Rehabilitation period after abdominal surgery: regimen and diet. Postoperative period. possible complications

Postoperative period - the period of time from the end of the operation until recovery or complete stabilization of the patient’s condition. It is divided into immediate - from the end of the operation to discharge, and remote, which occurs outside the hospital (from discharge to the complete elimination of general and local disorders caused by the disease and operation).

All postoperative period in the hospital they are divided into early (1-6 days after surgery) and late (from the 6th day until discharge from the hospital). During postoperative period There are four phases: catabolic, reverse development, anabolic and the phase of increasing body weight. The first phase is characterized by increased excretion of nitrogenous wastes in the urine, dysproteinemia, hyperglycemia, leukocytosis, moderate hypovolemia, and loss of body weight. It covers early and partly late postoperative period. In the phase of reverse development and the anabolic phase, under the influence of hypersecretion of anabolic hormones (insulin, growth hormone, etc.), synthesis predominates: electrolyte, protein, carbohydrate, and fat metabolism are restored. Then the phase of weight gain begins, which, as a rule, occurs during the period when the patient is on outpatient treatment.

The main points of postoperative intensive care are: adequate pain relief, maintenance or correction of gas exchange, ensuring adequate blood circulation, correction of metabolic disorders, as well as prevention and treatment of postoperative complications. Postoperative pain relief is achieved by administering narcotic and non-narcotic analgesics, using various options for conduction anesthesia. The patient should not feel pain, but the treatment program should be designed so that pain relief does not depress consciousness and breathing.

When a patient is admitted to the intensive care unit after surgery, it is necessary to determine the patency of the airways, the frequency, depth and rhythm of breathing, and the color of the skin. Impaired airway patency in weakened patients due to retraction of the tongue, accumulation of blood, sputum, and gastric contents in the respiratory tract require therapeutic measures, the nature of which depends on the cause of the obstruction. Such measures include maximum extension of the head and extension of the lower jaw, insertion of an air duct, aspiration of liquid contents from the airways, bronchoscopic sanitation of the tracheobronchial tree. If signs of severe respiratory failure appear, the patient should be intubated and transferred to artificial ventilation.

To acute respiratory distress in the near future postoperative period can lead to disorders of the central mechanisms of respiratory regulation, which usually arise as a result of depression of the respiratory center under the influence of anesthetic and narcotic drugs used during surgery. The basis of intensive therapy for acute respiratory disorders of central origin is artificial pulmonary ventilation (ALV), the methods and options of which depend on the nature and severity of respiratory disorders.

Disturbances in the peripheral mechanisms of respiratory regulation, more often associated with residual muscle relaxation or recurarization, can lead to rare gas exchange disorders and cardiac arrest. In addition, these disorders are possible in patients with myasthenia gravis, myopathies, etc. Intensive therapy for peripheral respiratory disorders consists of maintaining gas exchange by mask ventilation or repeated tracheal intubation and transfer to mechanical ventilation until muscle tone is fully restored and adequate spontaneous breathing.

Severe breathing disorders can be caused by pulmonary atelectasis, pneumonia, and pulmonary embolism. When clinical signs of atelectasis appear and the diagnosis is confirmed by X-ray, it is necessary to eliminate first of all the cause of atelectasis. With compression atelectasis, this is achieved by draining the pleural cavity to create a vacuum. For obstructive atelectasis, therapeutic bronchoscopy is performed with sanitation of the tracheobronchial tree. If necessary, the patient is transferred to mechanical ventilation. The complex of therapeutic measures includes the use of aerosol forms of bronchodilators, percussion and vibration massage of the chest, and postural drainage.

Postoperative pneumonia develops on the 2-5th day after surgery due to hypoventilation and retention of infected secretions. There are atelectatic, aspiration hypostatic, infarction and incurrent postoperative pneumonia. For pneumonia in intensive care include a set of breathing exercises, oxygen therapy, drugs that improve the drainage function of the bronchi, antihistamines, bronchodilators and aerosol drugs, cough stimulants, cardiac glycosides, antibiotics, etc.

