Medical record of a hospital patient suppuration of a postoperative wound. Suppuration of a postoperative wound
The deep location of the liver in the hypochondrium and the features of its complex topographic anatomical relationships with large arterial and venous vessels, the diaphragm and adjacent organs abdominal cavity significantly complicate the operational approach to it. These difficulties increase with anatomical resections, when the surgeon must freely manipulate when dressing glissonand caval legs, as well as when separating the interlobar and intersegment cracks. Anatomically substantiated operative access provides optimal conditions for processing the glisson and caval legs, separating the removed lobe along the interlobar sulcus and peritonization of the stump of the remaining liver. In addition, surgical access must meet the requirements necessary for examining the liver and its organs and addressing the volume and nature of the surgical intervention on this organ.
Online Access to the liver(by Petrovskyand Pochechuev) Along the edge of the edge of the arc(skew-cross and
skew longitudinal).
Transverse.Accesses along the edge of the costal arch and transverse approaches have been used to date in performing small atypical liver resections. However, they are of little physiology, since during these operations they intersect the intercostal nerves and blood vessels, which can lead to muscle paralysis below the incision and the formation of postoperative hernias. In addition, even small typical resections in the area are inconvenient to produce from these sections. right lobe the liver. Longitudinal approaches are considered more rational.
Longitudinal.It should be noted that transabdominal approaches make it difficult to approach the portal of the liver and limit the manipulation of the surgeon in the area of \u200b\u200bthe diaphragmatic surface of the organ. Therefore, for example, with anatomical resections of the liver, combined operative approaches are used.
Combined(sternomediastinolapar-
tomia and thoracophrenic-abdominal access).
CUTS ON THE EDGE OF THE CURVE ARC
Most often, in operations on the liver, oblique incisions along the costal arch are used (see Fig. 12-8). They are convenient for the surgeon, but the rectus muscle and intercostal nerves are damaged. Damage to the intercostal nerves leads to muscle atrophy and aponeurosis, in connection with which postoperative hernia difficult to treat.
Access Courvoisier-Cococher
It is used to expose the right lobe of the liver, gallbladder and extrahepatic
220 ♦ TOPOGRAPHIC ANATOMY AND OPERATIVE SURGERY<■ Глава 12
biliary tract. It is carried out from the top of the xiphoid process two transverse fingers below the costal arch and parallel to it. At the same time, the right rectum and wide abdominal muscles, intercostal nerves and vessels intersect (see Fig. 12-8, a).
Access Fedorova
It starts from the xiphoid process, then goes along the midline for 5 cm, after which it turns to the right and then runs parallel to the right costal arch. Access is less traumatic and provides ample space in the surgical wound, and also creates a good exposure of the gallbladder with extrahepatic biliary tract (see Fig. 12-8, b).
Access Rio Branco
Consists of two parts. The vertical part is drawn along the white line of the abdomen, without reaching two transverse fingers to the navel, and the oblique wraps at an angle and goes to the end of the X rib along the fibers of the external oblique muscle of the abdomen. This incision is less traumatic and provides good access to the lower surface of the liver (especially to the left lobe), gall bladder and extrahepatic biliary tract (see Fig. 12-8, e).
CROSS SECTION
If the rib angle is wide, and it is necessary to manipulate in the lower segments of both lobes of the liver, you can operate from a transverse section Sprengelin the epigastric region (see Fig. 12-8, f).
LONGITUDINAL CUTS
Of the large number of transabdominal approaches used for liver resection, the upper middle laparotomy is more rational, which is used for atypical resections of the left lobe, segment III resection, and in some cases for left-sided caval lobectomy (see Fig. 12-1). Advantages of Upper Midline Laparotomy over Other Abdominal Accesses during Surgery
walkie-talkies on the liver are that this incision is easy to expand due to median sternotomy or additional thoracotomy.
