The main achievements of modern surgery. Modern problems of science and education General and abdominal surgery

Introduction

Chapter 1. Solving the main problems in surgery before the period of great discoveries

1 The main stages of the development of surgery

2 Asepsis and antisepsis in ancient times

3 Anesthesiology in ancient times

4 Blood transfusion (empirical and anatomical and physiological periods of development)

Chapter 2. Solving the main problems in surgery, starting from the period of great discoveries (XIX-XX centuries)

1 Asepsis and antisepsis of the 19th century. Modern asepsis

2 Anesthesiology

2.1 Birth of anesthesiology

3 Blood transfusion

Conclusion

Bibliography

Introduction

The relevance of research.

The relevance of the chosen topic lies in the fact that the history of surgery is not limited to the study of only its past. The development of surgery as a science continues to this day, but

the history of the main problems of surgery is a separate, most interesting section that deserves much attention. The history of surgery can be written in many volumes in the form of an intriguing thriller, where sometimes comical situations coexist with tragic events, and there were, of course, more sad, tragic facts in the development of surgery. The history of medicine is a separate specialty that is taught in universities. But it is simply impossible to begin to get acquainted with surgery and its main problems, such as asepsis and antiseptics, anesthesiology and blood transfusion, without mentioning their history and development. Therefore, this course work focuses on the most important fundamental discoveries and events that significantly influenced the further development of surgery and all medicine.

The emergence of surgery dates back to the very beginnings of human society. Having started to hunt and work, a person was faced with the need to heal wounds, relieve pain, remove foreign bodies, stop bleeding and other surgical procedures. Surgery is the oldest medical specialty. At the same time, it is forever young, since it is unthinkable without the use of the latest achievements of human thought, the progress of science and technology.

Goal of the work.

The purpose of the work was to consider the main issues in surgery: asepsis and antiseptics, anesthesiology, blood transfusion. To achieve this goal, we had to solve the following tasks:

get acquainted with the centuries-old history of the main problems of surgery

analyze the main issues of asepsis and antisepsis, starting from ancient times

consider such important issues in surgery as anesthesiology and anesthesia, as well as their history

make sure that a process such as blood transfusion has played one of the main roles in surgery from recent times to this day.

Chapter 1. Solving the main problems in surgery before the period of great discoveries

.1 Main stages in the development of surgery

The development of surgery can be represented in the form of a classical spiral, each turn of which is associated with certain major achievements of great thinkers and practitioners of medicine. The history of surgery consists of 4 main periods:

■ Empirical period, covering the time from the 6th-7th millennium BC to the end of the 16th century AD.

■ Anatomical period - from the end of the 16th to the end of the 19th century.

■ The period of great discoveries of the late 19th - early 20th centuries.

■ Physiological period - surgery of the 20th century.

1.2 Asepsis and Antisepsis in ancient times

The importance of antisepsis and asepsis in the development of surgery cannot be overestimated. It was they who made it possible to expand the scope of surgical interventions and penetrate surgery into all areas of the human body. Before the introduction of asepsis and antisepsis methods, postoperative mortality reached 80%: patients died from purulent, putrefactive and gangrenous processes

In the emergence and development of asepsis and antisepsis, five stages can be distinguished:

■ empirical period (the period of application of certain scientifically unsubstantiated methods),

■ Dolister antiseptics of the 19th century,

■ Lister antiseptic,

■ the emergence of asepsis,

■ modern asepsis and antiseptics.

EMPIRICAL PERIOD

The first, as we now call "antiseptic methods"can be found in many descriptions of the work of doctors in ancient times. Here are just a few examples.

■ Ancient surgeons considered it mandatory to remove a foreign body from a wound.

■ Hebrew history: The laws of Moses prohibited touching a wound with one’s hands.

■ Hippocrates preached the principle of cleanliness of a doctor’s hands, spoke of the need to cut nails short; used rainwater and wine to treat wounds; shaved hair from the surgical field; spoke about the need for clean dressing material.

However, purposeful, meaningful actions of surgeons to prevent purulent complications began much later - only in the middle of the 19th century.

1.3 Anesthesiology in ancient times

Surgery and pain have been constantly evolving since the first steps in the development of medicine. "side by side".According to the famous surgeon A. Velpo, it was impossible to perform a surgical operation without pain; general anesthesia was considered impossible. In the Middle Ages, the Catholic Church completely rejected the very idea of ​​eliminating pain as anti-God, passing off pain as a punishment sent by God to atone for sins. Until the mid-19th century, surgeons could not cope with pain during surgery, which significantly hampered the development of surgery.

Modern medical historians believe that the first methods of anesthesia arose at the dawn of human development. Of course, then it was customary to act simply and crudely: for example, until the 18th century, the patient received general anesthesia in the form of a strong blow to the head with a baton; after he lost consciousness, the doctor could begin the operation.

In China and India, opium was unknown for a long time, but the wonderful properties of marijuana were discovered there quite early. In the 2nd century AD. During operations, the famous Chinese doctor Hua Tuo gave patients a mixture of wine and powdered hemp, which he invented, as anesthesia.

The civilization of ancient Egypt left the oldest written evidence of an attempt to use anesthesia during surgical interventions. The Ebers papyrus (5th century BC) reports the use of pain-relieving agents before surgery: mandrake, belladonna, opium, and alcohol. With slight variations, these same drugs were used independently or in various combinations in Ancient Greece, Rome, China, and India.

In Egypt and Syria they knew stunning by squeezing the vessels of the neck and used this during circumcision operations. A bold method of general anesthesia by bloodletting was tried before the onset of deep fainting due to anemia of the brain. Aurelio Saverino from Naples (1580-1639), purely empirically, recommended rubbing with snow for 15 minutes to achieve local anesthesia. before surgery.

Meanwhile, in America, which had not yet been discovered by Columbus, local Indians actively used cocaine from the leaves of the coca plant as an anesthetic. It is reliably known that the Incas in the high Andes used coca for local anesthesia: a local healer chewed the leaves and then dripped juice-rich saliva onto the patient’s wound to relieve his pain.

When people learned to produce strong alcohol, anesthesia became more accessible. Many armies began to take supplies of alcohol with them on campaigns to give it as a pain reliever to wounded soldiers. It is no secret that this method of anesthesia is still used in critical situations (on hikes, during disasters) when it is not possible to use modern drugs.

In rare cases, doctors tried to use the power of suggestion as anesthesia, for example, putting patients into hypnotic sleep.

Larrey, chief surgeon of the Napoleonic army, (1766-1842) amputated limbs from soldiers on the battlefield without pain, at a temperature of -29 degrees Celsius. At the beginning of the 19th century, the Japanese doctor Hanaoka used a drug consisting of a mixture of herbs containing belladonna, hyoscyamine, and aconitine for pain relief. Under such anesthesia, it was possible to successfully amputate limbs, mammary glands, and perform operations on the face. The 19th century was the century of the industrial revolution and the transformation of the feudal formation into a capitalist one. It was a century of great scientific discoveries. The idea of ​​pain relief does not belong to one person. Davy, while studying nitrous oxide, discovered that it had a peculiar laughing effect, so he called it “laughing gas” and suggested that it could be used to relieve pain during surgical operations. However, he was a chemist, and doctors were not yet ready for such a discovery. The Englishman Henry Hickman (1800-1830) was the first to understand that the task of anesthesia is not only to relieve pain, but also to prevent other harmful effects of the operation. In his experiments, Hickman studied both the analgesic properties of various substances and the effects on breathing, blood circulation, and wound healing. He used artificial lung ventilation (ALV) with special bellows to restore breathing, and electric current to restore heart function. However, his proposals were rejected by his contemporaries. In a state of deep depression, Hickman died at the age of 30.

Equally tragic is the fate of Horace Wells, who in 1844 experienced the effects of nitrous oxide on himself. He performed 15 successful anesthesia procedures for tooth extraction. However, the lack of knowledge about the clinic and mechanisms of action of anesthesia, as well as ordinary bad luck, led to the fact that the official demonstration of this method was unsuccessful. Nitrous oxide anesthesia was discredited for many years - a typical example of how illiterate and inept use of a valuable method brings harm, not benefit. Wells committed suicide in 1848.

2 years earlier than Wells, Long used anesthesia to remove a head tumor, however, he did not appreciate the importance of his discovery and reported about it only 10 years later. Therefore, it is fair to consider the day of the discovery of anesthesia to be October 16, 1846, when another dentist from Philadelphia, Thomas Morton, publicly demonstrated ether anesthesia when removing a jaw tumor and convinced those present that painless surgical operations were possible. This day is considered the day of the anesthesiologist.

1.4 Blood transfusion

The history of blood transfusion goes back centuries. People have long appreciated the importance of blood for the life of the body, and the first thoughts about using blood for medicinal purposes appeared long before our era. In ancient times, blood was seen as the source of vitality and with its help they sought healing from serious illnesses. Significant blood loss was the cause of death, which was repeatedly confirmed during wars and natural disasters. All this contributed to the emergence of the idea of ​​​​moving blood from one organism to another.

The entire history of blood transfusion is characterized by undulating development with rapid ups and downs. It can be divided into three main periods:

■ empirical,

■ anatomical and physiological,

■ scientific.

EMPIRICAL PERIOD

The empirical period in the history of blood transfusion was the longest in duration and the poorest in facts covering the history of the use of blood for therapeutic purposes. There is evidence that even during the ancient Egyptian wars, herds of sheep were chased after troops to use their blood in the treatment of wounded soldiers. In the writings of ancient Greek poets there is information about the use of blood for the purpose of treating patients. Hippocrates wrote about the usefulness of mixing the juices of sick people with the blood of healthy people. He recommended drinking the blood of healthy people to those with epilepsy and the mentally ill. Roman patricians drank the fresh blood of dead gladiators directly in the arenas of the Roman circus for the purpose of rejuvenation.

The first mention of blood transfusion is in the works of Libavius, published in 1615, where he describes the procedure of transfusing blood from person to person by connecting their vessels with silver tubes, but there is no evidence that such a blood transfusion was done to anyone.

