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Surgery is a field of medicine in which techniques are used surgical intervention for the treatment of injuries and diseases. Generally, a procedure is considered surgical when it involves cutting the patient's tissue or suturing a pre-existing wound.
All forms surgery are considered invasive procedures. So-called “non-invasive surgery” usually refers to an excision that does not physically penetrate the patient's organs/tissues (eg, laser corneal ablation). This term is also used to refer to radiosurgical procedures (irradiation of the tumor).

Historical reference

Surgery belongs to one of the most ancient branches of medicine. The oldest surgical technique is trepanation, which was performed for both medical and religious purposes. For example, in ancient Tibet, some monks had their “third eye” drilled out of the middle of their forehead, a practice that was often fatal. It is also known that in the 6th millennium BC, ancient people applied bandages in case of bone fractures. 1500 BC the first ancient Indian surgical instruments appeared. Hippocrates wrote, among other things, works on surgery, so this greatest ancient Greek healer proposed resection of the rib for pleural empyema (also known as purulent pleurisy). Surgery also developed in ancient Roman society. Doctors of that time successfully performed amputations and treated different types wound Surgeons helped the wounded on the battlefields and after gladiatorial battles.
The Middle Ages were a dark time for surgery. Talented doctors were afraid to offer their methods, so as not to expose themselves to the risk of being accused of heresy. This continued until the beginning of the Renaissance, which gave a powerful impetus to progress in the field of surgery. Famous representatives of this era (in the field of surgery) are Paracelsus and Ambroise Pare. In the 19th century, many major discoveries occurred, in particular, the Frenchman Louis Pasteur discovered factors that destroy microbes (high temperature and chemicals), the German surgeon F. von Esmarch invented a tourniquet to stop bleeding, and the Russian doctor M. Subbotin became the founder of asepsis.
In the 20th century, anesthesia techniques were improved, doctors made progress in preventing complications after surgery, and many surgical instruments were invented. This made it possible to radically expand the range of surgical interventions.

Diseases in surgery

There are many diseases for which surgical techniques can be used. Among them:

• pathologies of the male/female reproductive system (for example, uterine fibroids or prostate adenoma);
• proctological pathologies (for example, rectal prolapse);
• phlebological diseases (varicose veins, thrombophlebitis);
• diseases of the brain and nervous system (various tumors);
• cardiac pathologies (aneurysm, heart defects);
• spleen diseases;
• ophthalmological diseases;
• serious endocrinological pathologies, etc.

Sections of surgery

The branches of surgery include:

• neurosurgery;
• endocrine surgery;
• cardiac surgery;
• thoracic surgery (relates to the chest organs);
• abdominal surgery;
• laser surgery;
• metabolic surgery (usually used to radically combat diabetes mellitus);
• bariatric surgery (aimed at combating obesity);
• microsurgery (using microsurgical instruments);
• burn surgery;
• regenerative/replacement surgery;
• colorectal surgery;
• functional surgery (aimed at restoring the normal functioning of an organ).

Gynecology, traumatology, surgical dentistry, transplantology, oncology, etc. are closely related to surgery.

Diagnostic methods in surgery

In this area of ​​medicine, the following diagnostic methods are used:

• subjective examination (complaints, anamnesis analysis);
• objective examination (examination, palpation, measurements, etc.);
• laboratory tests (blood/urine tests, coagulogram, immunological tests, etc.);
• X-ray methods, including computed tomography;
• implementation of magnetic resonance imaging;
• radioisotope techniques;

In addition, diagnostic operations can be performed, such as punctures, arthroscopy, biopsy sampling of tissues or cells, etc.
When using diagnostic instrumental techniques, certain principles are followed. A simple and affordable examination is usually performed if it can provide the correct diagnosis. But in difficult situations it is better to immediately use a more expensive method.

Surgical methods of treatment

Surgical treatment methods include (non-exclusive list):

• resection (removal of tissue, bone, tumor, part of an organ, organ);
• ligation (binding of blood vessels, ducts);
• elimination of fistula, hernia or prolapse;
• drainage of accumulated fluids;
• removal of stones;
• cleaning clogged ducts and vessels;
• introduction of transplants;
• arthrodesis (surgical operation to immobilize bone joints);
• creation of a stoma (an opening that connects the lumen of an organ located inside and the surface of the body);
• reduction (for example, nose).

Stages of surgical treatment

There are several stages of surgical treatment:

1. Preoperative. It implies preparation for surgery.
2. Operation. This stage includes several stages: the use of anesthesia, surgical access (it must be anatomical, physiological and sufficient), surgical procedure, and exit from the operation.
3. Postoperative. It starts from the time the intervention ends and ends at the time of discharge from the hospital.

Surgery and human rights

Access to surgical treatment is increasingly recognized as an integral element of advanced health care, and is therefore becoming a component of the human right to health. Commission on Global surgery The Lancet highlighted the need for accessible, timely and safe surgical and anesthetic care.

Sources

On in simple language surgery means the medical branch that deals with the study of acute and chronic diseases that require prompt treatment using surgical methods. However, some pathological processes in the body may not require surgery, but must be controlled by surgeons. This section has very extensive boundaries, which are still expanding. Scientists are increasing surgical capabilities by developing new approaches and techniques for surgical therapy.

The mechanism of development of surgical pathologies is a topic that is of great interest to surgical scientists.

All the knowledge and capabilities that are available in modern surgery make it possible to cure people from terrible diseases and prolong their lives, relieving them of unpleasant symptoms.

History of surgery

Clinical surgery is rightfully considered the most ancient medical science. With its help, even before our era, experienced doctors performed operations to remove stones from the bladder, treated fractures and performed cesarean sections. From archaeological finds it is known that there was a large selection of surgical instruments in ancient times.

It did not stop developing until the 13th century, after which it had to pause a little for a whole century. This is due to the fact that during this period some changes occurred, which is why all operations with the risk of bleeding (and this is almost all major surgical interventions) were completely banned. Any development in this area of ​​activity was also prohibited.

The Renaissance turned out to be a stage of “rebirth” for medicine, in particular for surgery. Scientists set about improving techniques and inventing new tools. But what is more important is that doctors managed to learn how to do blood transfusions. This turned out to be life-saving in case of heavy blood loss.

The turning point occurred in the middle of the 19th century. In 1846, anesthesia was first used, with the help of which it became possible to perform difficult and lengthy surgical interventions. This also affected the reduction in mortality of operated patients.

The discovery of antibiotics at the beginning of the 20th century further improved the situation, because thanks to this, an active fight against infections began that could arise in the postoperative period and lead to the death of the patient. Antiseptics and aseptics began to be used to disinfect instruments and treat wounds, which led to the minimization of deaths in surgery.

Branches of surgery

Modern surgical branches include:

Related directions

Some branches of medicine are closely related to surgery, where it is worth mentioning:

• Gynecology, which uses surgical methods to treat diseases in the female reproductive system;
• Ophthalmology, for operations on the organs of vision;
• Otolaryngology, for serious pathologies of the ENT organs;
• Endocrinology, for surgical intervention in the endocrine system;
• Urology, for complicated pathological processes in the genitourinary system;
• Oncology, if tumors are found in the body that are indicated for removal;
• Traumatology and orthopedics, for surgical correction of the bone apparatus and joints.

Types of surgical operations

All surgical operations are divided into:

1. Diagnostic, with their help you can assess the condition of a particular organ in order to make an accurate diagnosis;
2. Symptomatic, produced to alleviate the patient’s condition. May be part of complex treatment;
3. Radical, during such treatment the cause of the disease is completely eliminated;
4. Palliative, used when a complete cure is not possible, is an auxiliary measure to temporarily improve the patient’s condition.

