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The surgical method of treatment of malignant tumors remains dominant, although its remote results can be considered satisfactory only in the I-II stage of the disease, and in the rest - the operation is considered as a mandatory component. special treatment.

Improving surgical equipment, achievements of anesthesiology and resuscitation, pharmacology and therapies made it possible to achieve significant progress in surgical oncology and significantly reduce contraindications to surgical treatment.

And at the same time, the danger of complications should not be forced to forget that a malignant tumor is a disease with an absolutely fatal exodus, and it means that it is also necessary to show the testimony to perform operations.

Since many oncological operations are extensive, functionally unfavorable (amputation of limbs, mastectomy, extirpation of the rectum), the murder is mandatory for the presence of malignant tumor to surgical intervention.

Classification of surgical interventions

Surgical intervention, depending on the degree of propagation of the tumor process, the volume and nature of the operation can be radical, palliative and symptomatic (Fig. 9.3).

Fig. 9.3. Types of operational interventions used in oncology.

Radical operations

These include such operations at which all visible tumor foci are fully removed together with an affected organ or part of possible regional metastasis, in the absence of clinically diagnosed remote metastases.

At the same time, operations for the III-IV cancer stage, even if all detected tumor foci are removed, relate to conditionally radical requiring additional chemo-impact impact.

It should be emphasized that operational interventions On-cancer patients differ significantly from the communal volume of removable organs and tissues, the obligatory removal of regional lymph nodes (lymphodissection) and often crushing character with pronounced functional disorders in postoperative period. In turn, radical operations are divided into a number of options.

Typical radical operations

In surgical oncology, standard surgical operations are developed in surgical oncology for all localization of malignant tumors.

That is, a typical operation is the optimum of tissue removed, which is necessary for sufficient, radicalism. Moreover, the main criterion of the standard is the resulting volume of lymphodissection, and not a removable volume of the affected organ. Typical radical surgical interventions have withstood the test of time and are the main basis for practicing oncologists.

Combined radical operations

The desire for maximum radicalism, as a rule, is associated with the removal of most or all the affected organ, as well as involved in the process of surrounding tissues and organs.

Therefore, in oncology, there is a concept of a combined radical operation. Combined surgical interventions include such operations at which the organ affected by the neoplasm and (in whole or in part) the neighboring organs to which the tumor spread is spread.

The use of combined operations is justified in cases where there is only the spread of a tumor to adjacent anatomical structures, but there are no remote metastases. Currently, such a type of operation is improved and are actively being introduced into clinical practice.

Modern anesthetical support, chemorabolic, immuno and hormonal, as well as other species additional treatment allow you to successfully carry out these extensive operations and receive remote treatment results, reliably better than when conservative methods Therapy.

Extended radical operations

Advanced are called such operations in which the block of removable tissues is forced to (due to the YUCSTAREGIONARY, METASTATING) or include additional (outside the standard) group lymph nodes.

Due to this approach, the border of the organ resection and mainly lymphodissection are significantly wider than typical schemes. Extended operations are usually complemented by adjuvant antitumor therapy.

Organized and economical operations

At the level of modern knowledge and advances in oncology, but mainly due to the development of methods of microsurgical autotransplantation, providing for immediate, after removal of a tumor, plastic reconstruction of the body with restoration of its function, created real conditions To develop new types surgical operations.

In this regard, there was an opportunity, within the framework of improving the quality and life expectancy of patients, use in oncology by organo-breeding and functionally friendly operations that meet all the necessary requirements of cancer radicalism with minimal functional damage [V.I. Numbers, 1999].

These include, for example, organ-powder operations in the mammary gland, limbs, etc. Not only in early stagesBut even with a local tumor process and recurrences of neoplasms. Such operations are most justified with bond precancerous diseases, in situ carcinoma and at the I cancer stage of some localizations.

Simultan operations

Under these terms, they understand the simultaneous removal (radical or palliative) tumors of various localizations, or the implementation of the oncological operation in combination with the operation common disease.

As the quality of the anesthesiological support, the possibilities of accompanying treatment and the equipment with modern crosslinking and other devices, the tendency to fulfill the simultaneous operations will steadily increase in oncology.

Palliative operations

Palliative operations involve the removal of the primary tumor in the volume of radical intervention in the presence of remote or failed regional metastases in order to extend the life of the patient and improve its quality. With technical availability and small sizes, single metastases can be removed at the same time.

Consequently, palliative surgical interventions do not suggest the complete elimination of the tumor process, the organism remains determined by the localization of single-regional-regional tumor foci or remote metastases to be then subject to special therapy.

Most often, the testimony for palliative resection serves as a threat to the development of vital or already evolved complications. So. For example, with a small pyloroantral cancer with stenosis, with metastases in the liver and lymph nodes outside the regional lymphatic reservoir, it may be more justified by the imposition of bypass gastroenteroanastomosis, but resection of the stomach.

In some cases, with a real threat to the development of vital complications (for example, perforation or development of profuse bleeding from the disintegrating tumor of the hollow organ, etc.) also justified palliative resection.

Of course, in these situations there should be a sense of measure. Outstanding oncologist B.E. Peterson (1976) indicated that their minimal risk should be an important condition for performing oncological operations.

He wrote that "... Surgeons are given and legal, and the moral right to risk the life of the patient in the name of the salvation of his life, but to risk, seeking only temporary relief, a short-term extension of life, is impossible. Therefore, the testimony for the use of palliative resection in oncological patients should be put with great caution, resorting to them only in cases where the risk is minimal. "

Palliative operations include operations performed in the plan comprehensive treatment generalized forms of hormone-dependent cancer forms (for example, ovarctomy, adrenalectomy, orchiectomy). Operations of this kind allow you to suspend growth, and in many cases achieve full regression of tumor foci, restore the ability to work and extend the life of patients for many years.

Citergrading operations

Cytralics, as a type of palliative operations, designed to apply additional treatment methods, are shown in disseminated tumors sensitive to radiation and / or drug treatment methods.

At the same time remove the bulk of the primary tumor ("scooting" "of the tumor) and / or its metastases so that the remaining array of tumor tissue is drug treatment He had a greater impact, since the effectiveness of chemotherapy is inversely proportional to the mass of the tumor.

