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1、General Surgery外科学外科学Hepatobiliary Surgery Ma Qingyong 2013.9.8 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. 2Introdu
2、ction 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. 34 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)43 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)5Meditech-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 6Basic Pathological Processes All somatic diseases have their origin
4、s in following six basic pathological processes:Congenital defectsInflammations Neoplasms Trauma Metabolic defects and degeneration Collagen defects7Phenomena Obstruction Perforation Erosion Tumors or masses 8Diseases due to Obstruction 9Examples of Perforation10Examples of Erosion11TumorsThe most s
5、ubtle 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 delaye
6、d, often tragically. 12Approach to surgical patient History Physical examination Laboratory and other examination 13History SurgeonGain the patients confidence and convey the assurance that help is available and will be provided. Demonstrate concern for the patient Be gentle and considerateCreate an
7、 atmosphere of sympathy, personal interest and understandingStructure histories formallyAvoid asking leading questions14History Most patients are eager to like and trust their doctors and respond gratefully to a sympathetic and understanding person. 15BUILDING THE HISTORY History taking is detective
8、 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 in t
9、he 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. 1617PainCareful analysis of the nature of pain How the pain began? Was it explosive in onset, rapid. or gradual？What is the precise character of the
10、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？ 18Reaction to PainA patient who shrieks and thras
11、hes 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 patients co
12、nfidence is often a more effective analgesic than an injection of morphine.19VomitingWhat did the patient vomit？How much？How often？What did the vomitus look like？Was vomiting projectile？It is especially helpful for the examiner to see the vomitus.20Change In Bowel HabitsA change in bowel habits is a
13、 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. 21Hematemesis or HematocheziaMost common error is that rectum bleeding is attributable to hem
14、orrhoids. 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? 22TraumaTrauma occurs so commonly that it is ofte
15、n 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 parent23TraumaWhat was the patients position? When the
16、 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 hit24Family His
17、toryPolyposis 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 history25Past HistoryPeople who are well
18、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 results26Patient Emotional BackgroundPsychiatric consultation is seldom required Emotionally a