One of the serious problems in intensive care of patients with respiratory failure is the need for mechanical ventilation. The guidelines for solving this problem are the respiratory rate of more than 35 per 1 min, Stange test less than 15 With, pO 2 below 60 mm rt. st. despite inhalation of a 50% oxygen mixture, hemoglobin oxygen saturation is less than 70%, pCO 2 is below 30 mm rt. st. . vital capacity of the lungs is less than 40-50%. The determining criterion for the use of mechanical ventilation in the treatment of respiratory failure is the increase in respiratory failure and the insufficient effectiveness of the therapy.

In early P. p. . acute hemodynamic disturbances can be caused by volemic, vascular or cardiac failure. The causes of postoperative hypovolemia are varied, but the main ones are blood loss that was not replaced during surgery or ongoing internal or external bleeding. The most accurate assessment of the state of hemodynamics is provided by comparing central venous pressure (CVP) with pulse and blood pressure; prevention of postoperative hypovolemia is complete compensation of blood loss and circulating blood volume (CBV), adequate pain relief during surgery, careful hemostasis during surgery, ensuring adequate gas exchange and correction of metabolic disorders both during surgery and in early postoperative period. The leading place in the intensive treatment of hypovolemia is occupied by infusion therapy aimed at replenishing the volume of circulating fluid.

Vascular insufficiency develops as a result of toxic, neurogenic, toxic-septic or allergic shock. In modern conditions in postoperative period Cases of anaphylactic and septic shock have become more frequent. Therapy for anaphylactic shock consists of intubation and mechanical ventilation, the use of adrenaline, glucocorticoids, calcium supplements, and antihistamines. Heart failure is a consequence of cardiac (myocardial infarction, angina, heart surgery) and extracardiac (cardiac tamponade, toxicoseptic myocardial damage) causes. Its therapy is aimed at eliminating pathogenetic factors and includes the use of cardiotonic agents, coronary lytics, anticoagulants, electrical pulse cardiac stimulation, and assisted cardiopulmonary bypass. In case of cardiac arrest, cardiopulmonary resuscitation is used.

Maximum shifts in water-electrolyte balance are observed on days 3-4 postoperative period. Most often, hypertensive dehydration occurs, the development of which after surgery is facilitated by vomiting, diarrhea, and wound exudation. Intensive therapy for hypertensive dehydration consists of intravenous infusion of a 5% glucose solution or, if there are no contraindications, administration of water, tea, or fruit juice through the mouth or gastric tube. The required amount of water is calculated using the following formula: water deficit ( l) = x 0.2 x body weight (in kg). There are other formulas. With a significant loss of sodium, the patient develops hypotonic dehydration, which is replenished by administering water, 3-5% sodium chloride solution, calculating the required amount of the drug using formulas. In addition to these forms of dehydration, isotonic as well as hypertonic hyperhydration can be observed.

Flow postoperative period to a certain extent depends on the nature of the surgical intervention, intraoperative complications, the presence of concomitant diseases, and the age of the patient. If the course is favorable postoperative period body temperature in the first 2-3 days can be increased to 38°, and the difference between evening and morning temperatures does not exceed 0.5-0.6°. The pain gradually subsides by the 3rd day. The pulse rate in the first 2-3 days remains within 80-90 beats per 1 min, CVP and blood pressure are at the level of preoperative values; the ECG on the next day after surgery shows only a slight increase in sinus rhythm. After operations under endotracheal anesthesia, the next day the patient coughs up a small amount of mucous sputum, breathing remains vesicular, and isolated dry wheezing can be heard, disappearing after coughing up the sputum. The color of the skin and visible mucous membranes does not undergo any changes compared to their color before the operation. The tongue remains moist and may be coated with a whitish coating. Diuresis corresponds to 40-50 ml/h, there are no pathological changes in the urine. After operations on the abdominal organs, the abdomen remains symmetrical, bowel sounds are sluggish on days 1-3. Moderate intestinal paresis resolves on the 3-4th day postoperative period after stimulation, cleansing enema. The first revision of the postoperative wound is carried out the next day after the operation. In this case, the edges of the wound are not hyperemic, not swollen, the sutures do not cut into the skin, and the wound remains moderately painful upon palpation. Hemoglobin and hematocrit (if there was no bleeding during surgery) remain at their original values. On days 1-3, moderate leukocytosis with a slight shift of the formula to the left, relative lymphopenia, and an increase in ESR may be observed. In the first 1-3 days, slight hyperglycemia is observed, but sugar in the urine is not detected. A slight decrease in the level of albumin-globulin ratio is possible.

