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Surgical diseases. Lecture notes: briefly, the most important

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Table of contents

1. Diseases of alimentary canal
2. Diseases of the stomach and duodenum
3. Diseases of the large intestine and rectum
4. Diseases of the organs of the pancreato-biliary system
5. Endemic and sporadic goiters
6. Mammary cancer
7. Appendicitis

Brief anatomical and physiological characteristics. There are three sections of the esophagus - cervical, thoracic and abdominal. Its total length is on average 25 cm. The esophagus is fixed only in the cervical region and in the region of the diaphragm, the rest of its departments are quite mobile both in vertical and lateral directions. It has three narrowings: in the initial section, at the level of the bifurcation of the trachea and at the transition through the diaphragm.

The blood supply of the cervical esophagus is carried out by branches of the lower thyroid arteries, in the middle third - from the bronchial and unpaired ones, coming directly from the aorta, small esophageal arteries, and below - from the esophageal branches of the left gastric artery and diaphragmatic arteries.

In the region of the esophagus, there are venous anastomoses between the portal vein of the liver and the superior vena cava.

The physiological function of the esophagus consists mainly of voluntary and involuntary acts.

Research methods. In addition to the generally accepted clinical methods, special research methods are used in the pathology of the esophagus: fluoroscopy, radiography, X-ray cinematography, esophagoscopy, pneumomediastenography.

For comprehensive data regarding the esophagus, X-ray examination it is advisable to carry out in the following order:

1) survey roentgenoscopy of the neck, chest and abdominal organs;

2) study with 1 - 2 sips of liquid barium suspension of the cardia area and the relief of the gastric mucosa;

3) examination of the pharynx and esophagus with a liquid barium suspension;

4) study of "pneumorelief" - double contrasting of the esophagus;

5) study of the contours of the peristalsis of the walls of the esophagus with a thick barium suspension;

6) study of the relief of the mucous membrane of the esophagus.

RџSЂRё esophagoscopy you can examine the entire mucosa of the esophagus, as well as the cardiac and subcardial sections of the stomach, determine the source of bleeding, the presence of diverticula, tumors, take a tumor site for a biopsy, using a camera attachment, you can get black-and-white and color photographs.

Classification of diseases of the esophagus

1. Malformations. These include atresia, congenital narrowing, congenital idiopathic enlargement, cardiac insufficiency (or chalazia), duplication of the esophagus, undescended stomach.

2. Foreign bodies of the esophagus.

3. Functional diseases of the esophagus (esophageal achalasia, cardiospasm, esophageal dyskinesia - esophagospasm).

4. Diverticula of the esophagus.

5. Burns of the esophagus.

6. Benign tumors and cysts of the esophagus.

7. Cancer of the esophagus.

In the vast majority of observations, malformations are manifested and diagnosed in childhood, and therefore they are the lot of pediatric surgeons.

functional diseases

Functional diseases of the esophagus according to the pathophysiological substrate include a variety of lesions of the esophagus and its sphincter mechanisms and are manifested by a peculiar clinical and radiological picture. A common clinical symptom of these diseases of the esophagus is dysphagia.

With cardiospasm at the time of swallowing and relaxation of the esophageal tube, an important function of opening the cardia falls out.

Cardiospasm is divided into three stages: the first is an intermittent spasm of the cardia, the second is hypertonic and the third is atonic.

With a long-term course, cardiospasm is not inclined to turn into cicatricial stenosis of the cardia, if the disease is not complicated by chemical or thermal damage (alcohol, spicy, salty, sour dishes, hot food, etc.), as well as significant tears of the esophageal wall during cardiodilatation.

This category of patients is treated with a metal Stark-type cardiodilator or a pneumatic dilator. Treatment of cardiospasm with a cardiodilator gives satisfactory long-term results, but requires repeated reinforcing sessions.

A number of methods for the surgical treatment of cardiospasm have been proposed: cardiogastroplasty, cardiomentoplasty, etc. The most widely used operation is B.V. Petrovsky's operation - plastic surgery of the cardia with a diaphragm flap on the leg.

Diverticula of the esophagus

Limited expansion of the lumen of the esophagus in the form of a saccular protrusion of its wall.

The classification of diverticula is based on their localization and mechanism of occurrence.

In the early stage of diverticulum formation, characteristic symptoms are not observed. Then, as the diverticulum increases (stages II-III), a characteristic clinical picture appears: due to the rapid filling of the diverticulum with food, the esophagus is compressed and dysphagia occurs. To swallow food, patients put pressure on the neck, tilt their heads in different directions, make vomiting movements, etc. When the bag is emptied, there is a noticeable improvement, the patient can swallow food again. However, part of the food remains in the diverticulum, stagnates and decomposes, a fetid odor appears from the mouth, and dyspeptic phenomena are observed.

Diagnosis diverticulum put on the basis of the clinical picture and mainly X-ray examination. Additional data are provided by esophagoscopy.

The radical method of treating diverticula is surgical. Operations are subject to diverticula II and III stages and especially complicated ones.

Foreign bodies

Most often, foreign bodies enter the esophagus by accident, with a hasty meal. The vast majority of these are various bones, dentures and other items. clinical picture disease depends on the size, shape and nature of the foreign body, on the level of its location and duration of stay in the esophagus, the degree of damage to the esophagus.

The simplest, most accessible and completely safe diagnostic method is an x-ray examination of the esophagus - non-contrast radiography and a study with contrast.

Where possible, esophagoscopy is used, during which a foreign body can be removed from the esophagus through an esophagoscope.

In case of unsuccessful attempts to remove a foreign body through an esophagoscope, it is necessary to use esophagotomy.

Burns of the digestive tract

Burns of the digestive tract with acids and alkalis are a severe pathology, as evidenced by high mortality (10 - 20%). As a result of ingestion of caustic substances, not only the esophagus and stomach are affected, but also the function and structure of the liver, kidneys, adrenal glands and other organs are disrupted due to neurotrophic disorders and intoxication due to resorption of poison, absorption of tissue decay products, and purulent infection.

In the clinical course of burns, three periods are distinguished: acute, low-symptomatic (recovery) and the period of outcomes.

The acute period, as a rule, within 10 days is manifested by severe pain, dysphagia, toxemia, fever, disorders of the functions of internal organs.

The asymptomatic (recovery) period occurs after the elimination of acute pain syndrome and the reduction of dysphagic disorders by the end of the 2nd - 3rd week from the moment of the burn. But this is a period of imaginary recovery.

The period of outcomes is characterized by the development of persistent consequences of burns and poisoning in the form of cicatricial narrowing of the esophagus, postnecrotic cirrhosis of the liver, chronic esophagitis, mediastinitis, chronic pneumonia, exacerbation of the tuberculosis process, and persistent functional disorders of internal organs.

Household burns of the pharynx and esophagus with various chemicals are quite common. Poisoning by acids and alkalis occurs in both children and adults. Patients need urgent medical care and appropriate treatment.

To do this, in the first hours after poisoning, the stomach is abundantly washed with warm water (5 - 8 liters).

In case of acid poisoning (acetic, hydrochloric, sulfuric, etc.), a 2% solution of ordinary baking soda, burnt magnesia can be used to neutralize. In case of poisoning with alkalis (caustic soda, caustic soda) - a solution of table vinegar diluted by half with water, a 1% solution of citric acid.

Within a few days (3-4) narcotic drugs should be prescribed. In violation of cardiac activity, caffeine, cordiamine are administered.

It is not recommended to induce a gag reflex, and if it appears, it must be suppressed. An ice pack is placed on the stomach area.

Treatment measures are carried out taking into account the severity of poisoning and the general condition of the patient.

To combat dehydration of the body and to maintain protein balance, a 5% glucose solution in an isotonic NaCl solution (2–3 l), polyglucin, blood, plasma, and blood substitutes are administered intravenously. The patient is prescribed a complete diet rich in vitamins. Recommend butter, fish oil, milk, cream, raw eggs, olive oil.

In order to prevent the development of a secondary infection in the oral cavity, pharynx and esophagus, large doses of antibiotics are prescribed. Care is needed for the oral cavity and pharynx, for which, in case of acid poisoning, alkaline rinses are prescribed, in case of alkali poisoning, a 2% solution of boric acid is prescribed.

After the general phenomena of intoxication pass, and the acute inflammatory process subsides, further treatment is continued. In milder cases of burns, it is advisable to start bougienage of the esophagus or draining its lumen with tubes on the 4th - 6th day, in severe cases - on the 8th - 10th day.

When a narrowing of the esophagus occurs, patients need to be operated on. Before proceeding with the operation, the surgeon must know which part of the esophagus is affected, how long the cicatricial narrowing has occurred, and whether there is damage to the stomach, since the choice of surgical intervention depends on this.

The success of the operation for the formation of an artificial esophagus depends not only on the location and extent of the cicatricial narrowing, but also on the anatomical features of the vessels that feed the segment of the intestine from which the artificial esophagus is formed.

The formation of an artificial esophagus is a multi-stage operation and consists of the following points:

1) the formation of a gastric fistula for temporary nutrition of the patient;

2) mobilization and conduction of the intestine to the cervical part of the esophagus;

3) connection of the summed intestine with the esophagus;

4) the formation of an anastomosis between the stomach and intestines with simultaneous closure of the gastric fistula.

Esophageal carcinoma

The esophagus is one of the organs that are very often affected by cancer, so the problem of esophageal cancer is in the focus of attention of Russian surgeons.

One of the earliest and main symptoms of esophageal cancer is dysphagia (difficulty swallowing). It is associated with the direction of tumor growth: with exophytic tumor growth, dysphagia appears relatively faster than with endophytic growth. When collecting an anamnesis, attention is drawn to the fact that the emerging swallowing disorder is slowly but steadily progressing.

At the onset of the disease, the general condition of most patients remains satisfactory, although some show weight loss by the time dysphagia appears.

Other primary local symptoms of esophageal cancer include pain and discomfort behind the sternum when food is swallowed. This is due to trauma to the inflamed wall of the esophagus near the tumor and spasm. Early local signs also include a feeling of fullness behind the sternum when swallowing hot food.

With germination and compression of the recurrent nerve by the tumor, hoarseness appears, indicating an advanced stage of cancer and its localization in the upper esophagus. A common symptom of esophageal cancer of various localizations is emaciation and progressive weight loss.

In the late stages of tumor development, especially in the presence of metastases, severe anemia, leukopenia, a shift of the leukocyte count to the left, and toxic granularity of neutrophils are noted in the blood.

In early diagnostics cancer of the esophagus, a decisive place belongs to x-ray examination. The presence of spasm in a certain area of ​​the esophagus makes one suspect the presence of a pathological process and obliges to repeat x-ray studies.

According to the X-ray examination, one can judge the extent of the lesion and the localization of the tumor in relation to the walls of the esophagus. In unclear cases, a thorough esophagoscopy is indicated.

The generally accepted method of surgical treatment of esophageal cancer is the resection of the esophagus, which is widely used in surgery.

Противопоказания to radical surgical treatment of esophageal cancer:

1) distant metastases in the cervical and supraclavicular lymph nodes;

2) involvement in the cancer process of the bronchus, recurrent and phrenic nerves, the trunk of the sympathetic nerve;

3) decompensation of cardiovascular activity due to organic heart disease and hypertension.

To access the cardial part of the stomach and the lower part of the esophagus, the following methods are currently used: pleural, transpleural-peritoneal, peritoneal, transperitoneal-pleural. If the tumor has spread to the fundus of the stomach, a loop of the small intestine is used for the bypass.

LECTURE No. 2. Diseases of the stomach and duodenum

Anatomical and physiological features. The stomach (ventriculus) is located in the epigastric region, mainly in the left hypochondrium. Its capacity is 1,5 - 2,5 liters.

The functions of the stomach are multifaceted, the most important of them is digestion. Mechanical, chemical and enzymatic processing of food in the stomach is of great physiological importance for the entire digestive process.

The stomach is involved in water-salt metabolism, hematopoiesis, has the ability of autonomous action, is closely connected with the central and autonomic nervous system, endocrine glands and has a complex structure, including glandular and muscular apparatus, suction devices, vascular and nervous formations.

The stomach consists of the following sections: cardiac, fundus, body, antrum and pylorus.

The wall of the stomach consists of serous, muscular, submucosal and mucous membranes. The serous membrane, passing to neighboring organs, forms the ligamentous apparatus of the stomach.

In the area of ​​​​the body and fundus of the stomach, there is the bulk of the main and parietal cells that produce hydrochloric acid and pepsin.

In the antrum there are pyloric glands that produce mucus and, in addition, a hormone, gastrin, is produced in the cells of the antrum.

The blood supply to the stomach is carried out by branches of the celiac trunk: the left gastric, hepatic and splenic arteries. All venous blood from the stomach flows into the system v. portae, where the veins are adjacent to the arteries of the same name.

The stomach is innervated by sympathetic and parasympathetic fibers, which form the extragastric nerves and intramural plexuses.

Depending on the direction of the lymph flow, the surface of the stomach is divided into territories associated with the lymph nodes, which are located along the vessels supplying the stomach:

1) the territory of the coronary artery;

2) territory of the splenic artery;

3) the territory of the hepatic artery.

Stomach ulcer and duodenal ulcer

Peptic ulcer of the stomach and duodenum is one of the main problems of gastroenterology.

When examining these patients, the following are necessary: ​​a carefully collected history, examination of the phases of gastric secretion, ph-metry, determination of gastric motility, fluoroscopy, fibrogastroscopy, fibroduodenoscopy.

According to localization, ulcers of the duodenum, pyloroanthral part of the stomach, ulcers of the lesser curvature of the stomach, cardial part of the stomach, other localizations (greater curvature of the stomach, esophagus, small intestine), peptic ulcer of the anastomosis and small intestine are observed.

According to the nature of gastric secretion, there are ulcers with reduced secretion in both phases (neuroreflex and neurohumoral, or antral), with normal secretion in both phases, with normal secretion in the first phase and increased in the second, with increased secretion in the first phase and normal in the second, with increased secretion in both its phases.

In the course of the disease, ulcers are uncomplicated and complicated. The latter are accompanied by increased proliferative-sclerotic processes on the part of the connective tissue (callous ulcers), penetration, perforation, bleeding, malignancy, pyloric stenosis and deformities of the stomach with impaired evacuation.

Treatment complicated peptic ulcer of the stomach and duodenum operational. There are absolute and relative indications for surgical treatment of this disease.

Absolute indications include perforation (perforation) of the ulcer, unstoppable bleeding, organic pyloric stenosis with impaired evacuation from the stomach, suspicion of the transformation of a stomach ulcer into cancer.

Relative indications - callous ulcers with penetration that do not tend to heal, re-bleeding ulcers, peptic ulcer disease, accompanied by a sharp limitation or disability, lack of effect of therapeutic treatment for 3-5 years, pyloric ulcers, ulcers of greater curvature and posterior wall, cardiac part of the stomach, as the most frequently malignant.

Currently, in the surgical treatment of gastric and duodenal ulcers, three methods of operations are used - gastroenterostomy, gastric resection and vagotomy.

Gastroenterostomy (imposition of the gastrointestinal anastomosis). The essence of this operation is to create a message between the stomach and the jejunum for the passage of food from the stomach into the small intestine, bypassing the pylorus and duodenum.

Of the existing methods of gastroenterostomy, anterior anterior colonic and posterior posterior colonic gastroenterostomy is currently used. In the first operation, the small intestine is brought to the stomach in front of the transverse colon and sutured to the anterior wall of the stomach. To avoid a "vicious circle" between the afferent and efferent loops of the small intestine, an inter-intestinal anastomosis according to Brown is applied. In the second operation, the small intestine is sutured behind the transverse colon to the posterior wall of the stomach.

An indication for the imposition of gastroenteroanastomosis in peptic ulcer disease is the cicatricial narrowing of the pylorus in the presence of contraindications to resection of the stomach due to the poor general condition of the patient.

Resection of the stomach. It consists in removing part of the stomach. According to the volume of the removed part of the stomach, resection of one third, half and two thirds is distinguished. Removal of the entire stomach, with the exception of its cardial section and fornix, is called subtotal resection, and the complete removal of the stomach, together with the cardia and pylorus, is called total resection or gastrectomy.

There are two main methods of operation: according to Billroth-1 (B1) and according to Billroth-H (B2).

Vagotomy. In a number of clinics, in the surgical treatment of peptic ulcer, along with resection of the stomach, operations on the vagus nerves are used in combination with antrumeclumia and drainage operations. The purpose of such operations is to preserve the entire or almost the entire gastric reservoir without recurrence of the ulcer by reducing the increased secretion of hydrochloric acid.

There are five types of vagotomies:

1) bilateral stem;

2) front stem, rear selective;

3) front selective, rear stem;

4) bilateral selective;

5) proximal selective or selective vagotomy of parietal cells.

Vagotomy with draining operations is also used - gastroenterostomy, pyloroplasty, gastroduodenostomy, etc.

Pyloric stenosis

Pyloric stenosis should be understood as a pathological change in the pyloric part of the stomach, which causes a narrowing of its lumen and disrupts the normal emptying of the stomach from its contents.

The greatest clinical significance is cicatricial pyloric stenosis or narrowing of the initial part of the duodenum, in which the evacuation of contents from the stomach is disturbed. Persistent narrowing of the pylorus usually develops after many years of peptic ulcer.

During the There are three stages of ulcerative stenosis: compensated (or relative), subcompensated and decompensated.

In the compensated stage, pyloric stenosis is not manifested by any pronounced clinical signs. The general condition of such patients usually suffers little. They note a feeling of heaviness and fullness in the epigastric region, mainly after a heavy meal. Some patients have sour eructations, and sometimes vomiting. Examination of gastric contents reveals hypersecretion. At this stage, the diagnosis of pyloric stenosis is difficult. X-ray examination of the stomach appears to be hypertonic, the evacuation of the contrast mass proceeds in a timely manner.

In the stage of subcompensation, the feeling of heaviness and fullness in the stomach increases. Paroxysmal pains associated with increased peristalsis of the stomach become more severe. There are unpleasant eructations with the smell of "rotten eggs" due to prolonged retention of food in the stomach. At times there is profuse vomiting, which brings relief, so patients try to cause it themselves. An objective examination of the majority of patients revealed on an empty stomach "splashing noise" in the stomach and visible peristalsis. This stage is characterized by general weakness, fatigue, emaciation, reduced digestibility of food, vomiting, impaired water-salt metabolism. Radiologically, there is a pronounced slowdown in the evacuation of the contrast mass, after 6–12 hours its remains are still in the stomach, but after 24 hours they are usually not detected.

With decompensated pyloric stenosis, the hypertrophied muscles of the stomach are no longer able to completely empty it, especially with a heavy meal. It stagnates for a longer period and undergoes fermentation. The stomach is stretched, the phenomena of the so-called gastroectasia occur. Gradually, clinical symptoms also increase: a feeling of heaviness and fullness in the epigastric region becomes longer, and then almost constant, appetite decreases, sour eructations appear, in some cases having a fetid odor. Sometimes excruciating thirst develops due to a sharply reduced flow of fluid into the intestines. Only a small amount of gastric contents passes into the duodenum. A full stomach begins to empty itself by vomiting, while the vomit contains the remnants of food eaten the day before or several days before, and in advanced cases even a week or longer.

In some patients, as a result of insufficient intake of food masses and water into the intestines, constipation develops, in others, due to the entry of pathological fermentation products from the stomach into the intestines - diarrhea.

In patients, water-salt metabolism is disturbed, diuresis decreases, the content of chlorides in the blood and urine, leading to thickening of the blood, which does not correspond to the true state of alimentary exhaustion, emaciation and anemization. Impaired renal blood flow causes albuminuria and azotemia. There are changes in neuromuscular excitability with symptoms of an obstetric hand, trismus and general convulsions (gastric tetany).

An objective examination shows the patient's weight loss, dry skin, it easily gathers in folds. Sometimes a distended, drooping stomach can be palpated through the abdominal wall. Boas described this condition as "gastric tension". It is possible to note at times the convulsive peristalsis of the stomach, visible to the eye and felt by the attached hand.

Diagnosis decompensated pyloric stenosis is established by X-ray examination. Due to the loss of muscle tone of the stomach, the peristaltic function is sharply reduced and finally lost. The contrasting mass, passing through the abundant gastric contents, falls to the bottom, accumulates in the lower part of the stomach in the form of a wide bowl or crescent with a wide upper horizontal level, above which the so-called intermediate zone is visible - a more or less wide gray layer of the liquid contents of the stomach. With severe decompensated pyloric stenosis, a contrast mass is found in the stomach after 24 hours, and in some cases even after several days, a week, and even after a longer period.

Treatment decompensated and subcompensated pyloric stenosis operative - resection of the stomach. Preoperative preparation is the same as in patients with callous-penetrating ulcers of the stomach and duodenum, with the addition of gastric lavage 2 times a day (morning and evening) with boiled water, acidified with hydrochloric acid. The management of patients in the postoperative period is the same as for callous-penetrating ulcers.

Pylorospasm. The essence of this process is due to a prolonged spasm of the pylorus. To distinguish pylorospasm from pyloric stenosis, a differential diagnostic technique is used. 3-5 days before the X-ray examination, the patient is given a bilateral pararenal blockade with a 0,25% solution of novocaine, subcutaneously 0,1% atropine 1 ml 2 times a day, gastric lavage. With this diagnostic technique, the phenomena of pylorospasm are removed.

Perforated ulcer of the stomach and duodenum

In the clinical course perforated ulcer of the stomach and duodenum into the free abdominal cavity II Neimark conditionally distinguishes three periods - shock, imaginary well-being, peritonitis.

In none of all acute diseases of the abdominal organs is there such a strong, sudden onset of pain as in a perforated ulcer of the stomach and duodenum. The pain in the abdomen is unbearable, "dagger", it causes severe abdominal shock. The patient's face often expresses fright, is covered with cold sweat, pallor of the skin and visible mucous membranes is noted.

The position of the patient is always forced, most often with the hips adducted to the navicular retracted tense "board-like" abdomen.

The abdomen does not participate or participates little in the act of breathing. The type of breathing becomes chest, superficial, rapid. Along with pain, irritation of the peritoneum also appears. Symptom Shchetkin - Blumberg sharply positive. The pain quickly spreads throughout the abdomen, although many patients indicate that the pain began suddenly in the upper abdomen. In the vast majority of patients, pneumoperitoneum phenomena are observed, determined by percussion (disappearance of hepatic dullness - a positive Spizharny symptom) or radiographically.

When making a diagnosis of a perforated ulcer of the stomach and duodenum, an ulcerative history is of great importance, but in some patients it may be absent and perforation occurs in a state of apparent complete health ("silent" ulcers).

A perforated ulcer of the stomach and duodenum must be differentiated from acute appendicitis, acute cholecystitis, acute pancreatitis, intestinal obstruction and other diseases of extraperitoneal localization that simulate an "acute abdomen" (pleuropneumonia, myocardial infarction, hepatic and renal colic, etc.).

Patients with perforated gastric and duodenal ulcers should be urgently operated upon diagnosis.

Currently, with a perforated ulcer of the stomach and duodenum, two operations are used - resection of the stomach and suturing of the perforated hole. In some cases, a total gastrectomy is performed.

Indications for resection of the stomach:

1) the time from perforation to the time of admission to the hospital should not exceed 6-8 hours;

2) the presence of an ulcer history before perforation;

3) a satisfactory general condition and the absence of severe concomitant diseases;

4) the age of the patient is from 25 to 59 years;

5) the absence of purulent exudate and a large amount of gastroduodenal contents in the abdominal cavity.

Contraindications for gastrectomy:

1) the phenomenon of advanced widespread peritonitis due to late admission;

2) old age with concomitant effects of cardiovascular insufficiency, pneumosclerosis and emphysema.

Indications for ulcer closure:

1) acute bezamnezny ulcer with soft edges and without inflammatory infiltrate;

2) severe general condition due to widespread acute peritonitis;

3) adolescence with perforation of a simple ulcer;

4) old age, if there are no other complications of peptic ulcer (stenosis, bleeding, the risk of cancerous transformation of the ulcer).

Acute gastroduodenal bleeding

Gastroduodenal (gastrointestinal-duodenal or gastrointestinal) bleeding may occur suddenly in the midst of full health or be accompanied by previous illnesses. These are formidable, often fatal complications of a number of diseases. clinical picture acute gastroduodenal bleeding mainly depends on their etiology and the degree of blood loss.

The first signs of gastroduodenal bleeding: general weakness, dizziness, pallor of the skin and mucous membranes, tachycardia, palpitations and a decrease in blood pressure. In some cases, a collapse with a relatively short loss of consciousness may develop: the face becomes pale, the skin becomes waxy and covered with cold sweat, the pupils dilate, the lips are cyanotic, the pulse is thready, frequent, sometimes not counted.

One of the main signs of gastroduodenal bleeding is bloody vomiting (hematemesis) such as coffee grounds, which accompanies gastric and esophageal bleeding and, extremely rarely, duodenal bleeding. Such vomiting most often occurs after a few hours (sometimes after 1 - 2 days) from the onset of bleeding when the stomach is full of blood. In some cases, it may be absent, and blood is excreted from the gastrointestinal tract in the form of tarry stools. Most often this happens with bleeding from the duodenum or with mild bleeding from the stomach, if it has time to empty itself from the bloody contents through the gaping pylorus.

Bloody vomiting such as coffee grounds is explained by the formation of hematin hydrochloride in the stomach, and tarry stools (melena) - by the formation of iron sulfate from hemoglobin in the intestine (under the influence of enzymes).

The results of a blood test (the content of the number of erythrocytes and hemoglobin) in the first 24-48 hours from the onset of acute gastroduodenal bleeding do not reflect the true amount of bleeding and cannot be a criterion for the severity of the condition. In this case, it is necessary to take into account the indicators of hematocrit and the volume of circulating blood (VCC). Determination of BCC and its components is a reliable method for determining the amount of blood loss in gastroduodenal bleeding.

Important objective data for the diagnosis of acute gastroduodenal bleeding gives an urgent x-ray examination of the stomach and duodenum, it does not aggravate the condition of patients, is diagnostically effective and in the vast majority of patients gives a clear idea of ​​the source of bleeding.

Fibrogastroscopy and fibroduodenoscopy are increasingly used in the differential diagnosis of gastroduodenal bleeding. A special role is played by fibrogastroscopy in the recognition of acute superficial lesions of the gastric mucosa, in which X-ray examination is not very effective.

Selective angiography is very valuable for recognizing the causes of bleeding, the value of which is not limited to the ability to determine only the localization of the source and the fact of ongoing bleeding.

When a patient with gastroduodenal bleeding is admitted to a surgical hospital, the doctor must find out the cause, source of bleeding and its localization, whether it has stopped or continues, and consider the measures necessary to stop it.

The anamnesis, laboratory, radiological and endoscopic methods of research help to solve the first question. To assess the severity of the patient's condition, solving tactical issues, gastric probing is used. The allocation of blood through a gastric tube indicates ongoing gastric bleeding, the absence of blood in the stomach indicates that the gastric bleeding has stopped.

All patients with gastroduodenal bleeding should be hospitalized in a surgical hospital.

For hemostatic therapy, drugs are used that increase blood clotting, and agents that reduce blood flow in the area of ​​bleeding. These activities include:

1) intramuscular and intravenous fractional administration of plasma, 20-30 ml every 4 hours;

2) intramuscular injection of a 1% solution of vikasol up to 3 ml per day;

3) intravenous administration of a 10% solution of calcium chloride;

4) aminocaproic acid (as an inhibitor of fibripolysis) intravenously in drops of 100 ml of a 5% solution after 4-6 hours.

The use of hemostatic agents must be monitored by blood clotting time, bleeding time, fibrinolytic activity and fibrinogen concentration.

Recently, along with general hemostatic therapy, the method of local hypothermia of the stomach is used to stop gastroduodenal bleeding. When performing an endoscopic examination, the bleeding vessel is clipped or coagulated.

When bleeding from arrosted varicose veins of the esophagus, the most effective is the use of an esophageal probe with Blakemore pneumoballoons.

In the complex of measures for acute gastroduodenal bleeding, an important place belongs to blood transfusion in order to compensate for blood loss. In addition to compensating for blood loss, transfused blood increases the body's defenses, stimulates compensatory mechanisms.

Urgent surgical treatment is indicated for non-stop bleeding. However, the effectiveness of surgical treatment largely depends on the establishment of the etiological factor that caused gastroduodenal bleeding.

Late complications after gastric surgery

Late complications after resection of the stomach for peptic ulcer disease are called post-gastroresection syndromes or disease of the operated stomach.

Recently, the issues of treatment of post-gastroresection syndromes have been closely and comprehensively studied. Functional changes in the central nervous system, the volume of circulating plasma, the function of the endocrine glands, the exchange of serotonin and bradykinin are determined.

The classification of A. A. Shalimov and V. F. Saenko is considered the most complete and differentiated:

1. Functional disorders:

1) dumping syndrome;

2) hypoglycemic syndrome;

3) post-gastroresection asthenia;

4) small stomach syndrome, afferent loop syndrome (functional origin);

5) food (nutritive) allergy;

6) gastroesophageal and jejuno- or duodenogastric refluxes;

7) post-vagotomy diarrhea.

2. Organic lesions:

1) recurrence of ulcers, including peptic ulcers, and ulcers due to Zollinger-Ellison syndrome, gastrointestinal fistula;

2) afferent loop syndrome (mechanical origin);

3) anastomosis;

4) cicatricial deformities and narrowing of the anastomosis;

5) errors in the operation technique;

6) post-gastroresection concomitant diseases (pancreatitis, enterocolitis, hepatitis).

Mixed disorders, mainly in combination with dumping syndrome.

Stomach cancer

Of the entire gastrointestinal tract, cancer most often affects the stomach. According to statistics, it occurs in approximately 40% of all cancer sites. At present, the possibilities of X-ray examination in the diagnosis of gastric cancer have significantly expanded, which is associated with the use of both new methods and new techniques (parietography, double contrasting, polypositional examination, X-ray cinematography, etc.).

precancerous diseases. It is necessary to pay special attention to the so-called precancerous diseases, which include chronic gastritis, gastric ulcers and polyposis of the gastric mucosa. Using active clinical examination and therapeutic measures, you can achieve real success in the prevention of stomach cancer.

International clinical classification of gastric cancer by TNM the same as in colon cancer.

V. V. Serov considers the following morphological forms:

1) crayfish with predominantly exophytic expansive growth:

a) plaque cancer

b) polyposis or mushroom-shaped cancer (including those developed from a stomach polyp),

c) ulcerated cancer (malignant ulcers); primary ulcerative form of gastric cancer (saucer-shaped or bowl-shaped);

2) cancers with predominantly endophytic infiltrating growth:

a) infiltrative-ulcerative cancer,

b) diffuse cancer;

3) crayfish with endoexophytic mixed growth patterns (transitional forms).

The syndrome of small signs of Savitsky A.P. includes:

1) loss of interest in the environment, in work, apathy, mental depression, alienation;

2) the appearance in patients during the last few weeks or months of general weakness, fatigue, decreased ability to work;

3) progressive weight loss;

4) loss of appetite, aversion to food or some of its types (meat, fish);

5) the phenomena of the so-called gastric discomfort - the loss of the physiological feeling of satisfaction from the food taken, the feeling of fullness and fullness of the stomach, heaviness in the epigastric region, belching;

6) persistent or growing anemia.

clinical picture gastric cancer also depends on its location. So, with cancer of the pylorus, the clinical picture of narrowing of the pylorus is typical, vomiting appears. After taking breakfast, the patient has a feeling of heaviness in the epigastric region, which intensifies after dinner, since not all food is evacuated from the stomach.

