease in tidal volume. Therefore, the patient must learn the elements of breathing exercises included in complex of physical therapy for the preoperative period.
Special preoperative preparation at for planned patients it can be long-lasting and extensive, in emergency cases it can be short-term and quickly effective.
In patients with hypovolemia, disturbances in water-electrolyte balance, and acid-base status, infusion therapy is immediately started, including transfusion of polyglucin, albumin, protein, and sodium bicarbonate solution for acidosis. To reduce metabolic acidosis, a concentrated solution of glucose with insulin is administered. Cardiovascular drugs are used at the same time.
In case of acute blood loss and stopped bleeding, blood, polyglucin, albumin, and plasma transfusions are performed. If bleeding continues, transfusion is started in several veins and the patient is immediately taken to the operating room, where an operation is performed to stop the bleeding under the cover of infusion therapy, which is continued after the operation.
Preparation of organs and homeostasis systems should be comprehensive and include the following activities:
improvement of vascular activity, correction of microcirculation disorders with the help of cardiovascular drugs, drugs that improve microcirculation (reopolyglucin);
combating respiratory failure (oxygen therapy, normalization of blood circulation, in extreme cases - controlled ventilation);
detoxification therapy - administration of fluids, blood-substituting solutions with detoxification action, forced diuresis, use of special detoxification methods - plasmaphoresis, oxygen therapy;
correction of disturbances in the hemostasis system.
In emergency cases, the duration of preoperative preparation should not exceed 2 hours.
Psychological preparation.
The upcoming surgical operation causes more or less significant mental trauma in mentally healthy people. At this stage, patients often develop a feeling of fear and uncertainty in connection with the expected operation, negative experiences arise, and numerous questions arise. All this reduces the body’s reactivity, contributes to sleep and appetite disturbances.
Significant role in psychological preparation of patients, hospitalized as planned, are allocated medical and protective regime, the main elements of which are:
impeccable sanitary and hygienic conditions in the premises where the patient is;
clear, reasonable and strictly observed internal rules;
discipline, subordination in the relationships of medical personnel and in the relationship of the patient to the staff;
cultural, caring attitude of staff towards the patient;
full provision of patients with medications, equipmentswarm and household items.
An established diagnosis of esophageal cancer is an absolute indication for surgery - everyone recognizes this.
A study of the literature shows that the operability of patients with esophageal cancer is quite low and, according to various surgeons, varies widely - from 19.5% (B.V. Petrovsky) to 84.4% (Adatz et al.). Average operability figures according to domestic literature are 47.3%. Consequently, approximately half of the patients are scheduled for surgery, and the second are not subject to surgical treatment. What are the reasons for such a large number of patients with esophageal cancer refusing surgery?
First of all, this is the refusal of the patients themselves from the proposed surgical treatment. It was reported above that the percentage of patients who refused surgery for various surgeons reaches 30 or more.
The second reason is the presence of contraindications to surgical intervention, depending on the condition of the already middle-aged organism. Esophageal resection surgery for cancer is contraindicated in patients with organic and functional heart diseases complicated by circulatory disorders (severe myocardial dystrophy, hypertension, arteriosclerosis) and lung diseases (severe pulmonary emphysema, bilateral tuberculosis), unilateral pulmonary tuberculosis is not a contraindication, and as well as pleural adhesions (A. A. Polyantsev, Yu. E. Berezov), although they, without a doubt, aggravate and complicate the operation. Diseases of the kidneys and liver - nephroso-nephritis with persistent hematuria, albuminuria or oliguria, Botkin's disease, cirrhosis - are also considered a contraindication to surgical treatment of esophageal cancer.
The operation of esophageal resection is also contraindicated in weakened patients who have difficulty walking and are severely exhausted until they are brought out of this condition.
The presence of at least one of the listed diseases or conditions in a patient with esophageal cancer will inevitably lead to his death either during the operation of esophageal resection or in the postoperative period. Therefore, radical operations are contraindicated for them.
There are different opinions regarding the age of patients scheduled for surgery. G. A. Gomzyakov demonstrated a 68-year-old patient who was operated on for cancer of the lower thoracic esophagus. She underwent transpleural resection of the esophagus with simultaneous anastomosis in the chest cavity. After the demonstration by F. G. Uglov, S. V. Geynats, V. N. Sheinis and I. M. Talman, the opinion was expressed that advanced age in itself is not a contraindication to surgery. The same opinion is shared by S. Grigoriev, B. N. Aksenov, A. B. Rise and others.
