外科学课件：2015 Introduction

1、General Surgery外科学外科学Hepatobiliary Surgery Ma Qingyong 马清涌马清涌2015.3.1 IntroductionManagement of surgical disorders requires Application of technical skills and Training in the basic sciences to the problems of diagnosis and treatment基本知识、基本技能、基础理论 Genuine sympathy and indeed love for the patient. 2I

2、ntroduction The surgeon A doctor in the old-fashioned sense An applied scientist An engineer An artist Philosopher Psychologist Sociologist A minister of his or her fellow human beings. 34 technical proficiency (CASE)C (Concept，观念，观念)A (Anatomy，解剖，解剖)S (Skill，技巧，技巧)E (Emergency，应急，应急)43 Relationship

3、s GG (General and Group，将军和团队，将军和团队)MM (Major and Minor，大手术和小手术，大手术和小手术)QQ (Quantity and Quality， 数量和质量数量和质量)5Meditech-bioelementCommunication-basic technical skillScientific research-soul Cooperation-security团队合作是完成良好治疗的保证团队合作是完成良好治疗的保证 6Basic Pathological Processes All somatic diseases have their

4、origins in following six basic pathological processes:Congenital defectsInflammations Neoplasms Trauma Metabolic defects and degeneration Collagen defects7Phenomena Obstruction Perforation Erosion Tumors or masses 8Diseases due to Obstruction System Disease Nature of obstruction CNS ENT Eye Lung Bil

5、iary tract GI GU Extremity Hydrocephalus Middle ear infection Glaucoma Atelectasis Cholicystitis Appendicitis Prostatism Intermittent claudication Congenital obstruction of cerebrospinal fluid Eustachian tube obstruction Obstruction of aqueous humor Mucus plug in bronchus Systic duct stone Fecalith

6、in appendix Prostatic hypertrophy arteriosclerosis 9Examples of PerforationSystem Disease Nature of Perforation CNS ENT Lung Biliary tract GI GU Vascular Cerebral hemorrhage Perforation of tympanic membrane Spontaneous pneumothorax Rupture of gallbladder Duodenal ulcer Ruptured bladder Aortic aneury

7、sm Rupture of CNS artery Infection with pressure Rupture of bleb Obstruction, distension, necrosis Perforation of ulcer Obstruction and distension Rupture of aneurysm 10Examples of ErosionSystem Disease Nature of Erosion CNS ENT Lung GI GU Extrimity Meningitis Pharyngeal carcinoma Tuberculosis Duode

8、nal ulcer Bladder stone Raynauds phenomenon Erosion of abscess wall; mastoiditis Bleeding; erosion into blood vessels Bleeding; granulomatous erosion into blood vessels Bleeding; ulcer erosion into blood vessels Bleeding; erosion of bladder wall Digital ulceration; ischemic erosion of skin 11TumorsT

9、he most subtle of these phenomena is a tumor, or mass. This explains in large measure why cancer is so often detected only after it induces one of the three processes. Because no vital flow is obstructed and perforation or erosion of the skin occurs very late, symptoms, and consequently diagnosis, a

10、re delayed, often tragically. 12Approach to surgical patient History Physical examination Laboratory and other examination 13History SurgeonGain the patients confidence and convey the assurance that help is available and will be provided. Demonstrate concern for the patient Be gentle and considerate

11、Create an atmosphere of sympathy, personal interest and understandingStructure histories formallyAvoid asking leading questions14History Most patients are eager to like and trust their doctors and respond gratefully to a sympathetic and understanding person. 15BUILDING THE HISTORY History taking is

12、detective work. Preconceived ideas, snap judgments, and hasty conclusions have no place in this process. The diagnosis established by inductive reasoning. The interviewer must first determine the facts and then search for essential clues, realizing that the patient may conceal the most important sym

13、ptom in the hope that if it is not specifically inquired about or if nothing is found to account for it in the physical examination, it cannot be very serious. 1617PainCareful analysis of the nature of pain How the pain began? Was it explosive in onset, rapid. or gradual？What is the precise characte

