47. Principles and rules for primary surgical processing of the Russian Academy of Sciences. Types of seams.

Primary surgical treatment (PHO) RAS - the main component of surgical treatment with them. Her goal is to create conditions for rapid wound healing and prevent the development of wound infection.

Distinguish early Po conducted in the first 24 hours after injury, delayed - throughout the second day and late - After 48 hours.

Task for conducting Pho wounds It is to remove non-visual fabrics from the wound and the microflora. PHO, depending on the type and nature of the wound, is either in complete excision of the wound, or in its dissection with excision.

Complete excision is possible, provided if no more than 24 hours passed from the moment of injury and if the wound has an easy configuration with a small damage zone. In this case, PHO wounds consists in excision of the edges, walls and the bottom of the wound within healthy tissues, with the restoration of anatomical ratios.

Drying with excision is produced with a complex configuration wound with a large damage zone. In these cases the initial processing of the wound consists of the following moments;

1) widespread wound;

2) excision of devoid of nutrition and contaminated soft tissues in the wound;

4) the removal of free-sided foreign bodies and devoid of perceivers of bone fragments;

5) wound drainage;

6) immobilization of the damaged limb.

PHO wounds start with the processing of the operating field and the separation of its sterile linen. If the wound is on the hair part of the body, then the hair is 4-5 cm in the circumference. With small wounds, local anesthesia is usually used.

Processing are starting with the fact that in one corner of the wound tweezers or the zeper ships capture the skin, slightly lifted it and from here produce a gradual excision of the skin throughout the wound circumference. After excision of softened areas of the skin and subcutaneous tissue, they expand the wound with hooks, inspect the cavity of it and remove unwanted areas of the aponeurosis. The available pockets in soft tissues are opened with additional cuts. In the primary surgical processing of the wound, it is necessary to change scalpels, tweezers and scissors during the operation periodically during operation. PHO is produced in the following order: first excreted damaged edges of the wound, then its walls, finally, the bottom of the wound. If there are small bone fragments in the wound, you need to remove those that have lost contact with the perception. With pho open fractures Bones should be removed by bone tongs protruding sharp ends of fragments that can cause secondary injury of soft tissues, vessels and nerves.

The final stage of PHO RAS, depending on the time, from the moment of injury and the nature of the wound may be the imposition of seams on its edge or its drainage. The seams restore the anatomical continuity of tissues, prevent the secondary infection and create conditions for healing by primary tension.

Along with the primary distinguish secondary surgical the processing of the wound, which is made in secondary testimony, due to complications and insufficient radicality of primary processing in order to treat wound infection.

Distinguish the following types of seams.

Primary seam - apply to the wound within 24 hours after injury. Primary seam terminates operational interventions under aseptic operations, in some cases, after opening abscesses, phlegmon (purulent wounds), if provided in the postoperative period good conditions For wound drainage, (use of tubular drainage). If after the injury passed more than 24 hours, then after conducting PHO wounds, the seams are not applied, the wound is drained (tampon with a 10% sodium chloride solution, ointment "Levomi-Kohl", etc., and 4-7 days before the appearance of granulations, provided that the wound suppuration did not occur, impose primary delayed seams. The deferred seams can be applied in the form of pier - immediately after it is necessary to tie them after 3-5 days, if there are no signs of the wound infection.

Secondary seam apply to a granulating wound, provided that the risk of wounds has passed. There are early secondary seams, which are imposed on granulating PHO.

Late secondary seam overload over 15 days from the date of operation. The rapprochement of the edges, the walls and the bottom of the wound in such cases is not always possible, in addition, the growth of the scar tissue along the edges of the wound prevents the healing after their comparison. Therefore, before the overlay of late secondary seams, excision excretion and mobilization of the edges of the wound and remove hypergranulation.

Primary surgical treatment should not be carried out at:

1) small surface wounds and abrasions;

2) small brushed wounds, including blind, without damage to nerves;

3) with multiple blind wounds, when a large number of small metal fragments are in the tissues (fraction, pomegranate fragments);

4) through bullet wounds with smooth inlet and outlet holes in the absence of significant damage to the tissues, vessels and nerves.

GOU VPO Izhevsk State Medical Academy of the Ministry of Health and Social Development of Russia

Department of Hospital Surgery

with a course of resuscitation and anesthesiology

treatment of Ran.

Tutorial

UDC 616-001.4-089.81 (075.8)

Compilers: K.M.N., Assistant Department of Hospital Surgery S.V. Sysoev; D.M., Associate Professor, Head of the Department of Hospital Surgery B.B. Kapustin; Ph.D., Associate Professor of the Department of Traumatology, Orthopedics and Military Field Surgery A.M. Romanov.

