How to perform abdominal surgery

2021-01-26 12:00 AM

The reason for hospitalization is the reason that the patient first comes into contact with the medical facility, not an administrative reason such as hospital transfer or surgery appointment. 

Ask the patient

Before asking a patient, it is imperative that we have social greetings to get to know the patient, to create the patient's trust with us, and also to learn about the intellectual level and culture of the patient to address the problem. questions that explore history appropriately. In addition, social questions are also to learn more about the patient's family and social situation. For people of high culture, it is necessary to have delicate questions, but for low culture people, choose simple and specific questions. Currently, almost all doctors and students ignore this section and often have a graceful attitude towards the patient. These manifestations are losing humanity, the minimal cultural representations of a person.

During the questioning and examination, the person making the medical record must record positive signs (signs the patient has) and also negative signs (signs the patient does not have) because there are many negative signs. has a great effect on differential diagnosis and definitive diagnosis. For example, the cramping pain in the ribs with hematuria will be different from the pain in the non-hemorrhagic rib, or the pain in the lower right side with fever and malaria will be very different from the pain below the right side without fever.

Reason for hospitalization

The reason for hospitalization is the reason that the patient first comes into contact with the medical facility, not an administrative reason such as hospital transfer or surgery appointment. The reason for admission is the key sign to exploit in the process of questioning. For example, the patient is hospitalized with abdominal pain. When a patient is admitted to the hospital for abdominal pain, it is most important to exploit the signals surrounding the abdominal pain. That will be a major part of exploring history. If the patient goes to the medical institution first to vomit blood, then the exploitation of markers related to blood vomiting will be the main part of the history.

Medical history

Medical history is to extract information around the reason for admission. We must first ask about the opportunity for this reason to appear and then the location of the reason for admission to the hospital for pain cases because normally each internal organ has an external correspondence. We begin to ask about the timing of the admission reason because we know that the progression of the disease is often correlated with time. It is primarily important to see if the patient is in an emergency condition or not. If the reason for hospitalization of the patient had been for a long time, it was very rare that it was a surgical emergency and if there was a surgical emergency it would be a bad thing, probably because of the medical level but it could also be due to Patients with low intellectual capacity or economically incapable people go to see a doctor and until they cannot stand it, they will go to see a doctor. Next time for the first signal we need to ask about the intensity of this signal. The intense or moderate-intensity only feel discomfort. Along with the intensity question, we need to continue asking the characteristic of this sign: whether there is an episode or not, whether it is continuous or not, whether it spreads in any direction. After we have asked them enough and carefully for these signs, we will ask for other signs that appear with this sign.

Take an example when a patient has colic because the majority of patients who come to the emergency room are because of colic. To exploit this token:

Chance of pain. It may be natural, but also after eating and drinking alcohol (pancreatitis) after heavy labor (urinary stones), or changes in weather (peptic ulcers).

Pain ever since, pain in any part of the abdomen. If it is the area above the navel, we often think of the gastro-duodenum, if the pain in the lower right rib, we think of the hepatobiliary, if the pelvic pain we think of the appendix, if the pain in the lower abdomen we think of the appendage or bladder. This thought comes from the anatomical site and the correlation coefficient between the external position and the pathology of the internal organs. However, if we prejudice this view, it can lead to errors in diagnosis. For children, for example, when appendicitis often begins to hurt in the area above the navel, or in many cases, pelvic pain belongs to appendage or colon pathology.

The intensity of pain also depends on the type of disease. For example, gastric perforation often comes on suddenly, severe pain like stabbing a knife in the abdomen causing the patient to bend over and because of the intense pain, they remember exactly when it happened and often went sick While appendicitis is painful only in prostitution, patients often come to the hospital quite late, including those with education or high positions.

Pain is also specific to each disease. Pain caused by intestinal obstruction or colitis, bile duct worms, ureteral stones ... often pain in typical bouts.

The spread of pain is also specific to a number of diseases: pancreatitis pain, gallstones often spreading to the back, the pain of a fistula herniation often spreading to the inner thigh (due to insertion of the groin) gallbladder, liver abscess, hepatitis often spread to the back and up the shoulder blades, urinary stones often spread down the genitals.