14、r of the pain？Is it so severe that it cannot be relieved by medication？Is it constant or intermittent？Are there classic associations, such as the rhythmic pattern of small bowel obstruction or the onset of pain preceding the limp of intermittent claudication？ 18Reaction to PainA patient who shrieks

15、and thrashes about is either grossly overreacting or suffering from renal or biliary colic. Very severe pain-due to infection, inflammation, or vascular disease-usually forces the patient to restrict all movement as much as possible.Moderate pain is made agonizing by fear and anxiety. Restore the pa

16、tients confidence is often a more effective analgesic than an injection of morphine.19VomitingWhat did the patient vomit？How much？How often？What did the vomitus look like？Was vomiting projectile？It is especially helpful for the examiner to see the vomitus.20Change In Bowel HabitsA change in bowel ha

17、bits is a common complaint that is often of no significance. Regular evacuations noticed a distinct change, particularly toward intermittent alternations of constipation and diarrhea, colon cancer must be suspected. 21Hematemesis or HematocheziaMost common error is that rectum bleeding is attributab

18、le to hemorrhoids. The character of the blood can be of great significance. Does it clot? Is it bright or dark red? Is it changed in any way, as in the coffee-ground vomitus of slow gastric bleeding or the dark, tarry stool of upper gastrointestinal bleeding? 22TraumaTrauma occurs so commonly that i

19、t is often difficult to establish a relationship between the chief complaint and an episode of trauma. Children: attribute the onset of an illness to a specific recent injury. Unaware of severe trauma Not overlook the possibility of trauma inflicted by a parent23TraumaWhat was the patients position?

20、 When the accident occurred?Was consciousness lost? Retrograde amnesia (inability to remember events just preceding the accident) always indicates some degree of cerebral damage. Gunshot and stab wounds, knowing the weapon, its size and shape, probable trajectory, position of the patient when hit24F

21、amily HistoryPolyposis of the colon is a classic example, but diabetes, Peutz-Jeghers syndrome, chronic pancreatitis, multiglandular syndromes, other endocrine abnormalities, and cancer are often better understood and better evaluated in the light of a careful family history25Past HistoryPeople who

22、are well are almost never sick. And people who are sick are almost never well. Review the past history by inquiring about each systemConsider the nutritional backgroundFluid and electrolyteTherapy before laboratory results26Patient Emotional BackgroundPsychiatric consultation is seldom required Emot

23、ionally and mentally disturbed patients require operations, cooperation between psychiatrist and surgeon is essentialSurgeon deals with the emotional patient (malignant disease, amputation of an extremity, ileostomy, or colostomy) Importance of psychosocial factors in surgical convalescence27Physica

24、l ExaminationComplete examination includes Physical examinationLaboratory tests x-ray examination Certain special procedures (gastroscopy and esophagoscopy)Follow-up examination Painful, inconvenient and costly procedures ordered as less as possible28Elective Physical ExaminationDone in an orderly a

25、nd detailed fashionAll patients are sensitive and somewhat embarrassed at being examined. Put the patient at ease,comfortable examining room and table, using drapes if the patient is required to strip for the examination.Talk a bit to relax and take the past history29Elective Physical ExaminationObs

26、erve the patients general physique and habitus Carefully inspect the handsMany systemic diseases show themselves in the hands (cirrhosis of the liver, hyperthyroidism, Raynauds disease, pulmonary insufficiency, heart disease, and nutritional disorders)30Elective Physical ExaminationEssential Steps I

27、nspectionPalpationAuscultationPercussion 31Elective Physical ExaminationInspectionComparison of the two sides of the body : The slight droop of one eyelid characteristic of Horners syndrome Female breasts, particularly as the patient raises and lowers her arms, will often reveal slight dimpling indi