COMBINED CUTS
Currently, anatomical lobar resection of the liver began to be performed mainly from thoracophrenic-abdominal approaches. With these accesses, two cavities are opened simultaneously: pleural and abdominal. The soft tissue incision is carried out along the seventh-eighth intercostal space from the back or middle axillary line to the navel with the intersection of the costal arch at the level of the corresponding intercostal space.
Access Quino
It is carried out from the lower corner of the right shoulder blade along the eighth intercostal space to the navel. At the same time, the pleural and abdominal cavities are opened and the diaphragm is dissected. This access exposes the superior posterior surface of the liver well (see Figure 12-12).
Access Petrovsky-Pochechuev
It is carried out from the lower corner of the right shoulder blade along the eighth intercostal space to the middle of the white line of the abdomen, followed by drawing it down and bordering the navel to the left. At the same time, the pleural and abdominal cavities are opened and the diaphragm is dissected. Using this access, the dorsal surface of the liver, the portal of the liver, and the adjacent III, IV, and V segments (see Fig. 12-13) can be widely exposed.
Access Longmeyer-Bregadze
It is advisable to use this thoracoabdominal approach in case of unclear localization of focal liver disease (Fig. 12-221).
Technics. In parallel with the left costal arch, an incision is made that first crosses the white line of the abdomen 2 cm below the xiphoid process, and then the chest. At the intersection of the costal arch, the right pleural cavity is opened along the sixth intercostal space. From this access, it is easier to mobilize the left half of the liver, since the left triangular and coronary ligaments are more accessible. If
Operations on the anterior abdominal wall and abdominal organs ♦ 221
Fig. 12-221. Thoracoabdominal Access Longmeyer Braaadzv.
the razhenie extends, as often happens, to the convex surface of the right lobe of the liver, the incision can be increased due to the intersection of the right costal arch.
Surgical access to the liver, gall bladder and bile ducts
Over 30 surgical approaches have been proposed to expose the liver, gall bladder, and bile ducts. These accesses can be divided into three groups: front, back and top.
Front accesses are most numerous; they can be divided into oblique, vertical and angular ( fig. 562).
562. Scheme of sections used in operations on the liver, gall bladder and bile ducts.
1 - oblique section (Kocher); 2 - oblique section (S.P. Fedorov); 3 - angular section (Rio Branco); 4 - wave-shaped section (Ker); 5 - wave-shaped section (Beavan); 6 - upper midline section; 7 - transrectal section; 8 - pararectal incision; 9 - thoracoabdominal incision (Raiferscheid); 10 - thoracoabdominal incision (F. G. Uglov); 11 - thoracoabdominal incision (Cuneo); 12 - patchwork incision (Brunschwig); 13 - angular section (Czerny); 14 - thoracoabdominal incision (Raiferscheid); 15 - thoracoabdominal incision (Kirchner); 16.17 - thoracoabdominal incision (Raiferscheid).
To oblique incisions of the anterior abdominal wall the following are sections: Kocher, S. P. Fedorov, Pribram, Sprengel, and others. Especially widespread are the sections of Kocher and S. P. Fedorov, as they create the most direct path and best access to the gall bladder, bile ducts and the lower surface of the liver.
Kocher cut start from the midline and spend 3-4 cm below and parallel to the costal arch; its length is 15-20 cm.
Section according to S.P. Fedorov start from the xiphoid process and first run down the midline for 3-4 cm, and then parallel to the right costal arch; its length is 15-20 cm.
To vertical sections of the anterior abdominal wall include: superior median, pararectal and transrectal.
Of this subgroup, the most commonly used midline incision is made between the xiphoid process and the navel. If this access is insufficient, it can be expanded by making an additional right transverse section.
Pararectal section of Lawson Tait (Lawson Tait) and transrectal section of O. E. Hagen-Thorn rarely used, although some clinics give them preference (V. A. Zhmur).
Corner and wave sections - Kera (Kehr), Biven (Bevan), Rio-Branco (Rio-Branso), Czerny (Czerny), V.R. Braitsev, Mayo-Robson (Mayo-Robson), AM Kalinowski and others - give free access to bile ducts and liver and are widely used.