Cancer of the cardial part of the stomach may not appear for a long time, but as the circular infiltration of the entrance to the stomach and the transition to the esophagus, symptoms of dysphagia occur, which are diverse. In some cases, patients complain of food retention when swallowing in the area of ​​the xiphoid process, at first this delay is temporary, and then becomes more permanent.

RџSЂRё differential diagnosis it is necessary to carry out esophagoscopy more widely, which in especially difficult cases can provide an invaluable service.

Currently, the treatment of stomach cancer is exclusively surgical, if there are no contraindications to it. Therefore, every patient who is diagnosed or suspected of having stomach cancer should be operated on.

Depending on the localization of the tumor, E. L. Berezov recommends the use of four types of gastric resection: simple, i.e., simple resection of the stomach, subtotal, total-subtotal and total extirpation.

LECTURE No. 3. Diseases of the large intestine and rectum

Brief anatomical and physiological characteristics

Colon consists of the ascending colon, which includes its initial section and the caecum, the transverse, descending and sigmoid colon. The latter passes into the rectum. Normally, the colon has a grayish tint (the small intestine is pinkish) and a special arrangement of muscle layers - the presence of longitudinal muscle bands, protrusions and omental appendages. The diameter of the colon is 4-5 cm.

Ascending colon (colon ascendens) is located in the right lateral region of the abdomen, somewhat closer to the midline than the descending one, and the right (hepatic) curvature lies in the right hypochondrium. From above and in front, the ascending colon is covered by the right lobe of the liver, and inside the right curvature is in contact with the bottom of the gallbladder.

Transverse colon (colon transversum) begins in the region of the right hypochondrium at the level of the 10th costal cartilage from the hepatic flexure, goes somewhat in an oblique direction from right to left and upwards to the region of the left hypochondrium. Here, at the level of the 9th costal cartilage or the 8th intercostal space, it ends at the left bend of the colon, passing into the descending colon.

Descending colon (colon descendens) starts at the top of the left (splenic) flexure, descends along the posterior wall of the abdomen, being located on its posterior surface, devoid of peritoneal cover, in front of the lateral section of the left kidney and square muscle of the lower back, to the level of the crest of the left iliac bone and passes into the next section - the sigmoid gut.

Sigmoid colon (colon sigmoideum) is the mesenteric part of the colon following the descending. It is located in the left iliac fossa, starting from above and laterally at the level of the posterior edge of the crista ilei. Having formed two loops, it goes to the right (medially) and down, bending over the boundary line, and enters the cavity of the small pelvis, where it passes into the rectum at the level of the III sacral vertebra.

Rectum consists of rectosigmoid, ampulla and anal.

The blood supply to the colon and rectum is carried out by branches of the superior and inferior mesenteric arteries. The veins accompany the arteries in the form of unpaired trunks and belong to the portal vein system, and the innervation of the colon is carried out by the branches of the superior and inferior mesenteric plexuses.

Lymph nodes related to the colon are located along the arteries, they are divided into nodes of the caecum and appendix and nodes of the colon.

There are the following diseases of the colon:

1) benign tumors (polyps, lipomas, fibroids, fibroids, angiomas);

2) diverticula;

3) nonspecific ulcerative colitis;

4) Hirschsprung's disease;

5) cancer.

Methods for examining the large intestine. Diseases of the colon belong to the section of proctology, and diseases of the rectum also belong to it. Therefore, it is advisable to consider methods for studying patients with diseases of the colon and rectum together.

For a successful examination of the colon and rectum, it is necessary to prepare the intestine the day before. Examination for urgent indications can be carried out without special preparation, which consists only of a cleansing enema. Initially, an enema is given the night before, and then at 7-8 in the morning on the day of the examination. In preparation for an X-ray examination of the colon the night before, the patient is not allowed to eat. At 5 o'clock in the morning he is given a cleansing enema.

Special methods for examining the rectum include external examination, digital examination, examination with rectal mirrors, sigmoidoscopy, X-ray examination, parietography, colonoscopy, anal sphincter function examination, coprological analysis.

External inspection. A detailed examination of the perineal-anal region is necessary in all cases when the patient makes relevant complaints. Examination is best done in the knee-elbow position of the patient, paying attention to the condition of the skin, the presence or absence of swelling, redness, maceration or damage to the skin and the circumference of the anus, the presence of external hemorrhoids, prolapse of the mucous membrane or all layers of the rectum, tumors, pararectal fistulas.

Finger research. This is the simplest, most accessible and safe method that should be applied to every patient who complains of pain, abnormal discharge from the rectum or dysfunction of this organ.

Inspection with rectal mirrors. The patient is examined in the knee-elbow position on the back with legs raised or on the side with the hips brought to the stomach. You can visually examine the anal and lower parts of the rectum, see anal fissures, internal hemorrhoids, polyps, tumors, ulcers, wounds, foreign bodies, rectovaginal fistulas, changes in the mucous membrane and other pathological processes at a depth of 8-10 cm.

Sigmoidoscopy. Sigmoidoscopy is performed for pain in the rectum, bleeding from the anus, suspected malignant or benign neoplasm, constipation and diarrhea (especially with blood and mucus), strictures, ulcers, rectovaginal, vesico-rectal fistulas and other indications, as well as in the absence of any complaints, i.e. with a preventive purpose to detect asymptomatic diseases, especially among workers in food and children's institutions. Sigmoidoscopy, if necessary, is used for the purpose of biopsy and taking material from the intestinal mucosa for sowing, smear, microscopic examination.

X-ray examination. It is a valuable diagnostic method for recognizing colon cancer. In combination with clinical data, it ensures the success of timely diagnosis of this disease.

Contrast breakfast, contrast enema, examination of the mucosal relief, the "double contrast" method are the stages of a full-fledged X-ray examination. They should not be considered as substitutes or as competing methods. However, of all these methods, the contrast enema, which is administered under screen control, with palpation examination through the anterior abdominal wall and radiographs, has the largest share. A contrast enema is the best method for clarifying the location of the tumor, it helps the surgeon in choosing an operative approach, in orienting during laparotomy, and also in drawing up a plan for surgical intervention.

In an x-ray examination of a patient with colon cancer, the main importance is attached to the following x-ray symptoms: changes in the relief of the mucous membrane, rigidity of the colon wall and the presence of a filling defect.

Colonoscopy. It makes it possible to identify pathological changes in the colon, is an additional and final diagnostic method, since with the help of an operating colonoscope, it is possible to take material for histological examination from any part of the colon.

Benign tumors

Polyps. It affects all parts of the colon, most often at a young age. With an increase in the number of polyps, the possibility of their malignancy increases.

The clinic of polyps and polyposis depends on their number, localization, distribution and structural features. With single polyps, the disease can be asymptomatic, with adenomatous polyps, loose stools appear mixed with blood and mucus. With polyposis, pain in the lumbar region and constipation are often observed, and when it is localized in the sigmoid colon, a feeling of incomplete emptying of the intestine. Such patients lose weight, become pale, anemic. With sigmoidoscopy, sigma polyps of various shapes, sizes and colors are visible. X-ray examination gives a typical cellular image, i.e. multiple filling defects.

Lipomas. They are characterized by duration and asymptomatic course. In some cases they have a broad base, usually covered by a normal mucosa. Lipomas can be palpated through the anterior abdominal wall. They have a smooth surface, move freely, and are often the cause of acute or chronic intussusception. X-ray examination will give valuable data, but sometimes the diagnosis can be established only during the operation.

Fibromyomas and angiomas. Rarely seen in the colon. Angiomas can produce persistent or intermittent, sometimes profuse bleeding during defecation, which can lead to significant anemia. If angiomas are localized in the sigmoid colon, then with sigmoidoscopy and fibrocolonoscopy, on a pale background of the mucosa, grape-shaped vascular formations protruding from the submucosal layer are visible.

The diagnosis of the above benign tumors of the colon is most often established on the operating table.

Diverticula

Colon diverticula are acquired limited saccular dilatations and occur mainly in individuals over 40 years of age. More often they are localized in the sigmoid colon, less often in other parts of the colon. Often in the diverticulum there is inflammation - diverticulitis.

Diverticulitis can give complications: intestinal obstruction, suppuration, fistulas, bleeding. For diverticulitis, spasmodic pain is typical, often constipation and less often diarrhea. Often there is an increase in temperature, weakness, leukocytosis in the blood, an admixture of pus, mucus and blood in the feces. In the cold period, in the recognition of diverticula, the main place is occupied by an X-ray examination, which gives a characteristic picture.

Nonspecific ulcerative colitis

Nonspecific ulcerative colitis is a disease of unknown etiology, characterized by the development of an inflammatory process, hemorrhage, ulcers, bleeding, secretion of mucus and pus from the colon and rectum.

There are a number of theories trying to explain the etiology and pathogenesis of nonspecific ulcerative colitis: infectious, enzymatic, endocrine, neurogenic, psychogenic stress theory, alimentary, the theory of large collagenosis, the theory of allergy, or autoimmune aggression.

With the flow There are acute (severe, fulminant) and chronic (continuous, recurrent) forms of ulcerative colitis.

According to the symptoms, there are four stages of nonspecific ulcerative colitis:

1) rectal bleeding (scarlet blood), normal stool, no mucus (stage "hemorrhoids" and "anal fissures");

2) after two weeks, the appearance of blood in the stool increases, mucus in large quantities, frequent stools (the stage of the "infectious hospital", or dysentery);

3) in the second month, the phenomena of intoxication increase, pain in the abdomen, hectic body temperature are noted;

4) in the third month of the disease, the stool becomes more frequent (10-80 times a day), the stool is fetid, in the form of a bloody irritating liquid, continuous tenesmus, the patient is untidy, depressed, there is depletion of subcutaneous tissue, pallor of the skin and mucous membranes with an icteric tinge, hectic body temperature , tachycardia, bloating, dry tongue, oliguria, leukocytosis, peitrophilic shift of the leukocyte formula to the left, hypoproteinemia, hypokalemia, hyponatremia, hypoalbuminuria.

Extraintestinal manifestations - arthritis, conjunctivitis, neurodermatitis, dermatitis, pyoderma gangrenosum of the anus.

Complications nonspecific ulcerative colitis:

1) specific - damage to the skin, joints, eyes;

2) associative - violations of the hematological picture, water and electrolyte balance, absorption from the small intestine, changes in the hemocoagulation system;

3) surgical:

a) perforation of the colon;

b) massive intestinal bleeding (usually rectosigmoid angle);

c) acute toxic dilatation of the colon (toxic megacolon);

4) lesions of the anorectal region - strictures, fistulas, anal fissures.

Complications of chronic nonspecific ulcerative colitis: colonic strictures, cancerous transformation, bleeding.

To make a diagnosis of nonspecific ulcerative colitis, special research methods are used - sigmoidoscopy, irrigoscopy, colonoscopy, aspiration biopsy.

Sigmoidoscopy at the height of the disease reveals the symptom of "weeping mucosa", contact bleeding, with a large release of blood, pus, with excessive growth of granulations (pseudopolyps), in the late stage - smoothness of the mucosa, deformation of the intestine. Colonoscopy gives the same picture.

Irrigoscopy provides data two months after the onset of the disease. Colon without haustra, shortened, caecum pulled up to the hepatic angle, there is no mucosal relief, pseudopolyps (at a late stage).

Aspiration biopsy establishes inflammation in the intestinal mucosa.

Nonspecific ulcerative colitis must be distinguished from Crohn's disease, tuberculosis, and cancer.

For treatment ulcerative colitis requires a diet (liquid food 6 times a day, in very serious patients - hunger). Food should be well thermally and mechanically processed and rich in proteins and vitamins. Carbohydrates, milk and canned foods should be excluded, the amount of fat is limited.

Parenteral nutrition provides mechanical and functional rest of the digestive tract. It compensates for the lack of enteroplastic material, reduces the exhaustion of patients, increases the overall resistance of the body, reduces toxemia, bacteremia, anemia, vitamin deficiency, improves water-electrolyte and protein metabolism. The effect of parenteral nutrition depends on the biological activity of the administered drugs, the balance of amino acids.

It is better to use protein preparations obtained by enzymatic hydrolysis of blood fibrin or casein, where there are less humic substances and ammonia. They must be retained in the body, well utilized by the liver and small intestine. The introduced protein is an energy building material, reduces hypoproteinemia, intestinal atony, and increases tissue regeneration.

Electrolytes are administered intravenously: salts of sodium, potassium, calcium, magnesium, chlorine, phosphorus, iron; subcutaneously - a triple daily dose of vitamins of groups A, B, C.

Hormone therapy eliminates adrenal insufficiency, suppresses hyperallergic inflammation, and reduces toxemia.

In severe forms, hydrocortisone is administered parenterally at 50-100 ml every 6-12 hours for 10 days. Then they switch to oral prednisolone (20-30 mg per day for 2-3 months, the last week - 5 mg per day).

They also carry out treatment aimed at eliminating dysbacteriosis.

Local treatment - enemas with manganese, rosehip oil, sea buckthorn with chamomile.

With multiple perforation of the intestine, toxic megacolon, profuse bleeding, emergency surgery is indicated.

Indications for planned surgical treatment: acute form of the disease, which is not amenable to conservative therapy within a month; chronic continuous form that lasts 3 years and is accompanied by bleeding; stricture in one of the sections of the colon, cancer that developed against the background of nonspecific ulcerative colitis.

Surgical treatment is divided into two stages:

1) subtotal colonectomy with removal of the ileostomy according to Brook;

2) ileosigmoanastomosis with sanitized sigma and rectum 3-6 months after the first stage.

colon cancer

Colon cancer is the fourth most common cancer after cancer of the stomach, esophagus and rectum. The small intestine is affected less frequently than the colon and rectum.

Colon cancer is a relatively benign form of cancer. With timely diagnosis and adequate therapy, treatment outcomes can be significantly better than with gastric cancer. Cancer affects all its departments, almost equally the right and left sides and relatively less often the transverse colon.

Clinical course. Colon cancer is characterized by many symptoms that are also characteristic of other pathological processes in the abdominal organs, as well as in the retroperitoneal space. There are no specific signs of colon cancer.

The most common symptoms of colon cancer include:

1) pain accompanied by some gastrointestinal disorders (constipation, loose stools);

2) anemia and intoxication without a palpable tumor, and sometimes with negative X-ray data;

3) phenomena resembling dysentery or colitis (loose stools, mucus, blood in the feces);

4) partial or complete intestinal obstruction;

5) phenomena resembling hemorrhoids (repeated bleeding, taken for hemorrhoidal).

Colon cancer is divided into periods of the disease:

1 Asymptomatic period (latent course of the disease).

2. Period of bowel disorder:

1) at first without a pronounced violation of the passage of the intestine, including with compensated stenosis of the intestinal lumen, detected by X-ray examination or on the operating table;

2) with severe disorders of intestinal patency:

a) moderate (long delays);

b) relatively partial;

c) acute (complete).

3. Period of general violations:

1) with intestinal disorders;

2) without intestinal disorders.

International classification (6th revision). This classification applies to all organs of the gastrointestinal tract:

T - primary tumor.

TX - insufficient data to evaluate the primary tumor.

TO - the primary tumor is not determined.

T in situ - preinvasive carcinoma.

T1 - the tumor infiltrates the intestinal wall to the submucosal layer.

T2 - the tumor infiltrates the muscular layer of the intestinal wall.

TK - the tumor infiltrates the subserosis or tissue of the overtonized sections of the intestine.

T4 - the tumor sprouts the visceral peritoneum or directly spreads to neighboring organs.

N - metastases in regional lymph nodes.

NX - insufficient data to assess the status of regional lymph nodes.

NO - no signs of metastatic involvement of regional lymph nodes.

N1, 2, 3 - there are metastases in the lymph nodes.

M - metastases to distant organs.

MX - insufficient data to determine distant metastases.

MO - no signs of metastatic lesions of regional lymph nodes.

Ml - there are distant metastases.

Domestic classification

Stage I - a tumor of small size, limited, localized in the mucous thickness and submucosal layer of the colon, without regional metastases;

Stage II - the tumor does not extend beyond the intestine, is relatively large, but does not occupy more than a semicircle of the wall, without regional metastases, or has the same or smaller size, single metastases are observed in nearby lymph nodes;

Stage III - the tumor process occupies more than the semicircle of the intestine, germinates its entire wall or adjacent peritoneum, there are metastases; a tumor of any size, with many metastases to regional lymph nodes;

Stage IV - an extensive tumor that grows into neighboring nearby organs and has multiple metastases, or a tumor of any size with distant metastases.

Diagnostics. When diagnosing colon cancer, it is necessary to take into account the data of anamnesis, external examination, palpation, sigmoidoscopy, colonoscopy, X-ray and laboratory studies of feces for obvious and latent blood.

When collecting anamnesis, it is necessary to find out whether the patient noted the phenomena of intestinal obstruction, if so, how they developed, whether there were short-term paroxysmal pains in the abdomen, whether there was rumbling, swelling, etc. pathological discharge from the rectum.

Most patients with colon cancer have an outwardly healthy appearance, with the exception of those in whom the disease proceeds against the background of anemia, which is especially characteristic of cancer of the right half of the colon. Relatively quickly to emaciation lead to manifestations of intestinal obstruction.

When the tumor is localized in the left half of the colon, local swelling and visible peristalsis appear, which are accompanied by rumbling, sometimes heard even at a distance. In some cases, this can cause splashing noise, which indicates the presence of a large amount of stagnant liquid content in the caecum and partly in the ascending colon.

Great importance in the diagnosis of colon cancer is attached to palpation examination, the success of which depends not only on the degree of bowel emptying and relaxation of the muscles of the anterior abdominal wall, but also on the anatomical localization of tumors. It is easier to palpate the tumor of the fixed part of the colon - the ascending and descending intestines, devoid of the posterior peritoneum.

With stenosing cancer of the distal colon, the "symptom of the Obukhov hospital" (an empty dilated rectal ampulla) is often positive. Differentiation of tumors of intestinal localization with tumors emanating from the genitals is helped by a combined vaginal and rectal examination. With a digital examination through the rectum, metastases can be determined in the Douglas space and in the pelvic tissue. The abdominal cavity should be palpated after thorough bowel cleansing.

Various methods of x-ray examination of the colon in the vast majority of clinically unclear cases of tumors of the colon give a clear answer, which puts x-ray examination in first place among other methods. This study makes it possible not only to diagnose colon cancer, but also to distinguish it from other diseases that are considered precancer. Colon cancer may be preceded by multiple villous tumors associated with adenomatous polyps.

X-ray examination should be carried out not only in cases of suspected colon cancer, but also in patients with prolonged intestinal disorders of unknown etiology and with severe symptoms of intoxication, anemia, and emaciation of unexplained origin.

Of the laboratory research methods for colon cancer, it is important to examine the feces for an admixture of explicit blood and the presence of occult blood (Gregersen, Weber reactions), while the patient should not eat meat for 3-4 days.

However, it must be borne in mind that occult blood in the feces can be with peptic ulcer of the stomach and duodenum, ulcerative colitis and other diseases. In addition, if there is no ulceration of the tumor, then the reaction to fecal occult blood will be negative.

Differential diagnosis. Colon cancer must be distinguished from:

1) dynamic intestinal obstruction;

2) specific inflammatory processes of the colon (tuberculosis, actinomycosis, gumma);

3) nonspecific inflammatory processes (appendicular infiltrate, diverticulitis, ulcerative colitis);

4) benign tumors of the colon (polyps, fibromyomas, lipomas, angiomas, leiomyomas);

5) tumors and inflammatory processes of the gallbladder and liver;

6) kidney diseases (tumors, mobile and horseshoe-shaped kidney).

Treatment. Colon cancer is treated exclusively with surgery. It consists in a wide resection of the affected area of ​​the intestine and the corresponding section of the mesentery with regional lymph nodes.

If colon cancer is not complicated by acute intestinal obstruction, where the surgeon is forced to perform an operation for urgent indications, then patients undergo thorough preoperative preparation, taking into account their individual characteristics. In preoperative preparation, diet is of great importance. Food should be high-calorie, rich in vitamins, with a small amount of fiber (chopped boiled meat, milk soup, butter, eggs, fruit juice, cream, rice, pure chocolate, crackers, dry biscuits). All hard-to-digest and coarse foods are excluded from food - potatoes, cabbage, mushrooms, fruits, etc.

To eliminate dehydration and hypoproteinemia, blood, plasma, polyglucin, saline are transfused intravenously.

B. L. Bronshtein recommends systematically taking a laxative in the form of a 8% solution of magnesium sulfate for 10 tbsp for 15-12 days before surgery. l. per day (about 6 doses). This laxative is not so debilitating. A single large dose of a laxative is contraindicated and dangerous. On the eve of the operation, cleansing enemas are done in the morning and evening. In order to reduce fermentation in the intestines, benzonaphthol and salol are prescribed before and after the operation, antibiotics are prescribed two days before the operation.

Proper management of patients in the postoperative period largely determines the outcome of surgery.

Immediately after the operation, a drip transfusion of blood (220 ml) is established, then a 5% glucose solution in an isotonic NaCl solution with the addition of vitamins. The first 2 - 3 days appoint narcotic drugs, atropine, cardiac. It is necessary to strictly observe oral hygiene to prevent parotitis. It is allowed to move in bed from the second day, all measures are taken to prevent postoperative pneumonia.

Intestinal function deserves special attention. For the unhindered discharge of gases and the prevention of increased pressure inside the colon, candles from glycerin and belladonna are used, a gas outlet tube is inserted into the rectum. Some surgeons perform digital sphincter stretching towards the end of the operation.

If the patient has a metastatic stage of the disease, then, in addition to surgical treatment, chemotherapy is used (usually in adjuvant mode). They use the well-known methyluracil, methotrexate, as well as modern xeloda, doxorubicin (anthrocyclines), paclitaxel (taxanes), etc. The drugs are administered both intravenously and intraperitoneally into the abdominal cavity through drains specially left during the operation. In liver metastases, drugs are injected into the round ligament of the liver.

Hemorrhoids

Hemorrhoids (varices haemorrhoidales) - varicose veins of the hemorrhoidal plexuses, accompanied by such clinical symptoms as bleeding, pain, inflammation, prolapse of hemorrhoids. However, not all of these symptoms appear at the same time.

There are internal and external hemorrhoids. The first develops from the internal venous plexus, the second - from the outside. However, there are cases when two plexuses are involved in the formation of hemorrhoids.

The development of hemorrhoids begins imperceptibly. In the anus, a feeling of tickling or itching gradually arises, in some cases - a feeling of heaviness and a feeling of the presence of a foreign body. When the expansion of the veins reaches a significant value, the intestinal lumen narrows and during the act of defecation, severe pain appears, which makes patients refrain from defecation as long as possible. All this leads to the destruction of the walls of the veins and causes bleeding, and then prolapse of hemorrhoids. The disease enters the phase of its full development.

V. R. Braitsev distinguishes four degrees of prolapse:

1) nodes fall out only during the act of defecation and go back themselves;

2) nodes fall out at sharp voltages, but do not reset on their own;

3) nodes fall out when walking and remain in this position until they are set to the patient;

4) nodes fall out constantly and after reduction they fall out again.

The prolapsed hemorrhoids close the opening of the anus and prevent normal bowel movements, resulting in headache, belching, vomiting, aversion to food, sometimes bloating, frequent urge to urinate or its delay, fever, and pulse quickens.

Bleeding is one of the typical and frequent manifestations of hemorrhoids. Mostly give bleeding internal hemorrhoids. It most often occurs during the act of defecation, when the anal ring relaxes, and the pressure in the hemorrhoidal veins increases (it proceeds painlessly). The amount of blood lost during hemorrhoidal bleeding can vary widely - from barely noticeable traces in the form of colored stripes on feces or poor staining of toilet paper to the expiration of a jet. Repeated heavy bleeding can lead the patient to anemia and severe exhaustion.

However, bleeding from the rectum can be caused not only by hemorrhoids, but also by polyps, cancer of the rectum and overlying colon, chronic ulcerative proctitis, anal fissures, etc. Bleeding from the rectum is a distress signal, so the patient should be comprehensively examined . Already in the conditions of the clinic, it is necessary to examine the intestine with the help of a rectal mirror.

In addition to bleeding, periodic inflammatory exacerbations of hemorrhoids are also possible. Sometimes inflammatory edema is expressed in such a way that the hemorrhoids take the form of large, round or oval tumors protruding around the circumference of the anus. Most often, an exacerbation occurs after some provocative moment (alcohol intake, hard hard work, etc.).

In addition to local phenomena, with hemorrhoids there are also general symptoms - a decrease or loss of ability to work, insomnia, headaches, nervous system disorders, anemia.

A. N. Ryzhykh gives the most simple, practically convenient clinical classification of hemorrhoids:

1) outer:

a) in the form of knots;

b) with thrombosis of nodes;

c) in the form of fringes;

2) internal:

a) with bleeding;

b) with periodic exacerbations (or in the stage of exacerbation);

c) with the loss of nodes;

d) with prolapse of the rectal mucosa;

3) combined - external and internal hemorrhoids.

Treatment hemorrhoids can be conservative and operational.

With uncomplicated hemorrhoids, conservative treatment is reduced to the use of a rational diet and a systematic toilet of the anus. Food should be varied, vegetable and dairy, high-calorie, with enough vitamins, and black bread is also required to prevent constipation in the patient. From the diet should be excluded alcoholic beverages, which can cause exacerbation of hemorrhoids. It is important to achieve daily soft stools, after a bowel movement sitz cooling baths are useful.

Drug treatment is aimed at eliminating individual symptoms of hemorrhoids. For this, patients are prescribed hemostatic, analgesic, antiseptic, anti-inflammatory and astringents.

A large number of sclerosing agents are offered, the most widely used of them are pure alcohol, quinine-urea (benzo mixture), 5% phenol in oil, varicocide, sombradecol, etc.

Indications for surgical treatment of hemorrhoids are repeated bleeding, recurrent inflammation and prolapse of hemorrhoids, frequent irritation and itching in the anus, prolapse of nodes and mucous membranes without inflammation.

Operations for hemorrhoids are carried out by the methods of Subbotin and Sklifosovsky, Milligan - Morgan - excision of hemorrhoids at points that correspond to the numbers 3, 7, 11 of the clock dial from the outside to the inside with stitching and bandaging of the vascular legs and suturing the perianal mucocutaneous wounds. This method does not give relapses.

Hemorrhoidectomy in the acute period in patients with thrombophlebitis of hemorrhoids is more effective, especially in combination with enzymes and anticoagulants.

In order to prevent hemorrhoids, attention must be paid to the fight against constipation.

Proctitis

Proctitis is an acute or chronic inflammation of the rectal mucosa.

Acute proctitis is characterized by pain, burning sensation and fullness in the rectum, frequent urge to defecate, release of liquid mucus, serous-bloody fluid, sometimes with an admixture of pus.

Chronic proctitis can develop from acute, and in some cases independently. There are catarrhal and ulcerative forms of chronic proctitis.

RџSЂRё treatment acute proctitis, the patient needs rest, a lightweight low-slag diet. Locally, 50 ml of a 0,5% solution of collargol or olive oil is injected into the rectum.

In chronic proctitis, the rectum should be washed daily with a weak solution of potassium permanganate, silver nitrate (1: 5000).

For the treatment of proctitis, chronic constipation, colitis, obesity, some diseases of the female internal genital organs, hepatitis, subaqueous enemas are used. Depending on the indications for such enemas, an isotonic sodium chloride solution, mineral waters, ordinary boiled water (38 - 39 ° C), to which essential oils or drugs are added, are used. Enemas are given to the patient, who is in a bath with water heated to 35 - 37 ° C. For a subaqueous enema, 25-30 liters of liquid is needed, which is injected into the rectum in portions of 1-2 liters. The procedure lasts no more than 30 minutes. The system of pipes supplying fluid for subaquatic bowel lavage and pipes through which water with excrement flows must be hermetically isolated from the water filling the bath. In a special funnel that collects wash water and excrement, negative pressure is created to facilitate evacuation from the intestines.

Fissures in the anus

An anal fissure (fissura ani) is a slit-like rupture of the mucous membrane of the anal canal, usually located on its back wall.

The onset of the disease can be imperceptible, gradual or acute, sudden. The patient is concerned about the burning sensation, pressure, expansion, the presence of a foreign body in the rectum with irradiation of pain in the perineum, bladder, sacrum, buttocks, inner thighs. The pain comes on shortly after a bowel movement and lasts for many hours.

The fissure of the anal canal in 90% of cases is localized on the back wall of the white line, in isolated cases (10%) - on the anterior wall of the anus (more often in women). There are no cracks on the side wall of the anal canal. In 3% of cases, there are two cracks on the back and front walls of the anal canal.

The length of the anal fissure is 0,5 - 2 cm, the depth is 0,3 - 0,5 cm.

Cause constipation cracks, hemorrhoids. In this case, the mucosa of the anal canal ruptures, as a result of which the nerves that are affected by toxins are exposed. With prolonged action of toxins, neuritis and spasm of the sphincter of the rectum occur, and this does not allow the fissure to heal.

With cracks, sharp pains occur both during defecation and after stool. Sometimes isolated drops of blood are released. Some patients are afraid of stools, restrict food intake, which further leads to constipation. An acute fissure (up to 3 months) later becomes chronic. With a chronic fissure, the pain in the anus is somewhat less than with an acute one.

Chronic fissure in 33% of cases has a distal tubercle and in 3% - a proximal tubercle in the form of a polyp.

Treatment: warm sitz baths, microclysters with chamomile, hemorrhoidal suppositories with anesthesin. Stretching of the sphincter of the rectum according to Recomier is used, the injection method is used with a mixture of Schnee (5% sovkain - 0,1 ml, phenolphthalein - 0,2 g, medical alcohol with a strength of 70% - 1 ml, peach oil - 8,7 g). After anesthesia with a 0,5% novocaine solution, 1,5 cm from the anal ring, 0,5 - 2,0 ml of Schnee fluid is injected under the bottom of the crack, where fiber degeneration occurs, and the pain disappears within a month. In addition, alcohol-novocaine blockade is used. A 0,5% solution of novocaine (50 ml) is introduced under the crack and medical alcohol with a strength of 90% (1 ml) is injected along the entire length. The procedure is repeated every 7-10 days. Widely used microclysters with a 0,5% solution of novocaine (50 ml).

Surgical treatment is indicated in cases where there is no effect within three months of conservative therapy, when a chronic fissure takes the form of an ulcer, when there are border tubercles and itching.

The operation for the fissure is performed according to Gabriel not in the form of a triangle, but in the form of a “racket” 3 × 3 cm in size. Sphincterotomy is not performed, in some cases a chronic fissure is excised with an incision of the outer portion of the sphincter so that no scar tissue remains.

The wound heals in 3-4 weeks. The patient is discharged on the 8th - 9th day.

Acute paraproctitis

Acute paraproctitis is called all acute purulent lesions of the rectal wall and surrounding tissue. The same concept includes pararectal ulcers, anal and perianal abscesses located under the skin and mucous membranes of the anus.

The reason the occurrence of acute paraproctitis are injuries (repeated superficial abrasions, cracks or tears) that occur when solid feces pass through a tonically closed anal canal. Overstretching of the perineal part of the rectum with constipation, loosening of the mucosa, as well as prolonged diarrhea can cause it to tear and excoriate.

The occurrence of paraproctitis is facilitated by diseases such as hemorrhoids, anal fissures, rectal strictures, proctitis of various etiologies (catarrhal, ulcerative, dysentery, typhoid, gonorrheal, tuberculosis).