A number of authors (N.M. Amosov, V.I. Kazansky, etc.) believe that age over 65-70 years is a contraindication to resection of the esophagus, especially through the transpleural route. We believe that elderly patients with esophageal cancer should be scheduled for surgery with caution. It is necessary to take into account all age-related changes and the general condition of the patient, take into account the scale of the proposed operation depending on the location of the tumor, its prevalence and the method of surgical approach. Without a doubt, resection of the esophagus for a small carcinoma of the lower esophagus using the Savinsky method can be successfully performed in a 65-year-old patient with moderately severe cardiosclerosis and pulmonary emphysema, while resection of the esophagus with a transpleural approach in the same patient may end unfavorably.
The third group of contraindications is caused by the tumor of the esophagus itself. All surgeons recognize that distant metastases to the brain, lungs, liver, spine, etc. serve as an absolute contraindication to radical resection of the esophagus. Patients with esophageal cancer with distant metastases can only undergo palliative surgery. According to Yu. E. Berezov, Virchow metastasis cannot serve as a contraindication to surgery. We agree that in this case it is possible to perform palliative, but not radical, surgery.
The presence of an esophageal-tracheal, esophageal-bronchial fistula, perforation of a tumor of the esophagus into the mediastinum, the lung are contraindications for resection of the esophagus, as well as a change in voice (aphonia), indicating the spread of the tumor beyond the wall of the esophagus when localized in the upper thoracic or, less often, in the mid-thoracic region. The operation is contraindicated, according to some surgeons (Yu. E. Berezov, V. S. Rogacheva), in patients with significant infiltration of the mediastinum by a tumor, determined by X-ray examination.
This group of contraindications, depending on the extent of the esophageal tumor, is determined by the technical impossibility of performing resection of the esophagus due to the growth of carcinoma into adjacent non-resectable organs or the futility of the operation due to extensive metastasis.
All other patients who have no contraindications undergo surgery with the hope of resection of the esophagus. However, as can be seen from table. 7 (see last column), resection of the esophagus is not possible for all operated patients, but 30-76.6%, according to various authors. Such a big difference in the given figures depends, in our opinion, not so much on the activity and personal attitudes of the surgeon, as Yu. E. Berezov believes, but on the quality of preoperative diagnostics. If you carefully study the patient's complaints, the history of the development of his disease, clinical and radiological examination data, taking into account the location of the tumor, its extent along the esophagus and infiltration of the mediastinum, then in most patients it is possible to correctly determine the stage of esophageal cancer before surgery. Errors are possible mainly due to metastases not recognized before surgery or underestimation of the stage of the process, which lead to trial operations.
When the stage of esophageal cancer is determined, then the indications are clear. All patients with esophageal carcinoma in stages I and II are subject to esophageal resection. As for patients with stage III esophageal cancer, we resolve the issue of esophageal resection in this way. If there are no multiple metastases in the mediastinum, in the lesser omentum and along the left gastric artery, then resection of the esophagus should be performed in all cases where it is technically possible to perform it, i.e. the tumor has not invaded the trachea, bronchi, aorta, or vessels of the root of the lung.
Almost all surgeons adhere to this tactic, and yet the resectability rate, i.e., the number of patients who can perform esophageal resection, ranges from 8.3 to 42.8% (see Table 7) in relation to all those admitted to the hospital. On average, operability is 47.3%, resectability is 25.7%. The obtained figures are close to the average data of Yu. E. Berezov and M. S. Grigoriev. Consequently, currently, approximately one in 4 patients with esophageal cancer who seek surgical treatment can undergo esophageal resection.
Since 1955, in the hospital surgical clinic named after A.G. Savinykh of the Tomsk Medical Institute, various operations have been used for resection of the esophagus for cancer, depending on the indications. Indications for the use of a particular method are based on the location of the tumor and the stage of its spread.
1. Patients with stage I and II esophageal cancer, when the tumor is localized in the thoracic region, undergo resection of the esophagus using the Savinykh method.
2. For stage III cancer of the upper and middle thoracic esophagus, as well as when the tumor is located at the border of the middle and lower sections, resection of the esophagus is performed using the Dobromyslov-Torek method through a right-sided approach. Subsequently, after 1-4 months, retrosternal-prefascial small intestinal esophagoplasty is performed.
3. For stage III esophageal cancer with tumor localization in the lower thoracic region, we consider partial resection of the esophagus with a combined abdomino-thoracic approach with simultaneous esophageal-gastric or esophageal-intestinal anastomosis in the thoracic cavity, or resection of the esophagus using the Savin method, indicated.
Childbirth is the most natural and most unpredictable process. Even a woman who is not becoming a mother for the first time cannot predict exactly how her child will be born. There are many cases when a woman, despite the doctors’ plans, gave birth safely on her own, but it happens that a seemingly successful birth ended in an emergency caesarean section. Let's find out what are the indications (and contraindications) for a cesarean section.
Elective caesarean section
There is a division into absolute and relative indications for this operation.
