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OPERATIONS ON THE ORGANS OF THE ABDOMINAL CAVITY Â

Puncture of an abdominal cavity Puncture of an abdominal cavity or laparocentesis - puncÂture of a anterior abdominal wall by a trocar. The puncture is carried out with the therapeutic purpose (for evacuation of a liquid at an ascites), with the diagnostic purpose (for detection of damage of organs of an abdominal cavity at a blunt trauma of an abdomen, small penetrating wounds), and also as one of stages of a laparoscopy. The laparocentesis is counterindicated for the patient with a abdominal distention, multiple postoperative scars on a anterior abdominal wall, as the probability of damage of interÂnal organs is very high. Position of the patient sitting, seriously ill patients - edgewise. Puncture made in points: on middle of distance beetwen umbilicus and pubis on a meÂdian line, little laterally from middle of distance between a umbiliÂcus and anterior superior iliac spine of the appropriate party. Previously a urinary bladder emptied in order to prevent its wound. For the prevention in the further ascitic fistula, infecÂtion of abdominal cavity the skin on a place of a puncture shoÂuld be displaced. By tip of a scalpel a small incision of a skin made, throÂugh which by a trocar other layers of an abdominal wall are piÂerced and it is entered in an abdominal cavity. The stilet is taken out. The liquid should be let out slowly, observing for pulse and respiration of the patient. The superior part of an abdomen pull together by a sterile towel or sheet for prevention of a collapse because of fast drop of pressure in an abdominal caviÂty. At a diagnostic puncture, if the blood, exudate, bile, inÂtestinal contents follows from an abdominal cavity, means - the organ is damaged. On this operation stopped. Otherwise the technique of a "searching" catheter is appÂlied. Into a tube of a trocar a chlorvinyl catheter with aperÂtures on the end introduced. A catheter entered in the directiÂon of

a liver, lien, lateral canals, to a pelvis. Thus the exÂternal end of a catheter is connected with a syringe and the aspiration is made. It is possible to introduce into abdominal cavity 10 ml of a sterile solution (Novocainum, normal saline solution etc.), and then it to aspirate. This method names as lavage of abdominal cavity. If in a solution the impurity of a blood, intestinal contents, urine, muddy exudate are found out, it proves damage of internal organs. Complications: damages of an intestine (at presence of adhesive process), formation of an ascitic fistula, infection of an abdominal cavity.

Laparoscopy Laparoscopy - optic-tool visual inspection of an abdominal cavity and its organs in the diagnostic purpose. It is indicated for detailed survey of an abdominal cavity with the purpose of detection of damages of organs, tumours and inflammatory processes, detection of a portal hypertension, clottage of mesenteric vessels etc. It is counterindicatied for the extremely serious patient, at the phenomena of a meteorism and adhesive process in an abÂdominal cavity. Trocar of a laparoscope are entered same as at a laparoÂcentesis. For expansion of an abdominal cavity into it a gas (air, Oxygenium, carbon dioxide) introduced through the special cock on a trocar or through a special needle from a set of a laparoscope. For introduction of gas usually use the special apparatus allowing it to sterilize. Then an optical tube entered for survey. Illumination of an abdominal cavity make by the lighter paired to an optical tube by means of a flexible light guide. That it is good to examine an abdominal cavity, it is neÂcessary to change a position of the patient on an operating table. Â

Surgical accesses and common rules of laparotomies The operation of opening of an abdominal cavity passes by the name of laparotomy. Distinguish a laparotomy therapeutic and diagnostic, or trial and relaparotomy (repeat). The therapeutic laparotomy includes, besides an abdominal section, inspection of an abdominal cavity and intervention on its organs. The diagnostic laparotomy is made for a final establishÂment of the diagnosis and opportunity of surgical removal of pathological formation, more often - malignant tumour.

The requirements to surgical incisions The cut for an access to organs of an abdomen should saÂtisfy to the following requirements: 1) the incision should be in a projection of an organ and provide the most brief way to it; 2) the size of a section should provide an easy approach to an operated organ;

3) the incision should minimally traumatize soft tissues, vessels and nerve and to provide formation of strong postoperaÂtive scar; 4) the incision should provide good cosmetic result. For an access to organs of an abdominal cavity there is a plenty of incisions. Depending on a direction of a incision in relation to an median line of a body the abdominal sections subdivide on longitudinal, transversal, oblique and angular.