ANATOMIC-PHYSIOLOGICAL PERIOD

The beginning of the anatomical and physiological period in the history of blood transfusion is associated with the discovery of the laws of blood circulation by William Harvey in 1628. From that moment on, thanks to a correct understanding of the principles of blood movement in a living organism, the infusion of medicinal solutions and blood transfusion received an anatomical and physiological basis.

In 1666, the outstanding English anatomist and physiologist R. Lower successfully transfused blood from one dog to another using silver tubes, which served as an impetus for the use of this manipulation in humans. R. Lower has the priority of the first experiments on intravenous infusion of medicinal solutions. He injected wine, beer and milk into the veins of the dogs. The good results obtained from blood transfusions and the administration of certain fluids allowed Lower to recommend their use in humans.

Attempts to perform blood transfusions were resumed only at the end of the 18th century. And in 1819, the English physiologist and obstetrician J. Blendel performed the first human-to-human blood transfusion and proposed a blood transfusion apparatus, which he used to treat bleeding women in labor. In total, he and his students performed 11 blood transfusions, and the blood for transfusion was taken from the patients’ relatives. Already at that time, Blendel noticed that in some cases, patients experience reactions during blood transfusion, and came to the conclusion that if they occur, the transfusion should be stopped immediately. When infusing blood, Blendel used something similar to a modern biological sample.

Matvey Pekan and S.F. Khotovitsky are considered the pioneers of Russian medical science in the field of transfusiology. At the end of the 18th and beginning of the 19th centuries, they described in detail the technique of blood transfusion and the effect of transfused blood on the patient’s body.

In 1830, the Moscow chemist Herman proposed intravenous infusion of acidified water to treat cholera. In England, the doctor Latta in 1832, during a cholera epidemic, administered an intravenous infusion of a solution of table salt. These events marked the beginning of the use of blood replacement solutions.

surgery asepsis anesthesiology blood transfusion

Chapter 2. Solving the main problems in surgery, starting from the period of great discoveries (XIX-XX centuries)

.1 Asepsis and Antisepsis

.1.1 Dolister antiseptic. Lister antiseptic. The emergence of asepsis

PRE-LISTER ANTISEPTICS OF THE 19TH CENTURY

In the middle of the 19th century, even before the works of J. Lister, a number of surgeons began to use methods to destroy infection in their work. A special role in the development of antiseptics during this period was played by I. Semmelweis and N.I. Pirogov.

a) I. Semmelweis

In 1847, the Hungarian obstetrician Ignaz Semmelweis suggested the possibility of women developing puerperal fever (endometritis with septic complications) due to the introduction of cadaveric poison by students and doctors during vaginal examination (students and doctors also studied in the anatomical theater).

Semmelweis proposed treating hands with bleach before an internal study and achieved phenomenal results: at the beginning of 1847, postpartum mortality due to sepsis was 18.3%, in the second half of the year it dropped to 3%, and the next year to 1.3%. However, Semmelweis was not supported, and the persecution and humiliation that he experienced led to the fact that the obstetrician was placed in a psychiatric hospital, and then, by a sad irony of fate, in 1865 he died of sepsis, due to panaritium, which developed after a wound to his finger. the time it takes to perform one of the operations.

b) N.I. Pirogov

N.I. Pirogov did not create comprehensive work to combat infection. But he was half a step away from creating the doctrine of antiseptics. Back in 1844, Pirogov wrote: “The time is not far from us when a careful study of traumatic and hospital miasmas will give surgery a different direction” (miasma-- pollution, Greek).N.I. Pirogov respected the works of J. Semmelweis and, even before Lister, in some cases used antiseptic substances (silver nitrate, bleach, alcohol of tartar and camphor, zinc sulfate) to treat wounds.

Works by I. Semmelweis, N.I. Pirogov and others could not make a revolution in science. Such a revolution could only be accomplished using a method based on bacteriology. The emergence of Lister's antiseptics was undoubtedly facilitated by the work of Louis Pasteur on the role of microorganisms in the processes of fermentation and decay (1863).

ANTISEPTICS LISTER

In the 60s In the 19th century in Glasgow, the English surgeon Joseph Lister, familiar with the works of Louis Pasteur, came to the conclusion that microorganisms enter the wound from the air and from the surgeon’s hands. In 1865, he, convinced of the antiseptic effect of carbolic acid, which the Parisian pharmacist Lemaire began to use in 1860, used a bandage with its solution in the treatment of an open fracture and sprayed carbolic acid in the air of the operating room. In 1867 in the magazine "Lancet"Lister published an article “On a new method of treating fractures and ulcers with notes on the causes of suppuration”,which outlined the basics of the antiseptic method he proposed. Later, Lister improved the technique, and in its full form it included a whole range of activities.

Antiseptic measures according to Lister:

■ spraying carbolic acid into the operating room air;

■ treatment of instruments, suture and dressing material, as well as the surgeon’s hands with a 2-3% solution of carbolic acid;

■ treatment of the surgical field with the same solution;

■ use of a special dressing: after the operation, the wound was covered with a multilayer dressing, the layers of which were impregnated with carbolic acid in combination with other substances.

Thus, the merit of J. Lister was, first of all, that he did not simply use the antiseptic properties of carbolic acid, but created a complete method of fighting infection. Therefore, it was Lister who went down in the history of surgery as the founder of antiseptics.

Lister's method was supported by a number of major surgeons of the time. N.I. played a special role in the spread of Lister antiseptics in Russia. Pirogov, P.P. Pelekhin and I.I. Burtsev.

N.I. Pirogov used the healing properties of carbolic acid in the treatment of wounds, supported, as he wrote "antiseptica in the form of injections".

Pavel Petrovich Pelekhin, after an internship in Europe, where he became familiar with the works of Lister, began to ardently preach antiseptics in Russia. He became the author of the first article on antiseptic issues in Russia. It must be said that such works have existed before, but they were not published for a long time due to the conservatism of the editors of surgical journals.

Ivan Ivanovich Burtsev is the first surgeon in Russia to publish the results of his own use of the antiseptic method in Russia in 1870 and draw cautious but positive conclusions. I. I. Burtsev worked at the Orenburg hospital at that time, and later became a professor at the Military Medical Academy in St. Petersburg.

It should be noted that Lister’s antiseptics, along with ardent supporters, also had many irreconcilable opponents. This was due to the fact that J. Lister "unsuccessful"chose an antiseptic substance. The toxicity of carbolic acid and its irritating effect on the skin of both the patient and the surgeon’s hands sometimes forced surgeons to doubt the value of the method itself.

The famous surgeon Theodor Billroth ironically called the antiseptic method "listing".Surgeons began to abandon this method of work, since its use killed not so much microbes as living tissue. J. Lister himself wrote in 1876: “An antiseptic in itself, since it is a poison, has a harmful effect on the tissue.”Lister's antisepsis was gradually replaced by asepsis.

THE ARISE OF ASEPSIS

Advances in microbiology and the works of L. Pasteur and R. Koch put forward a number of new principles as the basis for the prevention of surgical infection. The main one was to prevent bacteria from contaminating the surgeon’s hands and objects in contact with the wound. Thus, surgery included the cleaning of the surgeon’s hands, sterilization of instruments, dressings, linen, etc.

The development of the aseptic method is associated primarily with the names of two scientists: E. Bergman and his student K. Schimmelbusch. The name of the latter is immortalized by the name of the bix - a box still used for sterilization - the Schimmelbusch bix.

At the X International Congress of Surgeons in Berlin in 1890, the principles of asepsis in the treatment of wounds received universal recognition. At this congress, E. Bergman demonstrated patients operated on under aseptic conditions, without the use of Lister antiseptics. Here the basic postulate of asepsis was officially adopted: “Everything that comes into contact with the wound must be sterile.”

To sterilize dressing material, high temperature was used first of all. R. Koch (1881) and E. Esmarch proposed a method of sterilization with flowing steam. At the same time, in Russia L.L. Heidenreich was the first in the world to prove that steam sterilization under high pressure is the most perfect, and in 1884 he proposed using an autoclave for sterilization.

In the same 1884 A.P. Dobroslavin, a professor at the Military Medical Academy in St. Petersburg, proposed a salt oven for sterilization, the active agent in which was the steam of a saline solution boiling at 108C. Sterile material required special storage conditions and a clean environment. Thus, the structure of operating rooms and dressing rooms was gradually formed. Here, much credit goes to Russian surgeons M.S. Subbotin and L.L. Levshin, who essentially created the prototype of modern operating rooms. N.V. Sklifosovsky was the first to propose distinguishing operating rooms for operations with different levels of infectious contamination.

After the above, and knowing the current state of affairs, the statement of the famous surgeon Volkmann (1887) seems very strange: “Armed with an antiseptic method, I am ready to perform an operation in a railway latrine,”but it once again emphasizes the enormous historical significance of Lister’s antisepsis.

The results of asepsis were so satisfactory that the use of antiseptics began to be considered unnecessary, not corresponding to the level of scientific knowledge. But this misconception was soon overcome.

MODERN ASEPSIS AND ANTISEPTICS

High temperature, which is the main method of asepsis, could not be used to process living tissue or treat infected wounds.

Thanks to the successes of chemistry for the treatment of purulent wounds and infectious processes, a number of new antiseptic agents have been proposed that are much less toxic to the tissues and body of the patient than carbolic acid. Similar substances began to be used to treat surgical instruments and objects surrounding the patient. Thus, asepsis gradually became closely intertwined with antiseptics, and now surgery is simply unthinkable without the unity of these two disciplines.

As a result of the spread of aseptic and antiseptic methods, the same Theodor Billroth, who had recently laughed at Lister’s antiseptics, in 1891. said: “Now, with clean hands and a clear conscience, an inexperienced surgeon can achieve better results than before the most famous professor of surgery.”And this is not far from the truth. Now the most ordinary surgeon can help a patient much more than Pirogov, Billroth and others, precisely because he knows the methods of asepsis and antisepsis. The following figures are indicative: before the introduction of asepsis and antisepsis, postoperative mortality in Russia in 1857 was 25%, and in 1895 - 2.1%.

