TOPIC № 1. THE SUBJECT OPERATIVE SURGERY. THE MAIN PRINCIPLES OF OPERATIONS. THE STAGES, NAMES AND CLASSIFICATION OF OPERATIONS. - The subject operative surgery. Operative surgery is a science about general principles and technical of operations. The goals of this subject are: • To learn the principles of surgical treatment in dependence of the pathology and the disorders of the function. • To master operative technique and at the first the methods of disconnection and connection of the different tissues, temporary and finally hemostasis. • To master of the technical of the typical, especially urgent operations. • To understand the causes of the possible complications due to mistakes committed during patients’ management and stem operative treatment. The surgical operation is technical/instrumental intervention on the patient’s organs/ tissues, which is carried out by doctor in order to treatment, diagnostic or reconstruction of the organ function. It is carried out mainly by incision and different methods of the connection of the tissues. - The main operation principles. The surgeon carried out the operation must aim at patient’s life preservation and be influenced by following main points: 1. Anatomical accession 2. Technical possibility 3. Physiological permission Anatomical accession. Non each organ or formation can be easy accessible for carrying out of operation. Anatomical accession may be different. There are easy accessible organs (stomach, liver, bowel) and difficult accessible organs (esophagus, posterior mediastinum). Sometimes the operation may be non carried out due to impossibility for penetrating to the organ (base of the skull). Technical possibility. The many operations become possible there, where earlier were impossible. Due to developing of the science the hard operations of the heart and magisterial vessels excluding of the heart from blood circulation become possible. Using of the different equipment (heart-lung apparatus, US-generators, monitors, ect.) enlarges the diapason of the surgical interventions. Physiological permission. So that the first aim of the operation is the preservation of patient’s life, in some cases the organ function must be kept. For example, the operations on the pancreas are anatomically accessible, technically easy, but it must be solely carried out spared, in order to preservation its functional ability. This rule may be taken to other organs, from which patient’s health and life depend. Technically carrying out total pancreatectomy is not difficult, but patient’s surviving in this case is impossible. The main principle of these cases is radical removing of the pathologic hearth and maximally to keep of organ function. Stages of operation: 1. Operative access (start of operation) 2. Operative way (operative technique) 3. Going out from operation Operative access is first stage of the surgical intervention, which provides maximal mobilization of the operated organ. It must be rational so as provide maximal mobilization and visualization of the organ, which allows surgeon to carry out operative technique and minimally to damage that organs and tissues, from which operative access is carried out. Operative access is not specific for each operation. Through same access different surgical interventions are possible to carry out. For example, through middle-line laparotomy we can operate on stomach, duodenum, liver, gallbladder, small and large bowel. It is very important to choice the most rational access, because technical possibility of the operation and its result depend from it. Approximately 500 accesses were proposed for laparotomy; however the surgeons usually use 10-12 typical incisions, sometimes with its some modifications. Besides free possibility to operate on the organ, the surgeon has to remember about negative consequences, which may develop due to major traumatic incisions (postoperative hernias may be more suffering than the primary pathology). Incorrect operative access may develop such complications as rupture or incarceration of the nerves or vessels, atrophy of the muscles, incorrect adhesion of the ribs. Thus, the demands to operative access are small traumatism and maximal accession to the object. The operative access naturally may not be same for every case. Pathologic condition, size, localization and form of the organ in considerable degree have influence on the kind of the access and the size of the incision. Patient’s age, constitution, peculiarity of the region when operative intervention is carried out have essential meaning too. Marked above demands surgeon to analyze and learn used operative accesses. Sometimes the access may be changed during operation in dependence on character and extension of the pathologic process, which was determined after revision of operative field. Operative way or technique is a second stage of the surgical intervention, which is specific for given operation and determines the details of the operative intervention (cholecystectomy, partial gastrectomy, appendectomy ect.). The same operation may be carried out by different accesses. For example, cholecystectomy may be carried out by middle-line laparotomy, oblique incision by Kocher, or laparoscopy. The operative way depends on patient’s general condition, kind of the disease and surgical anatomy of the affected organs and tissues. Going out from operation is a third stage of the surgical intervention, during which the surgeon must restore the completeness of the tissues disturbed by operative access. Going out may include either complete (hermetically) restoration of the tissue completeness with operative region drainage or seldom tamponage by dressing materials. - The title of the operation. For term formation marked the title of the operation two components are used. The first is organ which must be operated, and second is operative way technique (partial gastrectomy, appendectomy, resection of thyroid gland, thoracotomy ect.). In the medical, especially surgical literature the Greek or Latin terms are usually used. The most common terms are: tomy – opening, stomy – fistula formation, ectomy – complete removing, resection – partial removing, amputation – removing of the peripheral part of the limb or organ ect (tracheostomy – formation of the fistula on trachea; appendectomy – removing of appendix; partial gastrectomy – removing of the part of the stomach). Classification of operations. Classification of surgical operations depends on character, aim and other factors may be put in its basis. I. The whole surgical operations are divided into two big groups: bloody and non-bloody. Second group includes comparison of the bony splinters in case of fracture with ostectopy, setting a bone, urinary bladder catheterization, laryngoscopy. All other operations belong to the first group. II. In dependence of developing of the possible complications carrying out the operations of the first group are divided into two groups: major and minor. The major are these operations, during which the complications, including mortal result, may develop. The minor operations have minimal risk of complications and named ambulatory. III. In dependence of the aim the operations may be curative and diagnostic. IV. In dependence of the character of carried out operations they may be radical and palliative. If during operation complete removing or liquidation of pathologic process don’t turn out, and patient’s suffering only is relieved or the life is saved, these operations are named palliative. V. By time of carrying out and indications the operations are divided into urgent, pressing and planned. Between the time of urgent operation and possibility of developing of the complications (including mortal result) the direct proportional communication presents. Differently, as the time lost before operation bigger, then the developing of the complications is more possible. In case of planned operations the developing of the complications doesn’t depend on the time of its carrying out, so that the operation may be carried out at any time. Pressing is the right urgent operations put off on short time, which is necessary for patient’s pre-operative management (6-24 hours). VI. The surgical interventions may be primary and recurring. The primaries are theese operations, which are carried out in case of establishment of the diagnosis. The operations, which are carried out repeatedly due to continuation of the principal disease of developed complication, are named recurring (for example, laparotomy/relaparotomy with the patient with continued peritonitis after appendectomy). VII. Those operations which aim is reconstruction of the lost function or anatomy of this or another organ are named plastic or reconstructive. This group includes also organ transplantation. VIII. Operations which demands special optic equipment are named microsurgical. IX. If the second stage of operation - the operative technics, follows directly the first stage (operative access), operation is called as single-step and if between operative access and a method there is a certain time, the operation is called as double-step. Can be three, four …and many-steps operations. X. Operations which are carried out by special endoscopes (laparo-, thoraco-, arthro- scopes) are named endoscopic. TOPIC № 2. BASIC PRINCIPLES OF CONNECTING AND DISCONNECTING TISSUES. Ligature and Suture Materials. Surgical Sutures. The first phase of the surgical operation, the surgical approach or access consists of disconnecting tissues for the mobilization