Transactions in abdominal

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Transactions in abdominal

Surgical treatment of diseases of the abdominal cavity was made possible only after the discovery of anesthesia, antisepsis and asepsis. Attempts to perform operations on the abdominal cavity prior to this period were unsuccessful and, as a rule, complicated by fatal peritonitis. Development of abdominal surgery after opening antiseptic and aseptic medicine owes such outstanding physicians, as a French surgeon Pean, an Austrian surgeon Billroth, German surgeons Bellefleur, Langenbuh, black, Coeur, local surgeons Spasokukotsky SI, II Greeks, S.P. Fedorov, S. Yudin, PA Herzen, EL birch etc. In anesthesia, aseptic and antiseptic, in the development of abdominal surgery study played an important role-tomographic analysis of physiological and biological properties of the peritoneum by the French physiologist Bichat (1801), a German scientist Wegner (1879) and a non-integer (1909), Soviet scientist Baron MA (1936).

The surface of the peritoneum is 20 cm2, LLC. The peculiarity of the peritoneum is the uniformity of its macro-and microstructure, a lot of it contains blood and lymph capillaries and abundant sensitive innervation, which makes the peritoneum of a large receptor field. In the abdomen there are constant currents of serous fluid from transsudiruyuschih (peritoneum of the small intestine) to the suction areas (large intestine). Especially strongly absorbed serous fluid in the upper parts (diaphragm), where there are mesothelial cover hatches stomatitis. Laxation causes - constant movement and mixing of the liquid and its distribution on zsey abdomen. The regularity and continuity of the capillary network creates the possibility of free and unlimited distribution of pathological processes on the peritoneum, and a large number of slots, pockets between the bodies - the possibility of stagnation pathological exudate.

The peritoneum has a powerful ability to plastic: even a minor irritation by mechanical, chemical or other agents causes an inflammatory response in it by the allocation of a fibrinous exudate, which glues together the serous surfaces in contact and causes the subsequent rapid organization of splices and turning it into the connective tissue adhesions. French surgeon Lambert in 1826 proposed to connect the intestinal loops, closure of intestinal wounds, and so lead them in constant contact peritoneal (serous) surface by cross-linking, and this leads to spayaniyu, resulting in an airtight connection that does not pass any liquid or microbes. Under the protection of the peritoneum is soldered the fusion and the other layers of the bowel wall: mucosa and muscle.

Other biological property of the peritoneum is its antibacterial aktiznosti allowing neutralize microorganisms. Because of this limited penetration in the peritoneum of microbes is inevitable in the course of any operation may not do any harm. But if in the peritoneal cavity penetrates simultaneously a large number of virulent bacteria, or if they come in small amounts, but for a long time, the protective properties of the peritoneum may be exhausted and developed peritonitis. Contributing moments can serve as the impact on the integrity of the peritoneum chemical effects (iodine), traumatic operative procedures, cooling, drying, poured out the blood, bile, urine, etc.

On the above properties of the peritoneum built in appliances operations of the abdominal cavity. The surgeon must first take all possible measures to prevent the receipt of infection in the abdominal cavity, strictly abide by the rules of asepsis: obkladyvat edge of the abdominal wound towels for the protection of output from contact with the skin, to operate as much as possible taken out of the abdominal cavity organs, before opening of the stomach or intestinal loops carefully isolate them gauze, use the stomach and intestinal zhomami after infection stages of the operation to change the gloves, surrounded by cushioning towels, gauze and instruments. Of paramount importance is the careful hemostasis and careful attitude to the tissues.

Surgical access to the abdominal organs

To perform operations on any of the abdomen produce laparotomy, or laparotomy (laparothomia) l. Incisions for access to the organs of the abdomen must meet the following requirements: 1) the place of opening the abdominal cavity must match the projection body to the skin of the abdominal wall and represent the most concise way to it, and 2) the value of the cut should enable the free operating: the deeper is the body or object at all operational techniques, the more must be cut and the angle of the operational actions (AY-Sozonov Yaroshevich), and 3) cross-section shall provide the operational lasting scar or damage the branches of the intercostal nerves to the muscles of the abdomen. Abdominal wall incisions are longitudinal, oblique, angular, lateral and combined. Go to the median longitudinal sections include, paramedian, and transrectal adrectal.

According Sozonov-YAROSHEVICH the most favorable conditions for operating in the depths of the wound creates a vertical axis of the operational actions when an object (the body), in which the operation is performed, is located on the plumb line from the middle of the section and is available inspection and the implementation of operational administration. Unfavorable conditions for the transactions are created when the axis is tilted, and this forms an acute angle with the plane of the section, and if the object is not available in full operation inspection of the cut, if the cut is less than the length of the body and is a "window".

The median, or median, the incision is carried along the median line of the abdomen above or below the belly button (upper or lower median laparotomy).

The middle section provides access to almost all the organs of the abdominal cavity and therefore beneficial in emergency surgery for acute surgical diseases of the stomach and penetrating wounds. The upper midline incision was used to access the bodies upper abdomen, lower - to the organs of the lower floor and the pelvis. Sometimes make cuts in the middle of a stretch - above and below the navel.

The middle section of the line runs through the musculo-aponeurotic layer and therefore does not damage muscles, blood vessels and nerves, but the fusion of cutting the white line is slower, in the elderly, in malnourished (cachectic) patients scar may be defective and sometimes leads to dehiscence, education postoperative hernia.