Stages of the operation

Surgical treatment is a series of sequential actions, and not just a period of surgery. It all starts with preparatory stage, during which the patient is carefully examined, inflammation is identified, and the functioning of some internal organs is stabilized.

The stage of administering anesthesia is a very important component, because the course of events during the operation depends on this drug. It must be correctly selected depending on the body's normal reaction to a certain type of pain reliever.

The surgical stage includes making the incision, the actual treatment and suturing.

The recovery stage implies a rehabilitation period necessary for the healing of sutures and the general adaptation of the patient.

Modern surgery

Despite its ancient origins, nothing remains of those original methods in modern surgery. She is no longer associated with a scalpel and huge, sloppy scars.

What modern surgery can do - you will learn about this from the video:

Minimally invasive surgical methods are widely used among surgeons to reduce the area of ​​injured tissue. This became possible after the introduction of high-tech equipment into surgery, including: electrocoagulators, endoscopes, ultrasonic knives and lasers.

In the world of scientists, work is underway to improve surgical technique, to minimize the stress received by the body during operations.

Surgical diseases

And although pharmacology is a fairly developed field, some diseases cannot be cured conservatively. The reason for this may be that the patient sought medical help late, or that a complicated pathological process has simply developed that requires surgical intervention. We are talking about such surgical diseases as.

Surgery today is a complex, multifaceted area of ​​medicine that plays an important role in the fight for human health, ability to work and life.

The progress of modern medical science is inextricably linked with the scientific and technological revolution, which has had a huge impact on the main areas of medicine. Being part of clinical medicine, modern surgery is at the same time developing as a large complex science, using the achievements of biology, physiology, immunology, biochemistry, mathematics, cybernetics, physics, chemistry, electronics and other branches of science. During surgery, ultrasound, cold, lasers, and hyperbaric oxygen are currently used; operating rooms are equipped with new electronic and optical equipment and computers. The progress of modern surgery is facilitated by the introduction of new methods of combating shock, sepsis and metabolic disorders, the use of polymers, new antibiotics, anticoagulants and hemostatic agents, hormones, and enzymes.

Modern surgery combines various branches of medicine: gastroenterology, cardiology, pulmonology, angiology, etc. Disciplines such as urology, traumatology, gynecology, and neurosurgery have long become independent. Over the past decades, anesthesiology, resuscitation, microsurgery, and proctology have emerged from surgery.

The successes of Soviet surgery are well known in our country and abroad. Soviet doctors, and primarily surgeons, made a huge contribution to the victory over the fascist hordes that threatened to enslave the peoples of Europe. This is evidenced, in particular, by the unprecedented results of the work of military surgeons during the Great Patriotic War of 1941-1945, through whose efforts more than 72% of the wounded were returned to duty.

General questions of surgery

The peculiarities of Soviet surgery are its dynamism, its organic connection with animal experimentation, which makes it possible to comprehensively test new methods of diagnosis and treatment. Without experimental study it is difficult to imagine the development complex issues modern surgery. Our country has provided surgeons with the opportunity to work in scientific laboratories equipped with the latest technology at clinics and research institutes.

Russian medicine is characterized by a tendency towards physiological and biological generalizations, coming from the works of N. I. Pirogov, I. P. Pavlov, I. M. Sechenov, as well as a close connection between theoretical, experimental and surgical thought. Naturally, such a community contributed to the birth of therapeutic methods that enriched domestic and world medicine, including such as artificial blood circulation, the foundations of which were developed by S. S. Bryukhonenko and N. N. Terebinsky, cadaveric blood transfusion, introduced into the practice of V. N. Shamov and S.S. Yudin, adrenalectomy proposed by V.A. Oppel, skin grafting with a migrating flap developed by V.P. Filatov, the operation of creating an artificial esophagus proposed by P.A. Herzen.

In his work, the surgeon must be guided by the principles of humanism and surgical deontology, since it is surgery that has such active methods of diagnosis and treatment, which are often used on the verge of life and death, and on the rational use of which the fate of the patient depends. Great importance for a specialist surgeon they have high technology, precise operation, maximum tissue sparing, and adherence to aseptic rules. The experience of the Great Patriotic War played an invaluable role in improving surgical technology.

Currently, the extremely rapid development of surgery is facilitated by the achievements of anesthesiology, resuscitation, hyperbaric oxygenation, and the rapid development of medical technology. Introduction to practical surgery ultrasonic methods examination, computed tomography, nuclear magnetic resonance and digital or computer angiography can significantly secure the process of examining the patient and at the same time make an accurate topical diagnosis necessary for drawing up a plan of preliminary measures and determining the tactical tasks of surgical intervention.

Anesthesiology creates optimal conditions for the modern surgeon and the patient during the most complex operations. Modern anesthesia is the most humane method of pain relief. It should, however, be emphasized that in recent years, in addition to anesthesia, for long-term but less traumatic interventions, surgeons have begun to increasingly use conduction anesthesia developed by A. V. Vishnevsky, local infiltration anesthesia using needle-free injectors, paravertebral and epidural anesthesia, as well as electronic anesthesia.

The introduction into clinical practice of endotracheal anesthesia, muscle relaxants and artificial ventilation was a stimulus for the progress of surgery of the heart and large vessels, lungs and mediastinum, esophagus and abdominal organs. Modern domestic anesthesia-respiratory devices successfully compete with world samples of similar devices. The Kholod-2F device, designed for craniocerebral hypothermia in a wide variety of clinical conditions, has gained international recognition. New promising muscle relaxants, gangliolytics and analgesics have been synthesized and put into practice. The future of anesthesiology and resuscitation is undoubtedly connected with the introduction of electronic computer technology and the creation of control and diagnostic complexes.

The successes of transfusiology are important for the development of surgery - the preservation and freezing of red blood cells for 10 years or more with the possibility of subsequent effective use, the creation of immune blood products. This has made it possible to reduce the number of whole blood transfusions worldwide and thereby reduce the risk of infection with viral hepatitis and the virus that causes acquired immunodeficiency syndrome (AIDS). In this regard, they began to actively develop and often use autotransfusion of blood taken several days before surgery from a patient, and retransfusion - transfusion of the patient’s own blood, sucked from the surgical wound during surgery. The problem of artificial blood (high-molecular solutions capable of transporting oxygen in the bloodstream) is also being developed.

One of the features of modern surgery is the active development of the reconstructive direction. Modern surgeons strive for maximum possible restoration lost physiological function. To do this, they not only use the body’s own strength, but also transplant organs and tissues, and use prosthetics. Surgery has become a widespread type of specialized medical care. Soviet surgery has achieved significant success in the surgical treatment of severe diseases of the heart, blood vessels, lungs, trachea, bronchi, liver, esophagus, stomach and other organs. Original methods of plastic surgery, reconstruction and transplantation are used, which are developed by teams led by leading surgeons of our country. Surgery is getting closer and closer to such disorders in the body, the elimination of which until recently seemed unrealistic. Thus, microsurgery allows a person to return fingers and entire limbs that were lost as a result of injury, while autotransplantation allows one to compensate for lost functions using the patient’s own tissues and even organs. X-ray endovascular surgery effectively complements vascular prosthetics and other types of plastic surgery, being in some cases an alternative treatment method. The risk of operations is reduced, their immediate and long-term results are improved.

Plastic surgery

Recent decades have been characterized by rapid development of plastic surgery, corresponding to the needs of the population to improve their appearance. Currently traditional circular lift facial surgery is rarely used anymore, giving way to SMAS operations, which provide a more pronounced and lasting aesthetic result.

