Indications for surgical treatment. Indications and contraindications for surgical treatment The therapist determines contraindications for surgery which order

Name surgical operation is made up of the name of the organ on which it is performed and the term that denotes the operational technique being performed.

The following terms are used:

Tomia- dissection, incision, opening;

ectomy- excision;

extirpation- isolating, husking;

resection- partial excision;

amputation- 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 - gut, ectomia - excision) - excision of the intestine.
• urethrostomy(urethra - urethra, stomia - creation of an artificial fistula) - the creation of an artificial fistula of the urethra.

Indications and contraindications for operations

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

Thereafter operation substantiate with relevant evidence. In all difficult and doubtful cases of determining indications for surgery, it is necessary to resort to a consultation.

« A cleverly 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 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, tympania of the scar, prolapse of internal organs);
• relative- those cases in which the operation can be omitted without causing significant damage to the health and productivity of the animal, or when the operation is not the only method of treatment (benign tumor, not strangulated hernia).

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

Contraindications for surgery- these are cases when the operation cannot or is undesirable to perform.

They are divided into:

Contraindications due to the serious condition of the animal:

With exhaustion, old age, exacerbation of the inflammatory process, fever, infectious disease, a large amount of damage, the second half of pregnancy, sexual hunting in females.

An exception is urgent operations (strangulated hernia, phlegmon, malignant tumor). In these cases, the entire risk must be explained to the owner of the animal.

Contraindications due to economic and organizational factors:

• when imposing a quarantine for an infectious disease characteristic of this type of animal (erysipelas, plague, washing horses, anthrax);
• before the transfer and regrouping of animals;
• 2 weeks before and within 2 weeks after preventive vaccination;
• in the absence of appropriate sanitary conditions for the postoperative maintenance of animals.

The exception is urgent cases that require emergency intervention, in which the operation must be performed in compliance with all the rules of one's own protection and prevention of the further spread of the disease.

Mass operations cannot be carried out in farms that do not have the proper conditions for the postoperative maintenance of animals (calves cannot be castrated if they are kept knee-deep in slurry).

Any surgical operation involving a risk to the life of the 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 imagines the whole need for an operation, must insist on its performance, and, if necessary, operate without waiting for consent.

Any surgical operation has a relative degree of risk.

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

Grade 2 - moderate.

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

Grade 3 - severe.

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

The 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 rather low and, according to various surgeons, varies widely - from 19.5% (BV Petrovsky) to 84.4% (Adatz et al.). The average figures for operability in the domestic literature are 47.3%. Consequently, approximately half of the patients are scheduled for surgery, and the second is not subject to surgical treatment. What are the reasons for such a large number of patients with esophageal cancer to refuse 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 in various surgeons reaches 30 or more.

The second reason is the presence of contraindications to surgical intervention, depending on the state of the already elderly organism itself. The operation of resection of the esophagus 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 emphysema, bilateral tuberculosis), unilateral pulmonary tuberculosis is not a contraindication, also as well as pleural adhesions (A. A. Polyantsev, Yu. E. Berezov), although they, no doubt, burden and complicate the operation. Diseases of the kidneys and liver - nephrosonephritis with persistent hematuria, albuminuria or oliguria, Botkin's disease, cirrhosis - are also considered a contraindication to surgical treatment of esophageal cancer.

The operation of resection of the esophagus is contraindicated and debilitated patients who have difficulty walking, severely emaciated, until they are taken out of this condition.

The presence of at least one of the listed diseases or conditions in a patient with cancer of the esophagus will inevitably lead to his death either during the operation of resection of the esophagus, or in the postoperative period. Therefore, with them, radical operations are contraindicated.

Concerning age of the patients appointed for operation, there are various opinions. G. A. Gomzyakov demonstrated a 68-year-old patient operated on for cancer of the lower thoracic esophagus. She underwent transpleural resection of the esophagus with a one-stage anastomosis in the chest cavity. After the demonstration by F. G. Uglov, S. V. Geinats, V. N. Sheinis and I. M. Talman, it was suggested that advanced age in itself is not a contraindication to surgery. The same opinion is shared by S. Grigoriev, B. N. Aksenov, A. B. Raiz and others.