Such operations were, in particular, were fulfilled with the ovarian cancer, the seminine of the egg, the disintegrating tumor of the breast, the nichestyperency of the lattern, recurrent and metastatic forms of the sarcom of soft tissues, colorectal cancer, etc.

IN last years Indications are expanding to cytotetuctive surgical interventions, as the possibilities of additional methods of antitumor therapy have increased significantly.

Symptomatic operations

Symptomatic operations are made most often in urgent and emergency order and no interference with the elimination of the tumor does not provide.

They are performed to restore the vital functions of the body (respiration, blood circulation, nutrition, diversion of the contents of thin, colon, biliary tract), whose disorders are due to remote metastases or tumor germination (tracheostomy, gastrostomy, gastroenterostomy, biliodygenic anastomoses, external intestinal fistulas, vascular bandage When bleeding, etc.).

Symptomatic operations do not prolong life expectancy, but improve its quality.

Diagnostic operations

Diagnostic operations (such as laparotomy, thoracotomy) are very common in oncology. They are shown like the final stage Diagnostics, in cases where all the possibilities are exhausted with a different way, as well as for the purpose of obtaining a material for morphological verification of the diagnosis.

They also allow a full-fledged revision and most objectively justify the refusal of a radical operation or translate diagnostic interference in the medical surgical surgery.

During the diagnostic surgery, issues of the feasibility of drug and / or radiation therapy may also be solved if the radical operation is refusing and designated by composing the boundaries of the irradiation fields.

Repeated - Second-Look - Operations

The purpose of such operations is the complete removal of the residual tumor after chemotherapy or radiation treatment, when the tumor was inoperable or deleted in part during the first operation.

Second-Look operations can also be used as a means of controlling the effectiveness of the antitumor therapeutic program and, if necessary, its correction.

Explorative (Protective) Operations

In the oncological surgery there is a situation where, due to intraoperative audit, it was established that there are favorable metastases or extensive germination of the tumor of the surrounding tissues or organs and the operation is limited only to the organ examination chest or abdominal cavity without medicinal manipulations.

Rehabilitation operations

Oncological operations are usually fairly traumatic, often lead to violation of organ function, accompanied by significant cosmetic defects, which significantly worsen the quality of life of such patients.

In recent years, as the results of anti-inflicted and non-estate treatment, real prerequisites have emerged to fulfill the implementation of the rehabilitation program in a broad sense of the so-called rehabilitation operations. These interventions are aimed at the maximum social, psychological, and sometimes labor adaptation of oncological patients.

It should be emphasized once again that surgical interventions in oncology on modern stage are the most significant in their effectiveness. However, the concepts "Operation" remain unshakable, that is, the patient's condition, which allows to perform surgical treatment, and "Inoperable", that is, a state that excludes the possibility of surgical treatment (according to anatomy-topographic, physiological and pathophysiological considerations).

Of course, these concepts are conditional and in each specific case require an individual approach, deep analysis and a collegial solution.

Operations and resectability

Operalness - This is an opportunity to perform in general surgery of a specific patient. Operable or inoperable is a patient, not a tumor. Evaluation of Operationality (inoperability) is, in fact, solving the issue of indications (contraindications) to the operation.

Operation as a term is based on a tumor prevalence and functional state organs and systems of the body of a particular patient.

The following types of operation distinguish: technical - the ability to remove the tumor under its local distribution; oncological - determined by the lack of remote metastases; Functional - determined by the state of cardiovascular, respiratory systems of the organism, degree of metabolic disorders.

As an indicator, the transmission also has a certain meaning and in the assessment of the work of oncosurgery hospitals. If you calculate the ratio (in%) of the number of operated patients to the total number of received in this hospital, then it is possible to obtain a sufficiently objective characteristic of its operation (as a whole and in individual, nosological forms of cancer).

It is obvious that the higher the indicator of the transmission, the higher the surgical activity, the higher the level of the dog-binding survey, and probably the level of professional training of employees.

At the same time, a high level of operation at low rectaging indicates an unjustified expansion of indications for surgical treatment and / or low level of preoperative surveys, and perhaps - and qualifications of surgeons.

Rectachableness - This is the presence of the technical possibility of radical or palliative tumor removal, which depends on the stage of the process and the overall condition of the patient. The inability to perform surgery, detected during the operation, must be confirmed by morphological (cytological or histological) study.

At the same time, the ratio (in%) of the number of radically operated patients with the total number of operated patients with this type of tumor can also characterize the operation of a particular surgical oncological hospital.

In conclusion, it is necessary to indicate that surgical interventions in common formations of neoplasms is sometimes difficult to put in any specific scheme, since it is impossible in each particular case to predict the particular particular clinical and life situation.

In this regard, before the surgeon, the task arises as it is possible to estimate the overall state of the patient, the prevalence of the tumor, the nature of its growth, possible intra- and

For the purpose of execution, all operations are divided into two groups: diagnostic and medicinal.

Diagnostic operations

The purpose of the diagnostic operations is to clarify the diagnosis, the definition of the process stage. Diagnostic operations are resorted only when clinical examination With the use of additional methods, it does not allow to put an accurate diagnosis, and the doctor cannot eliminate the presence of a serious disease in a patient, the tactics of the treatment of which differs from the therapy.

Among the diagnostic operations can be allocated of various types biopsy, special and traditional surgical interventions.

-Biopsy

When biopsy, the surgeon takes a fence of the area of \u200b\u200bthe organ (neoplasms) for the subsequent histological research in order to formulate the correct diagnosis.

Highlight three types of biopsy.

1) Excision biopsy

Removing the formation entirely. Is the most informative, in some cases may have a therapeutic effect.

Most often apply:

- excision of the lymphatic assembly (the etiology of the process is found: specific or nonspecific inflammation, lymphoganuleatosis, tumor metastasis);

- excision of the formation of the breast (for formulation of the morphological diagnosis) - at the same time, if malignant growth is revealed, after the biopsy immediately perform the therapeutic operation;

- If a benign tumor is detected - the initial operation itself is also therapeutic nature.

There are other clinical examples.

2) Incision biopsy

For histological research, part of the education (body) is excised.

For example, an increased, dense pancreas was revealed to operations, which resembles a picture of both the malignant damage and the indexing chronic pancreatitis. Surgeant tactics in these diseases are different. To clarify the diagnosis, we can excise a piece of iron for urgent morphological research and, in accordance with its results, take a certain method of treatment.