In elderly and senile people in early postoperative period characterized by the absence of an increase in body temperature; more pronounced tachycardia and blood pressure fluctuations, moderate shortness of breath (up to 20 v 1 min) and a large amount of sputum in the first postoperative days, sluggish peristalsis of the tract. The surgical wound heals more slowly, and suppuration, eventration and other complications often occur. Possible urinary retention.

Due to the tendency to reduce the time a patient spends in hospital, an outpatient surgeon has to observe and treat some groups of patients already from the 3-6th day after surgery. For a general surgeon in an outpatient setting, the main complications are most important postoperative period, which can occur after operations on the abdominal and chest organs. There are many risk factors for the development of postoperative complications: age, concomitant diseases, prolonged hospitalization, duration of surgery, etc. During the outpatient examination of the patient and in the preoperative period in the hospital, these factors must be taken into account and appropriate corrective therapy must be carried out.

With all the variety of postoperative complications, the following signs can be identified that should alert the doctor in assessing the course of P. p. Increased body temperature from the 3rd-4th or 6-7th day, as well as high temperature (up to 39° and above ) from the first day after the operation indicate an unfavorable course of P. p. hectic fever from the 7-12th day indicates a severe purulent complication. A sign of trouble is pain in the area of ​​the operation, which does not subside by the 3rd day, but begins to increase. Severe pain from the first day postoperative period The doctor should also be alerted. The reasons for the intensification or resumption of pain in the surgical area are varied: from superficial suppuration to intra-abdominal catastrophe.

Severe tachycardia from the first hours postoperative period or its sudden appearance on the 3-8th day indicates a developed complication. A sudden drop in blood pressure and at the same time an increase or decrease in central venous pressure are signs of a severe postoperative complication. In many complications, the ECG shows characteristic changes: signs of overload of the left or right ventricle, various arrhythmias. The causes of hemodynamic disturbances are varied: heart disease, bleeding, shock, etc.

The appearance of shortness of breath is always an alarming symptom, especially on the 3-6th day postoperative period. Causes of shortness of breath in postoperative period there may be pneumonia, septic shock, pneumothorax, pleural empyema, peritonitis, pulmonary edema, etc. The doctor should be alerted to sudden unmotivated shortness of breath, characteristic of pulmonary embolism.

Cyanosis, pallor, marbling of the skin, purple, blue spots are signs of postoperative complications. The appearance of yellowness of the skin and sclera often indicates severe purulent complications and developing liver failure. Oligoanuria and anuria indicate the most difficult postoperative situation - renal failure.

A decrease in hemoglobin and hematocrit is a consequence of unreplenished surgical blood loss or postoperative bleeding. A slow decrease in hemoglobin and the number of red blood cells indicates inhibition of erythropoiesis of toxic origin. Hyperleukocytosis, lymphopenia, or the reappearance of leukocytosis after normalization of the blood count is typical for complications of an inflammatory nature. A number of biochemical blood parameters may indicate surgical complications. Thus, an increase in the level of amylase in the blood and urine is observed with postoperative pancreatitis (but also possible with mumps, as well as high intestinal obstruction); transaminases - during exacerbation of hepatitis, myocardial infarction, liver; bilirubin in the blood - with hepatitis, obstructive jaundice, pylephlebitis; urea and creatinine in the blood - with the development of acute renal failure.