A number of authors (N. M. Amosov, V. I. Kazansky, etc.) believe that the age over 65-70 years is a contraindication to resection of the esophagus, especially by the transpleural route. We believe that elderly patients with esophageal cancer should be carefully scheduled for surgery. It is necessary to take into account all changes in the age character and the general condition of the patient, take into account the scale of the proposed operation, depending on the localization of the tumor, its prevalence and the method of the surgical approach. Without a doubt, resection of the esophagus for a small carcinoma of the lower esophagus using the Savinykh method can be successfully performed in a 65-year-old patient with moderate 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 due to the esophageal tumor itself. All surgeons recognize that distant metastases to the brain, lungs, liver, spine, etc. are 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's metastasis cannot serve as a contraindication to surgery. We agree that palliative but not radical surgery can be performed in this case.

The presence of an esophageal-tracheal, esophageal-bronchial fistula, perforation of a tumor of the esophagus into the mediastinum, lung are a contraindication to 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 it is localized in the upper thoracic or, less often, in the mid-thoracic region. Operation is contraindicated, according to some surgeons (Yu. E. Berezov, V. S. Rogacheva), in patients with significantly pronounced infiltration of the mediastinum by a tumor, determined by x-ray examination.

This group of contraindications, depending on the extent of the tumor of the esophagus, is determined by the technical impossibility of resection of the esophagus due to the germination of carcinoma in neighboring 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 the last column), resection of the esophagus can be performed not by all operated, but by 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, the data of clinical and radiographic studies, taking into account the localization of the tumor, its extent along the esophagus and mediastinal infiltration, then in most patients it is possible to correctly determine the stage of esophageal cancer before surgery. Errors are possible mainly r, but due to unrecognized metastases before the operation 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 resection of the esophagus. As for patients with stage III cancer of the esophagus, we solve the issue of resection of the esophagus in the following 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 those cases where it is technically possible to perform it, i.e. the tumor has not sprouted into the trachea, bronchi, aorta, vessels of the lung root.

Almost all surgeons adhere to this tactic, and yet resectability, i.e., the number of patients who manage to perform resection of the esophagus, 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 - 25.7%. The figures obtained are close to the average data of Yu. E. Berezov and M. S. Grigoriev. Therefore, at present, about one in 4 patients with esophageal cancer who seek surgical help can undergo resection of the esophagus.

In the hospital surgical clinic named after A. G. Savin of the Tomsk Medical Institute, since 1955, various operations have been used for resection of the esophagus in cancer, depending on the indications. Indications for the use of a particular method are based on the localization of the tumor and the stage of its spread.

1. Patients with cancer of the esophagus stage I and II, with the localization of the tumor in the thoracic region, resect the esophagus according to the Savinykh method.

2. In case of cancer of the upper and middle thoracic sections of the esophagus, stage III, as well as when the tumor is located on the border of the middle and lower sections, resection of the esophagus is performed according to the Dobromyslov-Torek method through the right-sided access. In the future, after 1-4 months, retrosternal-prefascial small-bowel esophagoplasty is performed.

3. In 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 a one-stage esophageal-gastric or esophago-intestinal anastomosis in the chest cavity, or resection of the esophagus using the Savinykh method, as indicated.

Absolute - shock (a serious condition of the body, close to terminal), except for hemorrhagic with continued bleeding; acute stage of myocardial infarction or cerebrovascular accident (stroke), except for the methods of surgical correction of these conditions, and the presence of absolute indications (perforated duodenal ulcer, acute appendicitis, strangulated hernia)

Relative - the presence of concomitant diseases, primarily the cardiovascular system, respiratory, kidney, liver, blood system, obesity, diabetes mellitus.

Preliminary preparation of the surgical field

One way to prevent contact infection.

