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Lecture notes, cheat sheets
Operative surgery. Cheat sheet: briefly, the most important
Directory / Lecture notes, cheat sheets Table of contents
1. Operational reception Operative surgery (the science of surgical operations) studies the technique of surgical interventions. Topographic (surgical) anatomy - the science of the relationship of organs and tissues in various areas of the human body, studies their projection on the surface of the human body; the ratio of these organs to non-displaced bone formations; changes in the shape, position and size of organs depending on body type, age, sex, disease; vascularization and innervation of organs, lymphatic drainage from them. Based on modern achievements in anatomy and physiology, operative surgery develops methods for the rational exposure of organs and the implementation of certain influences on them. Topographic anatomy describes the layered arrangement and relationship of organs by region, which allows you to determine the affected organ, choose the most rational operational access and reception. Surgical reception - direct actions at the object of surgical intervention, aimed at removing the altered organ or pathological focus. Performing an operative technique involves a sequence of actions when removing an organ or part of it, restoring the patency of the gastrointestinal tract, restoring blood or lymph flow through the corresponding vessel, etc. Certain requirements are imposed on the operative technique, it should be radical, minimally traumatic, and if possible bloodless ; minimally disrupt the vital activity of the body, ensuring the best elimination of the cause of the disease. The radicality of the surgical technique is understood as the most complete removal of the focus of the disease, often not only with the affected organ, but, for example, with malignant tumors, with regional lymph nodes or even part of neighboring organs. The bloodlessness of the surgical intervention is ensured by a thorough sequential stop of bleeding as the manipulations are carried out. In some cases, it is recommended to pre-ligate large arterial and venous trunks involved in the blood supply to the region. This is done during complex operations in the head and face, producing a preliminary ligation of the external carotid artery, the branches of which supply the maxillofacial region and the cranial vault. It is important to preserve (or restore) the function of the organ after the operation. It provides for the mandatory inclusion in the operation plan of the restoration of a particular organ and its functions after the operation. The requirements for operational access and reception are highly controversial; it is almost impossible to comply with all of them. As a rule, one operational access corresponds to one operational reception. Sometimes two accesses correspond to one operational reception. Of interest are situations where several approaches are performed from one access or the patient undergoes several accesses and surgical techniques during the operation. 2. Online access Operative access is those actions of the surgeon that provide exposure of the affected or damaged organ by the pathological process. Online access must meet certain requirements, which can be divided into qualitative and quantitative. The criteria for a qualitative assessment of surgical access are: breadth; the shortest distance to the operation object; compliance with the direction of the main vessels and nerves; good blood supply to the edges of the surgical wound (which contributes to rapid healing); distance from infected foci. The breadth of access is necessary to ensure the freedom of action of the surgeon. Access should pass through the least number of layers, along the shortest distance to the organ. To achieve this goal, it is necessary that the incision is located in the projection zone of the organ. Access should not be located near infected (contaminated) areas of the body. The quantitative assessment of surgical approaches is based on the criteria developed by A. Yu. Sozon-Yaroshevich. The criteria objectively evaluating operational access are as follows. Axis of operation. This is understood as a line connecting the surgeon's eye with the deepest point of the surgical wound (or the most important object of surgical intervention). Most often, the axis of the surgical action passes along the axis of the cone of the surgical wound or is the bisector of the angle between the side walls of the wound cavity. The angle of inclination of the axis of the operational action. This term refers to the angle formed by the axis of the surgical action and the surface of the patient's body within the operating zone (the plane of the wound aperture). Operating angle. This angle is formed by the walls of the cone of the surgical wound; it determines the freedom of movement of the surgeon's fingers and instruments in the wound. Wound depth. This term refers to the distance between the planes of the upper and lower apertures of the wound. The depth of the wound is determined by the axis of the cone, which is also the axis of the surgical action, or by the bisector of the angle of the surgical action. This is a segment of the axis of the surgical action from the plane of the wound aperture to the object of intervention. The access zone in the classical sense is the area of the bottom of the surgical wound. Modern technologies (video endosurgical equipment) allow, after a minimal incision of the abdominal or chest wall, to introduce a miniature television lens and a powerful light source for revision or intervention on almost all organs of the abdominal and chest cavities. In these cases, the viewing area will be many times greater than the area of the wound aperture (puncture holes). This ratio indicates a low traumatic surgical approach. The choice of online access should take into account the following conditions. 1. Physique (constitution) of the patient. 2. Features of the operation being performed. 3. The risk of surgery. 4. The patient has a large scar after a previous operation. 5. Possibility of wound infection. 6. Cosmetic considerations. 7. Compliance with the rules of ablastics. 8. The presence of pregnancy. 3. Types of transactions There are several types of operating aids. 1. Emergency (urgent, urgent) - are made according to vital indications immediately. 2. Planned - are made after examining the patient, establishing an accurate diagnosis, long-term preparation. Elective surgeries pose less danger to the patient and less risk to the surgeon than emergency surgeries. 3. Radical - completely eliminate the cause of the disease (pathological focus). 4. Palliative operations - do not eliminate the cause of the disease, but give only temporary relief to the patient. 5. Operation of choice - the best operation that can be performed for a given disease and which gives the best result of treatment at the current level of medical science. 6. Operations of necessity - the best possible option in this situation; depends on the qualifications of the surgeon, the equipment of the operating room, the condition of the patient, etc. Also, operations can be single-stage, two-stage or multi-stage (one-, two- or multi-stage). One-stage operations - operations in which, during one stage, all the necessary measures are performed to eliminate the cause of the disease. Two-stage operations are performed in cases where the patient's state of health or the risk of complications do not allow to complete the surgical intervention in one stage, or, if necessary, prepare the patient for a long-term dysfunction of any organ after the operation. Multi-stage operations are widely practiced in plastic and reconstructive surgery, and in oncology. In recent years, due to the increase in life expectancy, there has been a trend towards an increase in the number of patients suffering from several surgical diseases. Improvement in diagnostics, improvement of surgical technique and advances in the field of anesthesiology and resuscitation contributed to the expansion of indications for combined (simultaneous) surgical interventions. Combined (or simultaneous) operations are performed during one surgical intervention on two or more organs for various diseases. An extended operation is characterized by an increase in the volume of surgical admission for a disease of one organ due to the characteristics or stage of the pathological process. A combined operation is associated with the need to increase the volume of surgical treatment for one disease that affects neighboring organs. Evaluation of surgical operations. Evaluation is based on the results of the operation. They are divided into immediate and remote. Immediate results are determined by mortality on the operating table and in the coming days and weeks after surgery. The quality of immediate results largely depends on the surgeon himself. Long-term results are determined by the patient's condition months and years after the operation. 4. Blade, scissors The surgical separation of tissues is based on the principle of sequential layer-by-layer separation of the skin, subcutaneous tissue, muscle layers, etc. Instruments for mechanical separation of tissues are the oldest and most diverse. The cutting element is a blade made in the form of a wedge with a certain sharpening (sharpening) angle, the value of which depends on the purpose. The blades used for cutting soft tissues have a sharpening angle from 12° to 25°; for cartilage dissection - from 30° to 35°; for cutting bone tissue - 40 °. The smaller the sharpening angle, the sharper the knife, and the faster it loses its sharpness. There are three main ways to hold a scalpel in your hand: in the form of a bow, in the form of a writing pen and in the form of a table knife. When puncturing, the scalpel blade should be at an angle of 90° to the tissue surface, and when performing a dissection, at an angle of approximately 45°. The cutting edge of the blade can be of different shapes: straight, curved, closed circle. In general surgical practice, abdominal, pointed scalpels are most often used (scalpels with a removable blade are widespread); amputation knives. There are also many varieties of special cutting tools. To prevent corrosion, surgical knives are made of high carbon steel and coated with a layer of chromium and nickel. The cutting edge of the tool is not protected from corrosion and needs constant care. Scissors are another type of surgical instrument designed to separate tissues or separate their parts. They have two blades, which, when moving in the opposite direction, cut tissue. There are two types of surgical scissors: articulated and guillotine. Hinge-type shears operate on the principle of two wedges, which are in close contact with the tips at the moment they pass against each other at the cutting point. Usually they are used to cut layers that have a small thickness. For the convenience of working in deep wounds, the working part of the scissors can be bent vertically (Richter) or flat (Cooper). Guillotine-type shears have blades moving one on top of the other in special guides. They are used to cut ribs, costal cartilage, etc. The scissors sharpening angle usually corresponds to 70-85 °. In surgical interventions, as a rule, blunt-pointed scissors are used. Working with scissors can be convenient only with constant control of the movement of each branch, this is achieved only with the correct holding of the scissors: the nail phalanx of the IV finger must be inserted into the right ring of the scissors: the III finger rests on the ring indicating the lock (screw). Like surgical knives, scissors are made of high-carbon steel with an anti-corrosion coating. At present, more and more often, high-tech methods are used for tissue separation, which have a number of advantages over the traditional use of a knife or scissors. These include electrosurgical, cryosurgical devices, the use of ultrasound, plasma flow or laser for tissue dissection. 5. Electrosurgical devices In 1907, the American Lee De Forest designed an apparatus that dissected tissue using high-frequency alternating current. In Russia, electric current for the surgical treatment of tumors began to be used in 1910-1911. at the Military Medical Academy. Electrosurgery is based on the conversion of electrical energy into heat. A high-frequency electric current is used to cut and coagulate the tissue. To work in the coagulation mode, a modulated (pulsed) electric current of high frequency is used. To work in the "cutting" mode, unmodulated alternating current of low voltage is used. The effect of electrosurgical cutting is optimal when the tip of the electrode is in close proximity to the tissues, but does not touch them. Tissue cutting is more efficient if the electrode has a sharp edge, which ensures maximum energy density. Low-vascularized tissues (adipose tissue) have a relatively high tissue resistance, so the dissection of such tissues requires higher power. To dissect tissues with good blood supply (muscles, parenchyma), a minimum power is sufficient. Depending on the method of applying high-frequency current, the following methods are distinguished: monopolar (the surgeon's working tool is an active electrode, while the passive electrode provides electrical contact with the patient's body outside the operating field; heat is generated in the dissected tissue area due to the difference in the size of the electrodes); bipolar (both outputs of the generator are connected to active electrodes, the thermal effect is carried out in a limited space between the two electrodes). Cryosurgical instruments and devices The essence of the method is to eliminate the pathological formation by its rapid local freezing. The working part of the devices for cryosurgery are rapidly cooled tips. As a rule, liquid nitrogen, the boiling point of which is -196 °C, freon (-12 °C), etc., serve as a cryoagent. A cryoinstrument with a contact tip can only be considered as a point source of cold. Therefore, it is impossible to freeze large arrays of pathological neoplasms and the possibilities of cryosurgical technique are limited to the removal of only small pathological formations. As a result of the different properties of water at a high cooling rate, thermomechanical stresses arise in the tissue, the tissue structure is deformed and displacements and cracks are formed, which are most pronounced along the edges of the pathological focus, as a result of which the frozen zone can be removed in the form of a kind of "ice ball". Local blood flow during cryotherapy practically does not change. The cryosurgical method has found application in oncology, ophthalmology, dermatology, urology, proctology, etc. Local freezing is one of the main methods of destruction in stereotaxic neurosurgery. 6. Ultrasonic devices for tissue separation Such devices are in most cases based on the conversion of electric current into an ultrasonic wave (magnetostrictive or piezoelectric phenomenon). The operation of magnetostrictive transducers is based on the ability of bodies made of iron, nickel, their alloys and some other materials to periodically change their dimensions in an alternating magnetic field. In ultrasonic surgery, instruments are used, the cutting edge of which continuously fluctuates with frequencies of 10-100 kHz and an amplitude of 5-50 microns. The mechanism of the effect of ultrasound on tissues is based on the fact that high-frequency vibration leads to mechanical destruction of intercellular bonds; and on the cavitation effect (the creation of negative pressure in the tissues in a short period of time, which leads to the boiling of intra- and intercellular fluid at body temperature; the resulting steam leads to tissue separation). Coagulation also occurs due to protein denaturation. The resulting coagulation film is so strong that modern ultrasonic scalpels allow even large (up to 7-8 mm) vessels to be cut without their preliminary ligation. The use of an ultrasonic knife is most appropriate when isolating and excising scars, removing tumors, opening inflammatory foci, as well as when performing plastic surgeries. In addition, the ultrasonic knife can be used as an ultrasonic probe for finding metal and other foreign bodies in the tissues (i.e., it works on the principle of echolocation). This does not require contact with the object. Particularly suitable for working on bones. The basis of tissue dissection by a plasma flow is the formation of a plasma flow when a high-strength electric current is passed through a high-speed jet of an inert gas (argon). The power of the resulting plasma jet is usually about 100 watts. The manipulators of the installations are interchangeable metal cylinders with a pointed part and a nozzle with a diameter of 2 mm (coagulator) or 0,6 mm (destructor), which are pre-sterilized in formalin vapor. The greatest efficiency is achieved when working with muscles, lung tissue, when dissecting the tissue of parenchymal organs, when the diameter of the vessels and ducts damaged during the incision does not exceed 1,5 mm (coagulation effect). Vessels and ducts with a diameter of more than 1,5 mm must be stitched or clipped; during operations on the stomach and intestines, plasma scalpels are used to cut the walls of hollow organs. Plasma effect on the tissue is accompanied by ultraviolet radiation and the release of atomic oxygen, which contributes to additional sterilization of the wound. In addition, the plasma flow has a pronounced analgesic effect, allows you to treat any point of the surgical wound, and does not adversely affect the reparative processes. 7. Lasers in surgery The mechanism of action of a laser scalpel is based on the fact that the energy of a monochromatic, coherent light beam sharply increases the temperature in a corresponding limited area of the body and leads to its instantaneous combustion and evaporation. In this case, the thermal effect on the surrounding tissues extends over a very short distance, since the width of the focused beam is 0,01 mm. Under the influence of laser radiation, "explosive" destruction of the tissue also occurs due to the impact of a kind of shock wave, which is formed during the instantaneous transition of tissue fluid into a gaseous state. Features of the biological action of laser radiation depend on a number of its characteristics: wavelength, pulse duration, tissue structure, physical properties of the tissue. Consider the characteristics of the main lasers used in surgery. Laser with a wavelength of 1064 nm. The radiation penetrates relatively deep, up to 5-7 mm. At temperatures above 43 ° C, protein molecules are irreversibly damaged (denatured), the tissue dies, undergoing thermal coagulation; at temperatures above 100 °C, water begins to evaporate; at temperatures above 300 °C, combustion occurs with the release of combustion products and their deposition on the surface of the crater. The destruction of tissue by the formation of a crater, hole or incision during the laser operation is called ablation, and the conditions under which it occurs are called the ablation mode of the laser. At low radiation power and short-term exposure, tissue heating is relatively small and only its coagulation or melting occurs (subablation mode). A laser with a wavelength of 3 to 10 nm acts on soft tissues in a similar way. They are most often used in cosmetic procedures on the skin. Excimer lasers with a wavelength of 300 nm have the highest power compared to other groups of lasers. Energy is intensively absorbed by non-aqueous components of soft and hard tissues, including DNA proteins. The zone of thermal damage when exposed to it is several micrometers. The hemostatic effect is weakly expressed. The copper vapor laser with wavelengths of 578 and 585 µm has interesting properties. The skin is "transparent" for him, the substance that perceives radiation is melanin and hemoglobin, which provides unique opportunities in the treatment of hemangiomas. Due to its high coagulating and hemostatic properties, the laser has found wide application in operative endoscopy. The use of a laser scalpel is convenient for opening the lumen of hollow abdominal organs, resection of the intestine, formation of an inter-intestinal or gastrointestinal anastomosis, while the most crucial moment of the operation is performed on a "dry" field. In oncological patients, the risk of spreading malignant tumor cells outside the surgical field is reduced due to the coagulating and ablastic effects of the laser beam. Healing of laser wounds is accompanied by a minimal inflammatory response, which dramatically improves cosmetic results. 