19、nd 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 convalescence27Physical Examina
20、tionComplete 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 possible28Elective Physical ExaminationDone in an orderly and detail
21、ed 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 history29Elective Physical ExaminationObserve the
22、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)30Elective Physical ExaminationEssential Steps Inspection
23、PalpationAuscultationPercussion 31Elective 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 indicative of
24、 an infiltrating carcinoma barely detectable on palpation32Elective 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 palpation
25、 gives the physician the information being sought and inspires confidence and trustOne finger for tenderness in acute abdomenFrom outside to central33Elective Physical ExaminationPercussion for ascites (shifting dullness), liver, spleenAuscultation: The nature of ileus and the presence of a variety
26、of vascular lesions are revealed by auscultation. 35Examination 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 examinati
27、ons36Emergency 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 resuscita
28、tion)Is massive bleeding occurring?(if from extremity, elevation and pressure)37Emergency Physical ExaminationTension pneumothorax and cardiac tamponade may easily be overlooked if there are multiple injuriesCompletion of the survey examinationControl of pain Splinting of fractured limbsSuturing of
29、lacerationsOther types of emergency treatment 38Laboratory 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 requir
30、e surgery (hyperparathyroidism, pheochromocytoma) Evaluation of the nature and extent of metabolic or septic complications39Laboratory ExaminationComplete blood and urine examinationHistory of renal, hepatic, or heart disease requires detailed studies Surgeon is the only one with the experience and
31、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 responsibility40Imaging StudiesA complement not an alteration of PEx-ray filmB-mode ultrasoundCT scanMRI41Special examinations
32、Cystoscopy GastroscopyEsophagoscopyColonoscopy AngiographyBronchoscopy are often required in the diagnostic appraisal of surgical disorders. 42Aseptic 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( (sterilizati
33、on) )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）。43SterilizationThe only completely reliable methods of sterilization in wide current use for surgical instruments and supplies are steam under pressure (autoclaving) boiling
34、 methodsoaking methoddry heat, andformaldehyde fumigation44AutoclavingSaturated steam at a pressure (104-137.3kPa) (1520 psi) at a temperature of 121-126oC destroys all vegetative bacteria and most resistant dry spores in 30 minutes. Sterilization time is markedly shortened by the high-vacuum or hig