Also while asking about pain, we have to ask more patients during pain, what position to help relieve pain: if the stomach is punctured, the patient does not dare to breathe hard and bend over, holding hands around the upper abdomen While the pain from worms to the biliary tract, patients often lie with their buttocks or legs pressed against the wall.

Associated signs of abdominal pain are also characteristic. For example, urinary tract stones are often accompanied by hematuria, pain from intestinal obstruction, pancreatitis often accompanied by vomiting, and bowel retention. Biliary infections or liver abscesses or pyrogenic pyrexia are often accompanied by signs of high fever and chills, pain from cystitis or appendages, often with urinary urgency and urination, or pain from enteritis, often followed by nausea and dizziness.

It is important to be patient while asking the patient, not suggesting to the patient according to the physician's direction, to ask selective questions and if you see any doubts, ask again to avoid ideas. statue of the patient.

Medical history

History mining has an important value not only in diagnosis and treatment but also in research.

In history, exploiting the previous pathologies associated with this occurrence of the disease. For example, a person with a long history of constipation is a very favorable condition to cause hemorrhoids; or a history of long-standing bile duct-type pain that will be associated with gallstones, or a history of malaria will be associated with splenomegaly ... It is exploiting a history to support diagnose.

Exploit in the patient's history of any accompanying illness such as high blood pressure, diabetes, cardiovascular disease ... or a history of allergies such as an allergy to a drug for anesthesia and We have planned treatment in advance, avoiding the unfortunate turn of events. It is prehistoric mining for treatment.

Exploiting history to support scientific research, we need to exploit the habits of the patient's life such as smoking, eating salty food, drinking alcohol, or drinking un-boiled water ... so that we can find it. the cause or favorable conditions that cause this disease. At the same time, it is also necessary to exploit the family or neighbor who has the manifestation of the patient's disease so that it is possible to detect genetic diseases or diseases caused by the impact of environmental influences. Therefore, prehistory must be exploited seriously and meticulously, avoiding through loudspeakers, taking the current scale.

While we ask about the disease, at the same time, observe the patient from the color, skin color, lips, breathing pattern, breath, speech pattern, posture, pain pattern, and spirit ... to have a gradual orientation to things. will need to be done during the examination.

Medical examination

The examination must be built into a logical sequence to become a habit and thanks to this habit, good physicians rarely miss signs that can detect undesirable symptoms.

First of all, we must look at the skin and mucous membranes, pay attention to the eye mucosa (yellow, pale ...) and tongue mucosa (dirty ...), palpate the vessels clearly, evenly, quickly, and slowly. Take your temperature and measure your blood pressure. If the patient has difficulty breathing, the examiner must count the breathing rate by placing his hand on the epigastric region, eyes looking at the clock for at least a quarter of a minute. When the patient has abnormal manifestations of the pulse, blood pressure, breathing rhythm, namely fast, small, low blood pressure, too fast, or too slow breathing, we must immediately intervene because these are the signs. signal with the risk of affecting life before conducting an examination to detect the disease.

For example, a woman who came to the doctor because of severe abdominal pain went to the clinic, pale skin, pale skin, small tachycardia, low blood pressure. In this situation, if the inexperienced person has to do the warming, the infusion, and the blood test immediately and the experienced person will immediately look to diagnose the ectopic pregnancy rupture and move to the operating room to continue. perfect diagnosis and ready to intervene. If at that time we continue to examine and look for diagnostic signs, the risk of life-threatening angioplasty is very great and when the diagnosis is complete, it is too late to have no time to process. If the patient comes in a state of coma, loss of consciousness, at the receiving place, there must be a record of a group of three people who inventory all papers, assets, belongings on the body and in the pocket of clothing, and must name and address of the sender. One thing to keep in mind for abdominal emergency examination due to traffic accidents or living activities such as fighting or slashing. These are the cases that are related to later legal elements in the determination or examination of the injury, so all traces on the victim must be fully listed and elaborated in the medical record judgment.

Abdominal examination

Abdominal examination is an examination of the abdomen, groin, and rectum or vagina. So there must be a discreet place and for women, when a male doctor examines, it is compulsory to have two or more people.

