consequences of laparoscopy. Postoperative complications Late postoperative period

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Ministry of Education, Youth and Sports of Ukraine

National University of Physical Education and Sports of Ukraine

abstract

On the topic: « Causes of complications after surgery»

Prepared

Orlov Anton

Group 5.06

Introduction

1. Complications after surgery

2. Five classes of postoperative complications

Bibliography

Introduction

After surgery for endometriosis, as after any other surgical interventions, there can be various complications. Most of them pass quickly and are easily treated. The tips we provide below are general information. If you notice any unusual symptoms, deterioration of health, then tell your doctor about it. Also, be sure to tell your doctor if you have any bleeding, fever, swelling, or discharge from the postoperative wound.

1. Complicationsle surgery

Constipation is a fairly common complication of abdominal operations, especially if they are performed on the intestines. If this complication occurs, your doctor may prescribe laxatives for you. What can help prevent constipation after surgery? First, eat more fiber foods. the fact is that dietary fiber irritates the intestinal wall and stimulates intestinal motility (that is, the work of the intestine). Secondly, drink more water, up to seven glasses a day is recommended. Third, take small walks daily. Early activation promotes better breathing, and the diaphragm - the main respiratory muscle - has a “massaging” effect on the intestines.

Diarrhea is also a fairly common complication that occurs after abdominal operations, especially if they are performed on the intestines. If you have severe diarrhea or it is accompanied by fever, you should tell your doctor. Your doctor may prescribe medicine for diarrhea. In addition, diarrhea can be a manifestation of an infection in the intestines. In this case, antibiotics are usually prescribed. But in no case do not start taking any medications on your own without consulting your doctor. At home, you can prevent diarrhea with ginger tea or chamomile tea, and you should also limit your intake of dairy products, carbonated drinks, and caffeine.

Shoulder pain. During laparoscopy, carbon dioxide is injected into the abdominal cavity. Gradually it dissolves. However, after the operation, the gas rises to the diaphragm, on the lower surface of which the nerves are located. Irritation of these nerves with gas leads to unpleasant pain sensations that radiate to the shoulders. In this case, pain can be relieved by thermal procedures: heating pads can be placed in front and behind the shoulder. In addition, your doctor may prescribe pain medication for you. In order for carbon dioxide to be absorbed faster, mint or ginger tea, as well as carrot juice, are recommended.

Bladder irritation. Usually, during and after surgery, a catheter is inserted into the patient's bladder - a flexible plastic tube through which urine flows. This is to control urination during and after surgery. In addition, very often in the postoperative period, urinary retention may occur. This is a reflex phenomenon. Over time, it passes. However, the catheter itself can irritate the mucous membrane of the urethra, causing inflammation - urethritis. It is manifested by moderate pain and burning in the urethra during urination. To prevent this complication, it is recommended to drink plenty of fluids in the postoperative period, as well as personal hygiene. If you feel pain and cramps when urinating, as well as a change in the color of urine (urine becomes dark or pinkish), urination has become frequent, you should consult a doctor. These signs may indicate an infection in the bladder - cystitis. Antibiotics are usually prescribed for cystitis. Your doctor may prescribe painkillers to relieve pain. In addition, a plentiful warm drink is recommended, preferably rosehip decoctions. It is even better to drink cranberry juice, as cranberries have natural antiseptics that suppress the infection.

Thrombophlebitis and phlebitis. Phlebitis is an inflammation of the wall of a vein. Thrombophlebitis is a condition in which inflammation of a vein is accompanied by the formation of a blood clot on its wall - a thrombus. usually after surgery, phlebitis / thrombophlebitis can occur due to a long stay in the vein of an intravenous catheter. The situation is aggravated by the introduction of certain drugs into the vein that irritate the vein wall. Phlebitis / thrombophlebitis is manifested by redness, swelling and pain along the inflamed vein. If there is a thrombus along the vein, you can feel a small seal. If you experience these symptoms, you should immediately inform your doctor. With the development of phlebitis, heat compresses, painkillers and anti-inflammatory drugs are usually prescribed. In addition to compresses, anti-inflammatory ointments (for example, diclofenac) can be used. With the development of thrombophlebitis, heparin ointment is usually used. Heparin, when applied locally, is absorbed into the affected vein. However, heparin itself does not resolve the thrombus. It only warns its further development. The thrombus dissolves itself in the course of treatment.

Nausea and vomiting are very common after any operation performed under general anesthesia. In addition, some painkillers also cause these symptoms. It should be noted that gynecological operations are accompanied by nausea and vomiting in the postoperative period more often than other types of surgery. In many cases, the anesthesiologist can prevent nausea in the postoperative period by prescribing antiemetics before the operation itself. In the postoperative period, it is also possible to prevent nausea with the help of drugs (for example, cerucal). Home remedies for nausea prevention - ginger tea. In addition, many patients note that if they lie on their backs, then there is no nausea.

Pain. Almost every patient experiences pain of varying degrees in the postoperative period. You should not suffer and endure postoperative pain, as this can aggravate postoperative stress, lead to more fatigue, and also worsen the healing process. Usually, after surgery, the doctor always prescribes pain medication. They should be taken as directed by your doctor. You should not wait until the pain appears, painkillers should be taken before they begin. Over time, postoperative wounds heal, and the pain gradually disappears.

fatigue. Many women experience fatigue after laparoscopy. Therefore, you should rest as much as you can. When you return to normal work, try to plan your rest. In addition, a daily multivitamin is recommended to restore strength.

Scar formation. Wounds after laparoscopy are much smaller than after other surgical interventions and they scar much faster. Unfortunately, it is impossible to completely get rid of scarring after an incision, since this is a physiological process. However, if desired, even these small scars can be eliminated by the methods offered by plastic surgery. In addition, today the pharmaceutical industry offers ointments that dissolve scars. However, they can only be used effectively with fresh scars. For the speedy healing of the wound, it is necessary to adhere to a complete diet rich in vitamins, minerals and proteins. Vitamin E is especially important for better healing, which is confirmed by many years of experience in its use. surgical postoperative constipation thrombophlebitis

Infection. Compared to other types of surgery, laparoscopy is much less complicated by infection. The infection can be both in the area of incisions and in the abdominal cavity, which can manifest itself as an infiltrate or abscess, which is much more serious. The main signs of infection of the surgical wound: redness in the wound area, swelling, pain and soreness when touching the wound, as well as discharge from the wound. If the infection develops in the abdominal cavity, then there may be pain in the abdomen, bloating, constipation, urinary retention or, conversely, frequent urination, as well as fever and deterioration in well-being. If you have these symptoms, you should immediately inform your doctor. To prevent infectious complications after abdominal operations, including laparoscopy, a short course of antibiotics is prescribed. You should not take any antibiotics on your own, and even more so, painkillers, before you are examined by a doctor.

Headaches. It may seem paradoxical, but pain medications themselves can cause headaches. To eliminate them, you can use non-steroidal anti-inflammatory drugs, or acetaminophen. However, check with your doctor before using them. In addition, you can try lavender massage oil, which also has pain-relieving properties.

Hematomas and seromas. Sometimes fluid can accumulate in the area of the postoperative wound: ichor or serous fluid. This is manifested by swelling in the wound area, sometimes pain. Since the patient herself cannot find out what is hidden behind such complaints, it is necessary to consult a doctor for any changes in the wound area. Usually, hematomas and seromas can resolve on their own. To speed up this process, all kinds of thermal procedures are recommended in the wound area: at home, it can be a cloth bag with heated sand or salt. You can use electric heaters. In addition, you can use the services of a physiotherapy room. In the absence of the effect of these measures, a minor surgical intervention may be required: the doctor usually dissolves the suture and, using a small metal probe, releases the fluid accumulated under the skin. After that, the knapsack is washed and rubber drainage is left in it for a couple of days. The wound is covered with a sterile bandage. After a few days, the wound heals on its own.

2. Five classes of postoperative complications

Approximately 18% of patients after undergoing surgery experience one or another complication.

Some surgical complications develop frequently and in their manifestations they are relatively mild and do not pose any threat to health. Other surgical complications are rare, but they pose a certain threat not only to health, but also to the life of the patient.

In order to make it easier to navigate the likelihood of certain complications, as well as their severity, all postoperative complications are traditionally divided into five classes:

	Characteristics of complications	Examples of complications
	Mild complications that do not pose a threat to health, resolve on their own or require simple medications such as painkillers, antipyretics, antiemetics, antidiarrheals.	Cardiac arrhythmia that resolves after potassium administration Collapse of the lung (atelectasis), resolving after physical therapy Transient disturbance of consciousness that resolves on its own without any treatment non-infectious diarrhea Mild wound infection that does not require antibiotics
	Moderate complications requiring the appointment of more serious drugs than those indicated above. The development of these complications in most cases leads to an increase in the length of stay in the hospital.	Heart rhythm disorders Pneumonia Minor stroke followed by full recovery infectious diarrhea urinary tract infection wound infection Deep vein thrombosis
	Severe complications requiring reoperation. The development of these complications increases the duration of hospitalization.	Complications of this type are various disorders associated with the anatomical site of the operation. In most cases, all these cases require repeated surgery in an emergency or urgent manner.
	Life-threatening complications requiring treatment in the intensive care unit (intensive care unit). After this kind of complications, the risk of severe chronic diseases and disability is high.	Heart failure Respiratory failure Major stroke Intestinal obstruction Pancreatitis kidney failure Liver failure
	Fatal outcome

findings

Despite the fact that the main goal of any surgical intervention is to improve the patient's health, in some cases the operation itself is the cause of the deterioration of the patient's health.