Of this subgroup of cuts, the cut is most often used. Rio Branco, which is carried out along the midline from the xiphoid process down and, without reaching two transverse fingers to the navel, turn right and up to the end of the X rib.
Wide exposure of the liver provide thoracoabdominal approaches F.G. Uglova, Kirschner (Kirschner), Brunschwig (Brunschwig), Reiferscheid (Reiferscheid) and others.
Rear (lumbar) accesses of A. T. Bogaevsky, N. P. Trinkler used mainly for injuries, cysts or abscesses of the back of the liver.
Upper accesses: extrapleural A.V. Melnikova and transpleural Volkman-Israel (Folcman, Israel)used to expose the upper posterior diaphragmatic surface of the liver (Fig. 563 , 564 ) These accesses are used in operations for abscesses, cysts, and liver damage.
14198 0
Online access.For surgical interventions on the gastrointestinal tract and bile ducts, longitudinal, oblique or combined sections are used (Figure 6). Widely used are the midline lalarotomy. It creates sufficient access to the GP and the formations located in the thickness of the hepatoduodenal ligament. This incision is successfully used in any operation performed on the biliary system in all patients with asthenic and normosthenic physique.
Figure 6. Online access:
a - section along Brunswig - Tom That Tung; b - section along the Rio Branco; in - arch-shaped section; g - section along the joint venture. Fedorov; d - section according to S.P. Fedorov, continued to the left; e - section according to Longmeyer — Prikel; g — section along Sprengel; h - section according to B.V. Petrovsky — E. A. Pochechuev
A right rectal incision beginning from the costal arch 10-12 cm long also makes it possible to perform operations on the gastrointestinal tract and bile ducts, especially in obese men. The best access to the bile ducts and the ability to perform any surgical intervention are given by oblique incisions according to Kocher, De-Ruben, Braitsev and a combined incision according to Fedorov. In addition to operations, they create an opportunity for drainage of the abdominal cavity. These sections are considered advisable to apply in acute diseases of the biliary tract, especially in cases when pronounced infiltrative inflammatory changes are expected, when the diagnosis is not clear, when the physique is hypersthenic, etc. When applying an oblique incision, there is no need to dissect the tissue near the costal arch, bleeding from the wound, etc. is reduced. The incision begins from the midline, then crosses the right rectum and the external oblique muscles. Small incisions used in some cases, in which only part of the rectus muscle is crossed or do not cross at all, cannot provide sufficient access to the biliary tract.
In repeated and reconstructive operations, the incision is usually made in the direction of the scar. There are exceptions and cases when during the initial operation an atypical incision was made or when there is a purulent wound or fistula in the area of \u200b\u200bthe postoperative scar. After opening the abdominal cavity, further steps are aimed at creating access to the biliary tract, dissecting adhesions existing in the bottom of the ventricular tract between the surrounding tissues and organs.
Prior to removal of the pancreas, it is necessary to expose the anterior wall of hepaticoholedoch by means of a cross section of the peritoneum of this area. If necessary, the manipulation of the bile ducts and BDS must mobilize the duodenum. Palpation of the bile ducts and revision by a probe are performed before applying special research methods (cholangiomanometry, debitometry, cholangiography). If it is necessary to perform repeated and reconstructive operations to create access to the hepatoduodenal ligament, the upper surface of the liver is first isolated, separating the adhesions and adhesions between it and the diaphragm, and then the organs soldered to its lower surface are separated.
Cholecystostomy. This operation, as a rule, is not particularly difficult. It is produced by laparotomic access. In order to avoid damage to the vessels of the area of \u200b\u200bthe bed of the HP, it is emptied by puncture. A small incision is made at the bottom of the gastrointestinal tract, and a rubber catheter with lateral openings is inserted through the gastrointestinal tract through the ventricular lumen. The Petzer catheter is considered more convenient, which, after insertion into the pancreas, is fixed with a catgut ligature. Around the catheter impose two purse string sutures, which fix the PI to the parietal peritoneum. The cholecystostomy catheter is brought out with an additional incision on the abdominal wall (Figure 7). If it is impossible and difficult to hem the JP to the abdominal wall, cholecystostomy is applied “at a distance”. The section of the wall of the vesicle with two purse string sutures is fixed around the catheter. The latter is displayed in a separate incision and is fixed to the abdominal wall with several sutures.