In the field of mammoplasty, more and more advanced prostheses are used. Plastic surgeon Sergei Sviridov has developed a sutureless breast plastic technique that minimizes the risk of implant displacement, ensures the inconspicuousness of the seam, minimal blood loss during surgery, optimal conditions for healing and a shortening of the rehabilitation period.

Traditional tumescent liposuction, developed by Y-G.Illouz and P.Fournier in 1980, was supplemented by ultrasound, vibration-rotational, water-jet and laser methods and their combinations (see liposuction).

Emergency surgery

The most important problem of modern surgery is emergency surgical care for a number of diseases and injuries. There is no doubt that this is due to improved organization of primary health care, as well as improved surgical techniques. However, a number of issues, such as early diagnosis, timeliness of surgery and the fight against various complications, cannot be considered finally resolved; much work remains to overcome significant difficulties, as well as organizational shortcomings in this area.

In the structure of urgent diseases after acute appendicitis, the second and third places are occupied by acute cholecystitis and acute pancreatitis. Observations in recent years indicate an undoubted increase in the number of patients with these diseases, a significant part of which are elderly and senile people. Often acute cholecystitis is complicated by obstructive jaundice and purulent cholangitis, which significantly aggravates the condition of patients. Impaired outflow of bile and persistent hypertension in the biliary tract make conservative measures ineffective, and urgent operations undertaken in these conditions are associated with great risk. That is why endoscopic methods are widely used to provide assistance to such patients, which successfully combine diagnostic and therapeutic capabilities.

The method of endoscopic retrograde cannulation of the papilla of Vater and retrograde cholangiography allows in 95% of cases not only to identify the cause of bile duct obstruction, but also to perform nasobiliary drainage, often combining it with endoscopic papillosphincterotomy and removal of stones. If necessary, laparoscopic decompression and lavage of the gallbladder with antibiotics and antiseptics can be performed. The combination of such treatment with conservative measures makes it possible to eliminate acute cholangitis and obstructive jaundice in 75% of patients and prepare them for delayed surgery on the biliary tract. This significantly improves treatment results and reduces mortality.

Laparoscopy is also of particular importance in acute pancreatitis. With its help, it is possible not only to clarify the diagnosis, but to remove pancreatogenic effusion from the abdominal cavity, perform peritoneal dialysis and, if necessary, laparoscopic cholecystostomy, which greatly contributes to the elimination of toxemia. In the complex treatment of patients with acute cholangitis and pancreatitis, hyperbaric oxygenation plays a significant role, the use of which significantly improves the results of treatment.

Surgery of the gastrointestinal tract

Proximal selective vagotomy continues to be used in the complex treatment of duodenal ulcer.

A number of surgeons, in particular M.I. Kuzin, A.A. Shalimov, consider this operation to be physiologically justified and giving good results, therefore they clarify the indications for it and develop various modifications of its technique. Others consider selective vagotomy
as organ-preserving, but disrupting innervation, and therefore they doubt its suitability for mass use. This operation is associated with a relatively lower risk than gastrectomy: complications with it range from 0.3%, according to S. Muller, to 0.5-1.5%, according to J. R. Brooks and V. M. Sitenko. However, when the indications for the use of selective proximal vagotomy are expanded and the technique is violated, the percentage of complications, according to P. M. Postolov, A. A. Rusanov, N. Vinz, M. Ihasz, increases to 10%. This indicates the need for caution in the mass use of this operation and strict adherence to all rules and techniques during its implementation. Modern therapeutic methods for treating peptic ulcers, and especially medications, as well as the development of therapeutic endoscopy and hyperbaric oxygenation improve the effectiveness of conservative treatment of this disease.

As for the treatment of complications of gastric and duodenal ulcers, and especially bleeding, given that elderly and senile people prevail among patients with acute gastrointestinal bleeding, preference is increasingly given to gentle methods - endoscopic electrocoagulation of a vessel or photocoagulation with a laser beam, introduced into clinical practice by Yu. M. Pantsyrev, O. K. Skobelkin, P. Friihmorgen, F. E. Silverstein, etc. Endovascular embolization of a bleeding vessel or its system, developed by L. S., is also quite effective. Zingerman, I. X. Rabkin, J. Rosch, O. Adler, R. E. Gold. If necessary, radical surgery is performed in these patients in a delayed manner.

The development of surgery of the hepatopankreobiliary zone is associated with an increase in the number of patients with cholelithiasis and its complications, as well as with the improvement of diagnostic methods and surgical treatment of these diseases. Among diagnostic methods retrograde and intraoperative cholangioscopy, cholangiography and pancreatography, transumbilical portography, splenoportography, choledochoscopy, laparoscopy, etc. are often used. Surgeons dealing with the pathology of the liver, pancreas and extrahepatic tracts have adopted liver scanning, ultrasound echolocation, puncture percutaneous cholangiography, celiacography, puncture biopsy of the liver and pancreas using computed tomography and sonography.

During surgical interventions on the gallbladder and bile ducts, atraumatic needles of various diameters with absorbable and non-absorbable synthetic threads, microsurgical instruments, as well as magnifying, ultrasound and laser equipment are used.

Currently, such types of operations as the application of biliodigestive anastomoses, papillosphincterotomy, papillosphincteroplasty and a combination of these interventions such as double internal drainage of the common bile duct have been developed and widely introduced into practice, the initiators and propagandists of which in our country are V.V. Vinogradov, E. I. Galperin, A. V. Gulyaev, B. A. Korolev, P. N. Napalkov, O. B. Milonov, E. V. Smirnov, A. A. Shalimov, etc. In the surgical treatment of high scar strictures of the bile ducts The application of biliodigestive anastomoses in combination with controlled external transhepatic frame drainage is widely used biliary tract, for which E.I. Galperin and O.B. Milonov developed a special methodology and tools. A special place in the surgery of cholelithiasis and its complications is occupied by the endoscopic method of treatment.

There is positive experience in surgical treatment of some forms chronic hepatitis. Intraoperative diagnosis of these forms is based on liver biopsy data. In such patients, arteriolysis and desympatization of the hepatic artery and its branches are performed. A flowmeter is used to monitor the effectiveness of the intervention.

In recent years, there has been an increase in the number of cases of acute pancreatitis, which has led to the emergence of a very significant contingent of patients suffering from various types of chronic pancreatitis and cholecystopancreatitis. Research by both Soviet and foreign surgeons conducted in recent years has established that the root causes of chronic pancreatitis in most cases are nutritional factors and cholelithiasis. In a significant number of cases, the development of chronic pancreatitis is facilitated by hypotonic conditions of the duodenum, duodenal stasis, stricture of the papilla of Vater and its insufficiency. The development of new methods for diagnosing diseases of the pancreatoduodenal zone (duodenography in a state of hypotension, duodenokinesigraphy, pancreatography, computed tomography and computerized ultrasound tomography) contributed to the introduction of more advanced types of operations for this disease - pancreatic resection, papilloplasty, creation of pancreatodigestive anastomoses, the application of which can be combined with correction pathologies of the biliary tract.

Good results are provided by the sealing of the Wirsung duct with silicone elastomer, introduced into practice by D. F. Blagovidov, J. Little, J. Traeger and others, in order to turn off the excretory function of the pancreas in painful forms of pancreatitis or in the presence of certain types of pancreatic fistulas. The development of surgery in the hepatopancreatobiliary region entails the need to create specialized surgical departments equipped with the necessary modern equipment and qualified surgeons who are specialists in this field.