Paramedian incision used instead of the upper middle, hold the inner edge of the left rectus muscle, cut through the anterior vaginal wall, the edge of the muscle is pulled outwards, cut through the back wall of the vagina and the peritoneum. Since the cuts front and back walls of the vagina sewn separately and are separated by a straight muscle scar is a more durable than the median section.

Transrectal incision is carried out over the middle of the rectus muscle, it passes through the front and rear sheets of the vagina, and the rectus muscle fiber the lengthwise. The incision is used for access to the stomach for gastro-stoma, or for the imposition of fecal fistula at poperechnoobodochnaya intestine.

Adrectal section on Lennanderu conduct parallel lateral edge of the lower segment of the right rectus abdominis muscle. The front wall of the vagina straight cut through the abdominal muscles, the edge of the muscle is pulled inwards and cut through the back wall of the vagina and the parietal peritoneum. Adrectal incision used for appendectomy, the disadvantage is that if it can be damaged on the rear wall of the vagina branches of the intercostal nerves to the rectus.

The oblique abdominal incision is used for opening the abdominal cavity in the upper quadrant or iliac region, they are used to access the gall bladder, spleen, appendix, sigmoid colon. By oblique sections belong variables cuts in the iliac region: broad layers of muscles are not cut through, and pushing them along the fibers (see Fig. 510). Due to material differences between the lines the abdominal wall keeps moving apart after the operation his fortress; this contributes to more the fact that the oblique cuts here do not damage the nerves. The disadvantage of variable sections is that they give limited access.

Transects above the navel give access to the organs of the upper abdomen (stomach, etc.), while rectus reveal the most muscle is pulled apart and cut through the back wall of the vagina and the peritoneum. Rectus muscles can not delay, as well as cross in the transverse direction, for their subsequent function is not impaired (GA Valyashko). The transverse incision below the navel on Pfanenshtilyu for access to the pelvic organs (uterus, epididymis) during gynecological operations are on the belly skin fold, respectively, the upper boundary of the hair growth from one outer edge of the rectus muscle to the other. The cross-cut only the skin, in the midline longitudinal cut through the fascia white line, the exposed inner edges of the rectus muscle is pulled to the side, and then a longitudinal incision of the peritoneum.

Corner section provides access to the organs of the right and left upper quadrant.

Combined cut is a combination of laparotomy and thoracotomy, gives access to the lower abdominal and thoracic cavity, is used for operations on the cardia of the stomach and lower esophagus.

Technology laparotomy

The upper middle laparotomy. The skin incision and the subcutaneous layer in the midline starting at the top, deviate somewhat from the xiphoid process, and end up at the bottom, not reaching to the navel. Bleeding from small vessels stopped by pressure or ligature.

Over the skin incision cut through the fascia white line of the abdomen. The wound was draped large gauze or towels. Two anatomical tweezers to lift the middle of a stretch injury to the fold of peritoneum properitoneal fiber and its incised, the cut edges of the peritoneum immediately connect the terminals with Mikulic obkladyvayut towels, cut through the peritoneum along the length of the wound, lifting it entered the abdomen with your fingers.

After dissection of the abdominal wound stretched plate hooks, mirrors or automatic retractor. Then proceed to the inspection and to the production of the main stage of surgery.

After the operation the abdominal cavity should be dried tupferami from blood and pleural effusion and check, if left to her by chance napkins, balloons, tools.

Closure of the abdominal incision produce layers: first sutured peritoneum then musculo-aponeurotic layer, and finally the skin. Suturing the peritoneum with preperitoneal fiber and transverse fascia produce continuous catgut suture. Seam start from lower angle wounds abdominal viscera protect against possible needle punctures special spatula (Reverdy) or cloth that before the full closure of the wound are removed. If there is a great tension stitched edges of the peritoneum, you must first several strong silk sutures to bring together the edge of fascia. Aponeurosis white line stitch nodal silk sutures. In those cases where the floor seam impose impossible peritoneum aponeurosis crosslinked with interrupted sutures or abdominal wound is closed through-stitching through all layers. This is shown with a sharp depletion of the cancer or another when the abdominal wall sutures are cut, or when re-stitching seams after the incident divergence and loss viscera (eventration). Removing skin sutures conventional cases produce 7-8 days after surgery. In malnourished patients removal of sutures should be postponed until the 12th day.

If necessary, extend the incision continues its downward rounding belly button on the left, avoiding this intersection lig. Teres hepatis.

The lower median laparotomy is different in detail. After dissection of the white line of the abdomen in the surgical wound are seen inside edges of both rectus muscles that need to be carefully identified and shifted to the side. Dissection of the deep layers (transverse fascia, preperitoneal fat, peritoneum) in the lower part of the wound should be done with care to avoid injury of the bladder.

When you access to the organs of the lower floor of the abdominal cavity of the lower midline incision is usually still above the navel, beating him on the left.

Gastric surgery gastrostomy (gastrostomia)

Gastrostomy - imposing pischepriemnogo gastric fistula. The essence of the gastrostomy is to create an artificial entrance into the cavity of the stomach through the abdominal wall for the purpose of feeding the patient if you can not receive food through the mouth.

