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Surgical diseases

Surgery deals with diseases, for the treatment of which the main method of mechanical action on tissues is used, often accompanied by their separation to detect a pathological focus and its elimination. Improving, surgical practice uses the achievements of medical spiders in anatomy and physiology, pathology, pharmacology and microbiology.
The range of the surgical method in the past is very wide, in essence it is used for diseases of all organs and tissues of the body: the brain and spinal cord, heart, lungs, esophagus, kidneys, muscles, bone skeleton, etc. Modern surgery is a very complex act, during which the physiological functions of a diseased organism are studied. When violations are detected, a variety of mechanical, physical, chemical and biological measures are used to restore them. The name "surgery", which literally means "handwork", "skill", "craft", no longer fully meets its modern content.
Advances in technology and biological sciences have created the conditions for the transformation of surgery, along with therapy, into the main one - a very large and complex medical specialty, the need for which is great. Emergency services were organized - ambulance stations, trauma centers and traumatology institutes, round-the-clock duty was introduced in the corresponding departments of hospitals. All this provides early diagnosis, timely transportation of the patient to a medical institution and the provision of necessary surgical care on time.
Antiseptic and aseptic. Before the introduction of aseptic and antiseptic methods, postoperative mortality reached 80%: patients died from purulent, putrefactive and gangrenous processes. The nature of decay and fermentation, discovered by Louis Pasteur in 1863, became an incentive for the development of microbiology and practical surgery, and it has been argued that microorganisms are also the cause of many wound complications.
Antiseptics implies a set of measures aimed at the destruction of microbes on the skin, in a wound, pathological formation or the body as a whole. Physical, mechanical, chemical and biological antiseptics are distinguished.
With physical antiseptics, the outflow from the wound of the infected contents is ensured and thereby its purification from microbes, toxins and tissue breakdown products. This is achieved by the use of swabs of gauze, drainage of rubber, glass, plastic. The hygroscopic properties of gauze are greatly enhanced by wetting it with hypertonic solutions (5-10% sodium chloride solution, 20-40% sugar solution, etc.).
Open methods of treating wounds without applying a bandage are used, which leads to drying of the wound with air and thus creating unfavorable conditions for the development of microbes. The use of ultrasound, laser beams, and physiotherapeutic procedures also refers to physical antiseptics.
Mechanical antiseptics are techniques for removing infected and non-viable tissues from the wound, which serve as the main nutrient medium for microorganisms. These operations are called active surgical treatment of brine, as well as toilet wounds. They are of great importance for the prevention of the development of wound infections.
Chemical antiseptics provide substances with a bactericidal or bacteriostatic effect (for example, sulfonamide drugs) that have a detrimental effect on microflora.
Biological antiseptics constitutes a large group of drugs and techniques whose action is directed directly against the microbial cell and its toxins, and a group of substances acting indirectly through the human body. So, mainly on a microbe or its toxins are affected: 1) antibiotics - substances with pronounced bacteriostatic or bactericidal properties; 2) bacteriophages;
3) antitoxins, introduced, as a rule, in the form of serums (tetanus, tetanus, diphtheria, etc.).
Indirectly through the body, increasing its immunity and thereby enhancing its protective properties, vaccines, toxoids, blood and plasma transfusions, the introduction of immune globulins, methylthiouracil preparations, etc.
Proteolytic enzymes lyse dead and non-viable tissues, contribute to the rapid cleansing of wounds and deprive microbial cells of nutrients. According to observations, these enzymes, changing the habitat of microbes and destroying their membrane, can make the microbial cell more sensitive to antibiotics.
Asepsis. A method of surgical work that ensures the prevention of microbes entering the surgical wound or developing them in it. On all objects surrounding a person, in air, in water, on the surface of his body, in the contents of internal organs, etc. there are bacteria. Therefore, surgical work requires compliance with the basic law of asepsis, which is formulated as follows: everything that comes in contact with the wound must be free of bacteria, i.e. sterilize.