Examination of the abdomen of the examiner must require the patient to fully reveal from the nipple down to the upper thighs. The patient lies on his back with his legs on the bed so that his abdomen and thighs create an angle greater than 45 degrees, causing the abdominal muscles to slack. The examiner sits on the right if he is right-handed and sits on the left if he is left-handed. However, there are some cases of severe pain where the patient is unable to lie on his back for example in peptic ulcer perforation. In these cases, someone needs to gently inform the patient and quickly determine whether the patient has abdominal wall spasticity or not for a decisive diagnosis.

Observation

First of all, look. See if the patient's abdomen is moving with the rhythm of the breath or not, the abdomen is concave or distressed.

If the abdomen does not move with the rhythm of the breath, one can detect signs of contraction of the abdominal wall through observation: the straight muscles of the abdomen are prominent continuously like a person on the abdominal tendons.

If your abdomen is concave, your next move is to look for signs of Bouverie.

If the abdomen is distended, the next action is to determine if the gas or fluid distension is caused by typing.

In addition, it is important to observe whether there is an old incision on the abdomen or if there is any bulging, as well as whether the inguinal area is different or not ... This is very important in relation to the diagnosis.

If the patient has a surgical scar or injury scar on the abdominal wall, it is usually related to postoperative bowel obstruction.

If the patient has protrusions in the groin area, if the Margarine line (the line connecting the anterior pelvic spine to the right upper pubic bone) is usually an inguinal hernia, below this line is usually a thigh herniated mass; protrusion around the navel is usually an umbilical hernia, and a bulge under the surgical scar is usually a protrusion of the abdominal wall. These hernias are caused by weakness in the abdominal wall (congenital or acquired) that causes some of the intestinal loops to lie out of the abdomen and may become constricted.

In observation, we also need to look at the patient's wastes such as vomit, urine, feces ... to be able to lead to diagnoses such as vomiting blood or black stools, hematuria or urinary Pus, vomiting with bile fluid or not to distinguish between duodenal obstruction and pyloric stenosis.

Palpation of the abdomen

The purpose of palpation in surgical emergencies focuses on detecting the abdominal wall condition while also looking for other signs in the abdominal examination. The condition of the abdominal wall represents damage to the organs in the abdominal cavity, so the careful examination by experienced people has been of great value in the diagnosis of abdominal emergency and to date, with Using advances in adjuvant exploration, clinical examination is still decisive in the diagnosis and indication of the emergency surgical abdomen.

To evaluate the condition of the abdominal wall, the examiner needs to gently press his entire hand on the patient's abdomen, gently press slowly, not with the fingertips because the fingertips will stimulate the abdominal wall to create a response of the abdominal wall by reflex. The principle set out in the abdominal examination is the examination from the painless area to the painful area, to compare the state of the abdominal wall muscles in the opposite abdominal areas. Normally, only when the abdominal wall is completely soft can the tumors or organs in the abdominal cavity such as liver, spleen, gallbladder, kidney grow, and when the abdominal wall reacts or spasms, this effect is difficult to determine.

Abdominal wall reaction

The abdominal wall reaction is when the abdominal wall muscles contract when you gently press the patient's abdomen from shallow to deep. In order to avoid artificial abdominal wall reaction caused by the examiner, the patient's hand must be warmed before the examination, placing the whole hand on the abdomen, from the painless abdomen to the affected abdomen Compare the condition of the abdominal wall on the painful side with the opposite. The abdominal wall reaction can be manifested by the abdominal wall muscles stretching almost to the abdominal tendons, the expression of pain, and showing antagonistic movements such as holding the hand of the examiner, wiping the discoverer's hand ... The abdominal wall is a reflex of the abdominal wall to protect the internal organs from injury or infection.

Contraction of the abdominal wall

Abdominal wall spasticity means that the abdominal wall must constantly contract and unintentionally the patient.

Abdominal wall spasticity is divided into two types:

Local contraction of the abdominal wall - spasticity of only one muscle group in one area of ​​the abdomen - such as spasticity in the right pelvic fossa or below the right flank, while elsewhere remains soft.

Muscle contraction of the abdominal wall.

It should be noted when verifying that the abdominal wall spasticity means that the abdominal wall must be constantly and unintentionally spasmodic. Detecting this sign, just gently press the hand on the patient's abdomen to feel the constant spasticity of the abdominal wall muscles. Local spasticity means that an organ has ruptured but has not yet broken into the entire abdominal cavity and total spasticity is an early sign of perforation. 