The method of incision biopsy can be used at differential diagnosis Gastric ulcers and cancer, trophic ulcers and specific lesions and in many other situations. The most fully excision section of the organ on the border of pathologically modified and normal tissues. This is especially true for diagnosis. malignant neoplasms.

3) Penalty biopsy. It is advantageous to attribute this manipulation not to operations, but to invasive research methods. Perform a percutaneous puncture of the organ (education), after which the microstolbiik remaining in the needle, consisting of cells and tissues, is applied to the glass and sent for histological examination, the cytological study of the point is also possible. The method is used to diagnose dairy and thyroid disease, as well as liver, kidneys, blood systems (sternal puncture) and others.

This biopsy method is the least accurate, but the most simple and harmless to the patient.

Special diagnostic interventions

To this group of diagnostic operations include endoscopic research - Laparoscopy and thoracoscopy (endoscopic studies through natural holes - fibroesophagogastroscopy, cystoscopy, bronchoscopy - more correctly attribute to special research methods).

Laparoscopy or thoracoscopy can be performed in cancer patients to clarify the stage of the process (the presence or absence of carcinomyosis serous shells, metastases, etc.). These special interventions can be completed in an emergency in suspected internal bleeding, The presence of an inflammatory process in the appropriate cavity.

- Starty surgical operations with diagnostic purposes

Such operations are produced in cases where the survey does not make it possible to put an accurate diagnosis. Most often performed diagnostic laparotomy, while they say that it is the last diagnostic stage. Such operations can be carried out both in the planned and emergency.

Sometimes the diagnostic operations about malignant neoplasms are becoming. This happens if, with the audit of the organs during the operation, it is revealed that the stage of the pathological process does not allow the necessary amount of operation. The planned therapeutic operation becomes diagnostic (the process stage is specified).

Example. The patient planned the extirpation of the stomach for cancer. After laparotomy, multiple metastases in the liver are revealed. Performing an extirpation of the stomach is recognized in impractical. Abdominal cavity of the ears. The operation was diagnostic (determined by the IV stage of the malignant process).

Medical operations

Therapeutic operations are performed with the aim improving the condition of the patient. Depending on their effect on the pathological process. mix radical, palliative and symptomatic healing operations.

Radical operations

Radical are called operations that are performed in order to cure from the disease. Such operations in surgery are most.

Example 1. In the patient acute appendicitis: Surgeon performs appendectomy (removes appendix) and thus cures the patient.

Example 2. The patient acquired enabled umbilical hernia: The surgeon eliminates the hernia - the contents of the herniated bag will go into the abdominal cavity, the hernia is excised, and the plastic of the hernial gate is carried out. After such a operation, the patient is cured of hernia. Such an operation was called "Radical Operation of Undermining Hernia".

Example 3. There is no distant metastase in the patient of cancer, remote metastases: in compliance with all oncological principles, the subtotal resection of the stomach, aimed at the complete seraction of the patient.

Palliative operations

Palliative operations are aimed at improving the condition of the patient, but not to cure it from the disease.

Most often, such operations are performed in cancer patients, when radically remove the tumor is impossible, but it is possible to improve the patient's condition by eliminating a number of complications.

Example 1. In a patient, a malignant tumor of the pancreas head with germination of a hepatic-duodenal bunch, complicated by a mechanical jaundice (due to a choledoch compression) and the development of duodenal obstruction (due to the germination of the intestine tumor). Due to the prevalence of the process, the radical operation cannot be performed. However, it is possible to facilitate the condition of the patient by eliminating the most severe syndromes for it: mechanical jaundice and intestinal obstruction. Paliative operation is performed: choledochuyutomy and gastroinomitia (artificial workarounds are created for the passage of bile and food). At the same time, the main disease is a pancreatic tumor - not eliminated.

Example 2. In the patient of the stomach cancer with the presence of remote metastases in the liver. The tumor of large sizes, which causes intoxication and frequent bleeding. The patient operates: they perform palliative resection of the stomach, the tumor is removed, which significantly improves the condition of the patient, but the operation is not aimed at cure from the oncological disease, since multiple metastases remained, and therefore is palliative.

The need for palliative operations, despite the fact that they do not cure the patient from the underlying disease, is explained by the following circumstances:

- palliative operations prolong the life of the patient;

- palliative interventions improve the quality of life;

- after palliative operation conservative treatment may have greater efficacy;

- There is a possibility of the emergence of new methods that can cure a unreared major disease;

- There is a chance of error in the diagnosis, and the patient will be able after a palliative operation to recover almost completely.

Symptomatic operations Overall symptomatic operations resemble palliative, but, unlike the latter, not aimed at improving the patient's condition as a whole, but to eliminate a particular symptom.

Example. In the patient cancer of the stomach, gastric bleeding from the tumor. The implementation of radical or palliative resection is impossible (the tumor germinates into the pancreas and the root of the mesentery). The surgeon makes a symptomatic operation: bandages gastric vessels, blood supplying tumor, for try

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Types of surgical operations

Operation - performing a special mechanical impact on organs or tissues with therapeutic or diagnostic purpose.

Classification of surgical operations

Surgical operations are accepted to divide the urgency of their implementation and, if possible, full cure or facilitating the state of the patient.

Updated performance distinguishes:

1) emergencyoperations, they are performed immediately or in the coming hours from the moment of the patient's entry into the surgical department;

2) urgeredoperations, they are fulfilled in the coming days after receipt;

3) plannedoperations, they are performed in a planned manner (the timing of their implementation is not limited).

Allocate radical and palliative operations.

Radicalthey consider an operation at which by removing pathological education, a part or all of the organ, a refund of the disease is excluded. The volume of operational intervention, determining its radicalism, is due to the nature of the pathological process. With benign tumors (fibromes, lipoms, neuromets, polyps, etc.), their removal leads to curable patient. With malignant tumors, the radicalism of the intervention is not always achieved by the removal of a part or the entire organ, given the possibility of tumor metastasis. Therefore, radical oncological operations often, along with the removal of the organ, include the removal (or resection) of neighboring organs, regional lymph nodes. Thus, the radicalism of operation during breast cancer is achieved by removing not only all the breasts, but also a large and small breasting muscles, fatty tissue together with the lymph nodes of the axillary and subclavian regions. For inflammatory diseases The volume of interventions determining the radicality of the operation is limited by the removal of pathologically changed tissues: for example, produce osteonecrectomy in chronic osteomyelitis or removal of a pathologically changed organ - appendectomy, cholecystectomy, etc.