Anesthesiology is the science of pain relief.
The ability to use the medication to safely perform surgery can reduce complications during surgical treatment and significantly expand their range. Painful irritations alter and rearrange all physiological processes in the body. His reaction to pain is manifested by impaired blood circulation, metabolism, respiration, etc., which are especially pronounced during operations on organs such as the heart, lungs, etc. and in patients weakened by the underlying disease and age-related changes. Anesthesia involves not only the relief of pain. The task of the anesthetist is to manage the vital functions of the body, identify the causes of their violation in the operated patient, timely warning and elimination before, during and after the operation. Anesthesia - loss of sensitivity occurs due to temporary damage to the sensory nerves.
It is achieved by the action of an anesthetic substance on the brain - general anesthesia (anesthesia) or on the spinal cord (spinal anesthesia), on the nerve endings and trunks at the operation site (local anesthesia), there are other types of anesthesia.
Pathological processes underlying surgical diseases. Although there are many thousands of surgical diseases, they are based on only a few types of pathological processes:
1. Surgical infection - the introduction of microbes into the human body and the development as a result of inflammatory phenomena. The range of diseases is very wide - from simple skin abscess to such severe suffering as diffuse purulent peritonitis or general purulent infection - sepsis.
2. Injury is a wide variety of open and closed injuries: bruises, concussions, sprains, compression, fractures, dislocations, electrical damage, wounds, burns, frostbite, ruptures of internal organs, etc.
3. Tumor growth of tissues is fundamental in the occurrence of a variety of neoplasms affecting individual organs and tissues.
4. Circulatory disorders and related remove gangrene, ulcers, fistulas, etc.
5. Development anomalies that underlie many diseases.
6. Parasitic diseases requiring surgical treatment (echinococcosis, ascariasis, etc.).
Surgical operations: a mechanical effect on tissues and organs produced to cure a disease, alleviate suffering, or for the purpose of diagnosis.
Operations are divided into bloody, in which the integrity of the skin or mucous membranes is disrupted, and bloodless (for example, straightening a dislocation). Distinguish between therapeutic and diagnostic operations. Therapies are used most often and are of a different nature depending on the tasks that the surgeon sets himself.
Among them, radical ones are distinguished, with the help of which a pathological focus or organ is removed (for example, appendectomy or cholecystectomy), operations performed to improve the function of the organ, restore normal anatomical ratios (e.g. herniasis) and palliative surgery, which are aimed at alleviating the patient’s suffering in cases when cure is not possible (for example, a gastrostomy with advanced cancer of the esophagus). Diagnostic methods include biopsy, puncture of the pleura, joints, air injection into the pleura, renal pelvis, etc., as well as laparotomy, thoracotomy, etc.
By temporary necessity, emergency, urgent and non-urgent (planned) operations are distinguished. Emergency needs to be done immediately: a delay of several hours, and sometimes minutes, threatens the patient's life or sharply worsens the prognosis. These are operations for bleeding, asphyxia, acute surgical diseases (especially for genital perforation), etc.
Operations that cannot be postponed for a long period due to the steady development of the disease are considered urgent. So, it is impossible to delay operations for malignant tumors for a long time, because continued growth can lead to the formation of metastases. In these cases, only a period of time necessary for clarifying the diagnosis and preparing the patient is permissible.
Non-urgent operations (for example, cosmetic) can be performed at any time without harming the patient’s health.
Preoperative and postoperative periods.