The causative agents of paraproctitis are Proteus, Streptococcus aureus, Staphylococcus aureus, anaerobic bacillus, anaerobic gram-positive bacillus. The infection can be very different (both pyogenic and anaerobic).

The classification of acute paraproctitis is based on the anatomical location of the purulent accumulation. Distinguish:

1) subcutaneous paraproctitis, or perianal abscess;

2) ischiorectal (ischiorectal);

3) pelvic-rectal (pelviorectal);

4) retrorectal (retrorectal);

5) submucosal abscess of the rectum.

Subcutaneous abscesses are more common than other forms of acute paraproctitis. Pus accumulates in the subcutaneous tissue on either side of the anus (perianal abscess). If the abscess is located at the very edge of the anus, then it is called marginal or marginal, if in front of the anus it is perineal, and behind it is postanal.

Subcutaneous paraproctitis manifests itself acutely, body temperature rises to 38 - 39 ° C, chills are sometimes observed, the patient complains of pain in the anus, aggravated by defecation.

Swelling and hyperemia of the skin is locally determined, often at the edge of the anus. Finger research of a rectum is sharply painful. When establishing a diagnosis, an emergency operation is necessary - opening and draining the abscess.

The ischiorectal form of paraproctitis is in second place in terms of frequency of occurrence. Clinically the disease is manifested by a feeling of heaviness and dull pain in the depths of the buttock or perineum, body temperature rises to 38 - 40 ° C (often with chills), patients note increasing weakness, loss of appetite, insomnia. At the time of defecation, pain in the depths of the perineum intensifies, sometimes there is urinary retention. Locally, slight swelling of the corresponding buttock is noted. When pressed, deep pains are felt. After 3 - 6 days from the time of the first pain on the side of the anus, that is, on the right or left buttock, there is an extensive swelling of the tissues, painful when pressed. The skin, as a rule, is of normal color, but in some patients it is slightly hyperemic. Palpation reveals deep testiness, loose tissue infiltration. Fluctuation is not detected, it can only be after the breakthrough of the abscess under the skin, then skin hyperemia also occurs.

A digital examination of the rectum on the side of the lesion reveals a painful compaction of the rectal wall, sometimes with abscesses filling the entire ischiorectal fossa, a protrusion of this wall in the intestinal lumen is observed.

Ischiorectal ulcers, left to their own course, most often break out through the skin of the gluteal region, less often they open into the lumen or through the muscle that raises the anus, penetrate into the pelvic-rectal space.

With ischiorectal ulcers much more often than with subcutaneous ulcers, a horseshoe-shaped or bilateral form of paraproctitis is formed.

Ulcers in pelvic-rectal paraproctitis are localized in the fascial space of the same name, located between the levator ani muscle and the peritoneum of the pelvic floor. This is the most severe and difficult to recognize form of paraproctitis, which is relatively rare (7,5%).

Ulcers can occur in the lymphogenous way on the basis of minor damage (microtrauma) of the mucous membrane of the final section of the rectum. In rare cases, they develop secondary to purulent prostatitis and vesiculitis in men or infection of the appendages and broad ligaments of the uterus in women.

Clinical signs of the disease: pain and a feeling of heaviness in the pelvis, constant pressure on the bottom; pains sometimes radiate to the area of ​​the bladder, and in women - to the area of ​​the uterus; increased urination, sometimes pain at the end of it; during defecation, the pain is not sharp, sometimes absent.

When examining the perineum, anus and buttocks, no signs of the disease are noted. With superficial palpation of the buttocks, there is no pain, however, strong pressure with a finger or pushes on the buttock of the affected side causes a feeling of pain in the depths of the pelvis.

A digital rectal examination reveals a sharp painful induration of one of the side walls of the rectum, located above the levator ani muscle, i.e., 5 to 9 cm above the anus. Sometimes, with the localization of the abscess on the right, there are signs of acute appendicitis. There were cases when the abscess broke into the bladder, vagina and even into the abdominal cavity.

An important diagnostic sign of a posterior rectal abscess is a sharp pain with finger pressure on the skin of the posterior perineum between the tip of the coccyx and the anus.

Clinically, patients have an increase in temperature (37 - 38 ° C), worsening of the general condition. Complaints come down to a feeling of dull, sometimes throbbing pain in the lower rectum, heaviness in it. The pain is always aggravated by defecation. Outside, there are no signs of the disease. The diagnosis is made on the basis of a digital examination of the rectum, in the lumen of which a round elastic painful tumor is determined on one of the walls.

With primary acute paraproctitis of superficial localization, it is necessary to carry out a radical operation - to excise the outer wall of the abscess along with the affected crypts according to Gabriel.

With deep (ischiorectal, pelviorectal, retrorectal) acute paraproctitis, in order to eliminate the internal opening, it is recommended to open abscesses with necrectomy and passing a silk ligature through the internal opening.

If during the operation for acute paraproctitis of deep localization, with the introduction of methylene blue into the abscess cavity, the inner hole is not detected, and there is no visible purulent passage to the crypt line, then one can limit oneself to a wide arcuate opening of the abscess and drainage of the cavity.

Operations for acute paraproctitis should be performed under intravenous or mask anesthesia.

Fistulas of the rectum

Under the fistulas of the rectum, it is necessary to understand the fistulous passages located near the anus. Rectal fistulas are also considered as a pathological course or abnormal communication between the rectum and adjacent tissues, pelvic organs, or the skin of the perineal-buttock region.

Fistulas of the rectum are characterized by frequent recurrence. A significant proportion of relapses after operations for rectal fistulas depends on the presence of an undetected internal opening.

The formation of fistulous passages develops in the following stages:

1) the gate of infection on the mucous membrane of the anal canal;

2) primary purulent course;

3) pararectal abscess;

4) rectal fistula.

Fistulas of the rectum are the result of acute paraproctitis, in which there is always a more or less pronounced internal opening of the abscess in one of the Morganian crypts.

According to the anatomical location, the fistulas are divided into subcutaneous-submucosal, ischiorectal, pelviorectal, retrorectal and rectovaginal.

In relation to the sphincter - intrasphincteric, transsphincteric and extrasphincteric.

According to the location of the fistulous openings - complete (external and internal), incomplete (external and internal) with a temporarily recurrent internal opening.

According to the clinical picture - simple, complex (branched, with extensions, streaks, infiltrates), horseshoe-shaped and recurrent.

Diagnostics fistulas of the rectum begins with an external examination, which determines the location of the external opening of the fistula, the number of external openings, the nature of the discharge. The closer the external opening of the fistula to the anus, the easier the fistula.

On palpation, a cord-like cord can be determined, corresponding to the course of the fistula. A digital examination of the rectum finds the internal opening of the fistula, which can be located in one of the crypts - anterior, posterior or lateral.

The study of the fistulous tract with a bellied probe is mandatory, it helps to determine the location of the fistula in relation to the sphincter. If the thickness of the tissues above the probe does not exceed 1 cm, then we can assume an intra- or transsphincteric direction of the calico passage.

In cases where the fistulous tract is convoluted and the probe does not pass into the lumen of the rectum, a 1% solution of methylene blue is injected into the fistulous tract to determine the location of the internal opening of the fistula.

Fistulography is used for complex fistulas to clarify the directions of additional moves, the presence of streaks, pockets.

For treatment fistulas of the rectum, many surgical interventions have been proposed.

With subcutaneous-submucosal, intrasphincteric fistulas, Gabriel's operation is used - dissection of the fistula along the probe and removal in the form of a small triangle of the skin and mucous membrane covering it.

With transsphincteric fistulas, the Gabriel operation is also applicable with suturing the bottom of the wound and the crossed sphincter fibers.

With extrasphincteric fistulas with minor cicatricial changes around the internal opening, plastic surgery according to Aminev, Blinnichev or excision of the fistulous tract with suturing of the sphincter is possible. With recurrent extrasphincteric fistulas with large cicatricial changes, infiltrates, streaks, the ligature method is used.

After excision of the fistulous passage, a silk ligature passed through the internal opening is provisionally tied on the sphincter fibers and part of the wound is sutured. The tightening of the ligature begins from the 9th - 15th day after the operation, when the perineal wound is filled with granulations.

Polyps of the rectum

Rectal polyps are benign tumors of the mucous membrane, sitting on a stalk or on a wider base. In most cases, polyps are found in the clinic at the reception of a proctologist or in a hospital.

With a digital examination of the rectum, a polyp can be detected at a height of 7 - 8 cm. Large polyps (2 - 3 cm) can cause pain in the rectum, discomfort, blood and mucus. Small polyps (0,3 - 0,5 cm), as a rule, do not manifest themselves in any way and are discovered by chance during sigmoidoscopy.

According to the histological structure, polyps of the following types are distinguished.

Simple (hyperplastic) - small neoplasms that retain the morphological structure of the mucous membrane with the usual number of glands, but their number increases in the protrusion zone.

Adenomatous, or glandular. They are hyperplasia of the mucous membrane on a stalk or a wide base, built from glands lined with a cylindrical epithelium:

a) polyps with proliferation - in this group of polyps, proliferation of the epithelium can be observed, the cells of the proliferating epithelium are closely adjacent to each other. The nuclei in this case can be located at different levels, which creates a picture of the multinucleation of the epithelium;

b) polyps with malignancy - in this group of polyps there are pronounced signs of cellular atypia, which creates a picture of cancer in an adenomatous polyp. Unlike true cancer, this group of polyps almost never metastasizes.

Villous tumors - exophytic neoplasm, soft consistency, covered with a large number of villi. Most authors consider villous tumors to be a benign neoplasm, but with a high (up to 90%) frequency of malignancy.

Fibrous tumors - connective tissue neoplasms with a large number of vessels in the stroma.

The vast majority of authors adhere to surgical tactics for the treatment of rectal polyps. At the current level of development of oncology, the only stable way to cure rectal polyps is their surgical removal.

Types of surgical interventions:

1) transanal excision of polyps;

2) electrocoagulation through a rectoscope;

3) colotomy;

4) bowel resection.

Rectal cancer

Of all the neoplasms of the rectum, cancer is the most common. People of any gender and age suffer from rectal cancer, but most often from 40 to 60 years.

Depending on its localization, anal cancer, cancer of the rectal ampulla and its proximal part are distinguished.

Clinical course rectal cancer is diverse, it depends on the location of the tumor, the stage of its development, the degree of malignancy, the presence or absence of ulceration.

International clinical and domestic classifications are similar to colon cancer classifications.

In the initial period of the disease, regardless of the localization of cancer in the rectum, symptoms may be absent.

The first, most characteristic signs of rectal cancer include discomfort in the anus and sacrum, tenesmus, constipation, alternating with diarrhea, dull pain during bowel movements, the release of blood and mucus (sometimes blood and pus).

If there is ulceration of cancer of the anus, then blood is released. With deep infiltration of the sphincter, with the germination of sensory nerves, sometimes severe pain occurs. As a sign of developing stenosis, the ribbon-like shape of feces attracts attention. With an ulcerative form of cancer, a pronounced anemization of patients occurs, a pale icteric color of the skin. There are constant severe pains in the pelvic area and the sacrum, and sometimes dysuric phenomena when the tumor grows into the tissue of the pelvis or neighboring organs - the prostate gland, urethra, etc.

In some cases, highly located rectal cancer can give a picture of acute intestinal obstruction.

Diagnosis rectal cancer is placed on the basis of a digital examination, sigmoidoscopy and x-ray examination.

In digital examination, in cases where rectal cancer is available, the formation of a dense consistency, especially at the base and edges, ulceration with roller-like thickened and compacted edges is found. With highly located stenosing cancers, a sharp expansion of the empty ampoule is noted. In some cases, infiltration of the rectal wall without clear boundaries, traces of blood or bloody-purulent discharge on the finger are determined.

During sigmoidoscopy, you can take a piece of the tumor from the area of ​​​​altered tissue with a conchotome for biopsy.

X-ray examination of the rectum with suspected cancer is performed using a small amount of contrast mass. In this case, the following signs are revealed: rigidity of the rectal wall and narrowing of its lumen, absence of mucosal folds, filling defects with uneven and indistinct contours, expansion of the intestine above the site of narrowing, absence of peristaltic movements in the affected area.

Differential diagnosis rectal cancer should be performed with the following diseases: hemorrhoids, tuberculous ulcer of the perianal skin and anal canal, syphilis and rectal polyps, benign tumors, delimited infiltrative paraproctitis, chronic rectal fistulas, chronic anal fissures with callous edges and a dense base, chronic ulcerative proctitis , chronic rectovaginal fistulas.

Currently for treatment rectal cancer, various types of surgical interventions are used, both radical and purely palliative. The choice of the method of surgical intervention depends on the stage of development (spread) of the tumor process and the level of its location.

A. N. Ryzhykh divides surgical interventions on the rectum for cancer into three groups:

1) palliative operations, the purpose of which is to bring out the fecal masses by applying a fecal fistula (anus praeternaturalis), while the tumor remains intact;

2) conservative operations - removal of the main tumor focus (these operations are not radical enough);

3) operations in which both the main tumor-like focus and the lymph nodes involved in the process are completely and widely removed.

Patients in the preoperative and postoperative period undergo the same therapeutic measures as in colon cancer.

Epithelial-coccygeal passages

This is a congenital disease characterized by the presence in the subcutaneous tissue of a passage lined with epithelium.

There are mainly uncomplicated and complicated coccygeal passages.

RџSЂRё uncomplicated epithelial-coccygeal passages patients complain of dull constant pain in the sacrococcygeal region, especially when walking and physical activity, itching and maceration of the skin in the intergluteal region. Visually, strictly in the intergluteal fold at the level of the fifth sacral vertebrae, there is one or more holes, from which a bunch of long, thin, atrophic hair protrudes. If there are many holes, then they all communicate with each other. Away from the hole in the sacrococcygeal region, sometimes you can feel a soft tumor-like formation without inflammation. A meager amount of serous or serous-purulent fluid is released from the hole.

RџSЂRё complicated epithelial-coccygeal passages there is an abscess of the sacrococcygeal region on the basis of the epithelial-coccygeal passage, which occurs after an injury. There is malaise, general weakness, fever. Locally there is a painful swelling and infiltration in the intergluteal region, the skin over it acquires a bluish-violet or red tint. In the later stages, shaking appears. At the edge of the abscess, strictly along the intergluteal fold, there is always the primary opening of the epithelial-coccygeal passage.

There may also be an epithelial-coccygeal passage with secondary purulent fistulas and streaks.

After an independent or surgical opening of the abscess, a temporary improvement occurs, followed by an exacerbation with the formation of a new abscess, then additional fistulous openings with streaks appear. With a long-term course of the disease, multiple fistulous passages are observed against the background of scars and indurations of the skin of the sacrococcygeal region with an obligatory primary opening in the intergluteal fold at the level of the sacrococcygeal joint. This is the main differential symptom that distinguishes this disease from chronic paraproctitis and other suppurative diseases of the sacrococcygeal and perineal regions.

Differentiate the epithelial-coccygeal course with a rectal fistula it is difficult only if the primary opening of the epithelial-coccygeal passage is located atypically. To clarify the diagnosis, methylene blue is injected into the primary opening of the passage, which always pours out through the secondary fistulous passages.

Treatment epithelial-coccygeal passages - a rather difficult task. There are a large number of different methods of treatment. Conservative methods of treatment are abandoned by all. Now they use radical methods of surgical treatment of epithelial-coccygeal passages. All surgeons spend the first moment of the operation in the same way. It consists in excision of the epithelial-coccygeal tract along with its streaks and fistulas within healthy tissue under the control of methylene blue. The second part of the operation is performed differently.

A radical operation with a blind suture is used for uncomplicated epithelial-coccygeal passages and epithelial-coccygeal passages with secondary fistulas and inflows in the stage of stable remission. Sometimes this operation is also performed during an exacerbation of the process, but at the same time, the pathological focus is removed with careful hemostasis, leaving no dead spaces.

The tract is excised with a bordering incision along with secondary fistulas, the depth of excision of the tissue flap should reach the periosteum only in the area of ​​the sacrococcygeal joint, since the tract is fixed by a dense ligament to this place. The wound should be navicular, it is sutured with vertical mattress sutures. A dressing with alcohol is applied to the wound. Daily wound control. In case of inflammation, the sutures are partially removed. With a smooth course of the wound, the sutures are removed on the 10th - 12th day.

An open method of treatment (with radical surgery and wound tamponade) is used for purulent complications of the epithelial-coccygeal tract. Under the control of methylene blue, all pathological tissues are excised, granulation is scraped out with a bone spoon. The wound is tamponed with Vishnevsky's ointment.

A semi-open method of treatment (with a radical operation, partial suturing of the wound and leaving drainage in the center of the wound) is used for purulent complications of the epithelial-coccygeal tract, especially if the wound is very large after radical excision of the pathological tissues.

And, finally, a semi-closed method of treatment, developed in the clinic of the Research Institute of Proctology. After local anesthesia with a 0,25% solution of novocaine and marking of passages, fistulas and streaks with methylene blue under the control of the probe, the passage, secondary fistulas and surrounding scars are economically excised. If the numbness and fistula goes far away from the intergluteal fold, then an additional incision is made along the fistula. It turns out an irregularly shaped wound. Further, the edges of the wound are sutured to its bottom with separate catgut sutures as follows: the catgut ligature is passed through the edge of the skin wound on each side, retreating from the edge of 0,6 - 0,8 cm, then the needle is injected into the tissue along the midline of the bottom of the wound. The catgut thread is not tied, but taken on a clamp. Such seams are applied throughout the wound on both sides. Catgut sutures are tied first on one side, and then on the opposite side.

The semi-closed method of treatment provides a snug fit of the skin flaps to the bottom of the wound, eliminates the possibility of accumulation of exudate under the flap, establishes good drainage of the wound, and does not create tension on the skin flaps. The wound heals with a strong scar.

For each coccygeal move, you should choose your own operation.

Intestinal obstruction

Intestinal obstruction (ileus) is characterized by the cessation of the movement of intestinal contents in the direction from the stomach to the rectum and is one of the most formidable syndromes encountered in abdominal surgery.

Intestinal obstruction is a complex of symptoms (syndrome) characterized by pain, vomiting, stool retention, gas, bloating and combining numerous diseases of the abdominal organs with different etiology and course. Correct and timely diagnosis of intestinal obstruction plays a decisive role in the outcome of the treatment of this serious disease.

1. According to the mechanism of occurrence:

1) dynamic (functional) obstruction:

a) spastic;

b) paralytic;

2) mechanical obstruction:

a) obstructive (obturation by a tumor, blockage by a foreign body, fecal or gallstone, ascaris tangle, coprostasis);

b) strangulation (torsion, knotting, internal infringement);

c) mixed forms of obturation and strangulation obstruction (adhesions, intussusception);

3) vascular obstruction (intestinal infarction):

a) thrombosis of the mesenteric veins;

b) thrombosis and embolism of the mesenteric arteries.

2. According to the clinical course:

1) acute;

2) subacute;

3) chronic.

By degree:

1) complete;

2) partial.

By stages: the first - neuroreflex; the second is the stage of compensation and organic changes; the third is terminal.

Dynamic intestinal obstruction. Dynamic intestinal obstruction occurs as a result of a violation of the muscle tone of the intestine on the basis of functional or organic lesions of its innervation mechanisms.

Spastic intestinal obstruction (spastic ileus). It occurs with intestinal spasm and can be caused by various factors: helminthic invasions, fecal stones and other foreign bodies that irritate the intestines from the side of its lumen; bruises of the abdomen, hemorrhages in the abdominal cavity, hematomas and suppurative processes of retroperitoneal tissue (mechanical irritants of the intestines); renal and hepatic colic, basal pneumonia, hemo- and pneumothorax, which reflexively irritate the intestines; functional and organic lesions of the nervous system; spasm of intestinal vessels, dysentery.

Many of the factors in spastic ileus can cause paralytic ileus. So, in case of poisoning with morphine, nicotine, lead, intestinal spasm occurs first, and then its paresis or paralysis.

Paralytic ileus (paralytic ileus). Occurs with paresis or paralysis of the intestine. The most common causes of this type of obstruction are peritonitis, surgical trauma (during surgical interventions on the abdominal organs), blood, urine or bile that has poured into the abdominal cavity.

Mechanical intestinal obstruction. With mechanical obstruction, there is a violation of the patency of the intestine as a result of any mechanical obstruction. The symptomatology of mechanical intestinal obstruction consists of pain and dyspeptic syndromes, hemodynamic disturbances and disorders of water-salt, protein, carbohydrate metabolism, complicating factors associated with the development of peritonitis.

Diagnosis It is found out with a thorough history taking, an objective clinical examination, X-ray examination of the abdominal and thoracic cavities, laboratory tests of blood and urine.

Depending on the degree of violation of the blood supply to the intestine, mechanical obstruction is divided into obstructive and strangulation.

clinical picture mechanical intestinal obstruction is extremely diverse and depends on the duration of the disease, the level and type of obstruction, the individual characteristics of the patient (age, gender, general condition at the time of the disease).

The higher the level of obstruction, the more severe the disease.

Diagnosis and treatment. Of great importance in the diagnosis of intestinal obstruction is the anamnesis, since obstruction is not an accidental disease of a healthy person, but in most cases it is a complication or a secondary symptom complex of another disease. When collecting an anamnesis, it is necessary to establish whether the patient had abdominal injuries, operations on the abdominal organs, whether the patient suffers from peptic ulcer, cholecystitis, appendicitis, and women from inflammatory diseases of the genitals. All these data can lead to the idea that the patient has adhesive intestinal obstruction. Next, you need to pay attention to the activity of the intestines (the presence of constipation, followed by diarrhea).

It is important to find out when and what the patient ate before the onset of the disease, whether there were gross violations in the mode and quality of nutrition or a sudden increase in intra-abdominal pressure when lifting weights and other physical stresses.

The onset of the disease is acute or gradual. The acute onset indicates severe obturation or strangulation obstruction or an acute form of intussusception. Patients indicate the exact time of onset of the disease. With an exacerbation of chronic intestinal obstruction, the disease often begins not so violently.

One of the constant symptoms of intestinal obstruction is cramping pain. After fading away, she reappears. The periodicity and cramping nature of the pain are caused by increased peristalsis of the intestinal loops located above the obstacle, which is associated with the tension of the mesentery.

With gradually developing obstructive forms of intestinal obstruction, the pain syndrome is slightly expressed. At the onset of the disease, pain is localized in the upper or lower abdomen, in the left or right iliac region, later capturing the entire abdomen and most often radiating upward.

The second, almost constant sign of intestinal obstruction is nausea, accompanied by vomiting. Initially, it has a reflex character due to irritation of the peritoneum and intestinal wall. Fecal vomiting indicates a deep disorder of peristalsis and corresponds to the late stage of the disease. Unlike food and alcohol poisoning in intestinal obstruction, vomiting does not cause a feeling of relief, and the patient has a feeling that it will happen again.

The main classic symptom of intestinal obstruction is the retention of stools and gases. At the onset of the disease, intestinal stasis may depend on reflex phenomena from the site of intestinal obstruction, resulting in intestinal paralysis, especially of the large intestine.

When examining the abdomen, it is necessary to pay attention to its configuration, general or local flatulence and asymmetry of the anterior abdominal wall.

In the initial period of intestinal obstruction, the loop of the intestine closest to the site of obstruction is stretched first. It can even protrude somewhat (limited flatulence) - Val's symptom. Percussion in this place of the abdomen is heard high tympanitis. In some cases, with multiple constriction of intestinal loops, for example, by adhesions, sharply protruding stretched loops are noticeable, giving asymmetry of the abdomen.

An important sign of intestinal obstruction is peristalsis of the intestine, which is noticeable to the eye, which occurs independently or after mild irritation of the abdominal wall, such as palpation. Most often, the beginning of peristalsis coincides with an increase in pain, and the end - with their decrease. Visible peristalsis also serves as a reliable symptom of intestinal obstruction. Peristalsis is especially pronounced in chronic obstructive obstruction caused by intestinal tumors, with hypertrophy of the intestinal wall above the obstacle.

In acute intestinal obstruction, especially with strangulation, abdominal pain is noted during palpation. Sometimes it is possible to palpate the focus of obstruction - a tumor, induration at the site of invagination, a foreign body that caused obstruction.

Splashing noise, first described by I.P. Sklyarov in 1922, is of great diagnostic value in this disease.

Bowel sounds of various heights are auscultated, which are very diverse in nature (voiced, crackling, sometimes resembling the bursting of bubbles). The presence of bowel sounds indicates preserved peristalsis. For intestinal obstruction, the coincidence of intestinal noises with peristalsis and bouts of pain is characteristic.

With the development of peritonitis in the abdominal cavity, silence sets in, only occasionally can you hear the noise of a falling drop (Spasokukotsky's symptom) or rare peristaltic noises in high tones.

A digital examination of the per rectum can reveal a balloon-like swelling of an empty ampoule of the rectum, a "gaping anus" (a symptom of the Obukhov hospital).

In most cases, the temperature at the onset of the disease is normal, and with the development of peritoneal symptoms, it reaches 37,5 - 38,5 ° C.

X-ray diagnostics is a valuable tool in the recognition of intestinal obstruction. Panoramic fluoroscopy and radiography of the abdominal cavity without the use of contrast agents are widely used in our country. This method does not require preliminary preparation of the patient, is available to every doctor, is simple and safe.

X-ray signs of intestinal obstruction: the accumulation of gas in the gastrointestinal tract and the appearance of horizontal levels of liquid with gas bubbles above them in the form of overturned bowls, called Cloiber bowls.

In a laboratory study of blood, due to its thickening, erythrocytosis, an increase in hemoglobin, leukocytosis with a shift of the leukocyte formula to the left are observed, the specific gravity and viscosity of the blood increase.

When establishing a diagnosis of intestinal obstruction, it is first necessary to exclude a number of diseases of the abdominal organs - acute appendicitis, perforated stomach and duodenal ulcers, acute cholecystitis (calculous and acalculous), pancreatitis, perforation of a typhoid ulcer, strangulated hernia (internal and external), ectopic pregnancy , diseases of the female genital organs. It is also necessary to exclude diseases of organs located outside the abdominal cavity and giving a clinical picture similar to intestinal obstruction: renal colic, acute urinary retention, diseases of the central nervous system, lungs and pleura, sclerosis of the coronary vessels, lead poisoning, etc.

For differential diagnosis dynamic and mechanical obstruction, a number of therapeutic measures were proposed (atropine, physostigmine, morphine). However, the most effective and completely safe method of influencing the pathogenesis of dynamic obstruction is the pararenal novocaine blockade according to Vishnevsky and a warm bath.

In most cases of dynamic obstruction, when applying the above measures, patients experience pain in the abdomen after 10–15 minutes, after 30–45 minutes the abdomen becomes soft, then gases begin to pass and stools appear. In cases where these measures do not give the full effect within 30-45 minutes, the patient is prescribed a siphon enema.

The siphon enema, in addition to the therapeutic effect, also has a diagnostic value, since the height of the obstruction can be judged by the amount of fluid that has entered the intestine.

In some cases, patients with acute intestinal obstruction are admitted to the surgical hospital in a serious condition. Then, without wasting time, immediately before the operation, a number of measures are taken to combat vascular insufficiency: eliminate pain impulses, increase the mass of circulating blood, raise blood pressure, in addition, replenish the lack of chlorides in the blood and, if possible, produce detoxification.

Narcotic drugs are widely used for pain relief.

An effective means of combating acute vascular insufficiency is blood transfusion, in addition, it is advisable to transfuse polyglucin, plasma, protein preparations of hydrolysin, amino blood, etc. The introduction of anti-shock liquids is also of great importance in the fight against vascular insufficiency. Caffeine, adrenaline, ephedrine, etc. are used to raise blood pressure.

Of great importance in intestinal obstruction is the fight against violations of water-salt metabolism. For this purpose, physiological saline solution is injected intravenously with a 5% glucose solution.

Most authors divide all surgical interventions for intestinal obstruction into three groups:

1) elimination of the cause of mechanical intestinal obstruction (unwinding during volvulus, disinvagination during invagination, dissection of strangulation adhesions, bowel resection, etc.);

2) the imposition of various kinds of anastomoses to bypass the obstacle;

3) the imposition of an intestinal fistula above the place of the obstacle.

Separate forms and types of mechanical intestinal obstruction

Obstructive obstruction. With obstructive intestinal obstruction, there is no compression of the intestinal mesentery with its neurovascular apparatus, and therefore the blood supply to the intestine at the site of obstruction at the beginning of the disease is almost not disturbed. At a later date, venous stasis occurs in the leading section of the intestine, and due to the overstretching of this section of the intestine, capillary permeability is disturbed, which leads to cyanosis and edema of the intestinal wall.

Causes of obstructive ileus can be:

1) tumors that cause blockage of the intestinal lumen, ascaris tangles, fecal and gallstones;

2) tumors of other organs of the abdominal cavity, inflammatory infiltrates that compress the intestine from the outside;

3) adhesions and strands that cause bending of intestinal loops;

4) cicatricial stenosis as a result of ulcerative processes in the intestine (tuberculous or other).

Treatment obstructive mechanical obstruction in colon cancer only operational. With the development of acute intestinal obstruction with no symptoms of perforation of the tumor, it is first necessary to impose a fecal fistula, a radical operation should be performed after the elimination of intestinal obstruction.

When eliminating intestinal obstruction caused by narrowing of the intestine, the nature of the surgical intervention depends not only on the degree of narrowing of the intestine and the cause of the narrowing, but also on the number of strictures, their localization and the length of the narrowing.

If coprostasis is suspected, conservative treatment is carried out: siphon enemas, manual removal of feces when it is retained in the rectum. If conservative treatment fails, surgery is indicated.

Strangulation intestinal obstruction. With strangulation obstruction, the mesentery of the intestine with the vessels and nerves passing through it is infringed or compressed, which leads to a sharp violation of the blood supply. The nature of the circulatory disorder depends on the degree of infringement or compression of the mesenteric vessels and on the state of the blood vessels before the onset of the disease. Strangulation ileus includes volvulus, nodulation, strangulation of intestinal loops by adhesions and strands in internal hernial rings and congenital mesenteric defects.

inversion (volvulus) is called the rotation of the intestine over a greater or lesser extent around an axis (270 °, 360 °) perpendicular to the intestine and the line of the mesentery root. Following the intestinal loops, the mesentery is twisted.

The anatomical prerequisites for the occurrence of volvulus are the presence of a sufficiently long mesentery, the ratio of the width of the base of the mesentery and its length (the narrower the base, the closer the adductor and efferent loops (legs) of the corresponding intestine section are). Thus, there is a starting position for inversion. AT etiology torsion, undoubtedly, alimentary reasons also play a large role.

One of the most common types of strangulation intestinal obstruction is volvulus of the small intestine.

The earliest symptom of small bowel volvulus is an acute, indescribable pain, which is more often localized in the epigastric or umbilical region and less often in the right half or lower abdomen. In addition, a characteristic and early sign is vomiting of food eaten the day before. Initially, it has a reflex character, but as a result of irritation of the restrained mesenteric nerve trunks, it later becomes frequent, abundant and acquires a bilious character. The higher the level of volvulus, the earlier vomiting occurs and is more frequent and more abundant.

Early and permanent signs also include stool and gas retention. In some patients, immediately after the onset of volvulus, a false urge to stool and urination appears, sometimes in the first hours of the disease an act of defecation occurs due to the contents of the lower intestine, but there is no relief from this.

