Ebook Farquharson’s textbook of operative general surgery (9/E): Part 2
➤ Gửi thông báo lỗi ⚠️ Báo cáo tài liệu vi phạmNội dung chi tiết: Ebook Farquharson’s textbook of operative general surgery (9/E): Part 2
Ebook Farquharson’s textbook of operative general surgery (9/E): Part 2
14EMERGENCY LAPAROTOMYIntroductionEmergency laparotomy for non-traumatic haemorrhageEmergency laparotomy for peritonitisIntraoperative dilemmas in the Ebook Farquharson’s textbook of operative general surgery (9/E): Part 2e acute abdomen233 Surgery for the drainage of localized pus233Abdominal trauma: general principles234Laparotomy for trauma237References237239240246INTRODUCTIONAn exploratory laparotomy is carried out in conditions where the need for an operation is recognized but where a definitive diagnosis cannot Ebook Farquharson’s textbook of operative general surgery (9/E): Part 2 be made until the abdomen is opened. Whenever possible, however, an attempt should be made to arrive at an accurate, or at least a provisional, diagnEbook Farquharson’s textbook of operative general surgery (9/E): Part 2
osis before surgery. This not only allows the surgeon to plan the optimum surgical approach to the problem, but may also indicate an intra-alxlominal 14EMERGENCY LAPAROTOMYIntroductionEmergency laparotomy for non-traumatic haemorrhageEmergency laparotomy for peritonitisIntraoperative dilemmas in the Ebook Farquharson’s textbook of operative general surgery (9/E): Part 2ere the value of exhaustive investigations has to be balanced against any deterioration which may occur in the patient's general condition during the inevitable delay. A short delay, during which both active resuscitation and preliminary investigations are performed, is however usually beneficial as Ebook Farquharson’s textbook of operative general surgery (9/E): Part 2 surgery' on severely shocked or septic patients carries a high mortality. Intensive preoperative resuscitation has the potential to improve physiologEbook Farquharson’s textbook of operative general surgery (9/E): Part 2
ical status, and reduce the risk of perioperative death, but unfortunately deterioration can also occur. Cardiovascular stability, and adequate tissue14EMERGENCY LAPAROTOMYIntroductionEmergency laparotomy for non-traumatic haemorrhageEmergency laparotomy for peritonitisIntraoperative dilemmas in the Ebook Farquharson’s textbook of operative general surgery (9/E): Part 2ompromised by strangulation, or excessive dilatation, may infarct with resultant perforation and sepsis, and absorption of toxic products from any dead tissue will also continue (see Chapter II). The timing of surgery’ is therefore very important. The surgeon, aware of the deteriorating intra-abdomi Ebook Farquharson’s textbook of operative general surgery (9/E): Part 2-nal situation, is often impatient to operate on a patient unfit for major intervention. The anaesthetist, in contrast, may strive too long to optimizEbook Farquharson’s textbook of operative general surgery (9/E): Part 2
e a patient preoperatively in situations where deterioration is inevitable until the underlying pathology has been addressed by urgent surgery. Any ap14EMERGENCY LAPAROTOMYIntroductionEmergency laparotomy for non-traumatic haemorrhageEmergency laparotomy for peritonitisIntraoperative dilemmas in the Ebook Farquharson’s textbook of operative general surgery (9/E): Part 2for such cases.An emergency laparotomy may be required for major, or persistent, intra-abdominal haemorrhage, whether spontaneous or as a sequel to abdominal trauma. It is also necessary for any traumatic, infective or ischaemic condition in which the integrity of the gastrointestinal wall as a barr Ebook Farquharson’s textbook of operative general surgery (9/E): Part 2ier is threatened, or has already been breached. The surgery of intestinal obstruction is covered in more detail in Chapter 22, but the initial manageEbook Farquharson’s textbook of operative general surgery (9/E): Part 2
ment of the obstruction is conservative unless the gut wall is threatened by ischaemia. Similarly, infective intra-abdominal pathologies, in the absen14EMERGENCY LAPAROTOMYIntroductionEmergency laparotomy for non-traumatic haemorrhageEmergency laparotomy for peritonitisIntraoperative dilemmas in the Ebook Farquharson’s textbook of operative general surgery (9/E): Part 2d even small collections of pus can be re-absorbed. Larger collections or pus must be drained, but a laparotomy can be avoided in many situations by the use of image-guided percutaneous drainage techniques.EMERGENCY LAPAROTOMY FOR NON-TRAUMATIC HAEMORRHAGEImmediate intervention is indicated for mass Ebook Farquharson’s textbook of operative general surgery (9/E): Part 2ive intraabdominal haemorrhage which may be intraluminal, but more often is intraperitoneal or retroperitoneal. Surgery is required in parallel with tEbook Farquharson’s textbook of operative general surgery (9/E): Part 2
he continuing resuscitation, as any delay is detrimental when the requirement for blood replacement is massive and continuous. Urgent intervention is 14EMERGENCY LAPAROTOMYIntroductionEmergency laparotomy for non-traumatic haemorrhageEmergency laparotomy for peritonitisIntraoperative dilemmas in the Ebook Farquharson’s textbook of operative general surgery (9/E): Part 2intraperitoneal and extraperitoneal haemorrhageA shocked hypovolaemic patient without a history of trauma, or external blood loss, may have had a massive spontaneous intraperitoneal bleed. The most likely underlying234 Emergency laparotomypathology will depend on the age and sex of the patient. Rupt Ebook Farquharson’s textbook of operative general surgery (9/E): Part 2ured ectopic pregnancies (see Chapter 26) and ruptured abdominal aortic aneurysms (see Chapter 6) account for the majority of cases. Rarer causes inclEbook Farquharson’s textbook of operative general surgery (9/E): Part 2