8. Hemostatic instruments Represented by clamps, ligature needles, etc. The most commonly used are various types of hemostatic clamps. The most common are the clamp with oval jaws (Peana), the straight serrated clamp with notches (Kocher), the straight and curved clamp with notches without teeth (Billroth), the mosquito clamp (Halsted). The serrated clamp holds more firmly than the others, but punctures the tissue being gripped. Hold the hemostat in the same way as scissors. Only with this position of the fingers can you accurately aim the clip where you want it. When grasping a vessel or tissue, try to keep the clamp as perpendicular to the object as possible. The tip of the clamp should be as free as possible. The superimposed clamp should not be displaced unnecessarily, pulled by it, etc. The clamp is removed after tightening the first turn of the ligature. To stop bleeding from small vessels in surgery, the method of diathermocoagulation has become widespread. Auxiliary instruments are represented by a variety of tweezers, hooks, mirrors, retractors, etc. Most often, three types of tweezers are used during operations: anatomical, surgical and pawl. They differ in the device of grasping cheeks. On the cheeks of anatomical tweezers there are blunt transverse notches (used to work with delicate tissues), surgical tweezers have sharp teeth (used to hold rough formations), and paws have rounded paws with denticles. The length of the tweezers is from 15 cm to 20 cm or more. It is recommended to grab the tweezers with fingers in its middle part on one side with the thumb, and on the other side with the index and middle. Instruments for connecting tissues are represented by needle holders with needles, staples, staplers, etc. Surgical ones come in a wide variety of shapes, sizes, sections. They serve to connect or stitch tissues and organs. Modern surgical needles are equipped not with an ordinary eye, but with a springy dovetail split, which makes it possible to insert sutures almost automatically. The most commonly used cutting needle for stitching mostly coarse fabrics consists of three parts: an eye adjacent to the eye of a dihedral landing site for the needle holder and a working trihedral cutting part ending in a point. To hold the needles during the sewing process, special tools that firmly hold the needles are used - needle holders. This makes it possible to sew in the depths of the wound or cavity without touching the tissue with your hands. When suturing the heart, blood vessels, and intestines, atraumatic needles are often used. One end of these needles is sharpened, the other has a gap into which the thread is firmly rolled. The most common needle holders are the Hegar needle holder (with ring handles) and the Mathieu (with curved handles). As a rule, the needle is grasped closer to the eye so that at least 2/3 of the length of the needle (counting from the tip) is free. 9. Ways of temporary and final stop of bleeding With the development of bleeding from a large artery, the best method is to stop it completely, but if this turns out to be impossible, methods of temporarily stopping bleeding are used, which do not require special tools, are quick and easy to use. One way to temporarily stop bleeding is to finger press the artery to the bone above the injury site. The ability to stop bleeding by finger pressing the artery to the bone is determined by: the superficial location of the artery; the location of the bone close to the artery, directly below it. Places of possible finger pressing of the arteries: on the neck, the common carotid artery can be pressed against the carotid tubercle on the transverse process of the VI cervical vertebra. In the supraclavicular fossa, the subclavian artery can be pressed against the tubercle of the anterior scalene muscle on the XNUMXst rib. In the axillary fossa, the axillary artery can be pressed against the head of the humerus. The femoral artery is pressed under the inguinal ligament to the anterior branch of the pubic bone. To properly perform digital pressure on the artery, you need to know the topographic anatomy of the relevant areas: the position of the artery, the area of \uXNUMXb\uXNUMXbthe bone to which it is pressed, as well as the features of the relationship of muscles, fascia, neurovascular bundles, etc. This determines not only the point of pressure of the artery located at the intersection of the projection line of the artery with the underlying bone, but also the vector of digital pressure, which allows you to reliably stop bleeding and avoid complications. Stopping bleeding by finger pressure on the artery has the disadvantage that the method is applicable only for a short period of time. Therefore, finger pressure can only be used as an emergency measure, the first stage, after which you need to go to the final stop of bleeding or apply another method, for example, you can use a tourniquet. A modern standard tourniquet is an elastic rubber strip with a device for tightening and fastening in the form of buttons. In the absence of a standard tourniquet, an impromptu waist belt, scarf, towel, etc. can be used. The tourniquet is applied above (proximal) to the wound, as close as possible to it, since the circular compression of the tissues by the tourniquet almost completely eliminates the possibility of blood circulation below the site of its application. But, when choosing the place of application of the tourniquet, it is necessary to take into account some topographic and anatomical features. It is considered the most rational imposition on those parts of the limb where there is only one bone (shoulder, thigh). The imposition of a tourniquet on those parts of the limb in which there are two bones (forearm, lower leg) is less effective. The advantages of using a tourniquet include speed and ease of use. A significant disadvantage is that the tourniquet can be used for a limited time (no more than 2 hours) without the risk of complications. The methods of temporarily stopping bleeding can also include the imposition of a tight gauze bandage applied to the wound using an individual dressing bag. 10. Methods for the final stop of bleeding. Ligation of vessels in the wound Most often, for the final stop of bleeding, the imposition of ligatures on the ends of the vessels is used, there is a ligation of the vessels in the wound. In most cases, one ligature is applied to the end of the vessel. When stopping bleeding from large arteries, two ligatures can be applied. The operation of ligation of the vessel begins with a wide dissection of the wound, which must be performed along the course of the neurovascular bundle. Dissection of tissues is performed only after a temporary stop of bleeding with a tourniquet or finger pressure. After finding the ends of the damaged artery, clamps are applied to them. In this case, the clamp is superimposed so that its end is a continuation of the axis of the vessel. After applying a hemostatic clamp to the end of the artery with tweezers, it is necessary to carefully select it from the surrounding adipose and connective tissue in a 1-2 cm long area. If the artery is properly isolated, its wall becomes dull. With the correct application of the ligature, the pulsation of the end of the artery along with the ligature applied to it is detected. The condition for the reliability of stopping bleeding by ligating the artery in the wound is the mandatory application of ligatures to both the central and peripheral ends of the artery. Even if the peripheral end of the artery does not bleed, it still needs to be found and bandaged during the operation. Ligation of arteries throughout can be used not only as a way to stop bleeding from a damaged vessel, but also as a method of preventing it before performing some complex operations. For the correct exposure of the artery for the purpose of ligation throughout, it is necessary to perform an operative access, which requires knowledge of the projection lines of the arteries. It should be especially emphasized that for drawing the projection line of the artery, it is preferable to use the most easily defined and non-displaceable bone protrusions as a guide. To expose the artery, an incision is made strictly along the projection line, dissecting the tissues in layers. Such access is called direct access. Its use allows you to approach the artery in the shortest way, reducing surgical trauma and operation time. However, in some cases, the use of direct access can lead to complications. To avoid complications, an incision to expose the arteries is made somewhat away from the projection line. Such access is called roundabout. The use of a roundabout approach complicates the operation, but at the same time avoids possible complications. Operative method of stopping bleeding by ligating the artery throughout excludes the isolation of the artery from the sheath of the neurovascular bundle and its ligation. To avoid damage to the elements of the neurovascular bundle, novocaine is first introduced into its vagina for the purpose of "hydraulic preparation", and the vagina is opened using a grooved probe. Before ligation, the artery is carefully isolated from the surrounding connective tissue. 11. Collateral circulation The term collateral circulation is understood as the flow of blood into the peripheral parts of the limb along the lateral branches and their anastomoses after the lumen of the main (main) trunk is closed. The largest ones, which take over the function of the switched off artery immediately after ligation or blockage, are referred to as the so-called anatomical or preexisting collaterals. According to the localization of intervascular anastomoses, pre-existing collaterals can be divided into several groups: collaterals connecting the vessels of a basin of a large artery are called intrasystemic, or short paths of roundabout blood circulation. Collaterals connecting pools of different vessels with each other are referred to as intersystem, or long, detours. Intraorganic connections refer to connections between vessels within an organ. Extraorganic (between the branches of the own hepatic artery in the gates of the liver, including with the arteries of the stomach). Anatomical pre-existing collaterals after ligation (or blockage by a thrombus) of the main arterial trunk take on the function of conducting blood to the peripheral parts of the limb (region, organ). The intensity of collateral circulation depends on a number of factors: on the anatomical features of the pre-existing lateral branches, the diameter of the arterial branches, the angle of their departure from the main trunk, the number of lateral branches and the type of branching, as well as on the functional state of the vessels (on the tone of their walls). For volumetric blood flow, it is very important whether the collaterals are in a spasmodic or, conversely, in a relaxed state. It is the functionality of collaterals that determines regional hemodynamics in general and the magnitude of regional peripheral resistance in particular. To assess the sufficiency of collateral circulation, it is necessary to keep in mind the intensity of metabolic processes in the limb. Considering these factors and influencing them with the help of surgical, pharmacological and physical methods, it is possible to maintain the viability of a limb or any organ in case of functional insufficiency of pre-existing collaterals and promote the development of newly formed blood flow pathways. This can be achieved either by activating collateral circulation or by reducing tissue uptake of blood-borne nutrients and oxygen. First of all, the anatomical features of the pre-existing collaterals must be taken into account when choosing the site for applying the ligature. It is necessary to spare as much as possible the existing large lateral branches and apply a ligature as far as possible below the level of their departure from the main trunk. Of certain importance for collateral blood flow is the angle of departure of the lateral branches from the main trunk. The best conditions for blood flow are created with an acute angle of origin of the lateral branches, while an obtuse angle of origin of the lateral vessels complicates hemodynamics due to an increase in hemodynamic resistance. 12. Method of temporary prosthetics. Principles of mechanical vascular suture To restore blood flow for a relatively short period of time, the method of temporary prosthetics is used. It is used for wounds of the femoral, popliteal or other large main arteries (at least 6 mm). Temporary prosthetics is performed using a plastic tube (polyvinyl chloride, silicone, polyethylene, etc.) or a special T-shaped cannula. A plastic tube washed with a heparin solution is inserted into the distal and proximal ends of the damaged artery, securing it with a tourniquet. If a standard T-tube is used, then a heparin solution and antiplatelet agents are injected into the artery through its spur. The victim with a temporary prosthesis can be transported (within, as a rule, no more than 72 hours) to a medical institution for specialized medical care. A vascular suture that restores the integrity of the vessel and, consequently, normal blood circulation and nutrition of the limb is ideal from a physiological point of view. Indications for the use of a vascular suture are: damage to large main arteries (carotid, femoral, popliteal, subclavian, axillary); limb avulsions with the possibility of replantation. Contraindications to the imposition of a vascular suture in vascular injuries are suppuration in the wound, extensive defects in the damaged artery. In addition, an injury to one of the paired arteries of the extremities (arteries of the forearm, lower leg) is not considered an indication for the imposition of a vascular suture, given the relative sufficiency of collaterals. Considering that with a significant tension of the edges of the sutured artery, suture eruption occurs, diastasis between the parted ends of the artery is not more than 3-4 cm. cm; by bending the limb in the nearest joints and immobilizing it in a given position. A vascular suture around the circumference, applied with a complete rupture or violation of the circumference by more than two thirds of its length, is called circular. A vascular suture applied to the edges of a vessel wound that does not exceed one third of the circumference is called a lateral suture. Currently, more than 90 different ways of applying a vascular suture are known. All methods of applying a vascular suture are divided into two groups: manual suture of the vessel and mechanical suture of the vessel. The principle of a mechanical seam is that the ends of the vessel are passed through special bushings, the inner diameter of which corresponds to the outer diameter of the vessel. Then the ends of the vessel are turned inside out (flared) on these bushings. The ends of the vessel come together, and by pressing the lever of the apparatus, the flared sections of the vessel are stitched with metal clips, similar to how the sheets of a school notebook are connected. After that, it remains only to release the vessel from the clamps and bushings. The essential advantages of a mechanical vascular suture are: ensuring a good fit of the intima to the intima and sealing the suture line; the speed of vessel stitching. 13. Rules for performing a vascular suture For the successful implementation of the vascular suture, certain rules and conditions must be observed: wide access to the site of the damaged vessel; preservation of blood supply and innervation of the ends of the sutured vessel, careful selection of its ends. If, for ligation, the ends of the vessel are isolated from the connective tissue until the adventitia is removed, then before applying the vascular suture, the connective tissue around the ends of the vessel should be preserved in order not to disturb their blood supply and innervation. Carefully preserve the side branches extending from the vessel near the site of injury; carry out careful, gentle handling of the vessel wall. To temporarily stop bleeding and fix the vessel, only special soft clamps made of elastic metal, or clamps with an adjustable gap between the branches, should be applied to its ends. The next rule is an economical excision ("refreshment") of the ends of the damaged vessel. The crushed ends of the vessel, the damaged intima, as well as the excess of the outer adventitia, should be excised, since these tissues contain a lot of thrombokinase, which contributes to the formation of a thrombus in the lumen of the vessel after suturing. Excision of the edges of the vessel wound should be carried out with an impeccably sharp scalpel or razor. It is impossible to allow the wound and the vessel wall to dry out, as this increases the traumatization. When applying a vascular suture, it is necessary to prevent the occurrence of conditions conducive to the vortex movement of blood and slowing down the blood flow velocity at the suture site, which can lead to thrombosis. The seam line must be completely sealed. Suture material, if possible, should not protrude into the lumen of the vessel and delay blood flow. For the seam, such a suture material is used that does not cause subsidence of uniform elements and blood clotting (supramid, polyamide, sutralen, etc.). Before tightening the sutures, blood clots are carefully removed from the lumen of the connected ends of the vessel, washing them with a heparin solution; narrowing of the lumen of the vessel at the site of suture should not be allowed, since this forms a parietal vortex that promotes thrombosis. To prevent narrowing of the vessel, the sutures should be applied, stepping back from its edge no further than 1 mm. It is necessary to carefully restore the tightness along the line of contact between the edges of the vessel wall and in the places where the suture material passes. Most modern methods of manual vascular suture are based on the technique of the classic vessel suture according to A. Carrel. After applying small clamps to the vessel and refreshing its ends, their circumference is divided into three equal parts. Along the borders of the third, atraumatic needles are used to suture the holder, the tension of which turns the circle into an equilateral triangle. Sewing three straight sections after connecting the corresponding holders and accurately matching the ends of the vessel does not present a great technical difficulty. As a rule, a continuous suture is used, making sure that when it is tightened, the intima of the ends of the vessel fits well. 14. Types of nerve damage Nerve injuries are divided into closed and open. With closed injuries, the integrity of the outer sheath of the nerve is preserved. Depending on the nature of morphological changes in the nerve at the level of injury (among closed injuries), concussion is distinguished, which occurs as a result of the force of a side impact of a wounding projectile when it passes through the tissues away from the nerve; morphological changes in the nerve trunk cannot be detected, but short-term conduction disturbance is observed. Nerve contusion occurs with more severe impacts of a wounding projectile or blunt trauma with the formation of morphological changes inside the trunk. In this case, the nerve maintains anatomical continuity. Nerve compression is caused by foreign bodies, bone fragments, paraneural hematomas, excessive and prolonged compression of the limb with a tourniquet. The conduction disorder can easily recover if the factor causing the compression is removed shortly after the injury. In the case of nerve compression, ischemia develops in it, axonal atrophy occurs, and then a dense connective tissue scar is formed, leading to a persistent violation of conduction. Nerve compression can occur a considerable time after the injury when it is involved in adjacent scars or calluses. At the same time, conduction disturbance does not appear immediately after the injury, but after a certain period of time and increases over time. Dislocation of the nerve occurs as a result of damage to the fascial bridge that fixes it to the bone groove. As a result of repeated dislocations, traumatic neuritis develops with local thickening of the nerve due to growth and scarring of the connective tissue. Nerve sprains usually develop as a result of dislocations and fractures of bones, accompanied by a sharp stretching of the limb and nerve trunks beyond their elasticity and extensibility. Open injuries (wounds) of the nerve trunk are accompanied by the destruction of both the outer sheath and axons. Nerve wounds are divided into stab wounds and gunshot wounds. Ruptures or anatomical interruption of the nerve can be complete or partial: a partial interruption of the nerve in most cases occurs with a tangential wound, less often with a "perforated" wound, when a small injuring projectile passes through the thickness of the nerve trunk. With a complete rupture, the ends of the nerve diverge and are often displaced from their usual places, such damage leads to a complete loss of nerve function. When nerves are damaged, motor, sensory, vasomotor, secretory and trophic disorders occur. Movement disorders are manifested by muscle paresis or paralysis, muscle atrophy, decreased tone, and impaired tendon and periosteal reflexes. In the remote period, the development of movement restrictions in the corresponding joints is possible. Sensitivity disorders are manifested in the form of prolapse (hypoesthesia, anesthesia) and irritations (hypersthesia, pain). According to the severity of violations, an autonomous zone and a mixed zone are distinguished. Trophic disorders are the most severe. 