First gastrostomy was performed on animals in 1842 VA Basov. The first operation was performed on a person Cedillo (1849), but the successful results achieved English surgeon Sydney Jones (1875), and almost at the same time a French surgeon Verneuil (1891). Modern types of operations have been developed Witzel, Kader (1896), GS Toprover (1934).

Gastric fistula can be temporary or permanent. Impose a temporary fistula as a preliminary stage of the operations in the pharynx or esophagus. Impose a permanent fistula with inoperable tumors of the esophagus as a palliative intervention.

Indications. Stenosing tumors of the esophagus, gastric cardia, cicatricial narrowing of the esophagus after burns, cardiospasm. Pain relief. Local anesthesia.

The surgical procedure by Witzel. Opening transrectal abdominal incision is made on the left. From the edge of the left costal spend a vertical section of a length of 10 cm in the middle of the width of the rectus abdominis muscle. Consistently cut through the skin to the subcutaneous tissue, the front wall of the rectus sheath, stupidly split this muscle, cut through the back wall of the vagina along with the transverse fascia and the parietal peritoneum.

In wound output front wall of the stomach. In the middle between the small and large curvature of the body of the stomach along its long axis closer to the cardiac department apply a rubber tube with a diameter of 0.8 cm and dipped it in the formed by two folds of the stomach wall, connect the edge folds over the tube 5 - 7 sero-muscle knots silk sutures, firmly locking the phone. To the left of the last seam impose another one in the form of incomplete pouch, leaving him loosened. Inside it, two anatomical tweezers to grasp the fold of the stomach wall and straight scissors cut through it through all the layers. In the hole is introduced to a depth of 5 cm end of a rubber tube and tighten the purse-string suture. Thus, the rubber tube is disposed in the channel opening in the stomach cavity. The end of the rubber tube is directed to the area of ??gastric air bubble. The wall of the stomach into the circle of rubber tubing out of the channel is fixed by four nodal parientalnoy silk sutures to the peritoneum and the posterior leaf of the rectus sheath: impose one seam above and below the outlet tube and one - on either side of her.

Thus, the portion of the stomach at the exit of the channel tube tightly sutured to the abdominal wall and isolated from the abdominal cavity, and thereafter is formed with the stomach wall adhesions parietal peritoneum. The incision of the peritoneum and the posterior wall of the rectus sheath above and below the fixation of the stomach is sewn up nodal catgut sutures. The edges of the incision anterior wall of the rectus sheath above and below the derived out of rubber tubing connected nodes silk sutures, leaving room for the output tube. On the tube wear rubber sleeve, which is fixed to the edge of the seam of the skin incision.

Liquid food to feed the patient begin immediately after surgery. Outside of a meal period or pinch the tube is stoppered and tie a bandage to her stomach. If gastrostomy was made as a temporary operation, the tube is then removed and the hole usually closes by itself.

Gastrostomy in G.S. Toprover

Transrectal cut left the abdomen was opened, and output the front wall of the stomach in the form of a cone on top of the cone impose two silk seam-taped. The following is the vertex of three concentric purse-string suture is applied at a distance from one another 1.5-2 cm pouch ends of the filaments are not tightened. Reveal the gastric cavity at the top of the cone between taped, inserted into the opening rubber drainage tube of 1 cm diameter and thread imposed successively tightened purse-string sutures (Fig. 486, b). Thus, the insertion of a tube formed around a three-fold valve. To save the channel is formed, the cone of the stomach is fixed to the layers of the abdominal wall incision (Fig. 486, d) at the level of the deep-seated pouch wall of the cone is fixed to the parietal peritoneum, located above the site - to the cut edges of the rectus and the uppermost portion (at the level of first pouch) - the edges of the skin, joints impose these last so that the mucous membrane of the stomach at the level of the cut appeared over the incision. The remaining holes of the peritoneum, muscle and skin sutured sequentially. The tube was removed after the operation: a channel is formed with valves and gubovidny fistula. Stomach contents through the valve should not be poured out. Stomach contents through the valve should not be poured out. Feeding the patient to enter the fistula drainage tube. Surgery is indicated for cancer of the esophagus and cardia.

Gastrotomy by Kader. The operator is applied in small size of the stomach in children, adults - with extensive cancer of the lining of the stomach.

The surgical procedure. Transrectal access. Pull the cone front wall of the stomach and put it around purse-string suture, in the center pouch cut through all the layers of the wall and inserted a rubber tube into the stomach. Pouch tightened and knotted. Further, some distance of 1-1.5 cm to the periphery, concentrically superimposed second and third purse-string sutures, while tightening the tube which is the channel of direct (Sheer) direction. If lack of space to put the second and third pouch fails, the tube further strengthen between the two longitudinal folds of the stomach, connecting them with a few interrupted sutures. Gastropexy in the same way as in step Witzel.

Gastrectomy (resectio ventriculi)

Summary surgery is to remove all or part of the stomach. Distinguish piloroantralnuyu, and partial resection of the proximal stomach. Removal of the pyloric part of the body and is called piloroantralnoy resection, resection of the gastric cardia of the removal, the bottom and the body is called the proximal. In partial resection limited to removing only the affected part of the pathological process of the stomach (circular, wedge-shaped), now this operation is rarely used. By the volume of the removable portion distinguish total resection (gastrectomy) when the whole stomach is removed, including the porter and the cardia, subtotal resection, when the whole stomach is removed, except for the bottom (dome). When removing the cut-off line ZL stomach goes right through the beginning of the duodenum, and the left - from the point on the lesser curvature, located at the upper pole of the spleen. When you remove the stomach Yi left, the cut is on the lesser curvature from the same point to point on the greater curvature, located at the lower pole of the spleen.