Main complications of the postoperative period. Suppuration of a surgical wound is most often caused by aerobic flora, but often the causative agent is anaerobic non-clostridial microflora. The complication usually appears on the 5-8th day postoperative period, can occur after discharge from the hospital, but rapid development of suppuration is also possible already on the 2-3rd day. When the surgical wound suppurates, the body temperature, as a rule, rises again and is usually febrile. Moderate leukocytosis is noted, with anaerobic non-clostridial flora - pronounced lymphopenia, toxic granularity of neutrophils. Diuresis, as a rule, is not impaired.

Local signs of wound suppuration are swelling in the suture area, skin hyperemia, and severe pain on palpation. However, if suppuration is localized under the aponeurosis and has not spread to the subcutaneous tissue, these signs, with the exception of pain on palpation, may not exist. In elderly and senile patients, general and local signs of suppuration are often erased, and the prevalence of the process at the same time can be large.

Treatment consists of spreading the edges of the wound, sanitation and drainage, and dressings with antiseptics. When granulations appear, ointment dressings are prescribed and secondary sutures are applied. After careful excision of purulent-necrotic tissue, suturing over the drainage and further flow-drip washing of the wound with various antiseptics with constant active aspiration is possible. For extensive wounds, surgical necrectomy (complete or partial) is supplemented with laser, X-ray or ultrasound treatment of the wound surface, followed by the use of aseptic dressings and the application of secondary sutures.

If suppuration of a postoperative wound is detected when a patient visits a surgeon in a clinic, then with superficial suppuration in the subcutaneous tissue, treatment on an outpatient basis is possible. If suppuration in deep-lying tissues is suspected, hospitalization in the purulent department is necessary, because in these cases, more complex surgery is required.

Currently, there is increasing importance in postoperative period acquires the risk of clostridial and non-clostridial infection (see. Anaerobic infection), in which signs of shock, high body temperature, hyperleukocytosis, hemolysis, increasing jaundice, and subcutaneous crepitus may be detected. At the slightest suspicion of an anaerobic infection, urgent hospitalization is indicated. In the hospital, the wound is immediately opened wide, non-viable tissue is excised, intensive antibiotic therapy is started (penicillin - up to 40,000,000 units or more per day intravenously, metronidazole - 1 G per day, clindamycin intramuscularly 300-600 mg every 6-8 h), carry out serotherapy, carry out hyperbaric oxygen therapy.

Due to inadequate hemostasis during the operation or other reasons, hematomas may occur located under the skin, under the aponeurosis or intermuscularly. Deep hematomas in the retroperitoneal tissue, pelvic and other areas are also possible. In this case, the patient is bothered by pain in the area of ​​the operation, upon examination of which swelling is noted, and after 2-3 days - hemorrhage in the skin around the wound. Small hematomas may not be clinically apparent. When a hematoma appears, the wound is opened, its contents are evacuated, hemostasis is carried out, the wound cavity is treated with antiseptic solutions and the wound is sutured using any measures to prevent possible subsequent suppuration.

Therapy of psychosis consists of treating the underlying disease in combination with the use of antipsychotics (see. Neuroleptic drugs),antidepressants And tranquilizers. The prognosis is almost always favorable, but worsens in cases where states of confusion are replaced by intermediate syndromes.

Due to the exclusion of some parts of the digestive tract from the digestive processes, it is necessary to create a balanced diet, which assumes an average consumption of 80-100 for an adult G squirrel, 80-100 G fat, 400-500 G carbohydrates and the appropriate amount of vitamins, macro- and microelements. Specially developed enteral mixtures (enpits), canned meat and vegetable diets are used.

Enteral nutrition is provided through a nasogastric tube, or a tube inserted through a gastrostomy or jejunostomy. For these purposes, use soft plastic, rubber or silicone tubes with an outer diameter of up to 3-5 mm. The probes have an olive at the end, which facilitates their passage and installation in the initial part of the jejunum. Enteral nutrition can also be provided through a tube that is temporarily inserted into the lumen of an organ (stomach, small intestine) and removed after feeding. Tube feeding can be carried out using the fractional method or drip. The intensity of intake of food mixtures should be determined taking into account the patient’s condition and stool frequency. When performing enteral nutrition through a fistula, in order to avoid regurgitation of the food mass, the probe is inserted into the intestinal lumen at least 40-50 cm using an obturator.