Palliativescall operations performed in order to eliminate immediate danger to the life of the patient or facilitate its condition. Thus, during decay and bleeding from the tumor of the stomach with metastases, when the radical operation is impossible due to the prevalence of the process, the rescue of life is taken by resection of the stomach or wedge-shaped excision of the stomach with a tumor and a bleeding vessel. With a common edge of the esophagus with metastases, when the tumor completely fascinates the lumen of the esophagus, and it becomes impassable for food and even water, in order to prevent hungry death produce a palliative operation - the imposition of a fistine on the stomach (gastrostomy), through which the food is introduced into it. Palliative operations achieved a stop of bleeding or power supply, but the disease itself is not liquidated, since the tumor metastases remain or the tumor itself. With inflammatory or other diseases, palliative operations are also performed. For example, under paraensional phlegmon, complicating osteomyelitis, opens phlegmon, drain the wound to eliminate intoxication, prevent the development of a total purulent infection, and the main focus of inflammation in the bone remains. With acute purulent cholecystitis in the elderly, persons suffering from heart failure, the risk of radical operation is high. To prevent the development of purulent peritonitis, heavy intoxication, perform palliative operation - cholecystostomy: overlaying the fistula horse bubble. Palliative operations can play the role of a certain stage in the treatment of patients, as in the examples given (opening of phlegmon at osteomyelitis or cholecystostomy when acute cholecystitis). Subsequently, when improving the overall condition of the patient or creating local favorable conditions A radical operation can be performed. With inoperable oncological diseases, when radical intervention is impossible due to the prevalence of the process, the palliative operation is the only benefit that allows you to temporarily alleviate the patient's condition.

Operations can be simultaneous and multisote (two or three-year).

For somomantoperation All its stages produce directly one after another without breaking over time. Each is multomataoperations consists of certain stages of surgical treatment of the patient separated in time. As an example, multiomate operations in orthopedics can be given in or oncological practice. For example, with a tumor of the colon, which caused intestinal obstruction, initially impose anastomosis between the resulting intestine of the intestine or the fistula to the leading loop (1st stage), and then, after improving the patient's condition, the intestines of the intestine are performed along with the tumor (2nd stage).

IN modern conditions With the development of anesthesia, intensive therapy appeared the opportunity to simultaneously perform two or more operations in a patient - simultan(Simultaneous) operations. For example, in a patient with groin hernia and varicose extension Large subcutaneous veins can be done in one acceptance of two operations: herniashell and phlebectomy. In the patient of the ulcer of the stomach and chronic calculatory cholecisitis, resection of the stomach and cholecystectomy with a good condition of the patient can be produced simultaneously using one surgical access.

In surgical practice, situations are possible when the question of the possibility of performing operation is solved only during the most surgical intervention. This concerns oncological diseases: With the diagnosis of a tumor of one or another organ, a radical operation is assumed; During the intervention, it turns out that the planned operation is impossible due to the metastasis of the tumor into remote organs or germination into neighboring. This operation is called proba. . Operation surgical preoperative operation

Currently to diagnosticoperations are rarely resorted in connection with the presence of highly informative diagnostic research methods. Nevertheless, there are cases when the last means of establishing a diagnosis remains a surgical operation. If the diagnosis is confirmed, such an operation is usually ends as therapeutic. Diagnostic operations include biopsy: Taking for histological research of education, organ or their parts. This diagnostic method plays an important role in differential diagnosis Between a benign and malignant neoplasm, tumor and inflammatory process, etc. Such studies help clarify the readings for the operation or choose an adequate volume, such as, for example, with cancer or peptic disease Stomach: In the first case, perform gastrectomy (removal of the entire stomach), in the second - resection of the stomach (removal of its part).

There are typical operations (standard) and atypical.

Typicaloperations are performed by clearly developed schemes, techniques of operational intervention.

Atypicalsituations arise in the event of an unusual nature of the pathological process, which caused the need for operational treatment. These include heavy traumatic injuries, especially combined, combined injuries, firearms. In these cases, the operations can go beyond the framework of the standard, require a surgeon of creative solutions when determining the volume of operation, performing plastic elements, the implementation of the intervention at the same time in several organs: vessels, hollow organs, bones, joints, etc.

Distinguish closed and open operations. TO closedreplays the repositions of bone fragments, some types of special operations (endoscopic), turning the fetus on the leg in obstetrics, etc. With the development of surgery, a number of special operations have been separated.

Microsurgicaloperations are performed under an increase of 3 to 40 times using magnifying glasses or an operational microscope. At the same time use special microsurgical instruments and the finest suture threads. Microsurgical operations are increasingly introduced into the practice of vascular surgery, neurosurgery. With their help, they successfully fulfill the limbs, fingers after traumatic amputation.

Endoscopicoperations are carried out using endoscopic devices. Through the endoscope, the stomach, intestines, intestines, bladder, stop bleeding from the mucous membrane of these organs, coagulating the laser beam a bleeding vessel or closing it with a special glue. With the help of endoscopes, the stones are removed from the horizontal ducts, the bladder, foreign bodies from bronchi, esophagus.

Using endoscopic devices and television techniques, laparoscopic and thoracoscopic operations (cholecystectomy, appendectomy, embossing perforative ulcers, resection of the stomach, lung, breaking the bullio in an easy-to-bullous disease, herniashesta, etc.). Such closed endoscopic operations became the main in a number of diseases (for example, cholecystectomy, the edge resection of the lung) or are an alternative to open operations. Taking into account the testimony and contraindications, this type of operation is becoming more and more use in surgery.

Endovascularoperations - a type of closed intravascular surgical interventions performed under X-ray control: the expansion of the narrowed part of the vessel with the help of special catheters, artificial blockage (embolization) of a bleeding vessel, removal of atherosclerotic plaques, etc.

Repeatedoperations can be planned (multi-merating operations) and forced - in the development of postoperative complications, the treatment of which is possible only surgical (for example, relaparotomy in the insolvency of intercircuit anastomosis with the development of peritonitis).

