Introductio外科学概论-马清涌教授

GeneralSurgery,外科学,HepatobiliarySurgeryMaQingyong马清涌2013.9.8,Introduction,ManagementofsurgicaldisordersrequiresApplicationoftechnicalskillsandTraininginthebasicsciencestotheproblemsofdiagnosisandtreatment基本知识、基本技能、基础理论Genuinesympathyandindeedloveforthepatient.,2,Introduction,ThesurgeonAdoctorintheold-fashionedsenseAnappliedscientistAnengineerAnartistPhilosopherPsychologistSociologistAministerofhisorherfellowhumanbeings.,3,4technicalproficiency(CASE),C(Concept，观念)A(Anatomy，解剖)S(Skill，技巧)E(Emergency，应急),4,3Relationships,GG(GeneralandGroup，将军和团队)MM(MajorandMinor，大手术和小手术)QQ(QuantityandQuality，数量和质量),5,Meditech-bioelementCommunication-basictechnicalskillScientificresearch-soulCooperation-security,6,BasicPathologicalProcesses,Allsomaticdiseaseshavetheiroriginsinfollowingsixbasicpathologicalprocesses:CongenitaldefectsInflammationsNeoplasmsTraumaMetabolicdefectsanddegenerationCollagendefects,7,Phenomena,ObstructionPerforationErosionTumorsormasses,8,DiseasesduetoObstruction,9,ExamplesofPerforation,10,ExamplesofErosion,11,Tumors,Themostsubtleofthesephenomenaisatumor,ormass.Thisexplainsinlargemeasurewhycancerissooftendetectedonlyafteritinducesoneofthethreeprocesses.Becausenovitalflowisobstructedandperforationorerosionoftheskinoccursverylate,symptoms,andconsequentlydiagnosis,aredelayed,oftentragically.,12,Approachtosurgicalpatient,HistoryPhysicalexaminationLaboratoryandotherexamination,13,History,SurgeonGainthepatientsconfidenceandconveytheassurancethathelpisavailableandwillbeprovided.DemonstrateconcernforthepatientBegentleandconsiderateCreateanatmosphereofsympathy,personalinterestandunderstandingStructurehistoriesformallyAvoidaskingleadingquestions,14,History,Mostpatientsareeagertolikeandtrusttheirdoctorsandrespondgratefullytoasympatheticandunderstandingperson.,15,BUILDINGTHEHISTORY,Historytakingisdetectivework.Preconceivedideas,snapjudgments,andhastyconclusionshavenoplaceinthisprocess.Thediagnosisestablishedbyinductivereasoning.Theinterviewermustfirstdeterminethefactsandthensearchforessentialclues,realizingthatthepatientmayconcealthemostimportantsymptominthehopethatifitisnotspecificallyinquiredaboutorifnothingisfoundtoaccountforitinthephysicalexamination,itcannotbeveryserious.,16,17,Pain,CarefulanalysisofthenatureofpainHowthepainbegan?Wasitexplosiveinonset,radual？Whatistheprecisecharacterofthepain？Isitsoseverethatitcannotberelievedbymedication？Isitconstantorintermittent？Arethereclassicassociations,suchastherhythmicpatternofsmallbowelobstructionortheonsetofpainprecedingthelimpofintermittentclaudication？,18,ReactiontoPain,Apatientwhoshrieksandthrashesaboutiseithergrosslyoverreactingorsufferingfromrenalorbiliarycolic.Veryseverepain-duetoinfection,inflammation,orvasculardisease-usuallyforcesthepatienttorestrictallmovementasmuchaspossible.Moderatepainismadeagonizingbyfearandanxiety.Restorethepatientsconfidenceisoftenamoreeffectiveanalgesicthananinjectionofmorphine.,19,Vomiting,Whatdidthepatientvomit？Howmuch？Howoften？Whatdidthevomituslooklike？Wasvomitingprojectile？