In recent years, such researchers as M. D. Patsiora, V. V. Vakhidov, F. G. Uglov, K. N. Tsatsanidi, N. V. Blakemore, L. Ottinger and others have accumulated significant experience in operations for portal hypertension syndrome, including cirrhosis of the liver. The main indication for surgery in these cases is the presence of varicose veins of the esophagus and stomach and bleeding from them, the fight against which essentially represents the main direction in the surgery of portal hypertension syndrome. The second equally important area is surgical interventions for chronic ascites resistant to conservative therapy.

For acute bleeding from varicose veins of the esophagus and cardial part of the stomach, a special obturator probe with two pneumatic balloons is used, which allows stopping bleeding in 85% of patients. Increasing the volume of the gastric balloon allows uniform compression of a large area of ​​the cardiac part of the stomach with varicose veins and prevents the balloon and probe from moving from the cardiac zone to the esophagus. In some patients with subcompensated and decompensated liver cirrhosis, after a temporary stop of bleeding using an obturator probe, the method of endoscopic injection sclerosing therapy of bleeding varicose veins is used.

For compensated liver cirrhosis, the operation of choice currently is distal splenorenal anastomosis, which achieves decompression of the gastrocolic region and maintains perfusion of mesenteric blood through the liver. If this operation is not feasible, surgical intervention is limited to gastrotomy and ligation of varicose veins of the esophagus and the cardiac part of the stomach. In patients with severe clinical manifestations of hypersplenism, ligation of varicose veins is supplemented by splenectomy.

For chronic ascites resistant to drug therapy, in patients with liver cirrhosis and Chiari disease, a peritoneovenous shunt with a domestically produced valve mechanism was used at the All-Union Scientific Center for Surgery of the Academy of Medical Sciences. The development of methods of X-ray endovascular surgery allowed these patients to perform selective occlusion of the hepatic artery through the femoral artery according to Seldinger.

For extrahepatic portal hypertension, any type of splenorenal anastomosis can be used, however, these operations are feasible only in 5-6% of patients, due to the unsuitability of the splenic vein for bypass surgery. Under appropriate anatomical conditions, preference is given to a mesenteric-caval H-shaped anastomosis with an insertion from the internal jugular vein. In cases where it is impossible to perform vascular anastomoses in previously unoperated patients, the scope of surgical intervention is reduced to transperitoneal gastrotomy and ligation of varicose veins of the stomach and abdominal esophagus. Splenectomy in these patients is performed only in cases of severe hypersplenism. In other cases, splenectomy as an independent operation is considered unjustified. In previously operated patients with extrarenal portal hypertension when varicose veins are localized in the middle and upper third of the esophagus, the operation of choice is transpleural esophagotomy, which allows ligation of the veins of the cardial part of the stomach, the lower and middle third of the esophagus.

Esophageal surgery is one of the most difficult problems of modern surgery. Domestic scientists have made a significant contribution to solving this problem, proposing a number of original methods of diagnosis and surgical treatment of a wide variety of, including severe, types of esophageal pathology, especially cancer, which has expanded the indications for operations and significantly increased their effectiveness.

Surgery for cancer thoracic esophagus is often performed in two stages. At the first stage, extirpation of the esophagus is performed according to Dobromyslov-Torek, at the second - esophageal plastic surgery. This tactic is advisable due to the traumatic nature of the intervention in weakened patients and the inability to predict tumor recurrence and the appearance of metastases. B. E. Peterson, A. F. Chernousov, O. K. Skobelkin, Akiyma, T. Hennessy, R. O"Connell, A. Naidhard and others began to increasingly use one-step operations, without, however, completely abandoning two-stage interventions.

At the All-Union Scientific Center for Surgery of the Academy of Medical Sciences, an operation is performed that consists of simultaneous resection and plasty of the esophagus, and an isoperistaltic tube cut out from the greater curvature of the stomach is used as a graft. The stomach is mobilized in such a way that the graft is supplied with nutrition by the right gastroepiploic artery. When cutting out a graft, an original stapler is used, which allows the use of a laser scalpel. The essence of the method is that the stomach is stitched with two rows of paper clips, between which it is cut with a laser beam. The laser-mechanical suture is practically bloodless, the staple bead is small, and its sterility is achieved, which makes it possible to carry out the operation in “cleaner” conditions and avoid rough sutures. An apparatus for dissecting tubular organs and a laser scalpel are also used for proximal and distal resections of the stomach and plastic surgery of the esophagus and stomach in cases of burn strictures. For benign tumors of the esophagus, enucleation of esophageal leiomyoma is carried out by gradually suturing it and removing it outside the wall of the organ. More extensive operations - partial resection and extirpation of the esophagus - are allowed only for giant leiomyomas.

The most effective conservative method of treating burn strictures of the esophagus, as before, remains bougienage using plastic bougies carried out along a conductor string under X-ray television control. This technique has dramatically reduced the risk of esophageal perforation during treatment.

About 40% of patients admitted to the hospital late after a burn of the esophagus require surgical treatment. Indications for surgery are: complete cicatricial obstruction of the esophagus, rapid recurrence of the stricture after repeated courses of bougienage, futility of bougienage due to shortening of the esophagus, the occurrence of cardial insufficiency and reflux esophagitis. The choice of graft and type of plastic surgery (retrosternal, intrapleural, segmental, local, etc.) are determined by the location and extent of the stricture, and the architectonics of the feeding vessels. In some cases, the stomach can be used for plastic surgery of the esophagus, in others, preference should be given to colonic esophagoplasty, developed by S. S. Yudin, B. A. Petrov, V. I. Popov, A. A. Shalimov, Hennessy and O'Connell, Shields et al.

P. Banzet, M. Germain and P. Vayre developed a technique for moving a free graft (a piece of small or large intestine) to the neck using microsurgical techniques, which will improve the results of surgery on the esophagus.

At present, the existence of two forms of functional obstruction of the cardia, different in pathogenesis, should be considered proven, cardiospasm and achalasia of the cardia. In the treatment of functional obstruction of the cardia, Soviet and foreign specialists give preference to cardiodilation, which is carried out using an elastic pyeumocardiodilator. Repeated courses of dilation make it possible to achieve stable restoration of cardia patency in more than 80% of patients. Surgical treatment is considered justified if three consecutive courses of cardiodilation are ineffective, if dysphagia recurs within a short period of time after dilatation, and in cases where it is not possible to carry out a dilator. Diaphragmoplasty proposed by V.V. Petrovsky is used as a plastic operation, and when cardiospasm or achalasia of the cardia is combined with complicated duodenal ulcers perform antireflux esophagogastrocardioplasty with incomplete fundoplication and selective proximal vagotomy, developed by E. N. Vantsyan, U. Belsey.

Significant progress has also been made in diaphragm surgery, and indications and contraindications for its plastic surgery have been clarified. Original methods have been proposed to strengthen the diaphragm during its relaxation, when plastic material is placed between the sheets of the diaphragm; They use new types of surgical interventions for hiatal hernia and its complications: tunnelization of the esophagus with the creation of a cuff from a flap of the diaphragm, methods of abdominalization of the cardia and valve gastropplication for a short esophagus, resection of peptic stricture of the esophagus with the application of valve esophagofundoanastomosis, etc.

Surgery of the lungs and mediastinum

The differential diagnostic service occupies a large place in lung surgery. The most urgent task of outpatient, prehospital examination is to identify individuals in whom the pathological process in the lungs occurs against the background of clinical well-being. Among the new diagnostic methods, computed tomography and precision transthoracic punctures under tomographic control have gained importance. There is no doubt about the role of X-ray examination, electroradiography, bronchial arteriography, study of ventilation and perfusion of the lungs using the radionuclide method, which allows obtaining visual topical and quantitative information and predicting the degree of operational risk. The use of urgent cytological examination of puncture biopsy material has expanded, anesthetic care has improved, operations in the operating room have become more frequent, the use of x-ray surgical methods, adhesive cyanoacrylate compositions and fibrin glue, which are administered using a needle-free injector.