Reviewers: Head of the Department general Surgery GOU VPO "Bashkir State Medical University Roszdrava", D.M., Professor MA Natelakov; Head of the Department of Surgical Diseases with courses of urology, endoscopy, radiology of FPK and PPS GOU VPO "Tyumen State Medical Academy Roszdrava", D.M., Professor A.M. Mashkin.

The study manual examines the issues of surgical treatment of wounds and wounds of soft tissues and cavities. The classifications of the wound process are proposed, primary surgical treatment of the Russian Academy of Sciences in conditions of peaceful and wartime. The issues of the prevention of surgical infection were discussed. The tutorial is intended for students of therapeutic and pediatric faculty.

Treatment of the Russian Academy of Sciences: Tutorial / Sost. S.V. Sysoev, B.B. Kapustin, A.M. Romanov. - Izhevsk, 2011. - s. 84.

UDC 616-001.4-089.81 (075.8)

General characteristics and basic principles of surgical processing of wounds

Wound - Tissue damage accompanied by a disruption of the intake of skin and mucousproof coverings. Under early Understand the process of tissue damage, the entire complex and multifaceted set of those pathological changes that inevitably arise both in the field of the wound channel itself and in the whole body due to open damage.

The reaction of the body to wound: pain; blood loss (bleeding); shock; resorbative fever; wound infection; Wound exhaustion.

Microbial pollution is inevitable with each injection: primary, secondary, hospital.

Infection of wounds is a pathological process caused by the development of microbes. The development of microbes contributes: blood clots, dead fabrics, bacteria association, poor aeration, poor outflow; Tissue hypoxia; defeat bov; radiation sickness; blood loss, shock; depletion; Hyovitaminosis.

According to the degree of infection, it is customary to allocate aseptic, fresh-infected (contaminated) and purulent wounds.

Infected (bacterial contaminated) wounds - Wounds applied outside the operating room within 48-72 hours from the moment of damage. Microorganisms fall into the wound with a wounded object or from the skin of the victim. A high probability of infection of firearms and wounds with pollution of land, as well as wounds with significant breeding of tissues. The number of microorganisms in a fresh-infected wound does not exceed the "critical level", i.e. 10 5 -10 6 microbial cells, or rather colony-forming units (Code) in 1 g of tissue, 1 ml of exudate or 1 cm 3 wound surface. In such a fabric there are clinical signs Inflammation is often observed and systemic inflammatory response of the body. Wherein wound process It can develop in two ways: either inflammation is stopped and the wound heals the primary tension, or in the zone of the traumatic defect there is a microbial cumulation, the seed reaches and often exceeds the "critical level". Such a wound is called secondary purulent. ABOUT primary purulent The wound speaks in cases where it is formed after the surgical treatment of purulent focus during acute purulent diseases of soft tissues (abscess, phlegmon).

Purulent wounds They differ from the freshly infectious infection process in them with all classical signs of inflammation (pain, swelling, hyperemia, temperature increase and disruption of the functions of the damaged zone).

The main method of treating wounds is their surgical treatment. Under this understands operational intervention, aimed at creating the most favorable conditions for wound healing and warning a wound infection that may arise and develop. Practically surgical treatment of wounds is composed of the dissection of wounds and excision of non-viable and contaminated areas of damaged tissues, stopping bleeding with the removal of the wounds of the washing blood, blood clots and foreign languages.

Distinguish primary and secondary surgical processing of the Russian Academy of Sciences.

Primary Surgical Wound Processing (PHO)- the first operational intervention, produced by primary testimony, i.e. Regarding the damage itself. The main task is to create unfavorable conditions for the development of wound infection and ensuring rapid healing wounds.

Primary surgical treatment, depending on the period of operation, is divided into early, delayed and late. Under early Phounderstand the operation made to the visible development of the infectious wound process, i.e. During the first day (24 hours) from the moment of injury. Surgical processing produced throughout the second day (from 24 to 48 hours) delayed Phowounds. In cases where primary surgical treatment is performed in the presence of a developing wound infection (more often after 48 hours from the moment of injury), the operation is called late Pok..

Secondary Surgical Wound Processing- Operational intervention undertaken in secondary testimony, i.e. Due to changes in the wound caused by the wound infection (infiltration, swelling, suppuration, phlegmon).

1. Wire Wire (Blooming Blood and Pollution, Exemption from foreign bodies)

2. Dissection of the wound (corresponds to operational access). For the subsequent full-fledged audit, the dissection should be adequate in size. It is desirable to make a dissection along Langer's lines so that the gaping can be eliminated by imposing seams without tensioning tissues.