At the onset of the disease, the abdominal wall is not tense and is painless on superficial palpation. With deep palpation, pain is noted and sometimes a test conglomerate of intestinal loops is palpated. Percussion in sloping places of the abdominal cavity is determined by free effusion. Of the acoustic phenomena, splash noise is the most characteristic and earliest.

X-ray examination of the abdominal cavity helps to establish the diagnosis of small bowel obstruction and to some extent its level.

The above symptoms are observed not only with volvulus of the small intestine, but also with other types of strangulation obstruction of the small intestine.

In the presence of symptoms of volvulus of the small intestine, it is necessary to immediately perform an operation, without waiting for the appearance of the entire classical picture of the disease.

The volume and nature of the operation for volvulus of the small intestine depend on the anatomical changes and the functional state of the affected intestinal loops. With a viable intestine, in the event of the appearance of peristalsis and pulsations of the vascular arcades, they are limited to untwisting, sometimes adhesions are additionally dissected, which contribute to volvulus.

With obvious signs of necrosis (black color and dullness of the serous cover of the intestine, the presence of ichorous-hemorrhagic peritonitis), the intestine is resected together with the affected part of the mesentery, 30-40 cm above and below the affected area.

If there is doubt about the viability of the intestine, they resort to warming the intestinal loops with napkins moistened with warm saline saline.

Sigmoid volvulus represents the most common form of strangulation intestinal obstruction and slightly exceeds the frequency of volvulus of the small intestine. The causes of volvulus of the sigmoid colon are the same as for volvulus of other parts of the intestine.

Volvulus of the sigmoid colon develops either rapidly, accompanied by shock (acute form), or gradually, with preceding constipation, intestinal atony, and even partial obstruction (subacute form). In most patients, it proceeds more easily than volvulus of the overlying sections of the colon and the race of the intestines, and its onset, clinical course and outcome depend on the general condition of the patient at the onset of the disease.

For diagnostics volvulus of the sigmoid colon is of great importance history. Many patients, especially the elderly, had intestinal disorders characteristic of megasigma and megacolon in the past: persistent constipation alternating with diarrhea, bloating. In some patients, previously occurring volvulus of the sigma was eliminated with the help of conservative measures, in others - with the help of palliative operations.

The acute form of the disease is characterized by sudden severe cramping pains in the abdomen, often without exact localization or with localization in the left half, sometimes shock, retention of stool and gases, accompanied by severe bloating. Usually shock is accompanied by cases that are called "black sigma" and represent an acutely developed gangrene of this intestine.

With a subacute form of volvulus of the sigmoid colon, all symptoms are less pronounced.

Often an early sign of volvulus of the sigmoid colon is an asymmetry of the abdomen, in which a distended intestinal loop protrudes, located along an oblique line from the top left and going down to the right (Bayer's oblique abdomen). The pulse in the initial period is little changed, with the onset of peritonitis it becomes more frequent, the temperature is normal in most cases. Visible peristalsis is rare, as is splashing noise.

An important diagnostic measure in this disease is fluoroscopy.

Treatment volvulus of the sigmoid colon, especially its subacute forms, it is necessary to start with conservative measures (perinephric novocaine blockade according to Vishnevsky, gastric lavage, siphon enemas). In case of ineffectiveness of conservative treatment, the issue of surgical intervention should be considered.

bowel nodulation - one of the rarest and most severe types of strangulation intestinal obstruction, since in this form there is compression of the mesentery of both intestinal loops involved in nodulation, and one of them always refers to the small intestine.

There are four main types of knotting:

1) between the sigmoid and small intestines;

2) between two different loops of the small intestines;

3) between the small intestine and the ileocecal angle;

4) between the sigmoid colon and the ileocecal angle.

Nodulation most often occurs at night and is manifested by a severe constant pain syndrome. Patients at the same time are extremely restless, rush about in bed, often change their position of the body, many of them take a bent or knee-elbow position. Pain is more often localized in the umbilical or epigastric region, is permanent in nature with periodic amplifications. Most of the gases do not go away, there is also no stool, although it may be in the first hours. The face and skin quickly acquire an earthy-gray tint, covered with sticky cold sweat, acrocyanosis appears, the tongue becomes dry. The tension of the abdominal muscles, quite strong at the beginning of the disease, soon almost disappears. Due to rapidly developing intestinal paresis, peristalsis is not audible and intestinal loops are not contoured through the anterior wall. Abundant effusion accumulates in the abdominal cavity, in the future, as the necrosis of the intestinal loops, a picture of peritonitis develops.

X-ray in the restrained loops of the intestine, the presence of gas and horizontal levels of liquid is observed.

The only method treatment nodulation is an early surgical intervention. Even with undetectable blood pressure and a non-palpable pulse, it can save the patient's life.

Under invagination understand the introduction of one gut into another. Most often, it develops along the intestinal motility, but sometimes in a retrograde (ascending) way. In practice, the small intestine can be introduced into the small intestine, the small intestine into the large intestine, and the large intestine into the large intestine. Ileocecal intussusception is the most common.

Together with the loop of invagination, the mesentery of the intestine is also exposed. As a result of circulatory disorders that have arisen in this area, as well as inflammatory edema, a tumor-like formation is formed, consisting of three cylindrical layers of the intestinal wall (simple invagination). Distinguish between the head of the invaginate (the upper border of the invading intestine) and its neck (the place where the outer layer passes into the middle one).

Along with the general symptoms characteristic of acute intestinal obstruction (acute onset of cramping abdominal pain, vomiting, bloating, absence of stools and gases, visible peristalsis), intussusception also has its own specific signs - a palpable intussusceptum tumor and bloody-mucous stools.

The more acute the disease, the more intensely the blood circulation in the intussusceptum is disturbed and the level of penetration is lower along the length of the intestine, the sooner bloody discharge appears.

Clinical course intussusception can be acute, subacute and chronic. In childhood, especially in infants, most intussusceptions are severe.

Panoramic roentgenoscopy of the abdominal organs with intestinal intussusception reveals typical radiological signs of obstruction: horizontal levels (Kloiber bowls) and accumulation of gas in the intestine.

Depending on the clinical course, intussusception must be differentiated from acute appendicitis, appendicular infiltrate, intestinal tumors, colitis and helminthic invasions (with the latter mainly in children).

Treatment invaginations operational.

Adhesive intestinal obstruction. Adhesions and strands in the abdominal cavity occur after acute diffuse or limited peritonitis, abdominal trauma and hemorrhage. Adhesive intestinal obstruction can be at any level of the intestine. Often the omentum is soldered with a postoperative scar of the peritoneum or with organs injured during the operation.

Adhesive intestinal obstruction can occur in the form of strangulation, obturation and mixed ileus. The latter form is a combination of mechanical and dynamic obstruction.

In all cases, surgery is indicated.

LECTURE No. 4. Diseases of the organs of the pancreato-biliary system

Brief anatomical and physiological characteristics of the zone

Liver (hepar) is located in the upper abdominal cavity, asymmetrically to the midline of the body, most of it occupies the right hypochondrium and epigastric region, and the smaller one is placed in the left hypochondrium.

The liver has a wedge-shaped shape, its upper, lower and posterior surfaces are distinguished. In the abdominal cavity, the liver is located mesoperitoneally. The upper surface of the liver is completely covered by the peritoneum, on the lower surface the peritoneal cover is absent only in the area of ​​​​the furrows, the posterior surface is devoid of the peritoneal cover at a considerable distance.

The peritoneum covering the liver passes to neighboring organs and forms ligaments at the transition points, all of them, except for the hepatic-renal one, are double sheets of the peritoneum. These include the coronary, falciform, left triangular, right triangular, hepatorenal, hepatogastric, hepatoduodenal ligaments.

Blood enters the liver through the hepatic artery and portal vein.

The common hepatic artery (a. hepatica communis) usually departs from the celiac artery and is located in the retroperitoneal space along the upper edge of the pancreas, then it is divided into the proper hepatic and gastroduodenal arteries. In a number of people (30% of cases), accessory hepatic arteries participate in the arterial blood supply to the liver. Arterial blood, rich in oxygen, makes up one third of the total blood entering the liver.

The portal vein (v. portae) collects blood from almost the entire intestine, stomach, pancreas and spleen. The volume of blood entering the liver through the portal vein reaches 2/3 of the circulating blood in this organ. It is rich in chemical products that form the basis of synthesis during digestion.

The portal vein is formed behind the pancreas, at the border of the transition of the head into the body of the gland, corresponding to the XNUMXst lumbar vertebra, and its roots are most often the superior mesenteric and splenic veins.

Hepatic veins (vv. hepaticae), which flow into the inferior vena cava near its passage through the opening of the diaphragm, carry out the outflow of the venous vein from the liver.

Gallbladder (vesica fellae) is located in the fossa vesicae fellae of the liver, has a spindle-shaped or pear-shaped shape, contains 40-60 ml of bile, its length is 5-13 cm, the width at the base is 3-4 cm. The ratio of the gallbladder to the peritoneum is not constant. The neck of the bladder is located at the gate of the liver and continues into the cystic duct. The blood supply to the gallbladder is carried out from the cystic artery (a. cystica), which most often departs from the right branch of the hepatic artery.

bile ducts - external bile ducts - are a system of ducts that carry bile from the liver to the intestines. Their beginning consists of two trunks from the bile ducts (duct, hepaticus) of both hepatic lobes merging at an obtuse angle at the gates of the liver and the common hepatic duct (duct, hepaticus communis) created from them. The latter goes further down and to the right until it meets the gallbladder duct (duct, cysticus). The continuation of the common hepatic and cystic ducts is the common bile duct (duct, choledochus), which retains the direction of the duct, hepaticus communis and goes in the thickness and along the free edge of the lig. hepato-duodenale up to the place of attachment of the ligament to the duodenum. Further, the duct descends lower, crossing the horizontal part of the duodenum from behind. Approaching the inner wall of the descending part of the duodenum, the common bile duct obliquely perforates it and opens into the intestinal lumen at the top of the ampulla of vater (vater nipples) separately or together with the pancreatic duct.

Pancreas (pancreas) is an oblong, prismatic organ in shape, located retroperitoneally and lying almost across the posterior wall of the abdominal cavity.

The pancreas plays an important role in the processes of digestion and metabolism. Its external secretory activity consists in the release of pancreatic juice into the duodenum.

Pancreatic juice has an alkaline reaction (pH 8,4) due to the presence of sodium bicarbonate and is a colorless liquid. During the day, the pancreas secretes 1500 - 2000 ml of pancreatic juice, and the liver - 500 - 1200 ml of bile.

The composition of pancreatic juice includes enzymes that are of great importance in the processes of digestion - trypsin, lipase, amylase, maltase, lactase, invertase, nuclease, as well as a small amount of trepsin and renin.

The main pancreatic duct (ductus Wirsungi) runs through the entire length of the pancreas from tail to head, closer to its posterior surface. It is formed from the fusion of small ducts of the lobules of the gland. In the head of the pancreas, this duct connects with the accessory duct (duct, accessorius, s. Santorini), and then, making a slight downward bend, penetrates the posterior wall of the descending part of the duodenum with the common bile duct, opens into papilla Fateri, which is 2 - 10 cm from the pylorus.

The relationship between duct. Wirsungi and duct. Santorini can be very different. The intimate relationship of the duct, choledochus with the head of the pancreas, the various relationships of the common bile duct with the main pancreatic duct and, finally, their connection with the duodenum are of great importance for understanding the mechanism of development of pathological processes in the pancreas, biliary tract and duodenum.

In some cases, the inflammatory process can move from the biliary tract to the pancreatic parenchyma, in others - from the pancreas to the bile ducts. The sphincter of Oddi has powerful circular muscles around the common bile duct and longitudinal muscle fibers in its corner and in the pancreatic duct. Around the ampulla of Vater's papilla there is also a musculature consisting of circular and longitudinal muscle fibers.

A normally functioning sphincter tightly closes the entrance to both ducts, thereby preventing the penetration of contents from the intestine. Dysfunction of the sphincter can contribute to the development of pancreatitis.

Bile secretion is a specific function of the liver. Normally, a person secretes from 500 to 1200 ml of bile per day, but up to 4000 ml was obtained with a duodenal probe. Bile is involved in intestinal digestion: it helps to neutralize the acids of the food gruel coming from the stomach into the duodenum, splitting (hydrolysis) and absorption of fats and fat-soluble vitamins, and has an exciting effect on the peristalsis of the large intestine.

The role of the liver, which is a complex biochemical laboratory, in the interstitial metabolism is huge. In the liver, most of the carbohydrates that come with the blood of the portal vein from the intestines are processed into glycogen. The liver is a kind of barrier where decay products are neutralized - intestinal toxins, toxic drugs, etc.

The liver is in close functional connection with the kidneys. It destroys poisons, and the kidneys excrete less poisonous products resulting from the antitoxic function of the liver. Therefore, in some diseases, these two organs are often affected simultaneously or sequentially.

Methods for the study of the liver. All methods for examining the liver can be divided into three groups: laboratory, radiological and special.

- Laboratory research methods. These include research:

1) pigment metabolism (bilirubin in blood, urine, stercobilin in feces, urobilin and bile acids in urine);

2) protein metabolism (determination of prothrombin);

3) serum enzymes - transaminases, alkaline phosphatase, lactate dehydrogenase;

4) excretory function of the liver (bromsulfalein test);

5) carbohydrate metabolism (test with galactose);

6) fat metabolism.

Laboratory biochemical methods for studying the functional state of the liver during a clinical examination of patients with hepatic pathology help to clarify the diagnosis, determine the severity of the condition, the activity of the pathological process, and make it possible to more accurately assess the effectiveness of treatment and make a prognosis.

- Radiological research methods. Pneumoperitoneography - the introduction of gas into the abdominal cavity, followed by x-ray examination of the right subdiaphragmatic space.

Transumbilical portohepatography - the introduction of contrast agents into the portal system through the awakened umbilical vein, which lies extraperitoneally. This access is also used to measure intraportal pressure. Intraportal pressure with unchanged portal circulation averages 120 - 180 mm of water. Art., increasing it over 200 mm of water. Art. indicates portal hypertension.

After measuring intraportal pressure, transumbilical portohepatography is started.

Transumbilical manometry and portohepatography give a complete picture of the true numbers of intraportal pressure and more complete information about the vascular structure of the liver itself, about the trunk of the portal vein, the nature of intra- and extra-hepatic anastomoses and collaterals.

In particularly difficult cases, it is recommended to use a comprehensive angiographic study - transumbilical portohepatography and manometry in combination with splenoportography and splenomanometry.

Ciliacography - selective angiography of the branches of the abdominal aorta. Recently, it has been increasingly used due to its diagnostic capabilities, and its most common method is puncture through the femoral artery according to Seldinger under local anesthesia with a 0,25% novocaine solution. Ciliacography provides important data on the state of the arterial blood supply to the liver and spleen.

Direct portography - the introduction of a radiopaque substance into the mesenteric vessels, allows you to clarify the nature and degree of the disorder of the portal circulation (the state of the extra- and intrahepatic portal bed), identify collaterals that are not contrasted with splenoportography, helps determine the amount of surgical intervention.

- Special research methods. Application of methods of radioisotope diagnostics to study the function and structure of the liver. One of the tasks of radioisotope scanning is to determine the localization of the liver and the topographic position of various intrahepatic neoplasms in relation to generally accepted skeletal landmarks.

Rheography - registration on rheograms of fluctuations in electrical conductivity caused by changes in the blood supply of the studied organ in the cardiac cycle, when a high-frequency current is passed through the body. Fluctuations in conductivity are recorded by a rheograph, the output of which is connected to an electrocardiograph. Liver rheograms change both with various forms of diffuse lesions, and with focal ones.

Echography is the use of ultrasound, based on the uneven reflection of ultrasonic waves from tissues or organs due to their different acoustic resistance.

Laparoscopy is used in cases where it is impossible to make a diagnosis of liver disease by other methods. Modern laparoscopes are equipped with a photo and movie camera. In surgical hepatology, laparoscopy is used to diagnose focal lesions of the liver (tumors, cysts), gallbladder cancer, and for the differential diagnosis of jaundice. Laparoscopy does not replace trial laparotomy.

In recent years, puncture liver biopsy has been increasingly used in the clinic. There are three methods for obtaining biopsy material from the liver:

1) percutaneous, or blind, biopsy;

2) biopsy under the control of a laparoscope (targeted biopsy);

3) surgical, or open, biopsy.

Methods for studying the gallbladder and bile ducts. Special methods for examining the gallbladder and bile ducts include chromatic duodenal sounding (Febres colorful test) and oral, intravenous or infusion cholegraphy.

During duodenal sounding using the colorful Febres test, the patient is given 14 g of methylene blue orally 0,15 hours before sounding and during this time it is forbidden to eat and drink. D. Febres (1942) found that methylene blue administered orally is excreted partly by the kidneys, partly by the liver. When excreted from the liver, it becomes colorless, but in the gallbladder it again turns into a chromogen and stains the gallbladder bile in a bluish-greenish color, portions "A" and "C" have the usual yellow color.

An important role is played by laboratory and microscopic examination of the obtained portions of bile ("A", "B", "C").

X-ray examination of the biliary tract in chronic cholecystitis makes it possible to establish calculous and non-calculous forms, to identify patients with a non-functioning (disabled) gallbladder.

Cholecystography is based on physiological mechanisms: the ability of the liver to extract some contrast agents from the blood and excrete with bile, and the gallbladder to concentrate them in its contents. Currently, for cholecystography, the oral route of administration of the contrast agent bilitrast is mainly used.

Cholegraphy is an X-ray method of research in which an image of not only the gallbladder, but also the bile ducts is obtained on the radiograph.

Like cholecystography, cholegraphy is based on the ability of the liver to excrete organic iodine compounds from the blood with bile. For cholegraphy, contrast agents are used, with high hepatotropy and containing a lot of iodine (bilignost, adipiodone, cholegrafin, endographin, bilivpetan, etc.).

Intravenous holography. X-rays are taken within an hour every 15 minutes after the administration of the entire dose of the drug, then after 1,5-2 hours. The maximum intensity of the shadow of the bubble is observed 15 - 30 hours after the introduction of bilignost. After the patient has taken two egg yolks, the contractility of the gallbladder is studied.

Obese patients should use 20 ml of a 50% solution of biligrafin. Children bilignost administered at a dose of 0,1 - 0,3 g per 1 kg of body weight.

Cholangiography is an X-ray method for examining the biliary tract after the injection of a contrast agent directly into the gallbladder or into one of the bile ducts on the operating table (direct surgical cholangiography).

Methods for examining the pancreas. The diagnosis of pancreatic disease is made on the basis of anamnesis, clinical picture, physical, laboratory, functional research methods and radiological data.

A. A. Shelagurov pointed out that the main symptoms of various diseases of the pancreas are pain in the upper abdomen, dyspepsia, weight loss, disruption of the intestines (constipation, diarrhea), fever, jaundice, sometimes thirst, accompanied by glucosuria, multiple thromboses, disorders from the psyche and nervous system.

Methods of functional study of the pancreas determine the state of its external and internal secretion.

The study of the exocrine function of the pancreas is based mainly on determining the amount of enzymes isolated by it (L-amylase, lipase, trypsin, trypsin inhibitors) in the blood, urine and duodenal contents. Examine also feces for the content of fat, nitrogen and undigested muscle fibers in it.

The internal secretion of the pancreas is determined with a double load of glucose, this method was proposed by Staub and Traugott.

The X-ray method for studying diseases of the pancreas is based either on the basis of an examination of the pancreas itself or on indirect signs that come to light from the stomach, duodenum and intestines.

Plain radiography can reveal stones in the pancreas, calcification of the pancreas.

Of great importance in the diagnosis of various diseases of the pancreas is scanning, cytological examination and biopsy of the gland.

Acute cholecystitis

Acute cholecystitis is inflammation of the gallbladder.

The following classification of acute cholecystitis is most acceptable:

I. Uncomplicated cholecystitis:

1. Catarrhal (simple) cholecystitis (calculous or acalculous), primary or exacerbation of chronic recurrent.

2. Destructive (calculous or acalculous), primary or exacerbation of chronic recurrent:

a) phlegmonous, phlegmonous-ulcerative;

b) gangrenous;

II. Complicated cholecystitis:

1. Occlusive (obstructive) cholecystitis (infected dropsy, phlegmon, empyema, gangrene of the gallbladder).

2. Perforated with symptoms of local or diffuse peritonitis.

3. Acute, complicated by lesions of the bile ducts:

a) choledocholithiasis, cholangitis;

b) stricture of the common bile duct, papillitis, stenosis of the papilla of Vater.

4. Acute cholecystopancreatitis.

5. Acute cholecystitis complicated by perforated bile peritonitis.

The main symptom in acute cholecystitis is pain, which occurs, as a rule, suddenly in full health, often after eating, at night during sleep. The pain is localized in the right hypochondrium, but can also spread to the epigastric region, with irradiation to the right shoulder, scapula, supraclavicular region. In some cases, before its appearance, patients for several days, even weeks, feel heaviness in the epigastric region, bitterness in the mouth, and nausea. Severe pain is associated with the reaction of the gallbladder wall to an increase in its contents as a result of a violation of the outflow during inflammatory edema, an inflection of the cystic duct, or when the latter is blocked by a stone.

Often there is irradiation of pain in the region of the heart, then an attack of cholecystitis can proceed as an attack of angina pectoris (Botkin's cholecystocoronary syndrome). The pain is aggravated by the slightest physical exertion - talking, breathing, coughing.

There is vomiting (sometimes multiple) of a reflex nature, which does not bring relief to the patient.

On palpation, a sharp pain and muscle tension in the right upper square of the abdomen is determined, especially a sharp pain in the area of ​​the gallbladder.

Objective symptoms are not equally expressed in all forms of acute cholecystitis. Increased heart rate up to 100 - 120 beats per minute, intoxication phenomena (dry, furred tongue) are characteristic of destructive cholecystitis. With complicated cholecystitis, the temperature reaches 38 ° C and above.

When analyzing blood, leukocytosis, neutrophilia, lymphopenia, and an increased erythrocyte sedimentation rate are observed.

Specific symptoms of acute cholecystitis include:

1) a symptom of Grekov - Ortner - percussion pain that appears in the gallbladder area with light tapping with the edge of the palm along the right costal arch;

2) Murphy's symptom - increased pain that occurs at the time of palpation of the gallbladder with a deep breath of the patient. The doctor places the thumb of the left hand below the costal arch, at the location of the gallbladder, and the remaining fingers - along the edge of the costal arch. If the patient's deep breath is interrupted before reaching the height, due to acute pain in the right hypochondrium under the thumb, then Murphy's symptom is positive;

3) symptom of Courvoisier - an increase in the gallbladder is determined by palpation of the elongated part of its bottom, which protrudes quite clearly from under the edge of the liver;

4) Pekarsky's symptom - pain when pressing on the xiphoid process. It is observed in chronic cholecystitis, its exacerbation and is associated with irritation of the solar plexus during the development of an inflammatory process in the gallbladder;

5) Mussi-Georgievsky symptom ( phrenicus symptom) - soreness on palpation in the supraclavicular region at a point located between the legs of the sternocleidomastoid muscle on the right;

6) Boas' symptom - pain on palpation of the paravertebral zone at the level of IX-XI thoracic vertebrae and 3 cm to the right of the spine. The presence of pain in this place with cholecystitis is associated with zones of Zakharyin-Ged hyperesthesia.

uncomplicated cholecystitis. Catarrhal (simple) cholecystitis can be calculous or acalculous, primary or as an exacerbation of chronic recurrent. Clinically, in most cases it proceeds calmly. The pain is usually dull, appears gradually in the upper abdomen; amplifying, localized in the right hypochondrium.

On palpation, there is pain in the gallbladder area, there are also positive symptoms of Grekov - Ortner, Murphy. There are no peritoneal symptoms, the number of leukocytes is in the range of 8,0 - 10,0 - 109 / l, the temperature is 37,6 ° C, rarely up to 38 ° C, there are no chills.

Attacks of pain last for several days, but after conservative treatment they disappear.

Acute destructive cholecystitis can be calculous or acalculous, primary or exacerbation of chronic recurrent.

Destruction can be phlegmonous, phlegmonous-ulcerative or gangrenous in nature.

With phlegmonous cholecystitis, the pain is constant, intense. Dry tongue, repeated vomiting. There may be a slight yellowness of the sclera, soft palate, which is due to infiltration of the hepatoduodenal ligament and inflammatory edema of the mucous membrane of the bile ducts. Urine dark brown. Patients lie on their back or on their right side, afraid to change their position in the back, because in this case severe pain occurs. On palpation of the abdomen, there is a sharp tension in the muscles of the anterior abdominal wall in the region of the right hypochondrium, there are also positive symptoms of Grekov-Ortner, Murphy, Shchetkin-Blumberg. The temperature reaches 38 ° C and above, leukocytosis 12,0 - 16,0 - 109 / l with a shift of the leukocyte formula to the left. With the spread of the inflammatory process to the entire gallbladder and the accumulation of pus in it, an empyema of the gallbladder is formed.

Sometimes phlegmonous cholecystitis can turn into dropsy of the gallbladder.

Gangrenous cholecystitis in most cases is a transitional form of phlegmonous cholecystitis, but it can also occur as an independent disease in the form of primary gangrenous cholecystitis of vascular origin.

Clinic at first it corresponds to phlegmonous inflammation, then the so-called imaginary well-being may occur: pain decreases, symptoms of peritoneal irritation are less pronounced, temperature decreases. However, at the same time, the phenomena of general intoxication increase: frequent pulse, dry tongue, repeated vomiting, pointed facial features.

Primary gangrenous cholecystitis from the very beginning proceeds violently with the phenomena of intoxication and peritonitis.

Complicated cholecystitis. Occlusive (obstructive) cholecystitis develops when the cystic duct is blocked by a calculus and initially manifests itself as a typical picture of biliary colic, which is the most characteristic sign of cholelithiasis. A sharp pain occurs suddenly in the right hypochondrium with irradiation to the right shoulder, scapula, to the region of the heart and behind the sternum. Patients behave uneasily, vomiting appears at the height of the attack, sometimes multiple. The abdomen may be soft, while a sharply painful, enlarged and tense gallbladder is palpated.

An attack of biliary colic can last several hours or 1-2 days, and when the stone returns to the gallbladder, it suddenly ends. With prolonged blockage of the cystic duct and infection, destructive cholecystitis develops.

Perforated cholecystitis proceeds with the phenomena of local or diffuse peritonitis. The moment of perforation of the gallbladder may go unnoticed by the patient. If neighboring organs are soldered to the gallbladder - the greater omentum, the hepatoduodenal ligament, the transverse colon and its mesentery, that is, the process is limited, then complications such as subhepatic abscess, local limited peritonitis develop.

Acute cholecystitis, complicated by lesions of the bile ducts, can occur with clinical manifestations of choledocholithiasis, cholangitis, choledochal stricture, papillitis, stenosis of the Vater nipple. The main symptom of this form is obstructive jaundice, the most common cause of which is the calculi of the common bile duct, which obstruct its lumen.

When the common bile duct is blocked by a stone, the disease begins with acute pain, characteristic of acute calculous cholecystitis, with typical irradiation. Then, after a few hours or the next day, obstructive jaundice appears, which becomes persistent, accompanied by severe skin itching, dark urine and discolored (acholic) putty-like feces.

Due to the accession of the infection and its spread to the bile ducts, symptoms of acute cholangitis develop. Acute purulent cholangitis is characterized by severe intoxication - general weakness, lack of appetite, icteric coloration of the skin and mucous membranes. Constant dull pain in the right hypochondrium radiating to the right half of the back, heaviness in the right hypochondrium, with tapping on the right costal arch - a sharp pain. The body temperature rises in a remitting type, with profuse sweating and chills. Tongue dry, furred. The liver on palpation is enlarged, painful, soft consistency. Leukocytosis is noted with a shift of the leukocyte formula to the left. In a biochemical study of blood, an increase in the content of direct bilirubin and a decrease in the content of prothrombin in the blood plasma are observed. The disease can be complicated by life-threatening cholemic bleeding and liver failure.

Differential diagnosis. Acute cholecystitis must be differentiated from perforated gastric and duodenal ulcers, acute pancreatitis, acute appendicitis, acute coronary insufficiency, myocardial infarction, acute intestinal obstruction, pneumonia, pleurisy, thrombosis of mesenteric vessels, nephrolithiasis with localization of the calculus in the right kidney or right ureter, and also with liver diseases (hepatitis, cirrhosis) and biliary dyskinesia.

Biliary dyskinesia must be differentiated from acute cholecystitis, which is of practical importance for the surgeon in the treatment of this disease. Dyskinesia of the biliary tract is a violation of their physiological functions, leading to stagnation of bile in them, and later to the disease. Dyskinesia in the biliary tract mainly consists of disorders of the gallbladder and the trailing apparatus of the lower end of the common bile duct.

К dyskinesia include:

1) atonic and hypotonic gallbladders;

2) hypertonic gall bladders;

3) hypertension and spasm of the sphincter of Oddi;

4) atony and insufficiency of the sphincter of Oddi.

The use of cholangiography before surgery makes it possible to recognize the main varieties of these disorders in patients.

Duodenal sounding makes it possible to establish the diagnosis of an atonic gallbladder if there is an abnormally abundant outflow of intensely colored bile that occurs immediately or only after the second or third administration of magnesium sulfate.

With cholecystography in the position of the patient on the stomach, the cholecystogram shows a picture of a flabby elongated bladder, expanded and giving a more intense shadow at the bottom, where all the bile is collected.

When the diagnosis of "acute cholecystitis" is established, the patient must be urgently hospitalized in a surgical hospital. All operations for acute cholecystitis are divided into emergency, urgent and delayed. Emergency operations are carried out according to vital indications in connection with a clear diagnosis of perforation, gangrene or phlegmon of the gallbladder, urgent operations - with the failure of vigorous conservative treatment during the first 24-48 hours from the onset of the disease.

Operations are performed in a period of 5 to 14 days and later with a subsiding attack of acute cholecystitis and an observed improvement in the patient's condition, i.e., in the phase of reducing the severity of the inflammatory process.

The main operation in the surgical treatment of acute cholecystitis is cholecystectomy, which, according to indications, is supplemented by external or internal drainage of the biliary tract. There is no reason to expand the indications for cholecystostomy.

Indications for choledochotomy - obstructive jaundice, cholangitis, impaired patency in the distal sections of the common bile duct, stones in the ducts.

A blind suture of the common bile duct is possible with full confidence in the patency of the duct and, as a rule, with single large stones. External drainage of the common bile and hepatic ducts is indicated in cases of cholangitis with patency of the distal duct.

Indications for the imposition of a biliodigistic anastomosis are the lack of confidence in the patency of the Vater nipple, indurative pancreatitis, the presence of multiple small stones in the ducts in patients. Biliodigestive anastomosis can be performed in the absence of pronounced inflammatory changes in the anastomosed organs by a highly qualified surgeon. In other conditions, it should be limited to external drainage of the biliary tract.

The management of patients in the postoperative period must be strictly individualized. They are allowed to get up in a day, they are discharged and the stitches are removed after about 10-12 days.

Chronic cholecystitis

Classified in the same way as acute. Treatment surgery is performed, laparotomic incisions according to Fedorov, Kerr, upper median, transrectal can be used as an operative access. Laparoscopic gallbladder removal is also increasingly being used.

Cancer of the gallbladder and extrahepatic bile ducts

For gallbladder cancer characterized by infiltrating growth with rapid germination in the liver and with metastases to regional lymph nodes in the area of ​​the portal of the liver, as a result of which in most cases it is inoperable.