Contraction of the whole continuous abdominal wall.

Peritoneal induction

Peritoneal induction is a manifestation of signs in the peritoneum with inflammatory fluid or blood or in other words a state of the abdominal wall in case of peritoneal irritation due to inflammatory fluid or blood.

In these cases, the patient's abdomen is often swollen, an infected expression on the face if there is pus in the abdomen, or pale if there is blood in the abdomen. Very gentle abdominal manipulation also makes the patient unbearable or when you suddenly remove your hand from the abdominal wall after pressing deeply, causing the patient to bounce pain. In some cases, it is discreet, finding pain points around the navel to detect peritoneal induction is very valuable. You can also look for signs of peritoneal induction by reducing abdominal pressure abruptly during the examination: You press both your hand deeply evenly against the abdominal wall and then remove it abruptly. If the patient is in pain, it is a positive sign. At the same time with the manifestation on the abdominal wall, if we visit the rectum, we always find the pouch with Douglas swelling and pain. This sign is very loyal and valuable 

Look for pain spots

Recalling the abdominal segment.

The abdomen is divided into 9 regions because the two lines going from the center of the clavicle down are perpendicular to the two horizontal lines where the first horizontal line connects the upper anterior pelvic spines and the second horizontal line connects the cut point of the line with the two. ribs.

The region above the navel (corresponding to the stomach, transverse colon, pancreas, left liver lobe).

The area around the navel (corresponding to the small intestine).

The area below the navel (corresponding to the bladder, uterus).

Right lower rib region (corresponding to duodenum, gallbladder, liver, right kidney).

Right rib region (corresponding to the ascending colon, right ureter).

Right pelvic fissure (corresponding to appendix, cecum, appendages).

Below the left rib (corresponding to the pancreas tail, spleen, colon spleen, left kidney).

Left flank (corresponding to the descending colon and ureter).

Left pelvic cavity (corresponding to the polyhedron, ovary, and left ovary).

Specific pain points

In the emergency surgical abdominal examination, people pay attention to a number of points such as McBurney score in appendicitis, left thymus edge point in case of purulent left liver, left-back flank point in pancreatitis, or acute pancreatitis.

As well as looking for specific pain points, there are a number of tests that are usually done in conjunction with an examination. Examples are the Murphy test, the liver fibrillation test, and the stimulant test that causes increased motility of the gastrointestinal tract.

The Murphy test is intended to detect signs of inflammation of the gallbladder. The patient lies on his back with his legs propped on the bed at a 45-degree angle. The healer sits on the right, his hand on the right rib. When the patient inhales the physician's hand, gently pushes and pushes it upwards, if the gallbladder is inflamed, the patient will stop breathing. The mechanism of this test is that when the patient inhales, the diaphragm goes down, and pushes the liver and gallbladder along. When the physician raised his hand, the gallbladder was being pushed down by the inhalation action touching the doctor's finger and because the gallbladder was inflamed, so pain and so the patient naturally stopped breathing.

The liver fibrillation test is to detect pus-burning in the liver. The fingers of one hand are pressed against the intercostal cavities from 6 or below and then use the edge of the other hand tightly to the hand that is pressing the patient's ribs. If the test is positive, the patient is in pain.

The test stimulates increased bowel or stomach motility by gently twisting or pinching the abdominal muscles to stimulate and we look tangentially to the abdominal wall. If positive, we will see the intestinal motions roll up like a bovine because the positive sign is called the cow snake marker.

Hear the belly

Abdominal hearing to detect intestinal peristalsis to distinguish between motorized intestinal obstruction (with and increased peristalsis) with functional intestinal obstruction due to intestinal paralysis (loss of peristalsis), and in some cases aortic aneurysm sac rupture often represents a condition of the peritoneal syndrome, and in this case, a clear systolic murmur is heard when heard.

