Introductio外科學(xué)概論馬清涌教授

1、Introductio外科學(xué)概論馬清涌教授 IntroductionManagement of surgical disorders requires Application of technical skills and Training in the basic sciences to the problems of diagnosis and treatment基本知識、基本技能、基礎(chǔ)理論 Genuine sympathy and indeed love for the patient. 2Introduction The surgeon A doctor in the old-fash

2、ioned 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，觀念)A (Anatomy，解剖)S (Skill，技巧)E (Emergency，應(yīng)急)43 Relationships GG (General and Group，將軍和團隊)MM (Major and Minor，大手術(shù)和小手術(shù))QQ

3、 (Quantity and Quality， 數(shù)量和質(zhì)量)5Meditech-bioelementCommunication-basic technical skillScientific research-soul Cooperation-security團隊合作是完成良好治療的保證 6Basic Pathological Processes All somatic diseases have their origins in following six basic pathological processes:Congenital defectsInflammations Neoplas

4、ms Trauma Metabolic defects and degeneration Collagen defects7Phenomena Obstruction Perforation Erosion Tumors or masses 8Diseases due to Obstruction 9Examples of Perforation10Examples of Erosion11TumorsThe most subtle of these phenomena is a tumor, or mass. This explains in large measure why cancer

5、 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, are delayed, often tragically. 12Approach to surgical patient History Physical examination Labora

6、tory 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 considerateCreate an atmosphere of sympathy, personal interest and understandingStructure histories formall

7、yAvoid 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 detective work. Preconceived ideas, snap judgments, and hasty conclusions have no place in this

8、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 symptom in the hope that if it is not specifically inquired about or if nothing is found to account

9、 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 character of the pain？Is it so severe that it cannot be relieved by medication？Is it constant or intermi

10、ttent？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 and thrashes about is either grossly overreacting or suffering from renal or biliary colic. Very

11、 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 patients confidence is often a more effective analgesic than an injection of morphine.19VomitingWh

12、at 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 habits is a common complaint that is often of no significance. Regular evacuations noticed a disti

13、nct change, particularly toward intermittent alternations of constipation and diarrhea, colon cancer must be suspected. 21Hematemesis or HematocheziaMost common error is that rectum bleeding is attributable to hemorrhoids. The character of the blood can be of great significance. Does it clot? Is it

14、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 it is often difficult to establish a relationship between the chief complaint and an episode of t

15、rauma. 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? When the accident occurred?Was consciousness lost? Retrograde amnesia (inability to remember ev

16、ents 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 hit24Family HistoryPolyposis of the colon is a classic example, but diabetes, Peutz-Jeghers syndrome,

17、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 are well are almost never sick. And people who are sick are almost never well. Review the past h

18、istory by inquiring about each systemConsider the nutritional backgroundFluid and electrolyteTherapy before laboratory results26Patient Emotional BackgroundPsychiatric consultation is seldom required Emotionally and mentally disturbed patients require operations, cooperation between psychiatrist and

19、 surgeon is essentialSurgeon deals with the emotional patient (malignant disease, amputation of an extremity, ileostomy, or colostomy) Importance of psychosocial factors in surgical convalescence27Physical ExaminationComplete examination includes Physical examinationLaboratory tests x-ray examinatio

20、n Certain special procedures (gastroscopy and esophagoscopy)Follow-up examination Painful, inconvenient and costly procedures ordered as less as possible28Elective Physical ExaminationDone in an orderly and detailed fashionAll patients are sensitive and somewhat embarrassed at being examined. Put th

21、e 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 ExaminationObserve the patients general physique and habitus Carefully inspect the handsMany systemic diseases

22、 show themselves in the hands (cirrhosis of the liver, hyperthyroidism, Raynauds disease, pulmonary insufficiency, heart disease, and nutritional disorders)30Elective Physical ExaminationEssential Steps InspectionPalpationAuscultationPercussion 31Elective Physical ExaminationInspectionComparison of

23、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 indicative of an infiltrating carcinoma barely detectable on palpation32Elective Physical Examinatio

24、nRequires skill and gentlenessSpasm, tension, and anxiety caused by painful examination procedures may make an adequate examination almost impossible, particularly in childrenCareful, precise, and gentle palpation gives the physician the information being sought and inspires confidence and trustOne