28、cative of an infiltrating carcinoma barely detectable on palpation32Elective Physical ExaminationRequires skill and gentlenessSpasm, tension, and anxiety caused by painful examination procedures may make an adequate examination almost impossible, particularly in childrenCareful, precise, and gentle

29、palpation gives the physician the information being sought and inspires confidence and trustOne finger for tenderness in acute abdomenFrom outside to central33Elective Physical ExaminationPercussion for ascites (shifting dullness), liver, spleenAuscultation: The nature of ileus and the presence of a

30、 variety of vascular lesions are revealed by auscultation. 35Examination of Body OrificesComplete examination of the ears, mouth, rectum, and pelvis Every surgeon should acquire familiarity with the use of the ophthalmoscope and sigmoidoscope and should use them regularly in doing complete physical

31、examinations36Emergency Physical Examination Routine PE fit the circumstancesHistory limited to a single sentence The primary considerations are following: Is the patient breathing? Is the airway open? (intubation, mouth-to-mouth respiration)Is there a palpable pulse? Is the heart beating? (cardiac

32、resuscitation)Is massive bleeding occurring?(if from extremity, elevation and pressure)37Emergency Physical ExaminationTension pneumothorax and cardiac tamponade may easily be overlooked if there are multiple injuriesCompletion of the survey examinationControl of pain Splinting of fractured limbsSut

33、uring of lacerationsOther types of emergency treatment 38Laboratory ExaminationObjectives: Screening for asymptomatic disease that affect surgical result Appraisal of diseases that contraindicate elective surgery or require treatment before surgery (diabetes, heart failure) Diagnosis of disorders th

34、at require surgery (hyperparathyroidism, pheochromocytoma) Evaluation of the nature and extent of metabolic or septic complications39Laboratory ExaminationComplete blood and urine examinationHistory of renal, hepatic, or heart disease requires detailed studies Surgeon is the only one with the experi

35、ence and background to interpret the meaning of laboratory tests in the light of other features of the case-particularly the history and physical findingsTotal management is surgeons responsibility40Imaging StudiesA complement not an alteration of PEx-ray filmB-mode ultrasoundCT scanMRI41Special exa

36、minationsCystoscopy GastroscopyEsophagoscopyColonoscopy AngiographyBronchoscopy are often required in the diagnostic appraisal of surgical disorders. 42Aseptic technique无菌术无菌术 (Asepsis) 基本操作规范基本操作规范 针对可能的感染来源和途径所采取的有效预针对可能的感染来源和途径所采取的有效预防方法。防方法。 由灭菌法、消毒法、无菌操作规则及管理制由灭菌法、消毒法、无菌操作规则及管理制度所组成。度所组成。灭菌灭菌(

37、(sterilization) )是指杀灭一切活的微生物。是指杀灭一切活的微生物。消毒消毒( (disinfection) )是指杀灭病原微生物和其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他有害微生物，并不要求彻底杀灭所有微生物（如芽胞等）。（如芽胞等）。43SterilizationThe only completely reliable methods of sterilization in wide current use for surgical instruments and supplies are steam under pressure (autoclav

38、ing) boiling methodsoaking methoddry heat, andformaldehyde fumigation44AutoclavingSaturated steam at a pressure (104-137.3kPa) (1520 psi) at a temperature of 121-126oC destroys all vegetative bacteria and most resistant dry spores in 30 minutes. Sterilization time is markedly shortened by the high-v

39、acuum or high-pressure, 132-134oC，205.8kPa，4min.Sterilization can keep for 2 weeks45Boiling methodBoiling water (100oC) for 15-20 min Spores need 1 hour2 min more for every 300 m in altitude The pressure of autoclave sterilizer is 127.5kPa, T=124oC for 10 min 46Dry Heatexposure to continuous dry hea

40、t at 160oC for 2 hour (170oC,1h;180oC,30min)will sterilize articles that would be spoiled by moist heat or are more conveniently kept dry. If grease or oil is present on instruments, safe sterilization calls for 4 hours exposure at 160oC.47Soaking method2% glutaral (戊二醛) 30min for disinfection, 10 h