Outpatient management of patients after orthopedic and traumatological operations should be carried out taking into account the postoperative management of patients in the hospital and depends on the nature of the disease or damage to the musculoskeletal system for which surgery was performed, on the method and characteristics of the operation performed in a particular patient. The success of outpatient management of patients depends entirely on the continuity of the treatment process begun in a hospital setting.

After orthopedic and traumatological operations, patients can be discharged from the hospital without external immobilization, in various types of plaster casts (see. Plaster technique), on the limbs can be applied distraction-compression device, patients can use various orthopedic products after surgery (splint-sleeve devices, insoles, arch supports, etc.). In many cases, after operations for diseases and injuries of the lower extremities or pelvis, patients use crutches.

On an outpatient basis, the attending physician should continue to monitor the condition of the postoperative scar so as not to miss superficial or deep suppuration. It may be due to the formation of late hematomas due to unstable fixation of fragments with metal structures (see. Osteosynthesis), loosening of parts of the endoprosthesis when it is not firmly fixed in the bone (see. Endoprosthetics). The causes of late suppuration in the area of ​​the postoperative scar may also be rejection of the allograft due to immunological incompatibility (see. Bone grafting), endogenous infection with damage to the surgical site by hematogenous or lymphogenous route, ligature fistulas. Late suppuration may be accompanied by arterial or venous bleeding caused by purulent melting (arrosion) of the blood vessel, as well as pressure ulcers of the vessel wall under the pressure of a part of a metal structure protruding from the bone during immersion osteosynthesis or a knitting needle of a compression-distraction apparatus. With late suppuration and bleeding, patients require emergency hospitalization.

On an outpatient basis, the rehabilitation treatment started in the hospital continues, which consists of physical therapy for joints free from immobilization (see. Healing Fitness), sub-gypsum and ideomotor gymnastics. The latter consists of contraction and relaxation of the muscles of the limb immobilized with a plaster cast, as well as imaginary movements in joints fixed by external immobilization (flexion, extension) in order to prevent muscle atrophy, improve blood circulation and bone tissue regeneration processes in the area of ​​surgery. Physiotherapeutic treatment continues, aimed at stimulating muscles, improving microcirculation in the surgical area, preventing neurodystrophic syndromes, stimulating the formation of callus, and preventing stiffness in the joints. The complex of rehabilitation treatment in an outpatient setting also includes occupational therapy aimed at restoring movements in the limbs necessary for self-care in everyday life (walking stairs, using public transport), as well as general and professional ability to work. Balneotherapy in postoperative period not usually used, with the exception of hydrokinesitherapy, which is especially effective in restoring movement after joint surgery.

After spinal surgery (without damage to the spinal cord), patients often use semi-rigid or rigid removable corsets. Therefore, in an outpatient setting, it is necessary to monitor the correct use of them and the integrity of the corsets. During sleep and rest, patients should use a hard bed. On an outpatient basis, physical therapy exercises continue, aimed at strengthening the muscles of the back, hand and underwater massage, physiotherapy. Patients must strictly adhere to the orthopedic regimen prescribed in the hospital, which consists of unloading the spine.

After surgery on the bones of the extremities and pelvis, the doctor on an outpatient basis systematically monitors the condition of the patients and the timely removal of the plaster cast, if external immobilization was used after the operation, conducts an X-ray examination of the operation area after removing the plaster, and promptly prescribes the development of joints freed from immobilization. It is also necessary to monitor the condition of metal structures during immersion osteosynthesis, especially with intramedullary or transosseous insertion of a pin or screw, in order to timely detect possible migration, which is detected by X-ray examination. When metal structures migrate with the threat of skin perforation, patients require hospitalization.

