1、General Surgery外科学外科学Hepatobiliary Surgery Ma Qingyong 2013.9.82 IntroductionManagement of surgical disorders requires Application of technical skills and Training in the basic sciences to the problems of diagnosis and treatment基本知识、基本技能、基础理论 Genuine sympathy and indeed love for the patient. 3Introd
2、uction The surgeon A doctor in the old-fashioned sense An applied scientist An engineer An artist Philosopher Psychologist Sociologist A minister of his or her fellow human beings. 44 technical proficiency (CASE)C (Concept，观念，观念)A (Anatomy，解剖，解剖)S (Skill，技巧，技巧)E (Emergency，应急，应急)53 Relationships GG
3、(General and Group，将军和团队，将军和团队)MM (Major and Minor，大手术和小手术，大手术和小手术)QQ (Quantity and Quality， 数量和质量数量和质量)6Meditech-bioelementCommunication-basic technical skillScientific research-soul Cooperation-security团队合作是完成良好治疗的保证团队合作是完成良好治疗的保证 7Basic Pathological Processes All somatic diseases have their origi
4、ns in following six basic pathological processes:Congenital defectsInflammations Neoplasms Trauma Metabolic defects and degeneration Collagen defects8Phenomena Obstruction Perforation Erosion Tumors or masses 9Diseases due to Obstruction System Disease Nature of obstruction CNS ENT Eye Lung Biliary
5、tract GI GU Extremity Hydrocephalus Middle ear infection Glaucoma Atelectasis Cholicystitis Appendicitis Prostatism Intermittent claudication Congenital obstruction of cerebrospinal fluid Eustachian tube obstruction Obstruction of aqueous humor Mucus plug in bronchus Systic duct stone Fecalith in ap
6、pendix Prostatic hypertrophy arteriosclerosis 10Examples of PerforationSystem Disease Nature of Perforation CNS ENT Lung Biliary tract GI GU Vascular Cerebral hemorrhage Perforation of tympanic membrane Spontaneous pneumothorax Rupture of gallbladder Duodenal ulcer Ruptured bladder Aortic aneurysm R
7、upture of CNS artery Infection with pressure Rupture of bleb Obstruction, distension, necrosis Perforation of ulcer Obstruction and distension Rupture of aneurysm 11Examples of ErosionSystem Disease Nature of Erosion CNS ENT Lung GI GU Extrimity Meningitis Pharyngeal carcinoma Tuberculosis Duodenal
8、ulcer Bladder stone Raynauds phenomenon Erosion of abscess wall; mastoiditis Bleeding; erosion into blood vessels Bleeding; granulomatous erosion into blood vessels Bleeding; ulcer erosion into blood vessels Bleeding; erosion of bladder wall Digital ulceration; ischemic erosion of skin 12TumorsThe m
9、ost subtle of these phenomena is a tumor, or mass. This explains in large measure why cancer is so often detected only after it induces one of the three processes. Because no vital flow is obstructed and perforation or erosion of the skin occurs very late, symptoms, and consequently diagnosis, are d
10、elayed, often tragically. 13Approach to surgical patient History Physical examination Laboratory and other examination 14History SurgeonGain the patients confidence and convey the assurance that help is available and will be provided. Demonstrate concern for the patient Be gentle and considerateCrea
11、te an atmosphere of sympathy, personal interest and understandingStructure histories formallyAvoid asking leading questions15History Most patients are eager to like and trust their doctors and respond gratefully to a sympathetic and understanding person. 16BUILDING THE HISTORY History taking is dete
12、ctive work. Preconceived ideas, snap judgments, and hasty conclusions have no place in this process. The diagnosis established by inductive reasoning. The interviewer must first determine the facts and then search for essential clues, realizing that the patient may conceal the most important symptom
13、 in the hope that if it is not specifically inquired about or if nothing is found to account for it in the physical examination, it cannot be very serious. 1718PainCareful analysis of the nature of pain How the pain began? Was it explosive in onset, rapid. or gradual？What is the precise character of
14、 the pain？Is it so severe that it cannot be relieved by medication？Is it constant or intermittent？Are there classic associations, such as the rhythmic pattern of small bowel obstruction or the onset of pain preceding the limp of intermittent claudication？ 19Reaction to PainA patient who shrieks and
15、thrashes about is either grossly overreacting or suffering from renal or biliary colic. Very severe pain-due to infection, inflammation, or vascular disease-usually forces the patient to restrict all movement as much as possible.Moderate pain is made agonizing by fear and anxiety. Restore the patien
16、ts confidence is often a more effective analgesic than an injection of morphine.20VomitingWhat did the patient vomit？How much？How often？What did the vomitus look like？Was vomiting projectile？It is especially helpful for the examiner to see the vomitus.21Change In Bowel HabitsA change in bowel habits
17、 is a common complaint that is often of no significance. Regular evacuations noticed a distinct change, particularly toward intermittent alternations of constipation and diarrhea, colon cancer must be suspected. 22Hematemesis or HematocheziaMost common error is that rectum bleeding is attributable t