Longitudinal incisions 1. The median laparotomy (midline incision) is carried out on a linea alba of an abdomen. Depending on a position of a inÂcision in relation to a umbilicus distinguish the superior, meÂdial and inferior median laparotomy. At the superior midline laparotomy the incision is carried out between a xiphoid process and umbiliÂcus. A direction of a incision from a xiphoid process to the umbilicus (to not damage a liver). The inferior midline laparotomy is carried out from a pubis up to a umbilicus (direction of a incision - from a pubis to not damage a urinary bladder). The middle midline laparotomy is carried out with round of a umbilicus at the left (so that the manipulations in an abdominal cavity were not prevented by a round ligament of a liver). The midline laparotimy has received the greatest applicatiÂon, as gives the following advantages: 1) quickness of performance, 2) a wide access to the majority of organs of an abdominal cavity, 3) does not damage a muscle, vessels and nerves, 4) an insignificant bleeding, 5) in case of necessity can be prolonged both up, and from top to bottom, 6) the incision can be easily closed. Disadvantages of a incision: that the postoperative scar has a strong tension (as is a place of connection of three paÂirs wide muscles) and the median line initially is the badly strengthened and poorly blood supplied part of a anterior abdoÂminal wall - therefore postoperative hernias may occur. 2. A paramedian incision carry out according to internal edge of a rectus abdominis muscle, the anterior leaf of its sheeth is dissectied in the same direction, a rectus muscle by a hook allocate laterally, the posterior leaf of a sheeth disÂsectied together with a parietal peritoneum. The advantage of this incision consists in formation of strong postoperative scar, as the rectus muscle is displaced and also incisions of anterior and posterior layers of a sheeth of rectus muscle do not coincide. A disadvantage it is the restriction of length. 3. Transrectal incision. Anterior and posterior walls of a sheeth of a rectus muscle are dissectied, and muscle stratify on a course of fibers. The advantage is same as at paramedian incision - the muscular tissue rich vessels, quickly grows toÂgether and strong scar formed.

However, at wide incisions the nervous branches going to medial departments of a muscle are damaged. Development of an atrophy of medial departments of a muscle and occurrence of a postoperative hernia subsequently is possible. I.e., a disadvantage it is the restriction of length. 4. A pararectal incision. An example - the Lenander inciÂsion - made parallel lateral edge of a rectus muscle laterally and below umbilicus. Anterior wall of a sheeth of a rectus muscle a dissectied, edge of the muscle allocate medially, and then posterior wall cut together with a parietal peritoneum. The incision is applied at appendectomy. The advantages and disadvantages are same as at transrecÂtal incision.

The oblique incisions This cuts usually made in the superior part of a anterior abdominal wall - paralÂlel to edge of a costal arch, in the inferior part - parallel inguinal ligament and little above it or under an angle to it. They used mainly for accesses to a liver, gallbladder, biÂle ducts, lien, vermiform appendix, sigmoid colon etc.).

The transverse incisions made with crossing of one or two rectus muscles above or below umbilicus. They provide a wide access to organs of an abdominal cavity, strong postoperative scar. However they applied less often others in view of the greater difficulty of their perforÂmance and suture (in comparison with a median laparotomy).

The angular incisions made if necessary prolongations or enlargement of the before made incision in the other direction under angle (for example, at the superior median laparotomy as access to a liver the inÂcision may prolongated perpendicular to left costal arch).

The combined incisions - the incisions at which open two cavities - abdominal and thoÂracic (thoracoabdominal accesses). They are applied: if necessary of wide access to organs of an abdominal caÂvity (at a gastrectomy, slenectomy, resection of a liver and other operations), at a simultaneous operations on organs of both cavities (for example, at thoracoabdominal wounds, when the organs of a abdomen and thorax are injured), at operations on organ posed in both cavities (for exampÂle, at an esophagoplasty).

The alternating (gridiron, muscle-splitting) incision - incision at which direction separations of tissues in different layers is changed on a course of performance of cut. In each layer the direction of a section of tissues depended from a direction of muscular or aponeurotic fibers, i.e. incision is made on a course of muscular or aponeurotic fibers. The advantage of this incision - muscles do not cut and due to discrepancy of lines of separation of muscles, the abdoÂminal wall keeps after operation the durability.

Example: McBurney-Volkovitch incision for appendectomy, Pfannenstiel incision for operation in gynaecology. Disadvantage of alternating incisions - small access.

