Ameliorative surgery

Anaesthesia

Anaesthesia is the loss of feeling or sensation. It may be accom?plished without the loss of consciousness, or with partial or total loss of consciousness.

Anaesthesiology is a branch of medical science that relates to anae?sthesia and anaesthetics. The anaesthetist is a specialized physician in charge of supervising and administering anaesthesia in the course of a surgical operation. Depending on the type of operation and proce?dures used, there are two types of anaesthesia: general anaesthesia, which causes a loss of consciousness, and local anaesthesia, where the anaesthetic ?freezes? the nerves in the area covered by the operation. In local anaesthesia, the patient may be conscious during the course of the operation or given a sedative, a drug that induces sleep.

General: anaesthesia resulting in amnesia, with a loss of protective airway reflexes. While usually administered with inhalational agents, general anaesthesia can be achieved with intravenous agents, such as propofol. Amnesia is the main characteristic, while analgesia and mus?cle relaxation may be present, to varying degrees.

Regional: loss of pain sensation, with varying degrees of muscle relaxation, in certain regions of the body. It is administered with local anaesthesia to peripheral nerve bundles, such as the brachial plexus in the neck. Examples include the interscalene block for shoulder sur?gery, axillary block for wrist surgery, and femoral nerve block for leg surgery. While traditionally administered as a single injection, newer techniques involve placement of indwelling catheters for continuous or intermittent administration of local anaesthetics.

Spinal: also known as subarachnoid block. It refers to a regional block resulting from a small volume of local anaesthetics being in?jected into the spinal canal. The spinal canal is covered by the dura mater, through which the spinal needle enters. The spinal canal con?tains cerebrospinal fluid and the spinal cord. The subarachnoid block is usually injected between the 4^th and 5^th lumbar vertebrae, because the spinal cord usually stops at the 1^st lumbar vertebra, while the canal continues to the sacral vertebrae. It results in a loss of pain sensation and muscle strength, usually up to the level of the chest (nipple line or 4^th thoracic dermatome).

Epidural: it is a regional block resulting from an injection of a large volume of local anaesthetic into the epidural space. The epidu?ral space is a potential space that lies underneath the ligamenta flava, and outside the dura mater. This is basically an injection around the spinal canal.

Localanaesthesia is similar to regional anaesthesia, but exerts its effect on a smaller area of the body.

Not all surgical procedures require anaesthetic. Sometimes no anaesthetic is required, and conscious sedation is used, which does not result in loss of consciousness or significant analgesia, but frequently produces a degree of amnesia, and relaxes the patient.

Local anesthetics block pain in regions of the body without affect?ing other functions of the body or overall consciousness. They are used for medical examinations, diagnoses, minor surgical and dental proce?dures, and for relieving symptoms of minor distress, such as itching, toothaches, and haemorrhoids. They can be taken as creams, oint?ments, sprays, gels, or liquid; or they can be given by injection and in eye drops.

Some local anesthetics are benzocaine, bupivacaine, cocaine, lidocaine, procaine, and tetracaine. Some act rapidly and have a short duration of effect, while others may have a slow action and a long duration. Sprays can be used on the throat and related areas for a bronchoscopy, and gels can be used for the urethra to numb the area for catherization or cystoscopy.

Spinal anaesthesia is used for surgery of the abdomen, lower back and legs. Spinal or epidural anaesthesia is also used for surgery on the prostate gland and hip. A fine needle is inserted between two vertebrae in the lumbar (lower part) of the spine and the anaesthetic flows into the fluid surrounding the spinal cord. The nerves absorb the anaesthetic as they emerge from the spinal fluid. The area anaesthetized is controlled by the location of the injection and the amount of absorp?tion of the anaesthetic by the spinal fluid.

There are a number of possible complications that can occur un?der general anaesthesia. They include loss of blood pressure, irregular heart beat, heart attack, vomiting and then inhaling the vomit into the lungs, coma, and death. Although mishaps do occur, the chance of a serious complication is extremely low. Avoidance of complications depends on recognition of the condition of the patient before the ope?ration, the choice of the appropriate anaesthetic procedure, and the nature of the surgery itself. It is possible to have adverse reactions to local anaesthetics, such as dizziness, hypotension (low blood pres?sure), convulsions, and even death. These effects are rare but can oc?cur if the dose is too high or if the drug has been absorbed too rap?idly. A small percentage of patients (1?5 %) may develop headaches with spinal anaesthesia.

Modern Surgery

The era of modem surgery probably began with the notable event of the performance (1809) of ovariotomy (removal of the ovaria) in the treatment of ovarian disease by American surgeon Ephraim Mc?Dowell of Kentucky. Nathan Smith, a physician in Massachusetts, also performed ovariotomy in 1821, without knowing of McDowell?s

work. American surgeon Valentine Mott ligated important blood ves?sels in the treatment of aneurysm (abnormal expansion of a blood vessel); James Sims, of Alabama and New York, became known as the founder of modem gynaecology; Samuel Gross of Philadelphia was a great surgeon and teacher. Sir Astley Cooper of England and Sir Charles Bell and James Syme of Scotland were outstanding surgeons.