Of course, not only the operation, but also the ongoing anesthesia or the initial serious condition of the patient can be a causal factor in the deterioration of health. In this article, we will consider the complications, the occurrence of which is associated with the conduct of the surgical intervention itself.

Firstly, all surgical complications can be divided into two groups:

common complications

Specific complications

Common complications occur with all types of operations. Specific complications are inherent in only one specific type (type) of operations.

Secondly, complications after operations can be divided according to the frequency of their occurrence. So, the most common general complications of operations are:

fever

atelectasis

wound infection

deep vein thrombosis

And, thirdly, operational complications may differ in terms of their occurrence. In particular, complications can occur both directly during the operation itself, and in a long-term period of time - after several weeks or even months. Most often, complications after surgery occur in the early stages - in the first 1-3 days after surgery.

Bibliography

1. Gelfand B.R., Martynov A.N., Guryanov V.A., Mamontova O.A. Prevention of postoperative nausea and vomiting in abdominal surgery. Consilium medicum, 2001, No. 2, C.11-14.

2. Mizikov V.M. Postoperative nausea and vomiting: epidemiology, causes, consequences, prevention. Almanac MNOAR, 1999, 1, C.53-59.

3. Mokhov E.A., Varyushina T.V., Mizikov V.M. Epidemiology and prevention of postoperative nausea and vomiting syndrome. Almanac MNOAR, 1999, p.49.

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What complications can surgeons face?

Collapse.

Coma.

A coma, or coma, is a deep disturbance of consciousness that occurs as a result of damage to brain cells and a violation of its blood circulation. The patient has no reflexes and reactions to external influences.

Sepsis.

It is one of the most severe complications. People call it "blood poisoning". The cause of sepsis is the ingestion of pyogenic organisms into the wound and blood. At the same time, the likelihood of developing sepsis is higher in patients whose body is depleted and whose immunity is low.

Bleeding.

Any surgical intervention can be complicated by bleeding. In this case, bleeding can be not only external, but also internal. Bleeding can be caused both by a violation of blood clotting, and slipping of the ligature from the ligated vessel, violation of the integrity of the dressing, and so on.

Peritonitis.

After intra-abdominal operations, such a severe complication as peritonitis is possible. This is an inflammation of the peritoneum, the cause of which is the divergence of the sutures placed on the intestines or stomach. If the patient is not provided with immediate medical assistance, he may die.

Pulmonary complications.

Insufficient ventilation of one or another part of the lungs can lead to development. This is facilitated by shallow breathing of the operated patient, accumulation of mucus in the bronchi due to poor coughing, stagnation of blood in the lungs due to prolonged lying on the back.

Paresis of the intestines and stomach.

It is manifested by stool retention, flatulence, belching, hiccups and vomiting. All these manifestations are due to the weakness of the muscles of the digestive tract after abdominal surgery.

Postoperative psychoses.

Excitable people after surgery may experience hallucinations, delusions, motor agitation, lack of orientation in space. The reason for this behavior may be intoxication after anesthesia.

thromboembolic complications.

They are the most common complications after surgery. A patient who does not move enough develops thrombosis and inflammation of the veins, blood clots form.

Thromboembolic complications are most often found in people who are overweight, bleeding disorders. Women who have given birth several times and weakened people are also at risk.

Modern medicine pays great attention to the prevention and prevention of surgical complications. This is achieved through sanitary and hygienic measures in the hospital, ensuring sterility during surgery and postoperative care.

In addition, any patient entering a planned operation must undergo an examination, during which the degree of blood clotting, the state of the cardiovascular system, and so on are established. In case of detection of any pathologies, doctors take timely preventive measures to prevent negative consequences.

Modern combined intubation anesthesia. The sequence of its implementation and its advantages. Complications of anesthesia and the immediate post-anesthetic period, their prevention and treatment.

Method of examination of a surgical patient. General clinical examination (examination, thermometry, palpation, percussion, auscultation), laboratory research methods.

Preoperative period. The concept of indications and contraindications for surgery. Preparation for emergency, urgent and planned operations.

Surgical operations. Types of operations. Stages of surgical operations. Legal basis for the operation.

postoperative period. The reaction of the patient's body to surgical trauma.

The general reaction of the body to surgical trauma.

Postoperative complications. Prevention and treatment of postoperative complications.

Bleeding and blood loss. Mechanisms of bleeding. Local and general symptoms of bleeding. Diagnostics. Assessment of the severity of blood loss. The body's response to blood loss.

Temporary and permanent methods of stopping bleeding.

History of the doctrine of blood transfusion. Immunological bases of blood transfusion.

Group systems of erythrocytes. Group system av0 and group system Rhesus. Methods for determining blood groups according to the systems av0 and rhesus.

The meaning and methods for determining individual compatibility (av0) and Rh compatibility. biological compatibility. Responsibilities of a Blood Transfusion Physician.

Classification of adverse effects of blood transfusions

Water-electrolyte disorders in surgical patients and principles of infusion therapy. Indications, dangers and complications. Solutions for infusion therapy. Treatment of complications of infusion therapy.

Trauma, injury. Classification. General principles of diagnostics. stages of assistance.

Closed soft tissue injuries. Bruises, sprains, tears. Clinic, diagnosis, treatment.

Traumatic toxicosis. Pathogenesis, clinical picture. Modern methods of treatment.

Critical disorders of vital activity in surgical patients. Fainting. Collapse. Shock.

Terminal states: pre-agony, agony, clinical death. Signs of biological death. resuscitation activities. Efficiency criteria.

Skull injuries. Concussion, bruise, compression. First aid, transportation. Principles of treatment.

Chest injury. Classification. Pneumothorax, its types. Principles of first aid. Hemothorax. Clinic. Diagnostics. First aid. Transportation of victims with chest trauma.

Abdominal trauma. Damage to the abdominal cavity and retroperitoneal space. clinical picture. Modern methods of diagnostics and treatment. Features of combined trauma.

Dislocations. Clinical picture, classification, diagnosis. First aid, treatment of dislocations.

Fractures. Classification, clinical picture. Fracture diagnosis. First aid for fractures.

Conservative treatment of fractures.

Wounds. Classification of wounds. clinical picture. General and local reaction of the body. Diagnosis of wounds.

Wound classification

Types of wound healing. The course of the wound process. Morphological and biochemical changes in the wound. Principles of treatment of "fresh" wounds. Types of seams (primary, primary - delayed, secondary).

Infectious complications of wounds. Purulent wounds. Clinical picture of purulent wounds. Microflora. General and local reaction of the body. Principles of general and local treatment of purulent wounds.

Endoscopy. History of development. Areas of use. Videoendoscopic methods of diagnosis and treatment. Indications, contraindications, possible complications.

Thermal, chemical and radiation burns. Pathogenesis. Classification and clinical picture. Forecast. Burn disease. First aid for burns. Principles of local and general treatment.

Electrical injury. Pathogenesis, clinic, general and local treatment.

Frostbite. Etiology. Pathogenesis. clinical picture. Principles of general and local treatment.

Acute purulent diseases of the skin and subcutaneous tissue: furuncle, furunculosis, carbuncle, lymphangitis, lymphadenitis, hydroadenitis.

Acute purulent diseases of the skin and subcutaneous tissue: erysopeloid, erysipelas, phlegmon, abscesses. Etiology, pathogenesis, clinic, general and local treatment.

Acute purulent diseases of cellular spaces. Phlegmon of the neck. Axillary and subpectoral phlegmon. Subfascial and intermuscular phlegmon of the extremities.

Purulent mediastinitis. Purulent paranephritis. Acute paraproctitis, fistulas of the rectum.

Acute purulent diseases of the glandular organs. Mastitis, purulent parotitis.

Purulent diseases of the hand. Panaritiums. Phlegmon brush.

Purulent diseases of serous cavities (pleurisy, peritonitis). Etiology, pathogenesis, clinic, treatment.

surgical sepsis. Classification. Etiology and pathogenesis. The idea of the entrance gate, the role of macro- and microorganisms in the development of sepsis. Clinical picture, diagnosis, treatment.

Acute purulent diseases of bones and joints. Acute hematogenous osteomyelitis. Acute purulent arthritis. Etiology, pathogenesis. clinical picture. Medical tactics.

Chronic hematogenous osteomyelitis. Traumatic osteomyelitis. Etiology, pathogenesis. clinical picture. Medical tactics.

Chronic surgical infection. Tuberculosis of bones and joints. Tuberculous spondylitis, coxitis, drives. Principles of general and local treatment. Syphilis of bones and joints. Actinomycosis.

anaerobic infection. Gas phlegmon, gas gangrene. Etiology, clinic, diagnosis, treatment. Prevention.

Tetanus. Etiology, pathogenesis, treatment. Prevention.

Tumors. Definition. Epidemiology. Etiology of tumors. Classification.

1. Differences between benign and malignant tumors

Local differences between malignant and benign tumors

Fundamentals of surgery for disorders of regional circulation. Arterial blood flow disorders (acute and chronic). Clinic, diagnosis, treatment.

Necrosis. Dry and wet gangrene. Ulcers, fistulas, bedsores. Causes of occurrence. Classification. Prevention. Methods of local and general treatment.