35、h-pressure, 132-134oC，205.8kPa，4min.Sterilization can keep for 2 weeks45Boiling methodBoiling water (100oC) for 15-20 min Spores need 1 hour2 min more for every 300 m in altitude The pressure of autoclave sterilizer is 127.5kPa, T=124oC for 10 min 46Dry Heatexposure to continuous dry heat at 160oC f
36、or 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.47Soaking method2% glutaral (glutaraldehyde) 30min for disinfection, 10 ho
37、ur 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 min48Formaldehyde FumigationPotassium permanganate with 40% formaldehyde 1 hour for disinfection, sterilization for 6-12 hours49消毒法乙醇 75%碘伏 0.2%安尔碘过氧乙酸 0.2-0.5%有
38、效氯消毒剂50Skin AntisepticsThe most important applications of skin antisepsis are the hand scrub of the operating team and the preparation of the operative fields.51Hand Scrub RoutineAlthough the duration of the hand scrub is not universally defined, a 5-minute scrub before the first case-provided a bru
39、sh 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.52Opera
40、tive 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. Soap is
41、a weak antiseptic and is useful because of its nonirritating detergent action, especially when washing is combined with mechanical friction.53Operative Field PreparationIn the operating room-A 1-minute skin preparation using other 70% alcohol or 2% iodine in 90% alcohol-followed by a polyester adher
42、ent 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 irritat
43、ed or delicate skin or when the patient has a history of iodine sensitivity. 54Operative Field PreparationFor iodine sensitive patients, one can use 80% isopropyl or 70% ethyl alcohol. Apply to the skin with a gauze swab for 3 minutes and allow to dry before draping. Alternatively, tinted tincture o
44、f 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 higher
45、infection rate than using drapes that are firmly adherent.55Operative Field Preparation 2.53% iodine, then 70% alcohal twice1:1000 benzalkonium or 1:1000 chlohexidine twiceDisinfection from inside to outsideFor infective wound or anus from outside to insideArea15cm 56Universal PrecautionsAll surgica
46、l 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.57Universal PrecautionsSpec
47、ial precautions must be taken to avoid accidental injuries, eg, needle punctures and cuts.Workers who have any open wounds should avoid direct patient contact.If a glove is torn, it should be removed and changed as promptly as patient safety permits and the needle or instrument removed from the ster
48、ile field.58手术人员和病人手术人员和病人手术区域的准备手术区域的准备手术人员术前准备：手术人员术前准备：一般准备一般准备手臂消毒法手臂消毒法穿无菌手术衣穿无菌手术衣戴无菌手套戴无菌手套病人手术区的准备病人手术区的准备病人手术区皮肤消毒病人手术区皮肤消毒病人手术区铺巾病人手术区铺巾59手术人员一般准备手术人员一般准备更换手术室准备的清洁鞋和衣裤。更换手术室准备的清洁鞋和衣裤。口罩要盖住鼻孔，帽子要盖住全部头发。口罩要盖住鼻孔，帽子要盖住全部头发。剪短指甲。剪短指甲。手臂皮肤破损或有化脓性感染时，不能参加手手臂皮肤破损或有化脓性感染时，不能参加手术。术。60手臂消毒法手臂消毒法肥皂刷手