By the method of execution are two basic types of operations: resection of the Billroth I (BI) and resection of the Billroth II (BH) (see Fig. 490). When resection of both BI stump - the stomach and duodenum - connect end-to-end anastomosis. When the rest of the EP resection of gastric fistula connect fully supplied to it by the small intestine that is doing gastroenterostomy. The first type of surgery is more physiological, as it saves the normal movement of food from the stomach into the duodenum, the second type of operation the food passes into the intestine, bypassing the duodenum. Despite this, the operation of BI is being used less frequently, because, first of all, in many cases it is not possible to take the stump to the stomach and duodenum, and secondly, by pulling a danger of violation of the integrity of the anastomosis (the eruption of sutures). He and other types of resection were many variations and performed in several versions.

Indications. Stomach cancer at any site, complicated ulcers of the stomach and duodenum (the bleeding, penetrating, kalleznye), benign tumors (polyps, adenomas, fibroids).

The patient on the back.

Pain relief. Anesthesia, local anesthesia.

The operation to Hofmeister-Finsterer (modification of the method Billroth II) upper abdomen was opened through a midline incision. The first stage - the mobilization of the stomach by releasing a removable part of the ligament (lig. gastrocolicum, lig. Hepatogastricum) with simultaneous ligation of vessels. Display the stomach and the large intestine into the wound, the assistant throws their way to tighten the lig. gastrocolicum. Dissect a bunch of avascular place and begin to mobilize the removable portion of the stomach on the greater curvature. To do this through a hole formed in conjunction with your fingers or displace peeled located behind the mesocolon transversum, so as not to damage it in passing to the intestine and poperechnoobodochnaya. colica media. Lig. gastrocolicum consistently dissect between Kocher clamps, imposing on the land crossed by the ligature. In this way, isolating greater curvature of stomach necessary for: left - delineation before resection (usually up malososudistogo large field curvature at the joint between the left and right gastroepiploic artery), right - to the initial portion of the duodenum.

In order to mobilize the lesser curvature of the posterior wall of the stomach hold your index finger to a small gland, and, by doing stupid hole in it at the level of the antrum of the stomach, the stomach is pulled to the left and down. Dissect the avascular portion of the lesser omentum (lig. hepatogastricum); applied to a. gastrica dextra, and then a. gastrica sinistra two strong ligature and between vessels cross. Ligating the central segment of the left gastric artery is the most crucial factor in the mobilization of the stomach (double ligature is applied), and can be produced in the following stages of operation, the second stage - cut off from the right border gastric resection and stump treatment duodenum. Before you cut off the right end of the stomach, is a primary loop of jejunum and through a hole made in the mesocolon, print it out on the top floor in the bursa omentalis, which is held by an elastic applied to it bagasse or passing through its mesentery thick silk thread.

Mobilized on the top part of the duodenum impose pulp Payra; under the duodenum is supplied gauze, all after surgery fence off large gauze. Immediately above the pyloric part of the stomach to impose a removable hard histotribe. Then zhomami cross between the duodenum below the pylorus and cut her smeared with iodine. Gastric stump harbor large gauze and throws left. Begin to close the duodenal stump.

To do this, use Moynigena or through encircling stitch, which is immersed seroznomyshechnym-purse-string suture. To close the stump is also used machine UKL-60 and then immersed the seam line of hardware node sero-muscular. Seam duodenal stump further strengthen, fixing it 3-4 catgut sutures and fascia (capsule) adjacent area of the pancreas. The third stage - the removal of the stomach and the imposition of the gastrointestinal anastomosis. Superimposed on the right (pyloric) end of the stomach is removed electric pumps, pulp and impose a stump wrapped with gauze. Accordingly, the left boundary line clipping stomach applied transverse to the axis direction of the two gastric Kocher clamp. Clamps applied from small and large curvature towards each other: the upper (with a small curvature side) clamping member engages the 2/3 the diameter of the stomach, the lower (from the large curvature) - 1/3 of it. Distally (to the right), and parallel to these terminals on a removable part of the stomach is applied to the whole width of histotribe Payra.

After careful isolation of gauze is removed to the left and up the removed part of her stomach and cut with a scalpel on crushes zhomu. Then proceed to the top of the suturing of the gastric stump on the clip that was imposed by the small curvature. Suturing produce a continuous through-catgut suture through all layers around the clip, starting at the bottom of the seam from the contact noses and jaws are in the direction of up to the lesser curvature. When the upper jaw, produce tightening the joint in its ends at the moment when he came to the small curvature. Then, in the same cross-cutting obvivnym sew seam in the opposite direction to the large curvature of the nozzle to the remainder of the lower jig, the end of the suture is connected to its beginning. Close clearance can also hemostatic suture: sewing a continuous suture in the same direction to a small curvature, but always under the clamp, then piercing the wall sequentially from the front, then the back surface after each puncture made behind the last vykoli, reaching the small curvature clamp is removed, then the same thread, already obvivnym seam come back to the top of the seam, tie ends without cutting them.