Malformations of the skull, musculoskeletal system, digestive and genitourinary systems. Congenital heart defects. Clinical picture, diagnosis, treatment.

Parasitic surgical diseases. Etiology, clinical picture, diagnosis, treatment.

General issues of plastic surgery. Skin, bone, vascular plastics. Filatov stem. Free transplantation of tissues and organs. Tissue incompatibility and methods of its overcoming.

Postoperative complications. Prevention and treatment of postoperative complications.

Causes of complications:

tactical mistakes.

Technical errors.

Reassessment of the body's ability to undergo surgery.

The presence of comorbidities.

Non-compliance of patients with hospital regimen.

Complications that appeared directly during the operation.

Bleeding (small blood loss, large blood loss).

Damage to organs and tissues.

thromboembolic complications.

Complications of anesthesia.

Complications in organs and systems on which surgery was performed.

Secondary bleeding (causes: slipping of the ligature from the blood vessel; the development of a purulent process is erosive).

The development of purulent processes in the area of surgical intervention.

Divergence of seams.

Violation of the functions of organs after interventions on them (impaired patency of the gastrointestinal tract, biliary tract).

In a significant number of cases, these complications require repeated surgical interventions, often under adverse conditions.

Complications that appeared in the postoperative period.

(Complications in organs that were not directly affected by surgery).

Complications from the cardiovascular system.

Primary - when there is a development of heart failure due to a disease of the heart itself;

Secondary - heart failure develops against the background of a severe pathological process (purulent intoxication, blood loss, etc.);

Acute cardiovascular failure;

myocardial infarction; arrhythmias, etc.;

Collapse /toxic, allergic, anaphylactic, cardio- and neurogenic/;

Thrombosis and embolism / mainly slowing of blood flow in the vessels of the veins of the lower extremities with varicose veins, thrombophlebitis, etc., elderly and senile age, oncological pathology; obesity, activation of the coagulation system, unstable hemodynamics, damage to the walls of the vessel, etc./.

Complications from the respiratory system.

Acute respiratory failure;

Postoperative pneumonia;

Atelectasis;
Pulmonary edema.

Prevention principles.

Early activation of patients;

Breathing exercises;

Adequate position in bed;

Adequate anesthesia;

Antibiotic prophylaxis;

Sanitation of the tracheobronchial tree (expectorants, sanitation through an endotracheal tube; sanitation bronchoscopy);

Control of the pleural cavity (pneumo-, hemothorax, pleurisy, etc.);

Massage, physiotherapy.

Complications from the digestive organs are more often functional in nature.

Paralytic obstruction (leads to increased intra-abdominal pressure, enteral intoxication).

Ways to prevent paralytic ileus.

during the operation - careful attitude to tissues, hemostasis, blockade of the root of the mesentery of the intestine, minimal infection of the abdominal cavity;

early activation of patients;

adequate diet;

decompressive measures;

correction of electrolyte disorders;

epidural anesthesia;

novocaine blockade;

intestinal stimulation;

physiotherapy activities.

Postoperative diarrhea (diarrhea) - exhausts the body, leads to dehydration, reduces immunobiological resistance;

acholytic diarrhea (extensive resection of the stomach);

shortening of the length of the small intestine;

neuro-reflex;

infectious origin (enteritis, exacerbation of chronic bowel disease);

septic diarrhea on the background of severe intoxication.

Complications from the liver.

Liver failure /jaundice, intoxication/.

Complications from the urinary system.

acute renal failure /oliguria, anuria/;

acute urinary retention / reflex / ischuria;

exacerbation of existing pathology /pyelonephritis/;

inflammatory diseases /pyelonephritis, cystitis, urethritis/.

Complications from the nervous system and mental sphere.

sleep disturbance;

p / o psychosis;

paresthesia;

paralysis.

bedsores- aseptic necrosis of the skin and underlying tissues due to compression disturbance of microcirculation.

Most often occur on the sacrum, in the area of the shoulder blades, on the back of the head, on the back of the elbow joints, and on the heels. Initially, the tissues become pale, their sensitivity is disturbed; then puffiness, hyperemia, development of areas of necrosis of black or brown color joins; purulent discharge appears, the presenting tissues are involved up to the bones.

Prevention.

early activation;

unloading of the corresponding areas of the body;

smooth bed surface

treatment with antiseptics;
physiotherapy;
anti-decubitus massage;

Stage of ischemia - treatment of the skin with camphor alcohol.

Superficial necrosis stage - treatment with 5% potassium permanganate solution or 1% brilliant green alcohol solution to form a scab.

Stage of purulent inflammation - according to the principles of treatment of a purulent wound.

Complications from the surgical wound.

Bleeding (causes: slipping of the ligature from the blood vessel; development of a purulent process - erosive; initially insufficient hemostasis);

Formation of hematomas;

Formation of inflammatory infiltrates;

Suppuration with the formation of abscesses or phlegmon (violation of asepsis rules, primary infected operation);

Divergence of the edges of the wound with prolapse of internal organs (eventration) - due to the development of the inflammatory process, a decrease in regenerative processes (oncopathology, beriberi, anemia, etc.);

Prevention of wound complications:

Compliance with asepsis;

Careful attitude to fabrics;

Prevention of the development of the inflammatory process in the area of surgical intervention (adequate antiseptic).

Blood coagulation disorders in surgical patients and principles of their correction. hemostasis system. Research methods. Diseases with violation of the coagulation system. Influence of surgical operations and drugs on the hemostasis system. Prevention and treatment of thromboembolic complications, hemorrhagic syndrome. DIC is a syndrome.

There are two types of spontaneous hemostasis:

1. Vascular-platelet - ensuring the stop of bleeding in case of damage to the vessels of the microvasculature,

2. Enzymatic - playing the most prominent role in damage to vessels of a larger caliber.

Both types of hemostasis in each specific situation work almost simultaneously and in concert, and the division into types is caused by didactic considerations.

Spontaneous hemostasis is provided due to the coordinated action of three mechanisms: blood vessels, blood cells (primarily platelets) and plasma.

Vascular-platelet hemostasis is provided by spasm of damaged vessels, adhesion, platelet aggregation and their viscous metamorphosis, resulting in the formation of a blood clot obturating the damaged vessel and preventing bleeding.

Enzymatic hemostasis is a complex multicomponent process, which is usually divided into 2 phases:

A multi-stage and multi-component stage, as a result of which prothrombin is activated with its transformation into thrombin.

The final stage in which fibrinogen under the influence of thrombin is converted into fibrin monomers, which then polymerize and stabilize.

Sometimes in the first phase, 2 subphases are distinguished: the formation of prothrombinase (thromboplastin) activity and the formation of thrombin activity. In addition, in the literature, the post-coagulation phase following the polymerization of fibrin is sometimes distinguished - stabilization and retraction of the clot.

In addition to the coagulation system, the human body has an anticoagulant system - a system of inhibitors of the blood coagulation process, among which antithrombin-3, heparin and proteins C and S are of the greatest importance. The system of inhibitors prevents excessive thrombus formation.

Finally, the resulting thrombi can undergo lysis due to the activity of the fibrinolytic system, the main representative of which is plasminogen, or profibrinolysin.

The liquid state of the blood is provided by the coordinated interaction of the coagulation, anticoagulation systems and fibrinolysis. Under conditions of pathology, especially in case of damage to blood vessels, this complete and perfect balance of antagonistic pairs of activators and inhibitors of the blood coagulation process can be disturbed. Back in the 19th century, Claude Bernard established the fact of post-aggressive stimulation of blood clotting. This applies to any aggression, including surgical. The activity of the blood coagulation system begins to increase already during the operation and remains at a high level for 5-6 days of the postoperative period. This reaction has a protective value, aimed at reducing blood loss and creating conditions for the repair of tissue and vascular damage, if it is adequate to the strength and duration of aggression. If it turns out to be insufficient (less often) or excessive (more often), the deployment of adaptive-compensatory mechanisms in the patient's body is disrupted and prerequisites for the occurrence of complications are created.

By itself, post-aggressive hypercoagulation is not a pathogenic factor, but in combination with vascular damage during surgery and imminent postoperative hypodynamia with slowing blood flow in some vascular areas, it can lead to pathological thrombosis. This combination of conditions for pathological thrombus formation was described by R. Virchow and is known as the "Virchow triad".

Methods for studying hemostasis. There are classic laboratory tests that characterize the general ability of blood to clot, and differential. The study of classical tests is mandatory in each patient before performing an urgent or planned surgical intervention. The study of individual components of the coagulation system using differential tests is carried out according to special indications in case of detection of defects in the functioning of the coagulation system and its inhibitors.

Classic tests:

Blood clotting.

The duration of bleeding, or bleeding time.

The number of platelets per unit volume of peripheral blood.

Thrombotest.

Blood clotting. There are several ways to determine blood clotting, the most popular of which is the Lee-White method. All methods are based on determining the time of fibrin formation in blood or plasma. Normal blood coagulability values when determined according to Lee-White are 5-10 minutes (according to some sources, from 4 to 8 minutes)

The duration of bleeding, or bleeding time, is also determined in various ways, among which the Duke method is the most widely used. After dosed damage to small vessels of the palmar surface of the distal phalanx of the finger or earlobe, the time from the moment of damage to the stop of bleeding is determined. Normal values for Duke are 2.5 - 4 minutes.

