SURGICAL TREATMENT OF RAS

From Big Medical Encyclopedia

HIRURGYCHESKY PROCESSING

of RAS — the operative measure consisting in a wide section of a wound, a stop of bleeding, excision of impractical fabrics, removal of foreign bodys, free bone fragments, clots for the purpose of prevention of a wound fever and creating favorable conditions for a wound repair.

A. Paré, apparently, the first formulated the requirement about that at wound the surgeon immediately expanded a wound if only the field of its distribution it allows. The first operations, to-rye it is possible to consider as a prototype of modern surgical treatment of wounds, are described by the French surgeon of JIe Torn (H. F. Le Dran, 1685 — 1770) and are called by it a precautionary section of wounds. Tactics of a preventive section of wounds found support of prominent field surgeons of 18 — 19 centuries, including Bilger, P. Percy and D. Larrey. The section and clarification of wounds from pollution were recommended

by A. A. Charukovsky in the multivolume management «Military and marching medicine» (1836 — 1837). In development of questions of operational treatment of wounds in the war the big merit belongs to N. I. Pirogov, to-ry suggested to make a wide fasciotomy at a section of a wound and to excise impractical fabrics in the extensive gaping wound. Propagandized and applied active surgical tactics at gunshot wounds during the Russian-Turkish war of 1877 — 1878 K. K. Reyer. In 1898 Mr. P. Friedrich reported about experiments on animals, according to the Crimea the wounds contaminated by the garden earth excised and which are sewn up in the first 6 hours after pollution healed first intention. Despite it during World War I of 1914 — 1918 preventive operation was carried out only by certain surgeons. So, K. Garre and A. Polikar tried ‘to excise wounds by P. Friedrich's method;

A. Bir, AA. Payr, Lemettre, Tyuffye (Th. Tuffier), Gray (N. of Gray), etc. processed wounds as a precautionary section or supplemented it with partial excision of walls of a wound. V. A. Oppel, H in some cases resorted to surgical treatment of wounds. N. Burdenko, M. I. Rostovtsev, V. I. Ivanov, etc. Experience of World War I E. Berg a manna proved insolvency of the concept, to-ry considered a bullet wound of initially sterile, i.e. not demanding preventive operation. However until the end of war in one of the battling armies uniform approaches to surgical treatment of wounds were not developed.

In the years preceding ii to Patriotic war Is big, in the USSR deep and comprehensive study of pathology of a bullet wound (see Wounds, wounds), methods of its surgical treatment, prevention and treatment wound inf was conducted. complications, the principles of the organization of the surgical help in military conditions at mass arrival of wounded were formulated. These organizational and surgical principles underwent testing and were modified on the basis of combat experience near the lake Hassan (1938) and at river Halkhin-Gol (1939), and also during the Soviet finlyand-skogo of the conflict of 1939 — 1940.

Unlike so-called ideal excision of a wound according to Friedrich, M. N. Akhutin (1940, 1941) put forward the principle of a section excision of a wound supported by S. I. Banayti-s, H. N. Burdenko, A. A. Vishnevsky, S. S. Girgolav, P. A. Kupriyanov, V. N. Shamov, etc., on a basis to-rogo developed indications to surgical treatment of wounds and requirements to its equipment. The harmonious system of treatment of wounds which was repaid during the Great Patriotic War and kept in the main value in sovr was created. conditions both for field, and for an urgent surgery of peace time. On this system all wounds subdivide into subjects and not subject to surgical treatment. Carry to the wounds which are not subject to surgical treatment: bullet wounds of soft tissues with small (dot) entrance and output openings, not followed by bleeding, formation of big hematomas; multiple superficial wounds, to-rye, as a rule, heal without complications; chipped, cut and superficial (given by sharp objects) chopped wounds without symptoms of bleeding, on to-rye in some cases it is admissible to put primary stitches with obligatory infiltration by antibiotics of the fabrics surrounding a wound. Other wounds — with the gaping inlet and outlet openings, fragmentary, hurt, crushed, degloved, with symptoms of wound of a large vessel, destructions of a bone, etc. — are subject to surgical treatment.

Distinguish two types of surgical treatment of wounds — primary and secondary.

Primary surgical treatment of wounds is made according to primary indications which are directly connected with the injury. Main objective of X. the lake is creation of optimum conditions for a wound repair, first of all — prevention of a wound fever. Primary surgical treatment of a wound includes its section providing a wide gaping of a wound, good access to the wound channel, elimination of the tension of fabrics caused by traumatic hypostasis, and free outflow separated, removal from a wound of the destroyed fabrics, the centers of primary necrosis, foreign bodys, freely lying splinters of a bone, a careful stop of bleeding (see). Primary surgical treatment of wounds with excision of its edges, walls and a bottom is also used in surgical practice.