Soviet surgeons V. S. Savelyev, V. A. Smolyar, S. I. Babichev, M. V. Danilenko and others studied spontaneous nonspecific pneumothorax. The experience of successful treatment of about 2000 patients made it possible to study diagnostic issues, features of the course, methods of conservative treatment, indications and features of surgical treatment of this disease.

Acute chronic suppuration continues to occupy a significant place in pulmonary pathology. N. M. Amosov, Yu. V. Biryukov and others emphasize that when treating lung diseases accompanied by suppuration, one should take into account the state of the patient’s immune system, the role of viral and non-clostridial infections, changes in microflora and its increased resistance to antibiotics, the appearance of “small forms" of bronchiectasis, increased hemoptysis and pulmonary hemorrhage. For suppurative diseases (chronic abscess, bronchiectasis, chronic pneumonia, etc.) and tuberculosis, L.K. Bogush, A.I. Pirogov, V.I. Struchkov, E. Pouliguen consider lobectomy and segmental economical resections to be the operations of choice. Indications for complete removal of the lung are currently limited. In case of deep abscess formation in children, Yu. F. Isakov and V. I. Geraskin proposed disconnecting the affected area of ​​the lung from the bronchial system by surgical occlusion of the bronchus of the affected lobe or segment, opening and sanitizing the abscess cavity.

The absolute and relative number of patients undergoing surgery for lung cancer is increasing. At the same time, surgical activity increases significantly in relation to patients over 60 and even 70 years of age, as well as to patients with concomitant coronary heart disease, hypertension, diabetes mellitus and other age-related pathologies, which were previously preferred not to be operated on. The results of treatment of patients with lung cancer have improved, the criteria for operability have changed, and therefore in a number of clinics among hospitalized patients the number of operable patients exceeds 60%. Mortality after radical operations has decreased to 2-3% in recent years, and the number of cases of five-year survival has increased. Scientific and practical development of pulmonary surgery issues is aimed at early diagnosis lung cancer, because in some cases it allows for economical resection of the lung.

An important direction in the development of pulmonary surgery is the development of restorative and reconstructive operations on the trachea and large bronchi, introduced into clinical practice by O. M. Avilov, L. K. Bogush, N. S. Koroleva, A. II. Kuzmichev, M. I. Perelman, W. Williams, S. Lewis, L. Faber, R. Zenker. In our country, this branch of plastic surgery began to develop on a solid experimental basis, relying on extensive experience in the field of surgical treatment of diseases and injuries of the lungs. To date, considerable experience has been accumulated in the field of tracheobronchial tree plasty: extensive resections of the thoracic trachea with disconnection of the left lung, repeated tracheal resections, various options for resection of the bifurcation area of ​​the trachea and large bronchi, tracheal plasty using a T-shaped tracheostomy tube, operations on the main bronchi for the purpose of eliminating bronchial fistulas after pneumonectomy using transpericardial or contralateral access. The latest interventions are highly effective for benign and malignant tumors, for post-traumatic and post-tuberculosis stenosis.

New opportunities for improving operations on the lungs are opened up by the use of magnifying optics and particularly precise surgical equipment, the use of new staplers, laser and ultrasound devices. New methods have been developed for targeted (precision) biopsy and resection of the lungs using pinpoint electrocoagulation, isolated ligation of larger vascular and bronchial branches, resection of the lungs using lasers, cryodestruction of various pulmonary formations, the use of ultrasound for the prevention of infection of the pleural cavity, treatment of pleural empyema and bronchial fistulas (through a thoracoscope).

In recent years, endoscopic surgical techniques have gained great importance in pulmonary surgery. There is now a wide possibility of removing some benign tumors, palliative excision of malignant tumors, dilatation of scar stenoses and excision of scar tissue, introduction of endotracheal prostheses, endobronchial fillings, etc.

Improving the entire system of treating patients with lung diseases has made it possible to significantly reduce the number of severe postoperative complications and mortality. Thus, improvement of diagnostic methods, preoperative preparation, surgical techniques and postoperative management of patients with chronic suppuration of the lungs made it possible, according to V.I. Struchkov, to reduce postoperative complications to almost 4%, and postoperative mortality to 2%. At the Kiev Research Institute of Tuberculosis and Thoracic Surgery named after. acad. F. G. Yanovsky among patients operated on for purulent-destructive lung diseases, hospital mortality in uncomplicated disease was about 4%.

Cardiovascular surgery

Heart surgery has become a highly specialized clinical discipline based on the latest achievements of modern science. Over the past decades, it has acquired a reputation as an effective and, in many cases, the only method of treatment. Currently, operations are performed for all heart defects. In addition, cardiac surgery deals with the treatment of coronary heart disease and its complications. Such domestic and foreign surgeons as N. M. Amosov, V. I. Burakovsky, A. P. Kolesov, A. M. Martsinkevichyus, B. V. Petrovsky, R. G. Favaloro, W. made a great contribution to the development of problems in heart surgery. Scheldon, E. Garrett, D. Tyras and others. The relevance of cardiovascular vascular surgery, its formation and development are due to the high prevalence of cardiovascular diseases, which are the cause of disability and premature death of a large number of patients.

The first coronary artery bypass surgery for coronary heart disease was performed in the USA in 1964, and in Europe in 1968. The widespread use of this operation in the USA has reduced mortality from coronary heart disease, according to R. Lillum, by 30%. Currently, a number of surgeons have significant experience in such operations. Mortality among patients with low surgical risk is less than 1%, and among patients with increased risk it is more than 4%.

For coronary heart disease, operations such as coronary artery bypass grafting using an autovenous graft and internal mammary artery, resection of post-infarction aneurysms with thrombectomy and simultaneous cardiac revascularization have become widespread. They have proven to be highly effective interventions that provide high functional results. Thus, mortality in multiple coronary artery bypass grafting has now decreased, and the patency of coronary artery bypass grafts one year after surgery remains in 80% of cases or more. Experience has been accumulated in the surgical treatment of post-infarction left ventricular aneurysms.

Surgery for acquired heart defects has evolved from digital “closed” commissurotomy for mitral stenosis to the replacement of two or three heart valves with prosthetic valves. Many new methods, instruments, prostheses have been developed and proposed for clinical practice - mechanical (ball, disk, valve), created on the basis of the latest achievements of chemistry and engineering, and semi-biological, characterized by reliability, durability, lack of stimulation of thrombus formation and high operating parameters. Along with operations for rheumatic heart defects Soviet surgeons More and more interventions are being performed for valve pathology of septic origin, non-rheumatogenic defects, combined lesions, for example. coronary heart disease in combination with heart defects; Reconstructive valve-sparing operations developed by B. A. Konstantinov, A. M. Martsinkevichyus, S. Duran, A. Carpentier, etc. are becoming widespread. Mortality in isolated aortic valve replacement has been reduced to 3-4%, with mitral valve replacement - up to 5-7%, with closed interventions - up to 1%, however, with multiple valve replacement it remains high (15% and above).

In the surgery of congenital heart defects, palliative operations have given way to radical interventions. Surgical methods for the treatment of congenital heart defects in newborns and infants have been mastered and developed. The mortality rate for such uncomplicated defects as patent ductus arteriosus, coarctation of the aorta, ventricular and atrial septal defects does not exceed 1%. However, the issues of surgical correction of tetralogy of Fallot, transposition of the great vessels, complete atrioventricular block, etc. have not yet been sufficiently resolved.