Examination of herniated holes

In the normal abdominal exam in general and the emergency abdominal examination in particular, the examination of herniated holes and the rectal or vaginal examination is required. A hernia means a bowel loop through a hole in the inside of the abdomen (inner hernia) or under the skin of the abdomen, groin, or thigh (an external hernia). Internal hernias are common due to incomplete sealing, diaphragmatic herniation...An abdominal examination can detect only external hernias. Usually, a hernia is not an emergency surgical disease, but when the hernia is blocked, it will cause intestinal obstruction. And later, the intestine will become necrotic due to difficulty in supplying arterial blood to the loops. Towel along with the swelling of the bowel due to stagnation of the veins and veins, further increasing the hindrance to the arterial blood supply. The sign of a stuffy herniation is a herniated mass that does not spontaneously arise. Once determined as a blocked herniation, any attempt to push the hernia is absolutely forbidden. Because even if the hernia is pressed, the progression of the intestinal segment is indeterminate and if the necrosis causes inflammation severe peritoneum.

Even in the cases where surgery is indicated, after anesthesia, due to the soft muscle effect, in some cases, the hernia mass will fall. In these cases, for the safety of the patient, we still have to continue surgery to check for lumbar drop and resolve the cause of the hernia.

Rectal and vaginal check

Rectal or vaginal check is required in an emergency abdominal exam. This examination is required for three reasons:

  • It determines the condition of the peritoneum through the examination of the sac with Douglas. We all know that the pocket with Douglas is the lowest place of the peritoneal cavity and the physiological properties of this region is the worst reabsorption in the entire abdomen so when the fluid in the abdomen will accumulate in the sac this. Normally, the pouch with Douglas is a virtual space and when the fluid is filled, it fills up so when you visit the rectum or vagina, you will find that this sac is full and very painful.
  • Through rectal or vaginal examination, we can indirectly examine some organs across the sidewall (such as the appendix, appendage) or anterior wall (prostate, uterus).
  • When visiting the rectum or vagina, we can diagnose the cause of some diseases such as intestinal obstruction in the elderly. We can feel dry rectal tumors, in the intestinal obstruction in the suckling child, if the child refuses to suckle. People, crying with the rectal examination (with little finger) with blood on the glove. The diagnosis of intussusception will be confirmed, for women naturally fainting, hypotension but when checking the vagina blood by the glove, it will definitely break the womb.

The rectal and vaginal exam is a delicate examination. So it must be explained carefully about the reasons and procedures for dealing with patients and their family members before proceeding. For women, it is always necessary to have a female nurse or health worker present during the visit and if the woman is not sexually active it is not allowed to have a vaginal exam. The examination is conducted in a separate room, the patient lies on his back in a gynecological position, under the buttock is lined with a small acid. The examiner wears gloves, using the index finger for the rectal exam in adults, the little finger in children, and the index and middle finger for the vaginal exam. After wearing gloves, the examiner dips his finger in paraffin oil and then proceeds to examine. The physical examination must be very gentle, slow, and absolutely not rough because the roughness will give false results due to the patient's reaction.

After completing the abdominal examination, the physician must listen to the heart, lungs, examination of the neck and spine to detect comorbidities. These comorbidities may sometimes aid in diagnosis (such as when the abdominal examination is detected. Large and painful liver, hearing heart with diastolic fibrillation, certainly means liver enlargement is due to heart failure.

Subclinical exploration

After obtaining the functional symptoms through inquiry, physical symptoms through examination, and body factors, what direction does the examiner think about the diagnosis and for further clarification, will conduct subclinical investigations including blood tests, biochemical tests, imaging exploration, and some other investigations such as gastroscopy ...

Hematology test

Includes a test of red blood cell count and white blood cell formula, blood type hemoglobin, clotting time, bleeding, and hematocrit Red blood cells and hematocrit increase in case of blood concentration due to dehydration or shock and decrease with blood loss. Leukocytes increase in cases of infection or trauma of solid organs such as rupture of the spleen or rupture of the liver. Blood clotting and bleeding time to generalize the patient's clotting and hemostatic status. ABO blood type is sufficient for Vietnamese and Asians, but for Westerners, a Rh test is a must to ensure safety in blood transfusion.