The basic rules, which are necessary for keeping at all laparotomies and operations on organs of an abdominal cavity. At operations on organs of an abdominal cavity it is neÂcessary to keep a sequence in performance of stages of operatiÂon and certain rules of a laparotomy: 1. The incision of a anterior abdominal wall should be maÂde according to layers and according to layers to sew up (sequÂence of dissected layers depends on a kind of a incision - see above). 2. For preservation from pollution of an abdominal wall by contents of an abdominal cavity a wound covered by towels. 3. Most responsible stage of a laparotomy - opening of a peritoneum. A peritoneum open always under the control of an eye in order to prevent casual damage of organs of an abdominal cavity. The peritoneum is grasped and rises by two anatomic forcepses. Having convinced, that in the formed thus fold of a peritoneum there are no organs, the peritoneum is dissected and fixed to towels by Mikulicz forcepses. 4. A wound of an abdominal wall stretch by laminar hooks or retractor. It is necessary to keep up, that under branches of hooks the loops of an intestine, omentum and other organs should do not traumatize. In an abdominal cavity work only by anatomical forcepses. 5. The revision of an abdominal cavity should be carried out strictly methodically and in the certain sequence depending on its purposes. 6. The infringement of an integrity of a serousa of a orÂgan should be well-timed is noticed and is liquidated (sew). 7. It is desirable to operate on the emptied organ of an abdominal cavity. 8. To facilitate performance of operation and to prophyÂlactic of infection of an abdominal cavity the organ taken from it and operated outside of an abdominal cavity. If it is imposÂsible, it is carefully covered by napkins in depth of a wound, isolating thus from other organs. 9. For preservation from a desiccation the taken organ coÂvered by wet napkins. 10. After applying internal infected series of an intestiÂnal sutures closing a lumen of a organ, it is necessary to change covering towels and instruments; the operating brigade processes (washes) gloves by a disinfectant solution or changes them. 11. Upon termination of operation reliability of a hemosÂtasis is checked, whether the napkins, gauze globules, instruÂments are left in it. The abdominal cavity is carefully drained from a blood, exudate. 12. If it is necessary to put in an abdominal cavity a drainage or gauze tampons, they are recommended to prevent a divergence of sutures make this not through an operational woÂund, and through a contraperture - an additional incision away from basic.

Standard technique of performance of a laparotomy (Superior median laparotomy) Incision of a skin and subcutaneous layer carry out on a median line beginning above, a little having receded from a xiphoid process, and finish below, not reaching up to a umbiliÂcus. A bleeding from fine vessels stop by pressing or ligation. During a length of cutaneous incision lina alba dissected. A wound covered by the large gauze napkins or towels. By two anatomic forcepses on middle of a wound a fold of a peritoneum taken and cat it. The edges of a incision of a peritoneum joiÂned by Mikulicz forcepses to covering towels. A peritoneum dissected on all length of a wound, having raised by fingers, enÂtered in a cavity of a abdomen. After a section of a peritoneum a wound stretch by laminar hooks or automatic retractors. Then begin revision of an abdoÂminal cavity and performance of the basic stage of an operatiÂon. On a course of operation an abdominal cavity drained, conÂtents from canals, bursas and sinuses deleted by an electÂro-suction machine or gauze napkins. After operation it is recommended to make blockade of refÂlexogenic zones (celiac, superior and inferior mesenteric pleÂxuses) by 0,25 % solution of Novocainum. Upon termination of operation the abdominal cavity should carefully be drained by swabs from a blood and exudate and to check up, whether the napkins, globules, instruments are left in it casually. Abdominal wall sew up tightly or with introduction of draÂinages depending on the indications. Closing of an operational abdominal section make according to layers: at first sew up a peritoneum, then musculoaponeuroÂtic layer and, at last, skin. Suture of a peritoneum made by a continuous catgut suture. A suture begin in the inferior angle of a wound; the abdominal contents protected from possible punctures by the special spaÂtula (Reverden), or napkin, which before complete closing of a wound delete. Aponeurosis of a linea alba sewed by interrupted silk suÂtures. When to perform a levelby-level suture it is impossibÂle, a peritoneum sewed together with an aponeurosis. Even an abdominal wound closed by sutures through all layers. It hapÂpens at cancer or other attrition, when the sutures cut tissues of an abdominal wall, or at repeated operations after the ocÂcurred divergence of sutures and prolapse of organs (eventratiÂon). The putting off of cutaneous sutures in usual cases is maÂde through 7 - 8 days after operation.

Revision (exploration) of organs of an abdominal cavity It is made with the purpose of detection of damage of orÂgans at trauma of a abdomen, finding out of a source of inflamÂmatory process at a symptoms of an acute abdomen and decision of a question on an operability of malignant tumours of organs of an abdominal cavity. Operation will carry out from a median laparotomy sequencely and methodically.

At detection in an abdominal cavity of a blood first of all parenchymatous organs examined: a liver, lien, pancreas. During revision of a liver for survey are accessible its anteÂrior and inferior surface. The inferior surface becomes best outstanding after abduction of a transversal colon inferiorly. Visually a condition (integrity or damage) gallbladder and heÂpatoduodenal ligament determined. A diaphragmatic surface of a liver palpated by an hand entered in the right hypochondrium, under a dome of a diaphragm. In some cases for the best review it is necessary to dissect a falciform ligament of a liver. For survey of a lien a stomach displace to the right, and left colic flexure - to bottom. It allows to fin...

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