15. Restorative operations on the nerves. Suturing Immediately after an injury, accompanied by a violation of the integrity of the nerve fibers, the processes of degeneration and regeneration develop in the nerve. These phenomena are closely interconnected and synchronized. It is known that the simpler the nerve trunk is arranged, the fewer connections and connective tissue in it, the more complete the regeneration is, the lower the nerve trunk is damaged, the faster and more complete the regeneration is, therefore, damage to the proximal (high) parts of the nerve has a worse prognosis compared to damage to the distal (lower) parts of the nerve (Eckzold's law). All nerves can be divided into three groups according to the completeness of recovery: 1) nerves with the best regenerative capacity: radial and musculocutaneous; 2) nerves with the worst regenerative capacity: ulnar, sciatic and common peroneal; 3) nerves with intermediate regenerative capacity: axillary, median and tibial. Suturing. One of the main conditions for the regeneration of an injured nerve is the absence of diastasis between its ends, which requires their comparison with the help of sutures. Depending on the timing of the operation, primary interventions are distinguished, in which the nerve suture is performed simultaneously with the primary surgical treatment of the wound; delayed (early) operations, in which the nerve is sutured in the first weeks after the injury, and late, if the nerve is sutured later than 3 months after the injury. The advantages of a delayed suture are less risk of infectious complications after surgery; it is easier to determine the boundaries of the necessary resection of the nerve, since at this time scarring is already detected in the areas of intra-trunk damage. Nerve repair operations are usually performed under local infiltration anesthesia. This method of anesthesia allows you to clearly identify even the smallest vascular and nerve branches, which protects them from accidental damage; contact with the patient during electrodiagnostics on the operating table. With the primary suture of the nerve, the access made during the primary surgical treatment of the wound is usually used. With delayed operations, access must be made with the obligatory consideration of changes that occur after injury. Access requirements are as follows. They should be long enough to expose the nerve above and below the injury site within healthy tissues, this allows the surgeon to understand all the topographic and anatomical relationships and assess the nature of the injury and possible outcomes. Preference is given to roundabout or extra-projective approaches, in which the incision lines of the skin and fascia do not coincide with the projection of the nerve. This makes it possible to avoid the formation of a common scar between the sheaths of the nerve and the skin. 16. Types of operations on peripheral nerves: neurolysis and nerve suture The purpose of the neurolysis operation is to free the nerve from compression by its cicatricial adhesions, with which it is tightly fused. The operation is carried out "acute way". After performing an operative approach and exposing the nerve within healthy tissues, the nerve is gradually isolated from the scars with simultaneous excision of the altered surrounding tissues using eye tweezers and a scalpel. Then the remnants of the scar tissue directly surrounding the nerve are removed in the form of a thin and dense case, avoiding damage to the underlying nerve bundles. The released nerve trunk must be placed in a specially created bed between the muscles. Neurolysis allows to obtain positive results (restoration of nerve conduction) in approximately 50% of cases. The main surgical technique in reconstructive surgery of the nerve trunks is the suture of the nerve. Surgical reception consists of the following points: isolation of the nerve, mobilization of the nerve to eliminate its tension, resection of damaged areas, application of epineural sutures. Resection is performed after the introduction of 2 ml of a 1% solution of novocaine under the epineurium with an ideally sharp instrument (scalpel, safety razor blade) in a strictly transverse direction. An indicator of correct resection (sufficiency of excision) is good bleeding of the vessels of the epi- and perineurium (the bleeding is stopped with a ball with warm saline). The imposition of epineural sutures should be carried out in such a way that there is no twisting of the nerve and displacement of the intratruncal structures around the longitudinal axis. In addition, it is necessary to ensure that when tightening the seams, the bundles are not squeezed, not bent or bent. The first sutures are placed on the epineurium along the outer and inner edges of the nerve at strictly symmetrical points. The injection and puncture of the needle is carried out along the nerve, retreating 2-3 mm from the edge (the sutures in the transverse direction are stronger, but they can compress the bundles). A small diastasis may remain between the ends, but it should not exceed 1 mm. The free gap between the ends of the nerve will be filled with a hematoma, and later a connective tissue layer will form, through this hematoma and connective tissue strands of Schwaszyuvian cells and newly formed axons will grow. In recent years, mechanical sutures with tantalum staples applied to the perineurium have been used. The nerve repair operation is completed by suturing the wound. Before suturing the wound, it is necessary to form a bed for the nerve from the surrounding tissues to prevent coarse cicatricial adhesions, compression and deformities of the nerve trunk, especially in the suture area. To do this, the sutured nerve is placed in the wound in a muscular sheath so that it is covered by muscles and does not come into direct contact with aponeuroses, fascia and skin. After the operation, it is necessary to immobilize the limb for 2-3 weeks with fixation of the above- and underlying joint with a plaster splint or splint in a position in which the nerve trunk experiences the least tension. 17. Operations for tendon injuries Tendon injuries are divided into the following groups: closed injuries (subcutaneous ruptures), open injuries, incised wounds, lacerations, gunshot wounds. When wounded by a cutting object (knife, glass), the tendon is incised or completely intersected. When wounded with a blunt object, it is torn partially or completely (machine damage, transport injury). Most often, the tendons of the hand are damaged. There is a significant difference in the surgical treatment of the flexor and extensor tendons of the fingers, due to the anatomical features of their structure. It is much more difficult, due to the complexity of the anatomical structure, to ensure the restoration of the function of the fingers in case of damage to the flexor tendons, especially within the synovial-tendon tunnel. The tendon repair process begins immediately after surgery and continues for several weeks. On the 1st week, an unstable fibroblastic adhesion is formed at the junction of the ends, unable to withstand even the slightest tension. During the 2nd week there is a rapid connective tissue proliferation and vascularization. By the 9th day, the ends of the tendons are connected by means of still fragile collagen fibers, which, with increased muscle contraction, can break. In the same period, cicatricial adhesions appear between the tendon and surrounding tissues. On the 3rd week, the gap between the ends of the tendon is completely filled with newly formed tissue, connective tissue fibers become similar to tendon fibers. During this period, conditions are created for the start of active movements. Adhesions with surrounding tissues are still fragile and are easily destroyed when the tendons move. By the end of the 4-6th week, regeneration ends, the strength of the connection reaches the norm. The term for the final formation of the newly formed tendon tissue is 2-4 months. Yu. Yu. Dzhanelidze (1936) formulated the requirements for the suture of tendons, which remain unchanged to this day: the suture must be simple and easy to perform; the suture should not disrupt the blood supply to the tendon, for which it is necessary to capture the minimum number of tendon bundles in knots and loops; the seam should provide a smooth, sliding surface of the tendon, a minimum number of threads should remain on its surface; the suture should firmly hold the ends and not deflate the tendon; a fascial or synovial sheath should be restored over the tendon. The tendons are sutured with silk, nylon, nylon, and tantalum wire with a diameter of 0,1 mm. Access to the damaged tendon in open injuries is carried out through the wound. When the wound is insufficient in size, it is expanded by making additional incisions, taking into account the topographic and anatomical features of the area. For closed injuries and delayed operations, an incision should be made away from the tendon, and in order to avoid wide exposure of the synovial-aponeurotic apparatus, the incisions are made at an angle to the course of the tendon. 18. Amputations of limbs Amputation of a limb is a difficult and complex operation, including the separation (removal) of the peripheral part along the bone. Removal of a limb with the intersection of soft tissues at the level of the joint space is called exarticulation. There are indications for performing an amputation operation, which are divided into two groups: 1) absolute (or primary) indications, when the peripheral part of the limb is not viable, but the processes occurring in it do not threaten the life of the victim; 2) relative (or secondary) indications, when the peripheral part of the limb is viable, but the processes occurring in it threaten the life of the victim. Absolute (primary) indications: necrosis of the distal limb, gangrene caused by occlusion of the supply vessels; detachment of the distal limb when its replantation is impossible. However, for the replantation of a limb after its complete detachment, conditions are necessary, including the preservation of the viability of tissues, especially the main vessels, the high qualification of the surgeon, the possibility of follow-up, etc. Combined injuries of limb tissues include injuries in which the following are observed at the same level: fragmentation of a bone or bones; complete rupture of all neurovascular bundles; destruction of more than 2/3 of the muscle volume. Relative (secondary) indications are most often due to intoxication that develops under the following pathological conditions: anaerobic infection (gas gangrene); acute purulent inflammation (for example, drives) with the threat of developing sepsis; chronic nonspecific (for example, chronic osteomyelitis), specific (tuberculosis of bones and joints) inflammatory process that cannot be cured for a long time and threatens with amyloid degeneration of internal organs (liver, kidneys); malignant tumors of the tissues of the extremities; deformities of the limbs (the sixth finger of the hand), acquired deformities that cannot be corrected. An important point before the operation is the choice of the level of amputation. The level of amputation is the place where the bone was cut, which determines the length of the stump and its functionality. Among representatives of different surgical schools, the level of amputation is not the same. With all the diversity, two main directions are distinguished: displacement of the amputation level as distally as possible to the site of injury or pathological focus. Such amputations, as a rule, are performed in wartime, are preliminary (similar to the type of primary surgical treatment of the wound) and are performed without a blind suture or with delayed sutures of the stump, given that in the future many victims will be shown reamputation or reconstructive surgery. The stump becomes suitable for prosthetics after a series of rehabilitation operations; an individual prosthesis can be made for it. In peacetime, it is possible to use this method for amputations with the imposition of primary sutures on the tissues of the stump. 19. Circular amputation Circular amputation consists in the fact that all the soft tissues of the limb are dissected to the bone in one circular motion. If the bone is sawn at the same level, then such amputation is called guillotine. The contractility of the skin, subcutaneous tissue, own fascia, superficial and deep muscles is not the same at the level of amputation. A consistent decrease in the elasticity of tissues from the surface layers to the deep ones leads to the fact that after their circular intersection, a cone is formed with the apex facing the periphery (distally). Moreover, often its top is formed by a protruding sawdust of the bone. This leads to the subsequent formation of a stump of a sharply conical shape, unsuitable for prosthetics, which is the main disadvantage of one-stage amputation, but it is used in military field conditions, during mass defeats, during natural disasters and catastrophes. The advantages of single-stage amputation include: simplicity and speed of execution. The formation of a vicious stump after a single amputation makes it necessary to correct it later with the help of reamputation. Two-stage circular amputation. A feature of the two-stage amputation technique is the circular dissection of soft tissues in two steps, which allows you to create a certain "reserve" of tissues to close the stump and avoid the formation of a vicious stump. The first point is that the skin, subcutaneous tissue, superficial and own fascia are cut in a circular motion of the amputation knife. In this case, the edge of the skin that has contracted and shifted in the proximal direction serves as a guide for the next stage. The second point is that along the edge of the reduced skin, all the muscles to the bone are dissected in a circular motion. The formation of a sharply cone-shaped stump during a two-stage amputation can also be prevented by the formation of the so-called "cuff". To this end, after the first moment, the skin, subcutaneous tissue and own fascia are separated from the muscles in one block and turned up in the form of a "cuff". The second moment includes the intersection of the muscles, which is performed at the level of the base of the "cuff". After straightening the "cuff" downwards, the transverse section of the muscles and sawdust of the bones can be closed without tension by the skin with subcutaneous tissue and superficial fascia by soft tissues. Three-stage circular amputation. Three-stage cone-circular amputation was proposed by the outstanding Russian surgeon N.I. Pirogov. Its purpose is to create an array of soft tissues sufficient for reliable shelter of the stump. The first moment of amputation includes a circular incision of the skin, subcutaneous tissue and own fascia. The edge of the skin, reduced due to elasticity, is a guide for subsequent actions. The second moment is a circular intersection along the edge of the contracted skin of all muscles to the bone, then the skin and superficial muscles are maximally shifted in the proximal direction. The third moment is a repeated circular dissection of the muscles to the bone along the edge of the proximally displaced skin. The advantages of this amputation is the possibility of closing the sawdust of the bone with soft tissues with the formation of a stump suitable for prosthetics, and this amputation is also relatively simple. 20. Technique of patchwork amputations Lingual flaps are cut out of the tissues, which subsequently close the wound surface of the limb stump. Flap amputations are divided into single-flap and double-flap. For all types of flap amputations, the length of the flaps should be sufficient to cover the cross section of the limb at the level of the amputation. To calculate the length of the flaps, the circumference formula is used, by measuring the circumference at the level of amputation, depending on the number of flaps and their ratio, the initial length of each of them is determined. The length of the flap for a single-flap amputation should be equal to one third of the circumference, for a two-flap amputation one sixth. When performing a two-flap amputation with flaps of different lengths, their ratio may be different, but their total length should correspond to the cross-sectional diameter at the level of the amputation. Before cutting the flaps to the original (calculated) length, it is necessary to correct for skin contractility due to its elasticity; there are special tables that reflect skin contractility in various parts of the body. Depending on what tissues are included in the composition of the flaps, amputations are divided into several groups. 1. Fascial-plastic amputations. In this case, the composition of the flap includes skin, subcutaneous tissue and its own fascia. Its advantages are: the possibility of precise modeling of the shape of the stump; obtaining a mobile postoperative scar; relative ease of implementation. 2. Myoplastic amputations, where the composition of the flaps, along with the skin, subcutaneous tissue, own fascia, includes muscles. With myoplastic amputation, due to good microcirculation of blood and lymph, the wound heals faster and the stump is formed. 3. Periostoplastic amputations. The method consists in the fact that the periosteum is also included in the composition of the flap. Such an amputation is used on the shins, especially in children and adolescents, since the periosteum as part of the flap ensures the fusion of the ends, the bones of the lower leg into a single block, preventing their displacement and uneven growth. In the elderly, the inclusion of the periosteum in the composition of the flap increases the support of the stump. 4. Osteoplastic amputation. The flap consists of a bone fragment covered with periosteum. They are used on the lower extremities and are aimed at creating a stump that can bear the entire weight of the body and allow the patient to use the prosthesis more freely. After any amputation, the stump is unsupported for a long time, which is associated with pain at the end of the stump due to edema, infiltration, incipient scarring and other phenomena that cause irritation of the crossed nerve conductors and their endings; as well as with the loss of support of the bone sawdust. The absence of a periosteal cover leads to a violation of proprioceptive sensitivity. "Toilet of the stump" includes stopping the bleeding and treating the nerve trunks. Vessels are ligated at the end of the stump; truncation of nerves in order to prevent "phantom pains". 21. Toilet stump Vessel ligation consists of two elements: ligation of vessels of large and medium caliber. Without removing the tourniquet (elastic bandage) applied before amputation, the main arteries and veins are found on the transverse section of the limb. It is recommended to apply two ligatures to large vessels (femoral, axillary arteries) for greater reliability. On a smaller artery, one is enough. Vessels, even large ones, are tied up with catgut, i.e., absorbable suture material. Silk is used in cases where the victim is to be transported, excluding the possibility of constant medical supervision. The second point is the ligation of small-caliber vessels. To do this, weaken the pressure of the tourniquet, which leads to the appearance of minor bleeding and "marking" of the vessels. Ligatures in these cases should be applied by chipping. Good hemostasis at the end of the stump is the prevention of hematomas, which can cause suppuration, focal necrosis, rough connective tissue scars. Methods for processing nerves. There are many ways to treat nerves, the main goal of which is to prevent the formation of a neuroma at the end of the nerve. Neuroma is a manifestation of regenerative growth, belongs to the category of "physiological protective measures." There are mechanical, chemical, thermal methods of influencing the cut nerve: the Kruger method, in which the nerve is crushed with a clamp and its bandaging is distal to the crush site; Leven's method - freezing the nerve stump with carbonic acid; Ferster's method - the introduction of a 5% formalin solution into the perineurium; Guedry's method, in which the end of the nerve is cauterized with a thermocautery, etc. The following methods are aimed at slowing down the formation of a neuroma until the amputation stump is fully formed, in order to prevent adhesions and compression of the neuroma by the surrounding tissues: the Veer method, where the nerve stump is closed with an epineurium flap; Ritger's method - wedge-shaped excision of the end of the nerve, followed by stitching the edges; Chapple's method - closing the nerve stump with an epineurium cuff; the Moshkovich method - suturing the crossed nerves to the muscle; Bardengeyer's method - the formation of a loop from the terminal section of the nerve. None of the presented methods prevents the formation of a neuroma at the end of the nerve. To prevent the "growing" of the neuroma into the postoperative scar, each of the nerves is truncated 2-3 cm above the level of amputation when performing the toilet of the stump. In order for the injury during truncation of the nerve to be minimal, and, consequently, connective tissue growths do not lead to the formation of a large neuroma , truncation of the nerve is performed with one movement of the blade of a safety razor. Before crossing the nerve, a 1% solution of novocaine must be injected under the epineurium. Before this manipulation, the tissues surrounding the nerve are carefully moved apart to the level of the intended intersection. To prevent phantom pain in the stump, all nerves are shortened in the manner described, including the cutaneous ones. Amputation ends with suturing the surgical wound, only in cases of suspected gas gangrene, the stump is not sutured. 