Before a planned operation, it is necessary to carry out a complete sanitization. To do this, on the evening before the operation, the patient should take a shower or bathe, put on clean underwear; in addition, bed linen is changed. On the morning of the operation, the nurse shaves off the hairline in the area of ​​the upcoming operation with a dry method. This is necessary, since the presence of hair greatly complicates the treatment of the skin with antiseptics and may contribute to the development of infectious postoperative complications. Shaving should be mandatory on the day of surgery, and not before. When preparing for an emergency operation, they are usually limited to only shaving the hair in the area of ​​the operation.

"Empty Stomach"

With a full stomach after 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 the most severe 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 defecation does not occur. There is no need to do an enema before emergency operations - there is no time for this, and this procedure is difficult for patients in critical condition. It is impossible to perform enema during emergency operations for acute diseases of the abdominal organs, since an increase in pressure inside the intestine can lead to a rupture of its wall, the mechanical strength of which can be reduced due to the inflammatory process.

Bladder emptying

For this, the patient urinated on his own before the operation. The need for bladder catheterization is rare, 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 (surgery on the pelvic organs).

Premedication- the introduction of drugs before surgery. It is necessary to prevent some complications and create the best conditions for anesthesia. Premedication before a planned operation includes the administration of sedatives and hypnotics on the night before the operation and the administration of narcotic analgesics 30-40 minutes before it starts. Before an emergency operation, only a narcotic analgesic and atropine are usually administered.

The degree of risk of the operation

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 operation

I degree of risk - practically healthy patients.

II degree of risk - mild diseases without functional impairment.

III degree of risk - severe diseases with dysfunction.

IV degree of risk - serious diseases, in combination with surgery or without it, threatening the life of the patient.

V degree of risk - you can expect the death of the patient within 24 hours after surgery or without it (moribund).

emergency operation

VI degree of risk - patients of the 1st-2nd categories, operated on an emergency basis.

VII degree of risk - patients of the 3rd-5th categories, operated on an emergency basis.

The presented ASA classification is convenient, but is based only on the severity of the patient's initial condition.

The classification of the degree of risk of surgery and anesthesia recommended by the Moscow Society of Anesthesiologists and Resuscitators (1989) seems to be the most complete and clear (Table 9-1). This classification has two advantages. Firstly, she 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 for an objective scoring system.

There is an opinion among surgeons and anesthesiologists that the correct preoperative preparation can reduce the risk of surgery and anesthesia by one degree. Considering that the probability of developing serious complications (up to death) progressively increases with an increase in the degree of operational risk, this once again emphasizes the importance of qualified preoperative preparation.

Indications for surgery for Fallot's tetrad are actually absolute. All patients are subject to surgical treatment, especially in infants and patients with cyanosis, surgical intervention should not be postponed. Cyanosis, the sharpest hypertrophy of the right ventricle of the heart, continuously occurring changes in the anatomy of the right ventricle, its outlet section, in the structure of the lungs - all this necessitates the possible early surgical intervention, primarily in young children. If the defect proceeds with pronounced cyanosis, frequent dyspnea-cyanotic attacks, disturbances in general development, an urgent operation is indicated.

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

Methods of surgical interventions

In the surgical correction of Fallot's tetrad, 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 deficit 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 contribute to the growth of the trunk and branches of the pulmonary artery. An increase in pulmonary blood flow increases

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

Palliative bypass surgery improves the capacitive-elastic properties of the pulmonary arterial bed with an increase in the elasticity of the pulmonary vessels.

Among bypass palliative operations, the most common are:

1. subclavian - pulmonary anastomosis according to Blelock - Taussig (l 945) (Nobel Prize in 1948). It is the 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 (Coogy - 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 an adequate size of the anastomosis, since the degree of reduction in arterial hypoxemia is proportional to the amount of pulmonary blood flow. The large size of the anastomosis quickly leads to the development of pulmonary hypertension and. and small ones - to its rapid thrombosis, therefore, the optimal size of the anastomosis is 3-4 mm in diameter.

Operations are performed on a beating heart, access - 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 a radical correction of the defect. However, the positive effect of palliative surgery is not permanent. With an increase in the duration of the existence of intersystemic anastomoses, 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 an increase in cyanosis, a deepening of polycythemia, and a decrease in arterial blood oxygen saturation. Over time, the question arises of a second palliative operation or a radical intervention, 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 the preparation of patients at all stages of the surgical treatment of the defect, especially in recent years.