41、our for sterilization10% formaldehyde 20-30 min（甲醛）75% alcohol (ethanol) 30 min 1:1000 benzalkonium bromide (新洁尔灭)1:1000 chlorhexidine (洗必泰) 30 min48Formaldehyde Fumigation(甲醛熏蒸）甲醛熏蒸）Potassium permanganate with 40% formaldehyde 1 hour for disinfection, sterilization for 6-12 hours49消毒法乙醇 75%碘伏 0.2%安

42、尔碘过氧乙酸 0.2-0.5%有效氯消毒剂50Skin AntisepticsThe most important applications of skin antisepsis are the hand scrub of the operating team and the preparation of the operative fields.51Hand Scrub RoutineAlthough the duration of the hand scrub is not universally defined, a 5-minute scrub before the first cas

43、e-provided a brush is used-appears to be sufficient. Greatest attention should paid to the fingertips and nails, since these areas harbor the greatest number of bacteria. A 2-minute scrub is adequate in between cases. Solutions containing chlorhexidine or one of the iodophors appear to be the most e

44、ffective.52Operative Field PreparationInitial preparation of the skin is usually done in the afternoon or evening before operation. The area should be washed with soap and water, making sure that it is grossly quite clean. A shower or tub bath is satisfactory. The type of soap used makes little diff

45、erence. Soap is a weak antiseptic and is useful because of its nonirritating detergent action, especially when washing is combined with mechanical friction.53Operative Field PreparationIn the operating room-A 1-minute skin preparation using other 70% alcohol or 2% iodine in 90% alcohol-followed by a

46、 polyester adherent wound drape- is effective in controlling wound infectionsIodine is one of the most-effective skin antiseptics available. It rarely causes skin reactions in this concentration. Avoid streaming of iodine outside of the operating field. Dot use iodine on the perineum, genitalia, or

47、face; on irritated or delicate skin or when the patient has a history of iodine sensitivity. 54Operative Field PreparationFor iodine sensitive patients, one can use 80% isopropyl or 70% ethyl alcohol. Apply to the skin with a gauze swab for 3 minutes and allow to dry before draping. Alternatively, t

48、inted tincture of benzalkonium (1:750) may be used.For sensitive areas (perineum, around the eyes, etc), apply iodophor , chlorhexidine, or 1:1000 aqueous benzalkonium solution. The adherent drape is an important component of infection control. Using drapes that simply lie over the skin is associate

49、d with a higher infection rate than using drapes that are firmly adherent.55Operative Field Preparation 2.53% iodine, then 70% alcohal twice1:1000 benzalkonium or 1:1000 chlohexidine twiceDisinfection from inside to outsideFor infective wound or anus from outside to insideArea15cm 56Universal Precau

50、tionsAll surgical staffs should routinely use appropriate barrier precautions-gloves, masks, goggles, etc-to prevent skin and mucous membrane exposure when contact with blood or body fluids is anticipated. Immediate hand and other skin surface washing is necessary if contamination occurs.57Universal

51、 PrecautionsSpecial precautions must be taken to avoid accidental injuries, eg, needle punctures and cuts.Workers who have any open wounds should avoid direct patient contact.If a glove is torn, it should be removed and changed as promptly as patient safety permits and the needle or instrument remov

52、ed from the sterile field.58手术人员和病人手术人员和病人手术区域的准备手术区域的准备手术人员术前准备：手术人员术前准备： 一般准备一般准备 手臂消毒法手臂消毒法 穿无菌手术衣穿无菌手术衣 戴无菌手套戴无菌手套病人手术区的准备病人手术区的准备 病人手术区皮肤消毒病人手术区皮肤消毒 病人手术区铺巾病人手术区铺巾59手术人员一般准备手术人员一般准备 更换手术室准备的清洁鞋和衣裤。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。口罩要盖住鼻孔，帽子要盖住全部头发。 剪短指甲。剪短指甲。 手臂皮肤破损或有化脓性感染时，不能参加手手臂皮肤破损或有化脓性感染时