In modern asepsis and antiseptics, thermal sterilization methods, ultrasound, ultraviolet and X-rays are widely used; there is a whole arsenal of various chemical antiseptics, antibiotics of several generations, as well as a huge number of other methods of fighting infection.

Asepsis - This is a method of surgical work that prevents germs from entering the wound by destroying them on all objects that will come into contact with it.The basic law of asepsis is “everything that comes into contact with the wound must be free from bacteria, i.e., sterile.”

Antiseptics - This is a single treatment and prophylactic complex of measures aimed at reducing the number of microbes in the wound, reducing their viability, the danger of penetration into surrounding tissues and other environments of the body, as well as removing intoxication, increasing the immune-biological activity of the sick organism and its reactivity.

Modern surgical antisepsis is inextricably linked with asepsis and is combined with it into one common system. Depending on the principle of action, mechanical, physical, chemical, biological and mixed antiseptics are distinguished.

2.2 Anesthesiology

Pain relief and prevention of unwanted effects of surgery are achieved using local anesthesia (pain relief with preservation of consciousness) or anesthesia (pain relief with temporary shutdown of consciousness and reflexes).

Anesthesiology - This is the science of pain relief and methods of protecting the patient’s body from the extreme effects of surgical trauma (pain).

General anesthesia, or anesthesia , - a condition characterized by a temporary shutdown of consciousness, all types of sensitivity (including pain), some reflexes and relaxation of skeletal muscles due to the effects of narcotic substances on the central nervous system.

Depending on the route of administration of narcotic substances into the body, inhalation and non-inhalation anesthesia are distinguished.

Theories of anesthesia. Currently, there is no theory of anesthesia that clearly defines the mechanism of the narcotic action of anesthetic substances. Among the existing theories, the following are of greatest importance.

Lipidthe theory was proposed by G. Meyer (1899) and C. Overton (1901), who associated the effect of narcotic drugs with their ability to dissolve fat-like substances in the membranes of nerve cells and thereby disrupt their activity, which leads to a narcotic effect. The narcotic power of anesthetics is directly dependent on their ability to dissolve fats.

According to adsorptiontheories of Traube (1904) and O. Warburg (1914), the drug accumulates on the surface of cell membranes in the central nervous system, thereby changing the physicochemical properties of cells, and their function melts, which causes a state of anesthesia,

According to the theory inhibition of oxidative processesVerworn (1912), the narcotic drug blocks enzymes that regulate redox processes in brain tissue cells.

According to coagulationtheories of Bernard (1875), Bancroft and Richter (1931), narcotic drugs cause reversible coagulation of the protoplasm of nerve cells, which lose the ability to excite, which leads to the occurrence of narcotic sleep.

The essence physiologicaltheories of anesthesia B.C. Galkin (1953), based on the teachings of I.M. Sechenova, I.P. Pavlova, N.E. Vvedensky, comes down to explaining narcotic sleep from the standpoint of inhibition of the central nervous system that occurs under the influence of narcotic substances. The reticular formation of the brain is most sensitive to the action of the anesthetic (PA Anokhin).

Objectives of anesthesiology

Over the years of its existence, pain management has come a long way from applied skills to ensure painless operations to a science that controls and regulates the vital functions of the body during the operating and postoperative periods.

In modern conditions, an anesthesiologist is both a consultant physician and a primary care physician. The work of an anesthesiologist can be considered advisory because very little time (minutes or hours) is usually allocated to achieve the main goal of anesthesia - ensuring the safety of the patient's comfort during surgery. Since the anesthesiologist is responsible for all “non-surgical” aspects of the patient’s condition during the perioperative period, he is also the primary care physician. The "captain of the ship" concept, whereby the surgeon is responsible for every aspect of perioperative patient management, including anesthesia, is no longer valid. The surgeon and anesthesiologist must act collaboratively and effectively, and both are responsible to the patient rather than to each other. Patients can choose their own anesthesiologists, but their choice is usually limited by the medical staff of the hospital, the surgeon's preferences (if any), or the anesthesiologists who are on duty on a particular day.

2.2.1 Birth of anesthesiology

a) Date of birth of anesthesiology

In 1846, the American chemist Jackson and dentist Morton showed that inhaling ether vapors turns off consciousness and leads to loss of pain sensitivity, and they proposed using ether for tooth extraction.

On October 1846, in a Boston hospital, 20-year-old Gilbert Abbott, a patient at Harvard University, had a tumor in the submandibular region removed under anesthesia (!) by Harvard University professor John Warren. Dentist William Morton narcotized the patient with ether. This day is considered the birth date of modern anesthesiology, and October 16 is celebrated annually as anesthesiologist's day.

b) First anesthesia in Russia

On February 1847, the first operation in Russia under ether anesthesia was performed by Moscow University professor F.I. Inozemtsev. A.M. also played a major role in the development of anesthesiology in Russia. Filamofitsky and N.I. Pirogov.

N.I. Pirogov used anesthesia on the battlefield, studied various methods of introducing ether (into the trachea, into the blood, into the gastrointestinal tract), and became the author of rectal anesthesia. He owns the words: “Essential steam is a truly great remedy, which in a certain respect can give a completely new direction to the development of all surgery.”(1847).

DEVELOPMENT OF NARCOSIS

a) Introduction of new substances for inhalation anesthesia

In 1947, Edinburgh University professor J. Simpson used chloroform anesthesia.

In 1895, chlorethyl anesthesia began to be used. In 1922, ethylene and acetylene appeared.

In 1956, fluorotane entered into anesthesiological practice, and in 1959, methoxyflurane.

Currently, halothane, isoflurane, and enflurane are widely used for inhalation anesthesia.

b) Discovery of drugs for intravenous anesthesia

In 1902, V.K. Kravkov was the first to use intravenous anesthesia with hedonal. In 1926, hedonal was replaced by avertin.

In 1927, Pernok-tone, the first barbituric drug, was used for intravenous anesthesia for the first time.

In 1934, sodium thiopental was discovered, a barbiturate that is still widely used in anesthesiology.

In the 60s sodium hydroxybutyrate and ketamine appeared, which are also still used today.

In recent years, a large number of new drugs for intravenous anesthesia have appeared (Brietal, propanidide, diprivan).

c) The occurrence of endotracheal anesthesia

An important achievement in anesthesiology was the use of curare-like substances for muscle relaxation, which is associated with the name of G. Griffitts (1942). During operations, artificial controlled respiration began to be used, for which the main merit belongs to R. McIntosh. He also became the organizer of the first department of anesthesiology at Oxford University in 1937. The creation of devices for artificial ventilation of the lungs and the introduction of muscle relaxants into practice contributed to the widespread use of endotracheal anesthesia - the main modern method of pain relief during major traumatic operations.

Since 1946, endotracheal anesthesia began to be successfully used in Russia, and already in 1948 a monograph by M.S. Grigoriev and M.N. Anichkova "Intratracheal anesthesia in thoracic surgery."

HISTORY OF LOCAL ANESTHESIA

Discovery by Russian scientist V.K. Anrep in 1879, the local anesthetic properties of cocaine and the introduction into practice of the less toxic novocaine (A. Eingorn, 1905) served as the beginning of the development of local anesthesia.

A huge contribution to the doctrine of local anesthesia was made by the Russian surgeon A.V. Vishnevsky (1874-1948).

Anesthesiology has undergone such rapid development in just over a hundred years.

2.3 Blood transfusion

Donation

The entire history of blood transfusion is inextricably linked with the development of donation. Donor blood is the main source for the production of blood components and products. A donor (from the Latin dono - give) can be any healthy person aged 18 to 60 years who voluntarily agreed to donate blood.

The physiological dose of blood is considered to be 400 ml, however, for donors aged 18 to 20 years, as well as for those who give blood for the first time, as a rule, half of this dose is taken. The term “physiological dose” is explained: without harm to health. This blood volume is restored in the body within 30-35 days.

The health status of donors is determined during examination. Complete safety for the donor is the first law of transfusiology. Before giving blood, the hemoglobin content in it is determined. A hemoglobin value below 130 g/l in men and 120 g/l in women is a contraindication for blood sampling.

Blood collection is carried out at blood transfusion stations (BTS) and in blood transfusion departments (BTD) of medical institutions.

The scientific period in the history of blood transfusion and blood-substituting drugs is associated with the further development of medical science, the emergence of the doctrine of immunity, the emergence of immunohematology, the subject of which was the antigenic structure of human blood, and its significance in physiology and clinical practice.

The most important events of this period:

■ 1901 - the discovery of three human blood groups (A, B, C) by the Viennese bacteriologist Karl Landsteiner. He divided all people into three groups according to the ability of their blood serum and red blood cells to produce the phenomenon of isohemagglutination (erythrocyte gluing).

■ 1902 - Landsteiner's employees A. Decastello and A. Sturli found people whose blood type differed from the red blood cells and sera of the three groups mentioned. They viewed this group as a deviation from Landsteiner's scheme.

g. - Czech scientist J. Jansky proved that the new blood group is independent and all people, according to the immunological properties of the blood, are divided not into three, but into four groups, and designated them with Roman numerals (I, II, III and IV).

■ 1910-1915 - discovery of a method for stabilizing blood. In the works of V.A. Yurevich and N.K. Rosengart (1910), Justen (1914), Levison (1915), Agote (1915) developed a method for stabilizing the blood with sodium citrate, which binds calcium ions and thus prevents blood clotting. This was the most important event in the history of blood transfusion, as it made it possible to preserve and store donated blood.

■ 1919 - V.N. Shamov, N.N. Elansky and I.R. Petrov received the first standard serum to determine blood group and performed the first blood transfusion, taking into account the isohemagglutinating properties of the donor and recipient.

■ 1926 - the world's first Institute of Blood Transfusion (now the Central Institute of Hematology and Blood Transfusion) was created in Moscow. Following this, similar institutes began to open in many cities, blood transfusion stations appeared and a coherent blood service system and donation system were created, ensuring the creation of a blood bank (stock), its thorough medical examination and a guarantee of safety for both the donor and the recipient.