For the surgical treatment of cardiac arrhythmias, electric pacemakers have been created and put into practice, including atomic ones, the latest models of which are small in size. Electrodes and monitor systems have been developed and are produced by industry, and temporary pacemakers are also produced. Surgeries for pacemaker implantation for symptomatic bradycardia, destruction of conduction pathways with pacemaker implantation for brady-tachyarrhythmia syndrome, electrophysiological studies with programmed frequency pacing for endocardial, epicardial and transmural mapping of the passage of excitation through the heart are becoming increasingly common. These methods make it possible to diagnose supraventricular tachycardia and recognize arrhythmogenic foci responsible for ventricular tachycardia. However, the practical implementation of methods for the surgical treatment of tachyarrhythmias is still limited to a few centers, and the development of the necessary equipment lags behind the needs of healthcare.

Thanks to advances in diagnostics (echolocation, computed tomography), there are more and more reports of successful operations for primary heart tumors various localizations. These operations today, as a rule, give good results, their mortality rate is low, and the prognosis is favorable.

The development of modern cardiac surgery would be unthinkable without artificial blood circulation. As already noted, the method of artificial blood circulation itself and the first experiments with the artificial blood circulation apparatus were carried out by S. S. Bryukhonenko, S. I. Chechulin, N. N. Terebinsky. Currently, this method has become predominant in open heart surgery, and the perfusion technique and its provision have come far ahead. Disposable systems are widely used for perfusion, microfilters and automation are used for safety, and new perfusion media are being developed to replace large quantities of donor blood. Hypothermic perfusion with hemodilution, the use of pharmacocold protection of the myocardium, ultrafiltration of perfusate, the method of hemoconcentration, and the use of autologous blood during surgery have become widespread. Thanks to this, artificial blood circulation has become relatively safe and allows you to maintain acceptable physiological parameters of the body for 3-4 hours with the heart and lungs turned off from the blood circulation.

To combat shock and treat acute cardiovascular and respiratory failure, methods such as synchronized intra-aortic balloon counterpulsation, assisted perfusion methods, including assisted perfusion with a membrane oxygenator and maintaining blood flow using extracorporeal artificial ventricles are increasingly used. Great hopes are associated with the use of circulatory support methods in patients with acute heart failure, among which the most effective is left ventricular bypass. The first clinical trial of an artificial left ventricle of the heart was carried out by D. Liotta in 1963 in a patient in a state of decerebrate. In 1971, M. de Beki reported the successful use of an artificial left ventricle in two patients. The left-heart bypass method was further developed in the USA, Japan, and Austria. An artificial left ventricle is a small blood pump designed to shunt blood from the left atrium or ventricle to the aorta or large artery. An artificial ventricle is used to temporarily partially replace the function of the left chambers of the heart. It works in parallel with the patient’s heart, helping to restore coronary blood flow. After restoration of adequate cardiac activity, it is removed. This method is used in various major cardiology centers around the world by W. Bermliard, J. Olsen et al., J. Peters et al., W. Rae, J. Pennock, Golding (L. Golding), etc.

Experimental cardiac surgery faces many challenges. The most important of them is the complete replacement of the heart with a mechanical prosthesis with an external drive, and in the future - with an autonomous energy supply system. Some researchers consider this problem as an independent one, others see it as a “bridge” to biological transplantation of the heart or heart and lungs, which has already received limited use abroad today.

The practical implementation of the idea of ​​​​creating an artificial heart were the experiments of S. S. Bryukhonenko, and then V. P. Demikhov (1928, 1937), who removed the ventricles of the heart from dogs and connected a model of an artificial heart, consisting of two paired membrane-type pumps driven an electric motor located outside the chest. Using this device, it was possible to maintain blood circulation in the dog’s body for two and a half hours. Abroad, the first experimental replacement of the heart with a prosthesis was performed in 1957 by T. Akutsu and in 1958 by W. J. Kolff. Extensive research on this problem began only in the late 50s. (Great Britain, USA, Czechoslovakia, Germany, Japan). In our country, the first artificial heart laboratory was created in 1966 at the All-Union Scientific Center of Surgery of the Academy of Medical Sciences. Physicians, physicists, and engineers have already developed artificial heart models that can be used in animal experiments. The maximum survival rate for a calf with an implanted artificial heart is 101 days. At the All-Union Scientific Center for Surgery of the Academy of Medical Sciences, as well as at the Institute of Organ and Tissue Transplantation, a series of “artificial hearts” of type B IM were developed and experimentally tested. Artificial heart control systems have been created, mainly electro-pneumatic and electromechanical devices, and a drive with an isotope energy source is being developed.

The first human artificial heart implantation operation was performed by Cooley in April 1968. A two-stage total heart replacement operation was performed in a 47-year-old patient with progressive coronary artery occlusion, complete atrioventricular block and extensive myocardial fibrosis with the formation of a left ventricular aneurysm. The operating time of the prosthesis was 64 hours. As a second stage, the prosthesis was removed and replaced with a donor's heart. The patient died 32 hours after the second stage of the operation from respiratory failure. Patient B. Clark was the first patient to whom a permanent artificial heart was implanted in 1982 by W. S. Devries to prolong life. He lived 112 days. Despite some successes in the field of artificial heart implantation, it is still premature and hardly humane to introduce a complete mechanical heart prosthesis into clinical practice, as well as with subsequent heart transplantation or heart and lung transplantation without first solving many problems in experimental conditions. At the same time, in the future, after the technical improvement of the artificial heart, it will be used as a method of maintaining life, first for short and then for longer periods.

Currently, surgeons perform complex plastic and reconstructive interventions on blood vessels, and progress in this area is closely related to the emergence in angiosurgery of a new reconstructive approach to the correction of vascular pathology. Significant progress has been made in the surgical treatment of occlusive lesions of the brachiocephalic branches of the aortic arch. The basic principle of this difficult section cardiovascular surgery, introduced by M. D. Knyazev, A. V. Pokrovsky, S. Shin, and L. Malone, is the low invasiveness of extrathoracic interventions, reducing the number of operations using synthetic prostheses, which are still often used in the reconstruction of large arteries and the aorta. In case of subtotal stenosis of both carotid arteries, autovenous brachiocephalic bypass is considered the operation of choice; in case of occlusion of the brachiocephalic trunk and unchanged other arteries supplying blood to the brain, carotid-brachiocephalic bypass from left to right is performed with good postoperative results.

The operation of reimplantation of the subclavian artery into the common carotid in case of still syndrome has been mastered and introduced into surgical practice. In case of widespread lesions of the branches of the aortic arch and preservation of at least one intact line, stage-by-stage switching operations are performed; for example, in case of occlusion of the proximal parts of the left common carotid artery, it is initially reimplanted into the brachiocephalic trunk, and then the reimplanted carotid artery is anastomosed with the left subclavian artery. It is preferable to carry out these operations under conditions of hyperbaric oxygenation using craniocerebral hypothermia and in combination with artificial arterial hypertension, proposed by A.V. Berezin, V.S. Rabotnikov, Marshall (M. Marschall).

A large number of patients are currently undergoing surgery for occlusive lesions and aortic aneurysms. Reconstructive operations are performed for a wide variety of pathologies - from Leriche syndrome to renovascular hypertension. For uncomplicated abdominal aortic aneurysms, typical resection of the aneurysm followed by aortic replacement and wrapping of the prosthesis with the remaining walls of the aneurysmal sac is very effective. For dissecting aneurysms of the ascending aorta, often combined with Marfan syndrome, aortic valve replacement is also necessary, developed by A. M. Marcinkevičius, B. A. Konstantinov, W. Sandmann, J. Livesay, N. Borst.