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

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

Radical correction of TF consists in elimination of stenosis or reconstruction of the right ventricular outflow tract and closure of the ventricular septal defect. In cases of previously imposed intersystemic anastomosis - its elimination at the very beginning of the operation before connecting the heart-lung machine by isolating and tying or suturing the anastomosis from the lumen of the corresponding pulmonary artery.

A radical operation is performed under conditions of hypothermic cardiopulmonary bypass (28-30 degrees), pharmaco-cold 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 output section of the right ventricle, and therefore its longitudinal ventriculotomy is indicated. Infundibular stenosis of the right ventricle is revised, hypertrophied muscles are widely excised. Valvular stenosis is eliminated by dissecting the fused leaflets along the commissures. With a sharply changed valve, the elements of the latter are excised. To expand the outlet section, xenopericardial patches with an implanted monocusp are used, the dimensions of which vary (No. 14 - No. 18) in each case.

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

How is the adequacy of defect correction assessed? For this purpose, pressure is measured in the inlet 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 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 allows to normalize intracardiac hemodynamics, increase physical

working capacity and already a year after the operation up to 75% - 80% of the norm for healthy children.

Recent studies indicate that even with good results, latent heart failure is detected in the long term, due to prolonged arterial hypoxemia affecting delicate structures in vital organs (in particular, in cardiomyocytes). From this follows an important practical conclusion that children should be operated on at an early age, in any case up to two years. Unsatisfactory results of the operation are due to incomplete correction of the defect, VSD recanalization, and hypertension in the pulmonary artery system.

Operation indications determine its urgency and can be vital (vital), absolute and relative:

$ Vital indications for surgery – diseases or injuries in which the slightest delay threatens the life of the patient. Such operations are performed on an emergency basis, that is, after a minimum examination and preparation of the patient (no more than 2-4 hours from the moment of admission). Vital indications for surgery occur in the following pathological conditions:

¾ Asphyxia;

¾ Continued bleeding: with damage to the internal organ (liver, spleen, kidney, fallopian tube with the development of pregnancy in it, etc.), heart, large vessels, with stomach and duodenal ulcers, etc .;

¾ Acute diseases of the abdominal organs of an inflammatory nature (acute appendicitis, strangulated hernia, acute intestinal obstruction, perforation of a stomach or intestinal ulcer, thromboembolism, etc.), fraught with the risk of developing peritonitis or gangrene of an organ during thromboembolism;

¾ Purulent - inflammatory diseases (abscess, phlegmon, purulent mastitis, acute osteomyelitis, etc.) that can lead to the development of sepsis.

$ Absolute indications for surgery - diseases in which time is needed to clarify the diagnosis and more thorough preparation of the patient, but a long delay in the operation can lead to a condition that threatens the life of the patient. These operations are performed urgently after a few hours or days (usually within 24-72 hours of the preoperative period. A long delay in surgery in such patients can lead to tumor metastases, general emaciation, liver failure and other complications. Such diseases include:

¾ Malignant tumors;

¾ Pyloric stenosis;

¾ Obstructive jaundice, etc.;

$ Relative indications for surgery - diseases that do not pose a threat to the life of the patient. These operations are performed in a planned manner after a thorough examination and preparation at a time convenient for the patient and the surgeon:

¾ Varicose veins of the superficial veins of the lower extremities;

¾ Benign tumors, etc.

Revealing contraindications presents significant difficulties, since any operation and anesthesia pose a potential danger to the patient, and there are no clear clinical, laboratory and special criteria that assess the severity of the patient's condition, the upcoming operation and the patient's response to anesthesia.

Surgical intervention has to be postponed for some time in cases where it is more dangerous than the disease itself or there is a risk of postoperative complications. Most contraindications are temporary and relative.