The preoperative period begins from the moment the patient enters the surgical department. It is divided into diagnostic, when the diagnosis is clarified, the state of organs and systems is determined, indications for surgical intervention are made, and the period of preoperative preparation. In time, it can be of various durations, which depends on the degree of urgency and severity of the upcoming operation. Private preoperative preparation is provided, taking into account the specifics of a particular disease (for example, gastric lavage with stenosis of its exit, the appointment of hydrochloric acid for achilles, complete cleansing of the intestines and the appointment of colimycin inside before surgery on the colon, the desire to eliminate perifocal inflammation in chronic suppuration of the lungs, etc.) , and general preparation for all patients who have surgery (good sleep on the eve of surgery, a hygienic bath, wide shaving of the surgical field, restrictions in food intake the day of surgery, prevention of vitamin A deficiency and others.).
With a full outpatient examination and the necessary analyzes, the clinical observation of a patient preparing for the most common operation should not be delayed for more than 2-3 days. Scheduled operations should not be prescribed during menstruation, as these days there is increased bleeding and decreased reactivity of the body.
The postoperative period begins from the end of the operation until the patient is restored to working capacity. It is divided into three phases: the first
- early, duration 3-5 days, the second - 2-3 weeks, until the patient is discharged from the hospital, the third - remote, until recovery.
The normal course of the period after the operation is distinguished, when there are no severe violations of the functions of organs and systems, and complicated (hyperergic), when the body's reaction to surgical trauma is extremely negative and all kinds of postoperative complications develop. Even with the normal course of this period, there are always violations of the functions of almost all organs and systems, and with a complicated one, they are pronounced.
Care for surgical patients.
Features of surgical care for patients are determined primarily by the fact that the functions of the organs and systems of these patients undergo changes due to the disease (pathological focus), analgesia and surgery.
Postoperative wounds are the entrance gate through which pyogenic microorganisms can enter the body. Therefore, attention should be focused primarily on preventing the development of infection and accelerating the regeneration processes. It is important to monitor the condition of the dressing (sticker), not to let it slip and expose the postoperative suture.
If, for one reason or another, the dressing is profusely wet with blood or other discharge from the wound, it is necessary to inform the surgeon to have the dressing done. It is allowed to work only with sterile instruments, use only sterile dressings. If drainage pipes are installed, it is necessary to monitor the nature and amount of discharge through them, the tightness of the drainage system, etc.
One should always bear in mind the possibility of sudden bleeding from a postoperative wound. It happens in the early stages after surgery, usually when the ligature is superimposed on the vessel, or the thrombus is rejected from the vessel that is not ligated. When a postoperative wound is infected, bleeding is caused by purulent fusion of large vessels. If the wound is sewn up tightly, then the blood flowing out of the vessel accumulates in the tissues, a swelling forms, the incision area increases in volume, is deformed, the skin can change color, etc. Caregivers must be the first to notice the beginning of suppuration of the wound. The patient in such cases usually complains of the appearance of a throbbing pain in the wound. An increase in body temperature is noted, in the wound area there is a swelling, redness of the skin, etc.
The neuropsychic sphere of surgical patients is undoubtedly traumatized. Like the disease itself, often severe, the forthcoming anesthesia and surgery are associated with fear of consequences and fear of an unsuccessful outcome. All this is accompanied by a long, significant overstrain of internal forces. There are no people who are calm about the need to undergo surgery: the only difference is that some can and others do not, restrain their experiences without showing them.
Increased nervous irritability, insomnia, pain, etc. lead, not so rarely, to the development of postoperative psychoses, which can be life-threatening to the patient, if this possibility is not taken into account and appropriate measures are not taken.
It is also necessary to remember the possibility of postoperative paresis and paralysis. All this requires great attention to the neuropsychic state of the surgical patient already in the preoperative period. In these cases, calm explanatory conversations with the patient are of prophylactic importance; it’s good to put in a ward next to him a recovering person who has successfully undergone such surgery, it is advisable to visit a person who has had surgery long ago and feels well.
Violations of the functions of the cardiovascular system and anemia caused by blood loss are often observed in severe surgical patients, they can lead to a decrease in blood pressure, including acute (collapse). Forced lying position, low mobility entail venous congestion, thrombosis and embolism. Often there is increasing anemia (for various reasons), usually accompanied by hypoxemia (oxygen starvation): pallor, cyanosis, etc. appear.