3. Exhausting edges, walls and bottom of the wound. In this case, the mechanical removal of microbes, foreign bodies and necrotic tissues within healthy tissues occurs. The excision is subject to leather, subcutaneous fiber, aponeurosis, muscles. Nerves, vessels, internal organs. The thickness of the excised fabrics is usually 0.5-1 cm. On the face, the brushes and feet of excision should be more economical due to the deficiency of the tissue, up to the complete absence of excision during cut wounds (good blood supply to the face and brushes makes uncomplicated healing).

4. Revision of the wound canal. The audit should be only visual, since palpatorial or instrumental audit does not give a complete idea of \u200b\u200bthe nature of the damage to the tissues and organs.

5. Hemostasis in relation to bleeding caused by the traumatic agent and intraoperative bleeding.

6. Restore anatomical relationship. The seams are imposed on organs, fascia, aponeurosis, nerves, tendons, etc.

7. Rational drainage. It is shown when performing PHO at the later dates (more than 24 hours), with extensive damage, unreliable hemostasis, intersection of a significant amount of lymphottock paths.

8. Seam overlay on the skin.

Views of the closure of the wound

1. Independent epithelialization

2. Primary seam - superimposed on PHO operations

3. Primary-delayed seam - is superimposed on an infected wound to development in the wound of granulation (up to 5 days)

4. Forced early secondary seam - superimposed on a purulent wound with the successful use of active impact methods on a wound process for 3-5 days.

5. Early secondary seam - superimposed on a cleaned granulating wound (6-21 days)

6. Late secondary seam - superimposed after 21 days from injury after excision of granulation and scar, worsening the blood supply to the edges of the wound).

7. Skin plastic.

Views of Pho

1. Early (in the first 24 hours) is performed in the absence of inflammation, completes the imposition of the primary seam.

2. The delayed (24-48 hours) is performed under conditions of inflammation, when the primary seam is applied, it is necessarily completed with drainage. An option is also possible when the wound does not insert on the operation, and then in the first 5 days, in the absence of inflammation progression, the primary delayed seam is imposed.

3. Late (48-72 hours) is carried out in conditions of pronounced inflammation with significant tissue edema. The wound is left open, then the secondary seams are applied, they perform the skin plastic or leave the wound open to the completion of self-epithelizationia.

Postoperative treatment of a former infected wound is carried out according to the principles of treatment of aseptic wounds (see paragraphs 2-5). In addition, random injuries necessarily carry out the prevention of a tetanus (1 ml of anti-trusty anethoxine and 3000 units of anti-trust serum subcutaneously in different syringes in different parts of the body).

In the event of an early postoperative injury, treatment is carried out according to the principles of treatment of purulent wounds.

In terms of execution distinguish early, delayed and late Pho. Early PHO and a delayed PHO are performed in the wound, when there are no signs of inflammation (there are no more edema of the edges of the wound, the succinous separated), and it is designed for wound healing without complications; Late PHO is performed in the wound when there are general and local signs of inflammation (swelling, sucrie disconnected), and it is designed to prevent heavy infectious complications.

Along the canons of military field surgeons, early PHO is performed in the first 24 hours after injury; delayed - up to 48 hours, if measures were carried out on the prevention of infectious complications; Late - after 24 hours, if antibiotics were not introduced, and after 48 hours, if antibiotics were introduced for the prevention of infectious complications.
Currently, in connection with the introduction of preservatives in the surgery of the RAS, these deadlines are lengthened to 3-4 days.

The operation of the primary surgical processing of the wound is not performed at shock (but if it does not include the stop of the outer or internal bleeding). With extensive destruction of the limbs, primary surgical treatment with the formation of a cult is made simultaneously with the removal of shock. The primary surgical treatment can be not done with through the wounds of the limbs, if there is no greater destruction of the tissues (bullet with low flight speed), damage to vessels, nerves, bones; with end-to-end and blind wounds of the chest, if there is no internal bleeding,
Open and increasing pneumothorax. This assumption is particularly rational with the simultaneous arrival of a large number of victims. In a favorable setting, primary surgical treatment must be done if it is not very wound by injury. But if the processing is not executed, then intensive antibacterial therapyAnd the surgeon intently observes the wounded. For the slightest signs of injury infection (temperature, swelling, the appearance of pain in the wound), late primary surgical treatment is immediately performed.