ude haemorrhage from a liver tumour, rupture of a splenic artery aneurysm, and the spontaneous rupture of a spleen, rendered more fragile by glandular14EMERGENCY LAPAROTOMYIntroductionEmergency laparotomy for non-traumatic haemorrhageEmergency laparotomy for peritonitisIntraoperative dilemmas in the Ebook Farquharson’s textbook of operative general surgery (9/E): Part 2mically stable for a variable period before free haemorrhage into the peritoneal cavity ensues. If the diagnosis is in doubt, a computed tomography (CT) scan is helpful, but the delay for imaging is contraindicated in the unstable patient, and the surgeon must proceed directly to laparotomy without Ebook Farquharson’s textbook of operative general surgery (9/E): Part 2the benefit of confirmatory diagnostic evidence. The abdomen is opened through a generous midline incision, and the surgery is then that of the underlEbook Farquharson’s textbook of operative general surgery (9/E): Part 2
ying condition, as discussed in the relevant chapters. However, the first duty of the surgeon is to arrest the bleeding by a clamp, digital pressure o14EMERGENCY LAPAROTOMYIntroductionEmergency laparotomy for non-traumatic haemorrhageEmergency laparotomy for peritonitisIntraoperative dilemmas in the Ebook Farquharson’s textbook of operative general surgery (9/E): Part 2x II). Unfortunately, unless this is a procedure in common use in an operating theatre, attempts to institute it in an occasional emergency usually fail.Many elderly patients on long-term anticoagulation are at risk of a Spontaneous intra-abdominal haemorrhage. Presentations vary, but are seldom sud Ebook Farquharson’s textbook of operative general surgery (9/E): Part 2den or dramatic. The patient is more often anaemic than profoundly shocked. The haemorrhage is usually within the mesentery, the anterior abdominal waEbook Farquharson’s textbook of operative general surgery (9/E): Part 2
ll or retroperitoneum, where the expanding haematoma produces pressure effects and pain. The haematoma also activates and consumes clotting factors, a14EMERGENCY LAPAROTOMYIntroductionEmergency laparotomy for non-traumatic haemorrhageEmergency laparotomy for peritonitisIntraoperative dilemmas in the Ebook Farquharson’s textbook of operative general surgery (9/E): Part 2 range of 2.5-3.5, but this continues to rise, and levels as high as 8 or above are not uncommon in these circumstances. The first priority is to restore blood clotting by reversal of anticoagulation (see Appendix I), and no surgical intervention may be necessary. If there is a large haematoma evacu Ebook Farquharson’s textbook of operative general surgery (9/E): Part 2ation may be justified, especially as normal coagulation may be difficult to achieve with the haematoma in silit, but this surgery* must be covered wiEbook Farquharson’s textbook of operative general surgery (9/E): Part 2
th a fresh-frozen plasma infusion.Postoperative haemorrhagePRIMARY HAEMORRHAGEPrimary haemorrhage during the first 24 hours after abdominal surgery ma14EMERGENCY LAPAROTOMYIntroductionEmergency laparotomy for non-traumatic haemorrhageEmergency laparotomy for peritonitisIntraoperative dilemmas in the Ebook Farquharson’s textbook of operative general surgery (9/E): Part 2essel is involved but if bleeding continues then surgical intervention may have to be considered. Clotting abnormalities should be checked, and corrected, and it should be remembered that a large haematoma will derange the clotting factors. If bleedingcontinues, re-exploration is indicated. Often a Ebook Farquharson’s textbook of operative general surgery (9/E): Part 2haematoma is found, and evacuated, but no bleeding vessel, or persistent haemorrhage, can be identified. The abdomen is closed with a suction drain toEbook Farquharson’s textbook of operative general surgery (9/E): Part 2
the area from which the haematoma was evacuated, and further haemorrhage seldom ensues. If an actively bleeding vessel is identified, it is ligated b14EMERGENCY LAPAROTOMYIntroductionEmergency laparotomy for non-traumatic haemorrhageEmergency laparotomy for peritonitisIntraoperative dilemmas in the Ebook Farquharson’s textbook of operative general surgery (9/E): Part 2on packing with large gauze swabs, which are removed at a second laparotomy around 48-72 hours later, is often effective.SECONDARY HAEMORRHAGESecondary haemorrhage, which most commonly occurs at around 10 day's after surgery, is very difficult to deal with satisfactorily at reoperation. It may occur Ebook Farquharson’s textbook of operative general surgery (9/E): Part 2 in the pelvis after rectal surgery, or from the posterior wall of the lesser sac, either as a complication of pancreatitis or after gastric surgery.Ebook Farquharson’s textbook of operative general surgery (9/E): Part 2
It is associated with infection, and the tissue is friable. Sutures and ligatures tear through the tissue, and packing is normally the only practical 14EMERGENCY LAPAROTOMYIntroductionEmergency laparotomy for non-traumatic haemorrhageEmergency laparotomy for peritonitisIntraoperative dilemmas in the Ebook Farquharson’s textbook of operative general surgery (9/E): Part 2facilities are available, selective embolization offers a better alternative to surgical ligation.Haemorrhage into the lumen of the gastrointestinal tractOccasionally, the surgeon is forced to operate for massive and continuous intraluminal blood loss without the benefit of preoperative endoscopy, b Ebook Farquharson’s textbook of operative general surgery (9/E): Part 2ut more often the surgery can be delayed for full resuscitation, and endoscopic and radiological investigations. The surgical management of upper gastEbook Farquharson’s textbook of operative general surgery (9/E): Part 2
rointestinal haemorrhage is discussed in Chapter 17, and that of lower gastrointestinal haemorrhage in Chapter 22.Gynaecological and obstetric haemorrGọi ngay
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