22. Topographic and anatomical features of the cranial vault and some surgical techniques The skin of the frontal-parietal-occipital region is characterized by considerable thickness and low mobility. The subcutaneous fatty tissue is cellular due to the connective tissue septa connecting the skin with the tendon helmet. Stopping bleeding from the vessels of the fronto-parietal-occipital region is performed by pressing the soft tissues to the bones of the cranial vault with fingers, as well as sequentially suturing the soft tissues around the wound together with the vessels passing in the subcutaneous tissue, applying hemostatic clamps, followed by alloying of the vessels. The aponeurotic helmet lying under the subcutaneous tissue is a tendon stretching of the frontal and occipital muscles, it is firmly connected to the skin by connective tissue bridges. Loose tissue is located under the aponeurosis. The next feature of the fronto-parietal-occipital region are three layers of fiber: subcutaneous, subgaleal; subperiosteal. The bones of the cranial vault have a different structure in the fronto-parietal-occipital and temporal regions. The thinnest is the scales of the temporal bone, there is almost no spongy substance in it. This bone is very fragile, which predetermines the greatest probability of its cracks and fractures during injuries. The features of the bones of the cranial vault include: 1) "arched" structure, giving the vault of the skull a special resistance to mechanical stress; 2) "three-layer" bones, consisting of outer (up to 1 mm thick) and inner (about 0,5 mm thick) plates, between which there is a spongy substance. During operations on the skull and its contents, it is necessary to open the cranium, which is called craniotomy. There are resection and osteoplastic methods. In the resection method of trepanation, one or more trepanation holes are applied using a special cutter, followed by "biting out" or sawing out the required size of the bone fragment above the intracranial (intracerebral) focus. Upon completion of the operation, soft tissues are sutured over the bone defect. Osteoplastic trepanation is performed with a temporary resection of the bone. It is produced by forming a bone flap on the leg, which includes the periosteum. This allows at the end of the operation to close the defect after laying the bone flap in place. Among the surgical interventions performed on the skull, it is especially necessary to highlight the primary surgical treatment of wounds. This operation is emergency, and its technique differs from that used in other areas. There are two types of skull wounds: penetrating and non-penetrating. Penetrating wounds are those in which there is damage to the dura mater, and wounds that are not accompanied by a violation of the integrity of the dura mater are non-penetrating. The dura mater delimits the "internal environment" of the brain (liquor-bearing channels and spaces, the brain's own vessels, the arachnoid and choroid) from the external. Therefore, the prognosis for penetrating wounds of the skull is always very serious, during such injuries severe complications are often observed. 23. Topographic and anatomical features of the face The face area is distinguished by a number of anatomical and physiological features that are necessary when performing operations. These include compliance with cosmetic requirements, the superficial location of numerous and large vessels and nerves, the complex relief of the bones of the facial skeleton, the presence of cellular spaces and infected oral and nasal cavities with paranasal sinuses. Of particular importance for choosing the direction of incisions in the face is the position of the branches of the facial nerve, which provide innervation of the facial muscles. Damage to the facial nerve or its large branches entails paralysis of the corresponding muscle group, disfigurement of the face, serious functional disorders (lagophthalmos, salivation, impaired articulation of speech). The exit point of the facial nerve from the stylomastoid foramen on the face is projected at the base of the earlobe, 1,5-2 cm below the external auditory canal. Having penetrated into the thickness of the parotid salivary gland, the nerve divides into branches, which form the parotid plexus in the capsule of the gland. Five groups of branches of the facial nerve depart from the latter (large crow's foot), heading radially from the tragus of the ear to the facial muscles: 1st group - 2-4 temporal branches: up and forward to the upper edge of the orbit; 2nd group - 3-4 zygomatic branches: obliquely through the middle of the zygomatic bone to the outer edge of the orbit; 3rd group - 3-5 buccal branches: across the cheek and below the zygomatic bone to the wings of the nose and upper lip; 4th group - marginal branch of the lower jaw; 5th group - cervical branch: down behind the angle of the lower jaw to the neck. The branches of the facial nerve pass in the deep layer of the subcutaneous tissue of the corresponding areas, therefore, when dissecting the skin and superficial layers of the subcutaneous tissue, their damage can be avoided. Deep incisions, especially in the lateral part of the face, are oriented radially from the ear tragus. The openings through which the branches of the trigeminal nerve enter the face are projected on a vertical line drawn along the border of the medial and middle thirds of the upper edge of the orbit. For the supraorbital branch - at the upper edge of the orbit; for the infraorbital branch - 0,5-1 cm below the lower edge of the orbit; for the mental branch - in the middle of the distance between the lower and alveolar edges of the lower jaw. Primary surgical treatment of wounds of the soft tissues of the face is carried out simultaneously and at the earliest possible time. When the tongue is injured, suturing the wound of the tongue only in the longitudinal direction plays an important role, because this is the only way its function is preserved. Numerous veins and venous plexuses play an important role in the spread of infection and purulent foci on the face. With thrombophlebitis of these veins, infection can spread along their anastomoses into the system of intracranial sinuses. This is facilitated by a change in the direction of blood flow in vein thrombosis. The skeleton of the face represents its basis, the "bearing" structure. Injuries to the bones of the facial part of the skull are severe injuries leading to serious deformities. Immobilization of bone fragments is performed after the completion of the surgical treatment of the bone, but before suturing the soft tissues. 24. Triangles and fasciae of the neck By a horizontal plane drawn at the level of the body of the hyoid bone, the anterior neck is divided into suprahyoid and infrahyoid regions. The muscles located in the suprahyoid region form the bottom of the oral cavity, in this area three triangles are distinguished: unpaired submental, paired right and left submandibular triangles. The sublingual region is divided by the median line into the right and left sides. On each side, two large triangles and a rectangle are distinguished. The medial triangle is formed by the median line, the posterior belly of the digastric muscle, and the anterior edge of the sternocleidomastoid muscle; lateral triangle - the posterior edge of the sternocleidomastoid muscle, the upper edge of the clavicle and the lateral edge of the trapezius muscle. In the medial triangle, two triangles are formed - scapular-tracheal and scapular-hyoid (sleepy triangle) Fascia of the neck. There are 5 fasciae on the neck. The first fascia of the neck - the superficial fascia is of muscular origin, it is found in all parts of the neck. On the front surface of the neck, this fascia can be stratified by accumulations of adipose tissue into several plates. The second fascia of the neck - a superficial sheet of its own fascia - in the form of a dense sheet surrounds the entire neck, including both its anterior and posterior sections. Around the submandibular gland, sternocleidomastoid, and trapezius muscles, this fascia splits and forms a sheath. The third fascia (deep sheet of the own fascia of the neck) is of muscular origin. It is a thin but dense connective tissue plate stretched between the hyoid bone and the collarbone. At the edges, this fascia is limited by the scapular-subclavian muscles, and near the midline by the so-called "long muscles of the neck" and resembles a trapezium in shape. The fourth fascia (intracervical) is a derivative of the tissues that form the lining of the primary cavity. This fascia has two sheets: parietal and visceral. The visceral layer covers the organs of the neck: the trachea, esophagus, thyroid gland, forming fascial capsules for them. The parietal layer surrounds the entire complex of organs of the neck and the neurovascular bundle, consisting of the common carotid artery, the internal jugular vein, and the vagus nerve. Between the parietal and visceral sheets of the 4th fascia, anterior to the organs, a slit-like cellular space is formed - previsceral (spatium previsce-rale, spatium pretracheale). Behind the 4th fascia of the neck, between it and the fifth fascia, there is also a layer of fiber - the retrovisceral (spatium retro-viscerale) space. The fifth fascia (prevertebral) covers mm. longi colli lying on the anterior surface of the cervical spine. This fascia is of connective tissue origin. Continuing in the lateral direction, it forms a case (fascial sheath) for the brachial plexus with the subclavian artery and vein and reaches the edges of the trapezius muscles. Between the 5th fascia and the anterior surface of the spine, a bone-fibrous sheath is formed, filled mainly with the long muscles of the neck and surrounding them with loose fiber. 25. Topography of the cervical part of the thoracic lymphatic duct and carotid arteries The common carotid artery is the main artery located in the neck. She, along with the vagus nerve and the internal jugular vein in the lower half of the neck, is projected into the regio sternocleidomastoideus. Slightly below the level of the upper edge of the thyroid cartilage, the artery emerges from under the anterior edge of the muscle and divides into the internal and external carotid arteries. The bifurcation of the artery is located at the level of the notch of the thyroid cartilage and is projected in the carotid triangle of the neck. Within this triangle, both the common carotid artery and both of its branches are most accessible for exposure. The classical projection line of the common carotid artery is drawn through points, the upper of which is located midway between the angle of the lower jaw and the apex of the mastoid process, the lower one corresponds to the sternoclavicular joint on the left, and is located 0,5 cm outward from the sternoclavicular joint on the right . To verify (identify) the external and internal carotid arteries, the following features are used: the internal carotid artery is located not only posteriorly, but, as a rule, also laterally (outward) from the external carotid artery; branches depart from the external carotid artery, while the internal carotid artery does not give branches on the neck; temporary clamping of the external carotid artery above the bifurcation leads to the disappearance of pulsation a. temporalis superficialis and a. facialis, which is easily determined by palpation. It should be remembered that forced ligation of the common or internal carotid artery in case of injury in 30% of cases leads to death due to severe disorders of cerebral circulation. Equally unfavorable is the prognosis for the development of a bifurcation thrombus, which sometimes develops with an incorrect choice of the level of ligation of the external carotid artery. To avoid this complication, the ligature on the external carotid artery must be applied above the origin of its first branch - a. thyreoidea superior. Topography of the cervical part of the thoracic lymphatic duct Injuries to the cervical part of the thoracic duct are observed during sympathectomy, strumectomy, removal of supraclavicular lymph nodes, endarterectomy from the common carotid artery. The main clinical manifestation of a violation of the integrity of the thoracic duct is chylorrhea - the outflow of lymph. Measures to eliminate chylorrhea are tamponade of the wound or ligation of the ends of the damaged duct. In recent years, the operation of imposing a lymphovenous anastomosis between the end of the damaged thoracic duct and the internal jugular or vertebral vein has been used. The thoracic duct is accessed and isolated for repair of injury or for catheterization and drainage, typically along the medial border of the sternocleidomastoid muscle. It should be emphasized that the cervical part of the thoracic duct is difficult to access for direct examination. 26. Tracheostomy Tracheostomy is the operation of opening the trachea with the subsequent introduction of a cannula into its lumen in order to provide immediate air access to the lungs in case of obstruction of the overlying sections of the respiratory tract. Classical indications for tracheostomy: foreign bodies of the respiratory tract; impaired airway patency in wounds and closed injuries of the larynx and trachea; acute stenosis of the larynx in infectious diseases; stenosis of the larynx with specific infectious granulomas; acute stenosis of the larynx in nonspecific inflammatory diseases (abscessing laryngitis, laryngeal tonsillitis, false croup); stenosis of the larynx caused by malignant and benign tumors (rarely); compression of the tracheal rings from the outside by struma, aneurysm, inflammatory infiltrates of the neck; stenoses after chemical burns of the tracheal mucosa. Tracheostomy requires both general surgical instruments and a special set of instruments. The set of the latter usually includes: tracheostomy cannulas (Luer or Koenig), a sharp single-tooth tracheostomy hook of Shes-signac, a blunt hook for pushing back the isthmus of the thyroid gland; tracheo dilator for pushing the edges of the tracheal incision before inserting a cannula (Trousseau or Wulfson) into its lumen. Depending on the place of opening of the trachea and in relation to the isthmus of the thyroid gland, there are three types of tracheostomy: upper, middle and lower. With an upper tracheostomy, the second and third tracheal rings are cut above the isthmus of the thyroid gland. With a middle tracheostomy, the isthmus of the thyroid gland is dissected and the third and fourth tracheal rings are opened. With a lower tracheostomy, the fourth and fifth tracheal rings are opened below the isthmus of the thyroid gland. During upper tracheostomy, the incision is made from the level of the middle of the thyroid cartilage down by 5-6 cm. The "white line" of the neck is dissected along the probe and the long muscles located in front of the trachea are bred to the sides. Immediately below the thyroid cartilage, the visceral sheet of the 4th fascia is dissected in the transverse direction, fixing the isthmus of the thyroid gland to the trachea. With a lower tracheostomy, the incision of the skin and subcutaneous tissue starts from the upper edge of the jugular notch of the sternum and is carried out upwards by 5-6 cm. The 2nd fascia of the neck is dissected, the tissue of the suprasternal interaponeurotic space is bluntly stratified, if necessary, it is bandaged and the arcus venosus juguli located here is crossed. The 3rd fascia is cut along the probe and the sternohyoid and sternothyroid muscles are moved apart. Below the isthmus, the 4th fascia is incised and the isthmus is displaced upward, exposing the 4th-5th tracheal rings. Before opening the trachea to suppress the cough reflex, it is recommended to inject 1-1,5 ml of a 2% dicaine solution into its lumen with a syringe. The opening of the trachea can be done either by a longitudinal incision or a transverse one. During a longitudinal dissection of the trachea, the scalpel is held at an acute angle to the surface of the trachea (not vertically), with the belly up and 2 rings are crossed after tracheal puncture by moving from the isthmus of the thyroid gland and from the inside outward, as if "ripping" the wall. 27. Topographic anatomy and operative surgery of the thyroid gland The thyroid gland consists of two lateral lobes and an isthmus. The lateral lobes are adjacent to the lateral surfaces of the thyroid and cricoid cartilages and the trachea, reach the lower pole of 5-6 tracheal rings and do not reach the upper edge of the sternum by 2-3 cm. The isthmus lies in front of the trachea, at the level of its 4th rings. The posterior medial surfaces of the lateral lobes of the thyroid gland are adjacent to the esophageal-tracheal grooves, in which the recurrent nerves are located. In this zone, exfoliation of a thyroid tumor requires special care, since aphonia may develop if the recurrent nerves are damaged. The neurovascular bundles of the neck are adjacent to the outer sections of the lateral lobes of the gland. The blood supply to the gland is carried out by branches of the external carotid and subclavian arteries. Paired superior thyroid arteries, arising from the external carotid arteries, approach from the posterior surface to the upper poles of the lateral lobes and branch mainly in the anterior sections of the gland. Paired inferior thyroid arteries, arising from the subclavian arteries (truncus thyreocervicalis), approach the lower poles of the lateral lobes and supply mainly the posterior sections of the gland with branches. One of the most common thyroid surgeries is a strumectomy. It is called subtotal subcapsular resection of the thyroid gland. Surgical access is carried out by a horizontal arcuate incision 1-2 cm above the jugular notch of the sternum 8-1 cm long along one of the transverse skin folds ("collar" incision). When dissecting soft tissues, a thorough ligation of the vessels is performed. The resulting flaps, including the skin, subcutaneous tissue and superficial fascia, are peeled off in a blunt way and bred up and down. The sternohyoid muscles are transversely crossed. The muscles are moved apart from the midline, and the parietal sheet of the 2th fascia of the neck is dissected. Displacing the edges of the dissected fascia in a blunt way, they provide an approach to the thyroid gland and begin to perform an operative technique. After the release of the right lobe, the isthmus of the thyroid gland is crossed along the probe (or under the control of the finger). As the isthmus is dissected, hemostatic clamps are applied sequentially. Less often, the isthmus is crossed between the clamps, followed by stitching its tissue and tightening the ligatures. This is followed by a "navicular" excision of the tissue of the right lobe of the gland, which is performed under the control of the finger. By controlling the movement of the scalpel with a finger under the gland, a narrow plate of gland tissue is left in the area that is considered a "dangerous" zone, since the recurrent nerve and parathyroid glands are adjacent to it behind. The remainder of the gland should be sufficient to prevent hypothyroidism. The medial and lateral edges of the left parenchyma of the gland are sutured to each other in the form of two valves. The bed of the removed gland and the remaining stump is covered by the sternothyroid muscles. 28. Features of primary surgical treatment of neck wounds Neck - an area whose upper border runs along the lower edge of the lower jaw, the top of the mastoid process and the upper nuchal line. The lower border corresponds to the jugular notch of the sternum, the upper edges of the clavicles and the line connecting the acromial process of the scapula with the spinous process of the VII cervical vertebra. In the anterior part of the neck, separated from the posterior frontal plane, there are organs - the trachea, esophagus, thyroid gland, neurovascular bundles, the thoracic duct is located in the cervical vertebrae passing through the transverse processes. In the back of the neck there are only muscles enclosed in dense fascial cases and adjacent to the cervical vertebrae. Neck wounds have the following features: the wound channel, due to the large displacement of tissues, becomes tortuous and the outflow of wound contents is difficult; often observe simultaneous damage to large vessels and organs of the neck; wounds of the larynx, trachea and esophagus become infected not only from the outside, but also due to the contents; possible aspiration of blood into the respiratory tract, asphyxia. The wound channel is opened widely, the direction of the incision is chosen depending on the localization of the wound. In the medial part of the neck, transverse incisions are preferable, in the region of the sternocleidomastoid muscle - longitudinal incisions corresponding to the direction of its fibers. In the lateral part of the neck, transverse or oblique transverse incisions are made (along the clavicle or subclavian vessels and the brachial plexus). Soft tissues are excised sparingly, as contractures can form as a result of scarring. Extremely carefully excised tissues in the depth of the wound in view of the danger of damage to large vessels and nerves. If it is necessary to cross the veins, they are preliminarily bandaged to prevent air embolism. When performing manipulations in the outer triangle of the neck, it should be remembered that in adults the dome of the pleura protrudes 3 cm above the collarbones. All opened cellular spaces are carefully drained. Surgical treatment of wounds of the larynx and trachea consists in the economical excision of damaged tissues and the obligatory imposition of a tracheostomy. The damaged pharynx and esophagus are sutured with a double-row suture with synthetic threads, after which not only the paraesophageal and peripharyngeal tissues are drained, but also the posterior mediastinum. 