Материал: BASIC_SURGICAL_TECHNIQUES budapest

inclusion of the neighboring tissues. This intervention (requiring the harmonized movements of the operator and the assistant) consists of three phases: soaking, clamping and ligation. First, the asistant applys only a pressure with the sponge and soaks up the blood (so, he does not cause a temporary vasoconstriction). The operator grasps the bleeding vessel with a Péan. The tip of the Péan should always faces the person who will do the ligation. The scrub nurse gives the thread while she is keeping the two ends of it stretched. The thread used for ligation should be as thin as possible. After applying the first basic knot, the assistant releases the Péan but the surgeon stretches the thread further. After the 2nd knot, the operator cuts the thread as follows: the scissors are slid down to the knot and rotated a quarter turn. The least possible amount of the thread should stay in the wound (foreign body!). It is not advisable to use a ligation directly beneath the skin because it disturbs the healing process of the wound.

Suturing

Transverse, transfixing,”figure of 8” stitch (sutura circumvoluta). In cases of large-caliber vessels or diffuse bleeding, non-absorbable (e.g. silk, polyethylene or wire) and absorbable (e.g. catgut, polyglycolic acid (Dexon) or polyglactic (Vicryl) suture materials can be used. A double stitch (suture twice) is applied under the bleeding tissue to form an “8”shaped loop and the knot is then tied.

Preventive hemostasis (planned hemostasis)

It happens with ligatures. In the operating field, the vessel should be clamped with two Péans, the part of the vessel located between them is cut, and the two ends of the vessels should be tied separately. Deschamp needle and the Payr probe can be used for the same purpose.

Clips

Clips are metal or plastic. Applied with the help of disposable or non-disposable devices.

Bone wax

This is a sterile mixture of beeswax, almond oil and salicylic acid. It adheres readily to the bloody bone surfaces, thereby achieving local hemostasis of the bone. For example it is used to stop bleeding after cutting the sternum.

Expedients

Suction, drainage (Hemovac, Jackson-Pratt, etc.) to remove body fluids and air. This facilitates the emptying of dead spaces, improves tissue regeneration, and blocks the development of edema and hematoma.

Other devices or mechanical methods for handling bleeding

-Rubber bands for digits

-Esmarch bandage

-Penrose drain

-Vessel loops

-Pneumatic tourniquets

-Pressure dressings, packing (compression), tamponades, and sand bag

5.3.2. Thermal methods

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Laser surgery is based on the emission of radiation by light amplification through a tube at a microscopic level. Use: coagulation and vaporization (carbon or steam) in delicate and fine tissues (eyes: retina detachment repair, brain, spinal cord, or gastrointestinal tract). The operator must wear safety goggles. Suction of the steam (CO2) is necessary.

5.3.3. Hemostasis with chemical and biological methods

Characteristics: Easy handling, quick absorption, non-toxic, and local effects without systemic consequences. Expected consequences: vasoconstriction, coagulation and a hygroscopic effect. Aethoxysclerol (polydocanol): This is not used for active coagulation. Main indications:

small superficial skin varices (injection into the veins) and esophagus varix sclerotization (given to the proximity of the varix).

Absorbable gelatin: Gelfoam, Lyostypt or Spongostan: powder or compressed-pad form. Made from purified gelatin solution. Adsorption capacity: 45 times more than its own weight. Absorption takes place in 20-40 days.

Absorbable collagen: Collastat®: This is in the form of a hemostatic sponge, applied dry to the oozing or bleeding site. Its use is contraindicated when there is an infection or in areas where blood has pooled.

Microfibrillar collagen: Avitene®: This is a powder-like, absorbable material from a bovine source; it is applied dry. It stimulates the adhesion of platelets and the deposition of fibrin. It functions as a hemostatic agent only when applied directly to source of bleeding. It is applied to oozing surfaces, including bone and areas of bleeding difficult to reach.

Oxidized cellulose: Oxycel®, Surgicel®: made of cellulose, able to adsorb a large amount of blood, with blood make an artificial thrombus. They are absorbed in 7–30 days.

Oxytocin: This is a hormone produced by pitutary gland, but is also prepared synthetically. Use: e.g. bleeding from uterus.

Epinephrine: This hormone is secreted by the adrenal gland, is also prepared synthetically. It is a vasoconstrictor. It is rapidly dispersed and has a short duration of action.

Thrombin: This enzyme is extracted from the bovine blood. It combines rapidly with fibrinogen to form a clot. It is available in liquid (spray) and powder forms. It must not be allowed to enter large vessels. It is for topical use only and is never injected.

Novel hemostatic agents: Indications: External bleeding where the conventional pressure dressings fail. It is not used in those places were you can apply a tourniquet.

1.HemCon: It is available as a chitosan-based product, made from shrimp shell polysaccharide + vinegar. This is a firm 7x7 cm dressing that is sterile and individually packaged. It adheres to a bleeding wound, and exerts vasoconstrictive properties.

2.QuikClot: This granular zeolite absorbs fluid, acts as a selective sponge for water, dehydrates blood, has handling properties similar to those of sand, and can generate significant heat during the adsorption process.

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6. OPERATION (ACUTE, ELECTIVE, PREPARATION OF THE PATIENT,

SURGICAL EXPOSURES)

6.1. Preparations for an operation

”Salus aegroti suprema lex esto” = ”The well-being of the patient is the most important law." Aim: to perform the right operation, for the right reasons, on a right patient, and at a right time.

-From the financial and hygienic standpoints, the patient’s preoperative hospital stay should be as short as possible (Hospitalisation, iatrogenia, contamination)

-If it is possible, the patient should be admitted a day before operation or even at same day.

Careful examination of each patient individually is an important factor. The standpoint of ”Surgery is the aim!” should be neglected. We can think of increased surgical morbidity (and accompanying cardiacvascular, hepatic, and renal diseases) as the age of the patient is increasing.

6.2. Surgical indications, contraindications and risks

Indications

Proper evaluation of the surgical disease and risks:

-Vital indications: These are involved in the case of life-saving procedures. The patient can be treated only with an operation (100% mortality without operation). Example: rupture of an abdominal aorta aneurysm

-Absolute indications: These are involved in urgent procedures. The disease can be treated exclusively with an operation. The time can be chosen between narrow limits. Example: mechanical ileus.

-Relative indications: These are factors in elective procedures, e.g. programmed operations. The disease can be treated with or without surgery. The time of surgery can be choosen. Example: hernia.

Contraindications

In the cases of vital and absolute indications: only in moribund patients.

In the case of relative indication: decompensated accompanying diseases, does the surgery improve the survival?

Surgical risks

Surgical risks = risks of surgery itself + anesthesiological risks. The preoperative examinations must answer the questions of both surgeon and anesthesiologist, allowing them to give their agreed opinion in writing.

1.Low-risk surgery: Minor operations belong in this group (e.g. inguinal hernia repair), where the expected blood loss is less than 200 ml.

2.Medium-risk surgery: Surgical interventions of medium severity can be classified here (the expected blood loss is less than 1000 ml), e.g. colon resection.

3.High-risk surgery: Extended abdominal and thoracic operations (e.g. liver and lung resections) fall into this category. The blood loss exceeds 1000 ml. The patient needs postoperative intensive care and treatment. The rates of postoperative morbidity and mortality are high.

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The extent of the operation is a determinator:

Operations on body surfaces are running with the smallest risks. The risks of the operation increase if there is an opening of a body cavity. Operations done over the hollow organs are running with higher riks. The opening of many hollow organs is running with more risks. Operations in which 2 body cavities are opened at the same time are runnig with the highest risks.

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