Stages of surgical operation

Surgical operation consists of the following main stages:

* surgical access;

* The main stage of the operation (surgical admission);

* Enchanting the wound.

Surgical access

Requirements for surgical access - minimal traumatic, ensuring a good angle of operational activities, as well as conditions for careful execution of the main stage of the operation. Good access determines the minimum trauma of tissue with hooks, provides good review Operational field and thorough hemostasis. For all existing typical operations, appropriate surgical accesses have been developed, only with atypical operations (for example, with extensive damage to tissues during injury, firearms) You have to choose surgical access taking into account the above requirements.

Surgical reception

The main techniques in the implementation of the operation, the technique of specific operational interventions are subject to the course of operational surgery, the end of the main stage of the operation (before the injury of the wound) necessarily includes a thorough check of hemostasis - stopping bleeding, which is an important point of the prevention of secondary bleeding.

Wounding

The final stage of the operation is to escape the wound. It should be carried out carefully to avoid rubberizing seams, unleashing

ligatures, discrepancies of the drive of the operating room. Significant difficulties with the injury of the wound occur in atypical operations when it is necessary to close the wound by the displaced flap of fabrics, leather or free skin transplant.

When performing all stages of operation, an indispensable condition is careful treatment of fabrics,unacceptable coarse tissue tools, their extracts, donkeys. Careful hemostasis is extremely important. Compliance with the terms listed allows you to prevent the development of complications after surgery - secondary bleeding, purulent-inflammatory complications arising from endo- and exogenous infection of the Russian Academy of Sciences.

Preoperative period

Preoperative period- time from the receipt of the patient in medical institution Before the operation. Its duration is different and depends on the nature of the disease, the severity of the state of the patient, urgency of the operation.

Preoperative period begins from the moment of the patient's admission to the surgical department. It is divided into diagnostic when the diagnosis is specified, the state of the organs and systems is determined, indications of surgical intervention and the period of preoperative preparation are determined. In time, there may be different durations, which depends on the degree of urgency and severity of the upcoming operation. Private preoperative preparation is provided, which takes into account the peculiarity of a particular disease (for example, washing the stomach during the stenosis of its exit, the purpose of hydrochloric acid during the ahilia, the complete cleansing of the intestine and the purpose of the olimicine inside before the operation on the colon, the desire to eliminate the perifocal inflammation in chronic lung suppurations, etc.) , and general preparation for all patients who have to surpass (good sleep on the eve of the operation, hygienic bath, wide shave of the operating field, restrictions in the reception of food on the day of operation, prevention of vitamin failure, etc.).

With a complete outpatient examination and necessary analyzes, clinical monitoring of patients preparing for the most common operation should not be delayed more than 2-3 days. Planned operations should not be prescribed during menstruation, since these days there is an increased bleeding and a decrease in the reactivity of the body.

Maintenance tasks preoperative period:

1) to determine the diagnosis;

2) determine the indications, urgency of the performance and nature of the operation;

3) prepare a patient for the operation.

Basic targetpreoperative preparation of the patient - to minimize the risk of the upcoming operation and the possibility of the development of postoperative complications.

Installing the diagnosis of surgical disease, should be performed in a specific sequence the main actions ensuring the preparation of the patient to the operation:

1) determine the indications and urgency of the operation, find out the contraindications;

2) to carry out additional clinical, laboratory and diagnostic studies in order to find out the state of vital important organs and systems;

3) determine the degree of anesthesiological and operational risk;

4) to conduct psychological preparation of the patient to the operation;

5) to carry out the training of bodies, correction of violations of homeostasis systems;

6) carry out the prevention of endogenous infection;

7) select the anesthetic method, carry out premedication;

Carry out preliminary training of the operating field;

9) transport the patient into operational;

10) Put the patient on the operating table.

Postoperative period

Begins with the end of the operation before restoring the disability of the patient. It is divided into three phases: the first is the earnest, duration of 3-5 days, the second - 2-3 weeks, before the discharge of the patient from the hospital, the third is remote, until disability.

It allocate the normal course after the operation, when there are no severe disorders of the functions of organs and systems, and complicated (hypergic), when the body's reaction to the surgical injury is extremely negative, and all sorts of postoperative complications are developing. Even under the normal course of this period, there are always violations of the functions of almost all organs and systems, and with complicated they are sharply pronounced.

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Classification of surgical operations

Surgical operations are accepted to divide the urgency of their implementation and, if possible, full cure or facilitating the state of the patient.

Updated performance distinguishes:

• 1) emergencyoperations, they are performed immediately or in the coming hours from the moment of the patient's entry into the surgical department;
• 2) urgeredoperations, they are fulfilled in the coming days after receipt;
• 3) plannedoperations, they are performed in a planned manner (the timing of their implementation is not limited).

Allocate radical and palliative operations.

Radicalthey consider an operation at which by removing pathological education, a part or all of the organ, a refund of the disease is excluded. The volume of operational intervention, determining its radicalism, is due to the nature of the pathological process. With benign tumors (fibromes, lipoms, neuromets, polyps, etc.), their removal leads to curable patient. With malignant tumors, the radicalism of the intervention is not always achieved by the removal of a part or the entire organ, given the possibility of tumor metastasis. Therefore, radical oncological operations often, along with the removal of the organ, include the removal (or resection) of neighboring organs, regional lymph nodes. Thus, the radicalism of operation during breast cancer is achieved by removing not only all the breasts, but also a large and small breasting muscles, fatty tissue together with the lymph nodes of the axillary and subclavian regions. With inflammatory diseases, the volume of intervention, determining the radicalism of the operation, is limited by the removal of pathologically changed tissues: for example, produce osteonecrectomy with chronic osteomyelitis or removal of a pathologically changed organ - appendectomy, cholecystectomy, etc.