With the discovery (1842-47) of anaesthesia, the barrier to the progress in actual operations was removed. Hospital gangrene, septi?caemia, tetanus, and pyaemia remained as problems, however. Not until French chemist Louis Pasteur evolved his germ theory and dis?covered that fermentation is caused by microorganisms. When British surgeon Sir Joseph Lister applied the discoveries of Pasteur to surgery and formulated his theory concerning sepsis and antisepsis, another major obstacle was removed.

Surgery today is practiced for the following purposes: diagnosis, such as surgical opening of the body for exploratory purposes, and excision of tissue for examination (although modem diagnostic tools eliminate the need for some of this); the correction of deformity or defect; the cure of disease; the amelioration of suffering; and the pro?longation of life.

Corrective surgery

At present, corrective surgery is employed for clubfoot, harelip, cleft palate, bowlegs, deformed spine, congenitally dislocated hip joints, and many heart and blood-vessel diseases. In correcting defects caused by accident or disease, plastic surgery is used.

Curative surgery

Surgery is employed in the treatment of sarcoma, tuberculosis, and osteomyelitis. The brain is subjected to inspection and many kinds of operations, including removal of tumours, evacuation of abscesses, and clearing of blood clots and other obstructions to blood vessels are performed.

The vascular system, including the heart, has been brought within the domain of experimental and practical surgery. Whereas a large proportion of practical surgical work on the heart formerly dealt with injuries such as stab or gunshot wounds, many current heart opera?tions are performed to correct congenital heart abnormalities and tight or leaky heart valves resulting from diseases such as rheumatic fever. Many blood-vessel diseases that were formerly fatal or crippling are cured surgically today. The surgeon can restore normal blood circula?tion to vital organs by eliminating obstmctions and stopping leaks in arteries. Arterial defects can be repaired by opening the vessel and scraping out the clot; bypassing or replacing the obstructed segment with a natural or synthetic graft; or widening the bore of an artery by inserting material in its wall.

The history of thoracic surgery was entirely changed as a result of the invention of means of operating upon the lungs and other tho?racic viscera without collapse of the lungs. This is accomplished by various kinds of apparatuses designed to maintain the necessary dif?ferential air pressure during the operation, by the hypoatmospheric and hyperatmospheric methods. In present-day surgery, one lung or portions of a lung can be removed safely in patients with cancerous conditions or inflammatory infections such as tuberculosis.

In surgery of the gastrointestinal tract, ulcers and tumours are excised, injuries are repaired, adhesions resulting from inflammatory processes are broken up, and portions of the tract that are distorted as a result of adhesions are restored to normal function. Again, lasers may be used to cauterize lesions. Portions of the stomach and intestine are sometimes removed because of an ulcer or cancer. The liver and gall bladder and their appendages can also be operated on successfully. For example, when gallstones are present, the gall bladder can be re?moved ? cholecystectomy is performed.

The genitourinary system, that is, the kidney, bladder, and organs of reproduction, is the site of many operative procedures. Surgery of the female generative organs, such as ovaria, uterus, and Fallopian tubes, is a field in which impressive achievements have been recorded. The present trend in the surgical treatment of these organs is toward conservatism.

Ameliorative surgery

Surgery is often employed to ameliorate suffering when a cure is unlikely, especially in the relief of cancer. Suffering may be relieved by cutting nerves that are pressed on by tumours; by removing portions of malignant growth that impinge on other organs, causing pain or impaired function; and by clearing up ulcerating areas and skin grafting.

Operation

The patient was wheeled on a stretcher cart to the operating room.

At that time preparation for the operation was being carried on in the operating room. The surgical nurse was getting sterile gowns and dress?ings ready, sterilizing the necessary set of surgical instruments, prepar?ing the apparatuses for blood transfusion, checking up the presence and state of blood substituting solutions and preserved blood.

First of all the surgeon and his assistants began to prepare their hands ? they bared their arms above the elbow, scrubbed their hands and forearms for 15 minutes with soap and brush under hot running water. Then the doctors rinsed their hands twice in the solution of ammonium chloride. After rinsing the hands were sponged with alco?hol and the nails painted with iodine. It is essential that persons en?gaged in surgical work keep their nails trimmed short and clean. The doctors put on sterile caps and masks and having entered the operating room they put on sterile gowns and rubber gloves.

The patient was prepared for the operation; premedication was over, the abdomen was shaven and the patient was lying on the ope?rating table. The anesthetist began giving intratracheal anesthesia. The patient fell asleep.

The surgeon painted the operative field with iodine and covered the patient with sterile sheets leaving bare only the operative field. The surgeon made a midline abdominal incision with a scalpel. Bleeding was stopped with the clamps.

On laparotomy turbid exudates and food mass were found in the abdominal cavity. The stomach being lifted up, a perforated ulcer 0.5 cm in diameter was found on the posterior side of the lower por?tion of the stomach. The resection of the stomach was performed. Having cleansed the abdominal cavity from exudates and food mass and having introduced antibiotics into it, the surgeon closed the ab?dominal wound in layers with drainage. A patch was stuck on the wound. 300 ml of blood and 500 ml of glucose were transfused during the operation. The patient survived the operation well.

The patient was taken on a stretcher cart from the operating room to his ward. His postoperative course was uneventful. No complica?tions were noted, the wound was healing well. On the 7^th postoperative day the stitches were taken out.

Date: 2016-06-13; view: 783