If a device for external transosseous osteosynthesis is applied to a limb, the task of the outpatient doctor is to monitor the condition of the skin in the area where the pins are inserted, regular and timely dressings, and monitoring the stable fastening of the device structures. If necessary, additional fastening is performed, individual units of the device are tightened, and if the inflammatory process begins in the area of ​​the spokes, soft tissues are injected with antibiotic solutions. With deep suppuration of soft tissues, patients need to be sent to a hospital to remove the pin in the area of ​​suppuration and insert a new pin into the unaffected area, and, if necessary, reinstall the device. When the bone fragments are completely consolidated after a fracture or orthopedic surgery, the device is removed on an outpatient basis.

After orthopedic and traumatological operations on joints, physical therapy, hydrokinesitherapy, and physiotherapeutic treatment aimed at restoring mobility are carried out on an outpatient basis. When using transarticular osteosynthesis to fix fragments in cases of intra-articular fractures, the fixing pin (or pins), the ends of which are usually located above the skin, are removed. This manipulation is carried out within a time frame determined by the nature of the damage to the joint. After operations on the knee joint, synovitis is often observed (see. Synovial bursae), in connection with which it may be necessary to puncture the joint with evacuation of synovial fluid and administration of medications into the joint according to indications, incl. corticosteroids. When postoperative joint contractures develop, along with local treatment, general therapy is prescribed aimed at preventing scarring, para-articular ossification, normalizing the intra-articular environment, regenerating hyaline cartilage (injections of the vitreous, aloe, FiBS, lidase, rumalon, ingestion of non-steroidal anti-inflammatory drugs - indomethacin, brufen, voltaren, etc.). After removal of plaster immobilization, persistent swelling of the operated limb is often observed as a consequence of post-traumatic or postoperative lymphovenous insufficiency. In order to eliminate edema, they recommend manual massage or using pneumatic massagers of various designs, compression of the limb with an elastic bandage or stocking, and physiotherapeutic treatment aimed at improving venous outflow and lymph circulation.

Outpatient management of patients after urological operations determined by the functional characteristics of organs genitourinary system, the nature of the disease and the type of surgery undergone. Operation for many urological diseases is integral part complex treatment aimed at preventing relapse of the disease and rehabilitation. At the same time, continuity of inpatient and outpatient treatment is important.

To prevent exacerbations of the inflammatory process in the genitourinary system (pyelonephritis, cystitis, prostatitis, epididymo-orchitis, urethritis), continuous sequential use of antibacterial and anti-inflammatory drugs is indicated in accordance with the sensitivity of the microflora to them. The effectiveness of treatment is monitored by regular testing of blood, urine, prostate secretions, and ejaculate culture. If the infection is resistant to antibacterial drugs, multivitamins and nonspecific immunostimulants are used to increase the body's reactivity.

For urolithiasis caused by a violation salt metabolism or a chronic inflammatory process, after removal of stones and restoration of urine passage, correction of metabolic disorders is necessary.

After reconstructive operations on the urinary tract (plasty of the ureteropelvic segment, ureter, bladder and urethra), the main task of the immediate and long-term postoperative period is to create favorable conditions to form an anastomosis. For this purpose, in addition to antibacterial and anti-inflammatory drugs, agents that promote softening and resorption of scar tissue (lidase) and physiotherapy are used. The appearance of clinical signs of impaired urine outflow after reconstructive surgery may indicate the development of a stricture in the anastomotic area. For its timely detection, regular follow-up examinations, including X-ray radiological and ultrasound methods, are necessary. If the degree of narrowing of the urethra is slight, bougienage of the urethra can be performed and the above set of therapeutic measures can be prescribed. If the patient has chronic renal failure in the distant postoperative period it is necessary to monitor its course and treatment results through regular examination of biochemical blood parameters, drug correction of hyperazotemia and water-electrolyte disorders.

After palliative surgery and ensuring the outflow of urine through drainages (nephrostomy, pyelostomy, ureterostomy, cystostomy, urethral catheter), it is necessary to carefully monitor their function. Regular change of drains and washing of the drained organ with antiseptic solutions are important factors in the prevention of inflammatory complications in the genitourinary system.