Palliativescall operations performed in order to eliminate immediate danger to the life of the patient or facilitate its condition. Thus, during decay and bleeding from the tumor of the stomach with metastases, when the radical operation is impossible due to the prevalence of the process, the rescue of life is taken by resection of the stomach or wedge-shaped excision of the stomach with a tumor and a bleeding vessel. With a common edge of the esophagus with metastases, when the tumor completely fascinates the lumen of the esophagus, and it becomes impassable for food and even water, in order to prevent hungry death produce a palliative operation - the imposition of a fistine on the stomach (gastrostomy), through which the food is introduced into it. Palliative operations achieved a stop of bleeding or power supply, but the disease itself is not liquidated, since the tumor metastases remain or the tumor itself. With inflammatory or other diseases, palliative operations are also performed. For example, under paraensional phlegmon, complicating osteomyelitis, opens phlegmon, drain the wound to eliminate intoxication, prevent the development of a total purulent infection, and the main focus of inflammation in the bone remains. With acute purulent cholecystitis in the elderly, persons suffering from heart failure, the risk of radical operation is high. To prevent the development of purulent peritonitis, heavy intoxication, a palliative operation is carried out - cholecystostomy: overlay a fistula on a hand bubble. Palliative operations can play the role of a certain stage in the treatment of patients, as in the examples given (opening of phlegmon with osteomyelitis or cholecystostomy in acute cholecystitis). Subsequently, when improving the overall condition of the patient or creating local favorable conditions, a radical operation can be performed. With inoperable oncological diseases, when radical intervention is impossible due to the prevalence of the process, the palliative operation is the only benefit that allows you to temporarily alleviate the patient's condition.

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Odnoklassniki.

The concept of "radical surgery" in oncological patients is submitted to a certain extent relative. Nevertheless, the operation of this type, if they managed to fulfill, and at the same time the basic principles of radicalism are observed, ensure high efficiency and most stable oncological results. Radicalism is the oncologically reasonable removal of the affected organ within healthy tissues along with regional metastasis zones.

For many decades in oncology, strictly mandatory desire for the radicalism of interference and its conduct in ablastic and antiblastic conditions have been developed. As it was already indicated that the operation was radical, it is necessary to strictly take into account the principles of the anatomical zonality and tissue composition, remove the tumor with a single block with regional lymph nodes, having previously touched the vessel tumor from the zone. The principle of ablasticity of the operation is achieved by cutting on healthy tissues. The principle of antiblasticity is ensured by using various chemical and physical factors In order to influence tumor cells in the wound.

Often there are cases when the operation is performed on the ablation of ablasticity. For example, the resection boundaries are not far from the primary tumor, the metastases are revealed in all regional lymph nodes, but the remaining tumor tumor tumor was detected on the operation. Formally, such an operation must be attributed to the category of radical surgical interventions, but in fact, in such cases, we can talk about doubtfully radical, or conditionally radical, operation. It should be borne in mind that such operations, as a rule, performed at the III stage of malignant neoplasms, give unsatisfactory results and at least be supplemented with medicinal and / or radiation.

The desire for maximum radicalism, as a rule, is associated with the removal of large sections or the entire affected organ, as well as involved in the process of surrounding tissues and organs. Therefore, in oncology, in addition to standard radical operations, there are the concepts of combined and expanded surgical interventions. Modern anesthetic support, as well as progressive methods of chemorad, in a number of cases of immuno, hormonal and other types of additional treatment, make it possible to successfully carry out these extensive operations and to obtain remote treatment results are reliably better than with routine therapy methods.

Combined surgical interventions include such operations at which they are removed as a primary-struck organ and (fully or partially) neighboring organs that the tumor has spread. The use of combined operations is justified in cases where there are no remote metastases, and there is only the spread of a tumor to adjacent anatomical structures. An extended operations are expanded under which an additional lymphocollectors of the border of the organ resection and the excision of lymphatic barriers turn out to be wider than typical schemes. Such an interpretation of the concepts of combined and extended radical operations is quite simple and understandable, other definitions make a confusion into the creature of the case and make it difficult to understand the oncologists.

It should be emphasized that operational interventions in oncological patients differ significantly from the general merger. So, sick cancer of the stomach depending on the localization and local prevalence of the tumor process, such operations such as subtotal, total substal resection and gastrectomy with removal of large and small glands and even resection of the pancreas, liver, transverse colon are required. If the proximal diversity of the stomach and the tumor process spread to the esophagus, in most cases, together with the tumor, they remove the spleen through the transploveral or combined (thoracoabdomal) access. For easy cancer The smallest surgical intervention will be a forehead or bilobectomy with separate treatment of the root of the lung and removal of mediastinal lymph nodes and fiber. More often you have to remove everything easy, sometimes with resection of ribs, trachea and pericardia. In patients with malignant limb tumors in some cases, it is necessary to amputate the limb at various levels, while at the same time removing the regional lymphatic apparatus (simple or extended inhabited-iliac or armpit-connected-subcasel lymphadenectomy). Sometimes to save the life of the patient can be only such crousing operations as an inter-opumen-sander or intermediate-sacriven. Malignant damage to the pancreas and duodenal gut Forcing the surgeon not only to remove these organs, but also impose several technically difficult formed anastomoses.

As is well known, standard surgical operations have been developed for all localization of malignant tumors. These are typical radical surgical interventions that sustained the test of time and are the main basis for practicing oncologists.

At the same time, in the process of many years of use of typical operations, their disadvantages have been revealed. At the level of modern knowledge and achievements in the field of surgical equipment, medicinal, radiation and other antitumor influences, real conditions were created to develop new types of surgical operations.

These developments go in two directions. On the one hand, improved and are actively being introduced into clinical practice. various operations With resection or complete removal of several organs involved in the tumor process, supplemented by radiation and drug treatment methods. On the other hand, in the framework of improving the quality and life expectancy of patients, that is, in terms of the implementation of the rehabilitation program, in a broad sense, the most important and even growing importance is attached to by organo-breaching and functional transactions that meet all the necessary requirements of oncological radicalism, in particular with the initial forms of cancer ( V.I. Numbers, 1999). These include, for example, tracheobronchoplastic operations with mono- and polybronchial anastomoses, organ-saving operations on the mammary gland, limbs, etc. Moreover, in modern clinical oncology, such a new direction is successfully developing, as a organ-powder and functional treatment of patients, even with a locally common tumor process, including III and even IV stage of tumor, as well as recycling of neoplasms. This became possible not only due to the use of advanced technologies in the field of chemorad and other antitumor effects, but mainly due to the development of progressive plastics methods, in particular methods of microsurgical autotransplantation of organs and tissues, providing for the immediate plastic reconstruction of the organ immediately after removing the tumor with the restoration of its function . New methods of microsurgical autotransplantation of organs and tissues are successfully used in the treatment of malignant tumors of the head and neck, alternating, the cerinous and chest of esophagus, limbs, torso, etc. In the Research Institute of Oncology and Medical Radiology. N.N. Alexandrova (I.V. Zalutsky, 1994) and Moscow Niya. P.A. Herzen (V.I. Numbers, 1992, 1999) were conducted large-scale comprehensive studies under which donor zones were revealed in the human body having insulated blood circulation. In these zones, the transplant can be carved on an isolated vascular leg and moved to the wound defect zone formed as a result of wide tumor removal, while maintaining blood circulation (due to the mobilization of tissues and vascular legs) or with immediate recovery of blood circulation by anastomosing the vascular legs of the flap and blood supply source In the zone of the operated organ. Numerous types and methods of autotransplantation are developed and applied, allowing substantive wound defects to reducate anatomical structures, thereby ensuring that organ-bearing and functionally-sparing treatment under a number of nosological forms of malignant neoplasms.