Figure 7. The technique of cholecystostomy:
a - puncture of the ZhP; b, c - the imposition of a purse string suture and the introduction of drainage; g - suturing of the pancreas to the parietal peritoneum and aponeurosis
In recent years, laparoscopic cholecystostomy has been performed, which is performed under local anesthesia during laparoscopy. Using a puncture, the ventricles are emptied and its bottom is removed through a small incision in the abdominal wall. ZhP are drained with a thin catheter and fixed to the skin with several sutures.
Cholecystectomy The operation is usually performed after puncture and removal of its contents. This facilitates the differentiation and allocation of anatomical elements of the neck of the pancreas. The commissures between the pancreas and neighboring organs are dissected, the peritoneum passing from the pancreas to the hepatoduodenal ligament, and the arteries are isolated. They can be crossed only in conditions of good visibility of the gastrointestinal tract and the walls of hepaticoholedoch. PA is ligated twice and cross, leaving a stump no more than 3-4 mm long. If necessary, a cannula or a plastic tube for cholangiography is introduced into the stump of the PP. GI removed from the neck. Bleeding from the bed is stopped by electrocoagulation of blood vessels, U-shaped interrupted sutures or a continuous suture. To avoid damage to the intrahepatic bile ducts, the liver tissue is not deeply pierced. After surgical cholangiography, the cannula or tube is removed from the PP. The latter is bandaged twice, one of the stitches by stitching (Figure 8) [S.L. Kasumyan, OD. Barchuk, 1999].
Figure 8. The technique of cholecystectomy:
a, b, c - stages of separation of the bubble; g, d - removal of the pancreas and ligation of the cystic duct; e - peritonization of the bed of the bubble
With technical difficulties or the inability to remove the HP from the neck, it is removed from the bottom. For this purpose, novocaine is administered subzero, after which the peritoneum is dissected above the ventricular tract at a distance of 1.5-2 cm from the liver. GIs are separated from the liver, bleeding vessels are ligated or electrocoagulated. Approaching the area of \u200b\u200bthe ventricle, it is necessary to differentiate the cystic, hepatic and common bile ducts. With difficult orientation in these and other anatomical formations, the JV is removed after opening it in the bottom, emptying from bile, pus and removing stones. Subsequent separation of the JP is made over a finger inserted into its cavity. More appropriate and safe is the removal of the HP from the bottom.
Cholecystodigestion anastomoses. Superimposed with tumor and cicatricial obstruction of the terminal section of the OP. The feasibility of applying a cholepistodigestive anastomosis is determined according to the data of an intraoperative study. It is technically easier to apply cholecystogastrostomy or cholecystoduodenostomy. In functional terms, cholecystoyunoanastomosis is considered preferable. For the latter, they take the initial section of the TC at a distance of 50-60 cm from the Treitz ligament and separate it at a certain distance. 20 cm further from the FOOD, an intestinal anastomosis 4-5 cm wide is applied side to side. To exclude digestobiliary reflux, it is considered advisable to put on an anastomosis with a U-shaped loop of intestine (according to Ru), the diameter of the BDA is 3-4 cm.It is formed by two-story seams, the outer floor - nodal, the inner - continuous suture, thin chrome kettut.
Suproduodenal choledochotomy. To perform this operation, the front and right-side walls of the hepaticoholedoch are separated. Choose a place to open its lumen (usually in the middle part). The incision is made in the longitudinal direction. Its length can vary from 0.5 to 3 cm. The section is continued to the upper horizontal part of the duodenum. They open the lumen of the duct and remove the stones existing in it. After performing diagnostic and therapeutic manipulations, OSHs are sutured with nodal sutures, without involving SO in the sutures. With thin and delicate duct walls, it is sutured with a continuous suture. As a rule, a one-story seam is used with a chrome catgut or synthetic threads on an atraumatic needle. Drainage of the choledochotomy area is considered mandatory (Figure 9).