Absolute indications for elective caesarean section
Absolute indications for a cesarean section include reasons when natural childbirth is impossible or poses a very high risk to the health of the mother or fetus.
Narrow pelvis
Sometimes the anatomical structure of a woman does not allow the child to pass through the pelvic ring: the size of the mother’s pelvis is smaller than the presenting part (usually the head) of the child. There are criteria for the size of a normal and narrow pelvis based on the degree of narrowing.
With an anatomically very narrow pelvis:
- Grade III-IV surgery will be performed as planned;
- II degree of narrowing, the decision will be made during childbirth;
- I degree birth will take place naturally in the absence of other indications.
Mechanical obstacles preventing natural childbirth
This may be uterine fibroids in the isthmus region (i.e., the area where the uterus meets the cervix), ovarian tumors, tumors and deformities of the pelvic bones.
Threat of uterine rupture
It most often occurs when there is a scar on the uterus, for example due to a previous cesarean section, as well as due to numerous previous births, when the walls of the uterus are very thin. The health of the scar is determined by ultrasound and its condition before and during childbirth.
Placenta previa
Sometimes the placenta is attached in the lower third and even directly above the cervix, blocking the exit of the fetus. This is fraught with severe bleeding, which is dangerous for the mother and baby and can lead to placental abruption. Diagnosed by ultrasound, surgery is scheduled for 33 weeks of pregnancy or earlier if bleeding is detected, indicating placental abruption.
In these cases, it is necessary to carry out surgical delivery using a cesarean section, regardless of all other conditions and possible contraindications.
Relative indications for surgery
Chronic diseases of the mother
Cardiovascular diseases, kidney diseases, eye diseases, nervous system diseases, diabetes mellitus, cancer - in a word, any pathologies that can worsen during contractions and pushing. Such conditions also include exacerbation of diseases of the genital tract (for example, genital herpes) - although childbirth in this case does not significantly aggravate the woman’s condition, when passing through the birth canal the disease can be transmitted to the child.
Some complications of pregnancy that threaten the life of the mother or child.
The possibility of delivery through cesarean section is offered in severe forms of gestosis with dysfunction of vital organs, especially the cardiovascular system.
Recently, pregnancy after long-term infertility or occurring after an in vitro fertilization procedure has also become a relative indication for delivery via cesarean section. Women carrying a long-awaited child are sometimes so worried about the fear of losing him that, in the absence of physical disorders, they cannot “tune in” to the process of childbirth.
Malposition
History of anal sphincter rupture
Large fruit
A child whose weight at birth is 4 kilograms or more is considered large, and if its weight is more than five kilograms, then the fetus is considered gigantic.
Emergency caesarean section
Sometimes the impossibility of spontaneous childbirth becomes known only at the moment of contractions. Also, during pregnancy, situations may arise when the life of the mother and the unborn child is at risk. In these cases, emergency delivery is performed by caesarean section.
Persistent weakness of labor
If natural childbirth continues for a long time without progress, despite the use of medications that enhance labor, then a decision is made to have a caesarean section.
Premature placental abruption
Separation of the placenta from the uterus before or during childbirth. This is dangerous for both the mother (massive bleeding) and the child (acute hypoxia). An emergency caesarean section is performed.
Presentation and prolapse of umbilical cord loops
Sometimes (especially when the baby is breech), the umbilical cord or its loops fall out before the widest part of the baby is born - the head. In this case, the umbilical cord is pinched and, in fact, the child is temporarily deprived of blood supply, which threatens his health and even life.
Clinically narrow pelvis
Sometimes, with normal pelvic sizes at the time of birth, it turns out that the internal ones still do not correspond to the size of the fetal head. This becomes clear when there are good contractions, there is dilation of the cervix, but the head, with good labor and pushing, does not move along the birth canal. In such cases, wait about an hour and, if the baby’s head does not move, surgery is recommended.
Premature (before the onset of contractions) rupture of amniotic fluid in the absence of effect from cervical stimulation
With the release of water, regular labor may begin, but sometimes contractions do not begin. In this case, intravenous stimulation of labor with special drugs prostaglandins and oxytocin is used. If there is no progress, then a caesarean section is performed.
Abnormalities of labor that are not amenable to medication
Surgery has to be resorted to if the strength of the contractions is insufficient, and they themselves are very short.
Acute fetal hypoxia
During childbirth, the child's condition is monitored by heartbeat (the norm is 140-160 beats per minute, during contractions - up to 180 beats per minute). Worsening heartbeat indicates hypoxia, that is, lack of oxygen. An emergency caesarean section is required to prevent intrauterine death of the baby.
Previously undiagnosed threat of uterine rupture
The contractions are frequent and painful, the pain in the lower abdomen is constant, the uterus does not relax between contractions. When the uterus ruptures, the mother and child show signs of acute blood loss.