The number of platelets per unit volume of peripheral blood is counted in stained blood smears using special cameras or devices - celloscopes. The normal content of platelets is 200-300 x 10 / l (according to other sources, - 250 - 400 x 10 / l)

Thrombotest is a method that allows you to quickly assess the tendency of enzymatic hemostasis to hyper- or hypocoagulation. The principle of the method is based on the fact that blood plasma mixed with a weak solution of calcium chloride in a test tube gives a different character of a fibrin clot. The results are evaluated in conventional units - in degrees:

6-7 degrees - characterized by the formation of a dense fibrin sac of a homogeneous structure, - are noted with a tendency to hypercoagulation;

4, 5 degrees - a mesh bag of fibrin is formed in the test tube, - are characteristic of normocoagulation;

1, 2, 3 degrees - are characterized by the formation of separate threads, flakes or grains of fibrin, - are noted during hypocoagulation.

There are integrated tests that allow characterizing both individual types of spontaneous hemostasis and individual phases of enzymatic hemostasis.

The general state of vascular-platelet hemostasis is characterized by bleeding time, or the duration of bleeding. For a general assessment of enzymatic hemostasis, thrombotest and blood clotting are used. An assessment of the state of the first phase of enzymatic hemostasis can be carried out on the basis of a study of the prothrombin index according to Quick (PTI), which is normally 80-105%. The second phase can be characterized by the concentration of fibrinogen in venous blood (normal - 2-4 g / l)

Under conditions of pathology, fibrinogen degradation products may appear in the peripheral blood due to an increase in the activity of the fibrinolytic system, as well as a large number of fibrin monomers, which, when interacting with each other, form complex compounds that reduce the efficiency of enzymatic hemostasis, and sometimes block it. These compounds are detected using paracoagulation tests (ethanol, protamine sulfate and beta-naphthol). Positive paracoagulation tests indicate the development of a general DIC or massive local intravascular coagulation in the patient's body.

Thrombotic and thromboembolic diseases in surgical patients.

Deep vein thrombosis of the leg and pelvis (DVT)

DVT is a common complication of the postoperative period, in most cases it is asymptomatic. In a relatively small proportion of patients, when DVT occurs, poor clinical manifestations are noted in the form of aching pain in the calf muscles, aggravated by dorsal flexion of the foot, edema in the ankles, and moderate or mild cyanosis of the skin of the rear of the foot.

Diagnosis is carried out on the basis of clinical, instrumental and coagulation studies. Of the instrumental studies, ultrasonic angioscanning and radiopaque phlebography are the most informative. In coagulological studies, a decrease in the content of platelets, a decrease in the concentration of fibrinogen, and positive paracoagulation tests are noted.

Treatment has 2 tasks:

1. prevention of further progression of thrombosis,

2. prevention of pulmonary embolism.

To solve the first problem, direct anticoagulants are used - heparin and its low molecular weight fractions under the control of blood clotting and activated partial thromboplastin time (APTT) for 5-7 days, followed by a transition to long-term use of indirect anticoagulants under the control of IPT.

Preventive measures to prevent pulmonary embolism (PE) in diagnosed DVT:

Strict bed rest for the entire period of heparin therapy.

Thrombectomy - with segmental thrombosis of large veins.

Implantation of cava filters for floating thrombi in the femoral or iliac vein.

Pulmonary embolism (PE)

PE is closely pathogenetically associated with DVT and develops as a result of a thrombus detachment from the vascular wall and its migration into the pulmonary vessels.

Depending on which part of the pulmonary vessels is turned off from the blood circulation, the following forms of PE are distinguished:

supermassive (with the exclusion of 75-100% of the pulmonary vessels);

massive (with the exclusion of 45-75% of the vessels of the small circle);

non-massive, shared (15-45%);

small (up to 15%),

the smallest, or microvascular PE.

Accordingly, the following clinical forms are distinguished:

lightning fast and fast (heavy);

delayed (moderate);

erased, latent (light)

In the clinic, severe forms of PE are more common, accounting for about 5-8% of the causes of postoperative mortality.

Clinic. Clinical manifestations of pulmonary embolism are extremely variable and are determined primarily by the volume of pulmonary vessels excluded from the circulation.

In severe PE, manifestations of circulatory-respiratory failure play a leading role in the clinic. There are: an acute onset with pain behind the sternum or in the chest, shortness of breath (tachypnea), cyanotic coloration of the skin of the neck, chest, face, upper body, swelling of the cervical veins, tachycardia, lowering blood pressure. In cases of supermassive PE, death occurs within minutes.

With mild and moderate PE, there are no serious hemodynamic and respiratory disorders. Sometimes there is an “unmotivated increase in body temperature” against the background of a completely satisfactory general condition and unexpressed shortness of breath. In the early stages, radiographs do not find significant changes, and in the later stages, signs of infarction pneumonia can be detected.

Diagnosis is based on clinical, radiological, electrocardiographic and coagulation studies. On non-contrast chest radiographs, there is an increase in the transparency of the lung fields, along with an increase in the pattern of the roots of the lungs. An ECG study reveals signs of overload of the right heart.

The most highly informative diagnostic method is angiopulmography - x-ray contrast study of leukocytes.

In coagulological studies, as in patients with DVT, a decrease in the concentration of fibrinogen, a decrease in the content of platelets and the appearance in the peripheral blood of fibrinogen degradation products and fibrin-monomeric complexes are noted.

PE treatment.

Shock elimination.

Reducing hypertension in the pulmonary circulation.

Oxygen therapy.

Administration of cardiac glycosides.

Carrying out fibrinolytic therapy by intravenous administration of streptokinase, fibrinolysin and heparin preparations.

In specialized angiosurgical hospitals, it is possible to perform an operation - embolectomy.

Prevention of thrombotic and thromboembolic complications.

All patients who underwent surgery need to carry out preventive measures aimed at preventing the development of DVT and PE, but the nature of the measures taken varies depending on the degree of risk of thrombotic and thromboembolic complications.

At low risk, non-specific preventive measures are taken, which include:

Early activation of patients,

Physiotherapy,

pain relief,

Normalization of bowel function,

Maintenance of normal water and electrolyte balance and acid-base state of the blood, directed regulation of blood viscosity.

Non-specific measures are carried out in all patients who have undergone any surgical intervention.

In "thrombotic patients", in addition to these measures, it is necessary to carry out specific prophylaxis, since their risk of developing thrombotic and thromboembolic complications is incomparably higher than that of the "average patient".

Thrombo-prone patients include the following:

Patients with a preoperative marked increase in the content of fibrinogen in the blood and a decrease in fibrinolytic activity.

Patients with chronic disorders of venous circulation (with varicose veins of the lower extremities, post-thrombophlebitic disease)

Patients with widespread atherosclerosis, coronary artery disease with severe hemodynamic disorders.

Patients suffering from diabetes and obesity.

Patients with severe purulent infection, sepsis.

Cancer patients, especially those with advanced forms of metastatic cancer.

Specific methods for preventing DVT and PE include:

Tight bandaging of the lower extremities in violation of venous circulation.

Preoperative and postoperative administration of heparin or its low molecular weight fractions.

Postoperative appointment of antiplatelet agents and the introduction of low molecular weight dextrans.

Intermittent pneumatic compression of the legs.

DIC - syndrome (disseminated intravascular coagulation syndrome)

DIC is not a disease, but an acquired symptom complex that complicates many pathological processes and is characterized by a complete imbalance of the hemostasis system. According to the prevalence, DIC can be local, organ and general (generalized), and according to the clinical course - acute, subacute and chronic.

In surgical practice, one often encounters acute generalized DIC. The reasons for it may be:

Severe long-term operations, especially in patients with common malignant diseases;

Traumatic and hemorrhagic shock;

Massive transfusions of donor blood;

Transfusion of incompatible blood;

Severe purulent infection, sepsis.

In its development, DIC has 2 phases:

Hypercoagulation, intravascular platelet aggregation and activation of the kallikrein-kinin system and the complement system,

Hypocoagulation with increasing consumption coagulopathy, overactivation and subsequent depletion of the fibrinolytic system.

Diagnosis is based on a comparison of clinical and coagulological data.

The first phase is usually brief and asymptomatic.

The second phase is characterized by an outbreak of hemorrhagic manifestations on the part of the skin, gastrointestinal tract, urinary system, genitals, and wounds. Profuse bleeding, in turn, can lead to massive blood loss, hypovolemic shock and multiple organ failure with its clinical manifestations.

In coagulological studies, in the first phase, a decrease in blood clotting time is noted, in the second - an increase. In all phases of DIC, the following are noted: a decrease in the number of platelets, a decrease in the concentration of fibrinogen, the appearance and a progressive increase in the content of soluble fibrin-monomeric complexes and fibrinogen degradation products in the peripheral blood.

Treatment of DIC:

Intensive care of the underlying suffering that triggered DIC;

Intravenous infusions of low molecular weight dextrans in the hypercoagulable phase;

Transfusions of fresh frozen plasma at all stages of the evolution of DIC;

Transfusions of erythromass, erythrosuspension and platelet concentrates in the hypocoagulation phase, accompanied by massive bleeding;

In the later stages of the development of the disease - intravenous administration of antiprotease drugs;

Intravenous administration of corticosteroid hormones.

Diseases accompanied by a decrease in blood clotting.

Diseases accompanied by a decrease in blood clotting can be congenital and acquired.

Among hereditary coagulopathies, about 90-95% are hemophilia and hemophiloid conditions.