29. Operative surgery and topographic anatomy of the chest The upper border of the chest area runs along the upper edge of the manubrium of the sternum, collarbones, acromial processes of the scapula and further to the spinous process of the VII cervical vertebra; under the lower border is meant a line passing from the xiphoid process of the sternum along the edges of the costal arches, then along the lower edge of the XII rib to the spinous process of the XII thoracic vertebra. There are three serous sacs in the chest cavity: two pleural and one pericardial. The mediastinum is located between the pleural sacs in the chest cavity, in which a complex of organs is placed, which includes the heart with the pericardium, the thoracic part of the trachea, the main bronchi, the esophagus, vessels and nerves, surrounded by a large amount of fiber. The diaphragm with its dome protrudes high into the chest, as a result of which the lower border of the chest is located significantly below the lower border of the chest cavity. The anterior and posterior surfaces of the chest are conditionally divided along the midaxillary line. On each of them conditionally allocate 5 anatomical regions. On the anterior surface - anteromedian (limited on the sides by parasternal lines) and paired (right and left) anterior superior and anterior inferior (the border between them runs along the lower edge of the pectoralis major muscle). On the posterior surface, there are: posterior median (limited laterally by paravertebral lines), and paired posterior-superior and posterior-inferior regions (the border between the latter runs at the level of the angle of the scapula). The division of the chest wall into these areas is due to differences in the bone base and the structure of the soft tissue layers. The anterior upper-outer region incorporates well-developed pectoralis major and minor muscles, it is rich in intermuscular fiber, and the mammary gland is located in the surface layer. Between the clavicle and the upper edge of the pectoralis minor muscle, under the pectoralis major muscle, a trigonum clavipectorale is isolated. In this triangle, under the fascia leaf (fascia clavi pectoralis) are the subclavian artery, vein and brachial plexus. The close proximity of the neurovascular bundle with the clavicle causes injury to the artery and vein when the fragments of the clavicle are displaced. In the lower sections of the chest wall, the muscles of the abdominal wall (m. rectus, m. obliquus abdominis externus) are attached in front; behind the superficial layer of muscles is formed by the latissimus dorsi, under which lie the anterior and posterior dentate muscles. The deep layer of the muscles of the chest wall is represented mainly by the external and internal intercostal muscles, which fill the intercostal spaces. In this case, the external intercostal muscles are observed along the length from the tubercles of the ribs (near the transverse processes of the vertebrae) to the line of transition of the ribs into cartilage. Throughout the cartilaginous part of the ribs, they are replaced by a dense fibrous ligament (lig. Intercostale externum). The internal intercostal muscles occupy the intercostal spaces from the edge of the sternum to the costal angle. For the rest of the length (from the costal angle to the spine), the internal intercostal muscles are replaced by the internal intercostal ligament (lig. intercostal internum). 30. Topographic anatomy and operative surgery of the breast The mammary gland is located in women at the level of III-VI ribs between the parasternal and anterior axillary lines. The superficial fascia of the chest, which is divided into two sheets at the level of the third intercostal space, forming a capsule for the mammary gland, is fused with the clavicle and forms a lig. suspensorium mammae. The capsule gives off spurs that go into the depth between the lobules of the gland from the nipple in the radial direction. Usually there are 15 to 20 cloves. Parallel to the connective tissue septa, their excretory ducts of the mammary gland are also oriented. The connective tissue stroma of the gland is associated with the superficial fascia and the skin covering the mammary gland. Breast cancer is one of the most common sites of malignant growth. The growth of a malignant tumor of the mammary gland is accompanied by the germination of neighboring tissues (skin, own fascia, muscles, ribs), penetration into the lymphatic channel and into the lymph nodes, first in the regional, and then in the distant ones (metastasis of tumor cells), and therefore it is important know the ways of lymphatic drainage. The most important route for lymph drainage and spread of tumor cells is the axillary route. In breast cancer, several types of surgical interventions are mainly used: radical mastectomy; extended radical mastectomy; mastectomy with preservation of the pectoralis major muscle; resection of the mammary gland (extended sectoral resection, quadrantectomy). Radical mastectomy consists of four stages: access; removal of a breast tumor within healthy tissues; removal of regional lymph nodes; suturing the wound. The skin incision should be made at a distance of at least 5-6 cm from the edges of the palpable tumor. After dissection of the skin, the edges of the incision are prepared in the medial side to the middle of the sternum, in the lateral side - to the edge of the latissimus dorsi muscle, up - to the collarbone, down - to the epigastric region. The thickness of the fiber on the prepared skin should not exceed 5-7 mm. The second stage is based on one of the main methodological principles of ablasty - "anatomical casing of surgical intervention". Observing this principle, it is necessary to operate within the appropriate fascial sheaths that limit the spread of the tumor. The second stage is completed with a single-block removal of the entire isolated drug or, without removing the block of the mammary gland with pectoral muscles, as if “hanging” on a fascial-fat pedicle that continues into the axillary fossa, proceed to remove all regional (axillary) lymph nodes. Taking into account the principles of antiblastics, the electrosurgical method of operating in breast cancer is often used. The fourth stage of the operation. It consists in closing the surgical wound. If possible, bring together and sew the edges of the wound. With a slight tension of the edges of the wound along its periphery, laxative incisions are made on the skin in a checkerboard pattern. 31. Operative access to the organs of the chest cavity The requirements for online access are the anatomical accessibility of the object of intervention and the technical feasibility of all stages of the operation. All approaches to the organs of the chest cavity are divided into two groups: extrapleural and transpleural. When performing extrapleural accesses, the exposure of the anatomical formations of the mediastinum occurs without depressurization of the pleural cavities. The possibility of performing these accesses is determined by the position and ratio of the anterior and posterior borders of the pleura. With transpleural accesses, one or two (with the so-called transdouble-pleural accesses) pleural cavities are opened. Transpleural accesses can be used for operations both on the organs of the mediastinum and on the lungs. To perform a longitudinal sternotomy, a skin incision is made along the midline above the sternum, starting 2-3 cm above the sternum handle and ending 3-4 cm below the xiphoid process. Then the periosteum of the sternum is dissected and displaced by 2-3 mm to the sides of the incision line with a raspator. In the lower part of the wound, the white line of the abdomen is dissected for several centimeters and a tunnel is formed between the posterior surface of the sternum and the sternal part of the diaphragm in a blunt way (with a finger, a swab). Protecting the underlying tissues with Buyalsky's scapula (or in another way), a longitudinal sternotomy is performed. The edges are widely bred to the sides with a screw retractor, while trying not to damage the mediastinal pleura. After the end of the operation, the edges of the sternum are compared and fastened with special brackets or strong sutures. Anterolateral incision at the level of the fifth or fourth intercostal space. This is one of the most commonly used, "standard" accesses. The incision starts from the parasternal line and, continuing it along the intercostal space, is brought to the posterior axillary line. After dissection of the superficial layers of the chest wall, the edges of the wound are moved apart with hooks and the intercostal muscles and the corresponding ribs are exposed, after which the intercostal muscles and pleura are dissected. With lateral access, the chest cavity is opened along the V-VI ribs from the paravertebral to the mid-clavicular line. To perform a posterolateral approach. the soft tissue incision begins at the level of the spinous process of the III-V thoracic vertebra and continues along the paravertebral line to the level of the angle of the scapula (VII-VIII ribs). Having rounded the angle of the scapula from below, an incision is made along the VI rib to the anterior axillary line. Sequentially dissect all tissues to the ribs. The pleural cavity is opened along the intercostal space or through the bed of the resected rib. To expand the operational access, resection of the necks of two adjacent ribs is often resorted to. Transverse sternotomy is used in cases where it is necessary to expose not only the organs, but also the vessels of the mediastinum and nearby areas. The incision is made along the fourth intercostal space from the midaxillary line on one side, through the sternum, to the midaxillary line on the opposite side. 32. Wound of chest organs: shock, hemothorax One of the most common causes of breast surgery is wounds. They occur not only with the direct impact of firearms or edged weapons: organs are often damaged by fragments of the bone frame of the chest (ribs, sternum), which become additional sources of damage. All chest injuries are divided into two groups: 1) non-penetrating - without damage to the intrathoracic fascia; 2) penetrating - with damage to the intrathoracic fascia and parietal pleura in those places where it is adjacent to this fascia. The direction of the wound channel for penetrating wounds may be different. The most dangerous are sagittal injuries near the midline, since in these cases the heart and large vessels (aorta, vena cava, pulmonary artery) are often damaged. Methods for the treatment of penetrating wounds of the chest (including surgical ones) are aimed at preventing complications (traumatic shock, bleeding, infections) and correcting developing functional disorders. Shock. The course of shock resulting from penetrating wounds of the chest is characterized by the manifestation of a syndrome of cardiopulmonary disorders. The developing phenomena of shock are most severe in the wounded with hemo- and pneumothorax. In these cases, severe respiratory disturbances occur, leading to profound disturbances in gas exchange. Anti-shock measures are aimed at combating respiratory disorders, eliminating the pain factor, compensating for blood loss, correcting metabolism; vagosympathetic blockade according to Vishnevsky is used as one of the anti-shock measures. Hemothorax. The accumulation of blood in the pleural cavity is the result of internal bleeding from injuries of the heart, lung vessels, main vessels of the mediastinum, as well as damage to the vessels of the chest wall. Often hemothorax is combined with the ingress of air into the pleural cavity. This condition is called hemopneumothorax. Hemothorax can be free or (in the presence of adhesions) encysted. Allocate small - within the costal-diaphragmatic sinus; middle - to the level of the IV rib in front; total - from the diaphragm to the dome of the pleura. To determine whether the bleeding has stopped or continues, the Ruvelua-Gregouar test is used: a few milliliters of blood aspirated from the pleural cavity with a puncture needle is poured into a test tube. Rapid blood clotting indicates ongoing bleeding, non-clotting indicates its cessation. With stopped bleeding, the removal of the blood contained in the pleural cavity by pleural puncture and the introduction of antibiotics is indicated. With persistent bleeding due to damage to the intercostal arteries and the internal mammary artery, emergency thoracotomy is indicated. After its implementation, the revision of the pleural cavity is continued, the damaged vessel is found and ligatures are applied to it. 33. Pneumothorax This is an accumulation of air in the pleural cavity. With wound pneumothorax, air can enter the pleural cavity in two ways: through a hole in the chest wall with a penetrating wound, accompanied by damage to the parietal pleura (external pneumothorax); through a damaged bronchus (internal pneumothorax). It is customary to distinguish three types of pneumothorax: closed, open, valvular. With a closed pneumothorax, air enters the pleural cavity at the time of injury. This leads to atelectasis of the lung on the affected side. As a result of the collapse of the walls of the wound channel, which is small in size, the openings of the parietal pleura are closed, which leads to separation of the pleural cavity from the atmosphere. Open pneumothorax occurs more often with a gaping wound of the chest wall. This forms a free communication between the pleural cavity and atmospheric air. Open pneumothorax leads to a very serious condition, often ending in the death of the victim. First aid for open pneumothorax is to apply an aseptic occlusive dressing to the wound. Surgical treatment of open pneumothorax consists in urgent surgical closure of the chest wall wound and drainage of the pleural cavity, the purpose of which is the complete expansion of the lung. The operation begins with the primary surgical treatment of the wound of the chest wall, which is performed sparingly, excising only obviously non-viable tissues. In the absence of signs of ongoing internal bleeding, thoracotomy is not performed and surgical closure of the chest wall defect is started. The technique of suturing the wound of the chest wall with open pneumothorax. The sealing of the pleural cavity is achieved by applying a two-row suture. The first row is a hymen-muscular suture, which is applied with catgut. For greater strength, the parietal pleura, intrathoracic fascia and intercostal muscles must be included in the suture. When tightening the sutures, they try to achieve adhesion to each other of the sheets of the parietal pleura covering the edges of the wound. The second row of sutures is placed on the superficial muscles of the chest wall. In this case, it is desirable that the seams of the second row are projected onto the gaps between the seams of the first row in order to achieve better tightness. Several layers of muscle can be sewn with three rows of stitches. When suturing superficial muscles, it is imperative to include your own fascia in the suture; synthetic threads are usually used. With a "deficiency" of the intercostal muscles along the edges of the wound or the inability to pull them together with extensive damage, the adjacent ribs are brought closer to the remnants of soft tissues by suturing with a thick catgut capturing adjacent ribs. The next step is to mobilize the chest wall. With relatively large defects of the chest wall, it is possible to mobilize the edges of the wound by resection of one or two ribs lying above and below the wound. After such mobilization, soft tissues, as a rule, can be brought together and the open pneumothorax is sutured with a two-row suture. 34. Methods for closing a defect in open pneumothorax. Emphysema. Suturing the wound of the lung Plastic methods of closing a chest wall defect in open pneumothorax. Plastic surgery with a muscle flap on a leg, which is cut out from the muscles adjacent to the wound. For wounds localized in the lower parts of the chest, where there are few superficial muscles, diaphragmopexy can be used - pulling up and suturing the diaphragm to the edges of the wound of the pleural cavity around the entire perimeter. Pneumopexy - pulling up the lung and suturing it to the edges of the wound. Valvular pneumothorax occurs when a valve is formed from the tissues around the wound, through which air enters the pleural cavity at the moment of inhalation, and when exhaling, the valve closes and does not release air back from the pleural cavity. With valvular pneumothorax lies the decompression of the pleural cavity and the elimination of a sharp displacement of the mediastinum. The easiest way to do this is to puncture the pleural cavity with a thick needle in the second intercostal space along the midclavicular line. Surgical care for valvular pneumothorax, which develops when the chest wall is damaged, consists in excising the valve from the soft tissues during the primary surgical treatment and suturing the wound. With internal valvular pneumothorax associated with damage to the bronchus, active aspiration of pleural fluid is possible through a drain inserted in the seventh to eighth intercostal space along the middle or posterior axillary line. Emphysema. This is the ingress of air into the fiber, there are two types: subcutaneous and mediastinal. Subcutaneous emphysema is formed with external valvular pneumothorax. It does not pose a danger and dissolves after the elimination of the source of air intake. Mediastinal emphysema occurs when air enters the mediastinal tissue from the pleural cavity through a defect in the mediastinal pleura. Accumulating in the fiber of the mediastinum, the air causes compression of the heart and large vessels (primarily veins), difficulty breathing. Treatment consists in urgent drainage of the anterior mediastinum. To do this, a longitudinal or transverse incision is made in the suprasternal fossa, from where, in a blunt way, the surgeon penetrates the tissue of the anterior mediastinum and introduces drainage. Suturing the wound of the lung. With shallow wounds on the surface of the lung, to stop bleeding, it is enough to apply several interrupted sutures with thin round needles with synthetic or silk threads. To prevent the eruption of sutures, the Tigel-Melnikov technique is used, a feature of which is the preliminary holding of "support" threads along the edges of the wound through the thickness of the parenchyma of the lung, and then the application of interrupted sutures outside of them, passing under the bottom of the wound. With marginal damage to the lung tissue, accompanied by bleeding, a wedge-shaped resection is performed. For its implementation, two hemostatic clamps are applied to the lung tissue on both sides of the wound. Along the edges of the clamps facing inward, the affected area of the lung is excised in the form of a wedge. After that, a twisting seam is applied through the clamps, which, as they are gradually tightened, are carefully removed and removed from under the seam loops. 35. Damage to the pericardium and heart with penetrating wounds of the chest. Chylothorax. Pleural empyema Heart injuries are divided into two groups: non-penetrating - without damage to the endocardium; penetrating - with damage to the epicardium. Bleeding from heart injuries is often intrapleural. With bleeding into the myocardial cavity, cardiac tamponade may develop. Emergency help with threatening tamponade is a pericardial puncture. The puncture is performed with a thick needle. With the Marfan method, a puncture is made under the xiphoid process strictly along the midline, moving the needle from bottom to top to a depth of 4 cm, and then deflecting its end posteriorly. According to the Pirogov-Delorme method, a puncture is made at the left edge of the sternum in the fourth-fifth intercostal space, in the medial direction, behind the sternum, to a depth of 1,5-2 cm. According to Larrey, the needle is injected into the angle between the attachment of the left seventh costal cartilage and the base of the xiphoid process to a depth of 1,5-2 cm, and then it is deflected upwards parallel to the chest wall. According to the Kurshman method, the puncture is performed in the fifth intercostal space, retreating 4-6 cm from the edge of the sternum. The needle is passed in the medial direction (towards the apex of the heart). When revising the heart, it is necessary to examine its posterior surface along with the anterior one. Inspection should be done by bringing the palm of the left hand under the top of the heart and slightly "dislocating" it into the wound. For suturing the wound of the heart, round (preferably atraumatic) needles are used. Synthetic threads are used as suture material. The suture of the walls of the ventricles of the heart should capture the entire thickness of the myocardium, but the threads should not penetrate into the cavity of the heart, in order to avoid the formation of blood clots. With small wounds of the heart, interrupted sutures are applied, with wounds of a significant size, mattress sutures are used. Chylothorax is an accumulation of lymph in the pleural cavities when the thoracic duct or its tributaries is damaged. Conservative methods include repeated punctures of the pleural cavity with the removal of lymph. Surgical treatment of lymphorrhea and chylothorax is performed by transpleural (usually right-sided) thoracotomy with ligation of the ends of the thoracic duct with thin silk ligatures. The entry into the tissue of the mediastinum and into the pleural cavities of the contents of the esophagus leads to the development of purulent mediastinitis and pleurisy. Penetrating wounds of the esophagus, found during the revision of the chest cavity, are subject to suturing. The wound of the esophagus is sutured in the transverse direction to avoid narrowing of its lumen. The operation ends with drainage of the pleural cavity or mediastinum. Pleural empyema is a collection of pus in the pleural cavity. Surgical treatment of acute empyema consists in draining the pleural cavity in order to remove purulent contents and ensure lung expansion. With free empyema, pus accumulates in the costophrenic sinus. The puncture in this case is performed in the eighth intercostal space along the scapular or posterior axillary line. With small encysted empyema, the localization of the abscess is established percussion and radiographically. The puncture site is chosen near the lower border of the purulent cavity. 