53、，不能参加手术。术。60手臂消毒法手臂消毒法肥皂刷手法：肥皂刷手法： 用肥皂做一般的洗用肥皂做一般的洗手。手。 用无菌毛刷蘸肥皂用无菌毛刷蘸肥皂水刷洗手和臂，从水刷洗手和臂，从手指尖到肘上手指尖到肘上10cm处，两臂交替刷洗，处，两臂交替刷洗，特别注意甲缘、甲特别注意甲缘、甲沟、指蹼等处的刷沟、指蹼等处的刷洗。洗。61肥皂刷手法肥皂刷手法 一次刷完后，一次刷完后，手指朝上肘朝手指朝上肘朝下，用清水冲下，用清水冲洗手臂上的肥洗手臂上的肥皂水。皂水。 反复刷洗反复刷洗3遍，遍，共约共约10分钟。分钟。62肥皂刷手法肥皂刷手法 用无菌毛巾从手用无菌毛巾从手到肘部擦干手臂，到肘部擦干手臂，擦过肘部的毛

54、巾擦过肘部的毛巾不可再擦手部。不可再擦手部。 手臂在手臂在70%酒精酒精溶液中浸泡溶液中浸泡5分分钟，稍干后穿手钟，稍干后穿手术衣和戴手套。术衣和戴手套。63手臂消毒法手臂消毒法其它刷手法：其它刷手法： 碘尔康刷手法碘尔康刷手法 灭菌王刷手法灭菌王刷手法 洁芙柔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)流水冲洗无菌毛巾擦干手臂消毒：8-10ml涂抹，自然干燥65穿无菌手术衣穿无菌手术衣66戴无菌手套戴无菌手套 将右手插入右手手套内将右手插入右手手套内. 已带好手套的右手指插入左手套的翻折部，

55、已带好手套的右手指插入左手套的翻折部，帮助左手插入手套内。帮助左手插入手套内。 将手套翻折部翻回盖住手术衣袖口将手套翻折部翻回盖住手术衣袖口. 用无菌盐水冲洗手套外面的滑石粉。用无菌盐水冲洗手套外面的滑石粉。67病人手术区皮肤消毒病人手术区皮肤消毒消毒药物消毒药物 2.5-3%碘酊涂擦皮肤碘酊涂擦皮肤1遍，遍，70%酒精将碘酒精将碘酊擦净酊擦净2次。次。 0.5%碘尔康或碘尔康或1：1000苯扎溴铵涂擦苯扎溴铵涂擦2遍。遍。 婴儿、面部皮肤、口腔、肛门、外生殖婴儿、面部皮肤、口腔、肛门、外生殖器，一般用器，一般用0.75%吡咯烷酮消毒。吡咯烷酮消毒。 植皮时，供皮区的消毒用植皮时，供皮区的消毒

56、用70%酒精涂擦酒精涂擦23次次.68注意事项注意事项 非感染伤口：由手术区中心部向四周涂擦。非感染伤口：由手术区中心部向四周涂擦。 感染伤口或肛门：手术区外周涂向感染伤口或会感染伤口或肛门：手术区外周涂向感染伤口或会阴肛门处。阴肛门处。 已经接触污染部位的药液纱布不应再返擦清洁处。已经接触污染部位的药液纱布不应再返擦清洁处。 手术区皮肤消毒范围要包括手术切口周围手术区皮肤消毒范围要包括手术切口周围15cm的区域。的区域。69 颅脑手术颅脑手术 颈部手术颈部手术70 胸部手术胸部手术 腹部手术腹部手术71 腹股沟和腹股沟和阴囊部手术阴囊部手术肾部手术肾部手术会阴部和会阴部和肛门部手术肛门部手术72 四肢手术73病人手术区铺巾病