18、o hemorrhoids. The character of the blood can be of great significance. Does it clot? Is it bright or dark red? Is it changed in any way, as in the coffee-ground vomitus of slow gastric bleeding or the dark, tarry stool of upper gastrointestinal bleeding? 23TraumaTrauma occurs so commonly that it is
19、 often difficult to establish a relationship between the chief complaint and an episode of trauma. Children: attribute the onset of an illness to a specific recent injury. Unaware of severe trauma Not overlook the possibility of trauma inflicted by a parent24TraumaWhat was the patients position? Whe
20、n the accident occurred?Was consciousness lost? Retrograde amnesia (inability to remember events just preceding the accident) always indicates some degree of cerebral damage. Gunshot and stab wounds, knowing the weapon, its size and shape, probable trajectory, position of the patient when hit25Famil
21、y HistoryPolyposis of the colon is a classic example, but diabetes, Peutz-Jeghers syndrome, chronic pancreatitis, multiglandular syndromes, other endocrine abnormalities, and cancer are often better understood and better evaluated in the light of a careful family history26Past HistoryPeople who are
22、well are almost never sick. And people who are sick are almost never well. Review the past history by inquiring about each systemConsider the nutritional backgroundFluid and electrolyteTherapy before laboratory results27Patient Emotional BackgroundPsychiatric consultation is seldom required Emotiona
23、lly and mentally disturbed patients require operations, cooperation between psychiatrist and surgeon is essentialSurgeon deals with the emotional patient (malignant disease, amputation of an extremity, ileostomy, or colostomy) Importance of psychosocial factors in surgical convalescence28Physical Ex
24、aminationComplete examination includes Physical examinationLaboratory tests x-ray examination Certain special procedures (gastroscopy and esophagoscopy)Follow-up examination Painful, inconvenient and costly procedures ordered as less as possible29Elective Physical ExaminationDone in an orderly and d
25、etailed fashionAll patients are sensitive and somewhat embarrassed at being examined. Put the patient at ease,comfortable examining room and table, using drapes if the patient is required to strip for the examination.Talk a bit to relax and take the past history30Elective Physical ExaminationObserve
26、 the patients general physique and habitus Carefully inspect the handsMany systemic diseases show themselves in the hands (cirrhosis of the liver, hyperthyroidism, Raynauds disease, pulmonary insufficiency, heart disease, and nutritional disorders)31Elective Physical ExaminationEssential Steps Inspe
27、ctionPalpationAuscultationPercussion 32Elective Physical ExaminationInspectionComparison of the two sides of the body : The slight droop of one eyelid characteristic of Horners syndrome Female breasts, particularly as the patient raises and lowers her arms, will often reveal slight dimpling indicati
28、ve of an infiltrating carcinoma barely detectable on palpation33Elective Physical ExaminationRequires skill and gentlenessSpasm, tension, and anxiety caused by painful examination procedures may make an adequate examination almost impossible, particularly in childrenCareful, precise, and gentle palp
29、ation gives the physician the information being sought and inspires confidence and trustOne finger for tenderness in acute abdomenFrom outside to central35Elective Physical ExaminationPercussion for ascites (shifting dullness), liver, spleenAuscultation: The nature of ileus and the presence of a var
30、iety of vascular lesions are revealed by auscultation. 36Examination of Body OrificesComplete examination of the ears, mouth, rectum, and pelvis Every surgeon should acquire familiarity with the use of the ophthalmoscope and sigmoidoscope and should use them regularly in doing complete physical exam
31、inations37Emergency Physical Examination Routine PE fit the circumstancesHistory limited to a single sentence The primary considerations are following: Is the patient breathing? Is the airway open? (intubation, mouth-to-mouth respiration)Is there a palpable pulse? Is the heart beating? (cardiac resu
32、scitation)Is massive bleeding occurring?(if from extremity, elevation and pressure)38Emergency Physical ExaminationTension pneumothorax and cardiac tamponade may easily be overlooked if there are multiple injuriesCompletion of the survey examinationControl of pain Splinting of fractured limbsSuturin
33、g of lacerationsOther types of emergency treatment 39Laboratory ExaminationObjectives: Screening for asymptomatic disease that affect surgical result Appraisal of diseases that contraindicate elective surgery or require treatment before surgery (diabetes, heart failure) Diagnosis of disorders that r