Thus, radical surgical interventions in oncology at the present stage receive "second breathing". However, it should be emphasized that at the same time the concepts "Operation" remain unshakable, that is, the patient's condition, which allows to perform surgical treatment, and "INCREGRELS", that is, a state that excludes the possibility of surgical treatment (according to anatomy-topographic, physiological and pathophysiological considerations). Of course, these concepts are conditional and in each specific case require an individual approach, deep analysis and a collegial solution. It should be emphasized that due to targeted rational preoperative preparation, right choice Anesthesia and appropriate signature in the postoperative period can be expanded by testimony for surgical interventions and increase the radicality of the operational manual.

In conclusion, we give the statement of N.N. Blokhin (1977), remaining very relevant and these days when considering numerous questions of radical surgical treatment: "The presence of a modern oncologist of a number of treatment methods that can be complemented or even replaced surgical intervention, undoubtedly puts in principle the issue is not about expanding the scale Oncological operations, but to strive to develop enough radical and at the same time less crumbles. "

Radical operations on the lungs, ears, genital and digestive organs are surgical interventions involving the excision of large volumes of tissues. This is an extreme measure used in the ineffectiveness of conservative and minimally invasive surgical methods of treatment. Using partial or complete removal Organs can be eliminated from severe diseases. Depending on the degree of prevalence of the pathological process and the nature of its flow, the operation may have one degree of limitation.

Radical Operation on the ear allows you to stop the development of dangerous inflammatory processes. Restoration of affected areas is carried out by creating a smooth cavity in bone tissues. Purulent processes are most often developed in the middle hearing channel department.

The maternity process, the drumpoint and antrums are combined into the so-called operational field. This can be achieved by removing parts of the organ located in the drum area.

Reference remains and removed. Even inadvertent in the pathological process is a minimized process must be deleted. The new cavity in the ear is created by stripping not only affected, but also healthy fabrics.

Radical surgical intervention contributes to the formation of the cavity necessary to combine an external auditory passage with the bone space of the ear. The connection is made by means recovery operation. The epidermis fills the entire volume of the operating cavity covering it with a thin layer.

Tympano-Mastoidotomy allows you to stop the suppuration process. The radical operation prevents the development of complications associated with the launched forms of inflammatory processes. Temporal bone It becomes protected from the dangerous influence of purulent content. Often, the operation is the only way to prevent infection of brain tissues.

In addition to indisputable advantages, such radical measures Possess a number of shortcomings. Patients get rid of the risk of dangerous complications, however, the ability to perceive sounds is completely lost.

Deafness after the operation is irreversible, it occurs quite often. Often after the intervention, the selection of a pus from the newly formed cavity is observed. This is due to the incomplete coverage of this area of \u200b\u200bthe epidermis.

At the location evstarchy pipecoming into contact with mucous membranes, the epidermis may be absent. This leads to suppuration, so after surgery, the patient must remain in the hospital under the supervision of doctors.

Most often, decisive operations on the ear are applied at pathological conditionsleading to the appearance of lesions in the inside of the skull. If diseases cause a violation of sound, radical surgical intervention is the only chance for the preservation of hearing. Less often such operations are carried out at acute inflammation middle ear accompanied by necrosis drumpatch Or problems in the upper pyramid departments.

Radical operations in gynecology

Indications for surgical intervention are benign and malignant tumors of the uterus. Myoma often leads to the need to complete the removal of the body.

Access to the affected area can be carried out through puncture or incision in the abdominal cavity, as well as through the genitals. With hysterectomy, the surrounding tissues are partially excised.

With an abdominal operation, a complete or partial removal of the uterus can be performed. An overall amputation of the organ implies its extraction together with the ovaries and pipes.

The need to remove appendages is determined by the presence of pathological changes in them. With malignant neoplasms, overall amputation is the only way to rescue the patient's life.

Radical operations on the lungs

Such interventions on the lungs are used for tuberculosis, oncological diseases, bronchiectasia. Perhaps both complete and partial removal of the organ. The algorithm for performing surgical intervention is determined by the nature of the cut. When the patient is pressed on the back or the opposite affected area side.

If you need to provide posterior access, the patient must lie on the stomach. Such an operation on the chest organs should be performed under general anesthesia using neuropilegic preparations and novocaine Blocade Reflex dots: intercostal nerves, nerve endings of the root of the lung, aortic arc.

With advanced access, the incision starts from 3 ribs and is made with a small indentation from the parastinal line to the outside. The scalpel moves to the nipple area in men or breasts in women, envelopes them and heads toward the armpit. Crushing skin, fat, fascial and muscle tissue. For opening the chest, an incision in the region of the intercostal intercostals during operations in the upper lungs, and in the region of the intercostal region, with interventions in the lower share of the body or its complete removal is possible.

With the posterior access, the incision begins in the region of 3-4 of the breast vertebrae, moves down the paravertebral line to 4-6 ribs, envelopes the bladder bone and continues to the axillary region. Drinking leather, fatty fiber, fascia, trapezoidal and broadest back muscles. In the deepening of the operating room, the toothed and diamond muscles are affected. The detected ribs are snacking or ledated. The incision on the pleural shell is made in the area of \u200b\u200bthe extracted rib or intercostal. For removing lower parts Easy access is carried out through 7 edges, for pneumonectomy - after 6.