In the initial stage of the disease, the symptoms of gallbladder cancer are uncommon. They appear in an advanced stage, when a dense, bumpy tumor is palpated, cachexia or jaundice develops as a result of compression of the bile ducts by metastases in the liver or lymph nodes of the liver gate.

Most often, the diagnosis of gallbladder cancer is made during surgery for chronic calculous cholecystitis.

Operational treatment: the gallbladder is removed if the tumor has not spread beyond its limits, with the germination of the tumor in the bladder bed, a liver resection is performed.

Primary bile duct cancer causes relatively early from the onset of the disease severe clinical symptoms associated with obstruction of the common bile duct and developing jaundice in connection with this. The amount of hemoglobin in the blood increases. The stool is discolored, the reaction to stercobilin in it is negative.

With tumors of the Vater nipple obstruction of the duct develops gradually, stagnation of bile causes a significant expansion of the ducts and gallbladder, an enlarged, painless, elastic gallbladder is palpated (positive symptom of Courvoisier).

Surgery primary bile duct cancer presents a great challenge. Resection of the nipple of Vater is performed by the transduodenal route or resection of the bile duct with transplantation of its distal end into the duodenum.

Liver abscesses

Suppurative processes in the liver develop as a result of infection entering it by the hematogenous route from various organs: more often through the portal vein system, through which blood is drained to the liver from the abdominal organs, less often through the hepatic artery with a general purulent infection.

The appearance of abscesses in the liver is also possible when the infection passes from adjacent organs: as a result of a breakthrough of the gallbladder empyema into the liver, penetration of a stomach or duodenal ulcer into the liver, direct infection with a knife or gunshot wound to the liver.

In the vast majority of cases, so-called solitary abscesses occur, when there is only one cavity in the hepatic parenchyma, located subcapsularly. In some cases, there are also multiple non-communicating abscesses (small in size).

Early diagnosis of pyogenic liver abscesses is very difficult, since one of the main symptoms - liver enlargement - often appears very late. In the initial stage of the disease, the liver is almost painless on palpation, if the peritoneum and gallbladder are not involved in the process. It is necessary to take into account past sepsis, purulent lesions of the abdominal organs, etc.

In the initial stage of the disease, patients complain of dull pain in the right hypochondrium, epigastric region, aggravated by pressure. Pain radiates to the right shoulder, shoulder blade, back, diaphragm mobility is limited, breathing becomes difficult.

In patients with a strong increase in the liver, the gait changes. In bed, they usually lie motionless on their right side with legs bent and drawn to the stomach. The temperature in the evenings rises to 38 - 40 °C. K. G. Tagibekov notes that in severe, neglected cases, when the purulent cavity reaches a large size, an increase in temperature often follows tremendous chills, sometimes profuse sweats.

With large abscesses with a long course, the liver increases sharply, pain is noted during its palpation.

If a liver abscess is not diagnosed for a long time, the patient's strength quickly dries up - subekteria appears, asymmetry of the abdomen and chest. Locally, there is some tension in the muscles of the anterior abdominal wall, pain in the right hypochondrium and chest on the right during palpation and tapping.

When analyzing blood, leukocytosis is noted (18,0 - 20,0 - 10 9 / l) with a shift of the leukocyte formula to the left. The pulse is usually weak filling and often reaches 120 - 130 beats per minute.

It helps to establish the diagnosis and x-ray examination, which is characterized by three main signs: an increase in the shadow of the liver, an increase in mobility and a rise in the diaphragm. At present, the method of radioisotope hepatoscanning is successfully used, on the scan of the liver, abscesses appear as "silent fields".

When an abscess is localized in the anterior parts of the liver, intra-abdominal intervention is undertaken; if the abscess is located in the posterior upper parts of the liver, access to the abscess is opened by the transthoracic route. The operation is performed under intubation endotracheal anesthesia.

Liver tumors

All tumors are divided into malignant and benign.

Malignant tumors

1. Primary:

1) cancer:

a) hepatoma - a tumor of the liver cells;

b) cholangioma - a tumor from the cells of the bile ducts;

c) cholangiohepatoma - a tumor containing cells of both types;

2) sarcoma:

a) angiosarcoma (sarcoma and endothelial cells);

b) alveolar sarcoma;

c) spindle cell sarcoma;

d) round cell sarcoma;

e) lymphosarcoma.

2. Metastatic:

1) cancer;

2) sarcoma.

Benign tumors

1. Epithelial:

1) benign hepatoma;

2) benign cholangioma (solid type and cystic);

3) benign cholangiohepatoma.

2. Mesenchial:

1) hemangioma;

2) hemangioendothelioma.

Primary tumors occur in the form of massive cancer of the nodular form and cancerous cirrhosis (diffuse cancerous infiltration). According to A. L. Myasnikov, cirrhosis of the liver in 75% of cases precedes the onset of primary liver cancer. BM Tareev attaches great importance to epidemic hepatitis in the origin of primary liver cancer. In addition, parasitic diseases (in particular, opisthorchiasis), chronic hepatitis, cholelithiasis, syphilis, and alcoholism contribute to the emergence of primary liver cancer.

The disease develops gradually, patients begin to lose weight quickly, there are pains in the right hypochondrium, nausea, vomiting, diarrhea, sometimes, on the contrary, constipation. Appetite decreases, temperature rises, jaundice appears. Pain in the right hypochondrium in most cases of a aching nature, rarely paroxysmal. The liver is enlarged (sometimes up to the pubis), of dense consistency, bumpy. Ascites occurs, the cause of which many see in tumor thrombosis of the portal vein or compression of its lymph nodes; in other cases, its occurrence is due to cirrhosis of the liver and carcinomatosis.

Diagnosis primary liver cancer is based on the above symptoms, palpation of the tumor, x-ray data (chest x-ray to study the right dome of the diaphragm: its high standing, deformity).

The operability of secondary liver cancer, if it has developed as a result of germination from another organ, is decided by the removal of the primary affected organ, provided there are no metastases in the regional lymph nodes.

An extended resection of the stomach and the left lobe of the liver is performed when gastric cancer moves to the left lobe of the liver, and a wedge-shaped resection of the liver with removal of the gallbladder is performed when gallbladder cancer moves to the liver.

Of the modern methods of intravital morphological examination of the liver, laparoscopy and the method of radioisotope hepatoscanning, positron emission scanning are used.

portal hypertension syndrome. It characterizes a complex of changes that occur when blood flow in the portal system is obstructed due to various diseases.

The main changes in portal hypertension syndrome:

1) the presence of high portal pressure with slow blood flow;

2) splenomegaly;

3) varicose veins of the esophagus, stomach and bleeding from them;

4) expansion of the veins of the anterior abdominal wall;

5) expansion of hemorrhoidal veins;

6) ascites.

Classification of portal hypertension

1. Suprahepatic blockade of portal circulation:

a) Peak cirrhosis of cardiac origin;

b) Chiari disease (thrombosis of the hepatic veins);

c) Budd-Chiari syndrome (thrombosis of the inferior vena cava at the level of the hepatic veins, stenosis or obliteration of it above the hepatic veins, compression by a tumor, scars).

2. Intrahepatic blockade of portal circulation:

a) cirrhosis of the liver of various forms - portal, postnecrotic, biliary, mixed;

b) liver tumors (vascular, parasitic, glandular);

c) liver fibrosis (portal, cicatricial, after trauma, local inflammatory processes).

3. Extrahepatic blockade of portal circulation:

a) phlebosclerosis, obliteration, thrombosis of the portal vein or its branches;

b) congenital stenosis or atresia of the portal vein or its branches;

c) compression of the portal vein or its branches by scars, tumors, infiltrates.

4. Mixed form of blockade of portal circulation:

a) cirrhosis of the liver in combination with thrombosis of the portal vein (primary cirrhosis of the liver, thrombosis of the portal vein as a complication);

b) portal vein thrombosis with liver cirrhosis.

M. D. Patsiora distinguishes three stages of portal hypertension according to the clinical manifestation and the state of the portohepatic circulation.

The first is compensated (initial), which is characterized by a moderate increase in portal pressure, compensated intrahepatic circulation, splenomegaly with or without hypersplenism.

The second is subcompensated, in which there are high portal pressure, splenomegaly, varicose veins of the esophagus and stomach with or without bleeding from them, and pronounced disturbances in the portohepatic circulation.

The third is decompensated, in which there are splenomegaly, varicose veins of the esophagus and stomach with or without bleeding from them, ascites, severe disorders in the portohepatic and central circulation.

For intrahepatic portal hypertension is characterized by a clinic of cirrhosis of the liver.

Extrahepatic portal hypertension mainly manifests itself in two forms:

1) splenomegaly with or without hypersplenism;

2) splenomegaly with hypersplenism and varicose veins of the esophagus.

The third form is very rare - splenomegaly with hypersplenism, varicose veins of the esophagus and ascites that developed after bleeding.

The most common among conservative methods is the use of the Sengstakin-Blakemore probe.

Local hypothermia is considered an effective method of stopping bleeding from varicose veins of the esophagus and cardia of the stomach.

All modern methods of surgical treatment of portal hypertension can be divided into six main groups:

1) operations aimed at reducing portal pressure;

2) stop esophageal-gastric bleeding;

3) elimination of splenomegaly and hypersplenism;

4) elimination of ascites;

5) operations aimed at improving the functional state of the liver;

6) combined operations.

К diseases of the pancreas include:

1) damage to the pancreas;

2) acute pancreatitis;

3) acute cholecystopancreatitis;

4) chronic pancreatitis;

5) pancreatic cysts;

6) pancreatic cancer.

Injuries to the pancreas occur with blunt trauma to the abdomen, the formation of an intracapsular rupture or tear of the pancreatic parenchyma and a false cyst.

Injuries to the pancreas are combined with damage to other organs of the abdominal cavity (stomach, intestines, liver, spleen), proceed severely against the background of internal bleeding, necrosis, acute traumatic pancreatitis, widespread peritonitis.

Treatment operative: suturing the pancreatic capsule, stopping bleeding and draining the abdominal cavity.

Acute pancreatitis

The term "acute pancreatitis" means not only inflammation of the pancreas, but also its acute disease, accompanied by necrosis of the parenchyma of the gland and adipose tissue, as well as extensive hemorrhages in the pancreas and retroperitoneal tissue.

В etiology acute pancreatitis, the following factors are of great importance: disease of the biliary tract, stomach and duodenum, alcohol intake, circulatory disorders in the pancreas, overnutrition and metabolic disorders, allergies, abdominal trauma, chemical poisoning, infectious and toxic factors.

The disease begins suddenly after a rich fatty and protein food, accompanied by alcohol intake. Leading is the abdominal syndrome (pain, vomiting, dynamic intestinal obstruction).

Pain - one of the most constant symptoms of acute pancreatitis - is inherent in all forms of this disease. Excruciating pains occur in the epigastric region, in the navel region with irradiation to the lower back, shoulder blade, shoulders, and sometimes thighs. Girdle pain is the main subjective sign of this terrible disease.

Vomiting is the second most common symptom of abdominal syndrome. However, its absence cannot remove the diagnosis of acute pancreatitis. Most often, vomiting is continuous, bitter (with an admixture of bile), sometimes repeated and painful, so some patients suffer more from vomiting than from pain.

From the very beginning of the disease, the tongue is covered with a white coating, with the development of peritonitis it becomes dry.

The greatest number of symptoms of abdominal syndrome is detected during an objective examination of the abdomen.

On examination, the abdomen is swollen in the epigastric region, there is no peristalsis due to intestinal paresis. On palpation, there is a sharp pain in the epigastric region, no tension in the anterior abdominal wall is observed. Symptoms of Resurrection, Kerte, Mayo-Robson are positive.

Voskresensky's symptom - the absence of pulsation of the abdominal aorta above the navel as a result of compression of the aorta by the edematous pancreas.

Symptom Kerte - transverse soreness and resistance 6 - 7 cm above the navel, corresponding to the projection of the pancreas.

Symptom Mayo-Robson - pain in the left costovertebral angle.

Pancreatocardiovascular syndrome includes a number of symptoms that indicate the degree of involvement of the cardiovascular system in pancreatic disease. In this case, there is a general cyanosis with pouring sweat, cooling of the whole body and especially the limbs, a thready pulse, a drop in blood pressure, i.e., with signs of severe collapse.

At the beginning of the disease, the pulse is normal and very rarely slow, then it quickens, becomes weak. In a severe form of acute pancreatitis, arrhythmia, tachycardia are observed, and blood pressure decreases.

In a severe form of pancreatitis, the diaphragm is involved in the process, its excursion is difficult, the high standing of the dome is noted, breathing becomes superficial and rapid. An early leading sign of acute pancreatitis is shortness of breath.

When involved in an acute inflammatory process of the pancreas, all of its enzymes can be detected in the blood. However, due to some technical difficulties in many medical institutions, they are limited to the most accessible determination of L-amylase in the blood. With an increased content in the blood, L-amylase is excreted in the urine, in which it is easy to detect. A urine test for L-amylase must be repeated, since diastasuria is not persistent and depends on the phase of the course of acute pancreatitis.

The blood picture in patients with acute pancreatitis is characterized by leukocytosis, a shift of the leukocyte formula to the left, lymphopenia, and aenosinophilia.

For everyday practice, the following classification of pancreatitis and cholecystopancreatitis is accepted:

1) acute edema, or acute interstitial pancreatitis;

2) acute hemorrhagic pancreatitis;

3) acute pancreatic necrosis;

4) purulent pancreatitis;

5) chronic - recurrent and non-recurrent;

6) cholecystopancreatitis - acute, chronic and with periodic exacerbations.

Each of these forms of acute pancreatitis has a corresponding clinical and pathohistological picture.

Acute swelling of the pancreas (acute interstitial pancreatitis). This is the initial stage of acute pancreatitis. The disease usually begins with pronounced persistent pain in the epigastric region, which most often occurs suddenly, sometimes they are cramping. Most patients associate their appearance with a plentiful intake of fatty foods, while the pains are so strong that the patients scream and rush about in bed. Pain can be stopped by bilateral pararenal blockade or slow intravenous injection of 20-30 ml of a 0,5% solution of novocaine. Following the pain, as a rule, vomiting appears, the temperature rises.

During pain, the abdomen participates in the act of breathing, is somewhat swollen, palpation reveals soreness and stiffness of the muscles in the epigastric region, there are no symptoms of peritoneal irritation.

The content of L-amylase in the urine usually reaches 320 - 640 g / h / l, in some cases - and higher figures. In the study of blood, the number of leukocytes ranges from 8,0 - 12,0 109 / l without any significant changes in the leukocyte formula.

Acute edema of the pancreas is often accompanied by inflammation of the gallbladder.

Hemorrhagic pancreatitis. At the onset of the disease, the clinical picture of hemorrhagic pancreatitis is similar to that of acute edema. The disease begins with severe pain, with a characteristic irradiation upward, to the left, which is then joined by excruciating vomiting. As a rule, the general condition of such patients is severe. Visible mucous membranes and skin are pale, intoxication is pronounced, the pulse is quickened (100 - 130 beats per minute), weak filling and tension, the tongue is coated, dry, the stomach is swollen, there is a slight muscle tension in the epigastric region, symptoms of Voskresensky, Mayo - Robson , Kerte are positive. Dynamic intestinal obstruction is observed.

Pancreatic necrosis. The disease is acute, severe. It either passes from the stage of pancreatic edema, or begins on its own immediately with necrosis. Pancreatic necrosis is characterized by severe pain with severe intoxication, collapse and shock, peritoneal tension due to effusion, and the development of chemical peritonitis.

Leukocytosis is pronounced with a shift of the leukocyte formula to the left, lymphopenia, elevated ESR. Many patients have protein, leukocytes, erythrocytes, squamous epithelium, and sometimes hyaline casts in the urine. L-amylase in the urine usually reaches high numbers, but with extensive necrosis of the pancreatic parenchyma, its content drops.

It is difficult to establish the diagnosis of hemorrhagic necrosis of the pancreas when the process captures the posterior surface of the pancreas. At the same time, the symptoms from the abdominal cavity are not very pronounced, since the process develops retroperitoneally. However, in these patients, the disease begins with a typical localization and recoil of pain, while there is a pronounced intoxication, the content of L-amylase in the urine is increased, there are changes in the blood. To establish the correct diagnosis, dynamic monitoring of the patient is necessary.

The following signs of pancreatic necrosis are noted:

1) an increase in pain and symptoms of peritoneal irritation, despite conservative treatment with the use of bilateral pararenal novocaine blockade;

2) deepening of the state of collapse and shock, despite conservative therapy;

3) a rapid increase in leukocytosis (up to 25,0 - 109/l);

4) a drop in the level of L-amylase in the blood and urine with a deterioration in the general condition;

5) progressive decrease in the level of calcium in the blood serum (fat necrosis);

6) the appearance of methemoglobin in the blood serum.

The course of pancreatic necrosis is severe. Mortality is 27 - 40% (A. A. Shalimov, 1976).

Purulent pancreatitis. This is one of the most severe forms of pancreatic damage, most often found in elderly and senile people. Purulent pancreatitis can occur on its own or be a further development of acute edema, as well as hemorrhagic necrosis when an infection is attached to them. Initially, the clinical picture consists of symptoms of acute pancreatic edema or hemorrhagic necrosis, then, when an infection is attached, a pronounced leukocytosis appears with a shift of the leukocyte formula to the left, purulent intoxication, and a sharp temperature fluctuation.

Thus, at present, it is possible to make not only the diagnosis of acute pancreatitis, but also indicate the form of pancreatic lesion, since each of its forms is characterized by a corresponding clinical and pathomorphological picture.

Differential diagnosis and treatment. It is difficult to distinguish acute pancreatitis from other acute diseases of the abdominal organs due to the presence of the same manifestations that sometimes occur against the background of a severe general condition of the patient.

Acute pancreatitis must be differentiated from acute cholecystitis, perforated gastric ulcer, food intoxication, acute intestinal obstruction, mesenteric vascular thrombosis, ectopic pregnancy, acute appendicitis, and myocardial infarction.

In the treatment of acute pancreatitis, all measures should be directed to the main etiopathogenetic factors: perirenal blockade with a 0,25% novocaine solution according to Vishnevsky as an effect on neuroreceptor factors; creation of physiological rest to the affected organ - hunger, aspiration of gastric contents (probe through the nose); inhibition of the secretory activity of the pancreas - atropine 0,1% subcutaneously, 1 ml every 4-6 hours; intravenous administration of blood, plasma, polyglucin-novocaine mixture (polyglucin 50 ml + 1% novocaine solution 20 ml) up to 3-4 liters in order to eliminate circulatory disorders. Antienzymatic therapy - trasilol, tsalol, contrical (50 - 000 units, some recommend up to 75 units per administration), sandostatin, kvamatel; to eliminate pain - promedol (it is not recommended to use morphine, as it causes spasm of the sphincter of Oddi), diphenhydramine 000% - 300 - 000 times a day as an antihistamine; insulin - 2 - 2 units, 3% papaverine 4 - 12 times, nitroglycerin 2 g in tablets under the tongue; aminocaproic acid 2% in isotonic sodium chloride solution intravenously, 3 ml; corticosteroid hormones - hydrocortisone or prednisolone (intravenously or intramuscularly - 0,0005 - 5 mg); antibacterial therapy, cardiac (100% strophanthin but 15 - 30 ml 0,05 times, 0,5% corglicon 1 - 2 ml 0,05 time).

When the condition improves on the 4th - 5th day, patients can be prescribed table No. 5a, that is, food in liquid form with a limited calorie content, since carbohydrate-protein fat-free food reduces the secretion of the pancreas. The alkali that comes with food through the mouth also inhibits the separation of pancreatic juice.

On the 8th - 10th day, patients can be assigned table number 5 and fractional meals should be recommended. Upon discharge from the hospital, it is forbidden to eat fatty and fried meat, spicy and sour dishes, seasonings for 1-2 months.

If conservative therapy has no effect, and the patient's condition worsens, general intoxication of the body increases, pain does not stop or, on the contrary, intensifies, signs of peritoneal irritation appear, the amount of L-amylase in the blood and urine remains high or increases, i.e. acute edema If the pancreas turns into necrosis or suppuration, then surgical treatment is indicated.

Surgery consists of the following steps:

1) median laparotomy (incision along the midline from the xiphoid process to the navel);

2) approach to the pancreas into the cavity of the omental sac, preferably through the gastrocolic ligament (the most direct and convenient way for draining the pancreas);

3) removal of exudate from the abdominal cavity with electric suction and gauze swabs;

4) dissection of the peritoneum covering the gland;

5) drainage of the cavity of the stuffing bag with tampons and a rubber tube.

Not all authors recommend dissecting the peritoneum covering the pancreas.

Chronic pancreatitis

There are recurrent and primary chronic pancreatitis. A. V. Smirnov, O. B. Porembsky, D. I. Frid (1972) indicate that chronic pancreatitis, not associated with diseases of the biliary tract, is characterized by:

1) the rapid development of endocrine and metabolic disorders due to violations of external and internal secretion of the pancreas;

2) the occurrence of necrotic changes in the acute phase, followed by the formation of pancreatic pseudocysts;

3) relatively often observed formation of stones in the ducts and parenchyma of the pancreas.

An important factor in the pathogenesis of chronic pancreatitis is a violation of the outflow of pancreatic juice, stasis in the pancreatic duct system, various vascular disorders play a certain role. Some researchers attach great importance to metabolic factors in the genesis of chronic pancreatitis, others consider alcoholism one of the most important factors contributing to its occurrence.

Clinical manifestations chronic pancreatitis:

1) pain syndrome;

2) violations of the exocrine function of the pancreas;

3) violations of the insular apparatus;

4) symptoms of complications of pancreatitis caused by biliary hypertension, the formation of cysts and fistulas of the pancreas, portal hypertension, etc.

One of the main and earliest symptoms of chronic pancreatitis is pain in the upper abdomen radiating to the lower back, left shoulder, left shoulder blade, left shoulder girdle. It can be constant, incessant, painful, can be aggravated after eating fatty, hot or cold foods, occur at night and often resemble the pain of a duodenal ulcer. The pain syndrome can also be expressed in the form of recurrent attacks of pancreatic colic. A painful attack is associated with difficulty in the outflow of pancreatic juice, which causes hypertension in the pancreatic ducts.

On palpation, the abdomen is usually soft, painful in the upper section and in the projection of the pancreas.

In addition to pain with typical localization, patients experience a feeling of heaviness in the epigastric region after eating, belching, bloating, stool retention, constipation, in some patients - dyspeptic disorders, vomiting, loss of appetite.

In connection with the violation of the digestion and absorption of fats and proteins, insufficient absorption of nutrients and vitamins in the intestines and a disorder of pancreatic secretion, weight loss occurs, despite the fact that the appetite is preserved or even increased.

In chronic pancreatitis, a violation of the endocrine function of the pancreas is possible, manifested more often by the development of symptoms of diabetes mellitus and less often by hypoglycemia.

The clinical course of diabetes mellitus against the background of chronic pancreatitis has its own characteristics. Symptoms of diabetes mellitus occur several years after the onset of pain attacks, which indicates the secondary nature of the damage to the insular apparatus. One of the complications of chronic pancreatitis is the syndrome of biliary hypertension, and its main manifestations are obstructive jaundice and cholangitis. Partial or complete obstruction of the biliary tract may depend on the compression of the distal common bile duct by the inflamed and compacted head of the pancreas, as well as on the obstruction in the area of ​​the Vater nipple (stenosis, stone).

В diagnostics chronic pancreatitis attach great importance to the study of external and internal secretion of the pancreas. These studies include:

1) determination of the external secretion of the gland by examining the pancreatic secret both in the state of functional rest of the gland and under the action of physiological stimuli;

2) analysis of the state of external secretion depending on the digestive capacity of the pancreatic secret;

3) detection of the phenomenon of "evasion" of pancreatic enzymes by determining the latter in the blood and urine in the initial state and after the use of pancreatic secretion stimulants;

4) detection of insufficiency of the insular apparatus of the pancreas.

Uncomplicated chronic pancreatitis is treated therapeutically, and only if conservative treatment fails or complications occur, surgical treatment is used, which is one of the stages of complex treatment.

Surgical intervention, according to indications, is carried out on organs that are anatomically and functionally related to the pancreas - on the gallbladder and ducts, the nipple of Vater, the gastrointestinal tract, large branches of the abdominal aorta, the autonomic nervous system, on the pancreas itself and its duct system.

The choice of a specific method of surgical intervention depends on the nature of the anatomical and functional changes both in the pancreas and in adjacent organs.

Cysts of the pancreas

Most surgeons adhere to the following classification:

1. False cysts:

1) inflammatory origin (after acute and chronic pancreatitis);

2) after injury - blunt, penetrating wound, operating room;

3) in connection with a neoplasm;

4) parasitic (roundworm);

5) idiopathic.

2. True cysts:

1) congenital - simple cyst, polycystic disease, fibrocystic disease, dermoid cyst;

2) acquired - retention cysts (inflammatory origin, post-traumatic, secondary parasitic (ascariasis), parasitic (echinococcus, tapeworm);

3) tumor - benign (cystadenoma) vascular cyst, malignant - cystadenocarcinoma, teratoma.

false cyst - a cyst located inside the pancreas or on it, lined with fibrous tissue. The inner surface of the cyst does not have an epithelial cover, and its contents are pancreatic juice.

Clinically, a false cyst of the pancreas is manifested by pain in the epigastric region or the left side of the abdomen. There is nausea, vomiting, loss of appetite. Some patients are asymptomatic.

Palpation is determined by a round, smooth body, sometimes slightly mobile during breathing and palpation.

X-ray examination of the gastrointestinal tract, tomography of the pancreas with retropneumoperitoneum, as well as scanning helps to establish the diagnosis.

In the surgical treatment of a false cyst, two operations are mainly used - excision and drainage of the cyst (external or internal).

With external drainage, the cyst wall is sutured to the abdominal wall with the introduction of a drainage tube into the cyst cavity. With internal drainage, an anastomosis is applied between the cyst and the jejunum with additional enteroenteroanastomosis.

Pancreas cancer

Pancreatic cancer can be primary, secondary - with the transition of the cancer process from the stomach, biliary tract and metastatic - with cancer of the esophagus, duodenum and colon.

The growth and spread of pancreatic cancer occurs in the following ways:

1) germination in the surrounding organs and tissues, when the cancer captures the duodenum, stomach, colon and left kidney;

2) along the lymphatic tracts, especially perineural and perivasal.

The tumor is dense, compresses the pancreatic ducts, which leads to their stretching with a secret, sometimes retention cysts develop. As the tumor grows, compression of the common bile duct or tumor growth can occur, leading to stretching of the common bile duct and the overlying bile ducts and gallbladder. The bile in the bladder and bile ducts is absorbed and they fill with secretions (white bile).

Pain of varying intensity (an early symptom of pancreatic cancer) is localized in the upper abdomen, spreading to the lower back. Along with pain, there is often a loss of appetite, there may be nausea, vomiting, feces become discolored, urine becomes the color of beer. Some patients develop itching. The patient loses weight. Pain and weight loss are followed by jaundice.

With the localization of cancer in the head of the pancreas, there may be a positive symptom of Courvoisier. In patients, ascites is determined, which is associated with portal hypertension or with the spread of a cancerous process in the peritoneum.

In case of a cancerous lesion, the pancreas, as a rule, is not palpated, only in some cases at the site of its projection it is possible to feel a compacted gland, somewhat painful. Unlike gastric cancer, the lymph nodes in the left supraclavicular region are not palpable.

If pancreatic cancer is suspected, an X-ray examination can provide indirect or direct evidence of damage to this gland.

With this disease, palliative and radical operations are used. Palliative operations are aimed at combating obstructive jaundice in order to prevent the occurrence of secondary liver abscesses.

A significant number of biliodigistic anastomoses have been proposed:

1) cholecystogastrostomy;

2) cholecystoduodenostomy;

3) cholecystoethonostomy in various variants;

4) choledocho-duodenostomy;

5) choledochojejunostomy in various variants.

Radical operations include pancreatoduodenal resection and resection of the tail of the pancreas.

LECTURE No. 5. Endemic and sporadic goiter

Endemic goiter

This is a disease of the whole body, which is accompanied by an increase in the thyroid gland. It occurs constantly within certain geographical boundaries and has its own patterns of development.

It is now well known that endemic goiter is closely associated with iodine deficiency. As A.P. Vinogradov notes, endemic goiter occurs in "biogeochemical provinces", which are characterized by a low content of iodine in soil, water, food, and, as a result, in the human body. At the same time, normal metabolic processes in the human body are disturbed due to insufficient synthesis of iodinated thyroid hormones (thyroxine, triiodothyronine), which are the main iodine concentrators.

Endemic goiter in women is more common than in men, and develops against the background of an enlarged thyroid gland. It is especially common during puberty, during menstruation and pregnancy. Its development is also affected by unfavorable sanitary and hygienic conditions.

One of the methods for determining the enlargement of the thyroid gland is to examine it during swallowing. When swallowing, it is possible to determine the external shape, size and consistency of the thyroid gland.

Symptoms of clinical manifestation endemic goiter mainly depend on its location and size. Relatively often there is a displacement of the trachea in the direction opposite to the location of the goiter, which can be established by X-ray examination. Most often, respiratory distress occurs with a retrosternal location of the goiter, which is characterized by an increase in shortness of breath when turning the head. When the goiter is located in the posterior mediastinum, dysphagia (swallowing disorder) may occur due to pressure on the esophagus.

An in-depth and thorough examination of patients with endemic goiter reveals a number of common disorders of the nervous, cardiovascular and reproductive systems. There is hypotension and, as a result, increased fatigue, weakness, palpitations, dizziness.

Most often, endemic goiter develops slowly and gradually, however, under the influence of certain factors (nervous strain, change of residence, nature of work, injuries, childbirth, abortion, lactation), the progression of the disease can accelerate.

Endemic goiter can change from euthyroid to hyperthyroid form, give hemorrhages into the thyroid parenchyma (into cysts or nodes), go into a malignant form (most often into thyroid cancer).

Treatment. Conservative therapeutic treatment of endemic goiter is carried out mainly in the early stages of the disease with diffuse forms of goiter, especially in childhood and young age. This treatment can be considered as a preoperative preparation in the presence of nodular goiter in individuals who are indicated for surgical treatment.

The most reasonable and effective method of treating endemic goiter is with thyroid hormones (thyroxine, triiodothyronine) or the corresponding hormonal drug - thyroidin.

Treatment with thyroidin begins with small doses (0,025 g 2 times a day), then, under medical supervision, the dose is gradually increased, bringing it to 0,05 - 0,1 g 2 times a day. After obtaining a clinical effect, the therapeutic dose is reduced, leaving maintenance doses for a long time.

Surgical treatment of diffuse endemic goiter is indicated when signs of compression of the neck organs appear (impaired breathing, swallowing, etc.), which is more often observed with large goiter sizes. All nodular and mixed forms of endemic goiter are subject to surgical treatment, since they are not amenable to therapeutic treatment.

sporadic goiter

Unlike endemic, it occurs everywhere, occurs in connection with neurohormonal disorders in the body that cause an increase in the thyroid gland.

According to the general symptoms of manifestations, sporadic goiter is most often euthyroid. Treatment its the same as in endemic goiter.

Some progress has been made in the surgical treatment of endemic and sporadic goiter. In nodular and mixed forms of endemic and sporadic goiter, an economical resection of the thyroid gland should be performed.