The term "hemophilia" means 2 diseases:

hemophilia A due to deficiency of plasma factor 8,

hemophilia B (Christmas disease) associated with a deficiency of plasma coagulation factor 9 (the plasma component of thromboplastin, antihemophilic globulin B).

All other hemorrhagic diatheses caused by congenital deficiency of various coagulation factors are hemophiloid conditions (hemophilia C, hypoproconvertinemia, hypoprothrombinemia, hypo- and aphyrinogenemia)

Hemophilia affects only men. Hemophiloid conditions occur in both men and women.

Diagnosis of hemophilia is based on clinical and coagulological findings.

Characteristic manifestations of hemophilia are repeated bleeding provoked by various, often minor mechanical damage. Early and specific clinical manifestations of hemophilia are hemarthroses.

Laboratory both types of hemophilia are characterized by prolongation of blood clotting time and APTT with normal bleeding time, fibrinogen concentration and normal platelet count.

Depending on the content of deficient factors in the blood, 4 clinical forms of hemophilia are distinguished:

severe - with the content of a deficient factor from 0 to 3%;

moderate - with the content of a deficient factor from 3.1 to 5%;

light - from 5.1 to 10%;

latent - from 10.1 to 25%.

Tactics of the surgeon in hemophilia. Against the background of hemophilia, only emergency and urgent surgical interventions are performed. Operations are performed under the cover of transfusion of large doses of freshly stabilized blood, native and fresh frozen plasma, antihemophilic plasma and cryoprecipitate under the control of blood clotting and APTT.

For preoperative preparation, if it is necessary to perform urgent surgical interventions, you can use recombinant preparations obtained by genetic engineering methods - immunate, cogenate, recombinant.

Doses and frequency of administration of antihemophilic drugs are determined by the severity of the intervention and the initial state of hemostasis. In the postoperative period, the introduction of hemostasis correction agents (in the catabolic phase) is continued. Methods for monitoring the effectiveness of ongoing therapy are the determination of blood clotting and activated partial thromboplastin time (APTT)

In addition, in the catabolic phase of the postoperative period, intravenous transfusions of a 5% solution of aminocaproic acid are performed (the drug prolongs the action of coagulation factors contained in plasma and cryoprecipitate) and parenteral corticosteroid hormones are administered (suppress the reaction of post-traumatic inflammation, prevent isosensitization).

Acquired coagulopathy.

Of the acquired coagulopathies, manifested by a decrease in blood clotting, cholemia and acholia are of the greatest interest for surgery.

Cholemic bleeding occurs during operations performed for obstructive jaundice. The causes of cholemic bleeding are:

deficiency of calcium ions due to their binding in the blood by bile acids;

deficiency of prothrombin complex factors - due to malabsorption of vitamin K in the digestive canal.

In laboratory studies, patients with obstructive jaundice show an increase in blood clotting time and a decrease in PTI.

To prevent cholemic bleeding in patients with obstructive jaundice, Vikasol is administered parenterally before surgery and plasma containing deficient coagulation factors is transfused intravenously.

Acholic bleeding occurs during operations in patients with external or low internal bile duct fistulas. The cause of these bleedings is a deficiency of prothrombin complex factors, which develops as a result of malabsorption of vitamin K in the digestive tract. Prevention does not differ from that in patients with obstructive jaundice.

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INTRODUCTION

1. Postoperative complications. Their types

2. Clinic of the normal postoperative period after abdominal operations

3. Prevention of postoperative complications

4. General clinic of postoperative complications

5. Wound complications

6. Postoperative peritonitis

7. Postoperative intra-abdominal abscesses

8. Postoperative intestinal obstruction

9. Postoperative pancreatitis

10. Postoperative myocardial infarction

11. Postoperative deep vein thrombosis of the legs

12. Postoperative pneumonia

13. Postoperative parotitis

CONCLUSION

BIBLIOGRAPHY

INTRODUCTION

The problem of surgical treatment of early postoperative complications, such as peritonitis, early intestinal obstruction, intra-abdominal abscesses, acute pancreatitis, bleeding into the abdominal cavity and the lumen of the gastrointestinal tract, eventeration, complications from the laparotomic wound, is one of the central ones in abdominal surgery.

Identification of postoperative complications is ensured by careful clinical observation and examination of patients. Of great importance are the reports of doctors and nurses on duty at morning conferences, which reveal the behavior and condition of patients during the shift. Careful observation of the attendants helps the attending physician to suspect certain violations and, during the subsequent examination of the patient, confirm or refute the suspicion.

The morning round of the operated patients should begin with a detailed questioning of the staff on duty and a conversation with the patient about his well-being. When talking with the patient, it is necessary to get acquainted with the readings of his temperature, observe the depth and frequency of breathing, examine the frequency, filling and tension of the pulse, the state of the tongue, the color of the mucous membranes, etc.

It is necessary to find out the presence and nature of pain, check the condition of the dressing, its wetting (with blood, bile, pus, etc.), the presence or absence of swelling, edema, redness in the areas surrounding the surgical suture, etc. After that, they proceed to the examination the patient through the organs, while observing strict sequence and thoroughness. When examining the gastrointestinal tract, in addition to the previously obtained data on the state of the tongue, about the stool, they pay attention to the state of the abdomen (swollen, retracted, tense, soft, painful), what is the localization and intensity of the changes noticed. It is necessary to feel the liver, kidneys. When examining the lungs, percussion and auscultation are required not only from the front, from the sides, but also necessarily from behind, since when the patient is positioned on his back, postoperative pneumonia begins precisely in this place. For such an examination, the patient must be seated in bed. In cases where the study does not allow to give an accurate answer about the presence of complications in the lungs, it is necessary to resort to chest x-ray. The cardiovascular system is examined not only to determine the function of the heart, the frequency and filling of the pulse, but also to identify the possible formation of thrombophlebitis in the peripheral veins.

If necessary, the examination should be supplemented with x-ray, cardiological, laboratory and special types of research, some of which are done for all patients (for example, a complete blood count, urine test), while some are usually according to special indications (urine for diastasis, feces for stercobilin, blood for prothrombin etc.).

The data obtained enable the doctor to clarify the diagnosis of a particular postoperative complication and start its treatment in a timely manner.

1. POSTOPERATIVE COMPLICATIONS. THEIR TYPES

Postoperative complications are a new pathological condition that is not characteristic of the normal course of the postoperative period and is not a consequence of the progression of the underlying disease. It is important to distinguish complications from operational reactions, which are a natural reaction of the patient's body to illness and operational aggression. Postoperative complications, in contrast to postoperative reactions, dramatically reduce the quality of treatment, delay recovery, and endanger the patient's life. Allocate early (from 6-10% and up to 30% with prolonged and extensive operations) and late complications.

In the occurrence of postoperative complications, each of the six components is important: the patient, the disease, the operator, the method, the environment, and chance.

Complications can be:

the development of disorders caused by the underlying disease;

Violations of the functions of vital systems (respiratory, cardiovascular, liver, kidneys) caused by concomitant diseases;

Consequences of defects in the execution of the operation or the use of vicious methods.

The features of a hospital infection and the system of patient care in a given hospital, schemes for the prevention of certain conditions, dietary policy, and the selection of medical and nursing staff are important.

You can not discount the elements of chance, and maybe fate. Every surgeon who has been practicing for a long time does not lose sight of the absolutely absurd and incredible complications that do not leave individual patients alone, overlap each other and often end in death in the postoperative period.

Nevertheless, the features of the pathological process, homeostasis disorders, infection, tactical, technical and organizational mistakes of doctors, the level of technical support - this is a typical set of reasons that require competent prevention and adequate early treatment in any clinic and hospital.

Postoperative complications are prone to progression and recurrence and often lead to other complications. There are no mild postoperative complications. In most cases, repeated interventions are required.

The frequency of postoperative complications is about 10% (V. I. Struchkov, 1981), while the proportion of infectious ones is 80%. (hospital strains, immunodeficiency). The risk increases with emergency as well as long-term operations. The factor of the duration of the operation is one of the leading factors in the development of purulent complications - a marker of trauma and technical problems.

Technical errors: inadequate access, unreliable hemostasis, invasiveness, accidental (unnoticed) damage to other organs, inability to delimit the field when opening a hollow organ, leaving foreign bodies, inadequate interventions, “tricks” in the performance of operations, defects in sutures, inadequate drainage, defects in postoperative reference.

Complications from the nervous system.

The main complications after surgery from the nervous system are pain, shock, sleep and mental disorders.

Pain of varying intensity is noted in all patients after surgery. The strength and duration of pain directly depends on the extent, traumatism of the operation and the excitability of the patient's nervous system.

Psychic trauma and pain can lead to metabolic disorders and tissue regeneration processes. Painful sensations reflexively lead to disruption of the cardiovascular system, respiration, intestinal paresis, urinary retention, etc. IP Razenkov proved the presence of violations of blood chemistry as a result of pain.

For prevention and control of pain, it is important to know that the reaction to painful stimuli of the same strength in the same patient varies depending on the degree of fatigue, excitability of the nervous system, exhaustion, readiness of the psyche to endure pain, the attention of others, etc.

Prevention of postoperative pain is primarily determined by a good contact between the surgeon and the patient in the preoperative period, a decrease in the excitability of the patient's nervous system, as well as compliance with the rules of surgical deontology.