Absolute contraindications for surgery:

¾ Terminal state of the patient;

Relative contraindications to surgery (any concomitant disease):

¾ Cardiac, respiratory and vascular insufficiency;

¾ shock;

¾ Myocardial infarction;

¾ Stroke;

¾ Thromboembolic disease;

¾ Renal - liver failure;

¾ Severe metabolic disorders (decompensation of diabetes mellitus);

¾ Pre-comatose state; coma;

¾ Severe anemia;

¾ Severe anemia;

¾ Advanced forms of malignant tumors (stage IV), etc.

In the presence of vital and absolute indications, relative contraindications cannot prevent an emergency or urgent operation after appropriate preoperative preparation. Planned operations are preferably carried out after appropriate preoperative preparation. It is desirable to carry out planned surgical interventions after the elimination of all contraindications.

The factors that determine the operational risk include the age of the patient, the state and function of the myocardium, liver, lungs, kidneys, pancreas, the degree of obesity, etc.

Established diagnosis, indications and contraindications allow the surgeon to resolve issues of urgency and volume of surgical intervention, method of anesthesia, preoperative preparation of the patient.

Question 3: Preparation of patients for planned operations.

Planned operations - when the outcome of treatment is practically independent of the time of execution. Before such interventions, the patient undergoes a complete examination, the operation is performed on the most favorable background in the absence of contraindications from other organs and systems, and in the presence of concomitant diseases - after reaching the stage of remission as a result of appropriate preoperative preparation. Example: radical surgery for non-strangulated hernia, varicose veins, cholelithiasis, uncomplicated gastric ulcer, etc.

1.General activities: general measures include improving the patient's condition by identifying and eliminating as much as possible violations of the function of the main organs and systems. During the period of preoperative preparation, the functions of organs and systems are carefully studied and they are prepared for surgical intervention. The nurse with full responsibility and understanding should relate to preoperative preparation. She is directly involved in the examination of the patient and the implementation of therapeutic and preventive measures. Basic and mandatory research before any planned operation:

J Measurement of blood pressure and pulse;

J Measurement of body temperature;

J Measuring the frequency of respiratory acts;

J Measurement of height and weight of the patient;

J Carrying out a clinical analysis of blood and urine; determination of sugar in the blood;

J Determination of blood group and Rh factor;

J Examination of feces for eggs of worms;

J Statement of the Wasserman reaction (=RW);

J In the elderly - an electrocardiographic study;

J According to indications - a blood test for HIV; others

a) preparation of the psyche and physical condition: creating an environment around the patient that inspires confidence in the successful outcome of the operation. All medical personnel should eliminate the moments that cause irritation as much as possible and create conditions that provide complete rest for the nervous system and the patient. For the correct preparation of the patient's psyche for the operation, it is of great importance that the nurses follow the rules of deontology. Before the operation in the evening, the patient is given a cleansing enema, the patient takes a hygienic bath or shower and changes underwear and bed linen. The moral state of patients entering for surgery differs significantly from the state of patients who undergo only conservative treatment, since the operation is a great physical and mental trauma. One "waiting" for the operation instills fear and anxiety, seriously undermines the strength of the patient. Starting from the emergency room and ending with the operating room, the patient looks and listens to everything around him, is always in a state of tension, usually turns to the junior and middle medical staff, looking for their support.

The protection of the patient's nervous system and psyche from irritating and traumatic factors largely determines the course of the postoperative period.

The nervous system is especially traumatized by pain and sleep disturbance, the fight against which (prescribing painkillers, sleeping pills, tranquilizers, sedatives and other drugs is very important during the preoperative preparation.