Diffuse toxic goiter

This form has many names, which are based either on the names of the authors who described it (Basedow's, Perry's, Grevs', Flayani's disease), or individual manifestations of the disease (thyrotoxicosis, hyperthyroidism, etc.).

Mental disorders occupy one of the leading places in the manifestation of toxic goiter. These patients are restless, fussy, anxious, timid and indecisive. Patients with thyrotoxicosis are characterized by increased excitability, irascibility, irritability, excessive mood lability, a tendency to a sad mood, resentment, increased fatigue, unmotivated mood swings, attacks of melancholy that appear without an external reason, and the absence of intellectual impairment.

According to a number of authors involved in the treatment of patients with toxic goiter, neuropsychiatric disorders are caused by the direct effect of excessively produced thyroid hormones on the nervous system as a whole.

Mental and physical performance of patients is significantly reduced. They are unable to focus their attention on any subject for a long time, they are easily exhausted, distracted. They seem to have an accelerated flow of thoughts. Patients instantly give answers, even if they are mistaken. Most patients suffer from insomnia, sleep is short, disturbing, not having a sufficiently refreshing effect on them.

Patients with thyrotoxicosis have ocular symptoms. One of the most common (but optional) is exophthalmos. In addition to bulging, a number of symptoms are characteristic, such as expansion of the palpebral fissures (Delrymple's symptom), rare blinking (Stelwag's symptom), the appearance of a white strip of sclera above the iris when the eyeball moves downward (Graefe's symptom), deviation outward of the eyeball when fixing vision at close range. distance (Moebius symptom), absence of wrinkling of the forehead when looking up (Geofroy's symptom).

In some patients, cardiovascular disorders come to the fore, while they complain of shortness of breath, palpitations, which increase even with slight physical exertion, excitement. There are intermittent aching, stabbing pains in the region of the heart without characteristic irradiation.

Patients feel the pulsation of blood vessels in the neck, head. In the elderly, angina pectoris pains are observed with a return to the left arm, shoulder blade, behind the sternum. Their heartbeat is constant at rest and during sleep. The pulse rate can reach up to 120 - 160 beats per minute.

If a patient with primary thyrotoxicosis develops atrial fibrillation during dynamic observation, then its cause is toxic goiter. However, after surgery for toxic goiter, even in the elderly, where the cause of atrial fibrillation was thyrotoxicosis, it is removed with medication before surgery.

In the absence of severe atherosclerosis of the coronary vessels, pain in the region of the heart in thyrotoxicosis is never complicated by thrombosis of the coronary vessels.

V. G. Baranov, V. V. Potin distinguish three degrees of severity of thyrotoxicosis:

I. Mild degree (SBI 9,4 ± 0,3 μg% ) - mild symptoms, slight weight loss, moderate tachycardia (no more than 100 beats per minute), basal metabolic rate does not exceed + 30%;

II. Moderate (SBI 12,1 ± 0,4 μg%) - clearly expressed symptoms and weight loss, tachycardia (100 - 120 beats per minute), basal metabolism ranges from + 30 to -60%;

III. Severe (SBI 16,3 ± 1,7 μg%) - pronounced symptoms, rapidly progressive weight loss with significant weight loss, tachycardia (over 120 beats per minute), basal metabolic rate exceeds + 60%.

Regardless of the intensity of thyrotoxicosis, grade III includes its complicated forms - atrial fibrillation, heart failure, thyrotoxic liver damage, etc. Patients have muscle weakness, trembling of the whole body and its individual parts (eyelids, limbs, head, torso). Particularly characteristic is the frequent small involuntary trembling of the fingers of outstretched hands (with a relaxed hand), which is aggravated by excitement, fatigue and exacerbation of the thyrotoxic process.

There is a violation of thermoregulation, with a severe form of thyrotoxicosis, the temperature reaches 37,6 - 37,8 ° C. The nature of the temperature is thermoneurotic. Patients do not tolerate heat and thermal procedures, under the influence of which thyrotoxicosis can worsen. In addition, there is increased sweating, which, in severe form, can be so pronounced that it does not give patients rest day or night.

With thyrotoxicosis, all types of metabolism are increased, especially fat and water, fats burn intensively, the body loses a large amount of water. All this leads to drastic weight loss. Often weight loss is one of the first symptoms of thyrotoxicosis. If, in violation of metabolism, the breakdown of proteins is simultaneously increased, then emaciation and weakness are sharply expressed in patients.

Causes of appearance toxic goiter in childhood and adolescence are the same as in adults, but mental trauma does not occupy such a significant place in them. symptomatology the same as in adults. However, here in the first place are the symptoms associated with insufficiency of the adrenal cortex - general weakness, fatigue, severe pigmentation of the skin, low diastolic (minimal) blood pressure, sometimes reaching 0.

Clinic toxic goiter in the elderly is very diverse, but it is distinguished by a more pronounced manifestation of symptoms, the duration of the disease. With a long course of the disease, there are significant changes in the nervous, cardiovascular systems, in parenchymal organs.

Nodular toxic goiter (toxic adenoma)

The disease is characterized by the formation in one of the lobes of the thyroid gland of a single node, reaching the size of III-IV degree, with a sharply increased functional activity and a decrease in the function of the rest of the thyroid gland. Women are more likely to get sick, older and middle-aged people are more prone to this disease.

Clinically toxic adenoma is marked by a little noticeable onset, manifests itself gradually. Its initial symptoms: general weakness, fatigue, irritability, palpitations, weight loss. Then the disease progresses rapidly: efficiency decreases, headaches, sweating, increased heart rate, trembling fingers of outstretched hands appear, an increase in skin moisture is noted. Eye symptoms in toxic adenoma are mild or completely absent.

When examining the neck on its front surface in one of the lobes, a round or oval node is palpated, elastic, painless, with a smooth surface, not soldered to the surrounding tissues, participating in the act of swallowing.

Clinical course toxic goiter largely depends on the predominant involvement in the pathological process of one or another system - neuropsychic, cardiovascular, etc. A certain role is played by the constitutional features of the body, the age of patients, life and other factors of the external and internal environment of the body.

All methods of treatment of diffuse toxic goiter must be divided into two groups: therapeutic treatment with drugs and radioactive iodine and surgical. In some cases, therapeutic treatment is a method of preoperative preparation. There are deadlines for medical treatment, in case of ineffectiveness of which patients should be operated on.

Drug treatment. Treatment of diffuse toxic goiter, especially its severe and moderate forms, is a rather difficult task, since a number of vital organs and systems are involved in the pathological process.

In severe and moderate forms of the disease, treatment should begin in a hospital setting.

A patient with thyrotoxicosis must be provided with a deep 9-12 hour sleep, which is achieved by the appointment of bromides, hypnotics.

For the treatment of primary thyrotoxicosis, bromides are used, since they have a calming effect on the nervous system by weakening the irritable cortical process. Treatment should begin with the appointment of bromides, one teaspoon 2 times a day (0,1 g per day), if necessary, gradually increasing the dose to 1,2 g per day - 2% sodium bromide (one spoon 3 times a day ).

In primary thyrotoxicosis, a number of specific drugs have been proposed to affect the central nervous system and its peripheral parts. However, in terms of the effectiveness of the action, the alkaloid from the rauwolfia plant, reserpine, which has parasympathomimetic properties, is most widely used. Like bromides, it enhances inhibitory central impulses by activation, but unlike them, by the method of selective action on subcortical centers. At a dose of 0,5 - 1 mg per day, reserpine relatively quickly reduces the basal metabolism, blood pressure, slows down the pulse, relieves general nervous excitability, increases weight, while at the same time not being a specific thyreostatic drug. In combination with thyreostatic drugs, it enhances their effect.

for the treatment of primary diffuse toxic goiter offered different doses of iodine. Quite effective for varying severity of primary thyrotoxicosis doses of 0,0005 - 0,001 g of iodine and 0,005 - 0,01 g of potassium iodide per day, usually prescribed in pills or mixture.

Thyrostatic (antithyroid) drugs - mercazolil and potassium perchlorate - are widely used in clinical practice.

Mercazolil is a very effective thyreostatic substance. It reduces the synthesis of thyroxine and triiodothyronine in the thyroid gland, as a result of which it has a specific therapeutic effect in case of its hyperfunction, causing a decrease in basal metabolism.

In mild and moderate forms of thyrotoxicosis, 0,005 g of Mercazolil is prescribed 2 to 3 times a day. When removing the symptoms of thyrotoxicosis, it is necessary to take a maintenance dose of the drug for a long time (up to several months) at 0,0025-0,005 g per day daily or 2-3 times a week until a stable therapeutic effect is obtained.

The use of Mercazolil in diffuse toxic goiter in combination with reserpine (0,25 mg 2-4 times a day) is very effective, while in some cases the dose of Mercazolil can be reduced to 0,005 g 2 times a day.

Potassium perchlorate is also an antithyroid (thyreostatic) substance. Its thyreostatic effect is associated with inhibition of the thyroid gland to accumulate iodine, which leads to inhibition of the formation of tetra- and triiodothyronine. According to its thyreostatic action, it is less effective than Mercazolil. It is prescribed for mild and moderate forms of toxic goiter in persons with a short duration of the disease.

Contraindication for the appointment of potassium perchlorate is peptic ulcer of the stomach and duodenum. The effectiveness of treatment is associated with the individual sensitivity of patients to the action of the drug. The therapeutic effect usually occurs by the end of the 3rd - 4th week.

With a mild form of toxic goiter, the daily dose of the drug in the first 4-5 weeks is usually 0,5-0,75 g (0,25 g 2-3 times a day), then 0,25 g per day. The duration of the course of treatment is 2 - 4 months.

With moderate severity of toxic goiter, 0,75 - 1 g of the drug per day (0,25 g 3 - 4 times a day) is prescribed for 4 - 5 weeks, then the dose is reduced to 0,5 - 0,25 g per day. day. The duration of the course of treatment is 4-5 months. The total dose of the drug for the course of treatment is 70-100 g.

Also, in the treatment of diffuse toxic goiter, various drugs are used that stop the manifestations of this disease (blockers, etc.).

Surgery. In cases where therapeutic treatment of diffuse toxic goiter for 8-10 months does not work, surgical treatment is indicated. The sooner the operation is done, the faster and more fully the disturbed functions of the body will be restored and the faster the compensation will come. Therefore, the operation for toxic goiter must be carried out before the onset of decompensation in various organs and systems.

Acute forms of thyrotoxicosis with unsuccessful therapeutic treatment are operated on no later than 3 months from the start of treatment.

Currently, contraindications to surgical treatment of toxic goiter are sharply narrowed. The operation is contraindicated after a recent myocardial infarction, with acute cerebrovascular accident. In acute inflammatory diseases of various localizations, there are temporary contraindications. The advanced age of patients with toxic goiter is not a contraindication to surgical treatment, however, these patients need especially careful preoperative preparation, which should be carried out taking into account possible concomitant diseases.

In 1933, O. V. Nikolaev developed a method of extremely subtotal subfascial resection of the thyroid gland, in which the radicalness of the operation reaches a physiologically acceptable limit. He recommends a transverse incision at the site of the greatest protrusion of the goiter.

So, with subtotal resection of the thyroid gland, the basic principles of Nikolaev's operation are preserved: the decollete incision gives a good cosmetic result, the neck muscles that cover the thyroid gland do not intersect. Nodular toxic goiter, which is a functioning tumor of the thyroid gland, is subject only to surgical treatment.

Patients with nodular toxic goiter need the same thorough preoperative preparation as with diffuse toxic goiter, and its duration and intensity are determined individually, depending on the severity of thyrotoxicosis. A unilateral subtotal strumectomy is used.

Hypothyroidism and myxedema

Hypothyroidism is a disease of the thyroid gland, due to the insufficiency of its function.

Distinguish between primary and secondary hypothyroidism.

cause of primary hypothyroidism may appear:

1) congenital aplasia or underdevelopment of the thyroid gland (leads to cretinism), which is more often observed in foci of endemic goiter (endemic cretinism);

2) complete or partial shutdown of the function of the thyroid gland (X-ray irradiation, thyroidectomy - complete removal of the thyroid gland, more often with its malignant neoplasms);

3) weakening of the hormonal activity of the thyroid gland as a result of the action of thyreostatic factors, both natural and synthetic;

4) weakening of the hormone-forming activity of the thyroid gland as a result of various inflammatory processes in it;

5) genetically determined disturbances in the biosynthesis of thyroid hormones.

Secondary hypothyroidism associated with loss of action of thyroid-stimulating hormone (TSH) of the pituitary gland, which stimulates the function of the thyroid gland.

Clinical manifestations hypothyroidism is directly opposite to thyrotoxicosis.

Patients with hypothyroidism, as a rule, are inhibited, slow in movements, are distinguished by slow-wittedness and weakening of memory and mental abilities. There is indifference to sexual life, men often have impotence. Patients suffer from constipation. There are compressive pains in the region of the heart.

Treatment hypothyroidism is based mainly on the use of thyroid hormones (L-thyroskin, euthyrox), which compensate for thyroid insufficiency and normalize metabolic processes. It should be carried out only under the supervision and control of a physician. Treatment begins with small doses, gradually bringing to the desired effect.

Thyroid Cancer

Among all diseases of the thyroid gland, cancer is the most difficult problem in diagnosis and treatment, since the clinical peculiarity of malignant tumors is due to the fact that in some cases their forms are characterized by slow growth, duration of the course and mild general symptoms, in others they develop rapidly.

According to the World Health Organization, over the past 20 years, the incidence of thyroid cancer is significantly higher than the incidence of other forms of cancer, with the exception of malignant tumors of the lung.

Thyroid cancer most often occurs between the ages of 40 and 60.

International TNM classification (6th edition)

T - tumor.

T1 - one-sided single node.

T2 - unilateral multiple nodes.

T3 - bilateral, or isthmus, node.

T4 - the spread of the tumor outside the gland.

N - regional lymph nodes.

NO - no metastases.

N1a - nodes on the affected side.

N16 - bilateral, or contralateral nodes.

M - distant metastases.

MO - no metastases.

M1 - metastases are present.

There are primary thyroid cancer, which manifests itself in a previously unchanged thyroid gland, and secondary thyroid cancer, which occurs on the basis of nodular goiter.

Patients with nodular goiter should be under medical supervision. If a long-existing goiter suddenly begins to grow, if the node or nodes in it become dense to the touch, or the node reaches a size of 1 - 1,5 cm, if the patient complains of difficulty in swallowing, then there is always a suspicion of his malignant degeneration. Nodular goiter is a potentially precancerous condition, and therefore all nodular forms of goiter are subject to surgical treatment.

The following clinical symptoms are characteristic of thyroid cancer:

1) a rapid increase in the previous goiter with a sharp compaction of its consistency;

2) rapid enlargement of a previously normal thyroid gland (primary tumor);

3) compaction and tuberosity (if the tumor develops on the basis of a goiter, then the compaction appears in one of the isolated nodes, and then captures the entire gland);

4) the immobility of a pre-existing goiter, with the further development of the process, the tumor of the thyroid gland becomes immobile.

The immobility and compaction of the tumor create a mechanical obstacle to breathing and swallowing, as a result of which patients experience shortness of breath, difficulty swallowing, dilation of the veins of the neck. There are pains in the back of the head, paralysis of motor nerves, primarily recurrent, Horner's symptom (ptosis, miosis, endophthalmos).

Treatment thyroid cancer should be complex - surgery, radiation therapy, long-term use of L-thyroxine (at a thyreostatic dose of 2 μg / kg).

Treatment with radioactive iodine is used for medullary thyroid cancer or the metastatic stage of the disease. In this case, the main condition for starting therapy is the absence of thyroid tissue (thyroidectomy is performed).

Autoimmune thyroiditis (Hashimoto's goiter)

Autoimmune thyroiditis (lymphomatous goiter, lymphoid thyroiditis) was first described in 1912 by the Japanese scientist Hashimoto. This disease is based on diffuse infiltration of thyroid parenchyma by lymphocytes.

Most often, women aged 50 years and older get sick.

The blood serum of patients suffering from autoimmune thyroiditis contains thyroid autoantibodies, and the titer of these antibodies is very high.

Lymphoid tissue usually infiltrates both lobes of the thyroid gland, but the infiltration never extends to the tissues surrounding the thyroid gland. Lymphoid tissue destroys the parenchyma of the thyroid gland, and the place of the destroyed parenchyma is occupied by fibrous tissue.

Patients complain of thickening and soreness of the anterior surface of the neck in the thyroid gland, shortness of breath, symptoms of a feeling of food getting stuck in the esophagus when swallowing, weakness and general fatigue appear. On palpation, the thyroid gland is dense, but not to the same extent as with Riedel's goiter. The temperature is often elevated, leukocytosis is observed in the blood.

In the initial period of the disease, signs of hyperthyroidism are observed, which are soon replaced by symptoms of hypothyroidism. Radiologically, in most cases, there is a narrowing of the windpipe and esophagus.

В treatment autoimmune thyroiditis, pathogenetic therapy or a surgical method is used.

Pathogenetic treatment is aimed at the use of agents that can reduce the autoimmune stimulus, have an inhibitory effect on the process of autoimmunization, reduce or eliminate the infiltration of the thyroid gland by lymphocytes or plasma cells. This effect is exerted by some hormonal preparations and, first of all, thyroidin, the use of which contributes to the regression of the symptoms of autoimmune thyroiditis and the reduction of the thyroid gland to normal size. With this treatment, the general condition of patients improves, the level of antibodies in the blood decreases, and hypothyroidism decreases.

The drug is prescribed individually, and its initial dose is on average 0,1 - 1,15 g. Treatment continues for several months or years.

Recently, glucocorticoids (cortisone or prednisolone) and adrenocorticotropic hormone have been widely used to treat autoimmune thyroiditis.

Indications for surgical treatment:

1) symptoms of compression of the neck organs;

2) difficulties in differential diagnosis between autoimmune thyroiditis and thyroid tumors;

3) suspicion of a combination of autoimmune thyroiditis with adenoma or carcinoma of the thyroid gland.

During the operation, an economical or subtotal resection of both lobes and the isthmus of the thyroid gland is performed.

LECTURE № 6. Breast cancer

Epidemiology

Breast cancer (BC) is the most common type of cancer among women; in the structure of oncological diseases of women, it ranks first, accounting for 1% in the Russian Federation in 19,5, and the incidence is constantly growing. Approximately 2005 new cases of the disease are diagnosed each year, and approximately 25 women die from it each year, more than from any other cancer. It is the most common single cause of death among all women aged 000 to 15.

Anatomy and physiology

The mammary glands are glandular hormone-dependent organs that are part of the female reproductive system, which develop and begin to function under the influence of a whole complex of hormones: releasing factors of the hypothalamus, gonadotropic hormones of the pituitary gland (follicle-stimulating and luteinizing), chorionic gonadotropin, prolactin, thyroid-stimulating hormone, corticosteroids, insulin and , of course, estrogens, progesterone and androgens.

The blood supply to the mammary glands is carried out due to the branches of the internal thoracic (about 60%) and axillary (about 30%) arteries, as well as due to the branches of the intercostal arteries. The veins of the mammary gland accompany the arteries and anastomose widely with the veins of the surrounding areas.

From the position of oncology, the structure of the lymphatic system of the mammary gland is of great importance. There are the following ways of outflow of lymph from the mammary gland:

1. Axillary way.

2. Subclavian way.

3. Parasternal way.

4. Retrosternal way.

5. Intercostal way.

6. The cross path is carried out along the skin and subcutaneous lymphatic vessels passing the midline.

7. The path of Gerota, described in 1897. When tumor emboli blockade the main outflow tracts of lymph, the latter through the lymphatic vessels located in the epigastrium, perforating both layers of the sheath of the rectus abdominis muscle, enters the preperitoneal tissue, from there to the mediastinum, and through the coronary ligament - into the liver.

The main pathogenetic manifestations of breast cancer

Hypothyroid form - cancer of the young (4,3%), occurs at the age of 15 - 32 years. Features: hypothyroidism, early obesity, menstruation up to 12 years, follicular ovarian cysts and tissue hyperplasia are common. The prognosis is unfavorable, the course is rapid, distant metastases develop rapidly.

Ovarian form occurs in 44% of women. Pathogenetic influences for this group are associated with ovarian function (childbirth, sexual activity, fibroadenomatosis). The prognosis is unfavorable due to rapid lymphogenous dissemination, multicentric growth.

Hypertensive-adrenal (39,8%) - patients aged 45 - 64 years old, suffer from obesity, increased age-related levels of cholesterol, cortisol, and hypertension. Characterized by uterine fibroids, diabetes, signs of intensified aging. The prognosis is unfavorable due to the frequency of diffuse-infiltrative forms.

Senile, or pituitary (8,6%) occurs in women in deep menopause. characteristic age-related changes. The prognosis is relatively favorable, the process is localized for a long time, metastasis develops later and proceeds slowly.

Tumor during pregnancy and lactation. The prognosis is extremely unfavorable due to an increase in the level of prolactin and growth hormone.

International classification of breast cancer according to the TNM system (6th edition, 2003)

T - primary tumor

Tx - insufficient data to evaluate the primary tumor.

That - the primary tumor is not determined.

Tis - preinvasive carcinoma: intraductal or lobular carcinoma (in situ), or Paget's disease of the nipple without the presence of a tumor node.

Paget's disease, in which the tumor node is palpated, is classified according to its size.

T1 - tumor up to 2 cm in greatest dimension.

T1mic (microinvasion) - tumor up to 0,1 cm in greatest dimension.

- T1a - tumor up to 0,5 cm in greatest dimension.

- Tib - tumor up to 1 cm in greatest dimension.

- Tic - tumor up to 2 cm in greatest dimension.

T2 - tumor up to 5 cm in greatest dimension.

T3 - Tumor more than 5 cm in greatest dimension.

T4 Tumor of any size with direct extension to the chest wall or skin. The thorax includes the ribs, intercostal muscles, serratus anterior, but without the pectoral muscles.

- T4a - spread to the chest wall.

- T4b - edema, (including "lemon peel"), or ulceration of the skin of the breast or satellites in the skin of the gland.

- T4c - signs listed in T4a and T4b.

- T4d - inflammatory form of cancer.

N - Regional lymph nodes

Nx - insufficient data to assess the state of regional lymph nodes.

N0 - no signs of damage to regional lymph nodes.

N1 - metastases in the displaced axillary lymph nodes on the side of the lesion;

N2 - metastases in the axillary lymph nodes fixed to each other, or clinically detectable metastases in the internal lymph nodes of the mammary gland on the side of the lesion in the absence of clinically detectable metastases in the axillary lymph nodes.

N3 - metastases in the subclavian lymph nodes with or without metastases in the axillary lymph nodes or clinically detectable metastases in the internal lymph nodes of the mammary gland on the side of the lesion in the presence of metastases in the axillary lymph nodes; or metastases in the supraclavicular lymph nodes on the affected side with or without metastases in the axillary or internal lymph nodes of the mammary gland.

- N3a - metastases in the subclavian lymph nodes.

- N3b - metastases in the internal lymph nodes of the mammary gland on the side of the lesion.

- N3c - metastases in the supraclavicular lymph nodes.

M - Distant metastases

Mx - insufficient data to determine distant metastases.

MO - no signs of distant metastases.

M1 - there are distant metastases.

Category M1 can be supplemented depending on the location of distant metastases: lung - PUL, bone marrow - MAR, bones - OSS, pleura - PLE, liver - HEP, peritoneum - PER, brain - BRA, skin - SKI.

Clinical forms of breast cancer

1. Nodal.

2. Diffuse infiltrative:

1) edematous-infiltrative;

2) inflammatory (inflamatory):

a) mastitis-like;

b) erysipelatous Shell.

3. Cancer in the duct.

4. Paget's cancer.

Nodal shape. The most common among other forms of breast cancer (75 - 80%). In the early stages, the tumor usually does not cause unpleasant subjective sensations. The only complaint, as a rule, is the presence of a painless dense tumor-like formation or an area of ​​induration in one or another part of the gland, more often in the upper outer quadrant.

During the examination, 4 categories of signs are evaluated:

a) the condition of the skin;

b) condition of the nipple and areola;

c) features of palpable compaction;

d) state of regional lymph nodes.

On examination, the symmetry of the location and shape of the mammary glands, the condition of the skin, areola and nipple are determined. Even with small (up to 2 cm) tumors, the symptom of "wrinkling" can be determined. With a central location of the tumor, even with small sizes, one can notice the retraction of the nipple and its deviation to the side.

On palpation, you can determine the "minimal" cancer - about 1 cm, it all depends on the location of the tumor. With its superficial or marginal location, at the smallest sizes, due to the shortening of the Kupffer ligaments, a symptom of "wrinkling", or retraction of the skin over the tumor, appears. The node on palpation is often painless, without clear contours, dense consistency, limited mobility along with the surrounding glandular tissue.

Swelling and infiltration of the skin - a symptom of "lemon peel", various kinds of deformation of the gland tissue, visible retraction of the skin over the tumor - a symptom of "umbilization", swelling of the areola and flattening of the nipple - a symptom of Krause, germination and ulceration of the skin, retraction and fixation of the nipple, etc. E. There are signs of metastatic lesions of regional lymph nodes: the presence of single dense, enlarged, painless nodes or in the form of conglomerates.

In the metastatic stage, symptoms of tumor intoxication join: weakness, dizziness, loss of appetite, etc. Symptoms of damage to other organs appear: cough, shortness of breath, pain in the abdominal cavity and bones, which requires a clarifying diagnosis in order to establish the stage of the disease.

Diffuse forms of breast cancer

Common features for these forms is the triad:

1. Swelling of the skin and tissue of the gland.

2. Skin hyperemia and hyperthermia.

3. Significant local prevalence, poor prognosis.

Edematous-infiltrative cancer. It is characterized by the presence of a painless or slightly painful dense infiltrate without clear boundaries, occupying most of the gland. At the same time, the mammary gland is enlarged in size, the skin is edematous, hyperemic into a fold, it is difficult to assemble, it looks like an "orange peel" due to the blockade of the lymphatic tract by tumor emboli or compression by the tumor infiltrate. Edema is most pronounced on the areola and surrounding tissues. In the armpit, dense lymph nodes are often determined, merging into a conglomerate.

Inflammatory (inflammatory) cancer. This form is represented by mastitis-like and erysipelas. They are quite rare, but often cause serious diagnostic errors.

Mastitis-like cancer. In contrast to edematous-infiltrative cancer, the symptoms of skin hyperemia and hyperthermia are more pronounced. The mammary gland is enlarged, edematous, tense, infiltrated, hot to the touch. A painful infiltrate is felt in the thickness of the gland, the skin above it is hyperemic, cyanotic.

Erysipelas cancer. With erysipelas-like breast cancer, the skin is sharply hyperemic, with uneven scalloped edges in the form of "tongues of flame" due to the spread of tumor cells through the lymphatic capillaries and vessels - cancerous lymphangitis. Skin edema, hyperemia and hyperthermia acquire the greatest degree of severity.

Armored cancer. This is a relatively rare form, it proceeds for a long time, torpidly. Shell cancer is characterized by extensive tumor infiltration of both the gland tissue itself and the skin covering it. The process can go beyond the mammary gland and spread to the chest, as well as to another mammary gland. It is manifested by wrinkling, compaction and a decrease in the size of the mammary gland. Skin changes resemble a shell: many small confluent tumor nodes appear, the skin becomes dense, pigmented and poorly displaced.

Intraductal breast cancer most often develops from intraductal papilloma and is a microfollicular foci. In the initial stage, the only symptom indicating the presence of a pathological focus is bloody discharge from the nipple. Palpation of the tumor at first fails to determine due to its small size and soft consistency.

Paget's cancer - intraductal epidermotropic breast cancer arising from the mouths of the large excretory lactiferous ducts of the nipple. Paget's disease has a different clinical course: the nipple and areola are most often in the foreground, less often a tumor is determined near the nipple, and changes in the nipple are secondary.

Patients feel a burning sensation, tingling and moderate itching in the nipple area. In the initial stage, scales, superficial erosions, and non-healing cracks appear on the nipple and areola. The nipple is enlarged in volume, compacted, there is also swelling of the areola. The skin has a reddish color, in some places it appears granular, as if devoid of epidermis.

Over time, the nipple flattens, collapses, and an ulcerated surface forms in its place, then the process spreads to the areola. The appearance of the mammary gland changes: in place of the nipple and areola, an ulcerated disc-shaped surface is formed, rising above the level of the skin with ridge-like edges. In the future, the process spreads eccentrically, capturing all new areas. In the breast tissue, a tumor-like formation can already be clearly palpated.

Diagnosis of breast cancer

Diagnosis of breast diseases is based on examination of the mammary glands, their palpation, mammography, ultrasound, puncture of nodular formations and suspicious areas, and cytological examination of the punctate.

With relatively large cancerous tumors, the following symptoms can be detected:

1) a symptom of umbilization (due to shortening of the Cooper ligaments involved in the tumor);

2) a symptom of the site (the genesis is the same);

3) a symptom of "wrinkling" (the genesis is the same);

4) a symptom of "lemon peel" (due to secondary intradermal lymphostasis due to blockade of the lymphatic tracts of regional zones or due to embolism by tumor cells of deep skin lymphatic vessels);

5) hyperemia of the skin over the tumor (manifestation of specific lymphangitis);

6) Krause's symptom: thickening of the areola fold (due to edema due to damage by tumor cells of the lymphatic plexus of the subareolar zone);

7) Pribram's symptom (when pulling on the nipple, the tumor moves behind it);

8) Koenig's symptom: when the mammary gland is pressed flat with the palm of the hand, the tumor does not disappear;

9) Payr's symptom: when the gland is grasped with two fingers on the left and right, the skin does not gather into longitudinal folds, but transverse folding is formed.

Palpation of regional lymph nodes.

Mammography study - a highly effective method for the recognition and differential diagnosis of diseases, which plays an important role in the diagnosis of breast cancer.

Primary radiological signs of cancer: the presence of a characteristic tumor shadow. Most often it is an irregular, stellate, amoeboid, with uneven, fuzzy contours, a shadow with a radial heaviness. The tumor node may be accompanied by a "path" to the nipple, its retraction, thickening of the skin. The presence of microcalcifications, i.e. salt deposits in the wall of the duct. They are found both in cancer and in mastopathy, and even in the norm. However, their nature is different. In cancer, microcalcifications are usually less than 1 mm and resemble grains of sand. The more of them, the smaller they are, the greater the likelihood of cancer.

Ductography (galactography or contrast mammography). It is carried out after the introduction of a contrast agent into the milk ducts. It is indicated in the presence of discharge from the nipple of any nature and color, but especially with a significant amount and bloody character.

According to Ultrasound of the mammary glands it is possible to identify a pathological focus in the mammary gland, its localization, shape and size. However, ultrasound is effective only in young women who have well-developed glandular tissue.

Cytological diagnostic method breast cancer allows you to judge the process before the start of treatment, when the most reliable confirmation of the clinical diagnosis is required.

incisional biopsy - taking a piece of tissue for cytological and histological examination. This procedure is performed under local anesthesia.

Diagnostic sectoral resection of the mammary gland is used for non-palpable formations of the mammary gland or when it is impossible to verify the process using other research methods.

Treatment

Breast cancer is treated with surgery, radiation therapy, chemotherapy, hormone therapy, and immunotherapy. Depending on the stage of the disease, the rate of tumor growth, the severity of the infiltrative component, the condition of the tissues surrounding the tumor, the age of the patient, her hormonal background, immunobiological status, concomitant diseases, general condition, etc., treatment is planned, which can be radical and palliative, and also surgical, combined and complex, when various therapeutic methods are used simultaneously or sequentially.