For therapeutic purposes, subcutaneous injections of 1 ml of a 1% solution of morphine or a 2% solution of pantopon are usually used 2-3 times on the first day after surgery. With significant pain on the 2nd day, drugs are injected 1-2 times, on the 3rd day - only at night. The introduction of drugs can be continued for a few more days if the patient has severe pain, but one should always keep in mind the possibility of addiction to them and the development of morphinism - a serious disease that is difficult to fight. In addition, morphine, inhibiting the activity of the respiratory center, can lead to congestion in the lungs, it lowers metabolism, reduces diuresis. Produced in these patients on the 12th-14th day after the operation, fluoroscopy with the addition of liquid barium indicates a complete or almost complete absence of evacuation from the stomach. During the 3rd week after the operation, rapid exhaustion of the patient and scarring in the area of the inflammatory infiltrate of the anastomosis continue.

Sleep disturbance is a severe complication of the postoperative period, which may be associated with pain, intoxication, excessive excitation of the neuropsychic sphere, and feelings. The struggle for good sleep in the operated patient is an important task for the surgeon, since insomnia leads to disruption of the wound healing and recovery process.

Postoperative mental disorders in a pronounced degree are rarely observed, however, surgical patients always have a reaction from the psyche, the reactions, the degree and nature of which are different.

An operation, as a trauma to the nervous system, the patient's psyche, depending on his general condition, the extent of the intervention and compensatory capabilities, the reserves of the central nervous system, can lead to easily compensated changes or turn out to be a superstrong irritant and cause severe mental disorders.

Postoperative psychoses often develop in weakened, emaciated, intoxicated patients. This group usually includes all types of mental disorders that occur after surgery: exacerbation of previously former mental illnesses, reactive states, reactive intoxication psychoses, etc.

Postoperative psychoses not only disrupt the normal course of the postoperative period, but also pose a direct threat to the life of the patient and disrupt the healing process. Often they are accompanied by refusal to eat, sharp excitations with physical stress, which creates a number of additional dangers in the postoperative period.

Prevention of postoperative psychosis consists in normal preoperative preparation, which reduces intoxication, exhaustion of the patient and improves the function of all organs and systems, including the patient's nervous system.

An essential moment influencing the psyche of the operated patient is the external environment of the surgical department. It is necessary to abandon the “fear” of hanging pictures, curtains, upholstered furniture, etc., which creates comfort and coziness (P. I. Dyakonov, V. R. Khesin). Treatment of postoperative psychoses is carried out by psychiatrists, who sometimes keep these patients in special conditions and observe them together with the surgeon. In view of this, where possible, it is necessary to strive to more widely use pantopon, medial, veronal, pyramidon, bromine preparations, etc. to combat pain.

Obstruction of the anastomosis often develops in patients with severe perivisceritis after traumatic mobilization of the stomach and duodenum with penetrating ulcers. With stomach cancer, this complication is much less common.

The treatment of this complication in the first days of its development, when the nature of the obstruction of the anastomosis is not yet clear, should be carried out in two directions, namely in the direction of restoring the tone of the stomach and fighting infection.

To restore the tone of the gastric wall, it is necessary to ensure periodic or constant suction of its contents with a probe, active behavior of the patient, subcutaneous administration of strychnine. An important role in restoring the tone of the stomach is played by the correct diet, which should be individual for each patient and depend on the nature of the operation, the degree of obstruction of the anastomosis and the time elapsed since the operation. Of great importance is raising the tone of the whole organism by administering saline, 5% glucose, blood transfusion, etc.

To fight the infection, the patient is prescribed antibiotics (penicillin, streptomycin, biomycin, etc.), which contribute to the resorption of the inflammatory infiltrate.

In some of these patients, conservative treatment is not successful and it is necessary to resort to relaparotomy. Re-intervention should be carried out as soon as possible, as soon as the organic nature of the obstruction became clear. Given the exhaustion, weakness of patients, they must be prepared for it by infusions of glucose, blood transfusions, the introduction of cardiac drugs, etc. It is safer to perform the operation under local anesthesia. Usually, the operation consists in the imposition of an additional anterior gastrointestinal anastomosis with an interintestinal fistula, since the presence of infiltrate and perivisceritis of the anastomotic area in a severely weakened patient does not allow more radical intervention.

Atony of the stomach or spasm of the efferent loop of the small intestine also lead to a clinical picture of obstruction of the anastomosis, but usually its phenomena are not so constant, the patient is not so quickly dehydrated and exhausted, there is an improvement from subcutaneous administration of atropine, strychnine. The fight against this complication consists in constant or periodic emptying and gastric lavage through a tube, by subcutaneous administration of atropine, strychnine, blood transfusion, etc.

Belching indicates fermentation of the contents of the stomach, overflow or squeezing of the stomach by surrounding organs. Sometimes belching is noted with an inflammatory process in the upper abdomen, with paresis and stretching of the stomach.

Hiccups - convulsive periodically repeated contraction of the diaphragm - is very exhausting for the patient. Hiccups are caused by irritation of the phrenic or vagus nerve.

Localization of the source of irritation may be different. So, hiccups are often observed with tumors of the mediastinum or lung.

postoperative complication clinic treatment

2. CLINIC OF NORMAL POSTOPERATIVE PERIOD AFTER ABDOMINAL SURGERY

It includes operational aggression superimposed on the initial state of the patient. A surgical operation is a non-physiological effect, in connection with which the entire body, its individual systems and organs are overloaded. The body copes with operational aggression with open classical access within 3-4 days. In this case, the pain subsides and is felt only during movements and palpation. Feeling better. The temperature decreases from subfebrile or febrile numbers. Increased movement activity. The tongue is wet. The abdomen becomes soft, intestinal motility is restored by 3-4 days. On the 3rd day before the passage of intestinal gases and feces, moderate bloating and soreness may be noted with some deterioration in well-being. Slight pain remains only in the area of the operated organ with deep palpation.

Laboratory indicators: in proportion to the operational blood loss, a decrease in hemoglobin (up to 110 g/l) and erythrocytes (4 1012 l), an increase in leukocytes (9-12 109 l) with a shift of up to 8-10% of stab leukocytes are recorded.

Biochemical indicators are either within the normal range, or in the case of their initial disturbances with a tendency to normalization. Recovery slows down in patients operated on an emergency basis for initial purulent-inflammatory diseases or massive bleeding. They are more pronounced phenomena of intoxication or anemia. Due to the unpreparedness of the intestines on the 2nd day, bloating can be a problem.

3. PREVENTION OF POSTOPERATIVE COMPLICATIONS

There are no strict criteria for the portability of surgery in borderline conditions. The goal of prevention is to reduce risk as much as possible.

General principles:

1) systemic fight against nosocomial infection;

2) reduction of preoperative (if up to 1 day - 1.2% of suppuration, up to 1 week - 2%, 2 weeks and more - 3.5% - Kruse, Furd, 1980) and postoperative stay;

3) preparation in terms of strengthening specific and non-specific resistance, nutritional status;

4) identification of foci of infection in the body, including dormant in old postoperative scars (trial provocation with dry heat, UHF helps);

5) prophylactic use of antibiotics before and during operations;

6) high-quality suture material;

7) professional education of surgeons;

8) early diagnosis and the most complete examination - each patient with abdominal pain should be examined by a surgeon;

9) timely detection and surgical sanitation, adequate therapeutic treatment - a good state social policy;

10) participation in the postoperative treatment of the operating surgeon;

11) timely relief of postoperative reactions (for example, intestinal paresis);

12) uniform schemes of operational actions and postoperative management in the clinic (dressings, diet, activation);

13) reasonable implementation of the concept of “active management of the postoperative period” (early getting up, exercise therapy and early nutrition).

4. GENERAL CLINIC OF POSTOPERATIVE COMPLICATIONS

There are no asymptomatic complications. In each case there are specific signs. However, there are also common ones. They are mainly associated with ongoing intoxication, and are manifested by a change in appearance and a deterioration in well-being. The look is disturbing, the eyes are sunken, the facial features are pointed. Characterized by dry tongue, tachycardia, lack of peristalsis. Signs of ongoing intoxication syndrome: fever, sweating, chills, decreased diuresis. Sharply intensifying pains in the abdomen, and against the background of their blunted perception, is a sign of an abdominal postoperative catastrophe. Symptoms of peritoneal irritation.

Nausea, vomiting and hiccups are not typical for the normal postoperative period.

With the gradual development of complications, the most constant symptom is progressive intestinal paresis.

A sign of collapse is extremely alarming - it can be a sign of internal bleeding, suture failure, acute expansion of the stomach, as well as myocardial infarction, anaphylactic shock, pulmonary embolism.

Methodology of actions in case of suspected postoperative complication:

assessment of the level of intoxication syndrome (pulse, dry mouth, laboratory parameters) in dynamics (taking into account ongoing detoxification);

extended bandaging of the surgical wound with probing (under conditions of sufficient anesthesia);

Directed and exploratory instrumental examination (ultrasound, X-ray diagnostics, NMR).

5. WOUND COMPLICATIONS

Any wound heals according to biological laws. In the first hours, the wound channel is filled with a loose blood clot. The inflammatory exudate contains a large amount of protein. On the second day, fibrin begins to undergo organization - the wound sticks together. In the same period, the phenomenon of wound contraction develops, which consists in a uniform concentric contraction of the edges of the wound. On the 3rd-4th day, the edges of the wound are connected by a delicate layer of connective tissue from fibrocytes and delicate collagen fibers. From 7-9 days, we can talk about the beginning of scar formation, which lasts 2-3 months. Clinically, uncomplicated wound healing is characterized by the rapid disappearance of pain and hyperemia, the absence of a temperature reaction.