■ 1940 - discovery by K. Landsteiner and A. Wiener of the Rh factor, the second most important antigenic system, which plays an important role in immunohematology. Almost from this moment on, the antigenic composition of human blood began to be intensively studied in all countries. In addition to the already known erythrocyte antigens, platelet antigens were discovered in 1953, leukocyte antigens in 1954, and antigenic differences in blood globulins were discovered in 1956.

In the second half of the 20th century, methods for preserving blood began to be developed, and targeted drugs obtained by fractionating blood and plasma were introduced into practice.

At the same time, intensive work began on the creation of blood substitutes. Preparations have been obtained that are highly effective in their replacement functions and lack antigenic properties. Thanks to the advances in chemical science, it became possible to synthesize compounds that model individual components of plasma and blood cells, and the question arose about creating artificial blood and plasma. With the development of transfusiology, new methods of regulating body functions during surgical interventions, shock, blood loss, and in the postoperative period are being developed and applied in the clinic.

Modern transfusiology has many effective methods for correcting the composition and function of blood and can influence the functions of various organs and systems of the patient.

Conclusion

Having thoroughly examined the main problems of surgery, we became familiar with:

)History of asepsis and antisepsis, anesthesiology and blood transfusion, from ancient times to the 20th century

) Terms such as “asepsis” and “antiseptics”. After all, without knowing the meaning of these words, it is extremely difficult to consider history.

We also looked at:

) Solving the main issues of anesthesiology and anesthesia at different times

And also learned:

) That the entire history of blood transfusion is inextricably linked with the development of donation, and donor blood is the main source for the production of blood components and products

And we analyzed that:

)The history of blood donation and transfusion began with such important discoveries as

blood types

Rh blood factor

methods to prevent blood clotting

In conclusion, we can conclude that:

Asepsis and antiseptics, anesthesiology and the doctrine of blood transfusion became the three pillars on which surgery developed in a new quality. Knowing the essence of pathological processes, surgeons began to correct the impaired functions of various organs. At the same time, the risk of developing fatal complications, but most importantly, mortality, has significantly decreased.

Bibliography:

1. General surgery. Gostishchev V.K. (2002)

General surgery. Petrov S.V. (1999)

General surgery. Edited by G.P. Rychagova, P.V. Garelika, Yu.B. Martova(2002)

Asepsis and antiseptics. Methodological development for students. Tyumen State Medical Academy (2007). Associate Professor V.N. Gorbachev, ass. Chernov I.A., Doctor of Medical Sciences Tsiryatieva S.B.

5. Clinical Anesthesiology. J. Edward Morgan. Translation from English edited by PAMH academician A.A. Bunyatyan, Ph.D. honey. Sciences A.M. Tseitlina (2003)

6. Magazine “Be Healthy”. Article “History of anesthesia: opium, vodka, cocaine.” (10/16/2008) Author - Alexey Mikhailovsky

Similar works to - Solving the main problems in surgery, starting from the period of great discoveries (XIX-XX centuries)

World statistics show that the number of plastic surgeries performed annually increases by about 15. Thus, using the example of previous years, it was revealed that about 20 million people turn to aesthetic surgery per year, i.e., about 55,000 interventions are performed every day around the world. Today people correct a variety of “defects”: they straighten their noses, make their ears smaller and larger, pump out fat with lasers, and use it as a rejuvenating material. They inject themselves with various vitamin cocktails for quick and safe rejuvenation. Plastic surgery helps women regain beautiful breasts, make them fuller, some even reduce them when they have numerous health problems due to their weight.

The truth about plastic surgery abroad

And, unlike the post-Soviet space, plastic surgery abroad has long become an absolutely commonplace occurrence. For example, in the USA such interventions are covered by insurance, which is why almost every second person there has already gone under the knife at least once by the age of thirty. And in Brazil, in general, a “gift certificate” for aesthetic correction is the best gift from parents for their daughter’s coming of age.

The truth about plastic surgery - it’s generally not customary to talk about it out loud

And only in our country is it still considered bad manners to even discuss such interventions, and in case of any suspicion of such, it is customary to deny it. In confirmation: our patients, unlike European ones, when choosing routes of “penetration”, give preference to those that, although more dangerous and traumatic, are less noticeable. At the same time, in the West, the patient will choose a “simpler” intervention option, without even bothering about future traces. He will think about safety and health before aesthetics. So, for example, if our patient, when deciding on the type of access for installing a breast prosthesis, chooses the armpit (where the scar will be completely invisible), even despite the large number of possible complications and high morbidity, then the European woman will, without even thinking, prefer an incision under the areola, because such an operation is carried out much faster and involves fewer risks.

The problems of plastic surgery are greatly exaggerated

Against the background of such mystery, countless stereotypes, myths and conjectures began to form among the people, which for the most part have nothing to do with reality. And our media, perhaps without realizing it, only added fuel to the fire all this time, covering only unsuccessful cases. In fact, there are no more of them than in conventional surgery - somewhere around 9. And the problem is most often the lack of professionalism of the plastic surgeon, and, unfortunately, there are quite a lot of them here.

Incompetence of specialists is a problem in plastic surgery

Therefore, if you have become firm in your intention to undergo this kind of operation, then you need to choose a clinic and a surgeon with all the responsibility inherent in you.

To help you avoid plastic surgery problems associated with the incompetence of the surgeon, below is a list of questions that will help you evaluate your interlocutor during your first consultation:

• does the specialist have the appropriate education and the highest category (ask to present certificates, diplomas, diplomas, etc.);
• check your experience in plastic surgery (a professional surgeon should have more than 10 years of experience, but be careful: it is unlikely that during this period he would have physically managed to perform 10 - 30 thousand interventions);
• ask for a portfolio (you can even take the numbers of former patients);
• find out about all the possible risks and complications after the operation, let the surgeon make preliminary predictions (he can do these) so that you can figure out whether his approach suits you;
• Be sure to find out, firstly, how the legal agreement of the parties is drawn up, and secondly, who is responsible in the event of side effects.

If neither the tone, nor the behavior, nor the documents presented cause you suspicion, then the risk of plastic surgery problems is noticeably reduced. The only risks that remain are those that are characteristic of all surgery, and they are associated primarily with insufficient knowledge of the human body at this stage of medical development.

Modern plastic surgery: the safety problem has been solved with the transition to high technology

In general, modern aesthetic surgery has already moved far away from those previous conservative techniques with their deep incisions, long-term rehabilitation, unpredictability of results and visible scars. Today plastic surgery is minimally invasive. To carry out manipulation in the subcutaneous space, the surgeon now does not even look towards the scalpel. If he is a professional, he will have ultra-thin instruments in his arsenal, flexible and equipped with microscopic cameras that penetrate the upper tissues leaving almost no traces, and broadcast to the staff a super-accurate image on high-resolution screens online. This way they can observe the behavior of tissues during the operation. In addition, as practice shows, with the introduction of such techniques, another common problem of plastic surgery has noticeably decreased - the risk of tissue injury during the operation.

Today, long-term rehabilitation is not required - after most interventions, the patient returns home within 2 days, and can be seen in public 5 days after discharge. And one more important point: today’s interventions do not even require general anesthesia, being limited only to local anesthesia, which also reduces the risks of the former problems of plastic surgery.

In general, it is manufacturability and minimally invasiveness that are the hallmarks of modern plastic surgery, and the problems encountered here during classical interventions have mostly lost their relevance with the transition to high technology.

An unresolved problem of plastic surgery is the presence of numerous contraindications

The only thing is that today, as before, plastic surgery is still contraindicated for:

• diabetes mellitus;
• during pregnancy and lactation;
• during the period of exacerbation of chronic diseases;
• in case of blood clotting disorders;
• for infectious diseases;
• for diseases of the cardiovascular system;
• oncological diseases.

All these factors, by the way, are identified long before the operation itself. At the first consultation, the surgeon should send the patient for an examination, which includes the following tests:

• general blood analysis;
• biochemical analysis;
• blood for coagulogram;
• tests for HIV and other infections;
• cardiologist's conclusion based on ECG;
• gynecologist's report.

And only based on the results of these tests, the surgeon makes a decision to perform or refuse the operation.

V.V. Klyuchevsky, K.A. Gural

MODERN PROBLEMS OF INJURY SURGERY

Yaroslavl State Medical Academy (Yaroslavl) Tomsk Medical University (Tomsk)

Socio-political crises due to deterioration of social conditions, economic recession and population migration are usually accompanied by an increase in the number of victims. Ongoing local wars and conflicts in various regions of the former CIS have led to uncontrolled population movements for political, national and other reasons. In addition, large-scale natural disasters, man-made disasters, urbanization and the increase in the number of vehicles aggravate this problem. Yaroslavl acutely experiences all of the above social factors, as it occupies an advantageous geographical location. Yaroslavl, being an investment-attractive region, a major tourist and industrial center, a junction of railway, water, road and air transport, like a mirror, reflects the whole gamut of problems that have arisen in recent decades.

The city of Yaroslavl with a population of 680 thousand people has 470 orthopedic and traumatological beds, 400 of which are deployed in the Municipal Healthcare Institution KB SMP named after.

N.V. Solovyova. In fact, this is a single clinical orthopedic and traumatology center for the city and region, providing all the necessary assistance to victims around the clock and every day. The population of other cities and districts of the region (700 thousand) is served in 5 inter-district traumatological and 9 general surgical departments of regional hospitals, two of which have 20 trauma beds each. In Yaroslavl, on the basis of theoretical research and practical developments of the Department of Traumatology, Orthopedics and Military Surgery of the Yaroslavl State Medical Academy (head of the department, Doctor of Medical Sciences, Professor V.V. Klyuchevsky, chief traumatologist of the region) with the administrative support of the main health department of the Yaroslavl region and The Department of Health of the city of Yaroslavl has developed and is operating a medical route system - providing multi-stage centralized care to trauma patients. The medical route of a trauma patient is a dynamic assessment of the condition of the victim and the effectiveness of the medical care provided to him at the stages of evacuation with reference to medical institutions and services with a list of diagnostic and therapeutic measures.