After the end of a deep seam proceed through the imposition of sero-muscular nodal silk sutures. These sutures are gradually immersed angle formed by the edge of the stump of the stomach and small curvature, while also ushivaya site deserozirovannoy in the left gastric artery ligation. Take in the upper portion of the lumen of the stomach can also use the device UKZH-7 (stomach stapling apparatus of the stump) tantalum brackets. The device closes the lumen of the double-row suture of the stump, and this speeds up the progress of the operation, and seals.

Now to the back wall of the gastric stump on the part of the lower, not stitched part sew close sero-muscular sutures derived loop of jejunum. Please connect the leading ends and the discharging loop, resulting in the end, taken at a distance of 8-10 cm from flexura duodenojejunalis, multiple fixed-serous seam muscle sutured to the lower portion of the limb, then the discharging end of the loop is fixed at the nodal seam large curvature, thus resulting in end of the loop will be facing up to the lesser curvature of the stump, and the outlet - top to bottom, to the greater curvature. After this next node sero-muscular joint connecting the facing wall of the bowel loops and the rear wall of the stomach stump. Compound they must produce so that the seam was in the gut is not strictly longitudinal axis of the colon, and a spiral. Filaments of all serous cut-skeletal joints, except the first and last. Field operations draped gauze and reveal the jejunum parallel to the sutures, and then the bottom, captured Kocher clamp portion of the stump cut off and remove the electric pumps of the stomach contents.

Tightening the stomach and intestine sutured to it for the left strand of the first and last stitches, proceed to the imposition of continuous catgut suture on the posterior lip of anastomosis through all the layers. When finished suturing the rear lip anastomosis continue seam front lip anastomosis using screws up the seam Schmid.

Fistula is formed by the bottom third of the lumen of the stomach. Isolating napkins change and imposes a number of sero-muscular nodal silk sutures closing line of the legs anastomosis. Resulting in a loop of the small intestine is pulled up to the previously sutured portion of the stump of the newly formed small curvature and fix it 2-3 sero-muscular sutures. Check the patency (wide) anastomosis. A large gland in the cross-rechnoobodochnoy gut throws up, display anastomosis through a window in the mesocolon to the lower floor of the abdominal cavity and fix it with interrupted sutures to the edges of the hole. After using the toilet abdomen abdominal incision is closed in layers.

The advantage of Hofmeister-Finsterer over others is that: 1) the fixing loops of the small intestine anastomosis of the stomach above the sheer ensures its position and prevents food resulting in a loop and thence to the blind end of the duodenum, 2) due to anastomosis that is imposed only for the lower third of the gastric stump, the evacuation of food from it does not happen immediately, but gradually and continuously, which normalizes the process of digestion. When sewing on all the gastric stump in the gut, as is the case in the method of Reichel-Polya, delayed gastric emptying is excluded, as it was quickly evacuated through a wide anastomosis and gastric phase of digestion falls. The operation to BilrotI The mobilization of the stomach in the same way as described above, after resection anastomosis is applied between the stumps of the duodenum and stomach. Thus restoring the direct way to move food through the duodenum. Duodenum can not connect with the part and with the whole stomach stump: for this, Gabereru, the hole edges of the stomach by collecting it in a fold (embossing) is aligned with the hole intestine, thereby forming a kind of valve. By S. Yudin, reducing the lumen of the stomach is achieved less complicated method - dissection and suturing of the lesser curvature.

In some cases, the operation Billroth I, when to pull together the stump of the stomach and duodenum and the anastomosis difficult due to the great tension, the possibility of cutting the joints, have resorted to pre-mobilization of the duodenum by Kocher, allowing her to move to the left: the right edge of descending part of duodenum dissected the parietal peritoneum, renal peritoneal duodenal ligament, the duodenum with the head of the pancreas is peeled from the underlying fascia and retroperitoneal move to the left.

Gastric ulcer and duodenum shows resection of at least two thirds of the stomach to remove hormonal zone (antrum), the bulk of acid-producing glands (the body of the stomach), and possibly a full intersection of the branches of the vagus nerves (S. Yudin).

When duodenal ulcers may be permanently employed piloroantralnuyu resection of the stomach to "off". Although after resection for gastric ulcers stable recovery observed in 70-80% of cases, yet, in the opinion of a large number of doctors, this surgery is a crippling, gives a considerable percentage of mortality and the number of serious complications peptic ulcer of anastomosis, agastralnaya fatigue, relapses. At present, the surgical treatment of gastric and duodenal ulcers especially are becoming more common organ-preserving surgery. It is proved that deiervatsiey stomach through the vagus nerve neurotomy can achieve a sharp reduction of acidity and remove it one of the main causes of and supporting the existence of an ulcer. This operation is performed does not currently own, and in combination with other operations: pyloroplasty, piloroantralnoy resection, gastroenterostomy, because without them there persists a second reason ulcers - pilorospazm, pyloric stenosis. Vagotomy is particularly indicated for duodenal ulcers, accompanied by high acidity. It is produced in recurrent ulcers, peptic ulcers.