Reconstructive interventions for thoracoabdominal aneurysms are considered the most difficult in angiosurgery. In all cases, as a rule, the patency of the arteries involved in the aneurysmal process is restored. More often they resort to reimplantation of vessels into an aortic prosthesis or to prosthetics of affected vessels.

The choice of surgical treatment method for renovascular hypertension associated with damage to the renal arteries is carried out taking into account the etiology pathological process. Preference is given to the “direct” method of renal revascularization (without the use of plastic material). Autotransplantation of the kidney after reconstruction of its vessels in an extracorporeal position using microsurgical techniques and X-ray endovascular dilatation of the renal vessels are promising. In case of atherosclerosis, transaortic endarterpectomy from the mouth of the affected renal artery or reimplantation of the renal artery into the unaffected area of ​​the aorta is most often performed.

A relatively new branch of vascular surgery is interventions for chronic ischemia of the digestive organs. Due to the complexity and diversity of this pathology, the range of reconstructive operations is very wide. The optimal interventions are: transaortic endarterectomy from the affected visceral branches of the aorta, resection with reimplantation of these vessels into the abdominal aorta, and their autovenous replacement. Dilatation of the unpaired branches of the abdominal aorta is often performed both during surgery and using X-ray endovascular techniques.

There is also no doubt about the progress in surgical treatment of lesions of the main arteries of the extremities. The use of new suture material and microsurgical techniques has significantly expanded the range of possibilities for surgical correction of this type of pathology, for example. made it possible to reconstruct the peroneal arteries in the lower leg. For multiple occlusive lesions, the method of intraoperative vascular dilatation in combination with reconstructive operations on the aortoiliac and femoral-popliteal areas is widely used.

The search for new, more modern vascular prostheses on a synthetic and biological basis continues. An example of such prostheses are prostheses made of polytetrafluoroethylene (Gortex type) with improved thromboresistant properties and bioprostheses made from the carotid arteries of cattle. Using enzymatic-chemical processing, bioprostheses were obtained that had structural stability, resistance to enzymes of the patient's tissues, and pronounced thromboresistance. When reconstructing the femoral-popliteal area, the best option is an autovenous graft.

The problems of vascular surgery include not only purely medical ones, but also large organizational tasks, in particular the creation of an effective emergency vascular surgery service. Its development requires the training of specialists, in particular in the field of X-ray surgery (angioplasty), endoscopic technology, hyperbaric oxygenation, etc.

X-ray endovascular and endocardial surgery is a set of X-ray diagnostic studies and therapeutic interventions performed by a radiologist in a cath lab under X-ray control. The creation of this new direction was a qualitative leap in traditional radiology. To do this, radiologists had to master some techniques of surgical manipulation, the basics of cardiology, anesthesiology and resuscitation. Interest in endovascular and endocardial interventions has arisen due to the fact that these methods, compared to surgery, are more gentle, less painful and traumatic, and are associated with less danger to the patient’s life. X-ray endovascular interventions developed by I. X. Rabkin, V. S. Vasiliev, Ch. T. Dotter, W. Porstmann, J. Remy, A. Gruntzig, etc., allow you to expand coronary, renal and other narrowed arteries, and clog blood vessels during bleeding.

A new idea has emerged for reconstructing arteries and veins using dilatation or direct deletion area of ​​atherosclerotic lesions or blood clots, followed by endoprosthesis replacement with a spiral made of “memory” metal or special elastic and durable plastic.

If we also take into account that a positive clinical effect with the help of X-ray surgery and other new methods was achieved in 70-80% of patients, and their length of stay in the hospital and the duration of disability were reduced, then the significance of this direction in clinical medicine as a whole will become clear. Work in the X-ray operating room is impossible without the close collaboration of a radiologist, surgeon, cardiologist and clinical physiologist, therefore X-ray endovascular surgery should be developed on the basis of surgical vascular departments equipped with modern angiographic rooms.

The range of X-ray surgical procedures is rapidly expanding. Currently, there are four sections in X-ray endovascular and X-ray endocardial surgery:

1. dilatation, used to restore or improve blood flow through a stenotic or occluded vessel (carried out by dilating the vessel using special balloon catheters), recanalization of a thrombosed vessel, and in a number of blue-type congenital defects, in order to improve hemodynamics, a rupture of the interatrial septum is performed;
2. occlusion caused to interrupt or limit blood flow through a vessel through therapeutic embolization, thrombosis, coagulation;
3. regional infusion used to improve tissue trophism, microcirculation in organs, lysis of thrombotic masses;
4. removal of foreign bodies from the heart and blood vessels using special catheters.

Hyperbaric oxygen therapy in surgical clinic

A promising area of ​​clinical medicine, which is based on the use of oxygen under high pressure for therapeutic purposes, is hyperbaric oxygenation. This method is widely used in our country by S. N. Efuni, V. I. Burakovsky and abroad - I. Boegeme, J. Jackson, G. Friehs, D. Bakker, F. Brost, D. Sabo. In barooperative rooms, interventions are performed on the carotid arteries, trachea, bronchi, etc.

This significantly reduces the danger ischemic damage brain, the possibilities of surgical technology during reconstructive operations on the trachea are expanded, since prolonged apnea is provided (up to 10-20 minutes) without significant disturbances in hemodynamics, blood gas composition and other parameters of homeostasis. Carrying out barooperative interventions for recurrent gastrointestinal bleeding or extended operations in elderly patients improves their results. The use of hyperbaric oxygenation is highly effective for surgical delivery in women in labor with heart defects complicated by severe circulatory decompensation.

The use of hyperbaric oxygenation as a method of preoperative preparation of patients with rheumatic diseases and coronary heart disease makes it possible to increase the percentage of operability and reduce postoperative mortality. The use of hyperbaric oxygenation is advisable for complicated postoperative periods, for example. after reconstructive operations on the esophagus, when there is a threat of ischemic necrosis of the graft, with hypoxic damage to the c. n. With. after correction of heart defects, in case of postoperative circulatory decompensation.

Organ and tissue transplantation

In the problem of transplantation of vital organs, the most promising was kidney transplantation, developed and introduced into clinical practice by B.V. Petrovsky, N.A. Lopatkin, N.E. Savchenko, V.I. Shumakov, D.M. Hume , Van-Rod (J. Van Rood), Lee (N. Lee) and Thomas (F. T. Thomas), J. Dosset and others. Mostly kidneys taken from human corpses are transplanted. Some clinics perform kidney transplants taken from donors who are blood relatives of the patient; This type of transplantation in relation to the total number of kidney transplantations is about 10%. In recent years, there has been an improvement in the results of allogeneic kidney transplants, which is associated with an improvement in the immunological selection of donor-recipient pairs, which strictly takes into account compatibility not only with respect to group factors of the ABO and Rh factor systems, but also with leukocyte histocompatibility antigens. When selecting recipients undergoing program hemodialysis, the level of lymphocytotoxicity, the activity of warm and cold antilymphocyte antibodies, etc. must be taken into account. It has already been clearly proven that patients with a titer of lymphocytotoxic antibodies exceeding 50% should be excluded from the “waiting list” for kidney transplants. Methods for preserving cadaveric kidneys are also being improved.

From a technical standpoint, a kidney transplant operation also has some peculiarities. In particular, the increased level of surgical technology (with elements of microsurgery) makes it possible to successfully transplant kidneys with multiple arterial and venous trunks. Moreover, before transplantation, under conditions of ongoing hypothermia of the organ, various reconstructions of the renal transplant vessels are performed.