In the conditions of the district hospital, the operation of primary surgical processing of the wound is advisable to perform either in an emergency operating room (open fracture, extensive injuries, firearms, scramble and separation of the limbs), or in a pure dressing (wounds of soft tissues without damage to large vessels, nerves and internal organs). When planning the work of the functional premises of the department, the surgeon must provide in addition to emergency operating operations, where operations are performed acute diseases Abdominal organs, the possibility of operating in pure dressing. Therefore, this room should be large so that the operating table, tables for sterile material, sets of tools in paraformal oxycators can be signed there. In this dressing operating room, you can also provide for the elimination of victims from shock, the implementation of diagnostic and small healing manipulations (toracocentsis, puncture pleural cavity, Laparocentsis, diagnostic laparotomy, skeletal exhaust, lumbar puncture, toilet wounds, transport immobilization before the evacuation of the victim to the stage of specialized assistance, the reposition of the ray bone fractures in a typical location and fracture-dislocation of the ankle joint, the imposition of gypsum bandage). It is inappropriate to perform all this in an emergency operating basis due to possible pollution by its victims from the street and possible pollution in emergency strength operations.

Of course, the primary surgical treatment of breast and abdomen, heads should be carried out in the operating room.

The conditions for performing the operation of primary surgical treatment (PHO).

The inequal conditions of primary surgical treatment must be complete anesthesia and thorough laundering of the wound itself from dirt before primary surgical treatment.
The second without the first is properly impossible. Local infiltration anesthesia also provides muscle relaxation and latitude operational access For careful execution of all elements of primary surgical treatment.

Under local anesthesia, a 0.25% -0.5% solution of novocaine can be carried out primary surgical treatment of wounds that are not subject to hospital treatment (wounds that do not penetrate their own fascia).
Analysis of the material of the clinic showed that during the processing of wounds under local anesthesia, primary suppuration occurred 5 times more often than when processing under anesthesia.

What types of anesthesia should be preferred in the district hospital?

It all depends on the experience of a doctor-anesthesiologist there. Of course, the best anesthesia is anesthesia. But because of the impossible, sometimes even minimal, surveys of the emergency received patient in the context of CRH are limited by the possibilities of the inhalation period with intubation and muscle relaxation. And this is one of the obstacles to performing complete and exhaustive primary surgical treatment with open fractures in the CRH conditions.

We do not recommend that the primary surgical treatment of wounds of the limbs, damage to the brush, foot, open fractures and dislocation to resort to intraosseous anesthesia, as it requires the imposition of a harness, which, on the one hand, limits the operation time, and on the other, it enhances the tissue achemia, and Consequently, increases the possibility of infectious complications.

Under CRH, it is advisable to give preference to conductive anesthesia. With the addition of other non-resistant anesthesiological manual for emergency patients, it provides complete anesthesia in operations on the clavicle. upper limb, on the foot, shin and knee joint. The test method of conductor anesthesia is shown in operations on the shoulder joint and shoulder, elbow joint, forearm and brushes.

"Damage surgery"
V.V. Klyuchevsky

The wound is a mechanical damage in the presence of integrity disorders. skin cover. The presence of a wound, not a branchy or hematoma, can be determined by such signs as pain, gaping, bleeding, violation of functions and integrity. PHO wounds are carried out in the first 72 hours after injury, if there are no contraindications.

Varieties of Ran.

Each wound has cavity, walls and bottom. Depending on the nature of the damage, all wounds are divided into crushing, cutting, chopped, bruised, branched and poisoned. During PHO wounds, it must be considered. After all, the characteristics of the first aid depend on the nature of the injury.

• Cover wounds are always applied with a crossing item, such as a needle. Distinctive feature Damage is a high depth, but small damage to the cover. In view of this, it is necessary to make sure there is no damage to the vessels, organs or nerves. Kolotaya wounds are dangerous due to weak symptoms. So with wounds on the stomach there is a probability of liver damage. It is not always easy to notice when conducting PHO.
• The cutting wound is applied using an acute subject, so the destruction of fabrics is small. At the same time, the gaping cavity is easy to inspect and perform PHO. Such wounds are well treated, and healing is carried out quickly, without complications.
• Chopped wounds appear due to harm to acute, but heavy items, for example, an ax. At the same time, damage differ in depth, characteristic of the presence of a wide gaping and bruise of neighboring tissues. Because of this, the ability to regenerate is reduced.
• Broken wounds appear when using a blunt subject. These damages are distinguished by the presence of a set of damaged tissues, strongly impregnated with blood. When conducting PHO wounds, it should be borne in mind that there is a probability of the appearance of suppuration.
• The branched wounds are dangerous to the penetration of infection with a salivary, and sometimes a person. The risk of development appears acute infection And the appearance of rabies virus.
• Poisoned wounds usually occur in the presence of snake bite or spider.
• They differ in view of the applied weapons, features of damage and penetration paths. Great likelihood of infection.