36. Hernias and places of their occurrence Hernia of the anterior-lateral abdominal wall is a common disease (up to 7% of men and 2,5% of women). Often there is an infringement of the hernial contents, which requires emergency surgical treatment and is accompanied by a much higher mortality compared to a planned operation. The boundaries of the anterior-lateral wall of the abdomen are: at the top of the costal arches and the xiphoid process of the sternum; below the inguinal folds, pubic tubercles and the upper edge of the pubic symphysis; on the right and on the left, the border is a vertical line connecting the end of the XI rib with the iliac crest (Lesgaft line). The basis of the anterior-lateral abdominal wall is 4 pairs of muscles: on the right and left, the external oblique, internal oblique and transverse muscles; in front of the rectus abdominis muscles with longitudinally oriented fibers. Behind are the muscles that straighten the spine. All of these muscles form a ring in which the abdominal organs are enclosed. Muscles are constantly in a certain tone, more pronounced in a standing position, less in a horizontal position of the body. Most of the abdominal muscles reduce the volume of the abdominal cavity during contraction, except for the muscles that straighten the spine, which make up its support. Tendon bridges in the muscles, uniting the points of application of the forces of the muscle fibers, determine the stress vector. The combination of muscle tension of the abdominal wall with the elasticity of blood-filled parenchymal organs and peristaltic hollow abdominal organs determine the occurrence of intra-abdominal pressure. The value of intra-abdominal pressure ranges from 15 to 150 mm of water column, and depends on the tone of the abdominal muscles and the condition of the abdominal organs. Intra-abdominal pressure helps to maintain the normal function of the abdominal organs, activates blood and lymph circulation in the abdominal cavity and performs a number of other functions. If the value of intra-abdominal pressure rises for a long time and does not correspond to the mechanical strength of the abdominal wall, the viscera may be "pushed" out of the abdominal cavity. A similar phenomenon can occur with a single excessive physical effort, with an "overstrain" of the abdominal press. The exit of the viscera, covered with the parietal peritoneum, occurs through weak points in the muscular-aponeurotic layer of the abdominal wall, pelvic floor, and diaphragm. It is important to emphasize that with a hernia, the viscera that extend beyond the abdominal wall are necessarily covered by the peritoneum. The phenomenon when the viscera exit the abdominal cavity through a rupture of the parietal peritoneum is called eventration. The factors contributing to the occurrence of hernias are very diverse, and can be both general (congenital weakness of the muscles of the abdominal wall, sudden weight loss, etc.) and local (congenital or acquired "weak spots" of the abdominal wall). Among all the factors and causes of hernia formation, two should be highlighted: the “predisposing factor” (the presence of “weak spots” in the muscular-aponeurotic layer of the abdominal wall) and the “producing factor” (a sharp increase in intra-abdominal pressure). 37. Elements of hernial protrusion The following elements of hernial protrusion are distinguished. 1. Hernial orifice - a defect in the layers of the abdominal wall, through which the abdominal organs exit. Hernial gates can have a different structure and are divided into two groups: simple and complex. Simple hernial gates look like a ring. Complex ones are represented by interaponeurotic or intermuscular fissures and channels. 2. Hernial sac - a parietal sheet of the peritoneum, pushed out of the exiting viscera from the abdominal cavity. In the hernial sac, the neck, body and bottom are distinguished. The neck is called the area of the peritoneum, located at the level of the gate and is the anatomical boundary between the peritoneal cavity and the cavity of the hernial sac. The expanded part of the hernial sac is called the body, the final part of which forms the bottom. 3. The contents of the hernial sac. It can be almost any organ of the abdominal cavity, except for the head of the pancreas. Most often, the contents of the hernial sac are the greater omentum and loops of the small intestine as organs with the greatest mobility. Weak places of the anterior-lateral wall of the abdomen are located where there are holes in the fascia and aponeuroses, gaps between the connective tissue fibers or between the edges of the muscles, and also where there is an "incomplete set" of muscular-aponeurotic layers that make up the abdominal wall. In those areas where there are few muscular-aponeurotic layers, or their weakened areas are located one above the other, simple hernial gates (umbilical hernia) are formed. When the outer and inner rings are displaced relative to each other, a channel is formed in the abdominal wall, complex hernial gates (inguinal hernias) are formed. The white line of the abdomen has a different shape depending on the severity and level of location of the widest part. There are four forms of variability of the white line: with an extension at the level of the navel; with an extension above the navel; with an extension below the navel; white line of uniform width at all levels. Under the influence of prolonged tension of the anterior abdominal wall, the tendon fibers that form the white line can stretch and move apart. As a result, the gaps in the white line expand, new ones appear. Often these gaps correspond to the places of passage through the white line of blood vessels and nerves. With a significant increase in the size of the cracks, preperitoneal tissue can protrude through them, and then the parietal peritoneum with the formation of a hernia. Hernias of the white line are more often localized above the navel, where its width is greater, and the tendon fibers are less dense. Anatomical features that predispose to the formation of umbilical hernias are: poor development of the umbilical fascia (part of the intra-abdominal fascia); an increase in the diameter of the ring; the presence of peritoneal diverticula in the region of the umbilical ring. 38. The most typical sites of hernias The aponeurosis of the external oblique muscle of the abdomen has a mesh structure and consists of powerful longitudinal (continuing the direction of the muscle) and thinner transverse fibers. Between the bundles of longitudinal fibers, gaps are formed, which are unequally expressed in different people. Individual differences in the structure of the aponeurosis are a predisposing factor to the formation of hernias and force the use of methods for strengthening the aponeurosis during surgical interventions for a hernia. Along the line of transition of the fibers of the transverse muscle to the tendon stretch, relatively weak sections of the anterior abdominal wall are also located. This line has a crescent shape and is called the lunar (or Spigelian). the Spigelian line can be a weak point, especially in the lower sections, where the abdominal wall is relatively weakly strengthened. Predisposing factors for the formation of hernias of the Spigelian line are gaps along the vessels and nerves. The most common site for hernia formation is the inguinal canal. In the inguinal canal, the superficial and inner rings and the inguinal gap, which is the actual canal in the abdominal wall, are distinguished. The external opening of the inguinal canal is formed by fibers of the aponeurosis of the external oblique muscle of the abdomen, which, approaching the pubic symphysis, split into two legs. One of them (medial) is attached to the upper edge of the pubic symphysis, the other (lateral) - to the pubic tubercle. Of great importance in the pathogenesis of inguinal hernias are differences in the position of the lower edge of the internal oblique muscle relative to the deep inguinal ring. In 15-17% of cases, a high level of position of the edge of the internal oblique muscle is observed. In this case, the edge of the muscle does not reach the upper edge of the inguinal ring. At the same time, the deep inguinal ring is not covered by muscles, which creates anatomical prerequisites for the formation of a hernia. Of great importance as an anatomical structure that resists the formation of hernias is the intra-abdominal fascia. A practically significant formation (compaction) of the intra-abdominal fascia is the so-called iliopubic tract, or Thomson's ligament. The iliopubic tract is a dense cord located behind, parallel and slightly below the inguinal ligament. In close proximity to the inguinal canal is the internal opening of the femoral canal. It is limited: in front by the inguinal ligament, behind by the pubic bone, laterally by fascial fibrous fibers connecting the medial end of the inguinal ligament with the periosteum of the pubic bone near the pubic tubercle. The "weak point" that determines the possibility of the formation of femoral hernias is the internal opening of the canal, located under the pupart ligament on the border between the anterior abdominal wall and the pelvic cavity. Loose and mobile preperitoneal tissue sometimes penetrates into the fascial fissures and openings of the anterior wall of the abdomen, forming preperitoneal wen (lipomas), which contribute to the gradual expansion of the openings, becoming a predisposing factor in the development of hernias. Predispose to the formation of hernias are also observed in various places depressions and pits on the parietal peritoneum. 39. Operation for hernia The operation for abdominal hernia should be as simple as possible and least traumatic, but it is necessary to ensure the radical treatment. Operations for a hernia of the anterior abdominal wall are conditionally divided into three stages: access to the hernial orifice and hernial sac; processing and removal of the hernial sac; elimination of the defect of the abdominal wall (closure of the hernial ring). The following requirements are imposed on accesses for radical operations for a hernia: simplicity, safety; the possibility of a wide view of the hernial canal or hernial opening. In addition to direct accesses, in which tissues are cut in layers directly in the area of the hernial orifice, roundabout accesses are also used in surgical practice. Treatment and removal of the hernial sac constitute the second stage of the operation. This stage consists of several successive steps. First of all, the parietal peritoneum, which makes up the hernial sac, is carefully isolated from the surrounding tissues. This is achieved using the so-called "hydraulic preparation" method, i.e., introducing a 0,25% solution of novocaine around the wall of the hernial sac to facilitate the separation of the parietal peritoneum from adjacent tissues. With incomplete removal of the neck of the hernial sac, a pocket of the parietal peritoneum remains, which contributes to the recurrence of the hernia. To prevent this, the neck of the hernial sac is isolated to the hernial orifice. Next, an audit of the contents of the hernial sac is carried out in order to identify pathological changes in the hernial contents, dissection of adhesions (resection of necrotic parts of organs with strangulated hernias, etc.). After the revision, the neck of the hernial sac is sutured and bandaged to seal the abdominal cavity, followed by cutting off the sac over the ligatures. After cutting off the hernial sac, the preperitoneal tissue is removed from the hernial orifice. Then proceed to the final stage of the operation - the closure (plasty) of the hernial ring. There are many hundreds of ways to close or strengthen the hernial ring. It is advisable to divide them into three groups: 1) simple; 2) reconstructive; 3) plastic. Simple ways to strengthen the hernia orifice include such surgical techniques that involve closing an existing abdominal wall defect with sutures. They can be used only for relatively small hernias, their superficial location, simple structure of the hernia ring, good tissue elasticity. An example is the Lexer method used for umbilical hernias, which consists in imposing a purse-string suture around the expanded umbilical ring. For small inguinal hernias in children, a simple Roux method is used, which consists in applying several interrupted (or U-shaped) sutures to the aponeurosis of the external oblique muscle, narrowing the expanded external inguinal ring. The inguinal canal is not opened. All of them refer to tension methods for closing the hernia orifice, they are not radical and have limited application. 40. Reconstructive and pragmatic methods of closing the hernial orifice Reconstructive methods are aimed at changing the design of the hernial orifice in order to strengthen them. Reconstruction can be performed either with the help of fasciae and aponeuroses, or using both muscles and aponeuroses (muscle-aponeurotic methods). The duplication of the aponeurosis of the external oblique muscle of the abdomen is used to strengthen the anterior wall of the inguinal canal according to Martynov. According to this technique, duplication is created by suturing the upper edge of the aponeurosis of the external oblique muscle of the abdomen dissected along the inguinal canal to the inguinal ligament and then applying the lower edge of the aponeurosis of the same muscle to it. Another way of reconstruction is to strengthen the hernial ring with muscular-aponeurotic tissues. In this case, either the anterior or posterior wall of the inguinal canal is strengthened. Methods for strengthening the posterior wall of the inguinal canal include the Bassini method, in which, after opening the inguinal canal and excising the hernial sac behind the spermatic cord, sutures are placed between the edge of the rectus abdominis muscle with its sheath and the periosteum of the pubic tubercle, and then the internal oblique and transverse muscles are sutured with intra-abdominal fascia to the inguinal ligament. Also, the methods of strengthening the posterior wall of the inguinal canal include the Kukudzhanov method, during which the deep inguinal ring is narrowed. Another way to strengthen the posterior wall of the inguinal canal is the McVay method. When it is performed, the intra-abdominal fascia, together with the combined tendon of the internal oblique and transverse muscles, is sutured to the Cooper (pubic) ligament. According to Bobrov's method, the free edges of the internal oblique and transverse muscles are sutured to the inguinal ligament anterior to the spermatic cord or round ligament of the uterus. Then the edges of the aponeurosis of the external oblique muscle dissected during access are connected. According to the Bobrov-Girard method, the internal oblique and transverse muscles are sutured to the inguinal ligament throughout the inguinal canal anterior to the spermatic cord. In the Bobrov-Girard-Spasokukotsky method, to strengthen the anterior wall of the canal, the edges of the internal oblique and transverse muscles are sutured to the inguinal ligament of muscles along with the aponeurosis of the external oblique muscle adjacent to them. After that, a duplication is formed from the aponeurosis of the external oblique muscle. Multilayer hernioplasty (Sholdis method). For this purpose, to strengthen the posterior wall of the inguinal canal, the lateral edge of the intra-abdominal fascia is sutured to the medial with the first continuous suture. Plastic methods for closing the hernial orifice include plastic methods. As a plastic material, aponeurotic or muscle flaps on a pedicle from nearby areas, autodermal grafts, preserved allografts from the dura mater, and synthetic materials are used. Synthetic materials for closing hernial gates (lavsan, fluorolone, etc.) are widely used. Synthetic meshes retain their strength for a long time, rarely cause rejection reactions, and grow well with connective tissue during implantation. It is believed that with hernias of the anterior abdominal wall, it is more advantageous to place the explant under the muscles, sewing it in the form of a patch to the hernial orifice from behind. 41. Clinical anatomy of the abdomen The boundaries of the abdomen are considered to be at the top - the costal arches and the xiphoid process, below - the inguinal folds, pubic tubercles and the upper edge of the pubic symphysis. The boundary between the cavities of the abdomen and small pelvis is conditional and corresponds to a plane drawn through the boundary line. Since there is no anatomical barrier between the abdominal cavity and the pelvic cavity, fluids formed during pathological processes in the abdominal cavity, as well as blood from damaged parenchymal organs and blood vessels, often drain into the small pelvis, which leads to secondary inflammation of the peritoneum and organs lining it. According to Shevkunenko, two extreme forms of the abdomen are distinguished in the form of a pear with a different orientation of the base: with the base turned upward; with the base facing down. The walls of the abdomen are muscular-fascial layers that surround the internal organs on all sides. The abdominal cavity is a space lined with intra-abdominal fascia. The abdominal cavity is a space lined with a parietal sheet of the peritoneum, which, in the form of a bag, surrounds the organs lying inside it. The peritoneal cavity is a slit-like space between the parietal and visceral sheets of the peritoneum, containing a small amount of serous fluid. Preperitoneal space - a layer of fatty tissue between the parietal peritoneum and the intra-abdominal fascia lining the anterior abdominal wall. Retroperitoneal space - between the parietal peritoneum and the intra-abdominal fascia lining the back wall of the abdomen; it contains organs and large vessels. Considering the walls of the abdomen, one can conditionally distinguish between the anterolateral wall, bounded from above by the costal arches, from below by the inguinal folds, from the sides by a continuation of the middle axillary lines, and the posterolateral wall, bounded from above by the XII rib, from below by the iliac crest, from the sides by a continuation of the middle axillary line. The back wall of the abdomen is formed mainly by the muscles that are located along the spine. Anatomically, it is referred to the lumbar region, through which access to the organs of the retroperitoneal space is carried out. For convenience, when examining a patient, it is customary to divide the anterolateral wall of the abdomen into areas using conditional lines. Two of them are carried out horizontally - through the lower edges of the costal arches and the anterior superior iliac spines. As a result, three sections are distinguished - epigastric, celiac, hypogastric. Then draw vertical lines along the outer edges of the rectus abdominis muscles. As a result, each of the departments is divided into three areas: 1) epigastrium - on the epigastric and hypochondrium regions; 2) the womb - on the umbilical and lateral regions; 3) hypogastrium - on the pubic and inguinal regions. In each of the selected areas of the anterolateral wall of the abdomen, the corresponding organs of the abdomen or their departments are projected. 42. Access to the abdominal organs (special) General requirements for access for operations on the abdominal organs. The first requirement is a good view of the abdominal organ that is the object of the operation. The second requirement for access is low trauma. This implies minimal damage to the musculo-poneurotic layers of the abdominal wall during access to the abdominal organs, preservation, if possible, of the neurovascular bundles, careful handling of tissues, etc. The third requirement for the incision of the anterolateral wall of the abdomen is the simplicity and speed of the incision. The fewer layers of the abdominal wall that have to be dissected, the easier and faster the incision can be made. The fourth requirement is the possibility (if necessary) of extending the incision in the right direction (expansion of access). This may be due to the atypical position of the organ, the detection of tumor growth during the operation. The fifth requirement for access is the possibility of reliable closure and good healing of the edges of the surgical wound. 