Contraindications for cesarean section
There are no absolute contraindications to a cesarean section; nevertheless, this is often the only way to preserve the health and life of a woman and her child.
However, there are contraindications in which a cesarean section is undesirable.
Fetal health problems
If it becomes clear that it is impossible to save the child (intrauterine death of the fetus, extreme prematurity, developmental defects leading to early postnatal death of the child, severe or long-term fetal hypoxia), then the choice is made in favor of the health of the mother, and natural delivery as opposed to traumatic surgery.
High risk of developing purulent-septic complications in the postoperative period
These include infections of the birth canal, purulent diseases of the abdominal wall; amnionitis (inflammation of the membranes of an infectious nature).
Only the doctor observing her can judge whether a pregnant woman needs a cesarean section!
In any case, remember, no matter how your baby was born, naturally or through a cesarean section, it is important that both he and his mother are healthy!
Absolute – shock (serious condition of the body, close to terminal), except hemorrhagic with ongoing bleeding; acute stage of myocardial infarction or cerebrovascular accident (stroke), except for methods of surgical correction of these conditions, and the presence of absolute indications (perforating duodenal ulcer, acute appendicitis, strangulated hernia)
Relative - the presence of concomitant diseases, primarily the cardiovascular system, respiratory, kidney, liver, blood system, obesity, diabetes.
Preliminary preparation of the surgical field
One of the ways to prevent contact infection.
Before a planned operation, it is necessary to carry out complete sanitization. To do this, the evening before the operation, the patient must take a shower or wash in the bath, put on clean underwear; In addition, bed linen is changed. On the morning of the operation, the nurse dry-shaves the hair in the area of the upcoming operation. This is necessary, since the presence of hair makes it much more difficult to treat the skin with antiseptics and can contribute to the development of infectious postoperative complications. You should definitely shave on the day of surgery, and not before. When preparing for emergency surgery, they usually limit themselves to shaving the hair in the surgical area.
"Empty Stomach"
When the stomach is full, after induction of anesthesia, the contents from it can begin to passively flow into the esophagus, pharynx and oral cavity (regurgitation), and from there, with breathing, enter the larynx, trachea and bronchial tree (aspiration). Aspiration can cause asphyxia - blockage of the airways, which without urgent measures will lead to the death of the patient, or a serious complication - aspiration pneumonia.
Bowel movement
Before a planned operation, patients need to do a cleansing enema so that when the muscles relax on the operating table, involuntary bowel movements do not occur. Before emergency operations, there is no need to do an enema - there is no time for this, and this procedure is difficult for patients in critical condition. It is impossible to perform an enema during emergency operations for acute diseases of the abdominal organs, since an increase in pressure inside the intestine can lead to rupture of its wall, the mechanical strength of which can be reduced due to the inflammatory process.
Emptying the Bladder
To do this, the patient urinated on his own before the operation. The need for bladder catheterization occurs rarely, mainly during emergency operations. This is necessary if the patient’s condition is severe, he is unconscious, or when performing special types of surgical interventions (surgeries on the pelvic organs).
Premedication- administration of medications before surgery. It is necessary to prevent certain complications and create the best conditions for anesthesia. Premedication before a planned operation includes the administration of sedatives and hypnotics the night before the operation and the administration of narcotic analgesics 30-40 minutes before its start. Before emergency surgery, only a narcotic analgesic and atropine are usually administered.
Risk level of surgery
Abroad, the classification of the American Society of Anesthesiologists (ASA) is usually used, according to which the degree of risk is determined as follows.
Planned surgery
Risk degree I - practically healthy patients.
Risk degree II - mild illness without impairment of function.
III degree of risk - severe diseases with impaired function.
IV degree of risk - severe diseases, in combination with or without surgery, threatening the patient’s life.
V degree of risk - the patient’s death can be expected within 24 hours after surgery or without it (moribund).
Emergency surgery
VI degree of risk - patients of categories 1-2, operated on as an emergency.
VII degree of risk - patients of categories 3-5, operated on as an emergency.
The ASA classification presented is convenient, but is based only on the severity of the patient's initial condition.
The most complete and clear classification of the degree of risk of surgery and anesthesia, recommended by the Moscow Society of Anesthesiologists and Reanimatologists (1989) (Table 9-1). This classification has two advantages. Firstly, it evaluates both the general condition of the patient and the volume, nature of the surgical intervention, as well as the type of anesthesia. Secondly, it provides an objective scoring system.
There is an opinion among surgeons and anesthesiologists that proper preoperative preparation can reduce the risk of surgery and anesthesia by one degree. Considering that the likelihood of developing serious complications (including death) progressively increases with the degree of surgical risk, this once again emphasizes the importance of qualified preoperative preparation.