When characterizing the system of providing care to trauma patients, it is necessary to note the following stages:

1. Stage of self- and mutual assistance. At this stage, medical care is provided by self-

possible victim and/or the forces of others at the scene. The scope of assistance includes ensuring the rest of the victim and/or limb, performing immobilization using available means; taking analgesics; application of an aseptic, pressure, retaining bandage or tourniquet; calling an ambulance. As a rule, it is not possible to take into account the number of victims, but a number of victims come to the center due to the development of late complications after the “bright interval”. Typically, this situation occurs in the case of initial positive dynamics. The characteristics of the damage manifest themselves after some time as complications, often of an inflammatory nature. Such victims are sent to the trauma center already from the rehabilitation stage to provide them with specialized care. The results of treatment are taken into account and analyzed by the links of the control stage.

Example. Patient G., 42 years old. I.B. No. 12970.

On July 12, 2001, he went to the trauma center about a purulent wound on the anterior surface of the chest in the projection of the sixth rib near the sternal line on the left. Upon admission, the condition was satisfactory. The skin is of normal color, mucous, pale, pink. Ps - 92 beats/min. Blood pressure - 140/75mm Hg. Art., respiratory rate - 20 per 1 min., T - 37.3 °C. On the anterior surface of the chest in the projection of the VI rib near the sternum line on the left there is a stab wound 2.5 x 0.8 cm with hyperemia of the skin around it, a coating of fibrin and serous-fibrinous discharge from the wound itself. Auscultation: breathing is symmetrical on both sides, hard. Heart sounds are muffled, rhythm is preserved. The apex beat is not detected. There is an increase in the volume of the superficial veins of the neck. A computed tomography scan of the chest organs was performed - liquid blood and clots were detected in the pericardial cavity. A left-sided thoracotomy and revision of the pericardium were performed. After removal of the clots, bleeding from the wound of the right ventricle. The heart wound was sutured and the pleural cavity was drained. Stitches are applied in layers. The postoperative period was complicated by left-sided pneumonia and pleurisy. 22 days after the operation he was discharged for outpatient treatment in satisfactory condition.

2. First aid stage. At this stage (without touching on diagnostic issues, which should be as fast and accurate as possible and aimed at identifying the dominant injuries), the victim is examined, as a rule, by a doctor or paramedic of the line team that arrived at the scene of the incident

ambulance or specialized - resuscitation, less often by paramedics of FAPs or health centers of factories, a doctor at a clinic or emergency room, and in a central district hospital - an on-duty surgeon or traumatologist.

At the stage of first aid, available therapeutic measures are carried out - correct application of a bandage, if possible, temporary stopping of bleeding; applying or repositioning a tourniquet (indicating the time of application of the tourniquet in the accompanying note); giving a physiologically favorable position and performing transport immobilization of the damaged segment with service splints; administration of analgesics, analeptics, glucocorticoids, puncture or catheterization of a vein and establishment of infusion of blood substitutes and transportation to the stage of qualified or specialized medical care.

3. Stage of qualified care - carried out throughout the region by 5 inter-district traumatological and 9 general surgical departments of district hospitals. In the city - the duty service of the MUZ KB SMP named after. N.V. Solovyov, who, if necessary, provides specialized assistance. By qualified assistance we mean the entire scope of resuscitation and anti-shock measures. The scope of assistance at this stage includes conservative and surgical techniques (final stop of external and internal bleeding; elimination of cardiac tamponade, hemo- and pneumothorax; application of temporary vascular shunts to save a limb if it is impossible to perform a suture; primary stabilization of fractures of long tubular bones and pelvic bones with rod devices , decompressive brain surgery).

An important distinguishing feature in the conditions of the city of Yaroslavl and the region is the support of the employees of the MUZ KB SMP named after. N.V. Solovyov of medical personnel at the stage of first medical aid and qualified assistance in health care facilities of the city and region. This support is provided in the form of consultations, telephone or radiotelephone discussion of the clinical case by the medical worker providing assistance and traumatologists or resuscitators of the trauma center. In addition to a consultation discussion, in difficult cases a therapeutic and advisory visit is added. The timeliness of medical and advisory visits is ensured by the air ambulance service. The essence of this event is as follows: as a result of a consultative discussion between the doctor and the traumatologist of the MUZ KB SMP named after. N.V. Solovyov, a decision is made on the need for an on-site examination of the victim and therapeutic and diagnostic measures by a doctor at the trauma center to determine the further program of action.

A trauma center specialist (usually a traumatologist), who is on duty at home in the air ambulance system, goes to the stage of qualified assistance at the health care facility where the victim is located. After examining the patient and clarifying the diagnosis, subsequent therapeutic and surgical tactics are developed. If there are emergency indications, surgical treatment of the patient is performed on site. In complex clinical cases (trochanteric fractures, fractures of the spine, acetabulum, joints, foot), treatment measures are agreed upon and the timing and medical and technical support for transferring the victim to one of the departments of the Municipal Health Institution KB SMP named after. N.V. Solovyov, where he will receive specialized assistance. Improving the quality of operations performed by surgeons and traumatologists at the stage of qualified care is facilitated by regular and systematic training of specialists from all medical institutions in the region providing emergency trauma care in the cycles of PDO FUV, conducted at the Department of Traumatology, Orthopedics and Military Surgery of YSMA.

4. Stage of specialized assistance. In the conditions of the city of Yaroslavl, assistance at the stage of qualified and specialized care is provided by the duty service and employees of nine trauma departments of the MUZ KB SMP named after. N.V. Solovyov (hereinafter referred to as the trauma center). To provide specialized care, the medical institution has all the necessary functional units (3 operating units for urgent, planned and microsurgical interventions; X-ray department; laboratory department, including an express diagnostic laboratory; functional diagnostic department; ultrasound, endoscopy, computed tomography rooms), allowing quickly determine the leading injury, formulate a diagnosis, develop tactics and provide the entire scope of emergency surgical care to victims, regardless of the presence and nature of the injuries. In the trauma center, emergency care is provided daily by the team on duty, consisting of the team leader, 2 traumatologists, 1 neurosurgeon, 1 anesthesiologist, 1 resuscitator, 1 therapist and 1 cardiologist. Microsurgical assistance is provided daily from 8 a.m. to 3 p.m. by department staff. Then, from 15:00 to 21:00, a duty officer is assigned, who is located in the microsurgery department, and from 21:00 to 8:00 the next day, another doctor of the department is on duty at home (delivery time 20 minutes). A special feature is that the head of the trauma team is a “polyvalent” surgeon. He is appointed from among the most experienced doctors in the trauma center. As a rule, this is a general surgeon who has specialized in traumatology and has sufficient experience in providing care to victims.

patients with polytrauma, or a traumatologist with specialization and experience as a general surgeon. In addition, the head of the trauma team must be able to perform decompressive operations on the brain and spinal cord and master the vascular suture technique. In the event of simultaneous admission of several victims, all on-duty traumatologists and surgeons from other services are involved in providing assistance under the supervision of the head of the trauma team. In addition, to strengthen the team, if necessary, it has the opportunity to attract employees from the hospital, the department of traumatology, orthopedics and military surgery of YSMA and city hospitals.

5. Rehabilitation stage. Patients treated at the MUZ KB SMP named after. N.V. Solovyov, as well as in other health care facilities of the city and region, are not left without the support of traumatologists at the rehabilitation stage. Rehabilitation therapy and rehabilitation courses are conducted on the basis of the city rehabilitation center and sanatorium “Bolshie Soli”. However, most trauma patients undergo rehabilitation treatment in community clinics. Despite this, any patient can receive advice from a traumatologist, one of the doctors at the trauma center, who conducts daily outpatient visits. In addition, any patient can receive advice from the staff of the Department of Traumatology, Orthopedics and Military Surgery of YSMA and leading specialists of the trauma center on any day of the week, except Sunday.

6. Control stage. Control over the quality of treatment and the correctness of medical documentation is carried out as follows: firstly, the initial internal check of medical documentation after completion of the course of treatment is carried out by the head of the department. Then the medical documentation is checked by the deputy chief physician for surgical work and examination. In addition, at daily morning medical conferences, there is a discussion of the volume and effectiveness of assistance provided to victims admitted over the past 24 hours, and a discussion of intensive care patients. There is weekly discussion and planning of surgical procedures that need to be performed for inpatients in need. There is a weekly discussion of discharged patients with a mandatory analysis of the surgical procedures performed and in case of complications. In case of ineffectiveness of treatment and death, the traumatologists who provided assistance to the patient are required to attend a forensic medical examination of the corpse. At the dissecting table, they take part in assessing the volume and nature of damage, in post-mortem diagnosis and establishing the causes of death, and determining the effectiveness of the treatment provided.

help. Clinical and anatomical conferences are held based on the medical documentation of the previous stages and on the materials of forensic medical studies, the purpose of which is to re-evaluate the facts surrounding the case being analyzed. A re-evaluation of the mechanism of injury, clinical picture, volume and nature of diagnostic and therapeutic measures performed at each stage is carried out; analysis of difficulties encountered, possible errors and complications; and after revealing the reasons for the unfavorable outcome, proposals for improving the quality of care for victims are discussed. Secondly, expert departments of insurance companies (after our country’s transition to a market economy) check medical documentation after the patient completes an inpatient course of treatment, make comments, and sometimes apply penalties when defects are discovered. Thirdly, control is carried out by the service of chief specialists of the city and region. Fourthly, the forensic medical examination service. All deceased victims are taken to the regional bureau of forensic medicine. Based on the materials of forensic medical research, clinical, anatomical and procedural issues are resolved.

Example. Patient T., 43 years old. I.B. No. 11162. Admitted to the trauma center due to failed arthrodesis of the left knee joint, a year after resection of the knee joint for purulent arthritis and arthrodesis performed according to Ilizarov. When determining the cause of nonunion, it was found that after 2 months. after arthrodesis, the CDA was removed by a doctor at the clinic (early removal). The case was discussed at a medical conference.

The use of a system for providing multi-stage centralized care to trauma patients allows us to provide specialized care to all trauma patients in need in Yaroslavl. The experience of such an organization of trauma care that has existed for 36 years has confirmed its feasibility and revealed its shortcomings.