Currently, various adhesive compositions, in particular cyanoacrylate adhesives, are widely used in kidney transplantation. Using glue, you can achieve ideal sealing not only of vascular anastomoses, but also strengthening of the ureterovesical anastomosis, usually performed using the Brown-Mebel method. It is more justified to use cyanoacrylate glue to fix the kidney in the iliac fossa, which reliably prevents its spontaneous displacement, sometimes accompanied by deterioration in the function of the transplanted organ.

The use of cyclosporine A as the main immunosuppressant has significantly improved the results of allogeneic kidney transplantation. As experience in the use of this drug has shown, its use significantly reduces the number of irreversible rejection crises both in the early postoperative period and in the long term. Compared with standard therapy with imuran and steroids, when using cyclosporine A, the number of long-term functioning grafts increases, according to G. Klintmalm, P. Mottram, P. Hodgkin, by 20-25%, reaching by the end first year 85-90%.

It has become possible to perform reconstructive operations for various pathologies of transplanted allogeneic kidneys. In particular, surgical interventions are effective for stenosis of the artery of the allogeneic kidney, which developed in the long term after the intervention, and for strictures of the ureterovesical anastomosis. There are unconditional successes in the functional-instrumental diagnosis of rejection crises, especially in their subclinical forms. In this case, transplant echography, thermography, rheography, Doppler studies and radioisotope research methods are purposefully used.

As for transplantation of other vital organs (heart, liver, lungs, pancreas), a lot of work has been done in this area in recent years, but there are still a number of serious problems that need to be solved.

Prevention and treatment of surgical infection

Improvements in surgical techniques, pain management methods, intensive observation and treatment have significantly reduced the incidence of postoperative complications and mortality. However, to date, infection still occupies the leading position in the structure of all complications, which is due to many factors. Indications for operations in those most vulnerable to cancer are expanding purulent infection a contingent of patients, which includes elderly and senile people suffering from concomitant chronic diseases (including purulent-inflammatory ones), who have undergone immunosuppressive therapy (radiation or medication). Numerous, sometimes invasive, instrumental methods procedures performed on surgical patients for diagnostic and therapeutic purposes increase the risk of infection. Finally, long-term, usually unsystematic use antibacterial drugs in surgical patients, it changes the ecology of microorganisms, grossly disrupts the evolutionarily established microbiocenoses, the ratio of microorganisms to the macroorganism. The latter has led to the fact that the causative agents of surgical infections that occur today are significantly different from the causative agents of surgical infections in the past. Until now, the role of staphylococcus in the occurrence of surgical infections after “clean” operations remains significant, but multidrug-resistant gram-negative bacteria - representatives of all types of enterobacteria and non-fermenting bacteria - are becoming increasingly important. New methods of bacteriological research with the cultivation and identification of microorganisms under conditions of anaerobiosis have revealed the participation of non-spore-forming anaerobes in the development of local and generalized forms of surgical infection. It was established that non-spore-forming anaerobes played the most significant role in the etiology of acute peritonitis, and in terminal peritonitis they are found in 80-100% of patients. The majority of anaerobes in patients with surgical infection are gram-positive cocci, bacteroides, and anaerobic gram-positive rods. An integral part of bacteriological research is the determination of the drug sensitivity of microorganisms, which is necessary for prescribing etiotropic therapy. The leading role of multiresistant and gram-negative microflora in the etiology of surgical infection, the presence of non-spore-forming anaerobes in it necessitate the use in modern surgical clinics of new highly active antibiotics of the group of aminoglycosides and cephalosporins, as well as drugs that selectively act on non-spore-forming anaerobes (metronidazole, clindamycin).

There have been advances in the prevention of suppuration of surgical wounds and purulent diseases. Factors of increased risk of suppuration have been studied, which makes it possible to differentiate their development. The use of preoperative immunization of patients, additional treatment of the surgical site, parenteral use of proteolytic enzymes, antiseptics and antibiotics in combination with flow dialysis and active drainage of wounds, widespread use of atraumatic and biologically active suture material, physical factors (UHF, Bernard currents, “blue” and “ red laser, ultrasound) allow, according to V.I. Struchkov and V.K. Gostishchev, to reduce the number of postoperative complications by more than 2 times and thereby reduce the time of treatment in the hospital, which has a significant economic effect. The creation of immobilized antiseptics (antibacterial drugs included in suture threads, dressings, biocompatible polymer absorbable films) allows in some cases to avoid purulent complications. Synthetic suture threads (fluorlon, lavsan), collagen preparations, polymer composition MK-9, etc., which included various antiseptics (lincomycin, tetracycline, nitrofurans, sulfonamides, etc.), were studied. It turned out that the effect of the bacterial drug is prolonged due to its long-term, gradual release from the polymer base. The antibacterial agents gradually released from the suture threads significantly reduce the degree of bacterial contamination of the tissues in the canal area after the puncture.

A new direction of clinical medicine – enzyme therapy for nonspecific surgical infection – has received further development. Proteolytic enzymes have become widely used as necrolytic and anti-inflammatory agents. Extensive experience has been accumulated in experimental and clinical studies of various types of immobilized proteinases and their inhibitors in the treatment of purulent wounds, acute pancreatitis, etc. Immobilized enzymes, according to V.I. Struchkov, reduce the first phase of the wound process by 3-4 times. The creation of gnotobiological installations with a controlled abacterial environment and the introduction into clinical practice of immunostimulating drugs, mastered in teams led by M. I. Kuzin and Yu. F. Isakov, significantly expanded the arsenal of tools used by a modern surgeon to combat infection.

Timely clinical diagnosis of the localization and nature of the infectious process, correct bacteriological diagnosis with determination of the sensitivity of the pathogen to antimicrobial drugs, immediate and adequate drainage of the source of infection, the use of therapeutic doses of bactericidal etiotropic antibacterial drugs with control of their pharmacokinetics, sessions of hyperbaric oxygenation allow obtaining an optimal effect in the treatment of surgical infections. To eliminate purulent-resorptive fever and generalized forms of surgical infection, the use of hemosorption and ultraviolet irradiation of blood is very promising.

In matters related to the treatment and prevention of surgical infection, as well as any disease of infectious etiology, regular sanitary and bacteriological control is important. Experience shows that the use of antibacterial drugs alone cannot solve the problem of preventing surgical infection, therefore, the requirements for compliance with the rules of asepsis and antisepsis in the operating room and dressing room, and for determining the indications for surgical intervention in patients with a high risk of developing postoperative purulent-inflammatory complications remain extremely high. A surgeon, resuscitator, and infection treatment specialist should take part in preparing the patient for surgery; this allows you to clarify the indications for surgery, determine the tactics of the necessary preoperative preparation with careful sanitation of the patient with purulent-inflammatory foci. Currently, immunological methods are becoming important in the prevention, diagnosis and treatment of surgical infections. They are especially important in organ and tissue transplantation and in intensive care.

To combat infection in the surgical clinic, a comprehensive program has been created, including good organization of the clinic, hospital with the allocation of purulent departments, isolation of purulent patients, sanitization of personnel, etc. In this case, the state of the patient’s immunity and modern requirements for preoperative preparation are always taken into account.

Modern surgery is a complex branch of medical science, including theoretical developments, experiment and practice. The forecasts for its development are promising: along with the possible discovery of the true causes of cancer, atherosclerosis, collagenosis and the development of methods for their treatment, as well as the emergence of reliable means of preventing infections, we can expect very important achievements in the field of organ transplantation and replantation, the creation of artificial organs, new implantable artificial materials, etc.

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