Itisespeciallyhelpfulfortheexaminertoseethevomitus.,20,ChangeInBowelHabits,Achangeinbowelhabitsisacommoncomplaintthatisoftenofnosignificance.Regularevacuationsnoticedadistinctchange,particularlytowardintermittentalternationsofconstipationanddiarrhea,coloncancermustbesuspected.,21,HematemesisorHematochezia,Mostcommonerroristhatrectumbleedingisattributabletohemorrhoids.Thecharacterofthebloodcanbeofgreatsignificance.Doesitclot?Isitbrightordarkred?Isitchangedinanyway,asinthecoffee-groundvomitusofslowgastricbleedingorthedark,tarrystoolofuppergastrointestinalbleeding?,22,Trauma,Traumaoccurssocommonlythatitisoftendifficulttoestablisharelationshipbetweenthechiefcomplaintandanepisodeoftrauma.Children:attributetheonsetofanillnesstoaspecificrecentinjury.UnawareofseveretraumaNotoverlookthepossibilityoftraumainflictedbyaparent,23,Trauma,Whatwasthepatientsposition?Whentheaccidentoccurred?Wasconsciousnesslost?Retrogradeamnesia(inabilitytoremembereventsjustprecedingtheaccident)alwaysindicatessomedegreeofcerebraldamage.Gunshotandstabwounds,knowingtheweapon,itssizeandshape,probabletrajectory,positionofthepatientwhenhit,24,FamilyHistory,Polyposisofthecolonisaclassicexample,butdiabetes,Peutz-Jegherssyndrome,chronicpancreatitis,multiglandularsyndromes,otherendocrineabnormalities,andcancerareoftenbetterunderstoodandbetterevaluatedinthelightofacarefulfamilyhistory,25,PastHistory,Peoplewhoarewellarealmostneversick.Andpeoplewhoaresickarealmostneverwell.ReviewthepasthistorybyinquiringabouteachsystemConsiderthenutritionalbackgroundFluidandelectrolyteTherapybeforelaboratoryresults,26,PatientEmotionalBackground,PsychiatricconsultationisseldomrequiredEmotionallyandmentallydisturbedpatientsrequireoperations,cooperationbetweenpsychiatristandsurgeonisessentialSurgeondealswiththeemotionalpatient(malignantdisease,amputationofanextremity,ileostomy,orcolostomy)Importanceofpsychosocialfactorsinsurgicalconvalescence,27,PhysicalExamination,CompleteexaminationincludesPhysicalexaminationLaboratorytestsx-rayexaminationCertainspecialprocedures(gastroscopyandesophagoscopy)Follow-upexaminationPainful,inconvenientandcostlyproceduresorderedaslessaspossible,28,ElectivePhysicalExamination,DoneinanorderlyanddetailedfashionAllpatientsaresensitiveandsomewhatembarrassedatbeingexamined.Putthepatientatease,comfortableexaminingroomandtable,usingdrapesifthepatientisrequiredtostripfortheexamination.Talkabittorelaxandtakethepasthistory,29,ElectivePhysicalExamination,ObservethepatientsgeneralphysiqueandhabitusCarefullyinspectthehandsManysystemicdiseasesshowthemselvesinthehands(cirrhosisoftheliver,hyperthyroidism,Raynaudsdisease,pulmonaryinsufficiency,heartdisease,andnutritionaldisorders),30,ElectivePhysicalExamination,EssentialStepsInspectionPalpationAuscultationPercussion,31,ElectivePhysicalExamination,InspectionComparisonofthetwosidesofthebody:TheslightdroopofoneeyelidcharacteristicofHornerssyndromeFemalebreasts,particularlyasthepatientraisesandlowersherarms,willoftenrevealslightdimplingindicativeofaninfiltratingcarcinomabarelydetectableonpalpation,32,ElectivePhysicalExamination,RequiresskillandgentlenessSpasm,tension,andanxietycausedbypainfulexaminationproceduresmaymakeanadequateexaminationalmostimpossible,particularlyinchildrenCareful,precise,andgentlepalpationgivesthephysiciantheinformationbeingsoughtandinspiresconfidenceandtrustOnefingerfortendernessinacuteabdomenFromoutsidetocentral,33,ElectivePhysicalExamination,Percussionforascites(shiftingdullness),liver,spleenAuscultation:Thenatureofileusandthepresenceofavarietyofvascularlesionsarerevealedbyauscultation.,35,ExaminationofBodyOrifices,Completeexaminationoftheears,mouth,rectum,andpelvisEverysurgeonshouldacquirefamiliaritywiththeuseoftheophthalmoscopeandsigmoidoscopeandshouldusethemregularlyindoingcompletephysicalexaminations,36,EmergencyPhysicalExamination,RoutinePEfitthecircumstancesHistorylimitedtoasinglesentenceTheprimaryconsiderationsarefollowing:Isthepatientbreathing?Istheairwayopen?(intubation,mouth-to-mouthrespiration)Isthereapalpablepulse?Istheheartbeating?(cardiacresuscitation)Ismassivebleedingoccurring?(iffromextremity,elevationandpressure),37,EmergencyPhysicalExamination,TensionpneumothoraxandcardiactamponademayeasilybeoverlookediftherearemultipleinjuriesCompletionofthesurveyexaminationControlofpainSplintingoffracturedlimbsSuturingoflacerationsOthertypesofemergencytreatment,38,LaboratoryExamination,Objectives:ScreeningforasymptomaticdiseasethataffectsurgicalresultAppraisalofdiseasesthatcontraindicateelectivesurgeryorrequiretreatmentbeforesurgery(diabetes,heartfailure)Diagnosisofdisordersthatrequiresurgery(hyperparathyroidism,pheochromocytoma)Evaluationofthenatureandextentofmetabolicorsepticcomplications,39,LaboratoryExamination,CompletebloodandurineexaminationHistoryofrenal,hepatic,orheartdiseaserequiresdetailedstudiesSurgeonistheonlyonewiththeexperienceandbackgroundtointerpretthemeaningoflaboratorytestsinthelightofotherfeaturesofthecase-particularlythehistoryandphysicalfindingsTotalmanagementissurgeonsresponsibility,40,ImagingStudies,AcomplementnotanalterationofPEx-rayfilmB-modeultrasoundCTscanMRI,41,Specialexaminations,CystoscopyGastroscopyEsophagoscopyColonoscopyAngiographyBronchoscopyareoftenrequiredinthediagnosticappraisalofsurgicaldisorders.,42,Aseptictechnique,无菌术(Asepsis)基本操作规范针对可能的感染来源和途径所采取的有效预防方法。由灭菌法、消毒法、无菌操作规则及管理制度所组成。灭菌(sterilization)是指杀灭一切活的微生物。消毒(disinfection)是指杀灭病原微生物和其他有害微生物，并不要求彻底杀灭所有微生物（如芽胞等）。,43,Sterilization,Theonlycompletelyreliablemethodsofsterilizationinwidecurrentuseforsurgicalinstrumentsandsuppliesaresteamunderpressure(autoclaving)boilingmethodsoakingmethoddryheat,andformaldehydefumigation,44,Autoclaving,Saturatedsteamatapressure(104-137.3kPa)(1520psi)atatemperatureof121-126oCdestroysallvegetativebacteriaandmostresistantdrysporesin30minutes.Sterilizationtimeismarkedlyshortenedbythehigh-vacuumorhigh-pressure,132-134oC，205.8kPa，4min.Sterilizationcankeepfor2weeks,45,Boilingmethod,Boilingwater(100oC)for15-20minSporesneed1hour2minmoreforevery300minaltitudeThepressureofautoclavesterilizeris127.5kPa,T=124oCfor10min,46,DryHeat,exposuretocontinuousdryheatat160oCfor2hour(170oC,1h;180oC,30min)willsterilizearticlesthatwouldbespoiledbymoistheatoraremoreconvenientlykeptdry.Ifgreaseoroilispresentoninstruments,safesterilizationcallsfor4hoursexposureat160oC.,47,Soakingmethod,2%glutaral(glutaraldehyde)30minfordisinfection,10hourforsterilization10%formaldehyde20-30min75%alcohol(ethanol)30min1:1000benzalkoniumbromide(新洁尔灭)1:1000chlorhexidine(洗必泰)30min,48,FormaldehydeFumigation,Potassiumpermanganatewith40%formaldehyde1hourfordisinfection,sterilizationfor6-12hours,49,消毒法,乙醇75%碘伏0.2%安尔碘过氧乙酸0.2-0.5%有效氯消毒剂,50,SkinAntiseptics,Themostimportantapplicationsofskinantisepsisarethehandscruboftheoperatingteamandthepreparationoftheoperativefields.,51,HandScrubRoutine,Althoughthedurationofthehandscrubisnotuniversallydefined,a5-minutescrubbeforethefirstcase-providedabrushisused-appearstobesufficient.Greatestattentionshouldpaidtothefingertipsandnails,sincetheseareasharborthegreatestnumberofbacteria.A2-minutescrubisadequateinbetweencases.Solutionscontainingchlorhexidineoroneoftheiodophorsappeartobethemosteffective.,52,OperativeFieldPreparation,Initialpreparationoftheskinisusuallydoneintheafternoonoreveningbeforeoperation.Theareashouldbewashedwithsoapandwater,makingsurethatitisgrosslyquiteclean.Ashowerortubbathissatisfactory.Thetypeofsoapusedmakeslittledifference.Soapisaweakantisepticandisusefulbecauseofitsnonirritatingdetergentaction,especiallywhenwashingiscombinedwithmechanicalfriction.,53,OperativeFieldPreparation,Intheoperatingroom-A1-minuteskinpreparationusingother70%alcoholor2%iodinein90%alcohol-followedbyapolyesteradherentwounddrape-iseffectiveincontrollingwoundinfectionsIodineisoneofthemost-effectiveskinantisepticsavailable.Itrarelycausesskinreactionsinthisconcentration.Avoidstreamingofiodineoutsideoftheoperatingfield.Dotuseiodineontheperineum,genitalia,orface;onirritatedordelicateskinorwhenthepatienthasahistoryofiodinesensitivity.,54,OperativeFieldPreparation,Foriodinesensitivepatients,onecanuse80%isopropylor70%ethylalcohol.Applytotheskinwithagauzeswabfor3minutesandallowtodrybeforedraping.Alternatively,tintedtinctureofbenzalkonium(1:750)maybeused.Forsensitiveareas(perineum,aroundtheeyes,etc),applyiodophor,chlorhexidine,or1:1000aqueousbenzalkoniumsolution.Theadherentdrapeisanimportantcomponentofinfectioncontrol.Usingdrapesthatsimplylieovertheskinisassociatedwithahigherinfectionratethanusingdrapesthatarefirmlyadherent.,55,OperativeFieldPreparation,2.53%iodine,then70%alcohaltwice1:1000benzalkoniumor1:1000chlohexidinetwiceDisinfectionfrominsidetooutsideForinfectivewoundoranusfromoutsidetoinsideArea15cm,56,UniversalPrecautions,Allsurgicalstaffsshouldroutinelyuseappropriatebarrierprecautions-gloves,masks,goggles,etc-topreventskinandmucousmembraneexposurewhencontactwithbloodorbodyfluidsisanticipated.Immediatehandandotherskinsurfacewashingisnecessaryifcontaminationoccurs.,57,UniversalPrecautions,Specialprecautionsmustbetakentoavoidaccidentalinjuries,eg,needlepuncturesandcuts.Workerswhohaveanyopenwoundsshouldavoiddirectpatientcontact.Ifagloveistorn,itshouldberemovedandchangedaspromptlyaspatientsafetypermitsandtheneedleorinstrumentremovedfromthesterilefield.,58,手术人员和病人手术区域的准备,手术人员术前准备：一般准备手臂消毒法穿无菌手术衣戴无菌手套病人手术区的准备病人手术区皮肤消毒病人手术区铺巾,59,手术人员一般准备,更换手术室准备的清洁鞋和衣裤。口罩要盖住鼻孔，帽子要盖住全部头发。剪短指甲。手臂皮肤破损或有化脓性感染时，不能参加手术。,60,手臂消毒法,肥皂刷手法：用肥皂做一般的洗手。用无菌毛刷蘸肥皂水刷洗手和臂，从手指尖到肘上10cm处，两臂交替刷洗，特别注意甲缘、甲沟、指蹼等处的刷洗。,61,肥皂刷手法一次刷完后，手指朝上肘朝下，用清水冲洗手臂上的肥皂水。反复刷洗3遍，共约10分钟。,62,肥皂刷手法用无菌毛巾从手到肘部擦干手臂，擦过肘部的毛巾不可再擦手部。手臂在70%酒精溶液中浸泡5分钟，稍干后穿手术衣和戴手套。,63,手臂消毒法,其它刷手法：碘尔康刷手法灭菌王刷手法洁芙柔刷手法,64,流水冲洗双手臂取洗手液4-5ml七步洗手法（手掌相对，手掌对手背，双手十指交叉，双手互握，拇指，指尖，手臂至上臂下1/3)无菌毛巾擦干手臂消毒：8-