1. Longitudinal incisions through the sheath of the rectus muscle. Paramedian cut. This incision is carried out over the medial edge of the rectus abdominis muscle, while dissecting the anterior leaf of her vagina in the same direction. The advantage of this incision is the formation of a strong postoperative scar due to the "rocker" displacement of the rectus abdominis muscle and the mismatch of the projections of the incisions of the anterior and posterior layers of her vagina. Transrectal incision (access through the thickness of the rectus abdominis). The incision is made parallel to the outer edge of the rectus abdominis muscle. The anterior wall of the vagina of the muscle is dissected, its edge is retracted medially, and then the posterior wall of the vagina and the parietal peritoneum are dissected. The incision can only be made over a limited extent. 2. Oblique cuts. The subcostal oblique incision is widely used to perform operations on the biliary tract and spleen. The incision is made from the xiphoid process down and outward with a bend parallel to the costal arch, departing from it by 2-3 cm. Oblique incisions can also be made in other parts of the abdominal wall, Volkovich-Dyakonov-McBurney oblique access. Angular (combined) incisions of the abdominal wall are used if access is needed to be expanded, sometimes, by "combining" a longitudinal incision with an oblique one, a massive flap is formed, which allows opening a wide view of the corresponding area. Minimally invasive methods of operations performed with the help of endovideosurgical equipment are widely used in modern surgery. Surgical interventions performed in abdominal surgery, according to the urgency of execution, can be divided into emergency and planned. Emergency interventions can be performed for diseases, postoperative complications or trauma to the abdominal organs. 43. General access to the abdominal organs To expose the abdominal organs, accesses through the anterolateral abdominal wall are most often used. Through this area, you can approach almost all organs of the abdominal cavity in the shortest way. In addition, a large area of the anterior-lateral wall of the abdomen allows for wide accesses and provides the possibility of extending the incisions in the required direction. Lateral accesses to the abdominal organs from the sides are used less frequently. They are unsuitable because they violate the integrity of the broad abdominal muscles. In addition, these accesses allow you to operate on the organs of only the corresponding side - right or left. They are used in operations on individual organs (spleen, liver, right and left flanks of the large intestine). Very rarely, the abdominal organs are exposed from behind - through the lumbar region. This zone is small in size, limited by bone formations - the iliac crest, XII ribs and the spine, which does not allow large incisions. Accesses through the lumbar region are used mainly for operations on the pancreas and duodenum, kidneys. According to the direction of the cut, accesses are divided into four types: longitudinal, transverse, oblique, angular (combined). A typical representative of the general longitudinal accesses is the median laparotomy. Depending on the length and location of the incision, the following types of median laparotomy can be distinguished: upper median (above the navel); lower median (below the navel); total median (from the xiphoid process to the pubic symphysis). The most complete overview of the organs is achieved with a median total laparotomy. With the upper and lower laparotomy, more limited access is provided, respectively, to the organs of the upper and lower floors of the abdominal cavity. Median laparotomy has the following advantages: it allows a good view of most of the abdominal organs; when dissecting tissue does not damage the muscles; when performing a median laparotomy, it keeps large vessels and nerves intact; Access is technically easy. If necessary, the upper median laparotomy can be extended downwards, the lower median laparotomy can be extended upwards. A total midline laparotomy can be supplemented with a transverse incision or an angled lateral incision (such an approach is called an angled approach). The disadvantages of median laparotomy include a relatively slow fusion of the edges of the wound due to poor blood supply to the aponeuroses of the broad abdominal muscles along the white line. In the postoperative period, the suture line experiences a strong load due to the traction of the wound edges in the transverse direction. In some cases, this can lead to the formation of an inferior scar and postoperative hernias. Wide access to the organs of the abdominal cavity can be provided when performing transverse incisions. A transverse section of the abdominal wall, carried out 3-4 cm above the navel from one mid-axillary line to the other, allows you to examine most of the abdominal organs. 44. Bowel resection Techniques for bowel resection can be divided into several main stages. The first of these is the mobilization of the loop to be resected. The second stage of the operation is the removal of the damaged and mobilized section of the intestine. To perform this stage of the operation, it is necessary to delimit the removed part of the intestine with special intestinal sphincter. The pulp is applied at an angle of 30° to the long axis of the intestine in such a way that the free edge of the intestine is cut off to a greater extent than the mesenteric. The excision of the removed part of the intestine is performed between the sphincter, after which they begin to apply the anastomosis. There are 3 types of inter-intestinal anastomoses: end-to-end, side-to-side, and end-to-side. The most physiological is the end-to-end anastomosis, due to the simplicity and reliability in emergency surgery, side-to-side anastomosis is more often used. After applying the anastomosis, regardless of its type, it is necessary to suture the mesenteric defect. This final stage of bowel resection should be performed in such a way that the sutures do not compress the vessels passing through the mesentery. If it is impossible to suture the intestinal wound and if there are contraindications to resection, a method for removing the damaged loop from the abdominal cavity can be applied. In case of damage to the ascending colon, the operation of choice is suturing the wound with the simultaneous application of a cecostomy to unload the damaged area. In case of wounds of the transverse colon, small defects are sutured with a three-row suture. In connection with the mention of such terms as fecal fistula (colostomy, cecostoma, sigmostoma) and unnatural anus (anus praeternaturalis), it is necessary to dwell on the differences in the technique of performing these operations and indications for them. A fecal fistula is formed by a surgeon either to isolate (remove from the abdominal cavity) the damaged area of the colon, or to "unload" (removal of gases and, in part, intestinal contents) the underlying area. Technical implementation consists in suturing to the parietal peritoneum of the serous cover of the large intestine around the existing wound. P With a fecal fistula, part of the intestinal contents is released outside (through the fistula), part passes through the intestine to the underlying sections (partial unloading). With the imposition of an unnatural anus, the goal of the operation is the complete removal of the intestinal contents through the wound of the abdominal wall, the isolation of the underlying sections of the intestine from the entry of intestinal contents into them. This is achieved either by bringing the adductor and efferent ends of the intestine onto the abdominal wall after its resection, or by forming the so-called "spur". The latter is a fold of the intestinal wall at the site of its inflection and is formed by the surgeon with the help of special sutures that are applied to the walls of the afferent and efferent loops in contact with each other on both sides of the mesentery. As in the case of a colostomy, the serosa of the intestine around the area with the formed spur is sutured to the parietal peritoneum. 45. Resection of the stomach. Gastrostology According to the volume of the part to be removed, there are: 1) total resection (gastrectomy), when the entire stomach is removed; 2) resection of 3/4 of the stomach; 3) resection of 1/2 of the stomach. According to the method of execution, they distinguish: 1) Billroth-I resection; 2) Billroth-II resection. During resection of Billroth-I, the stumps of the stomach and duodenum are connected end to end. During Billroth-II resection, the remaining part of the stomach is connected to the small intestine brought to it. The first type of operation is more physiological, as it preserves the normal movement of food from the stomach into the duodenum. During resection of Billroth II in the Hofmeister-Finsterer modification, after mobilization of the stomach by crossing its ligaments with simultaneous ligation of the vessels, the stomach is cut off along the right border of the resection and the duodenal stump is treated. Before that, the initial loop of the jejunum is found and through the hole made in the mesocolon, it is brought out to the upper floor, into the bursa omentalis. The stomach stump is covered with a large gauze napkin and folded to the left. Proceed to close the stump of the duodenum, for which it is immersed in two pouches and sutured with the second row of interrupted sutures. Then proceed to the removal of the stomach and the imposition of the gastrointestinal anastomosis. Two Kocher clamps are applied along the line of the left border of the resection in the direction transverse to the axis of the stomach, the resected area is cut off with a scalpel along the crushing pulp, the upper part of the stomach stump is sutured along the clamp applied from the side of the lesser curvature. The withdrawn loop of the jejunum is sutured to the uneared part next to the serous-muscular sutures, anastomosis is applied and fixed in such a way that the leading end of the loop is directed upwards, to the lesser curvature of the stump, and the leading end to the greater curvature. During the Billroth I operation, the duodenum is mobilized according to Kocher until the resected area is cut off, then an end-to-end or end-to-side anastomosis is applied between the stomach and the duodenum. Another of the common operations on the stomach is a gastrostomy (the imposition of an alimentary gastric fistula). It is produced when it is impossible to take food through the mouth. First performed on animals in 1842 by V. A. Basov. The first operation on a human was performed by Zedillo (1849). When applying a gastrostomy according to Witzel, a transrectal incision is made on the left. The anterior wall of the stomach is brought into the wound. In the middle of the distance between the lesser and greater curvature of the body of the stomach along its long axis, closer to the cardial section, a rubber tube with a diameter of 0,8 cm is applied and immersed in a gutter formed by two folds of the stomach wall and fixed with 5-7 serous-muscular interrupted silk sutures , to the left of the last seam, another one is applied in the form of a pouch, leaving it loose. Inside it, the wall of the stomach is dissected, the end of the rubber tube is inserted into the hole formed to a depth of 5 cm and the purse-string suture is tightened. Thus, the rubber tube is located in the channel opening into the stomach cavity. 46. Appendectomy The most common operation in abdominal surgery is appendectomy. Many options for the operation have been proposed. In our country, the Mac Burney-Volkovich method is the most common. An incision 8-10 cm long is made at the border of the middle and outer third of the line connecting the anterior superior iliac spine with the navel, perpendicular to it, and its upper third should be above it, and the lower two thirds - below. Dissect the skin, subcutaneous tissue, aponeurosis of the external oblique muscle. Under the aponeurosis, the internal oblique is stupidly pushed apart parallel to the fibers, and deeper - the transverse abdominal muscle and stretched with Farabef hooks. The transverse fascia of the abdomen is dissected, the wound is covered with gauze napkins, the fold of the parietal peritoneum raised by two anatomical tweezers is cut and its edges are fixed to the napkins. After opening the abdominal cavity, the wound is stretched with lamellar hooks and the search for the appendix is started. The caecum is recognized by its position, grayish color, by the presence of muscle bands (taenia). The appendix is pulled upward so that its entire mesentery is clearly visible. The mesentery of the process is dissected between sequentially applied clamps up to its base. After crossing the mesentery, the captured areas are tied up. A silk serous-muscular purse-string suture is applied to the wall of the caecum, 1,5 cm from the base of the process, leaving its ends untightened. The appendix is squeezed at its base with a clamp, a ligature is applied to the squeezed place, and its ends are cut off; distal to the ligation site, a clamp is applied to the process. Holding the base of the process with anatomical tweezers, it is cut off over the ligature immediately below the applied clamp. The stump of the appendix is cauterized with iodine and immersed into the intestinal lumen with anatomical tweezers; the pouch is tightened and after the tweezers are removed, they are tied in a knot. A serous-muscular suture in the form of the Latin letter z is applied over the purse-string suture, which is tightened after cutting off the ends of the purse-string suture. The caecum is pushed into the abdominal cavity. The abdominal cavity is dried, drained if necessary, the wound is sutured in layers. In case of damage to hollow organs, their integrity is restored, the damaged areas are isolated from the abdominal cavity and, if indicated, drained. Although the nature of the operations performed for abdominal wounds, their volume and degree of complexity are very different, they all require the use of special sutures to restore the tightness and integrity of the gastrointestinal tract. All types of sutures used in abdominal surgery are collectively known as intestinal sutures. Currently, a two-row, or two-tier, Albert suture is generally accepted, representing a combination of two types of intestinal sutures: through all layers - the serous, muscular and mucous membranes - the suture of Jelly and the serous-serous suture of Lambert. 47. Topographic anatomy Under the "pelvis" in descriptive anatomy is meant that part of it, which is called the small pelvis and is limited to the corresponding parts of the ilium, ischium, pubic bones, as well as the sacrum and coccyx. The pelvic cavity is divided into three sections, or floors: peritoneal, subperitoneal, subcutaneous. The peritoneal region is a continuation of the lower floor of the abdominal cavity and is delimited from it (conditionally) by a plane drawn through the pelvic inlet. In men, in the peritoneal part of the pelvis, the part of the rectum covered by the peritoneum, as well as the upper, partially posterolateral and, to a small extent, the anterior wall of the bladder, are located. Passing from the anterior abdominal wall to the anterior and upper walls of the bladder, the peritoneum forms a transverse cystic fold. Further, the peritoneum covers part of the posterior wall of the bladder and, in men, passes to the rectum, forming the rectovesical space, or notch. In the space between the bladder and the rectum, there may be part of the loops of the small intestine, sometimes the sigmoid colon, less often the transverse colon. In women, the same parts of the bladder and rectum as in men, and most of the uterus with its appendages, wide uterine ligaments and the upper part of the vagina are placed in the peritoneal floor of the pelvic cavity. When moving from the uterus to the rectum, the peritoneum forms two folds that stretch in the anteroposterior direction and reach the sacrum. In the recto-uterine space, intestinal loops can be placed, and in the vesico-uterine space - a greater omentum. The recto-uterine recess is known in gynecology as the pouch of Douglas. The right mesenteric sinus is delimited from the pelvic cavity by the mesentery of the terminal portion of the ileum. The second floor (subperitoneal) is enclosed between the peritoneum and the sheet of the pelvic fascia, which covers the muscles of the pelvic floor. Here, in men, there are retroperitoneal (subperitoneal) sections of the bladder and rectum, the prostate gland, seminal vesicles with their ampoules, and the pelvic sections of the ureters. Women have the same sections of the ureters, bladder and rectum as men, as well as the cervix, the initial section of the vagina. The internal and external iliac arteries, passing in the subperitoneal pelvis, are branches of the common iliac arteries. The third floor of the pelvis is enclosed between the sheet of the pelvic fascia, which covers the pelvic diaphragm from above, and the skin. It contains parts of the organs of the genitourinary system and the final section of the intestinal tube. Topographically, the lower part of the pelvis corresponds to the region of the perineum, the frontiers of which are the pubic and ischial bones in front; from the sides - ischial tubercles and sacrotuberous ligaments; behind - coccyx and sacrum. The line connecting the ischial tubercles, the perineal region is divided into the anterior section - the genitourinary triangle and the posterior - anal triangle. In the anal perineum there is a powerful muscle that lifts the anus and a more superficially located external sphincter of the anus. 48. Operative surgery of the pelvic organs Inspection of the peritoneal pelvis and organs located there can be performed through the anterior abdominal wall by lower laparotomy or using modern endovideoscopic (laparoscopic) methods. Among the urgent surgical interventions in the peritoneal floor of the pelvis, operations for complications of ectopic pregnancy are among the most frequent. Access to the peritoneal floor of the pelvis in a disturbed ectopic pregnancy can be either "open" (laparotomy) or "closed" (laparoscopy). Various methods of vascular surgery (prosthesis, shunting, endovascular methods, etc.) are used for the surgical treatment of diseases of the aorta of the iliac or iliac-femoral segments of the arteries of the lower limb. Ligation of the internal iliac artery is a complex intervention, associated with a certain risk. When applying ligatures to the iliac arteries, as well as during operations on the pelvic organs, especially when removing the uterus and its appendages, one of the serious complications is damage to the ureters. Treatment of ureteral injuries is almost always surgical. The primary suture of the ureter is rarely used, only for surgical injuries recognized during surgery. During the primary surgical intervention, they are limited to diversion of urine by nephropyelostomy and drainage of urinary streaks. After 3-4 weeks after the injury, a reconstructive operation is performed. With urinary retention and the inability to perform catheterization (urethral injury, burns, prostate adenoma), a suprapubic puncture of the bladder can be performed. For long-term and permanent diversion of urine, thoracic puncture of the bladder can be used. Puncture of the bladder during thoracic epicystostomy is performed 3-4 cm above the pubic symphysis with the bladder filled with 500 ml of an antiseptic solution. After removing the stylet, a Foley catheter is inserted into the bladder cavity along the trocar sleeve, which is pulled up to a stop and tightly fixed with a silk ligature to the skin after the trocar tube. During the operation of the suprapubic vesical fistula, drainage is installed in the lumen of the bladder. Access to the bladder - median, suprapubic, extra-peritoneal. The bladder incision around the drainage tube is sutured with a double-row catgut suture. The wall of the bladder is fixed to the muscles of the abdominal wall. Then the white line of the abdomen, subcutaneous tissue and skin are sutured. The drainage tube is fixed with two silk sutures to the skin. Inflammation of the perirectal tissue, which is part of the tissue of the ischiorectal fossa, is called paraproctitis. By localization, the following types of paraproctitis are distinguished: subcutaneous submucosal, ischiorectal, pelviorectal. With paraproctitis, surgical intervention is indicated. Drainage incisions are made depending on the location of the abscess. 