Distinguish the early, delayed and late primary surgical treatment of wounds. Experience of wartime and researches conducted in peace conditions showed that a wound fever (see) seldom arises before 24 hours after wound, by means of active antibacterial therapy it is possible to prolong an incubation interval for 24 hours. Allocation early (not later than the first days) and delayed (not later than second day, by all means under protection of antibacterial agents) primary surgical treatment is based on it. The early and delayed primary surgical treatment are regarded as interventions of precautionary character. Primary surgical treatment executed after 24 hours to the wounded without «protection» by antibiotics and after 48 hours under «protection» is accepted for late, deprived of preventive value. This classification, by

A. A. Vishnevsky's definition, has generally organizational and planned, but not clinical orientation, is used during the calculation of forces and means, potrebny for rendering the surgical help in the forthcoming combat operation. For a wedge, this classification is more whole cannot form the basis since processing, early on term, is quite often made at already violently developed infection (e.g., anaerobic) and, on the contrary, late (for the fourth or fifth days) processing can provide an uncomplicated wound repair with second intention. Therefore the surgeon, estimating value of the actions for processing of a wound, shall proceed first of all from a condition of a wound and from a clinical picture in general, but not from the term which passed from the moment of wound. Carrying out the delayed and late surgical treatment of wounds is a compulsory measure at an adverse medicotactical situation and mass arrival of wounded when all persons in need cannot execute surgical treatment in early terms.

During the transferring of primary surgical treatment of a wound for later terms the events reducing danger of emergence inf shall be held. complications. The correct organization of medical sorting first of all treats them (see Sorting medical), at a cut the wounded needing immediate surgical treatment of a wound are allocated (wounded with the proceeding bleeding, the imposed plaits, separations and extensive destructions of extremities, signs of a purulent or mephitic gangrene). In group of wounded, the Crimea surgical treatment of a wound can be delayed, carry the soft tissues which were injured with damages by steady bullets in flight, small • splinters, ball, needle and arrow-shaped elements without symptoms of severe bleeding. The most favorable conditions for the delayed surgical treatment can be reached by means of various antibacterial agents, preferential antibiotics (see) if in an organism, especially in a wound, create high concentration of drug of a wide range and the prolonged action. The most effective is infiltration by solution of antibiotics of the fabrics surrounding a wound (paravulnarny introduction).

Primary surgical treatment of a wound is made with the smallest risk for the wounded. The wounded in a condition of traumatic shock (see) before operation hold a complex of antishock events for completion of blood loss (see), stabilization of the ABP, pulse and breath, improvement of the general state. Only at the proceeding bleeding it is admissible to carry out surgical treatment urgently at simultaneous carrying out an intensive care.

Before an operative measure carefully study the nature of a wound for the purpose of clarification of the direction of the wound channel, existence of injury of bones, joints, the main vessels (definition of pulse on the periphery of extremities, auscultation on the course of a vascular bundle are obligatory in any conditions). Comparison of localization of entrance and output openings at through wounds allows to define rather precisely the direction of the wound channel and anatomic educations, through to-rye it takes place. At indications it is necessary to make a X-ray analysis of field of damage. On the volume of an operative measure, a ratio of a section and excision of fabrics all wounds can be divided into four groups: 1) wounds with insignificant damage of fabrics, but with formation of hematomas or bleeding, are subject only to a section for the purpose of a stop of bleeding and a decompression of fabrics; 2) wounds of the big sizes, at to-rykh it is possible to make processing without additional section of fabrics (e.g., the extensive tangent wounds given by bullets or large splinters), are subject only to excision;

3) the perforating and blind wounds (especially

with a fracture of bones) given with about BP nominal ma in l of an eye of l iberny

bullets and large splinters are subject to a section and excision;

4) wounds with difficult very tectonics of the wound channel, extensive damages of soft tissues and bones cut and exsect; at such wounds make also additional cuts and counteropenings (see) for ensuring full drainage (see).

Operation of a section excision of a wound is made at strict observance of all rules of an asepsis and antiseptics. The method of anesthesia is chosen on the basis of assessment of character, weight and localization of a wound, presumable duration and injury of operation in comparison to the general condition of the wounded. At slight and simple wounds preference shall be given to local anesthesia (see Anesthesia local), at wounds heavy and difficult — to the general anesthesia (see the Anaesthesia).