25、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 variety of vascular lesions are revealed by auscultation. 35Examination of Body OrificesComplet

26、e 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 examinations36Emergency Physical Examination Routine PE fit the circumstancesHistory limited to

27、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 resuscitation)Is massive bleeding occurring?(if from extremity, elevation and pressure)37Emergen

28、cy Physical ExaminationTension pneumothorax and cardiac tamponade may easily be overlooked if there are multiple injuriesCompletion of the survey examinationControl of pain Splinting of fractured limbsSuturing of lacerationsOther types of emergency treatment 38Laboratory ExaminationObjectives: Scree

29、ning 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 that require surgery (hyperparathyroidism, pheochromocytoma) Evaluation of the nature and extent o

30、f 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 experience and background to interpret the meaning of laboratory tests in the light of other features

31、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 examinationsCystoscopy GastroscopyEsophagoscopyColonoscopy AngiographyBronchoscopy are often requir

32、ed in the diagnostic appraisal of surgical disorders. 42Aseptic technique無菌術(shù) (Asepsis)基本操作規(guī)范針對可能的感染來源和途徑所采取的有效預(yù)防方法。由滅菌法、消毒法、無菌操作規(guī)則及管理制度所組成。滅菌(sterilization)是指殺滅一切活的微生物。消毒(disinfection)是指殺滅病原微生物和其他有害微生物，并不要求徹底殺滅所有微生物（如芽胞等）。43SterilizationThe only completely reliable methods of sterilization in wide c

33、urrent use for surgical instruments and supplies are steam under pressure (autoclaving) 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 resista

34、nt dry spores in 30 minutes. Sterilization time is markedly shortened by the high-vacuum or high-pressure, 132-134oC，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 sterilize

35、r is 127.5kPa, T=124oC for 10 min 46Dry Heatexposure to continuous dry heat 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 exposu

36、re at 160oC.47Soaking method2% glutaral (glutaraldehyde) 30min for disinfection, 10 hour for sterilization10% formaldehyde 20-30 min75% alcohol (ethanol) 30 min 1:1000 benzalkonium bromide (新潔爾滅)1:1000 chlorhexidine (洗必泰) 30 min48Formaldehyde FumigationPotassium permanganate with 40% formaldehyde 1

37、hour for disinfection, sterilization for 6-12 hours49消毒法乙醇 75%碘伏 0.2%安爾碘過氧乙酸 0.2-0.5%有效氯消毒劑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 s

38、crub is not universally defined, a 5-minute scrub before the first case-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 co

39、ntaining chlorhexidine or one of the iodophors appear to be the most effective.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 showe

40、r or tub bath is satisfactory. The type of soap used makes little difference. 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 prepara

41、tion using other 70% alcohol or 2% iodine in 90% alcohol-followed by a 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

42、of the operating field. Dot use iodine on the perineum, genitalia, or 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 gauz

43、e swab for 3 minutes and allow to dry before draping. Alternatively, tinted 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 infe

44、ction control. Using drapes that simply lie over the skin is associated 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 inf

45、ective wound or anus from outside to insideArea15cm 56Universal PrecautionsAll 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

46、 skin surface washing is necessary if contamination occurs.57Universal 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

47、 promptly as patient safety permits and the needle or instrument removed from the sterile field.58手術(shù)人員和病人手術(shù)區(qū)域的準(zhǔn)備手術(shù)人員術(shù)前準(zhǔn)備：一般準(zhǔn)備手臂消毒法穿無菌手術(shù)衣戴無菌手套病人手術(shù)區(qū)的準(zhǔn)備病人手術(shù)區(qū)皮膚消毒病人手術(shù)區(qū)鋪巾59手術(shù)人員一般準(zhǔn)備更換手術(shù)室準(zhǔn)備的清潔鞋和衣褲?？谡忠w住鼻孔，帽子要蓋住全部頭發(fā)。剪短指甲。手臂皮膚破損或有化膿性感染時，不能參加手術(shù)。60手臂消毒法肥皂刷手法：用肥皂做一般的洗手。用無菌毛刷蘸肥皂水刷洗手和臂，從手指尖到肘上10cm處，兩臂交替刷洗，特別注意甲緣、甲溝、指蹼等處的刷洗。61肥皂刷手法一次刷完后，手指朝上肘朝下，用清水沖洗手臂