Surgery remains a leader in the treatment of breast cancer to date. The volume of surgical interventions used for breast cancer is different:

1. Radical mastectomy according to Halsled W., Meyer W. consists in the removal of a single block of the mammary gland along with the pectoralis major and minor muscles and their fascia, subclavian, axillary and subscapular tissue with lymph nodes within the anatomical cases.

2. Radical modified mastectomy according to Patey D., Dyson W., which differs from the Halsted operation in that it preserves the pectoralis major muscle.

3. Simple mastectomy. Removal of the mammary gland with the fascia of the pectoralis major muscle. From an oncological standpoint, it is regarded as a non-radical operation, since it does not remove the regional lymph collector.

4. Radical quadrantectomy of the breast is an organ-preserving operation. The operation consists in removing the breast sector together with the tumor, the underlying fascia of the pectoralis major muscle, the pectoralis minor muscle or only its fascia, as well as the subclavian, axillary and subscapular tissue with lymph nodes in one block.

Radiation therapy. This is a method of locoregional influence on the tumor process. It is used both in the preoperative and postoperative periods. Preoperative radiation therapy reduces the degree of malignancy of the primary tumor due to the death of its poorly differentiated elements, reduces intraoperative dissemination of tumor cells, deprives devitalized tumor cells of the ability to implant into distant organs in the irradiation zone and, thereby, prevents the occurrence of early relapses.

To achieve these goals, total focal doses (SOD) of 40 - 50 Gy are considered sufficient, summed up for 4 - 5 weeks to the postoperative scar (or mammary gland) at 40 Gy to the lymph drainage zones.

Chemotherapy and hormone therapy. Unlike radiation therapy, chemotherapy is a method of systemic treatment, i.e., capable of affecting tumor cells in all organs and tissues of the body. Bilateral ovariectomy, radiation castration, or gonadotropin-releasing hormone are used to reduce estrogen levels in patients of reproductive age. A synthetic analogue of this hormone - the drug Zoladex (Zoladex) - with constant use due to inhibition of the release of luteinizing hormone by the pituitary gland, leads to a decrease in the content of estradiol in the blood serum to a level comparable to that which occurs in menopausal women. The antiestrogen synthetic drug tamoxifen (Nolvadex, Zitazonium) is widely used in breast cancer, the mechanism of action of which is based on the ability of the drug to compete with estrogen receptors of tumor cells and prevent their interaction with estrogens, primarily with estradiol. Currently, tamoxifen is prescribed at 20 mg per day for 5 years.

To reduce the level of estrogen in this category of patients, drugs are used - aromatase inhibitors (mamomit, femara, etc.)

Chemotherapy standards are: 6 cycles of chemotherapy in AC mode (adriamycin + cyclophosphamide) or ACF (adriamycin + cyclophosphamide + fluorouracil) or CMF (cyclophosphamide + methotrixate + fluorouracil).

In low-risk patients, tamoxifen may be recommended or no additional drug treatment may be given.

The standard of neoadjuvant chemotherapy is the AS regimen (adriamycin + cyclophosphamide). The search for more effective neoadjuvant chemotherapy regimens is ongoing. To this end, chemotherapy combinations include cisplatin, navelbin, taxanes, as well as completely new drugs - xeloda and hercentin.

The optimal regimen of neoadjuvant chemotherapy is 4 courses.

Hercentin, a drug of a fundamentally new mechanism of action, is effective in case of overexpression of HER-2/neu in a breast tumor. Hercentin is recommended to be used in combination with hormone therapy and chemotherapy.

Immunotherapy. It is known that almost all cancer patients have impaired immune status due to the immunosuppressive effect on the body of the tumor itself, as well as as a result of therapeutic measures (surgery, chemotherapy and radiation therapy). Therefore, immunotherapy to one degree or another is indicated for all cancer patients.

LECTURE №7. Abdominal hernia

General information about hernias

Abdominal hernia - exit under the skin of the abdominal organs, covered with a parietal sheet of the peritoneum, through various openings of the abdominal wall or pelvis.

If, during an injury, the muscles of the anterior abdominal wall and parietal peritoneum rupture, and any organ of the abdominal cavity falls out through the resulting defect, then they speak of prolapse (prolapsus).

Subcutaneous eventration (eventratio) - divergence of sutures on the peritoneum, aponeurosis and muscles, with an unopened wound of the skin (after surgical interventions).

There are external and internal hernias.

External hernias (herniae abdominalis externae) are protrusions that come out through holes in the abdominal wall. These holes are often normal anatomical formations, usually filled with adipose tissue, but they can occur as a result of various traumatic injuries or diseases.

By origin, external abdominal hernias are congenital (congenita) and acquired (acquisita).

Internal hernias (herniae abdominalis internae) - entry of abdominal organs into abdominal pockets or diverticula (bursa omentalis, foramen Winslowi, recessus duodenoje-junalis, etc.). Diaphragmatic hernias are also internal.

Internal hernias often cause a picture of intestinal obstruction and are inaccessible to research without opening the abdominal cavity.

The constituent elements of hernias are the hernial ring, the hernial sac and its contents.

Hernial orifices are natural fissures and channels that pass through the thickness of the abdominal wall (inguinal, femoral canals, etc.), as well as those acquired as a result of injuries or after surgical interventions.

The hernial sac is part of the parietal peritoneum that exits through the hernial orifice. They distinguish the mouth, neck, body and bottom.

The contents of the hernial sac can be any of the abdominal organs: more often the small intestine, omentum, colon (large) intestine, etc.

Classification of hernias by localization: inguinal, femoral, umbilical, white line of the abdomen, xiphoid process, lateral abdomen, lumbar Greenfelt-Lesgaft triangle, sciatic, obturator, perineal.

In the course of hernia, they are divided into uncomplicated (reducible) and complicated (irreducible, strangulated, with symptoms of coprostasis and inflammation).

Uncomplicated hernia

With uncomplicated hernias, patients complain of pain localized at the site of the hernia, in the abdomen, lumbar region. The appearance of pain usually coincides with the entry of hernial contents into the hernial sac or with the reduction of the hernia. From the gastrointestinal tract, various disorders can be observed: nausea, sometimes vomiting, belching, constipation, bloating.

One of the objective symptoms characteristic of a reducible hernia is a visually defined tumor-like formation, which appears and disappears in the area of ​​the hernia gate. Hernial protrusion is usually associated with abdominal tension, coughing (a symptom of "cough push"), and in the patient's lying position, it goes into the abdominal cavity on its own or with the help of manual reduction.

With incipient hernias, the protrusion is determined only by a finger inserted into the hernial canal, which feels it as a push when coughing or straining.

According to the degree of development, hernias are distinguished:

1) beginning;

2) incomplete, or intracanal;

3) complete;

4) hernia of huge size.

In addition to examination and palpation, when examining a patient with a hernia, it is necessary to use percussion and auscultation. So, the presence of a hollow organ (intestine) in the hernial sac during percussion gives a tympanic sound, and during auscultation - a sensation of rumbling. If there is a dense organ in the hernial sac (for example, an omentum), then percussion gives a dull sound. If there is a suspicion of the presence in the hernial sac of the bladder, an x-ray examination is performed with the introduction of a contrast agent into the bladder.

Treatment hernia in the absence of contraindications should be only operational. In the surgical treatment of uncomplicated hernias, absolute and relative contraindications are possible.

Absolute contraindications to surgical treatment include acute infectious diseases or their consequences, decompensated heart disease, malignant neoplasms.

Relative contraindications to surgical treatment are early childhood, old age in the presence of chronic diseases, late pregnancy.

A radical operation consists in removing the hernial sac after bandaging it at the neck and narrowing the hernial canal by plastic techniques to strengthen the muscles and aponeurosis of the abdominal wall, depending on the location of the hernia.

Most hernia repair is performed under local anesthesia (can be combined with neuroleptanalgesia), some under anesthesia, which is used mainly for children.

These patients do not require special preoperative preparation. On the eve of the operation, they take a hygienic bath, shave their hair (1-2 hours before the operation, otherwise skin irritation may develop, as a result - inflammation and poor healing of the postoperative wound) on the abdomen, pubis and scrotum, empty the intestines with an enema. Before delivery to the operating room, the patient must empty the bladder.

The management of the patient in the postoperative period depends on the type of hernia, the nature of the surgical intervention, the presence of complications, etc. It is necessary to take all measures to prevent postoperative complications, especially in the elderly.

After the operation and the discharge of the patient home (with the primary healing of the wound), persons engaged in mental work are issued a sick leave for up to three weeks, then they start work. However, they are not recommended to engage in heavy physical labor for 2 to 3 months.

Conservative methods of hernia treatment are currently used extremely rarely: only with existing contraindications to surgery and the patient's categorical refusal from it. Such patients are prescribed wearing a bandage. However, the bandage in the area of ​​the hernia injures organs and tissues and does not protect against infringement of the hernia.

Prevention of hernias should be aimed at eliminating reasons for their formation. A.P. Krymov notes two groups of such reasons:

1. Increasing intra-abdominal pressure:

1) disorder of the act of defecation (constipation, diarrhea);

2) cough;

3) cry;

4) difficulty urinating (strictures of the urinary canal, prostate adenoma, phimosis);

5) playing wind instruments;

6) tight tightening of the abdomen;

7) difficult childbirth;

8) vomiting;

9) hard physical work (lifting weights, carrying loads, working in a half-bent or other uncomfortable position, etc.).

2. Weakening the abdominal wall:

1) pregnancy, stretching and thinning the abdominal wall, especially repeated;

2) diseases that cause weight loss and weakening of the muscles of the body;

3) all kinds of injuries of the abdominal wall.

prophylactic, preventing the formation of hernias, is physiotherapy exercises. Sports exercises carried out under the supervision of a doctor strengthen the muscles of the anterior abdominal wall.

To prevent hernias in childhood, proper care of the child is of great importance. Moments that increase intra-abdominal pressure should be avoided: tight swaddling of infants, tossing up when crying and screaming.

inguinal hernia

Inguinal hernias are formed within the inguinal triangle, the lower side of which is the pupart ligament, the upper side is a horizontal line drawn from a point located on the border between the outer and middle thirds of the pupart ligament, to the intersection with the rectus abdominis muscle. The third side of the triangle will be a perpendicular extending from the pubic tubercle to the horizontal line indicated above, which corresponds to the outer edge of the rectus abdominis muscle.

inguinal canal It has four walls and two holes. The anterior wall is formed by the aponeurosis of the external oblique abdominal muscle, the posterior by the transverse fascia of the abdomen, the upper by the edges of the internal oblique and transverse abdominal muscles, and the lower by the pupart ligament.

External (subcutaneous) inguinal opening formed by the legs of the aponeurosis of the external oblique muscle of the abdomen, which are attached to the pubic tubercle.

Internal (abdominal) opening of the inguinal canal is an opening in the transverse fascia of the abdomen and is located, respectively, in the external inguinal fossa (fovea inguinalis externa). In men, the spermatic cord passes through the inguinal canal, consisting of the vas deferens, spermatic artery, vein, nerve and lymphatic vessels, in women - only the round ligament of the uterus.

Inguinal hernias are divided into oblique and direct.

Oblique inguinal hernia exits through the external inguinal fossa and is located outside of art. epigastric inferior. The course of an oblique inguinal hernia strictly corresponds to the course and direction of the spermatic cord, that is, the path along which the testicle went in the process of lowering into the scrotum. With oblique inguinal hernias, the internal opening of the inguinal canal, located in the external inguinal fossa, does not coincide with its external opening, but lies 4–5 cm laterally from it. To exit through the opening of the inguinal canal, the hernial sac must pass this oblique path 4– 5 cm, therefore such hernias are called oblique.

Oblique inguinal hernias can be acquired and congenital. At congenital hernias the abdominal organs enter the uncovered vaginal process of the peritoneum with the testicle lying on its bottom. With congenital inguinal hernias, attention should be paid to the location of the testicle in the hernial sac. The testicle, in the process of descending into the scrotum, does not enter the hernial sac (open peritoneal-inguinal process), but only approaches the wall of the peritoneal-inguinal process and is covered by the peritoneum.

Direct inguinal hernia exits through the internal inguinal fossa (fovea inguinalis media), which is a permanent anatomical formation and is located between the lateral vesico-umbilical ligament and the fold a. epigastrica inferior (plicaepigastrica).

Direct inguinal hernia has a direct direction due to the fact that the internal fossa (internal hernial ring) is located against the external opening of the inguinal canal. The hernial sac goes in a straight (sagittal) direction, and in connection with this, such hernias are called direct inguinal. With direct hernias, the hernial sac lies medially in relation to the elements of the spermatic cord, therefore they are called internal. With oblique hernias, the hernial sac is located outward, lateral to the elements of the spermatic cord.

According to its etiology, direct inguinal hernias are always acquired and are observed mainly in the elderly.

Sometimes when sliding hernias internal organs, partially covered by the peritoneum (caecum, bladder), form part of the wall of the hernial sac. The slippage of these organs passes through the retroperitoneal tissue, through the hernial ring. Sliding inguinal hernias are most often irreducible, their hernial ring is larger than usual. Patients with sliding inguinal hernias have constipation, bloating, abdominal pain, in the area of ​​the hernial protrusion during defecation, frequent urge to urinate, and pain radiating to the lumbar region.

X-ray examination is of great importance for the preoperative diagnosis of sliding inguinal hernias. In women, a bimanual examination helps to make the diagnosis before surgery. However, the exact diagnosis of sliding inguinal hernias is most often established during the operation, but it must be remembered that during the operation, instead of the hernial sac, a hollow organ can be opened.

Differential diagnostics. Oblique inguinal hernias descending into the scrotum must be differentiated from dropsy of the testis, as well as dropsy of the spermatic cord.

Dropsy of the testicle (hydrocaele) develops slowly, without causing any pain. The fluid produced by the serous membrane of the testicle accumulates in the cavity formed by the testicle and its own membrane. As fluid accumulates, the dropsy cavity becomes more and more stretched, becomes tense and does not retract into the abdominal cavity, the testicle and epididymis are not palpated. When palpating the spermatic cord at the external opening of the inguinal canal with hydrocaele, you can freely close your fingers at its upper pole, feeling the vas deferens between them, while with an inguinal-scrotal hernia, you cannot close your fingers. You can also do diaphanoscopy. In a dark room, a brightly glowing cystoscope bulb is brought under the scrotum. With dropsy of the testicle, half of the scrotum, stretched from the accumulation of serous fluid, turns into a luminous bright pink flashlight, at the bottom of which the shadow of the testicle that does not let light through is clearly visible.

The clinical difference (hydrocaele communicans) from dropsy of the testis is the phenomenon of emptying the dropsy cavity at night when the patient is in the supine position, and filling the sac again during the day when walking. In this case, diaphanoscopy also helps to make a differential diagnosis.

In addition, inguinal hernias must be differentiated from expansion of the veins of the spermatic cord (varicocaele), which is predominantly on the left, where the spermatic vein flows at a right angle into the renal vein. On examination, you can see the knots of intertwining varicose veins running along the spermatic cord, which go high into the inguinal canal. In such cases, patients complain of pain along the spermatic cord, radiating to the lower back, a feeling of heaviness in the lower abdomen.

It is also necessary to carry out a differential diagnosis with lymphadenitis, in which, in addition to pain in the protrusion zone, there may be reddening of the skin, local hyperthermia, a negative symptom of a cough shock, leukocytosis.

It is also necessary to carry out a differential diagnosis of groove hernias with a tumor lesion of both the testicle and the lymph nodes.

Treatment. To resolve the issue of surgical intervention for inguinal hernias, it is necessary to carefully examine the patient, establishing indications and contraindications for surgical treatment.

The task of surgical intervention for inguinal hernias is the elimination of the hernial sac and the closure of the hernial ring.

Operations for oblique inguinal hernias. Anesthesia is often carried out locally with a 0,25% solution of novocaine, in excitable individuals it can be combined with neuroleptanalgesia, in children - only general.

Surgical intervention consists of the following stages: incision of the skin, subcutaneous tissue and superficial fascia 8-12 cm long, 2 cm above the inguinal ligament; dissection of the aponeurosis of the external oblique muscle of the abdomen; separation of the hernial sac from the outer flap of the aponeurosis of the external oblique muscle of the abdomen and from the elements of the spermatic cord; opening the hernial sac and repositioning the contents into the abdominal cavity; flashing the neck of the hernial sac and cutting off its peripheral part. Plastic surgery of the inguinal canal is carried out according to one of the methods.

When plastics of the inguinal canal, the methods of Girard, S. I. Spasokukotsky, A. V. Martynov, M. A. Kimbarovsky, V. I. Lichtenstein, as well as other methods of operations that the surgeon is well versed in, are more often used.

The Girard method consists in strengthening the anterior wall of the inguinal canal over the spermatic cord. First, the edge of the internal oblique and transverse muscles is sutured with interrupted silk sutures to the inguinal fold over the spermatic cord, and then, throughout the incision, the inner flap of the aponeurosis is sutured to the edge of the inguinal ligament. The outer flap of the aponeurosis is placed over the inner one (like the floors of a double-breasted coat) and sutured to the latter with interrupted silk sutures. Catgut sutures are applied to the subcutaneous tissue, and silk sutures are applied to the skin. Aseptic bandage on the skin, suspensory.

According to the way Spasokukotsky the inner flap of the aponeurosis of the external oblique muscle of the abdomen, together with the edges of the internal oblique and transverse abdominal muscles, is sutured to the pupart ligament with one row of interrupted silk sutures, and the outer flap of the aponeurosis is sutured over the inner one. Many surgeons use the mixed Girard-Spasokukotsky method.

process Martynov is reduced to the formation of duplication from the sheets of the dissected aponeurosis: the inner flap of the aponeurosis of the external oblique muscle of the abdomen is sutured to the pupart ligament, the outer one is laid over the inner one and sutured to the latter.

According to the way Kimbarovsky the internal flap of the dissected aponeurosis of the external oblique muscle of the abdomen and the underlying muscles are sutured from the outside to the inside, retreating 1 cm from the edge of the incision; for the second time, the needle is passed only through the edge of the inner flap of the aponeurosis, going from the inside to the outside, then the edge of the pupart ligament is sutured with the same thread; over the inner flap, the outer flap of the aponeurosis is sutured.

But all the above methods are tension ones, now more and more attention is paid to non-tension methods (when a defect in the aponeurosis is closed without tissue tension), they include hernia orifice plastic surgery using allo- or autografts. As autografts, specially treated patient's skin, a fascio-muscular flap taken from another part of the body can serve. As allografts, special hypoallergenic meshes are used (Lichtenstein plastic). From the grafts, a flap of the required size is cut out and sutured.

According to various authors, the frequency of hernia recurrence after non-stretch repair is several times lower than with tension repair.

Operations for direct inguinal hernias. With direct inguinal hernias, the hernial sac usually has a wide base, so the neck of the sac is sutured with an internal purse-string suture, and the sac is excised distally to the ligature.

Plastic surgery of the inguinal canal is carried out by the Bassini method or by the N. I. Kukudzhanov method.

process Bassini It is as follows:

1) the spermatic cord is taken up and outward;

2) with interrupted silk sutures, the edge of the internal oblique and transverse muscles is sutured together with the underlying transverse fascia to the inguinal ligament;

3) in the region of the pubic tubercle, the edge of the sheath of the rectus abdominis muscle is sutured with 1-2 sutures to the pupart ligament and periosteum of the pubic bone;

4) after tying all the sutures in turn, the spermatic cord is placed on the created muscle bed;

5) over the spermatic cord, the edges of the aponeurosis of the external oblique muscle of the abdomen are sutured with a number of interrupted sutures.

At the heart of the method Kukudzhanova lies the principle of strengthening the posterior and anterior walls of the inguinal canal; in the region of the internal hernial orifice, the preperitoneal fatty tissue is sutured with several sutures, the spermatic cord is retracted anteriorly, the transverse fascia is sutured with two mattress sutures with capture into the sutures of the iliac-pubic and inguinal ligaments, the rectus sheath and aponeurotic fibers of the internal oblique and transverse muscles are sutured to the medial iliac region -pubic and inguinal ligaments. The spermatic cord is placed in place and the edges of the dissected aponeurosis of the external oblique muscle of the abdomen are sutured over it in the form of a duplicate.

Operations for congenital inguinal hernias. With congenital inguinal hernias, two methods of surgical interventions are mainly used - without opening the inguinal canal (according to Roux - Oppel) and with opening the inguinal canal.

According to the way Ru - Oppel after dissection of the skin and subcutaneous tissue, the hernial sac is isolated and opened, the hernial contents are set into the abdominal cavity. The hernial sac brought into the wound is tied up at the neck, cut off, the stump is immersed in the preperitoneal tissue. The external opening of the inguinal canal is sutured with two or three silk ligatures. Interrupted sutures are placed on the anterior wall of the inguinal canal, capturing the aponeurosis of the external oblique muscle of the abdomen and the underlying muscles slightly above the inguinal canal, and on the other hand, the inguinal ligament. This method is used for small initial hernias, both congenital and acquired.

With the method of opening of the inguinal canal access to the hernial sac is the same as for acquired oblique inguinal hernias. Along the spermatic cord, fascia cremasterica is cut along with the fibers of m. cremaster and fascia spermatica interna secrete the anterior wall of the hernial sac and open it at the neck. The hernial contents are pushed into the abdominal cavity, the posterior wall of the hernial sac at the neck is separated from the elements of the spermatic cord, and then dissected in the transverse direction. The neck of the selected part of the hernial sac is stitched with a silk ligature, bandaged and cut off, the testicle is brought into the wound along with the rest of the hernial sac. The latter is excised and twisted around the testicle and spermatic cord, stitching it with rare interrupted sutures. If the hernial sac is larger; then it is excised over a large extent, leaving the peritoneum only on the spermatic cord and testicle. Plastic surgery of the inguinal canal in one of the ways.

femoral hernia

The localization of femoral hernias corresponds to the area of ​​the Scarpovsky triangle, the upper limit of which is the pupart ligament. From the pupart ligament to the pubic tubercle, the iliac-scallop ligament departs, which divides the entire space between the inguinal ligament and the bones (iliac and pubic) into two sections: the muscular lacuna (lacuna musculorum) - the outer section - and the vascular (lacuna vasorum) - internal department.

The muscular lacuna has the following boundaries: in front - the inguinal ligament, behind - the ilium, from the inside - the iliopectineal ligament.

The vascular lacuna is limited by the following ligaments: in front - the inguinal and the superficial sheet of the broad fascia fused with it, behind - the iliac-pubic (lig. iliopubicum) and the scallop fascia starting from it, outside - lig. iliopectineum, from the inside - lig. lacunar.

The femoral vessels pass through the vascular lacuna, of which the femoral artery is located on the outside, the vein is on the inside. Both vessels are surrounded by a common vagina, in which the artery is separated from the vein by a septum.

Knowledge of all anatomical spaces is of great importance in the differential diagnosis of various types of femoral hernias that form under the pupart ligament along its entire length.

The inner third of the vascular lacuna, corresponding to the gap between the femoral vein and the lacunar ligament, is called the inner femoral ring. In front, it is limited by the pupart ligament, behind - by the iliac-pubic ligament and the scallop fascia starting from it, from the inside - by the lacunar ligament, from the outside - by the sheath of the femoral vein.

The path that a femoral hernia makes for itself is called the femoral canal (its length is 1-2 cm). It has a triangular shape, and its walls are: in front - the falciform process of the wide fascia, behind and inside - the scalloped fascia, outside - the sheath of the femoral vein. Normally, the femoral canal does not exist.

Unlike inguinal femoral hernias, they come out below the pupart ligament: within the upper half of the oval fossa, inside from the femoral vein. In practice, typical femoral hernias emerging from the femoral canal are more common.

N.V. Voskresensky divides all femoral hernias into:

1) muscular-lacunar (Hesselbach's hernia);

2) emerging within the vascular lacunae:

a) external, or lateral external, vascular-lacunar, extending outwards from the femoral artery;

b) median, or prevascular, emerging in the region of the vessels and located directly above them;

c) internal (typical femoral hernia) exiting through the femoral canal between the femoral vein and the lacunar (gimbernate) ligament;

3) hernia of the lacunar ligament.

Femoral hernias are more common in women due to the large size of the female pelvis.

There are the following forms of typical femoral hernias:

1) initial, when a small hernial sac is located in the region of the internal opening of the femoral canal;

2) canal - the hernial sac moves into the femoral canal, reaches the outer femoral ring, forming an incomplete femoral hernia;

3) a complete hernia that has gone beyond the femoral canal and is determined during examination and palpation.

Femoral hernias must be differentiated from enlarged lymph nodes of this area in various diseases, metastases of malignant neoplasms to the lymph nodes of this area, benign tumors of the femoral region, varicose veins of the lower extremities, aneurysmal nodes, specific swell abscesses, cysts located under the pupart ligament.

Treatment. Depending on the method of operation, various skin incisions are made.

In hernia repair with closure of the hernial orifice from the side of the thigh, the most common is the Lockwood method. A skin incision 10–12 cm long is carried out vertically above the hernial tumor, the beginning of which is 2–3 cm above the pupart ligament, or an oblique incision passing above the hernial tumor parallel to and below the pupart ligament. The hernial sac is isolated from the bottom to the neck, opened and its contents are set into the abdominal cavity. The neck of the bag is stitched high with a silk ligature, tied up and cut off, and its stump is set under the inguinal ligament. The internal opening of the femoral canal is closed by suturing the inguinal ligament to the periosteum of the pubic bone with two or three knotted silk ligatures.

In case of hernia repair with closing of the hernial orifice from the side of the thigh according to the Lockwood method, the modifications of Bassini, A.P. Krymov, as well as the method of A.A. Abrazhanov are used.

In hernia repair with the closure of the hernial orifice from the side of the inguinal canal, the methods of Ruji, Parlavecchio, Reich, Praksin are used.

process Rudzhi is as follows:

1) the skin is cut above and parallel to the pupart ligament, as in inguinal hernias;

2) open the inguinal canal;

3) dissect the back wall of the inguinal canal - the transverse fascia;

4) the hernial sac is isolated and dislocated into the wound from under the pupart ligament;

5) the hernial sac is opened and the hernial contents are pushed into the abdominal cavity;

6) the neck of the bag is stitched and the latter is cut off distally to the ligature;

7) with three or four sutures, the inguinal ligament is sutured to the iliac-pubic ligament, which closes the hernial orifice;

8) restore the inguinal canal.

If it is difficult to close the large hernial orifice by suturing the inguinal ligament to the iliac-pubic one, then they resort to the plastic methods of G. G. Karavanov, Watson-Cheyne and others.

umbilical hernia

Umbilical hernia (hernia umbilicalis) - the exit of the abdominal organs through defects in the abdominal wall in the navel.

The layers that form the navel are composed of dense tissue, the front surface of which is soldered to the skin, umbilical fascia and peritoneum. There is no subcutaneous or preperitoneal tissue. The umbilical vein, which runs from the navel to the liver, is located in the canal, which is often called the umbilical canal.

Both the umbilical ring and the umbilical canal can be the site of a hernia. The umbilical canal has an oblique direction, so umbilical hernias that exit through it are called oblique.

Umbilical hernias follow inguinal and femoral hernias in frequency, although in fact the anatomical predisposition to them arises from the day of birth.

N.V. Voskresensky divides all umbilical hernias into hernias: adults, children, embryonic, developing with underdevelopment of the abdominal wall along the midline, umbilical cord.

Embryonic umbilical hernias are subject to surgical treatment immediately after the birth of a child. Surgical treatment is contraindicated for very large or, conversely, small congenital hernias.

There are three ways to treat embryonic umbilical hernias: ligation of the hernial sac, extraperitoneal and intraperitoneal. A simple dressing of a hernia at the border of the skin with the amnion is used for a small and reducible hernia. However, this method is rarely used.

Extraperitoneal method Olsthausen consists in the following: on the border with the hernia, the skin is cut and the outer (amniotic) membrane and the jelly are separated from the hernial sac. Next, bandage and cut off the formation of the umbilical cord. The hernial sac along with its contents is pushed into the abdominal cavity. The edges of the skin are refreshed and sewn with silk sutures, closing the hernial orifice.

RџSЂRё intraperitoneal (intraperitoneal) method, the hernial sac is opened and its contents are pushed into the abdominal cavity, the hernial membranes are completely resected and the abdominal wall is sutured in layers.

Umbilical hernias in children and adults can be operated both extraperitoneally and intraperitoneally. However, in most cases, the operation is performed intraperitoneally.

For medium and large umbilical hernias, the methods of K. M. Sapezhko and Mayo are used, and for small ones, the Lexer method.

process Sapezhko consists of the following. The skin is cut over the hernial protrusion in the vertical direction, the hernial sac is isolated, and the hernial ring is cut up and down along the white line of the abdomen. According to the generally accepted method, the hernial sac is treated. The edge of one side of the dissected aponeurosis is sutured with interrupted silk sutures to the posterior wall of the sheath of the rectus abdominis muscle of the opposite side. The remaining free edge of the aponeurosis is placed on the anterior wall of the sheath of the rectus abdominis muscle of the opposite side and fixed with a number of nodal silk ligatures. Sutures are applied to the skin.

With the method Mayo two semilunar skin incisions are made in the transverse direction around the hernial protrusion. After exfoliation of the skin flap from the aponeurosis around the hernial orifice for 5-7 cm, the hernial ring is dissected in the transverse direction. Having selected the neck of the hernial sac, it is opened and the contents are set into the abdominal cavity. Then the hernial sac is excised along the edge of the hernial ring and removed along with the skin flap, and the peritoneum is sutured with a continuous catgut suture. The lower flap of the aponeurosis is sutured to the upper one with a row of interrupted U-shaped sutures so that when they are tied, the upper flap overlaps the lower one, the free edge of the upper flap is sutured with a row of interrupted sutures to the lower one. Interrupted silk sutures are applied to the skin.

With the method Lexera a semi-lunar incision of the skin, semi-enclosing the hernial tumor, is carried out from below. The skin with subcutaneous tissue is peeled upward and a hernial sac is isolated, which is opened, and its contents are set into the abdominal cavity. The neck of the bag is stitched with a silk ligature, tied up and the bag is cut off. The hernial ring is closed with a purse-string silk suture, over which 3-4 silk sutures are applied to the anterior walls of the sheaths of the rectus abdominis muscles. The skin flap is placed in place and sutured with a number of interrupted sutures.

With this method of hernia repair, the navel can be removed or left.

Hernias of the white line of the abdomen

The white line of the abdomen is formed by the intersecting tendon bundles of the six abdominal muscles, separates both rectus muscles and corresponds to the midline of the body. It stretches from the xiphoid process to the symphysis and above the navel has the form of a strip, the width of which increases towards the navel. In the white line of the abdomen there are through slit-like spaces that pass through its entire thickness to the peritoneum, and through them - vessels and nerves or adipose tissue that connects the preperitoneal tissue with the subcutaneous tissue. Usually the sizes of such hernias are insignificant. Most often, the contents of the hernial sac is the omentum, less often the small intestine and the transverse colon (only with large hernias).

Clinical course hernia of the white line of the abdomen is diverse. Sometimes they are discovered by accident. Some patients complain of pain in the epigastric region, aggravated by palpation. They are concerned about nausea, belching, heartburn, a feeling of fullness in the pancreas.

Examination of a patient with a hernia of the white line of the abdomen should be carried out lying down and standing with the patient straining and with complete relaxation of the abdominal wall.