Outpatient management of patients after gynecological and obstetric operations determined by character gynecological pathology, volume of the operation performed, features of the course postoperative period and its complications, concomitant extragenital diseases. A set of rehabilitation measures is carried out, the duration of which depends on the speed of restoration of functions (menstrual, reproductive), complete stabilization of the general condition and gynecological status. Along with general restorative treatment (vitamin therapy, etc.), physiotherapy is carried out, which takes into account the nature of the gynecological disease. After surgery for tubal pregnancy, medicinal hydrotubation is performed (penicillin 300,000 - 500,000 units, hydrocortisone hemisuccinate 0.025 G, lidase 64 UE in 50 ml 0.25% novocaine solution) in combination with ultrasound therapy, vibration massage, zinc electrophoresis, and then resort treatment is prescribed. To prevent adhesions after surgery for inflammatory formations, zinc electrophoresis and low-frequency magnetic therapy are indicated (50 Hz). To prevent relapse of endometriosis, electrophoresis of zinc and iodine is performed, sinusoidal modulating currents, and pulsed ultrasound irradiation are prescribed. Procedures are prescribed after 1-2 days. After operations on the uterine appendages for inflammatory formations, ectopic pregnancy, benign formations ovary, after organ-preserving operations on the uterus and supravaginal amputation of the uterus due to fibroids, patients remain disabled for an average of 30-40 days, after hysterectomy - 40-60 days. Then they carry out an examination of their ability to work and give recommendations, if necessary, to exclude contact with occupational hazards (vibration, exposure to chemicals, etc.). Patients remain on dispensary registration for 1-2 years or more.

Outpatient treatment after obstetric surgery depends on the nature of the obstetric pathology that caused surgical delivery. After vaginal and abdominal operations (obstetric forceps, fetal destruction operations, manual examination of the uterine cavity, cesarean section), postpartum women receive maternity leave of 70 days. An examination in the antenatal clinic is carried out immediately after discharge from the hospital; in the future, the frequency of examinations depends on the particular course of the postoperative (postpartum) period. Before being removed from the pregnancy dispensary (i.e. by the 70th day), a vaginal examination is performed. If the reason for operative delivery is extragenital pathology, an examination by a therapist, and, if indicated, by other specialists, and a clinical and laboratory examination are required. Perform a complex of rehabilitation measures, which includes general strengthening procedures, physiotherapy, taking into account the nature of somatic and obstetric pathology, the characteristics of the course postoperative period. For purulent-inflammatory complications, zinc electrophoresis with low-frequency diadynamic currents and pulsed ultrasound are prescribed; For postpartum women who have suffered toxicosis of pregnant women with concomitant kidney pathology, microwave therapy with effects on the kidney area, galvanization of the collar zone according to Shcherbak, and pulsed ultrasound are indicated. Since ovulation is possible even during lactation 2-3 months after birth, contraception is mandatory.

Bibliography: Antelava D.N., Pivovarov N.N. and Safoyan A.A. Primary retinal detachment, p. 121, Tbilisi, 1986; Bodyazhina V.I. Obstetric care in antenatal clinic, p. 159, M., 1987; Varshavsky S.T. Outpatient urology, Tashkent, 1987; Vikhlyaeva E.M. and Vasilevskaya L.N. Uterine fibroids, M., 1981; Valin E., Westermarck L. and Van der Vliet A. Intensive care, trans. from English, M., 1978, bibliogr.; Gryaznova I.M. Ectopic pregnancy, With. 118, M., 1980; Kaplan A.V. Damage to bones and joints, p. 53, M., 1979; Karpov V.A. Therapy of nervous diseases, p. 218, M., 1987; Kurbangaleev S.M. Purulent infection in surgery, p. 171, M., 1985; Makarenko T.P., Kharitonov L.G. and Bogdanov A.V. Management of general surgical patients in the postoperative period, M., 1989, bibliogr.; Malyshev V.D. Intensive therapy of acute water and electrolyte disturbances, p. 181, M., 1985; Pytel Yu.A. and Zolotarev I.I. Emergency urology, M., 1986; Wounds and wound infection, ed. M.I. Kuzina and B.M. Kostyuchenok, M., 1981; Guide to eye surgery, ed. L.M. Krasnova, M., 1976; Guide to neurotraumatology, ed. A.I. Arutyunova, parts 1-2, M., 1978-1979; Sokov L.P. Course of traumatology and orthopedics, p. 18, M., 1985; Strugatsky V.M. Physical factors in obstetrics and gynecology, p. 190, M., 1981; Tkachenko S.S. Osteosynthesis, p. 17, L., 1987; Hartig V. Modern infusion therapy, trans. from English, M., 1982; Shmeleva V.V. Cataract, M., 1981; Yumashev G.S. Traumatology and orthopedics, p. 127, M., 1983.