When removing the entire light wound is widely disclosed, pleural spikes are cut. This allows you to access easy root. In this area, a novocaine solution is introduced, which blocks nervous conductivity and simplifies the process of separating pulmonary and bronchial vessels. A large pulmonary vessel bandage and cut off.

Bronchine is ligated in the nearest to the trachea of \u200b\u200bthe region, cut and sew the double seam. The cultivation of vessels is treated with the UKP-60 apparatus, the cult of bronchi - the UCB-7 apparatus. After performing these operations, easy to remove from pleural cavity. The sheets of pleura are stitched so that it overlap the bronchus cult.

Drainage is installed in the area of \u200b\u200b8 or 9 intercostal on the rear axillary line. The incision is cut in stages. There are other methods of surgical interventions - lobectomy (removal of pulmonary share) and segmental resection (removal of the affected segments of the organ). These are the safest types of radical operations.

Radical operations in oncology

Such surgical interventions are widespread in oncology. When detecting malignant tumors, they are the only effective way of treatment. Not only affected organs and their departments, but also regional lymph nodes are removed.

When conducting radical operations in the early stages of cancer, the following conditions must be observed. Surgical intervention should contribute to the preservation of the maximum volumes of healthy tissues, but this should not interfere with the radical removal of malignant neoplasm. Restoration of affected organs is carried out using transplantation and microsurgical methods.

In addition to preserving tissues, methods must be used to preserve the functions of the operated organ. The radical surgery should not significantly affect the overall condition of the body. In the treatment of oncological diseases, it is necessary to use methods that exclude the interaction of affected tissues with the main cut and the distribution of metastases:

• the use of cytostatics when processing the relevant regions;
• study of sections of remote fabrics;
• purpose of postoperative treatment, preventing division of cancer cells.

The degree of limited surgical intervention in malignant neoplasms is determined by quantitative indicators. The risk of distant metastases is associated not only with the volume of removable tissues, but also with the presence of secondary foci before the operation. Despite this, radical interventions significantly reduce this indicator, the number of deaths due to recurrences is reduced.

The efficiency of radical intervention is determined by the stage of the pathological process. For example, its conduct of 1-2 stages in most cases leads to the recovery of the patient. However, during cancer 4 degrees, radical surgical intervention is pointless: multiple lesion foci is found in all organs and tissues.

Surgical intervention remains the main method of treating almost all types of malignant tumors. The basic principle of a radical surgical surgery is the removal of part of the organ within the boundaries of healthy tissues with the obligatory removal of regional lymph nodes, which is specific for each organ.

When performing a radical surgery, the following principles must be followed:

1. The principle of zonality is a tumor is removed within an anatomical fascial case, the mobilization of the tumor is carried out from the supply vessels to avoid dispersion of malignant cells. This is done in order to prevent the formation of metastases after a radical surgical operation.
2. The standard volume of the radical surgical surgery is to conduct a histological examination of the cut line of the removed part of the organ, good insulation of the manipulation zone from the rest of the wound (ablasty), processing the operating zone by anti-cancer (antiblastics).
3. If possible, the maximum preservation with a radical surgical operation of the function not affected by the tumor of organs, the use of plastics of large organ defects.
4. A radical surgical surgical operation should if possible be organ-resistant, but without prejudice to radicality. If possible, microsurgery and organ transplantation should be used.

Are there any benefits of radical operations?

With severe general condition A cancer patient is sometimes not possible to carry out a radical surgery in full. This condition is called functional inoperabilityThis compromise operations are carried out (for example, the removal of a part of the lung with bronchus instead of removing the entire lung with its malignant tumor). Such operations can still be called conditionally radical.

During the top-common types of tumors, extended and combined radical surgical operations are performed. Extended operation is the removal of additional groups of lymph nodes. Combined operation is the removal of parts of neighboring organs affected by a tumor.

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Surgical surgery (intervention) is a bloody or bloodless medical or diagnostic event carried out by means of physical impact on organs and tissues.

By the nature of surgical intervention:

1. Elegencies

Radical. The goal is to completely eliminate the cause of the pathological process (gastrectomy with a stomach cancer, cholecystectomy with cholecystitis). The radical operation is not necessarily operational operation. There are a large number of reconstructive-reducing (plastic) radical operations, such as plastic of the esophagus during cepar stricture.

Palliative. The goal is to partially eliminate the cause of the pathological process, thereby facilitating its current. It is performed when the radical operation is impossible (for example, the operation of the Gatman with the removable part of the tumor, the creation of the pocket and the imposition of single-barreled colostitors). The name of the operation is sometimes introduced the explanatory term characterizing its purpose. Palliative operation does not always mean the impossibility and hopelessness of the patient's cure (for example, with the Fallo tetrade ("blue" heart rate) after a palliative operation in infancy, there is the possibility of radical surgical correction in the subsequent).

Symptomatic. The goal is to facilitate the patient's condition. Performed when a radical or palliative operation for any reason is impossible. The name of the operation is introduced the explanatory term characterizing its purpose (nutritical gastrostomy In inclaversary patients with esophagus cancer; Draining cholecystotomy with general serious condition and attack of cholecystitis, sanitary mastectomy with a breaking breast cancer). The symptomatic operation does not always mean the impossibility and hopelessness of the cure of the patient, often the symptomatic operation is performed as a stage or as an addition of radical treatment.

2. Diagnostic

Diagnostic operations include: biopsy, puncture, laparocentsis, thoraccentsis, thoracoscopy, arthroscopy; as well as diagnostic laparotomy, thoracotomy, etc. Diagnostic operations represent a certain danger to the patient, therefore should be applied at the final stage of diagnostics, when all the possibilities of non-invasive diagnostic methods are exhausted.

Urgency:

Emergency. Produced immediately after the formation. Purpose - rescue enforcement. According to emergency testimony, there should be an acute impact-sighted respiratory tract; puncture performicardial sumps of the hearts.

Urgent. Produced in the first hours of arrival in the ina. Thus, in the decision of the "acute appendicitis" of the patient, the patient must be operated on in the first 2 hours of office.

Planned operations. Performed after complete preoperative preparation at a time that is convenient from organizational considerations. This does not mean, however, that it is possible to delay the scheduled operation for a long time. Existing still in some polyclinic institutions vicious practice of the queue on the planned operational treatment leads to unreasonable delay of the operations shown and reduce their effectiveness.