When conducting PHO wound, the presence of suppuration plays an important role. Such injuries are purulent, freshly infected and aseptic.

Purpose of Pho

Primary surgical treatment is necessary to remove harmful microorganisms that have fallen into the wound. For this, all damaged dead tissues are cut off as well as blood clots. After that, the seams are superimposed and drainage is performed if there is a need.

The procedure is needed in the presence of damage to tissues with uneven edges. Deep and contaminated wounds are required. The presence of damage to large blood vesselsAnd sometimes bones and nerves also require performing surgical work. PHO spend simultaneously and exhaustively. The surgeon assistance is necessary for a patient for up to 72 hours after the injury. Early PHO is held during the first day, holding on the second day is a delayed surgical intervention.

Tools for pho

For conducting the initial processing procedure, a minimum of two sets of dialing is required. They are changed during the operation, and after carrying out a dirty stage - dispose of:

• clamp "Corncang" direct to which the operating field is processed;
• scalpel Pointed, brushy;
• lowering thrilks are used to keep dressing and other materials;
• kohler, Bilrot and Mosquito clips are used to stop bleeding, when conducting PHO wounds, they are used in a huge amount;
• scissors, they are straight, as well as curved plane or edge in several copies;
• kochker probes, grave and burgted;
• needle set;
• needle holder;
• tweezers;
• hooks (several pairs).

The surgical set for this procedure also includes injection needles, syringes, bandages, gauze balls, rubber gloves, all sorts of tubes and napkins. All items that will be needed for PHO - suture and dressing sets, tools and medicationsintended for processing wounds - laid out on the surgical table.

Necessary medicines

Primary surgical treatment of the wound does not cost without special medicines. Most often, such:

Stages Pho

Primary surgical treatment is carried out in several stages:

How to do pho

For surgical intervention The patient is put on the table. Its position depends on the dislocation of the wound. The surgeon should be convenient. The wound toilet is carried out, the operating field is processed, which is degraded with sterile disposable linen. Next, the primary tension is performed, aimed at healing the wounds of wounds and anesthesia is injected. In most cases, the surgeons apply the Vishnevsky method - a 0.5% novocaine solution is introduced at a distance of two centimeters from the edge of the core. The same solution is introduced on the other side. With the proper reaction of the patient on the skin around the wound, the "citric crust" is observed. Firearms often require the administration to the general anesthesia patient.

The edges of damage to 1 cm are adhered to the COHHER clamp and cut off with a single block. When performing a procedure on the face or fingers, a non-high-influxed fabric is cut off, after which it is superimposed by a tight seam. Replacing gloves and tools used.

The wound is washed with chlorhexidine and its inspection is carried out. Crowded wounds having small but deep cuts, dissect. If the edges of the muscles are damaged, they are removed. Also come with bone fragments. Next, hemostasis is performed. The inner part of the wound is treated at first with a solution, and then with antiseptic preparations.

The treated wound without signs of sepsis is sewn tightly primary and covered with a gate aseptic. The seams are performed, evenly capturing all the layers in width and depth. It is necessary that they touch each other, but not tightened. When performing work, it is necessary to obtain cosmetic healing.

In some cases, the primary seams are not superimposed. A cutting wound may have more serious damage than it seems at first glance. If there is a doubt, the surgeon is used primary delayed seam. Such a method is used if the wound has been infected. The embedding is carried out to the fatty tissue, and the seams are not tightened. A few days after surveillance, to the end.

Wounds from ukuusov

PHO Wounds, branched or poisoned, has their differences. When biteing, non-poisonous animals are the likelihood of rabies infection. On the early stage The disease is suppressed by anti-grade serum. Such wounds in most cases become purulent, so they try to delay Pos. When performing the procedure, the primary-delayed seam is superimposed and antiseptic drugs are used.

The wound received from the bite of the snake requires the imposition of a tight harness or bandage. In addition, the wound is frozen by novocaine or apply cold. For neutralization of poison, anti-ray serum is injected. Spider bites are blocked by potassium permanganate. Prior to that, the poison is extruded, and the wound is processed by an antiseptic.

Complications

Changing processing of the wound with antiseptics leads to the wound supplements. An incorrect means of anesthesia, as well as causing additional injuries, causes anxiety in a patient due to the presence of pain.

Rough attitude to tissues, bad knowledge of the anatomy leads to damage to large vessels, internal organs and nerve endings. Insufficient hemostasis causes inflammatory processes.

It is very important that the primary surgical processing of the wound was carried out by a specialist in all rules.