Figure 9. ZhP removed, OP opened. stone is visible in it (according to Ker)
External drainage of the bile ducts. It is carried out through a holsdochotomy wound, a separate opening of the hepaticoholedoch, stump of the PP or through the liver parenchyma (transhepatic route). To this end, a T-shaped drainage tube is often used. The latter does not interfere with the outflow of bile in a natural way, does not deform the OPL and is easily removed. Around the drainage, the duct wall is carefully sutured with interrupted or continuous sutures. Catgut or Dacron threads are commonly used. The tightness of the joints and the position of the drainage are monitored using cholangiography and fluid introduced under pressure into the drainage.
Choledochoduodenostomy (CDA). Anastomosis is superimposed by an atraumatic needle. The formation of CDA begins with the back wall. After the back wall is sutured by applying 3-4 sutures, stitches are sequentially and alternately stitched on the right and left semicircles of the future anastomosis, gradually moving from the bottom up. Sutures are applied through all layers of the intestine and duct, so that they are located on the duodenal wall from the outside to the inside, and on the wall of the VLP from the inside out. The peculiarity of suturing with this technique is that the sutures are not immediately tied, but taken on the holders, so that they intersect the crossed vessels. Sipping these seams, between them on the common bile duct make a longitudinal incision 3 cm long, not reaching the intestinal wall. This intervention is performed after mobilization of the duodenum according to Kocher, without separation of the retroduodenal part of the common bile duct. OJP intersects in its lowest part. Finishing the diagnostic and therapeutic procedures (probing of BDS, removal of stones), the lumen of the duodenum is opened in a transverse direction by a small incision. The direction of the latter is actually a continuation of the choledochus section.
More often, lateral supra duodenal lateral lateral CDA is used. This method is technically affordable and more effective, it provides immediate and long-term stable results. Multiple methods are proposed (Finsterer, Juras, Flerken, etc.) CDA. The goal of all these options is to ensure the reliability of the joints of the anastomotic region, improve the functional results of surgical intervention, prevent digesto-biliary reflux and, if possible, reduce the inevitable formation of a “blind sac” on the switched-off part of the common bile duct (Figure 10). The correct comparison of the edges of the anastomosis and the exclusion of its deformation and narrowing is very important [V.V. Vinogradov, 1977]. To ensure tightness, the suture area is additionally covered with the peritoneum of the hepatoduodenal ligament. To prevent the development of anastomotic suture insufficiency, glue MK-2 is used. In all cases, an anastomosis of at least 3-4 cm wide is considered an important condition, since it narrows in the first months. In addition, a sufficiently wide anastomosis prevents stagnation of bile and the development of cholangitis [V.N. Evening, 1995; SL Dadwani et al., 1999; Rathke, 1995].
Figure 10. Methods of choledochoduodenostomy:
a - Finsterera; b - Flerken; in - Jurash
Transduodenal sphincteroplasty. The introduction of the endoscopic papillosphincterotomy method has changed the tactics and technique of operations on the biliary tract and the papilla papilla. However, this valuable and attractive method is accessible only to a narrow circle of specialists, is technically complicated and not without the danger of developing serious complications. Because of this circumstance, endoscopic papillosphincterotomy cannot yet serve as an alternative to traditional methods of surgical treatment for choledocholithiasis and narrowing of the terminal part of the common bile duct.
Percutaneous transhepatic drainage of the biliary tract. In recent years, with breast cancer in clinical practice, the method of transdermal-transhepatic drainage and decompression of the biliary tract began to be used. If necessary, bile duct endoprosthetics are also performed. These operations are used as a palliative remedy. Transhepatic drainage consists of three successive stages:
1) cholangioscopy;
2) cholangiography;
3) external, external-internal or internal drainage.