UNSOLVED PROBLEMS

Changes in economic formations, changes in living and working conditions, and stratification of society have revealed socially unprotected groups of the population and declassed elements. Low social adaptation of the population has led to unmotivated cruelty and to showdowns involving injuries (often while intoxicated). In a state of alcoholic intoxication in the MUZ KB SMP named after. N.V. Solovyov, Yaroslavl in 2001, 14,704 people out of 19,589 were delivered, in 2002 - 12,862 out of 19,772 and in 2003 - 13,102 out of 19,679 (Table 1).

There continues to be an increase in emergency hospitalization of trauma patients, with a slight decrease in the number of visits to the hospital for emergency care.

It should be noted the actions of doctors and paramedics at the first aid stage, including the trauma center of the MUZ KB SMP named after. N.V. Solovyov, who, without proper specialized training in traumatology or experience, send patients who do not require hospitalization to the trauma center, which is reflected in Table 2.

As can be seen from the above data, a large amount of outpatient care remains at the stages of qualified and specialized care, which under the new economic conditions is an unacceptable luxury.

The main reason for refusals in hospital treatment, in our opinion, is the inability to make a clear diagnosis at the early stages of medical routes due to insufficient training of medical personnel for extreme situations and severe alcohol intoxication of the victims, which forces them to be examined and dynamically monitored at the stages of qualified and specialized assistance. Secondly, the inadequacy of the condition of patients associated with intoxication leads to the fact that a large number of victims refuse hospitalization and receive further assistance at their place of residence or without permission.

leave and go to the hospital only if complications develop.

The next problem when providing first aid to trauma victims in the city and region is that the diagnosis of mild shock is often not made with normal or slightly elevated systolic pressure for fractures of the trochanteric zone in the elderly and elderly; for tibia fractures, polytrauma, especially in combination with TBI; for injuries and injuries to the chest, as well as fractures of the pelvic bones.

Example. Patient E., 54 years old. I.B. No. 12480. She was admitted to the trauma center on December 26, 2001, 40 minutes after the accident (she was hit by a truck). Diagnosis: Road polytrauma. CCI. Brain concussion. Open fracture of the right femur. Laceration of the right thigh. Rupture of the acromioclavicular joint. Alcohol intoxication (The diagnosis of shock was not made!). Upon admission, consciousness was preserved, the general condition was assessed as moderate to severe. At the same time, blood pressure remained at the level of 130/80 mm Hg. Art., Ps-88 beats/min. Upon admission during resuscitation under spinal anesthesia, PSO of the wound was performed, and a rod CDA was applied to the thigh. On January 10, 2002, after the wound had healed in satisfactory condition, external osteosynthesis of the right hip with bone autoplasty was performed.

Table 1

Appeal to the MUZ KB SMP named after. N.V. Solovyov, Yaroslavl

2001 2002 2003

Total number of hospitalized patients 19205 19772 19744

Hospitalized while intoxicated (total) 14,704 (76.6%) 12,862 (80.2%) 13,102 (66.4%)

Hospitalized for emergency reasons due to injury (total) 15729 15609 15499

Hospitalized urgently for trauma 5118 5143 5372

Visited trauma departments, but were not hospitalized (outpatient care) 10611 10464 10127

table 2

Some results of the actions of doctors and paramedics at the first aid stage

2001 2002 2003

Not hospitalized 10611 10464 10127

Of these sent by ambulance 5725 5750 5745

Of these sent by the emergency room 2098 1851 1876

Of these, referred by other health care facilities 1703 1679 1698

Without direction 1085 1184 878

Table 3

Main reasons for refusal of hospitalization

2001 2002 2003

Outpatient care 10611 10464 10127

No readings 6581 6396 6122

Refused hospitalization or left without permission 3754 3690 3764

Referred to other health care facilities 276 378 241

Discharged in satisfactory condition for follow-up treatment on January 23, 2002.

Example. Patient E., 18 years old. I.B. No. 13944. She was admitted to the trauma center on December 18, 2001 with a diagnosis of combined trauma (polytrauma). TBI. Brain concussion. Bruised head wound. Stab wounds to the chest on both sides. Right-sided pneumothorax. Incised wounds on both shoulders and thighs. Flame burn of the face, neck, chest of I-III degree, with a total area of ​​7%. (The diagnosis of shock was not made!). Upon admission, the general condition was assessed as serious. At the same time, blood pressure remained at the level of 150/100 mm Hg. Art., Ps -98 beats/min. On December 18, 2002, against the background of intensive therapy, PSO of wounds of the head, chest, both hips, shoulders, thoracocentesis on the right in the 2nd intercostal space, and drainage of the pleural cavity were performed. After treatment, she was discharged in satisfactory condition on December 30, 2002.

Unfortunately, transport immobilization for hip fractures is still carried out incorrectly, which undoubtedly aggravates the condition of patients during transportation. Of the 675 such patients delivered to the MUZ KB SMP named after. N.V. Solovyov in Yaroslavl over the past 12 years, the Diterichs splint was used only in 3.5% of cases. Both at the stages of first medical and qualified care, and at the stage of specialized care, due attention is not paid to the diagnosis and treatment of “mild shock” and significant blood loss in polytrauma, open and closed fractures. Mild shock should be diagnosed in all patients with polytrauma; with fractures of the femur, and in the elderly and elderly with trochanteric fractures; for fractures of the leg bones, if there is no adequate transport immobilization; for fractures of the pelvis and spine; with possible blood loss of more than 1 liter. All these patients should undergo early stabilization of fractures and anti-shock therapy for 2 to 4 days. In trauma hospitals of the Central District Hospital, primary therapeutic immobilization (rod devices) and minimally invasive immersion osteosynthesis for fractures of the hip, pelvis and especially for polytrauma have not yet found proper use during the period of recovery from shock. We believe that the use of traditional skeletal traction for these purposes is not justified, since it does not immobilize bone fragments, contributing to the development of complications in the acute period.

Example. Patient B., I.B. No. 13408. Admitted to the trauma center by transfer from the Pereslavl Central District Hospital

04.12.2002 at 20 o'clock with a diagnosis: Road polytrauma. CCI. Brain concussion. Fracture of the middle third of the right femur. Condition after skeletal traction. From the anamnesis: road injury on December 3, 2002 at about 8:30 a.m., he doesn’t remember the circumstances - he fell asleep at the wheel. He was taken to the Pereslavl Central District Hospital approximately 2 hours after the injury (his leg was caught in a mangled car). Upon admission, the patient’s condition was assessed as satisfactory, conscious, adequate. Blood pressure 140/90 mm Hg. art., Ps - 96 beats/min. Upon admission, novocaine blockade of the fracture site was performed,

Damper skeletal traction was established, infusion therapy was performed in a volume of 800 ml. 12 hours after admission, shortness of breath appeared up to 30 per minute, the temperature rose to 38.5 ° C, the pulse increased to 130 beats/min, blood pressure - 100/70 mm Hg. Art., urination through the catheter according to the volume of infusion. Blood laparoscopy was performed, no intestinal contents were detected. X-rays of the skull bones and chest organs did not reveal any traumatic changes. There is no evidence of cardiac contusion on the ECG. Despite the initiation and ongoing intensive therapy, the patient's condition continued to deteriorate. Confusion and lethargy appeared. After a telephone consultation, specialists from the trauma center went to the site in an intensive care vehicle. When assessing the situation after examining the victim and due to the lack of the necessary material base for further therapy, the patient was transferred to the Yaroslavl trauma center against the background of intensive therapy and adequate transport immobilization (Diterichs splint). Travel time is 2 hours.

Upon admission to the MUZ KB SMP named after. N.V. Solovyov, 36 hours after the injury, the patient’s condition is serious, Ps - 108 beats/min., BP - 110/70 mm Hg. Art., shortness of breath up to 28 per 1 min. The DSV was reinstalled. Performed against the background of resuscitation and respiratory support (in BiPAP mode, Dreiger apparatus) CT scan of the brain (moderate diffuse cerebral edema), chest organs (moderate dilatation of large pulmonary vessels was noted, no areas of hypoventilation were identified). General blood test: Er - 2.49 x 106; Hb - 64; Ht - 0.2; L -18.0 x 103; N - 2; P - 14; C - 68; L - 16; ESR - 57; blood clotting time according to Sukharev - 5"25"; pH

7.352; PCO2 - 50 mmHg; PO2 - 29.2І mmHg; HCO3a

27.7 mm/L; HCO3s - 24.7 mm/L; tCO2 - 29.2 mm/ L; BE (vt) - 1.6 mm/L; BE (vv) - 0.6 mm/L; PO2 -

29.2 mmHgi; O2SAT- 51.6%; Na - 161.6T mm/L; K

4.2mm/L; Ca - 1.09 mm/L.

On December 5, 2002, psychomotor agitation occurred. After the consultation under the leadership of prof. V.V. Klyuchevsky On December 5, 2002, an operation was performed: open retrograde intraosseous osteosynthesis of the right hip with a rectangular rod. ECG -

05.12.02 EOS normal. Sinus tachycardia -109 beats/min. The load on the left ventricle is increased (its hypertrophy is likely). Impaired nutrition of the left ventricular myocardium. Early repolarization syndrome. Rotation of the heart counterclockwise around the longitudinal axis. 06.12.02 compared to

On 12/05/02, signs of impaired nutrition of the myocardium of the anterior parts of the left ventricle were somewhat more pronounced. Otherwise, the condition is the same;

On December 6, 2002, a tracheostomy was performed. Subsequently, against the background of intensive therapy, the patient’s condition gradually improved, and on December 21, 2002 he was completely transferred to spontaneous breathing. On December 30, 2002, the patient was discharged in satisfactory condition for outpatient follow-up treatment.

This example shows the ineffectiveness of skeletal traction in polytrauma and

the possibility of early osteosynthesis against the background of developed fat embolism syndrome. But only in a specialized hospital! We believe that early intraosseous osteosynthesis in patients in a state of mild shock (while maintaining high and stable hemodynamic parameters) is a promising direction for the prevention of early complications.