Equipment of primary surgical treatment of wounds. The section of skin is made through a wound, and at perforating bullet wounds — from entrance and output openings. After edges of a skin wound dispersed, scissors or a scalpel economically excise the hurt sites of skin and hypodermic cellulose. Excision of a wound the bordering section which is carried out at distance

of 1 — 1,5 cm from its edges is not always reasonable since it has no essential advantages before economical excision; the big skin defects which are formed at the same time can bring in the subsequent to formation of extensive is long not healing wounds and rough hems. Length of a skin section shall provide good access for processing of the wound channel. Further widely cut an aponeurosis through a wound opening. Edges of a wound opening economically exsect scissors then the aponeurosis is in addition cut in the field of corners of a section in transverse direction so that the section of an aponeurosis took the Z-shaped form. It is necessary in order that edges of an aponeurosis were not closed and the aponeurotic case did not squeeze edematous muscles after operation.

After a section of an aponeurosis of edge of a wound part with hooks and layer-by-layer excise the centers of a necrosis and sites of impractical fabrics. About viability of muscles judge by existence in them of bleeding, sokratitelny ability and characteristic resilience (elasticity) noted at their excision. Muscles exsect to healthy fabrics. Special attention is paid on the sites of muscles impregnated with blood, to-rye can keep by the time of processing bleeding, to some extent — sokratitelny ability and even elasticity, but, as a rule, perish later. In process of excision of impractical fabrics delete foreign bodys and freely lying small bone fragments from a wound; the pockets which are branching off from the wound channel open and if necessary process as well as the wound channel. It is not necessary to try to conduct search of bone fragments (especially small) or hurting shells located far from the main wound channel for the purpose of their removal since it leads to an additional section, stratification and traumatization of muscles, increase in the sizes of a wound and finally — to creation of unfavorable conditions for its healing. If at excision of muscles large vessels or nervous trunks are found, their carefully blunt retractors temporarily push aside in the parties.

Fragments of the injured bone, as a rule, do not process, except for the acute ends capable to cause secondary traumatization of soft tissues. Such ends economically saw round or skusyvat bone nippers (see. Surgical instrumentar y). The bone splinters connected with muscles stack in a bone wound and on an adjacent layer of healthy muscles put rare stitches for cover of a naked bone for the purpose of prevention of wound osteomyelitis (see). Cover with muscles also naked vessels and nerves in order to avoid thrombosis of vessels (see Thrombosis) and death of nerves.

At the long wound channel with existence of branches and pockets, to-rye it is not possible to process from entrance and output openings, do an additional section of skin and an aponeurosis. In the presence of indications impose counteropening in the most convenient for drainage of a wound the place.

At surgical treatment of wounds of a face, a pilar part of the head and hands make very economical excision of impractical fabrics, a cut would allow to put stitches on a wound (see Seams surgical) without tension of fabrics and deformation of the damaged area and to gain good cosmetic and functional effect.

In the conditions of war to supplement primary X. the lake of river rekonstruktivnovosstanovitelny operations — suture on vessels and nerves (see. A vascular seam, the Nervous seam), fixing of a fracture of bones metal designs (see the Osteosynthesis), a skin autoplasty (see. Skin plastics) — it is admissible at a favorable situation and only when on the nature of wound it is possible to expect the favorable result of operation with confidence. In the conditions of peace time recovery and reconstructive operations usually are a component of primary surgical treatment of wounds (see. Plastic surgery).

At all options of surgical treatment of wounds paramount significance is attached to a careful stop of bleeding (see). For audit of a large vessel and an operative measure on it it is admissible to use a dissect wound only at its arrangement convenient for this purpose; the thicket needs typical classical access by a separate section. The riparian forest the tamponade of a wound gauze tampons for a stop of so-called parenchymatous bleeding is inadmissible since it promotes development of a wound fever (see). Operation is completed infiltration of walls of a wound solutions of antibiotics, drainage or (in the presence of indications) suture.

For drainage of a wound sometimes the forced and temporary action should resort to its tamponade (see) as. Thus use gauze tampons, the moistened 10% solution of sodium chloride or 0,02% solution of Furacilin more often. Gauze tampons enter into a wound well straightened and stack on its walls in the form of straight lines (not corrugated) matches. The gauze quickly enough loses a capillarity, and further tampons only complicate clarification of a wound. Use tubular, hl is more effective. obr. polyvinyl chloride or silicone drainages. Use one - and dvukhprosvetny tubes with a diameter from 5 to 10 mm with multiple perforation openings on the end. In a wound, in dependence from its sizes, enter one or several drainages. Dvukhprosvetny drainage tubes allow to wash out periodically a wound antiseptic solutions or to enter into it solutions of antibiotics without removal of a bandage. Are perspective for drainage of wounds the drainages made of coal sorbents to-rye widely are applied to hemosorption (see volume 10, additional materials) at toxicoses. Coal sorbents are most acceptable fibrous or wattled (in the form of fabric products). Having high hydrophily (see) and sorption ability (see Sorption), they very well occlude from a wound liquid exudate (see), small clots of fibrin, fabric a detritis, etc., promote clarification of a wound, reduction of hypostasis of fabrics and reduction of the period of hydration during a wound process (see Wounds, wounds).