Papillosphincterotomy.It is performed with cicatricial-sclerotic narrowing of the BDS to restore the normal outflow of bile. After mobilization of the duodenum, its large papilla is found and dissected above the probe head on the front wall. The length of the cut is on average 15–20 mm (Figure 11).
Figure 11. Papillosphincterotomy and papillosphincteroplasty:
a - choledochotomy, insertion of the probe into the VL; c - the anterior wall of the duodenum, above the large papilla, is dissected; c - dissection of the upper wall of the duodenal papilla; g - crosslinking of the mucous membrane of the OP and duodenum
Without violating the integrity of the opening of the main pancreatic duct, papillosphincteroplasty is performed, with a thin atraumatic needle, the choledoch and duodenal ulcer are sutured along the length of the incision. The duodenotomy wound is sutured with two-story sutures, the bile duct is drained. Check the integrity of the posterior wall of the duodenum and retroduodenal part of the common bile duct. In recent years, endoscopic papillosphincterotomy has been used. She is considered evidence of choledocholithiasis, accompanied by jaundice, an extremely high risk of surgical intervention, stones injected into the papilla of the papilla, benign stenosis and restenosis (after the initial operation), BDS, CP, due to narrowing of the outlet of the pancreatic duct, residual stones, narrowing of CDA [V.S. Saveliev et al., 1985; E.I. Halperin et al., 1988; AL. Shestakov et al., 1999; Ahaulli, 1981].
Circular seam of the common bile duct. Superimposed in case of accidental damage to the duct or after excision of the scar-narrowed section. Anastomosis is superimposed P-shaped and with continuous sutures, carefully comparing the CO duct. To prevent tension of the stitched ends, mobilize KDP according to Kocher.
Through the opening of the duct, a T-shaped or single-lumen drainage is introduced into its lumen, which serves as a skeleton for the formation of the anastomotic region. In case of damage or cicatricial obstruction of the proximal part of the hepatic duct, reconstructive surgery is performed. More often hepaticoejunoanastomosis is used, relatively rarely hepaticoduodenoanastomosis.
Methods for completing the operation. After the operation is completed, the abdominal cavity is sutured tightly or drained. The first method is considered acceptable for cholecystectomy about XX, as well as for the application of a fistula on an uninflamed veins. For stitching tightly, a complete condition is the complete absence of bleeding and bile flow into the abdominal cavity. In all other cases, it is shown to drain the abdominal cavity with a silicone diameter of 0.6-0.8 cm tube. The drainage tube is led to the screw hole at a shallow depth. The outer end is removed through an additional incision in the right hypochondrium.
The need for plugging the abdominal cavity is rare: with unstoppable capillary bleeding from the bed of the posterior tract, the flow of bile, and, finally, after opening the parabubular abscesses. Tampons are brought out through the lower corner of the surgical wound.
Should, if necessary, be combined with drainage operations that provide free passage of food from the stomach to the duodenum.
STEM VAGOTOMY (DIAGRAM)
Indication.Stomach ulcer. Tools.Laparotomy set and two dissectors.
Online access
Upper median laparotomy.
Paramedian laparotomy.
Prompt reception
The front branch of the vagus is not
open abdominal moat
water, take on the holders.
nerve nerve 0.5-1 cm long.
The posterior branch of the vagus nerve is isolated
in the nude section of the esophagus, take on
holders.
Resection of the mobilized wander-
nerve nerve 0.5-1 cm long.
SewingCULTIVESTWELVEGUTS
An important step in gastric resection surgery is the closure of the duodenal stump. Most often, when suturing the stump of the duodenum, a double-row suture is used, in which various types of
stitches. Currently, for the imposition of the second row, separate nodular serous-muscular sutures are used along To Lambeur.In this case, blood supply to the edge of the intestine is not disturbed, there is no infection of the suture line at the level of the first row, the possibility of the formation of infected cavities between the first and second row of sutures is excluded. In addition, this method allows to achieve tightness due to the wide contact of homogeneous serous surfaces and leads to the formation of a durable scar.