Example. Patient M., 32 years old. I.B. No. 2920. Admitted to the trauma center on March 13, 2003, 25 minutes later. after an industrial injury with a diagnosis of a closed uncomplicated fracture of the right femur at the border of the upper and middle third. Abrasion of the skin of the forehead on the right. Bruised wound of the right shin in the middle third. Shock. Upon admission, the condition was satisfactory. Ps - 72 beats/min., BP - 140/90 mm Hg. Art. During antishock therapy, the patient underwent intraosseous osteosynthesis with a rectangular rod 2 hours after admission. He was discharged in satisfactory condition on March 24, 2003 for outpatient treatment.

Example. Patient E., 19 years old. I.B. No. 6516. Delivered to the trauma center on June 12, 2002, after 1 hour 30 minutes. after the injury in satisfactory condition. On admission: Ps - 81 beats/min; Blood pressure - 120/80 mm Hg. Art. The diagnosis was made: Closed fracture of the pelvic bones. Fracture of the pubic and ischial bones of the pelvis on both sides. Fracture of the lateral masses of the sacrum on the right. Rupture of the vaginal mucosa. Shock. Domestic injury. Upon admission, against the background of intensive anti-shock therapy, a CDA was applied to the pelvic bones and colposcopy. On June 18, 2002, after stabilization of the patient’s condition, an operation was performed: Dismantling of the CDA. External osteosynthesis of the pubic bones. On July 3, 2002, the patient was discharged in satisfactory condition for outpatient follow-up treatment.

As can be seen from the examples given, early stabilization of fractures allows one to avoid complications of the acute period of a traumatic disease. If the blood pressure is normal, a diagnosis of shock is made. We believe that the period of primary stabilization of hemodynamic parameters after injury is a manifestation of shock in the stage of latent decompensation.

WAYS TO SOLVE PROBLEMS

We believe that in order to effectively combat negative phenomena in emergency surgery, a more in-depth study of the problem of mild shock in emergency surgery, which undoubtedly includes traumatology, is necessary. To ensure continuity in the treatment of trauma patients and especially with polytrauma, surgeons for the Central District Hospital must be trained through a two-year internship, with one year devoted to training in hospital and general surgery and only then the second in trauma and neurosurgery. Such a system of training specialists will make it possible to build a logical chain of care for acute trauma.

We regard traumatic shock as a staged and phased process, characterized by dysfunction of all organs and systems of the body in response to severe injury. Based on this definition, to optimize the provision of emergency care to victims in a multidisciplinary hospital, during medical triage we use the following classification of the acute period of a traumatic illness - traumatic shock. According to the classification, with a certain degree of convention, we distinguish 4 degrees and a phase of latent decompensation of the torpid phase of traumatic shock.

Severity of traumatic shock:

A) Stage of compensation of vital functions (extreme state). Extreme states are “conditions of the body that arise under the influence of strong (extraordinary) pathogenic influences and are characterized by extreme tension in the body’s protective reactions.”

Mild shock

a) TS 0 - phase of latent decompensation - (probably - a period of primary stabilization or latent shock or pre-shock) - when there are local primary disorders, there are no clinical manifestations, but partial development of an organ outside the area of ​​the primary focus of hypocirculatory and hypoperfusion syndrome has already occurred

Blood pressure is more than 100 mm Hg. Art., pulse less than 100 beats/min., general condition is satisfactory; When the primary focus is eliminated (stabilization of the fracture) and adequate therapy, deepening of the thyroid joint does not occur.

b) HS I degree - a period of compensated reversible shock - actually mild shock - when there is a tendency to suppress central hemodynamics, there are not pronounced clinical manifestations - systolic blood pressure is less than or equal to 100, but more than 90 mm Hg. Art., pulse is less than 100, but the development of organ, outside the affected area, hypocirculatory and hypoperfusion syndrome has already occurred, and a general hypocirculatory and hypoperfusion syndrome is developing; When the primary focus is eliminated (stabilization of the fracture) and adequate infusion therapy, deepening of the TB does not occur. Prescribing adequate therapy in the phase of latent decompensation and the period of compensated reversible shock is the prevention of the development of possible early complications of a traumatic disease. The entire range of bone surgeries can be performed.

c) Stage of decompensation of vital functions (critical condition) - extreme degree - violation of “autoregulation of functions and compensatory mechanisms, which requires artificial replacement or support of vital functions.”

Moderate shock

HS II degree - a period of decompensated reversible shock - when clinical disorders of central hemodynamics are aggravated (local unresolved primary disorders, and/

or ineffectiveness of treatment contributed to the development of general hypocirculatory and hypoperfusion syndrome, but the development of local acirculatory and aperfusion syndrome with the development of tissue necrosis did not occur) - blood pressure is less than 90, but more than 70 mm Hg. Art., pulse is more than 100, with the elimination of the primary focus and adequate therapy, deepening of the TS does not occur. It is possible to perform the entire complex of stabilizing bone surgeries against the background of adequate therapy.

Severe shock

TS III degree - a period of decompensated conditionally reversible shock, there are more pronounced clinical disorders (local unresolved primary disorders, and/or ineffectiveness of treatment allowed the development of a general hypocirculatory and hypoperfusion syndrome, the development of an acirculatory syndrome in one organ with the development of necrosis -otic processes against the background of organ and organismal hypocirculatory and hypoperfusion syndrome), when blood pressure is less than 70, but more than 50 mm Hg. Art., pulse more than 120 beats/min., against the background of infusion therapy, hemodynamics can be stabilized within 12 hours. From this period, multiple organ failure develops. Stabilization of fractures is carried out as a resuscitation aid - using minimally invasive methods (stabilization of pelvic bones, large bones with rod devices), against the background of adequate therapy.

d) The stage of loss of vital functions (terminal state), which is defined as a state occupying an intermediate position between life and death.

Terminal shock

TS IV degree - decompensated irreversible shock. There are more pronounced clinical disorders. Local unresolved primary disorders and/or ineffectiveness of treatment (complications in later stages of traumatic disease) allowed the development of general hypocirculatory and hypoperfusion syndrome, and the development of local acirculatory and aperfusion syndrome in more than one organ) when blood pressure is less 50, pulse more than 120 in the carotid arteries, shallow or periodic breathing, absent or doubtful consciousness. During infusion therapy, hemodynamics cannot be stabilized. Stabilization of fractures is carried out using minimally invasive methods, or the victim remains in transport immobilization.

Example. Patient A., 19 years old. I.B. No. 3226. Admitted in terminal condition on July 7, 2001 with a diagnosis of road polytrauma. TBI. Fracture of the base of the skull through the anterior cranial fossa. Brain contusion. Fracture of the lower jaw. Comminuted fracture of the left femur in the middle third. IV degree shock. The patient is taken to the preoperative room on a gurney by the EMS team. Blood pressure is not determined. Ps - 130 per minute on the carotid arteries.

Breathing is periodic. Against the background of resuscitation measures and mechanical ventilation, stabilization of the femoral fracture with a rod device (10 minutes from the moment of hospitalization), after which the victim was transferred to a hospital gurney. After 15 days

Osteosynthesis of the femur with a plate, after 23 days - osteosynthesis of the lower jaw. On September 7, 2001 (62 days after the injury) he was discharged in satisfactory condition.

Stage V TS - agony - pulse and blood pressure are not determined, agonal breathing, severe general hypocirculation, organ circulation or hypoperfusion, but cellular metabolism is preserved.

TS VI degree - clinical death - cellular metabolism is maintained for one time or another.

We believe that wider implementation of the above classification will allow earlier use of anti-shock therapy with a complex of resuscitation measures, which will reduce the number of complications of the acute period of traumatic illness.

All of the above indicates the need to create a system of algorithms for the treatment of trauma patients at all stages of care with their economic justification. To effectively combat shock, it is necessary to retrofit ambulances with vacuum suits and Dieterichs tires. Introduce integrative systems for diagnosing extreme conditions into clinical practice more widely. It is necessary to differentiate the volume of assistance depending on the stage, based on the qualifications of personnel, and provide funding depending on the volume of assistance provided. To control the operation of this system, quality standards for the provision of medical services are needed, based on which the surgeon could determine which stage of treatment a particular victim corresponds to.

LITERATURE

1. Klyuchevsky V.V. Traumatic shock. Long-term crush syndrome. Fat embolism / V.V. Klyuchevsky, K.A. Gural // In the book: Surgery of injuries: A guide for paramedics, surgeons and traumatologists of district hospitals / V.V. Klyuchevsky. - Ed. 2nd. - Rybinsk: Publishing House OJSC “Rybinsk Printing House”, 2004. -

2. Klyuchevsky V.V. Modern problems of Russian traumatology / V.V. Klyuchevsky, K.A. Gural, Yu.A. Filimendikov // Modern problems of Russian traumatology and orthopedics: Sat. scientific tr. - Voronezh, 2004. - pp. 26-28.

3. Sarkisov D.S. General human pathology / D.S. Sarkisov, M.A. Paltsev, N.K. Khitrov. - M., 1997. - P. 269.

4. Zilber A.P. Critical care medicine / A.P. Zilber. - Petrozavodsk: Petrozavodsk University Publishing House, 1995. - Book. 1. - 358 p.

9884 0

Today the world, and with it surgery, has stepped into the 3rd millennium, where only science fiction writers dared to look quite recently. A huge amount of knowledge, experience, skills and craftsmanship has been accumulated. The opening prospects are truly limitless. But they will become a reality only when we can not only appreciate the victories and achievements of surgeons, but also comprehend the problems, difficulties and obstacles, both inherited from the last millennium, and those created by fast-flying time. Determining the main ways to overcome them, the timely solution of new, sometimes unexpected and very complex tasks facing surgeons, caused by the non-linear development of society and science, are the conditions without which further progress of our specialty is impossible.

Modern surgery has reached unprecedented heights, and rapid specialization has largely contributed to this. It is no coincidence that the best results of complex operations on the heart, blood vessels, lungs, and liver were achieved in large, highly specialized centers. Meanwhile, the general level of surgery is determined not by the individual, most significant achievements of specialized academic institutions, but by the quality of work in district and regional hospitals of practical surgeons, who were and remain universal surgeons.