34、equire surgery (hyperparathyroidism, pheochromocytoma) Evaluation of the nature and extent of metabolic or septic complications40Laboratory ExaminationComplete blood and urine examinationHistory of renal, hepatic, or heart disease requires detailed studies Surgeon is the only one with the experience
35、 and background to interpret the meaning of laboratory tests in the light of other features of the case-particularly the history and physical findingsTotal management is surgeons responsibility41Imaging StudiesA complement not an alteration of PEx-ray filmB-mode ultrasoundCT scanMRI42Special examina
36、tionsCystoscopy GastroscopyEsophagoscopyColonoscopy AngiographyBronchoscopy are often required in the diagnostic appraisal of surgical disorders. 43Aseptic technique无菌术无菌术 (Asepsis) 基本操作规范基本操作规范 针对可能的感染来源和途径所采取的有效预针对可能的感染来源和途径所采取的有效预防方法。防方法。 由灭菌法、消毒法、无菌操作规则及管理制由灭菌法、消毒法、无菌操作规则及管理制度所组成。度所组成。灭菌灭菌( (ste
37、rilization) )是指杀灭一切活的微生物。是指杀灭一切活的微生物。消毒消毒( (disinfection) )是指杀灭病原微生物和其是指杀灭病原微生物和其他有害微生物，并不要求彻底杀灭所有微生物他有害微生物，并不要求彻底杀灭所有微生物（如芽胞等）。（如芽胞等）。44SterilizationThe only completely reliable methods of sterilization in wide current use for surgical instruments and supplies are steam under pressure (autoclaving)
38、 boiling methodsoaking methoddry heat, andformaldehyde fumigation45AutoclavingSaturated steam at a pressure (104-137.3kPa) (1520 psi) at a temperature of 121-126oC destroys all vegetative bacteria and most resistant dry spores in 30 minutes. Sterilization time is markedly shortened by the high-vacuu
39、m or high-pressure, 132-134oC，205.8kPa，4min.Sterilization can keep for 2 weeks46Boiling methodBoiling water (100oC) for 15-20 min Spores need 1 hour2 min more for every 300 m in altitude The pressure of autoclave sterilizer is 127.5kPa, T=124oC for 10 min 47Dry Heatexposure to continuous dry heat at
40、 160oC for 2 hour (170oC,1h;180oC,30min)will sterilize articles that would be spoiled by moist heat or are more conveniently kept dry. If grease or oil is present on instruments, safe sterilization calls for 4 hours exposure at 160oC.48Soaking method2% glutaral (glutaraldehyde) 30min for disinfectio
41、n, 10 hour for sterilization10% formaldehyde 20-30 min75% alcohol (ethanol) 30 min 1:1000 benzalkonium bromide (新洁尔灭)1:1000 chlorhexidine (洗必泰) 30 min49Formaldehyde FumigationPotassium permanganate with 40% formaldehyde 1 hour for disinfection, sterilization for 6-12 hours50消毒法乙醇 75%碘伏 0.2%安尔碘过氧乙酸 0
42、.2-0.5%有效氯消毒剂51Skin AntisepticsThe most important applications of skin antisepsis are the hand scrub of the operating team and the preparation of the operative fields.52Hand Scrub RoutineAlthough the duration of the hand scrub is not universally defined, a 5-minute scrub before the first case-provid
43、ed a brush is used-appears to be sufficient. Greatest attention should paid to the fingertips and nails, since these areas harbor the greatest number of bacteria. A 2-minute scrub is adequate in between cases. Solutions containing chlorhexidine or one of the iodophors appear to be the most effective
44、.53Operative Field PreparationInitial preparation of the skin is usually done in the afternoon or evening before operation. The area should be washed with soap and water, making sure that it is grossly quite clean. A shower or tub bath is satisfactory. The type of soap used makes little difference.
45、Soap is a weak antiseptic and is useful because of its nonirritating detergent action, especially when washing is combined with mechanical friction.54Operative Field PreparationIn the operating room-A 1-minute skin preparation using other 70% alcohol or 2% iodine in 90% alcohol-followed by a polyest
46、er adherent wound drape- is effective in controlling wound infectionsIodine is one of the most-effective skin antiseptics available. It rarely causes skin reactions in this concentration. Avoid streaming of iodine outside of the operating field. Dot use iodine on the perineum, genitalia, or face; on
47、 irritated or delicate skin or when the patient has a history of iodine sensitivity. 55Operative Field PreparationFor iodine sensitive patients, one can use 80% isopropyl or 70% ethyl alcohol. Apply to the skin with a gauze swab for 3 minutes and allow to dry before draping. Alternatively, tinted ti
48、ncture of benzalkonium (1:750) may be used.For sensitive areas (perineum, around the eyes, etc), apply iodophor , chlorhexidine, or 1:1000 aqueous benzalkonium solution. The adherent drape is an important component of infection control. Using drapes that simply lie over the skin is associated with a
49、 higher infection rate than using drapes that are firmly adherent.56Operative Field Preparation 2.53% iodine, then 70% alcohal twice1:1000 benzalkonium or 1:1000 chlohexidine twiceDisinfection from inside to outsideFor infective wound or anus from outside to insideArea15cm 57Universal PrecautionsAll
50、 surgical staffs should routinely use appropriate barrier precautions-gloves, masks, goggles, etc-to prevent skin and mucous membrane exposure when contact with blood or body fluids is anticipated. Immediate hand and other skin surface washing is necessary if contamination occurs.58Universal Precaut