In peace time the wide spread occurance in a wedge, practice finds a method of active aspiration wound separated by means of the silicon perforated drainage tubes connected to the water-jet suction or other devices creating vacuum in these tubes (see. Aspiration drainage). Quite often active aspiration is supplemented with constant or periodic irrigation of a wound antiseptic solution. This effective method provides a possibility of imposing on a wound of primary seam (see), to-ry in modern a wedge, finds for practice in peace time more and more broad application. In combat conditions of the indication to use of primary seam after primary surgical treatment at mass arrival of wounded are extremely limited therefore resort to imposing of the delayed primary or secondary seams more often (see). Imposing of primary seam is allowed only after surgical treatment simple (without explicit pollution) wounds of a face, a pilar part of the head, a brush, superficial wounds of a trunk and upper extremities, at to-rykh pyoinflammatory complications meet considerably less than at wounds of other areas, and also cut, chipped and superficial chopped wounds of other areas of a body after their washing by antiseptic solution and infiltrations of edges antibiotics.

At primary surgical treatment of wounds treat excessive excision of not changed skin in the field of a wound the most essential mistakes; an insufficient section of a wound, especially fastion and subjects of muscles, depriving opportunity to make reliable audit of the wound channel and full excision of impractical fabrics; incomplete excision of impractical fabrics; insufficient persistence in search of a bleeding point and excessive — in search of foreign bodys; a hard tamponade of a wound for the purpose of a hemostasis at an undetected bleeding point or not stopped bleeding from small vessels; a section of a wound in the absence of indications to it; use for drainage of wounds of gauze tampons in a corrugated look.

The preventive effect of primary surgical treatment of a wound increases if precedes it and it is completed by washing of a wound cavity a pulse jet of the oxygenated antiseptic solution under the pressure up to 3 atm, and during the operation of a wall of a wound process the same solution with use of the special aspirator which is carrying away particles of fabrics.

Secondary surgical treatment of wounds is applied at wounded, the Crimea roughing-out did not give effect. Serve as indications: development of a wound fever (anaerobic, purulent, putrefactive); it is purulent - the resorptive fever (see) caused by a delay separated, zatekam (see), okoloranevy abscess (see) or phlegmon (see), a secondary necrosis of fabrics; manifestations of various forms of sepsis (see). Indications can arise after wound in the next few days.

Depending on character of a suppurative focus the volume of secondary surgical treatment of a wound can be various. At localization of inflammatory process on the course of the wound channel he widely (sometimes with an additional section of a wound) is revealed under anesthetic, delete accumulation of pus, excise the centers of a necrosis. The wound rykhlo is tamponed or drained. At extensive and deep necroses when devitalized fabrics completely cannot be excised, resort to their consecutive excision during the next bandagings and to impact on them proteolytic enzymes (see Pep-tid-gidr about manholes), and also to use of the bandages (see) having sorption properties in combination with parenteral administration of antibiotics. After full clarification of a wound, at good development of granulations, imposing of secondary early or secondary late seams is admissible (see. Secondary seam). At emergence of a zatek, abscess or phlegmon away from the wound canal they are opened. Drainage of a wound in these cases is carried out by means of perforated one-and dvukhprosvetny tubes, through to-rye a cavity of an abscess washed out antiseptic solutions and delete pz it a wound discharge. At development of a mephitic gangrene secondary surgical treatment of a wound is made most considerably (see. Mephitic gangrene).

Treatment of wounds after their primary and secondary surgical treatment is carried out by the general rules with use of antibacterial agents, immunotherapies, fortifying therapy, proteolytic enzymes, ultrasound, etc. (see Wounds, wounds); treatment of wounded in conditions gnotobiol is effective. isolation (see. The managed abacterial environment), and at a mephitic gangrene — using a barotherapy (see).

In the conditions of peace time there is a large number of the directions and methodical approaches to the maintenance of surgical treatment of wounds, including use of additional mechanical and chemical methods of clarification of wounds, prevention of wound complications, imposing of primary seams, etc. that reflects scientific search of the most effective methods of treatment of wounds.

In field conditions performance early is very difficult (in the 1st days) primary surgical treatment of wounds all wounded, the Crimea it is shown. The existing gap in time and the place of rendering the qualified and specialized medical care (see. Stage treatment) can result in need to operate many wounded twice, making, e.g., processing of a wound of soft tissues at the advanced stage (usually in MSB, OMO), and processing of the bone and joint damage which is available for it — in specialized hospital.

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