Another reason for the breakthrough achieved in the treatment of complex diseases is the active widespread introduction of modern technologies that are rapidly changing the face of surgery. This applies to both diagnosis and treatment of patients. The revolution in computer technology and the design of video systems, which occurred in the last 20 years of the previous century, made it possible to create highly informative diagnostic methods and fundamentally improve the technology for performing many operations. Standard X-ray, endoscopic examinations and ultrasound were relegated to the category of routine techniques. They have been replaced by computer technologies that make it possible to obtain three-dimensional, three-dimensional, so-called 3D images of organs and tissues. It has become possible to perform intraoperative optical tissue biopsy with a resolution that approaches histological resolution. The emergence of new diagnostic techniques goes in parallel with the integration of existing ones, increasing their information content by an order of magnitude.

The general trend towards non-invasive research methods is extremely valuable. First of all, this applies to ultrasound diagnostics, which can be used to examine almost any patient’s organs on an outpatient basis. If previously angiography was considered the “golden” standard in the diagnosis of vascular lesions, now this place has been firmly occupied by ultrasound angioscanning.

Modern ultrasound, endoscopic, angiographic, radionuclide diagnostic methods, computer (CT) and magnetic resonance (MRI) tomography and other cutting-edge diagnostic technologies often provide invaluable information. However, reliance on computer technology, numbers and graphs should not overshadow clinical thinking. It is difficult to argue with the unforgettable Kozma Prutkov, who argued that every narrow specialist, even the most brilliant, becomes “like gumboil.” Only a broad-minded clinician who knows the strengths and weaknesses of all existing diagnostic techniques can correctly evaluate and integrate the data obtained.

Combining the strengths of specialization and integration in medicine in general and surgery in particular is one of the primary challenges of our time, and its importance will only increase with the advent of new diagnostic technologies.

In addition, many research methods, at least at present, are based on the use of very expensive devices and equipment, and for a long time will be the prerogative of a small number of large surgical centers. Therefore, both in the near future and in the distant future, a clear system of priorities is needed in the training and practical activities of both surgeons and doctors of other specialties: in the first place - the clinical picture, the person, the patient, with all his physical and mental characteristics, and only then - even the most valuable data from instrumental and laboratory methods. Otherwise, the doctor will inevitably find himself buried under a Mont Blanc of numbers and indicators that will obscure the essence of the pathological process and the prospects for treatment.

Correctly and timely diagnosis of the patient is important, but still only the first stage of the surgeon’s work. The main thing, of course, is to save a person from this suffering. The last decade has been a period of rapid introduction of new technologies in the treatment of patients. First of all, this is minimally invasive surgery, which has made it possible to combine what many generations of surgeons have dreamed of: radicalism, cosmetics, low trauma and quick rehabilitation. In many cases, it is the access, and not the volume of intervention, that determines the overall tolerability of the operation, the rate of recovery, and the period of restoration of working capacity. Minimally invasive surgery is a broad concept. It combines endoscopic interventions performed through natural anatomical openings, endosurgical interventions - through punctures in the chest or abdominal wall, open operations - through small surgical approaches. Minimally invasive interventions for tumors of the lungs, mediastinum, esophagus, intestines, bile ducts, stomach, and hernias are performed today in hundreds of clinics.

The advantages of such interventions over traditional ones are obvious in many cases. However, the most important issue remains the formulation of indications for endosurgical operations. It is dangerous when endosurgical access becomes an end in itself. The surgeon should not proceed from adherence to methods and follow fashion trends. The choice of treatment method, and this is fundamentally important, should always be adequate to the existing clinical situation.

X-ray endovascular surgery has enormous prospects. Already now, it can restore the patency of arteries and veins, treat heart defects, portal hypertension and aneurysms, stop bleeding, prevent pulmonary embolism and much more. Lasers have come into X-ray endovascular surgery and are actively used. The possibilities and proportion of endovasal interventions performed “without an incision and anesthesia” will increase significantly in the future.

What is expected in the near future? The so-called intelligent surgery, which is based on the use of robots, microrobots and teleoperation systems, has already moved from the sphere of science fiction to the field of experimental execution. This provides the ability to remotely perform a wide variety of operations through minimal online access. The surgery is precision performed by a microrobot controlled by a surgeon using a teleoperation system that generates a three-dimensional computer image that allows the doctor to feel inside the chest or abdominal cavity. Many operations using robotics have already been successfully performed in cardiac surgery, orthopedics, and urology. At the same time, the widest expansion of technological capabilities equally significantly increases the importance of the surgeon’s intelligence, knowledge and experience.

In the more distant future, apparently, the face of surgery and many surgical operations will completely change, and there will be a need to equip operating rooms for tissue engineering, genetic, and biochemical interventions. Transplantation of stem cells and autologous skeletal myoblasts into the post-infarction scar area is already being experimentally used to improve the functional state of this area.

As a rule, the most advanced, revolutionary diagnostic and treatment technologies are used in the provision of planned surgical care. However, this does not mean that the role of emergency surgery is diminishing. Emergency surgery has been and remains the most difficult section of our profession. Surgeons will have to deal with acute appendicitis, intestinal obstruction, strangulated hernias, and injuries at any level of development of society, science and technology. In urgent surgery there is rarely time for complex diagnostic studies, and the most critical tactical decisions have to be made in conditions of lack of information and time. At the same time, the complexity of “ordinary” surgical interventions for destructive processes, peritonitis, and bleeding can significantly exceed the technical problems of planned reconstructive operations. Treating a patient with diffuse peritonitis is often much more difficult than performing aortic replacement or esophagoplasty.

What can improve the results of treatment for this category of patients? The fate of a huge number of patients is in the hands of clinic doctors. With timely detection and adequate treatment of patients with tumors, cholelithiasis (GSD) and peptic ulcers, and uncomplicated hernias, the number of advanced forms and severe complications of these diseases will significantly decrease. In order to fully use this reserve for improving treatment results, it is necessary, at a new level of knowledge, organization and material support, to return to prevention, routine mass medical examinations, which were repeatedly ridiculed for formalism, and active promotion of medical knowledge and the possibilities of surgery in the media.

At the turn of the millennium, there was a need to take a fresh look at such general surgical problems as bleeding, infection, venous thromboembolic complications, and oncological diseases. What is this connected with? The development of humanity does not proceed strictly in a positive, progressive direction. Epidemics of infectious diseases that threaten the very existence of life on Earth, unfortunately, are not a thing of the distant past. Moreover, new, hitherto unknown and deadly viral diseases are appearing. Their distinctive feature is the possibility of infection through blood. In this regard, the fight against such a basic, generic problem for surgery as bleeding takes on a completely different direction.

Today, transfusion of blood and its components poses a huge danger to the patient, since the blood can be infected with hepatitis and human immunodeficiency viruses. Existing test systems do not allow detecting the presence of the virus in the early stages of the disease. Today we know that there is no absolutely safe transfusion. Blood transfusion turns into “Russian roulette”, when each dose of plasma or red blood cells can take a person’s life. Even the transfusion of gelatin solutions, traditionally widely used as a colloidal blood substitute, poses an increasing threat of the spread of the causative agent of transmissible spongiform encephalopathy, called “mad cow disease” in the media, which is not destroyed by commonly used sterilization regimes.

Under these conditions, the need to create effective and safe blood substitutes that have a gas transport function and are capable of performing other blood functions increases sharply. Along with this, a number of alternative ways are being developed, related, in particular, to the use of the patient’s own blood and the creation of individual blood banks. And, of course, in bloodless surgery programs, a huge role will belong to effective physical methods of stopping bleeding (using a microwave and ultrasonic knife, laser argon coagulator), as well as modern local and systemic hemostatic agents.

The patterns of the microorganism-human relationship also require rethinking, primarily the solution of conceptual issues related to such a problem as sepsis. Another great N.I. Pirogov made great efforts to solve the problems of wound infection and “blood poisoning.” Despite all the achievements of clinicians and pharmacologists, even now, at the beginning of the 21st century, with a significant reduction in the total number of wound infectious complications, the mortality rate for sepsis is about 40%. The reason for this is the selection of extremely resistant microorganisms, which occurred under the influence of the uncontrolled prescription of antibiotics, the widespread use of invasive methods of diagnosis and treatment, and the influence of various factors causing a decrease in immunity. The frequency of isolation of microorganisms, the names of which were previously completely unknown to clinicians, has increased.

Another serious problem that equally worries traumatologists, orthopedists, gynecologists, and urologists along with surgeons is postoperative venous thromboembolic complications. Now that the skill of surgeons has increased, against the background of a general decrease in postoperative mortality, there is an alarming increase in the proportion of fatal pulmonary embolisms. The increasing prevalence of acute venous thrombosis, which is their source, is due to the general increase in the age of the population, physical inactivity, obesity, the prevalence of previous chronic venous diseases, congenital and acquired disorders of the blood coagulation system, cancer, and the growing frequency of complex surgical interventions.

The solution to this problem should follow the path of primary prevention, preventing thrombotic lesions of the veins. To do this, along with the prophylactic use of modern pharmacological agents, the most effective of which are low molecular weight heparins, it is imperative to persistently use nonspecific methods, primarily elastic compression and early activation of patients.

The growth of oncological pathology due to environmental and demographic problems is very alarming. Treatment of the tumor process has its own principles, many features and details. Meanwhile, a significant number of these patients are admitted urgently to non-core institutions with severe complications in the late stages of the disease. Knowledge of the basic principles of oncology and the ability to correctly navigate a clinical situation are now necessary for a surgeon of any profile.

The process of specialization in medicine cannot be stopped. However, most future doctors will come to work not in large specialized centers, but in emergency and regional hospitals, where they will have to master a wide range of interventions and become general surgeons. Therefore, along with narrow specialization, the role of basic medical education and a broad clinical outlook will only increase. In order to help a patient, desire and the most sincere compassion are not enough. Flair and intuition, skill and professionalism are always based on knowledge, which can only be obtained through hard work.

Surgery is entering the new millennium with a valuable store of knowledge, experience, skill and has enormous potential for development. The extent to which this potential will be realized depends on you and me.

Savelyev V.S.
Surgical diseases