The functions of the respiratory system undergo changes in the postoperative period, especially pronounced during operations on the chest and its organs, on the abdominal wall and organs of the abdominal cavity. Due to pain in the area of ​​the operation, respiratory movements are usually limited, pulmonary ventilation is reduced, and one or another degree of hypoxemia is observed. The immobility or low mobility of patients, especially when standing on their backs, in old and old age, leads to venous congestion in the lungs, impaired coughing up sputum, which accumulates in the bronchi and contributes to the development of hypostatic, atelectic postoperative pneumonia. In addition, operations on the abdominal and chest organs are often extensive, traumatic, and are accompanied by damage to a large number of blood vessels in which numerous small blood clots form, creating conditions for thromboemological postoperative pneumonia. Oxygen deficiency, shortness of breath, pneumonia, pleurisy - this is an incomplete list of complications that threatens the surgical patient from the respiratory system.
An important concern for the caregiver is to prevent this possibility. Patients at risk for pulmonary complications are best placed on a functional bed.
The doctor and sister should not spare time on how to teach the postoperative to breathe deeply, to clear his throat and to make sure that he lies in bed with an elevated torso. With the phenomena of oxygen starvation, it is necessary to take care of oxygen therapy. It should be remembered that in most cases, postoperative pneumonia is the result of ignoring the rules for patient care.
The functions of the digestive organs are impaired in all postoperative patients, but especially sharply after operations on the abdominal organs. The intoxication caused by the disease and surgical trauma primarily affects the cells with the most differentiated function (nerve and glandular), including those "responsible" for the functioning of the digestive organs and the secretion of digestive juices.
Следствием отклонений является: потеря аппетита, расстройство пищеварения (поносы), понижение перистальтики или даже ее отсутствие, приводящее к запорам и др. Чтобы наладить работу кишечника, надо придерживаться ряда требований. До нормализации функций слюнных желез - обязательна тщательная санация полости рта. Для восстановления желудочно-кишечной секреции - вкусная, разнообразная, богатая витаминная диета. При застое в желудке содержимого - его промывание, очистительные клизмы. До восстановления перистальтики кишечника - его стимулирование фармакологическими препаратами.
Нарушения водносолевого обмена. Обильные, повторные рвоты, экссудация, поносы приводят к значительной потере организмом больного воды и солей: выраженное обезвоживание и обессоливание требуют возмещения.
Intoxication. Все больные с гнойным очагом страдают от двойной интоксикации: продуктов жизнедеятельности бактерий и некротического распада тканей, вызванных воспалительным процессом. Причем ткань при каждой операции травмируется дополнительно. Количество распадающихся тканей, а следовательно и степень послеоперационной интоксикации, определяются объемом оперативного вмешательства. Известно, что даже после небольших операций у больных наблюдается плохое самочувствие, бессонница, небольшое повышение температуры, изменение состава крови, ухудшение аппетита и тд.
Чем больше операция, а следовательно больше разрушенных тканей, тем выраженное и длительнее сохраняются симптомы интоксикации. Они усиливаются с развитием нагноения в операционной ране. Учитывая это, принимают меры по дезинтоксикации (обильное питье, оксигенотерапия, обеспечение оттока распада и др.).