Vagotomy or dissection is performed by the intersection area (2-3 cm) of the left vagus nerve below the diaphragm on the gastric wall: this is achieved by "selective vagotomy" as produced excision only those nerve branches which go to the stomach. Excision above the diaphragm of one or both (right and left) violates the nerves and nerve function and other organs (liver, pancreas). Pyloroplasty is that region gatekeeper its front wall, sectioned longitudinal section, then sutured in transverse direction, and this greatly enhances and facilitates the evacuation lumen of the gastric contents. Pyloric resection combined with vagotomy can be done in a more limited extent, and in some cases with duodenal ulcer gastroenterostomy replace it.

In cancer to prevent recurrence produce a complete or nearly complete removal of the stomach - gastrectomy or subtotal resection. Together with stomach was removed from all his ligaments are laid down in the lymph nodes and the entire greater omentum, which can be a metastasis of cancer cells. During germination of the tumor into adjacent organs - the liver, pancreas, poperechnoobodochnaya intestine, spleen - in the absence of distant metastases at the present time as extended and combined resection, which removes part of the liver, pancreas and intestine poperechnoobodochnaya (EL Voloshin, 1956 ). This method while increasing the risk of the operation, but provides a more favorable long-term results than a standard gastrectomy.

After extensive resection of the stomach digestive tract exercise recovery sewing on the stump of the esophagus or gastric cardia (if removed and cardia) of the decal in the jejunum or replace a segment of stomach ulcers by Zakharov.

Operations in the large intestine

Operations in the large intestine differ from operations in the small number of features. The subtlety and tenderness wall, the worst of its power, the presence of areas not covered by peritoneum, more infected intestinal contents do seam large intestines less reliable. Instead of double-row suture on the colon is advisable to use three rows: one internal and two through sero-muscular, and the third row can be replaced by a fixation to the line of sero-muscular fat seam pendants. In imposing the end anastomoses on the colon sometimes have marginal necrosis, and dehiscence. Therefore, if conditions permit, the safer is the overlay is not the end, but the side anastomoses. For these same reasons, in some cases it is advisable to make a resection of the colon is not a primary patency as in the small intestine and in two phases (dvuhmomentnaya operation).

A number of types of operations on the colon, which often have to produce for malignant tumors. These interventions are divided into radical and palliative.

By radical operations include one-stage resection of the bowel poperechnoobodochnaya Side (at sufficient length remaining ends) or end anastomosis, resection of the sigmoid colon (usually with end anastomosis), resection of the right and left halves of the colon (hemi-colectomia dextra, hemicolectomia sinistra), etc. By palliative operations include the imposition of fecal fistula colopexostomy, creating a bypass anastomosis - Connect the bowel anastomosis neutrally bowel tumor site to the periphery of it.

Appendectomy (appendektomia)

In the beginning of the last century pointed to disease of the appendix as a possible cause of ulcers in the right iliac region. In 1886, Reginald Fitz described the symptoms of appendicitis and recommended emergency surgery and he also coined the term "appendicitis". The first successful appendzktomiyu in 1887 produced Morton, and in Russia - in 1890, AA Troy-new. Systematically began to do surgery for appendicitis in 1904, when Sonnenburg published work, based on 1500 operations.

Indications. An acute attack of appendicitis. The operation must be carried out urgently, in the first hours after the onset of the attack, and chronic appendicitis - in the cold period.

The patient on the back.

Pain relief. Local infiltration anesthesia. Anesthesia. The surgical procedure for Mac Stormy-Volkovich. 8-10 cm long incision is carried out between the middle and the outer thirds of the line connecting the front upper iliac spine to the navel 1. The incision is perpendicular to this line, the upper third of the above it should be, and the lower two-thirds - below. Cut through the skin with subcutaneous fat and downstream fibers - the aponeurosis of the external oblique muscle. Under the aponeurosis stupidly pushing parallel to the fibers first internal oblique and deeper - the transversus abdominis and stretch their plate hooks farabeuf. Cut through the transverse abdominal fascia and draped gauze wound. Cut raised two anatomical tweezers fold parietal peritoneum and fix it to the edge of the napkins.

If, during the operation but the access is not sufficient, the incision can be extended. In the medial incision lengthened by moving apart the muscle layer by layer, it usually reveal the rectus, the edge of her back and pulled muscles dissected laterally extending back wall of the vagina. On completion of the vaginal wall to be carefully sewn.

If necessary, extend the incision in the lateral side of the line of the original incision continues outward, upward slanting cut through the skin first, and then the scissors in the same direction all the layers of muscles at once.

After opening the abdominal wound stretched plate hooks and proceed to the determination of the appendix. To do this, fenestrated forceps or tweezers to anatomical wound withdrawn cecum with the terminal ileum and find the appendix. Cecum recognize in her position, grayish color that distinguishes it from the pinkish color of the small intestine, and the presence of muscle strips (taenia). Honors from the cecum and sigmoid colon poperechnoobodochnaya is the absence of mesenteric fat and pendants. In case of difficulties in finding process should be guided by the taenia libera, which always leads down to the base of the appendix.