For the correct preparation of the patient's psyche for surgery, it is of great importance that the nursing staff follow the following rules of surgical deontology:

¾ When a patient enters the emergency department, it is necessary to provide him with the opportunity to calmly communicate with his relatives accompanying him;

¾ The diagnosis of the disease should be communicated to the patient only by a doctor who, in each individual case, decides in what form and when he can do this;

¾ It is necessary to address the patient by name and patronymic or last name, but do not call him impersonally “sick”;

¾ The patient before the operation is especially sensitive to the look, gesture, mood, carelessly spoken word, captures all the shades of the nurse's intonation. Particularly careful should be conversations during a planned round and rounds conducted for pedagogical purposes. At this moment, the patient is not only an object for research and teaching, but also a subject who catches every word of the bystanders and the teacher. It is very important that these words and gestures contain benevolence, sympathy, sincerity, tact, endurance, patience, warmth. The indifferent attitude of the nurse, the negotiations of the staff about personal, irrelevant things in the presence of the patient, the inattentive attitude to requests and complaints give the patient reason to doubt all further measures, alarm him. The talk of the medical staff about the poor outcome of the operation, death, etc. has a negative effect. A nurse who performs appointments or provides any assistance in the presence of patients in the ward must do it skillfully, calmly and confidently so as not to cause them anxiety and nervousness;

¾ Medical history and diagnostic data should be stored in such a way that they cannot become available to the patient; the nurse must be the keeper of medical (medical) secrets in the broadest sense of the word;

¾ In order to distract the patient from thoughts about his illness and the upcoming operation, the nurse should visit him as often as possible and, if possible, involve him in conversations far from medicine;

¾ The medical staff should ensure that in the hospital environment surrounding the patient there are no factors that irritate and frighten him: excessive noise, frightening medical posters, signs, syringes with traces of blood, bloody gauze, cotton wool, sheets, tissues, tissue, organ or parts of it, etc.;

¾ The nurse must strictly monitor the strict observance of the nosocomial regimen (afternoon rest, sleep, bedtime, etc.);

¾ Medical staff should pay special attention to their appearance, given that untidiness, sloppy appearance causes the patient to doubt the accuracy and success of the operation;

¾ When talking with the patient before the operation, the operation should not be presented to him as something easy, at the same time he should not be frightened by the riskiness and the possibility of an unfavorable outcome. It is necessary to mobilize the patient's strength and faith in a favorable outcome of the intervention, eliminate fears associated with perverted ideas about the upcoming pain sensations during and after the operation, report postoperative pain. When explaining, the nurse must adhere to the same interpretation that the doctor gave, otherwise the patient ceases to believe the medical staff;

¾ The nurse must timely and conscientiously fulfill the doctor's prescriptions (taking tests, obtaining research results, medication prescriptions, preparing the patient, etc.), it is unacceptable to send the patient from the operating table to the ward due to his unpreparedness due to the fault of the medical staff; the nurse must remember that nursing at night is of particular importance, since there are almost no external stimuli at night. The patient is left alone with his illness, and, naturally, all his senses are sharpened. Therefore, care for him at this time of day should be no less thorough than during the day.

2.Specific events: these include activities aimed at preparing those organs on which the operation is to be performed. That is, a number of studies are being carried out related to the operation on this organ. For example, during heart surgery, heart sounding is performed, during lung surgery - bronchoscopy, during stomach operations - analysis of gastric juice and fluoroscopy, fibrogastroscopy. On the eve of the evening in the morning, the contents of the stomach are removed. With congestion in the stomach (pyloric stenosis), it is washed. At the same time, a cleansing enema is given. The patient's diet on the day before the operation: a regular breakfast, a light lunch, and sweet tea for dinner.

Before surgery for biliary tract it is necessary to examine the gallbladder, pancreas and bile ducts using special methods (ultrasound) and study the laboratory parameters of the functions of these organs and the exchange of bile pigments.

At obstructive (mechanical) jaundice the flow of bile into the intestines stops, the absorption of fat-soluble substances, which include vitamin K, is disrupted. Its deficiency leads to a deficiency of clotting factors, which can cause severe bleeding. Therefore, before surgery, a patient with obstructive jaundice is given vitamin K ( vikasol 1% - 1 ml), a solution of calcium chloride, transfuse blood, its components and preparations.