49、法：肥皂刷手法：用肥皂做一般的洗用肥皂做一般的洗手。手。用无菌毛刷蘸肥皂用无菌毛刷蘸肥皂水刷洗手和臂，从水刷洗手和臂，从手指尖到肘上手指尖到肘上10cm处，两臂交替刷洗，处，两臂交替刷洗，特别注意甲缘、甲特别注意甲缘、甲沟、指蹼等处的刷沟、指蹼等处的刷洗。洗。61肥皂刷手法肥皂刷手法一次刷完后，一次刷完后，手指朝上肘朝手指朝上肘朝下，用清水冲下，用清水冲洗手臂上的肥洗手臂上的肥皂水。皂水。反复刷洗反复刷洗3遍，遍，共约共约10分钟。分钟。62肥皂刷手法肥皂刷手法用无菌毛巾从手用无菌毛巾从手到肘部擦干手臂，到肘部擦干手臂，擦过肘部的毛巾擦过肘部的毛巾不可再擦手部。不可再擦手部。手臂在手臂在70%
50、酒精酒精溶液中浸泡溶液中浸泡5分分钟，稍干后穿手钟，稍干后穿手术衣和戴手套。术衣和戴手套。63手臂消毒法手臂消毒法其它刷手法：其它刷手法：碘尔康刷手法碘尔康刷手法灭菌王刷手法灭菌王刷手法洁芙柔刷手法洁芙柔刷手法64流水冲洗双手臂取洗手液4-5ml七步洗手法 （手掌相对，手掌对手背，双手十指交叉，双手互握，拇指，指尖，手臂至上臂下1/3)无菌毛巾擦干手臂消毒：8-10ml涂抹，自然干燥65穿无菌手术衣穿无菌手术衣66戴无菌手套戴无菌手套将右手插入右手手套内将右手插入右手手套内.已带好手套的右手指插入左手套的翻折部，已带好手套的右手指插入左手套的翻折部，帮助左手插入手套内。帮助左手插入手套内。将手
51、套翻折部翻回盖住手术衣袖口将手套翻折部翻回盖住手术衣袖口.用无菌盐水冲洗手套外面的滑石粉。用无菌盐水冲洗手套外面的滑石粉。67病人手术区皮肤消毒病人手术区皮肤消毒消毒药物消毒药物2.5-3%碘酊涂擦皮肤碘酊涂擦皮肤1遍，遍，70%酒精将碘酒精将碘酊擦净酊擦净2次。次。0.5%碘尔康或碘尔康或1：1000苯扎溴铵涂擦苯扎溴铵涂擦2遍。遍。婴儿、面部皮肤、口腔、肛门、外生殖婴儿、面部皮肤、口腔、肛门、外生殖器，一般用器，一般用0.75%吡咯烷酮消毒。吡咯烷酮消毒。植皮时，供皮区的消毒用植皮时，供皮区的消毒用70%酒精涂擦酒精涂擦23次次.68注意事项注意事项非感染伤口：由手术区中心部向四周涂擦。非
52、感染伤口：由手术区中心部向四周涂擦。感染伤口或肛门：手术区外周涂向感染伤口或会感染伤口或肛门：手术区外周涂向感染伤口或会阴肛门处。阴肛门处。已经接触污染部位的药液纱布不应再返擦清洁处。已经接触污染部位的药液纱布不应再返擦清洁处。手术区皮肤消毒范围要包括手术切口周围手术区皮肤消毒范围要包括手术切口周围15cm的区域。的区域。69 颅脑手术颅脑手术 颈部手术颈部手术70 胸部手术胸部手术 腹部手术腹部手术71 腹股沟和腹股沟和阴囊部手术阴囊部手术肾部手术肾部手术会阴部和会阴部和肛门部手术肛门部手术72 四肢手术73病人手术区铺巾病人手术区铺巾小手术仅盖一块孔巾即可。小手术仅盖一块孔巾即可。较大手术
53、需铺盖无菌巾和其他必要的布单。除术野较大手术需铺盖无菌巾和其他必要的布单。除术野外，至少要有两层无菌布单覆盖。外，至少要有两层无菌布单覆盖。一般的铺巾方法：一般的铺巾方法：四块无菌巾覆盖手术切口周围。先铺操作者对面或相对不四块无菌巾覆盖手术切口周围。先铺操作者对面或相对不洁区，最后铺靠近操作者一侧。无菌巾铺下后只能由手术洁区，最后铺靠近操作者一侧。无菌巾铺下后只能由手术区向外移。区向外移。然后铺中单、大单，大单头端应盖过麻醉架，两侧和足部然后铺中单、大单，大单头端应盖过麻醉架，两侧和足部应垂下超过手术台边应垂下超过手术台边30cm。74病人手术区铺巾病人手术区铺巾7576手术进行中的无菌原则手
54、术进行中的无菌原则手术人员一经洗手，手臂即不准再接手术人员一经洗手，手臂即不准再接触未经消毒的物品。触未经消毒的物品。穿无菌手术衣和戴无菌手套后，背部、穿无菌手术衣和戴无菌手套后，背部、腰部以下和肩部以上为有菌地带，手腰部以下和肩部以上为有菌地带，手术台边缘以下布单也不要接触。术台边缘以下布单也不要接触。不可在手术人员的背后传递器械及手不可在手术人员的背后传递器械及手术用品。术用品。坠落到无菌巾或手术台边以外的器械坠落到无菌巾或手术台边以外的器械物品，不准拾回再用。物品，不准拾回再用。77手术中如手套破损或接触到有菌地方，手术中如手套破损或接触到有菌地方，应更换无菌手套。应更换无菌手套。前臂或
55、肘部碰触有菌地方，应更换无前臂或肘部碰触有菌地方，应更换无菌手术衣或加套无菌袖套。菌手术衣或加套无菌袖套。无菌巾、布单等物如已被湿透，应加无菌巾、布单等物如已被湿透，应加盖干的无菌单。盖干的无菌单。术前要清点器械、敷料，手术结束时，术前要清点器械、敷料，手术结束时，检查胸腹等体腔，核对器械、敷料数检查胸腹等体腔，核对器械、敷料数无误后，才能关闭切口。无误后，才能关闭切口。78切口边缘应以大纱布垫或手术巾遮盖，并用巾钳和缝线固定，仅显露手术切口。术前手术区粘贴无菌塑料薄膜可达到相同目的。 在手术过程中，同侧手术人员如需调换位置时，应先退后一步，转过身，背对背地转到另一位置。79作皮肤切口或缝合皮
56、肤之前，需用作皮肤切口或缝合皮肤之前，需用75%酒精再涂擦消毒皮肤一次。酒精再涂擦消毒皮肤一次。切开空腔脏器前，要先用纱布垫保护切开空腔脏器前，要先用纱布垫保护周围组织。周围组织。参观手术人员不可太靠近手术人员或参观手术人员不可太靠近手术人员或站得太高，也不可经常在室内走动。站得太高，也不可经常在室内走动。手术进行时不应开窗通风或用电扇，手术进行时不应开窗通风或用电扇，室内空调机风口也不能吹向手术台。室内空调机风口也不能吹向手术台。80手术室的管理手术室的管理同一日内，先作无菌手术，后作感染手术。同一日内，先作无菌手术，后作感染手术。每次手术完毕和每日工作结束时都应彻底清每次手术完毕和每日工作
57、结束时都应彻底清刷地面，清除污液、敷料和杂物。刷地面，清除污液、敷料和杂物。每周应彻底大扫除每周应彻底大扫除1 1次。次。手术室内应定期进行空气消毒。手术室内应定期进行空气消毒。在破伤风、气性坏疽手术后需用在破伤风、气性坏疽手术后需用40%40%甲醛溶甲醛溶液消毒手术室。液消毒手术室。在在HbsAgHbsAg阳性，尤其是阳性，尤其是HbeAgHbeAg阳性的病人手术阳性的病人手术后，地面和手术台需用后，地面和手术台需用0.1%0.1%次氯酸钠水溶液次氯酸钠水溶液消毒。消毒。 81凡进入手术室的人员，必须换上手术室的清凡进入手术室的人员，必须换上手术室的清洁鞋帽、衣裤和口罩。洁鞋帽、衣裤和口罩。
58、参观手术人员数目不宜超过参观手术人员数目不宜超过2人。人。患有急性感染和上呼吸道感染者，不得进入患有急性感染和上呼吸道感染者，不得进入手术室。手术室。82本节教学目的、要求本节教学目的、要求（1）掌握外科学的范畴。）掌握外科学的范畴。（2）树立学习外科学的正确观点。）树立学习外科学的正确观点。（3）掌握无菌术的概念，熟悉常用的灭）掌握无菌术的概念，熟悉常用的灭菌、消毒法。菌、消毒法。（4）掌握洗手、穿无菌手术衣、戴无菌）掌握洗手、穿无菌手术衣、戴无菌手套的方法。手套的方法。（5）掌握手术区皮肤的消毒及铺巾。）掌握手术区皮肤的消毒及铺巾。（6）掌握手术进行中的无菌原则。）掌握手术进行中的无菌原则。 8384