If the patient complains of abdominal pain and dyspeptic disorders, it is necessary to exclude peptic ulcer of the stomach and duodenum, gastritis, cholecystitis, appendicitis by methods of general and special research.

Hernias of the white line of the abdomen are operated on by the method Sapezhko - Lyakonova. A skin incision over the hernial protrusion is carried out in the longitudinal or transverse direction. The hernial sac is isolated and processed in the usual way. The hernial ring is dissected along the linea alba and duplication is created from the flaps of the aponeurosis of the linea alba in the vertical direction, first applying 2-4 U-shaped sutures, as in the Mayo method. The edge of the free flap of the aponeurosis is sutured with interrupted sutures to the anterior wall of the sheath of the rectus abdominis muscle. Stitches on the skin.

Causes of recurrence of hernias of the white line of the abdomen:

1) healing of a postoperative wound by secondary intention due to its infection;

2) flabbiness of tissues or their cicatricial changes in the hernia area;

3) excessive physical activity, especially in the early postoperative period;

4) technical errors during the operation.

Postoperative hernia

According to the place of surgical intervention, postoperative hernias can be of different localization. Most often they are formed with operational access along the white line of the abdomen. In men, they occur after operations on the stomach, in women - after operations on the pelvic organs. Postoperative hernias may appear after appendectomy, cholecystectomy and other surgical interventions, especially if tampons were placed in the abdominal cavity.

V. M. Voilenko distinguishes three forms of postoperative hernias:

1) hemispherical, with a wide base and wide hernial ring;

2) flattened from front to back due to adhesions connecting the walls of the hernial sac and the inside;

3) typical, with a narrow neck and an extended bottom.

Large incisional hernias are best operated under anesthesia using relaxants, small ones - under local anesthesia.

Postoperative hernias operate as follows:

1) the skin is cut within healthy tissues on both sides of the postoperative scar, which is excised;

2) release the aponeurosis from fatty tissue;

3) dissect the hernial sac and conduct an audit of the abdominal cavity;

4) cut off the entire hernial sac;

5) carry out the plasty of the hernial orifice.

V. M. Voilenko divides all plastic methods into three groups:

1) aponeurotic;

2) muscular-aponeurotic;

3) other types of plastic surgery (plasty with a skin flap, alloplasty, etc.).

In aponeurotic plasty, to close a defect in the abdominal wall, a simple suturing of the edges of the aponeurosis is performed, connecting them by doubling, and one or two flaps cut from the aponeurosis are sutured to the edges of the defect. The most common methods of aponeurotic plastics are the methods of A. V. Martynov, N. Z. Monakov, P. N. Napalkov, Championer, Heinrich, Brenner.

In muscular aponeurotic plasty, aponeurosis together with muscles is used to close the hernial orifice. This group of plastics includes the methods of V. P. Voznesensky, K M Sapezhko, A. A. Troitsky, as well as I. F. Sabaneev in the modification of N. 3. Monakov and the method of I. V. Gabay.

In practice, the Voznesensky method is most common, which consists of the following:

1) make a median incision with excision of the postoperative scar;

2) open the abdominal cavity;

3) the left and right rectus abdominis muscles are sutured to the full thickness with a catgut thread from the side of the peritoneum and then they are tied in turn, starting from the upper corner of the wound;

4) the second row is applied more superficially, capturing the rectus muscles;

5) excess peritoneum and aponeurosis are excised, their edges are sewn with a continuous silk suture; suturing the skin.

Patients with incisional hernias must be carefully prepared for surgery. Two days before it, a laxative is given, then cleansing enemas are prescribed. In the postoperative period, early rising is prohibited, the sutures are removed on the 10th - 12th day.

Rare forms of hernias

Rare forms of hernias include hernia of the xiphoid process, lateral hernia of the abdomen, lumbar, obturator, ischial and perineal hernias, etc.

Hernia of the xiphoid process is rare. The main symptoms are pain in the area of ​​the xiphoid process, the presence of a protrusion there, after the reduction of which it is possible to probe the hole.

Treatment - removal of the xiphoid process and excision of the hernial sac.

Lateral hernia of the abdomen can appear in the region of the rectus abdominis, along the Spigelian line in the muscular part of the abdominal wall, and as a result of injury - anywhere in the abdominal wall. With underdevelopment of any of the muscles of the abdominal wall, congenital abdominal hernias occur, which can manifest clinically at any age.

There are three types lateral abdominal hernias: hernia of the vagina of the rectus muscle, hernia of the Spigelian line, hernia from stopping the development of the abdominal wall.

Hernias of the vagina of the rectus muscle are more common in the lower abdomen, where there is no posterior leaf of the vagina, and with traumatic ruptures of the rectus muscle.

Hernias of the Spigelian line can be subcutaneous, interpicial and preperitoneal. Such hernias are localized along the line connecting the navel and the anterior-superior iliac spine, but sometimes they are located below or above

pubic line.

The main symptoms of a lateral abdominal hernia are pain and hernial protrusion of various sizes, depending on the width of the hernial orifice.

Treatment of lateral abdominal hernias is only surgical. In case of small hernias, after removal of the hernial sac, the hernial orifice is sutured with layer-by-layer suturing on the transverse and internal oblique muscles, as well as on the aponeurosis of the external oblique muscle. For large hernias, plastic methods are used.

Lumbar hernia - hernial protrusion on the back and side walls of the abdomen, emerging through various cracks and gaps between the muscles and individual bones of the lumbar region.

Lumbar hernias exit through such anatomical formations as the Petit triangle, the Greenfelt-Lesgaft gap and the aponeurotic fissures. The most common contents of the hernial sac are the small intestine and omentum. The main symptom is an increase in hernia during physical exertion. Complications of a lumbar hernia include its infringement. The radical method of treatment is surgical.

Obturator hernia appears through the obturator canal, passing under the pubic bone, and occurs mainly in older women. Their symptoms can be very diverse. Treatment of obturator hernias is only surgical. The operation is performed by the femoral method, with the help of laparotomy or in a combined way.

Sciatic hernia extends to the posterior surface of the pelvis through a large or small sciatic foramen, occurs mainly in older women with a wide pelvis and large ischial foramen. There are three types of sciatic hernias, emerging above the piriformis muscle, under the piriformis muscle and through the small sciatic foramen.

Treatment of ischial hernias is only surgical. The technique of operations is very diverse and depends on the approach to the hernial ring.

The most common complication of ischial hernia is its incarceration. A strangulated ischial hernia is recommended to be operated on in a combined way, starting with a laparotomy, and when dissecting the hernial orifice, one should be aware of the possibility of injuring the gluteal vessels.

Diaphragmatic hernia - the exit of the abdominal organs into the chest cavity through a physiological or pathological opening in the diaphragm of congenital or traumatic origin. At the same time, we can talk about hernial orifices and hernial contents, but the hernial sac is mostly absent.

Diaphragmatic hernias are divided into traumatic and non-traumatic. The trauma factor is of great importance in the development of the disease, determines the type of hernia, diagnosis and prognosis.

Non-traumatic hernias are located in certain typical places - in the esophageal opening, Bochdalek's opening, Larrey's fissure, the dome of the diaphragm.

According to the clinical course, traumatic diaphragmatic hernias are divided into acute and chronic.

The symptomatology of diaphragmatic hernias is associated with a dysfunction of both the displaced abdominal organs and the compressed organs of the chest cavity. Thus, with a diaphragmatic hernia, disorders of the digestive tract, respiratory and circulatory disorders, as well as diaphragmatic symptoms can be observed.

X-ray method of research is the main one in the diagnosis of diaphragmatic hernias. It makes it possible to establish which organs have left the abdominal cavity, where the hernial opening is located and what is its size, whether there are adhesions of the released organs in the hernial orifice and with the organs of the chest cavity.

The most severe complication of a diaphragmatic hernia is infringement, which can occur immediately after damage and the formation of a hernia, but more often develops much later, after 2-3 and even 10-15 years.

Diaphragmatic hernia is an absolute indication for surgery. It can be operated on by thoracotomy, laparotomy, or a combination.

Hernia complications

Complications of hernias include infringement, coprostasis, inflammation.

Strangulated hernia. Under the infringement of the hernia understand the sudden compression of the contents of the hernia in the hernial orifice. Any organ located in the hernial sac can be infringed. Usually it occurs with a significant tension in the abdominal press (after lifting weights, with strong straining, coughing, etc.).

When any organ is infringed in a hernia, its blood circulation and function are always disturbed, depending on the importance of the incarcerated organ, general phenomena also occur.

There are the following types of infringement: elastic, fecal, and both at the same time.

With elastic infringement, intra-abdominal pressure increases. Under the influence of this and a sudden contraction of the abdominal muscles, the insides quickly pass through the hernial orifice into the sac and are incarcerated in the hernial ring after the intra-abdominal pressure normalizes.

With fecal infringement, the contents of the overflowing intestine consist of liquid masses mixed with gases, less often solid ones. In the latter case, infringement can join coprostasis.

Pathological changes in the incarcerated organ depend on the time elapsed from the onset of the infringement and the degree of compression by the infringing ring.

When the intestine is incarcerated, a strangulation groove is formed at the site of the infringing ring with a sharp thinning of the intestinal wall at the site of compression. Due to the stagnation of the intestinal contents, the adducting segment of the intestine is significantly stretched, the nutrition of its wall is disturbed and conditions for venous stasis (stagnation) are created, as a result of which the plasma leaks both into the thickness of the intestinal wall and into the lumen of the intestine. This stretches the adductor intestine even more and impedes blood circulation.

Stronger than in the leading section, changes are expressed in the place of the strangulated intestinal loop. With compression of more pliable veins, venous stasis is formed, and the intestine takes on a bluish color. Plasma leaks into the lumen of the pinched loop and its wall, increasing the volume of the loop. As a result of increasing edema, the compression of the vessels of the mesentery increases, completely disrupting the nutrition of the intestinal wall, which becomes dead. Vessels of the mesentery at this time can be thrombosed over a considerable extent.

Most often, infringement occurs in patients suffering from hernias, in exceptional cases it can occur in people who have not previously noticed hernias. When a hernia is infringed, severe pain appears, in some cases it causes shock. The pain is localized in the area of ​​the hernial protrusion and in the abdominal cavity, often accompanied by reflex vomiting.

An objective examination of the anatomical location of the strangulated hernia reveals an irreducible hernial protrusion, painful on palpation, tense, hot to the touch, giving dullness during percussion, since there is hernial water in the hernial sac.

It is most difficult to diagnose parietal infringements, since they may not interfere with the movement of contents through the intestines, moreover, parietal infringement sometimes does not give a large hernial protrusion.

Forcible reduction of a strangulated hernia is unacceptable, since it can become imaginary. In this case, the following options are possible:

1) moving the restrained viscera from one part of the bag to another;

2) the transition of the entire strangulated area together with the hernial sac into the preperitoneal space;

3) reduction of the hernial sac along with the restrained viscera into the abdominal cavity;

4) rupture of intestinal loops in the hernial sac.

In all these variants, hernial protrusion is not observed, and all symptoms of intestinal strangulation persist.

It is also necessary to keep in mind retrograde strangulation, in which there are two strangulated intestinal loops in the hernial sac, and the intestinal loop connecting them is in the abdominal cavity and is the most altered.

Patients with strangulated external abdominal hernias should be urgently operated on.

During surgery for strangulated external abdominal hernias, the following conditions must be met:

1) regardless of the location of the hernia, it is impossible to dissect the restraining ring before opening the hernial sac, since the restrained entrails without revision can easily slip into the abdominal cavity;

2) if there is a suspicion of the possibility of necrosis of the strangulated sections of the intestine, it is necessary to revise these sections by removing them from the abdominal cavity;

3) if it is impossible to remove the intestine from the abdominal cavity, a laparotomy is indicated, in which the presence of retrograde infringement is simultaneously revealed;

4) special attention must be paid to the dissection of the infringing ring and to accurately imagine the location of the adjacent blood vessels passing in the abdominal wall.

If, during the revision, it is established that the strangulated intestine is not viable, then it is removed, then the hernia gate is plastic and sutures are applied to the skin. The minimum boundaries of the resected non-viable small intestine: 40 cm of the afferent loop and 20 cm of the outlet.

After the operation, the patient is taken to the ward on a gurney, the issue of postoperative management and the possibility of getting up is decided by the attending physician. This takes into account the age of the patient, the state of the cardiovascular system and the nature of the surgical intervention.

Coprostasis. With irreducible hernias in the intestinal loop located in the hernial sac, coprostasis (fecal stasis) is observed.

Inflammation of a hernia occurs acutely, accompanied by sharp pains, vomiting, fever, tension and severe pain in the area of ​​the hernial sac. Treatment is emergency surgery.

With phlegmon of the hernial sac, it is necessary to perform a laparotomy away from the phlegmonous area with the imposition of an intestinal anastomosis between the inlet and outlet ends of the intestine, going to the infringing ring. The off loops of the intestines to be removed are tied at the ends with gauze napkins and sufficiently strong ligatures. Having completed the operation in the abdominal cavity, the inflamed hernial sac is opened and the dead loops of the strangulated intestines are removed through the incision, and the phlegmon is drained.

LECTURE No. 8. Appendicitis

Acute appendicitis is literally an inflammation of the appendix. The appendix arises from the posterior-internal segment of the caecum at the point where the three band muscles of the caecum begin. It is a thin convoluted tube, the cavity of which on one side communicates with the cavity of the caecum. The process ends blindly. Its length ranges from 7 to 10 cm, often reaching 15 - 25 cm, the diameter of the channel does not exceed 4 - 5 mm.

The appendix is ​​covered on all sides by the peritoneum and in most cases has a mesentery that does not prevent its movement.

Depending on the position of the caecum, the vermiform appendix can be located in the right iliac fossa, above the caecum (with its high position), below the cecum, in the small pelvis (with its low position), together with the caecum among the loops of the small intestine along the midline even in the left side of the abdomen. Depending on its location, the corresponding clinic of the disease arises.

Acute appendicitis - non-specific inflammation of the appendix caused by pyogenic microbes (streptococci, staphylococci, enterococci, Escherichia coli, etc.).

Microbes enter it by enterogenous (the most frequent and most likely), hematogenous and lymphogenous route.

On palpation of the abdomen, the muscles of the anterior abdominal wall are tense. Pain at the site of localization of the appendix during palpation is the main, and sometimes the only sign of acute appendicitis. To a greater extent, it is expressed in destructive forms of acute appendicitis and especially in perforation of the appendix.

An early and no less important sign of acute appendicitis is local tension in the muscles of the anterior abdominal wall of the abdomen, which is more often limited to the right iliac region, but can also spread to the right half of the abdomen or throughout the entire anterior abdominal wall. The degree of tension of the muscles of the anterior abdominal wall depends on the reactivity of the body to the development of the inflammatory process in the appendix. With reduced reactivity of the body in malnourished patients and the elderly, this symptom may be absent.

If acute appendicitis is suspected, vaginal (in women) and rectal examinations should be performed, in which pain in the pelvic peritoneum can be determined.

An important diagnostic value in acute appendicitis is the Shchetkin-Blumberg symptom. To determine it, the right hand gently presses on the anterior abdominal wall and after a few seconds it is torn off from the abdominal wall, while there is a sharp pain or a noticeable increase in pain in the area of ​​\uXNUMXb\uXNUMXbthe inflammatory pathological focus in the abdominal cavity. With destructive appendicitis, and especially with perforation of the appendix, this symptom is positive throughout the right side of the abdomen or throughout the abdomen. However, the Shchetkin-Blumberg symptom can be positive not only in acute appendicitis, but also in other acute diseases of the abdominal organs.

The symptoms of Voskresensky, Rovsing, Sitkovsky, Bartomier - Michelson, Obraztsov have a certain value in the diagnosis of acute appendicitis.

With a symptom Voskresensky pain appears in the right iliac region when the palm is quickly held through the patient's tight shirt along the front wall of the abdomen to the right of the costal edge down. On the left, this symptom is not defined.

Symptom Rovsingand is caused by pressure or pushes with the palm of the left iliac region. At the same time, pain occurs in the right iliac region, which is associated with a sudden movement of gases from the left half of the large intestine to the right, as a result of which oscillations of the intestinal wall and the inflamed appendix occur, which are transmitted to the inflammatory-altered parietal peritoneum.

With a symptom Sitkovsky in a patient lying on his left side, pain appears in the right iliac region, caused by tension of the inflamed peritoneum in the region of the caecum and mesentery of the appendix due to its marking.

Symptom Bartomier - Michelson - pain on palpation of the right iliac region in the position of the patient on the left side.

Symptom Obraztsova - pain on palpation of the right iliac region at the time of raising the straightened right leg.

Critical and objective assessment of these symptoms expands the possibilities of establishing a diagnosis of acute appendicitis. However, the diagnosis of this disease should not be based on one of these symptoms, but on a comprehensive analysis of all local and general signs of this acute disease of the abdominal organs.

For the diagnosis of acute appendicitis, a blood test is of great importance. Changes in the blood are manifested by an increase in leukocytes. The severity of the inflammatory process is determined using a leukocyte formula. A shift of the leukocyte formula to the left, i.e., an increase in the number of stab neutrophils or the appearance of other forms with a normal or slight increase in the number of leukocytes, indicates severe intoxication in destructive forms of acute appendicitis.

There are several forms of acute appendicitis (according to histology):

1) catarrhal;

2) phlegmonous;

3) gangrenous;

4) gangrenous-perforative.

Differential diagnosis of acute appendicitis

Acute diseases of the abdominal organs have a number of main symptoms:

1) pain of a different nature;

2) reflex vomiting;

3) disorder of the normal discharge of intestinal gases and feces;

4) tension of the abdominal muscles.

Until a specific diagnosis of an acute abdominal disease is established, patients should not be prescribed painkillers (the use of drugs relieves pain and smoothes the clinical picture of an acute disease of the abdominal organs), wash the stomach, use laxatives, cleansing enemas and thermal procedures.

Acute diseases of the abdominal organs are easier to differentiate in the initial stage of the disease. Subsequently, when peritonitis develops, it can be very difficult to determine its source. It is necessary to remember in this regard the figurative expression of Yu. Yu. Dzhanelidze: "When the whole house is on fire, it is impossible to find the source of the fire."

Acute appendicitis must be differentiated from:

1) acute diseases of the stomach - acute gastritis, food toxic infections, perforated ulcers of the stomach and duodenum;

2) some acute diseases of the gallbladder and pancreas (acute cholecystitis, cholelithiasis, acute pancreatitis, acute cholecystopancreatitis);

3) some intestinal diseases (acute enteritis or enterocolitis, acute ileitis, acute diverticulitis and its perforation, acute intestinal obstruction, Crohn's disease, terminal ileitis

4) some diseases of the female genital area (acute inflammation of the mucosa and uterine wall, pelvioperitonitis, ectopic pregnancy, ovarian rupture, twisted ovarian cyst);

5) urological diseases (renal stones, renal colic, pyelitis);

6) other diseases simulating acute appendicitis (acute diaphragmatic pleurisy and pleuropneumonia, heart disease).

Treatment of acute appendicitis

Currently, the only treatment for patients with acute appendicitis is early emergency surgery, and the sooner it is performed, the better the results. Even G. Mondor (1937) pointed out: when all doctors are imbued with this idea, when they understand the need for rapid diagnosis and immediate surgical intervention, they will no longer have to deal with severe peritonitis, with cases of severe suppuration, with those distant infectious complications, which and now too often overshadow the prognosis of appendicitis.

Thus, the diagnosis of acute appendicitis requires immediate surgery. The exception is patients with limited appendicular infiltrate and patients requiring short-term preoperative preparation.

The phenomena of acute appendicitis can be found in patients with myocardial infarction, severe pneumonia, with acute cerebrovascular accident, decompensated heart disease. For such patients, dynamic monitoring is established. If during the observation the clinical picture does not subside, then, according to vital indications, they resort to surgery. In acute appendicitis complicated by peritonitis, despite the severity of the somatic disease, the patient is operated on after appropriate preoperative preparation.

A number of authors point out that in the complex of therapeutic measures in this category of patients with acute appendicitis, preoperative preparation is of great importance, which serves as one of the means to reduce the risk of surgery, improves the general condition of the patient, normalizes homeostasis, and enhances immune protective mechanisms. It should not last more than 1-2 hours.

If during appendectomy it is impossible to use intubation anesthesia with muscle relaxants, then local infiltration anesthesia with a 0,25% novocaine solution is used, which, if indicated, can be combined with neuroleptanalgesia.

However, it is necessary to give preference to modern endotracheal anesthesia with the use of muscle relaxants, in which the surgeon has the maximum opportunity to conduct a thorough revision of the abdominal organs.

In mild forms of acute appendicitis, where the operation is short, appendectomy can be performed under mask anesthesia using muscle relaxants.

The most common approach for uncomplicated acute appendicitis is the Volkovich-McBurney oblique incision. The incision proposed by Lennander is used somewhat less frequently, it is made with an atypical location of the appendix, widespread purulent peritonitis caused by perforation of the appendix, and also with the possible appearance of peritonitis from other sources, when a wider revision of the abdominal organs is necessary. The advantage of the Volkovich-McBurney incision is that it corresponds to the projection of the cecum, it does not damage the nerves and muscles, which minimizes the frequency of hernias in this area.

The transverse approach is convenient in that it can be easily expanded medially by transection of the rectus abdominis muscle.

In most cases, after an appendectomy, the abdominal cavity is sutured tightly.

If there is an effusion in the abdominal cavity with perforated appendicitis, which is removed with gauze swabs, electric suction, then a thin rubber tube (polyvinyl chloride) is inserted into it for intraperitoneal administration of antibiotics.

With destructive forms of acute appendicitis in the postoperative period, antibiotics are prescribed intramuscularly, while taking into account the sensitivity of the patient to them.

Proper management of patients in the postoperative period largely determines the results of surgery, especially in destructive forms of acute appendicitis. The active behavior of patients after surgery prevents the development of many complications.

In uncomplicated forms of acute appendicitis, the condition of patients is usually satisfactory, and no special treatment is required in the postoperative period.

After delivery from the operating room to the ward, the patient can immediately be allowed to turn on his side, change body position, breathe deeply, cough.

Getting out of bed should begin gradually. On the first day, the patient can sit up in bed and begin to walk, but he should not overpower himself for the sake of getting up early. This issue must be approached strictly individually. A decisive role is played by the well-being and mood of the patient. It is necessary to start early nutrition of patients, which reduces the frequency of intestinal paresis and contributes to the normal function of the digestive organs. Patients are prescribed easily digestible food, without overloading the gastrointestinal tract, from the sixth day they are transferred to the general table.

Most often, after an appendectomy, the stool occurs on its own on the 4th - 5th day. During the first two days, gas is retained due to intestinal paresis, which most often stops on its own.

In the postoperative period, there is often urinary retention as a result of the fact that most patients cannot urinate while lying down. To eliminate this complication, a heating pad is applied to the perineum. If the patient's condition allows, then he is allowed to stand near the bed, trying to cause a reflex to urinate by blowing a stream from the kettle. Intravenously, you can enter 5 - 10 ml of a 40% solution of urotropine or 5 - 10 ml of a 5% solution of magnesium sulfate. In the absence of the effect of these measures, bladder catheterization is carried out with strict observance of aseptic rules and mandatory washing after catheterization with a solution of furacilin (1: 5000) or silver sulfate (1: 10, 000: 1).

In the postoperative period, exercise therapy is of great importance.

If during the operation no changes were found in the appendix, then an audit of the ileum (for 1 - 1,5 m) should be carried out in order not to miss diverticulitis.

Complications of acute appendicitis

Complications in the preoperative period. If the patient does not contact the doctor in time, acute appendicitis can give a number of serious complications that endanger the life of the patient or deprive him of his ability to work for a long time. The main, most dangerous complications of untimely operated appendicitis are considered to be appendicular infiltrate, diffuse purulent peritonitis, pelvic abscess, pylephlebitis.

appendicular infiltrate. This is a limited inflammatory tumor that forms around a destructively altered appendix, to which intestinal loops, the greater omentum and closely located organs are soldered with fibrinous overlays. Appendicular infiltrate is localized at the location of the appendix.

In the clinical course of the appendicular infiltrate, two phases are distinguished: early (progression) and late (delimitation).

At an early stage, the appendicular infiltrate is just beginning to form, it is soft, painful, without clear boundaries. Its clinical picture is similar to that of acute destructive appendicitis. There are symptoms of peritoneal irritation, leukocytosis with a shift of the leukocyte formula to the left.

In the late stage, the clinical course is characterized by a general satisfactory condition of the patient. The general and local inflammatory reactions subside, the temperature is in the range of 37,5 - 37,8 ° C, sometimes normal, the pulse is not quickened. On palpation of the abdomen, a slightly painful dense infiltrate is determined, which is clearly delimited from the free abdominal cavity.

After the diagnosis is established, the appendicular infiltrate is treated conservatively: strict bed rest, food without a large amount of fiber, bilateral pararenal blockade with a 0,25% novocaine solution according to Vishnevsky, antibiotics.

After treatment, the appendicular infiltrate can resolve, if treatment is ineffective, it can fester and form an appendicular abscess, be replaced by connective tissue, not dissolve for a long time and remain dense.

7-10 days after the resorption of the appendicular infiltrate, without discharging the patient from the hospital, an appendectomy is performed (sometimes 3-6 weeks after resorption in a planned manner when the patient is re-admitted to the surgical hospital).

The appendicular infiltrate may be replaced by a massive development of connective tissue without any tendency to resorption. V. R. Braytsev called this form of infiltrate fibroplastic appendicitis. At the same time, a tumor-like formation is palpated in the right iliac region, there is aching pain, symptoms of intermittent intestinal obstruction appear. Only a histological examination after hemicolectomy reveals the true cause of the pathological process.

If the appendicular infiltrate does not resolve within 3-4 weeks, remains dense, then the presence of a tumor in the caecum should be assumed. For differential diagnosis, it is necessary to conduct an irrigoscopy.

When the appendicular infiltrate passes into the appendicular abscess, patients experience a high temperature of an intermittent nature, high leukocytosis with a shift of the leukocyte count to the left, and intoxication.

Pelvic appendicular abscess. It can complicate pelvic appendicitis, and sometimes accompany phlegmonous or gangrenous forms of acute appendicitis.

With a pelvic appendicular abscess, a purulent effusion descends to the bottom of the small pelvis and accumulates in the Douglas space. The purulent content pushes upward the loops of the small intestine, delimited from the free abdominal cavity by adhesions that form between the loops of the intestine, the greater omentum, and the parietal peritoneum.

Clinically, a pelvic appendicular abscess is manifested by pain in the depths of the pelvis, tenderness with pressure above the pubis, and abdominal distension. In some cases, there may be vomiting, which is caused by relative dynamic intestinal obstruction due to paresis of the loops of the small intestine involved in the inflammatory process.

Pelvic appendicular abscess is characterized by high temperature (up to 38 - 40 ° C), high leukocytosis with a shift of the leukocyte formula to the left. The tension of the muscles of the anterior abdominal wall of the abdomen is weakly expressed.

Of great importance for establishing the diagnosis of pelvic appendicular abscess are local symptoms of irritation of organs and tissues adjacent to the abscess - the rectum, bladder. At the same time, there are frequent fruitless urges to the bottom, diarrhea with an admixture of mucus, swelling of the mucosa around the anus, the sphincter gapes. Urination is frequent, painful, and sometimes there is a delay. During digital examination of the per rectum on the anterior wall of the rectum, a fluctuating painful tumor-like formation is determined, the puncture of which reveals pus.

Treatment of pelvic infiltrate before suppuration is the same as for appendicular, with suppuration - operational (median incision with drainage of the abdominal cavity).

Pylephlebitis. This is purulent thrombophlebitis of the portal vein, a very rare but very dangerous complication of acute appendicitis, which almost always ends in purulent hepatitis.

The initial symptoms of pylephlebitis are fever up to 38 - 40 ° C, chills, indicating developing purulent hepatitis, they are joined by the intermittent nature of pain in the right hypochondrium. On palpation, a painful liver is determined, an early appearance of not very intense jaundice, high leukocytosis is characteristic. The general condition of the patient is very serious. X-ray examination shows high standing and limited mobility of the right dome of the diaphragm, sometimes there is an effusion in the right pleural cavity.

Complications in the postoperative period. The classification of postoperative complications in acute appendicitis is based on the clinical and anatomical principle:

1. Complications from the surgical wound:

1) hematoma;

2) suppuration;

3) infiltrate;

4) divergence of edges without eventration;

5) divergence of edges with eventration;

6) ligature fistula;

7) bleeding from a wound in the abdominal wall.

2. Acute inflammatory processes in the abdominal cavity:

1) infiltrates and abscesses of the ileocecal region;

2) abscesses of the Douglas space;

3) interintestinal;

4) retroperitoneal;

5) subphrenic;

6) subhepatic;

7) local peritonitis;

8) diffuse peritonitis.

3. Complications from the gastrointestinal tract:

1) dynamic intestinal obstruction;

2) acute mechanical intestinal obstruction;

3) intestinal fistulas;

4) gastrointestinal bleeding.

4. Complications from the cardiovascular system:

1) cardiovascular insufficiency;

2) thrombophlebitis;

3) pylephlebitis;

4) pulmonary embolism;

5) bleeding into the abdominal cavity.

5. Complications from the respiratory system:

1) bronchitis;

2) pneumonia;

3) pleurisy (dry, exudative);

4) abscesses and gangrene of the lungs;

4) atelectasis of the lungs.

6. Complications from the excretory system:

1) urinary retention;

2) acute cystitis;

3) acute pyelitis;

4) acute nephritis;

5) acute pyelocystitis.

Chronic appendicitis

Chronic appendicitis usually develops after an acute attack and is the result of the changes that occurred in the appendix during the period of acute inflammation. In the appendix sometimes there are changes in the form of scars, kinks, adhesions with nearby organs, which can cause the mucosa of the appendix to continue a chronic inflammatory process.

clinical picture in various forms of chronic appendicitis is very diverse and not always sufficiently characteristic. Most often, patients complain of constant pain in the right iliac region, sometimes this pain is paroxysmal in nature.

If, after an attack of acute appendicitis, pain attacks in the abdominal cavity periodically recur, then this form of chronic appendicitis is called recurrent.

In some cases, chronic appendicitis from the very beginning proceeds without an acute attack and is called primary chronic appendicitis or asymptomatic.

In chronic appendicitis, some patients associate attacks of abdominal pain with food intake, others with physical activity, and many cannot name the cause of their occurrence. Often they complain of intestinal disorders, accompanied by constipation or diarrhea with vague pain in the lower abdomen.

If patients have a history of one or more acute attacks of appendicitis, the diagnosis of chronic appendicitis sometimes does not present great difficulties.

During an objective examination, patients with chronic appendicitis complain only of pain on palpation at the location of the appendix. However, this soreness may be associated with other diseases of the abdominal organs. Therefore, when making a diagnosis of chronic appendicitis, it is always necessary to exclude other diseases of the abdominal organs by a thorough and comprehensive examination of the patient.

Chronic appendicitis must be differentiated from uncomplicated peptic ulcer of the stomach and duodenum, diseases of the kidneys, liver, etc.; chronic kidney diseases (pyelitis, nephrolithiasis); chronic cholecystitis - duodenal sounding, cholecystography. In women, chronic diseases of the uterine appendages are excluded. In addition, it is necessary to differentiate chronic appendicitis from helminthic invasion and tuberculous mesoadenitis.

Treatment chronic appendicitis - surgical.

The technique of the given operation is similar to a technique of operation at an acute appendicitis.

Author: Selezneva T.D.

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