49. Primary ways of distribution of purulent processes The primary pathways are those in which the distribution occurs without destruction of the anatomical structures and elements, as the fiber gradually "melts" in the natural interfascial and intermuscular spaces. Connective tissue, adipose tissue is the area through which pus spreads. The features of clinical manifestations during the development of a purulent process in a case for any muscle group are influenced by the following topographic and anatomical features: a discrepancy between the relatively large internal volume of the entire case, which includes a muscle group, and the relatively small capacity of the slit-like space between the fascia and muscles. This predetermines a relatively small amount of pus inside the case, as well as a weak severity of local signs of inflammation with a deep localization of the purulent process. The muscles located in the fascial sheath are rich in blood and lymphatic vessels and represent a large resorptive surface, which determines the absorption of toxins and the severity of general symptoms of inflammation. The significant thickness of the wall of the fascial case makes it almost impossible for the purulent process to pass from one case to another. Due to the closed space and the relatively small volume of the fascial case, exudation and gradual accumulation of pus cause an increase in pressure inside it, which can lead to compression of the vessels and nerves supplying the muscle and a rapid increase in ischemic pain symptoms. Another of the topographic and anatomical features of fascial cases is their large length, which determines the so-called "jumping" nature of the spread of the purulent process. Some characteristic features differ in the primary pathways for the spread of purulent processes, formed by tendon sprains (aponeurosis) and wide fascial sheets, "replacing" the reduced muscles. The most typical and practically significant are the palmar and plantar aponeuroses. With a superficial purulent focus (skin, subcutaneous tissue), the spread of pus in the subcutaneous tissue above the aponeurosis is limited by connective tissue bridges, therefore, at first serous and then purulent exudate, not being able to break through the skin to the outside, spreads in depth, as if "falling through" through commissural openings. When the purulent process spreads through the fine-mesh structures of the palmar or plantar aponeuroses, the abscess that forms has the form of a "cufflink" or "hourglass". The fascial plates do not have through holes, and therefore the purulent process, as a rule, does not go beyond the corresponding cellular layer, and the fascia formed at the site of the reduced muscles are fixed at the edges to the bone protrusions, which helps to delimit the abscess from neighboring areas. 50. Topographic and anatomical features of the distribution of purulent processes in the fascia of primary coelomic origin The fasciae of primary coelomic origin include the fasciae lining the inside of the body cavity, the "endofascia". With the genetic identity of these fascias, the layers of fiber adjacent to these fascias also have similar features, which predetermines the possibility of a wide spread ("spreading") of the purulent process along the plane of the fascial sheets lining the cavity, and sometimes the transition from one cavity to another, and it is also possible the formation of pus streaks in the direction not only from top to bottom, but also from bottom to top, which is facilitated by the suction action of the respiratory movements of the diaphragm. Under the fasciae of secondary coelomic origin, one should understand the connective tissue plates formed as a result of the reduction and transformation of the embryonic mesentery of the internal organs in the process of ontogenesis. Inflammatory processes can be localized in different layers of the retroperitoneal tissue and, depending on the topography, are called paranephritis, paracolitis, etc. The spread of the purulent process in the indicated cellular spaces is distinguished by the following features: 1) the defeat of not only the tissue surrounding the corresponding organ (fat capsule), but also the possibility of streaks along the fascial sheets into the paraorganic tissue of another organ, usually belonging to the same anatomical system (for example, with paranephritis, spread to the periureteral and perivesical tissue ; 2) the purulent process rarely goes beyond the layer limited by the fascial sheets. With purulent processes developing in body cavities (thoracic, abdominal, pelvic), streaks may form in neighboring areas along the fascial sheets, neurovascular bundles and intermuscular spaces outside the cavity bounded by coelomic fascia. This occurs through anatomical openings, limited by bone-ligamentous and muscular elements. Features of the spread of purulent processes in paraangial cases. The first law: all vascular sheaths are formed by "fibrous" (according to N. I. Pirogov), i.e., dense connective tissue and represent a doubling of the wall (often the back) of the muscular sheaths. The second law: in cross section, the connective tissue sheath has a triangular ("prismatic") shape, which determines the special strength and rigidity of its design. The third law emphasizes the fixation of the vascular sheaths to the bones of the limbs. According to the description of N. I. Pirogov, one of the facets of the vagina, as a rule, "is in a mediocre or direct connection with the nearby bones." That is, they have relatively thick and significantly strong walls, forming a trihedral space in which neurovascular bundles pass, surrounded by loose fiber. Cases have a constant orientation along the axis of the limb due to rigid fixation to the underlying bones. 51. Secondary ways of spreading purulent processes Purulent-septic diseases or complications are observed in a third of the total surgical contingent of patients; no practitioner can avoid encountering purulent diseases and their complications. The spread of purulent processes occurs in the subcutaneous and intermuscular tissue, along the cases of the neurovascular bundles, along the fascial cases and interfascial fissures, through the intermuscular spaces, etc. The secondary pathways for the spread of purulent processes include those that are formed as a result of the destruction of anatomical elements. With the accumulation of pus in muscle cases and a significant increase in pressure, it is most often the rupture of the common connective tissue wall and the transition of the purulent process from the muscle to the vascular receptacle that occurs. The weak points of the joint capsules were described by V. F. Voyno-Yasenetsky, who found that in those areas where the tendons are closely adjacent to the capsule, its thinning is observed due to a significant decrease in fibrous bundles. In particular, in the area of the tendon of the long flexor of the thumb near the talus, the capsule of the ankle joint is devoid of fibrous bundles reinforcing it, the tendon of the muscle directly touches the synovial membrane of the ankle joint, which determines the possible place of rupture during the spread of the purulent process. The treatment of purulent diseases is based on an integrated approach. The classical rule known for centuries "Ubi pus, ibi evacu" has not lost its relevance in the era of antibiotics, and the opening of a purulent focus, wide drainage is the main surgical technique. The goals of the operation in the treatment of a purulent process are as follows: elimination of a purulent necrotic focus, limitation of the purulent process, prevention of complications, and the fight against intoxication. The operation begins with a wide incision, which is performed directly above the purulent focus, in compliance with the basic rule of tissue dissection - maintaining the integrity of the main neurovascular bundles. When making incisions, pus is evacuated, purulent-necrotic foci are removed and conditions are created for outflow (drainage), to limit the spread of the process, eliminate purulent intoxication and for secondary wound healing. Incisions at the opening of a purulent focus have some features: for a better outflow of wound discharge, the length of the incision should be twice the depth; after emptying the purulent focus, a revision of the wound is mandatory in order to detect and open purulent streaks, while maintaining the integrity of the connective tissue partitions that delimit the purulent cavity from neighboring, healthy tissues. If the main incision to open the purulent focus does not create an effective outflow of purulent discharge, it is necessary to apply a counter-opening that provides outflow from the deepest part of the wound by gravity, or drains and drainage systems. If necessary, several counter-openings can be applied. 52. The concept of endoscopic surgery Endoscopic surgery is a field of surgery that allows radical operations or diagnostic procedures to be performed through pinpoint tissue punctures, or through natural physiological openings. The idea of performing a visual examination of the internal organs without a wide dissection of the integument was put forward in 1901 by G. Kelling. Compared with open surgeries, endosurgery has the following advantages: low trauma, which manifests itself in the form of a decrease in postoperative pain, a quick (1-2 days) recovery of physiological functions; short hospital period; reduction of the period of disability by 2-5 times; good cosmetic effect (traces of 5-10 mm punctures are not comparable with the scars left after traditional operations); economic efficiency (despite the higher cost of the operation, the treatment is more cost-effective due to the saving of medicines, reducing the length of the hospital period and the patient's rehabilitation period). Indications for endosurgical intervention in most cases are the same as for the operation performed by the open method. Contraindications to endosurgical interventions are somewhat wider. This is determined by increased intra-abdominal pressure associated with the creation of pneumoperitoneum, a decrease in venous return and lung excursion. Physiological changes in pneumoperitoneum become clinically significant in concomitant diseases of the cardiovascular and pulmonary systems, this also occurs if the operation lasts more than 2 hours. Relative contraindications obstructive pulmonary disease; cardiovascular insufficiency of 2-3 degrees; transferred myocardial infarction; transferred operations on the heart and large vessels; congenital and acquired heart defects. In these situations, surgery is possible without the imposition of pneumoperitoneum (using a laparolift) or traditional laparotomic access. Diffuse peritonitis requires a traditional abdominal surgery, requiring careful sanitation of all parts of the abdominal cavity. In case of doubt in the diagnosis, it is useful to start the operation with a diagnostic laparoscopy. The risk of bleeding in severe coagulopathies may be the cause of complications and subsequent conversion. The introduction of a trocar is difficult for patients suffering from obesity of 3-4 degrees, having a thick layer of adipose tissue. Portal hypertension, especially with varicose veins of the anterior abdominal wall, contributes to a significant increase in the risk of bleeding. Preparation for laparoscopic surgery with preparation for open surgery. In the event of technical difficulties or complications, the patient should be psychologically prepared for the transition to immediate laparotomy. Decompression is characterized by the insertion of a tube into the stomach and a catheter into the bladder. The operation is performed under anesthesia due to the poor tolerance of awake patients to stretching of the abdominal wall during gas insufflation. 53. Endosurgical instrument kit Endosurgical operations require special, rather complex and expensive equipment and instruments. This list includes equipment and instruments for applying pneumoperitoneum: an electronic laparoflator (insuff-flator) for supplying gas and maintaining constant pressure in the cavity; Veress needle; syringe 10 ml; telescopes (straight, with a viewing angle of 30°, diameter 10 mm; angular, with a viewing angle of 45°, diameter 10 mm); trocars with a diameter of 5,7 and 10 mm; electrosurgical unit (equipment for hemostasis - combined electrosurgical apparatus for mono- and bipolar electrocoagulation); light source and video equipment: a xenon light source with a power of at least 175 W, a fiber-optic light guide, an endovideo camera, a color monitor, a video recorder or other device for recording an image for later viewing or analysis of the operation in case of complications; aquapurator - a device for suction and injection of fluid into the cavity; cannula with a diameter of 5 mm; electrosurgical instruments with a dielectric coating: loop, spherical and L-shaped electrodes, a dissector and scissors, a group of plucked instruments (surgical and anatomical clamps, instruments for passing and tightening a ligature, applying clips to tubular formations), instruments for puncturing organs and taking a biopsy. All equipment is usually located on the operating rack (mobile rack). The optimal composition of the operating team: surgeon; two assistants; operating nurse; junior nurse. Dissection of tissues and ensuring hemostasis in endosurgery is based on the use of high-frequency electric current from an electrosurgical generator. Current is applied to special tools with a dielectric coating. Tissue preparation is carried out in cutting and coagulation mode. A ligature, a metal clip, or staplers are used on large tubular structures. In addition to the electric current, new ultrasonic devices for hemostasis and bloodless dissection of tissues have appeared in the arsenal of surgeons, which allow arterial vessels with a diameter of 4 mm or more to be crossed without prior ligation. Complications such as pneumomediastinum or subcutaneous emphysema result from the creation of pneumoperitoneum under high pressure (above 16 mm Hg). They are prone to spontaneous resorption and rarely lead to cardiac rotation or compression of the tracheal bifurcation. The development of pneumothorax during laparoscopy may be due to injury of the diaphragm, large diaphragmatic hernia, or spontaneous rupture of a lung cyst. There is a development of gas embolism as a result of direct puncture of the vessel with a Veress needle or as a result of pressure of a gas embolus into the gaping lumen of the vessel, damaged during tissue preparation. This very rare complication can be fatal. Electrosurgical injuries are characterized by tissue burns or low-frequency electric shock. 54. Laparoscopy. Indications for laparoscopy Sometimes, despite the high qualifications, experience of the doctor and the help of the patient, determining an accurate diagnosis for diseases and disorders in the pelvic and abdominal cavity causes some difficulties. In this case, diagnostic laparoscopy takes place, which today is one of the most common modern diagnostic (and in some cases, therapeutic) procedures aimed at examining the abdominal organs. Laparoscopy is an operative method of research. Several (usually two) tiny incisions are made in the abdominal cavity, after which air is injected. Through one incision, a device is inserted - a laparoscope (a thin tube with a lens at one end and an eyepiece at the other; or one end of the laparoscope can be connected to a video camera, the image from which is transmitted to the screen during manipulations), a manipulator device is inserted through another incision, serving in order to help the doctor examine the internal organs in detail, displacing them. Laparoscopy is a method used by a doctor and helping him visually, with his own eyes, examine the internal organs of the abdominal cavity and their possible changes. The air in this procedure increases the field of view of the specialist. The purpose of this procedure is to establish an accurate diagnosis. Indications for laparoscopy in gynecological practice is infertility. This technique is a tool for quickly and painlessly determining the presence of physiological disorders that prevent pregnancy, as well as their elimination. For example, the so-called obstruction of the fallopian tubes, which is a consequence of infertility in about a third of women, experts advise to identify and simultaneously eliminate it with the help of laparoscopy. In the case of an ectopic pregnancy, laparoscopy can save the fallopian tubes, and, therefore, the woman retains the ability to conceive and give birth to a child. Also, laparoscopy is widely used for ovarian cysts, uterine fibroids, endometriosis and other inflammatory diseases of the internal genital organs. It is necessary to carry out laparoscopy in severe forms of secondary dysmenorrhea. Here, the operation is carried out not so much for diagnosis, but for the direct treatment of the disease. At the same time, approximately 80% of women suffering from secondary dysmenorrhea experience a significant improvement in their condition after laparoscopy. 55. Laparoscopy technique Since, in essence, laparoscopy is a surgical operation, then, as well as before other surgical interventions, before the procedure, it is required to carefully prepare the patient for it, which includes: 1) a general clinical blood test (moreover, its results are valid only for two weeks); 2) general urinalysis and fecal analysis; 3) x-ray or fluorography according to the doctor's indications; 4) electrocardiogram; 5) Ultrasound of the internal genital organs; 6) conclusion of the therapist about the absence of contraindications to laparoscopy; 7) abstinence from food before the procedure for 8 hours. The conclusion of the therapist should be given special attention, because, despite the harmlessness and safety of laparoscopy, nevertheless, as with any treatment method, there are a number of individual contraindications to laparoscopy. After preoperative preparation, before the operation itself, a premedication procedure is performed, which is the introduction of special medications to the patient, which enhance subsequent pain relief. After that, an experienced anesthesiologist makes general anesthesia (basically, a special mask with a breathing mixture is applied to the face). The respiratory system during the operation is under careful control all the time, and its successful functioning is ensured by special devices. Laparoscopy can also be performed under local anesthesia, this issue is decided individually with each patient. The beginning of the operation occurs with the fact that the abdominal cavity is inflated with carbon dioxide, which contributes to the elevation of the abdominal wall and the best access to the internal organs. The next step is the introduction of a special needle through the navel, with which a small puncture is made. Pre-treatment of the entire abdomen of the patient is carried out with an antiseptic solution, which prevents bacteria or other microorganisms from entering the wound. It must also be taken into account that the wound is so small and insignificant that after it there are absolutely no scars left, which is an important point for any woman. After reaching a certain gas pressure in the abdominal cavity, the surgeon introduces a special device called a laparoscope. It is characterized by a small diameter and the presence of a micro-camera that displays a view of the internal organs on the monitor, which helps specialists to obtain the most complete and reliable information about the state of the body and about the causes of any failures. According to the doctor's recommendations, after laparoscopy, it is necessary to stay in the hospital for at least a day. This need is due to the need to control the condition of the woman and the healing process. 56. Contraindications to laparoscopy. Pros and cons of laparoscopy. Regime after laparoscopy Absolute contraindications to laparoscopy include the so-called terminal conditions of the patient (agony, preagony, clinical death, coma), severe disturbances in cardiopulmonary activity, sepsis or purulent peritonitis. Relative contraindications (that is, those in which the operation is in principle possible, but there is a certain amount of risk): 1) extreme degree of obesity; 2) blood clotting disorders; 3) late pregnancy; 4) general infectious diseases; 5) recently transferred open abdominal operations. In modern gynecology, laparoscopy is perhaps the most advanced method for diagnosing and treating a number of diseases. The positive aspects are the absence of postoperative scars and postoperative pain, which is largely due to the small size of the incision. Also, the patient does not have to comply with strict bed rest, and the restoration of normal health and performance occurs very quickly. At the same time, the period of hospitalization after laparoscopy does not exceed 2-3 days. This operation is characterized by very little blood loss, extremely low injury to body tissues. In this case, there is no contact of tissues with the surgeon's gloves, gauze wipes and other means, inevitable in a number of other operations. As a result, the likelihood of the formation of the so-called adhesive process, which can cause various complications, is minimized as much as possible. Among other things, the undoubted advantage of laparoscopy is the ability to conduct diagnostics simultaneously with the elimination of certain pathologies. The disadvantage of laparoscopy, as a rule, is the use of general anesthesia, which, however, is inevitable in any surgical operation. It is worth remembering that various contraindications to anesthesia are clarified even in the process of preoperative preparation. Given this, the specialist concludes that general anesthesia is safe for the patient. If there are no contraindications to laparoscopy, the operation can be performed under local anesthesia. Bed rest after laparoscopy is no more than a day, although a 2-3-day stay in the hospital is possible at the request of the patient, but for medical reasons this is rare. Wound healing is practically not accompanied by various painful sensations, so there is no need to use strong painkillers, especially narcotic analgesics. Very often, patients are concerned about the problem of contraception after laparoscopy. Contraceptives are selected on the basis of consultation with a specialist. At the same time, some women, without any reason, believe that after the operation some time should pass before conceiving a child. In general, we can say that after laparoscopy there is no special regimen that must be strictly observed. The only thing that is required is to carefully monitor your health and regularly undergo examination by a qualified gynecologist. Author: Getman I.B.
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