Vermix pulled upwardly so as to be visible clearly its entire mesentery. Mesentery process dissect between successively imposed Kocher clamps down to its foundation. After crossing the mesentery of the captured land her tied catgut thread. On the wall of the cecum, the indentation of 1.5 cm from the base of the appendix, impose sero-muscular silk purse-string suture, leaving the ends are loosened. Peredavlivayut appendix at its base koherovskim clip on peredavlennoe place impose catgut ligature and cut off the ends of her; distal to the ligation process to impose a Kocher clamp. Hold the base of the anatomical tweezers process, it cut off above the ligature immediately below clipping. Stump sprouts sear iodine and anatomical forceps is dipped into the lumen; pouch tightened and knotted knot breeding pair of tweezers. Not cutting off the ends of threads purse-string suture around the pouch impose sero-muscular suture in the form of the Latin letter z, which tightened after cutting the ends of the purse-string suture. Overlay z-stitch optionally. Cecum to reduce a peritoneal cavity.

Small tupferom introduced into the abdominal cavity, check, whether it is stored blood, lots of blood, and if it is added, straighten the ileocecal angle, finds bleeding vessels and their carefully ligated. Obkladyvayut tissue is removed and the peritoneum closed with a continuous catgut suture. After suturing the peritoneum one or two catgut sutures loosely tightening the transverse and internal oblique muscles and joints 5-6 - aponeurosis of the external oblique muscle. Two fine catgut sutures sutured subcutaneous fat and nodal silk sutures are placed on the skin incision.

Retrograde removal process. When fixing process spikes deep into the iliac fossa removing it can be produced by retrograde. To do this, in the mesentery at the base of the hole making process; process at this level, tied catgut thread and let down, capturing its distal Kocher clamp, cross, without separating from the mesentery and adhesions. Central bandaged stump sprouts immersed in a pouch. Cecum were taken aside and release process from the base to the apex, gradually slicing and ligating the mesentery and adhesions.

Ligature removal process. Appendectomy produce the usual way, but the stump sprouts are not immersed in the pouch, but only tied. This method was proposed to avoid the 'education immersed in a pouch around the stump of a closed space in which infection can develop and form a granuloma - a chronic inflammation (appendicitis without an appendix), and even an abscess. The risk of infection of the peritoneum from the stump is removed by burning off stump mucosa of carbolic acid. Most surgeons do not consider ligature method bezopasnyA and prefer to dive in a purse-string suture of the stump. Dore method is shown in those cases where the cecal wall infiltrated by purse-string suture, and imposition difficult due to its cutting. It is also used in children.

Gall bladder surgery, biliary tract and liver cholecystectomy (cholecystectomia)-removal of the gallbladder

Removal of the gallbladder was first produced in 1882 by the German surgeon Langenbuhom. A major role in the development of evidence and methods of operation on the biliary tract owned by Russian surgeon SP Fedorov and German surgeon Qeru. Indications. Chronic recurrent cholecystitis (calculous and without stones) in the case of prolonged unsuccessful conservative treatment. The immediate indications are gangrene, perforation of the gallbladder.

The patient on the back, under the lower part of the chest or raise enclose roller designed for this purpose section of the operating table. Pain relief. General anesthesia or local anesthesia.

The surgical procedure. Good access is cut according to Fedorov. His start in the midline below the xiphoid process, conduct a few inches down, and then parallel to the right costal arch, 2-3 cm below it. Most are slightly convex downward cut Courvoisier, also going along the costal arch. Convenient for interventions on the biliary tract at the corner section of Rio Branco, it starts below the xiphoid process and lead the midline down, short of a few centimeters to the navel incision is turned to the right and slightly curved line direct to the end of the XI rib.

In the medial part of these cross sections of the rectus abdominis, which is tied up in the interior of a. epigastrica superior. In the lateral part of the wound subsequently slit outer, inner and lateral abdominal muscles, the transverse fascia and peritoneum.

After opening the abdominal cavity of the right lobe of the liver lifted up, and poperechnoobodochnaya and duodenum being pushed downward. Liver hold a special rectangular mirror or directly by hand using a muslin cloth. Produce inspection and palpation of the gall bladder. Biliary tract and surrounding organs. Removal of the gallbladder produced either from the bottom or from the neck. With both methods, the most important point is to separate the operation and ligation of cystic artery and cystic duct in the hepatoduodenal ligament. This point is related to the risk of damage to the hepatic artery or its branches, as well as the portal vein, accidental or involuntary artery ligation causes necrosis of the liver and portal vein of injury occurs it is difficult to stop bleeding. The orientation of the wound is often difficult because of the presence of adhesions, inflammatory edema, scars and atypical location of the branches of the hepatic artery.

Before removing the gallbladder surgical field should be isolated by three gauze, one laid down in the duodenum and colon poperechnoobodochnaya, the other - between the liver and the upper pole of the kidney to the vinslovovu hole, the third - in the stomach.

Gallbladder removal of the cervix. Pulling up the liver and duodenum downward pull hepatoduodenal ligament. Along the right edge of the level of the bladder neck down to the duodenum, carefully incised leaf front peritoneal ligaments, pushing the tissue, exposing the common duct and the place of confluence of the cystic duct. Allocate the cystic duct, usually forming a few bends. A dedicated channel impose a silk ligature, and the periphery of it, closer to the bladder neck, to impose a curved duct clamp Billroth. To prevent damage to the wall of common bile duct ligature is applied at a distance of 1.5 cm from the confluence of the ducts, the longer limb leaving undesirable since it may lead to the formation subsequently ampuloobraznogo extension (new "gallbladder") with stone formation. After ligation and clip the cystic duct between the two intersect, cauterize the stump with iodine and cover with gauze. In the upper right corner of the wound is a guide to the right and up a few cystic artery, its isolated and carefully tie up two silk ligatures and cross, beware grab a ligature right branch of hepatic artery, from which the cystic artery departs. Then proceed to the allocation of the gall bladder (Fig. 513, b). If he dramatically extended the liquid contents, it is advisable first to empty his puncture and close the puncture purse-string suture or impose on him the fenestrated forceps Luer. Clip the neck of the bladder is pulled from the liver so that you can see the place of transition visceral peritoneum bladder to the liver. Along this line, carefully cut through the peritoneum along one edge of the bubble. When the incision is made, a finger or blunt tupferom bladder wall is peeled from his bed; separation bubble is facilitated by a hydraulic dissection of 0.25% solution of novocaine AV Vishnevsky. Then cut through the peritoneum along the other edge.