Biochemical test

Common biochemical tests are urea, blood sugar. If urea is high, then creatinine should be used to determine kidney failure and potassium in blood to assess the degree of kidney failure. If the blood sugar is high, the urinary tract must be performed immediately to determine whether or not diabetes is present. If the patient vomits a lot, then electrolytes should be tested. If the patient has jaundice, bilirubin should be tested together with bile salts and bile pigments in urine. If the patient has a history of injection, testing for HIV, hepatitis C, and hepatitis B is required.

Exploration diagnostic imaging

Abdominal imaging unprepared.

The signs obtained on the film of the abdomen are not prepared to include: contrast stones, sickle gas, steam level ... Partial uncomplicated abdominal imaging helps confirm the diagnosis (such as sickle gas under the diaphragm in the perforation hollow) or differential diagnosis (the pelvic fossa must have images of ureteral stones different from right pelvic pain due to appendicitis). However, these signs are not a substitute for clinical signs.

Supersonic

Ultrasound is an exploratory method used extensively because it is not dangerous or painful to the patient. Ultrasound allows the first assessment of whether or not the peritoneal cavity is fluid. Next, ultrasound allows for definitive diagnosis of some injured organs such as cholangiocarcinoma with or without stones, inflammation and gallbladder stones, solid organ rupture, uterine and ovarian conditions, pancreatic condition, kidney. On an empty organ, one can sometimes see an appendix or a tumor of the intestine. For blood vessels, the ultrasound can determine the diameter of the portal vein, detect the bulging sacs of the aorta or other arteries in the abdomen. However, one major disadvantage of a diagnostic ultrasound depends a lot on the quality of the machine and especially the experience and level of the ultrasound reader.

Computerized tomography

In general, nowadays, computerized tomography is not a common probe in first aid in our country and the value in the emergency diagnosis of the abdomen is not much more than ultrasound.

Gastrointestinal endoscopy

In cases of gastrointestinal bleeding, one of the essential indications for determining the cause of bleeding is gastroduodenal endoscopy. First of all, it determines bleeding due to rupture of esophageal varices or peptic ulcers or biliary tract (whether the fluid flowing through Oddie is bloody or not), and it can intervene temporarily to stop bleeding like fiber injection into esophageal varices or ulcer hemostasis drugs.

Abdominal lavage

If in the early years of the twentieth century, laparotomy was mentioned in a surgical abdominal emergency but now this method has been replaced by abdominal lavage. After inserting a catheter below the navel toward Douglas, physiological fluid is poured into the abdomen from 500 to 1000ml. Then use the principle of a siphon to let this wash solution run by itself. If the macroscopic clear that bloody or gastrointestinal fluid is enough to indicate surgery but if it is not clear, the fluid is centrifuged to red blood cells, white blood cells, and amylase test. Abdominal lavage gives a high diagnostic value.

Laparoscopy

In some suspected cases, to avoid tentative abdominal surgery, some conditional establishments may conduct laparoscopy for diagnosis and through laparoscopy may perform necessary procedures such as stitching. gastric perforation, appendectomy, cholecystectomy, intestinal removal. This is a new direction of surgery in the twenty-first century.

Other exploration

In case of suspecting that the patient has another disease with a full body examination, other investigations such as pulmonary (for TB), electrocardiogram (for people with high blood pressure) are required. or suspected heart disease). Especially now, in the threat of the HIV pandemic, all high-risk patients (especially injecting drug users, prostitution), testing for HIV, hepatitis B, and hepatitis C are required.

Conclusion

The surgical abdominal examination begins with an inquiry. By asking about the disease, we will gather the functional symptoms. On the basis of these functional symptoms, we will focus on looking for physical symptoms through examination. Gathering the functional symptoms and physical symptoms together we will get the clinical symptoms as the basis for the direction of some clinical diagnosis. From these clinical diagnoses, we have to add other groups of tests and investigators to distinguish some similar clinical manifestations of some different diseases towards definitive diagnosis. Once a definitive diagnosis has been made, the development of treatment options is not difficult. In order to have a good treatment, we have to get a correct diagnosis, and to get the correct diagnosis we have to know how to ask about the disease, how to examine a doctor, how to request other subclinical tests and exploration. When this information is available, confirm the exclusion or differential diagnosis in a logical mindset to lead to the definitive diagnosis. Never forget to have a full-body exam to check for underlying conditions or possible causes of false surgical abdominal signs such as heart failure or pneumonia.