Before the operation on the large intestine for the prevention of endogenous infection, it is very important to thoroughly cleanse the intestines, but at the same time, the patient, often emaciated and dehydrated by the underlying disease, should not starve. He receives a special diet containing high-calorie food, devoid of toxins and gas-forming substances. Since an operation with an opening of the large intestine is supposed, to prevent infection, patients begin to take antibacterial drugs during the preparation period ( colimycin, polymyxin, chloramphenicol and etc.). Fasting and the appointment of laxatives are resorted to only according to indications: constipation, flatulence, lack of a normal stool. On the evening before the operation and in the morning, the patient is given a cleansing enema.

For operations in the area rectum and anus(for hemorrhoids, anal fissures, paraproctitis, etc.) it is also necessary to thoroughly clean the intestines, since in the postoperative period the stool is artificially retained in the intestines for 4-7 days.

To survey departments large intestine resort to radiopaque (barium passage, irrigoscopy) and endoscopic (sigmoidoscopy, colonoscopy) studies.

Patients with very large, long-term hernias of the anterior abdominal wall. During the operation, the internal organs located in the hernial sac are pushed into the abdominal cavity, this is accompanied by an increase in intra-abdominal pressure, displacement and high standing of the diaphragm, which complicates cardiac activity and respiratory excursions of the lungs. To prevent complications in the postoperative period, the patient is placed on a bed with a raised leg end, and after the contents of the hernial sac have been reduced, a tightening bandage or sandbag is applied to the area of ​​the hernial orifice. The body is "accustomed" to the new conditions of the high standing of the diaphragm, to the increased load on the heart.

Special training on limbs comes down to cleansing the skin from contamination with baths with a warm and weak antiseptic solution (0.5% ammonia solution, 2-4% sodium bicarbonate solution, etc.).

Other diseases and operations require appropriate special studies and preoperative preparation, often in a specialized surgical department.

¾ Preparation of the cardiovascular system:

On admission - examination;

Carrying out a general blood test

Biochemical analysis of blood and, if possible, normalization of indicators

Measurement of heart rate and blood pressure

Removing an ECG

Taking into account blood loss - preparation of blood, its preparations

Instrumental and laboratory research methods (ultrasound of the heart).

¾ Respiratory system preparation:

· To give up smoking

Elimination of inflammatory diseases of the upper respiratory tract.

Carrying out breath tests

Teaching the patient how to breathe and cough properly, which is important for the prevention of pneumonia in the postoperative period

· Chest x-ray or X-ray.

¾ Gastrointestinal preparation

Sanitation of the oral cavity

Gastric lavage

Suction of the contents of the stomach

Meals before surgery

¾ Preparation of the genitourinary system:

Normalization of kidney function;

· Carry out studies of the kidneys: urine tests, determination of residual nitrogen (creatinine, urea, etc.), ultrasound, urography, etc. If pathology is detected in the kidneys or in the bladder, appropriate therapy is carried out;

· For women, before the operation, a gynecological examination is mandatory, and if necessary, treatment. Planned operations during menstruation are not carried out, since these days there is increased bleeding.

¾ Immunity and metabolic processes:

Improving the immunobiological resources of the patient's body;

Normalization of protein metabolism;

· Normalization of water-electrolyte and acid-base balance.

¾ Skin covers:

Identification of skin diseases that can cause severe complications in the postoperative period, up to sepsis (furunculosis, pyoderma, infected abrasions, scratches, etc.). Preparation of the skin requires the elimination of these diseases. On the eve of the operation, the patient takes a hygienic bath, shower, changes underwear;

· The operating field is prepared immediately before the operation (1-2 hours in advance), since cuts and scratches that may occur during shaving may become inflamed over a longer period of time.

On the eve of the operation the patient is examined by an anesthesiologist, who determines the composition and timing of premedication, the latter is carried out, as a rule, 30-40 minutes before the operation, after the patient has urinated, removed dentures (if any), as well as other personal belongings.

The patient, covered with a sheet, is taken on a gurney head first to the operating unit, in the vestibule of which he is transferred to the gurney of the operating room. In the preoperative room, a clean cap is put on the patient's head, and clean shoe covers are put on his feet. Before bringing the patient to the operating room, the nurse should check whether the bloody underwear, dressings, and instruments from the previous operation have been removed there.

The medical history, x-rays of the patient are delivered simultaneously with the patient.