Isolation can be done differently: the front section of the leaf hepatoduodenal ligament continue to bubble to the wall in the form of two poluovalov passing near the axis of the gall bladder and converging at the bottom. Each of the resulting flap otpreparovyvayut visceral peritoneum from the surface of the bubble toward the edges. When the edge of the bubble exposed, it is easy to extirpate from his bed blunt. After removal of the bladder peritoneum is sutured over the bed of bubble continuous hepatic nodular or catgut suture, extending it along the cut hepato-duodenal ligament, thereby peritoniziruyut bed bladder and duct stump. Insulating cloth was removed to the bed of the gall bladder and the stump is fed 2-3 strips of gauze swabs, a width of 3 cm each, brought them to the bottom of the wound, but short of hepato-duodenal ligament, gauze sponges output from the surgical wound. Remove them gradually pulling out from the 9-11th day. The roller is removed, for relaxation of the abdominal wall slightly lift the upper body and begin to close the wound. The abdominal wall was sutured in layers: a continuous catgut suture - the peritoneum, the nodal silk sutures - crossed the muscles of the vaginal wall and the rectus abdominis muscle and skin.

Removal of the gallbladder from the bottom in the reverse order: first isolated gallbladder, and then carry out methods of isolation and ligation of the cystic duct and artery. For this the marked bubble is pulled, then revealed cystic artery, which is isolated and cross between the two ligatures as described above. After that, isolated, ligated and cross the cystic duct. The further course of the operation is the same as the allocation of the bladder neck. Isolation of a bubble from the bottom less appropriate, as this small stones from the bladder cavity is easy to drive into the ducts.

And choledochendysis holedohostomiya (choledochotomia, choledochostomia) - opening common bile duct and overlay fistulas

Indications. Choledochotomy usually produce during the main operation - Cholecystectomy - in cases where the patient before the operation was jaundice, and there is reason to assume the presence of stones in the common bile duct, in the presence of a bubble in the deleted set of stones with cholangitis - inflammation of the bile ducts that prevents the free flow of bile into the duodenum. It is indicated for the revision of the bile ducts by their sensing for drainage - create a temporary outflow, the inflammatory process and to remove the stones if they are available.

Choledochotomy and produce a solo surgery to remove the stones, not detected during the first operation, or re-emerged after her. The prerequisite is choledochotomy X-ray bile ducts - cholangiography on the operating table by the introduction of contrast medium into the common bile duct, thus identifies the intra-and extrahepatic bile ducts and can be found stones, for example, at the confluence of the common bile duct into the duodenum - faterova in the nipple, that is, in the most inaccessible to other studies (palpation, probing) of the site. In order to identify the obstacles the flow of bile from the ducts also produce pressure measurement of bile - holangiomanometriyu. If there is a basis for the revision of the common bile duct, the choledochendysis shown to remove the gall bladder as it is not known in advance whether there is a removable duct (stone, inflammatory edema) or unavoidable (the tumor, scar reduction) obstacles. In the latter case, the bladder should be saved and used for bile flow by imposing a fistula between him and the stomach (holetsistogastrostomiya) or duodenal ulcer (holetsistoduodenostomiya).

The surgical procedure. The abdomen was opened under the hepato-duodenal ligament sum gauze strip and draped gauze surgical field: over the common bile duct cut through the front piece of lig. hepatoduodenal, hepatic and cystic ducts clamp fingers neutrally intended location opening; sectioned front wall ductus choledochus for 1-1.5 cm and through the opening towards the duodenum introduced probe. In the case of stone pushed his fingers to the hole and remove the special spoon or clip. If the stone is at the bottom, the department of pancreatic duct or major duodenal papilla, it tend to push into the duodenum.

In cases where the major duodenal papilla incarcerated in stone can not be offset, resort to transduodenalnym choledochotomy, ie, for the opening of the front wall of the descending part of the duodenum and dissection of the mouth of the common bile duct from the gut cavity.

When the stones removed and the flow of bile into the duodenum is free of uncovered ductus choledochus drainage administered by AV Vishnevsky. Drainage is a rubber tube the size of a conventional catheter number 20, the inner end of which is introduced in the direction of the hepatic duct. Drainage is discharged through an incision in the wall of the common bile duct and fix it here two catgut sutures. The other end of the drainage is discharged outside through a separate incision in the abdominal wall (lower operational), and by building up its rubber tube is dipped into a bottle of disinfectant. When inflammation of the bile duct is extinguished, bile begins to drain through the window to enter the duodenum. Drainage can also be set using the T-shaped rubber tube.