METHOD Elephant
When resecting the stomach to close the stump of the duodenum, the author proposed the use of a Z-shaped purse string suture. Over clip Payraon the stump of the duodenum impose a catgut sewing upholstery. Then, a Z-stitch is sewn with silk thread so that the last stitch is 3-4 cm closer to the base of the stump than the first, and is tightened. When tightening the threads, the stitched sections of the intestine tightly touch and close the stump well. As a result of the fact that the first and last needle injections are made somewhat outward from the location of the entire seam, after tying the threads a semblance of the second floor of the seam is formed. This option has several advantages compared to a conventional purse string suture: no assistant is needed to immerse the stump, after tying the threads a semblance of the second floor of the seam is formed, which makes it more durable.
METHOD MEYO
After cutting the duodenum from the stomach, a twisted serous-muscular suture is imposed on the sides of the clamps with catgut thread. In this case, stitching of the duodenal stump is performed parallel to the clamp on both sides. The ends of the threads of the twisting seam are tightened, the stump is invaginated with two tweezers. The ends of the thread are not cut: one of them is used for applying a second twisted serous-muscular suture, after which the ends of the thread are tied. Dipping a stump without a hemostatic suture is dangerous.
METHOD MOINIKHANA
After the duodenum is cut off from the stomach, the mucous membrane and intestinal wall are treated with iodine, both walls are stitched with a continuous continuous twisted catgut suture under the clamp. The stitches are laid at a distance of 0.5-0.7 cm from each other, while the thread is not tightened. The clamp is removed, the catgut stitch is tightened and tied. As a second row use a purse string suture.
OPERATIONSON THELIVERS
OPERATIONALACCESSTOLIVERS
Allocate the following online accesses ti the liver.
Transabdominal.
Transpleural.
Extracavitary.
Combined.
The type of cut depends on the alleged damage. With penetrating and non-penetrating wounds of the abdominal cavity with liver damage, preference is usually given to abdominal accesses. With extensive operations on the liver, when a good mobilization of the organ is necessary, then the cancer-abdominal approaches have an advantage. (Quino, Petrovskogo-Pochechuev).
Access Courvoisier-Cococherused to expose the right lobe of the liver, gall bladder and extrahepatic bile ducts. It is carried out from the top of the xiphoid process 2 transverse fingers below the costal arch
and parallel to her. At the same time, the right rectum and broad muscles of the abdomen, intercostal nerves and vessels cross.
Access Fedorovastarts from the xiphoid process, then goes along the midline for 5 cm, after which it turns to the right and then goes parallel to the right costal arch. Access is less traumatic and provides ample space in the surgical wound, and also creates a good exposure of the gallbladder with extrahepatic bile ducts.
Access Riedel-Kocherspend 1-2 cross fingers down and parallel to the right edge of the costal arch.
Access Sprengelspend from the xiphoid process parallel to the right costal edge to the outer edge of the rectus abdominis muscle, from where the incision turns to the end of the X rib.
Access Rio Brancoconsists of two parts. The vertical part is drawn along the white line of the abdomen, without reaching two transverse fingers to the navel, and the oblique wraps at an angle and goes to the end of the X rib along the fibers of the external oblique muscle of the abdomen. This incision is less traumatic and provides good access to the lower surface of the liver (especially to the left lobe of the liver), gall bladder and extrahepatic bile ducts.
Access Quinospend from the lower corner of the right shoulder blade along the eighth intercostal space to the navel. At the same time, the pleural, abdominal cavities are opened and the diaphragm is dissected. This access reveals the superior posterior surface of the liver.
THE SEAMLIVERS
FEATURES OF SURFACING OF SURFACES ON PARCHIMATOUS BODIES
The seam must be laid so that along
in relation to the vessels, it was located along
pepper. If the wound runs in parallel
vessels, a seam is imposed through both its edges.
In other cases, two rows of stitches are applied.
on both sides of the wound, after which the threads, on
walking from opposite ends of the seam,
bind.
To stop parenchymal bleeding
it is advisable to plug the wound with an omentum, muscle, or use hemostatic films.