Гиподинамия (недостаточная подвижность) нарушает кровообращение, ведет к застоям крови, гипостазам, тромбозам, эмболиям, уменьшает вентиляцию легких, усиливает гипоксемию (кислородное голодание), ухудшает все функции пищеварительных органов, вызывает атрофию мышц и т.д. Недостаточная подвижность хирургических больных может быть вынужденной (многочисленные тяжелые переломы, другие травмы, обширные операции и т.д.) или связанной с общей слабостью, вызванной болезнью. Она в значительной степени усиливает все послеоперационные нарушения функций органов и систем и может быть первопричиной многих тяжелых осложнений. Осознавая это, врач и ухаживающий персонал должны принимать самые активные меры для ее устранения, используя разнообразные методы активных и пассивных движений больного - лечебную физкультуру, массаж, приспособления, помогающие больному садиться и пр. Гимнастика, проведенная утром после подъема, улучшает работу всех органов и систем организма и, что особенно важно, устраняет застойные очаги кровообращения, неминуемо возникающие во время сна. Утреннюю зарядку могут проводить по существу все хирургические больные, она не показана только особо тяжелым по указанию лечащего врача. Ходячие больные могут выполнять упражнения стоя, средней тяжести - сидя на стуле, а лежачие - лежа в кровати.
Важно выполнять весь комплекс движений для всех групп мышц и суставов в определенной последовательности и с достаточной нагрузкой. Примерной схемой проведения утренней зарядки продолжительностью 12-15 минут может быть следующая.
Для мышц и суставов головы и шеи ( в течение 3-4 мин.): а) наклоны головы вперед, назад, влево и вправо (8-10 раз); 6) повороты головы вправо и влево (8-10 раз); в) вращательные движения головы справа налево и наоборот (8-10 раз).
Для мышц рук и плечевого пояса: а) выбрасывание рук в стороны, вверх и вперед с распрямлением их и приведением к туловищу со сгибанием в локтевых суставах (10 раз); б) вращение вытянутых рук спереди назад и сзади вперед (10 раз); в) схватывание руками туловища спереди (выдох) и разведение их в стороны (вдох) (8-10 раз); г) движения в лучезапястных суставах - сгибание и разгибание по 10-15 раз и вращение предплечья (15-20 раз); д) сжимание пальцев в кулак и разгибание их по 10-15 раз.
Для мышц и суставов позвоночника: а) сгибание и разгибание вперед, назад, вправо и влево; б) вращение позвоночника вправо и влево с вытянутыми в стороны руками; в) сгибание позвоночника вперед с доставанием пола кончиками пальцев (8-10 раз).
Для мышц и суставов нижних конечностей: а) ходьба на месте с максимальным сгибанием в коленных и тазобедренных суставах; б) поочередное движение прямой ноги вперед и назад с одновременным движением прямых рук в этом же направлении по 10-12 раз каждой ногой; в) поочередное вращательное движение правой и левой вытянутой ноги спереди назад и сзади вперед по 10-12 раз каждой ногой.
Во время упражнений следует следить за вдохом и выдохом.
Естественно, что часть движений нельзя выполнять лежа в кровати или сидя на стуле. В этих случаях их следует заменить другими или совсем исключить. Важно только следить за тем, чтобы все 4 группы мышц получали достаточную нагрузку.
Что касается мышц туловища, брюшного пресса, то они активно работают при упражнении рук, ног и позвоночника, а дыхательные мышцы - во время вдоха и выдоха.
Уход за кожей и профилактика пролежней. Помимо общих правил содержания постели и белья, необходимо помнить о периодическом изменении положения больного с тем, чтобы одни и те же места тела не подвергались длительному сдавливанию, особенно у истощенных больных. Туалет кожи и санация возможных очагов инфекции на ней имеют особое значение. Наличие гнойных прыщей, фурункулов и других гнойных очагов служит противопоказанием для проведения плановой операции, а при экстренных неотложных вмешательствах значительно ухудшает прогноз. Нередко, особенно у пожилых больных, р кожных складках, в подмышечных впадинах, в пахах и на промежности отмечаются дерматиты, вызванные грибками.
В предоперационном периоде все эти процессы должны быть излечены. Помимо обязательных ежедневных гигиенических ванн при особо упорных грибковых поражениях необходимо протирать складки кожи спиртом и припудривать присыпками, содержащими тонко размельченный нистатин или леварин.

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