Alternative-exudative processes are aggravated by rough manipulations in the wound, drying (dry dressing), significant electrocoagulation with tissue charring, infection with the contents of the intestine, abscess, etc.). Biologically, microflora is needed, as it contributes to the rapid cleansing of the wound. The critical level of bacterial contamination is 105 microbial bodies per 1 g of wound tissue. Rapid reproduction of microorganisms occurs after 6-8 hours from the operation. In the wound, hermetically closed with sutures for 3-4 days, the exudative process spreads in depth along the interstitial pressure gradient. Under conditions of infection, the wound heals through granulation tissue, which transforms into scar tissue. The growth of granulations slows down in anemia and hypoproteinemia, diabetes mellitus, shock, tuberculosis, beriberi, and malignant tumors.

Patients with pronounced cellular tissue are prone to wound complications with its increased trauma.

There is a strict sequence of complications.

Bleeding external and internal 1-2 days.

Hematoma - 2-4 days.

Inflammatory infiltrate (8 - 14%) - 3-6 days. The tissues are impregnated with serous or serofibrinous transudate (prolonged hydration phase). The boundaries of the infiltrate - 5-10 cm from the edges of the wound. Clinic: pain and a feeling of heaviness in the wound, subfebrile fever with rises up to 38 °. moderate leukocytosis. Locally: swelling of the edges and hyperemia, local hyperthermia. Palpation compaction.

Treatment - wound probing, exudate evacuation, removal of some of the sutures to reduce tissue pressure. Alcohol compresses, heat, rest, physiotherapy, x-ray therapy (rarely).

Suppuration of the wound (2-4%) - 6-7 days. As a rule, due to a scanned hematoma, and then an infiltrate. Rarely unresponsiveness of the patient with a particularly virulent infection, but then it occurs very quickly.

Clinic: hectic fever, profuse sweat, chills, headache. The wound area swells, hyperemic, painful. With the subaponeurotic location of the abscess due to irritation of the peritoneum, there may be dynamic obstruction and then differential diagnosis with postoperative peritonitis is relevant.

With an anaerobic or other virulent infection, the purulent process can proceed rapidly, manifesting itself 2-3 days after the operation. Severe intoxication and local reaction. Emphysema of the perivulnar area.

Treatment. Removal of stitches. In the cavity of the abscess, pockets and streaks open. The wound is cleaned from non-viable tissues (washing) and drained. If an anaerobic process is suspected (tissues have a lifeless appearance with a purulent-necrotic coating of a dirty gray color, the muscle tissue is dull, gas is released) - a mandatory wide excision of all affected tissues. With a wide distribution - additional incisions.

Yellow or white pus, odorless - staphylococcus aureus, Escherichia coli; green - green streptococcus; dirty gray with a fetid odor - putrefactive flora; blue-green - Pseudomonas aeruginosa; raspberry with a putrid odor - anaerobic infection. In the process of treatment, the flora changes to the hospital.

With a putrefactive wound infection, there is abundant hemorrhagic exudate and fetid gas, gray tissues with necrosis.

As granulations develop and the exudative phase stops, either the imposition of secondary sutures (tightening the edges with a patch), or the transition to ointment dressings (in cases of extensive wounds).

6. POSTOPERATIVE PERITONITIS

Occurs after any operation on the organs of the abdominal cavity and retroperitoneal space. This is a new qualitatively different form of the disease. It is essential to distinguish postoperative peritonitis from progressive, ongoing, or indolent peritonitis, in which the first operation does not (and sometimes cannot) solve all problems.

Etiopathogenesis. Three groups of reasons:

medical errors of technical and tactical plan (50-80%);

deep metabolic disorders leading to insufficiency of immunobiological mechanisms and defective regeneration;

Rare, casuistic reasons.

In practice, often: insufficient delimitation of the abdominal cavity from enteral infection, unsystematic revision, careless hemostasis (modern technique: “tweezers-scissors-coagulation”), lack of sanitation of the abdominal cavity at the end of the operation (dry and wet sanitation, toilet pockets and sinuses of the abdominal cavity) . The problem of insolvency of gastrointestinal anastomoses is relevant, including due to technical defects (prevention in maintaining sufficient blood supply, wide contact of the peritoneum without trapping the mucosa, infrequent sutures). Classification of postoperative peritonitis.

By genesis (V. V. Zhebrovsky, K. D. Toskin, 1990):

1. Primary - infection of the abdominal cavity during surgery or in the near future after it (perforation of acute ulcers, necrosis of the wall of the abdominal organ with an incorrect assessment of viability, unnoticed intraoperative damage);

2. Secondary peritonitis - as a result of other postoperative complications (failure of sutures, abscess rupture, with intractable paralytic ileus, eventration).

According to the clinical course (V. S. Saveliev et al., 1986):

1. Lightning

3. Sluggish

By prevalence:

1. Local

By type of microflora:

1. Mixed

2. Colibacillary

3. Anaerobic

4. Diplococcal

5. Pseudomonas

By type of exudate:

1. Serous-fibrinous

2. Serous hemorrhagic

3. Fibrinous-purulent

4. Purulent

5. Gallic

6. Fecal

Clinic. There is no universal clinical picture of postoperative peritonitis. The problem is that the patient is already in a serious condition, has a surgical disease, has undergone surgical aggression, and is being intensively treated with medications, including antibiotics, hormones, and drugs. It is impossible in all cases to focus on the pain syndrome and the tension of the muscles of the anterior abdominal wall. Therefore, diagnosis should be carried out at the level of microsymptoms.

Clinically, there are two options: 1) acute deterioration against the background of a relatively favorable course (soft abdomen, good physical activity, but fever is possible). The later peritonitis occurs, the better it is to diagnose; 2) a progressive severe course against the background of ongoing intoxication.

Signs of peritonitis:

Direct (defense), - are not always detected against the background of intoxication, hypoergy and intensive treatment;

Indirect - violation of homeostasis (tachycardia, hypotension), impaired motility of the stomach and intestines (not decreasing reflux through the intestines), preservation or aggravation of the intoxication syndrome, despite intensive treatment.

As a rule, the clinic of recurrent intestinal paresis and the progressive development of the systemic inflammatory response syndrome, accompanied by multiple organ failure, is the leading one.

There are no asymptomatic postoperative peritonitis.

Diagnostic principles:

Dominant of the surgeon's clinical thinking;

Comparison of the predicted normal course of the postoperative period in this patient and the existing one;

Progression or preservation of intoxication syndrome with intensive detoxification.

The basis of diagnosis are: persistent intestinal paresis, endogenous intoxication (fever, dry tongue), tendency to hypotension, tachycardia, decreased diuresis, development and progression of renal and hepatic insufficiency.

An obligatory stage is an extended revision of the wound with its probing.

The next stage of diagnosis is the exclusion of other sources of intoxication: broncho-pulmonary process, gluteal abscesses, etc. X-ray (free gas in the abdominal cavity, be careful!), Ultrasound of the abdominal cavity (presence of fluid in the abdominal cavity), and endoscopy. Treatment. Conservative treatment gives 100% lethality. The key is relaparotomy followed by intensive detoxification and, in some cases, repeated sanitation.

The operation should be as radical as possible, but correspond to the vital capabilities of the patient - individual surgery.

General principles: suction of exudate, removal of the source, postoperative lavage, drainage of the intestine. Sometimes, if circumstances permit, you can limit yourself to a minimum. The latter is possible with early diagnosis and accurate determination of the degree of damage.

For example, in case of peritonitis caused by failure of the gastrointestinal anastomosis during distal resections of the stomach, N. I. Kanshin (1999) recommends, in the absence of a pronounced purulent process in the anastomosis area, reinforcing sutures (cover with Tachocomb) and along the anastomosis transverse through perforated drainage (permanent aspiration with suction of air and periodic washings), and insert a probe for decompression and enteral nutrition into the outlet loop through the anastomosis. With a significant defect in the anastomosis and severe peritonitis, a double-lumen tube is inserted into the afferent loop with fixation to the edge of the defect, covered with an omentum, and an jejunostomy is applied at a distance of 50 cm.

Important peritoneal detoxification - up to 10-15 liters of heated solution, as well as intestinal decompression: transnasal up to 4-6 days or through intestinal fistula.

A variant of a suspended compression enterostomy for peritonitis according to N.I. Kanshin: a Petzer catheter with a cut bottom of its socket is inserted through the minimum enterotomy opening and is crimped with a purse-string suture. The catheter is brought out through the puncture of the abdominal wall, pressing the intestine to the peritoneum, and is fixed in a predetermined position with a tightly dressed rubber bar until compression. If peritonitis occurs after endovideoscopic interventions, then re-intervention can also be performed endovideoscopically or from a mini-access (the professionalism of the operator is very important, which, however, is also essential in classical reoperations).

7. POSTOPERATIVE INTRA-ABDOMINAL ABSCESSES

There may be intraperitoneal, retroperitoneal and abdominal abscesses. They are localized in bags, pockets, canals and sinuses of the abdominal cavity, cellular spaces of retroperitoneal tissue, as well as in the liver, spleen, pancreas. Predisposing factors are the neglect of acute surgical diseases, insufficient sanitation, sluggish peritonitis, irrational and inefficient drainage of the abdominal cavity.

Clinic. On the 3rd-10th day, deterioration of the general condition, pain, fever, tachycardia. There are phenomena of intestinal motor insufficiency: bloating, inadequacy of the effect during intestinal stimulation, pronounced reflux through the gastric tube. Dominant of active search and clinical diagnostics. The key is to palpate to look for even minimal soreness and infiltration, starting from the postoperative wound, along the anterior, lateral and posterior walls, ending along the intercostal spaces. Hope for the universal help of ultrasound, CT, NMR cannot be absolute.

Subdiaphragmatic abscesses. Persistent vomiting is an important manifestation. The key symptom is Grekov's - pain when pressed with fingers in the lower intercostal spaces above the abscess. Also important are Kryukov's symptom - pain when pressing on the costal arches and Yaure's symptom - balloting of the liver.

Informative x-ray examination in a vertical position (gas bubble above the liquid level, immobility of the dome of the diaphragm, concomitant pleurisy).

Treatment. With right-sided localization, high subdiaphragmatic abscesses are opened with resection of the 10th rib according to A.V. Melnikov (1921), the posterior ones with resection of the 12th rib according to Oksner, and the anterior ones according to Clermont.

Interintestinal abscesses occur with a combination of a septic process and intestinal obstruction (diamic and mechanical). Diagnosis is predominantly clinical. The beginning of treatment is conservative (at the stage of infiltration). Old technique: X-ray therapy. With an increase in the septic state, an autopsy is more often from a median relaparotomy. The use of puncture and catheterization under ultrasound guidance is promising.

8. POSTOPERATIVE INTESTINAL OBSTRUCTION

Allocate early (before discharge) and late (after discharge).

Talk about early adhesive obstruction should only be after a period of restoration of normal function of the gastrointestinal tract and at least one normal bowel movement.

Causes of early mechanical obstruction:

Adhesions in violation of the integrity of the serous cover (mechanical, chemical, thermal trauma, purulent-destructive process in the peritoneal cavity, talc, gauze);

obstruction due to anastomosis, compression of the loop by infiltrate (by the type of “double-barrel”);

obstruction due to the unsuccessful location of tampons and drains (compression from the outside, torsions);

obstruction due to technical defects in the execution of the operation (defects in the imposition of anastomoses, picking up in a ligature when suturing a laparotomic wound of the intestinal wall). Clinic. Violation of the passage of intestinal contents with gas retention and defecation further 4 days after surgery, persistent bloating, increased amount of discharge through the gastric tube.

Diagnostics. It is important to differentiate early p/o intestinal obstruction due to actual adhesions, for example, stimulated by tampons, from involvement of the intestine in an inflammatory infiltrate, as well as from intestinal paresis due to a septic process in the abdomen. It is difficult to notice the transition from dynamic to mechanical. The critical time for making a surgical decision is 4 days.

Great help in X-ray method.

Separately, there is a high obstruction during interventions on the stomach and duodenum (acute anastomositis after resections of the stomach, obstruction of the duodenum after suturing perforated ulcers, compression in the head of the pancreas), which manifests itself as a significant discharge along the gastric tube. The modern way out is to conduct gastroscopy with bougienage of the narrowed area and holding a nutritional probe below the narrowing site, the usefulness and safety of which were proven back in the 80s by V. L. Poluektov.

Surgery should be complemented by nasoenteric intubation, colonic decompression with an anorectal tube, and anal sphincter divulsion.

Adequate intensive care.

9. POSTOPERATIVE PANCREATITIS

It develops after operations on the bile ducts and pancreas, stomach, after splenectomy, papillotomy, removal of the large intestine, when there is direct or functional contact with the pancreas.

Occurs 2-5 days after surgery. Manifested by dull pain in the epigastric region, bloating, gas retention. Amylazemia and amylasuria explain the cause of the deterioration. The emergence of psychotic disorders old doctors attributed, first of all, to postoperative pancreatitis.

The key is active drug prophylaxis with antienzymatic drugs and sandostatin in patients with the above interventions, in which a pancreas reaction can be predicted.

In the treatment, the same actions are valid as in other forms of pancreatitis with the priority of intensive care and antibiotic therapy.

10. POSTOPERATIVE MYOCARDIAL INFARCTION

The occurrence of peri- and postoperative infarction is real with the following risk factors (Weitz and Goldman, 1987): heart failure; myocardial infarction within the previous 6 months; unstable angina; ventricular extrasystole with a frequency of more than 5 per minute; frequent atrial extrasystoles or more complex arrhythmias; age over 70 years; the emergency nature of the operation; hemodynamically significant aortic stenosis; general severe condition. The combination of any three of the first six indicates a 50% chance of perioperative myocardial infarction, pulmonary edema, ventricular tachycardia, or death of the patient. Each of the last three factors individually increases the risk of these complications by 1%, and any combination of two of the last three increases the risk to 5-15%.

A heart attack usually develops in the first six days after surgery. It is important to record the ECG on days 1, 3 and 6 after surgery.

11. POSTOPERATIVE DEEP VEIN THROMBOSIS

About 80% of cases of deep vein thrombosis after surgery have no clinical manifestations (Planes et al., 1996). The most dangerous is thrombosis of the muscular veins of the lower leg due to: 1) turning off the central mechanism of outflow of blood from the legs in bed patients - the muscular-venous pump of the lower leg; 2) a high frequency of silent ectasias of the tibial and muscle veins of the leg; 3) subclinical manifestations; 4) the absence of leg edema due to the preserved outflow of blood from the limb.

Important: prevention in the broad and narrow terms; identification of risk groups; daily palpation of the calf muscles as a standard for postoperative monitoring.

12. POSTOPERATIVE PNEUMONIA

The most severe of bronchopulmonary complications.

Causes: aspiration, microembolism, stagnation, toxicoseptic state, heart attack, prolonged standing of the gastric and intestinal probes, prolonged mechanical ventilation. It is predominantly small-focal in nature and is localized in the lower sections.

Clinic: exacerbation of fever not associated with wound findings, chest pain when breathing; cough, flushed face. It starts as tracheobronchitis. Appears for 2-3 days.

Three flow options (N.P. Putov, G.B. Fedoseev, 1984):

1) a clear picture of acute pneumonia;

2) with prevalence of the phenomena of bronchitis;

3) an erased picture.

Severe prognosis indicators for nosocomial pneumonia (S. V. Yakovlev, M. P. Suvorova, 1998):

1. age over 65;

2. IVL for more than 2 days;

3. severity of the underlying disease (head injury, coma, stroke);

4. severe concomitant diseases (diabetes mellitus, chronic obstructive pulmonary disease, alcoholism and liver cirrhosis, malignant tumors);

5. bacteremia;

6. polymicrobial or problematic (P. Aeruginosa, Acinnetobacter spp., fungi) infection;

7. previous ineffective antibiotic therapy.

In the complex of treatment, antibacterial treatment is important, taking into account the characteristics of the nosocomial infection of the medical institution and operational control of bronchial patency (bronchoscopy).

13. POSTOPERATIVE PAROTITIS

Acute inflammation of the parotid salivary gland. More often in patients of elderly and senile age, with diabetes mellitus. Contribute to carious teeth, decreased function of the salivary glands due to dehydration, in the absence of chewing, prolonged standing of the probes, leading to the multiplication of microbial flora in the oral cavity.

Clinic. On the 4th - 8th day, pain, swelling, hyperemia in the parotid areas occur with the development or aggravation of a septic condition. In addition, dry mouth, difficulty opening the mouth.

Prevention: Sanitation of the oral cavity, rinsing the mouth, removing plaque from the tongue, chewing sour.

Treatment: Local (compresses, dry heat, rinsing) and general (antibacterial therapy, detoxification). If suppuration occurs, open with two incisions parallel to the vertical part of the lower jaw and along the zygomatic arch (work digitally on the gland).

CONCLUSION

Monographs, congresses, conferences, plenums are devoted to the issues of etiology, pathogenesis, diagnosis, clinic, prevention and treatment of postoperative infectious complications. The development in recent years of clinical microbiology, clinical immunology, biochemistry and other fundamental disciplines makes it possible to assess the etiopathogenetic aspects of the onset, development and course of infection from new positions.

The development and implementation of modern methods of antimicrobial, detoxification therapy, immunotherapy, enzyme therapy, physiotherapy, the creation of new drugs and antiseptics, the improvement of treatment technologies and prevention schemes will significantly reduce the incidence and reduce the adverse effects of postoperative infectious complications.

Bibliography

1. Zhebrovsky V.V., Toskin K.D. The problem of postoperative complications in abdominal surgery // Postoperative complications and dangers in abdominal surgery. M.: Medicine, 1990; 5-181.

2. Savchuk T.D. Purulent peritonitis. M.: Medicine, 1979; 188 p.

3. Milonov O.T., Toskin K.D., Zhebrovsky V.V. Postoperative complications and dangers in abdominal surgery. M.: Medicine, 1990; 560.

4. Toskin K.D., Zhebrovsky V.V., Bereznitsky F.G. Postoperative intraperitoneal and extraperitoneal abscesses // Postoperative complications and dangers in abdominal surgery. M.: Medicine, 1990; 84-133.

5. Vilenskaya I.F., Sheprinsky P.E., Osipova A.N. et al. Features of postoperative complications in the surgical hospital // Proceedings. report II Russian. scientific and practical. conf. from int. participation. M., 1999; 51-2

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