POSTOPERATIVE PERIOD- the period from the end of the operation to the restoration of the patient’s ability to work, during which a set of measures is carried out aimed at preventing and treating complications, as well as promoting the processes of reparation and adaptation of the body to the anatomical and physiological relationships created by the operation.

There are immediate and distant P. p. Nearest P. p. begins from the end of the operation and continues until the patient is discharged from treatment. institutions. The long-term postoperative period occurs outside the hospital and is used for the final elimination of general and local disorders caused by surgical trauma (see Rehabilitation).

In the near future, the most responsible period is the early period, i.e., the first 2-3 days. At this time, those changes in the activity of organs and systems that are a direct consequence of surgical trauma and pain relief are most pronounced. Early P. depends on the characteristics of the pathol, the process for which the operation was performed, the condition of the patient before the operation, concomitant diseases, the age of the patient, the volume and nature of the surgical intervention, complications that may occur during the operation, the course of anesthesia and etc.

After lengthy and traumatic operations, for example, on the thoracic and abdominal organs, on the head and spinal cord As a rule, patients in early P. are in the intensive care unit (Fig. 1 and color Fig. 4-9) or in specially designated postoperative wards on the territory of the surgical department. Monitoring and monitoring of patients is carried out by specially trained medical personnel, if available, with the help of monitor and monitor-computer systems (Fig. 2), recording basic physiol, body parameters (see Monitoring). If necessary, special studies are performed - catheterization of the heart and monitoring the pressure in its cavities, echocardiography (see), radiopaque, endoscopic, radioisotope studies (see Radioisotope study), etc.

The main goals of therapy in early P. p. are: maintaining cardiac activity and systemic circulation, functions external respiration, fight against hypovolemia, hypoxia, water disorders electrolyte balance, metabolism and acid-base balance, which is especially important after traumatic, extensive operations.

Based on the nature of the course, a distinction is made between uncomplicated and complicated postoperative periods.

Uncomplicated postoperative period characterized moderate impairments biol, balance in the body and mildly expressed reactive processes in the surgical wound. In the process of normalizing metabolism in P., 4 phases can be distinguished: catabolic, transitional, anabolic, and the phase of increasing body weight (mass). Immediately after the operation, due to an increase in the intensity of metabolic processes, the body's need for energy and plastic material increases; in conditions of limited supply of nutrients, it is provided mainly by the internal reserves of the body by stimulating catabolic processes with appropriate hormones (catecholamines, glucocorticoids). As a result, the excretion of nitrogenous wastes in the urine increases, a negative nitrogen balance occurs, dysproteinemia is observed, an increase in the concentration of free fatty acids in the blood, etc. Impaired carbohydrate metabolism is manifested by postoperative hyperglycemia due to increased formation of glucose from glycogen and increased gluconeogenesis. V. A. Oppel called this condition “minor surgical diabetes.” Hyperkalemia (see) resulting from hyperfunction of the adrenal glands and increased breakdown of proteins causes the development of postoperative acidosis (see). Already in the near future after the operation, there is a shift in the acid-base balance (see) towards metabolic alkalosis (see) due to hypovolemia, hypochloremia and hypokalemia (see). This phase is characterized by the patient's weight loss. During the transition phase, a balance occurs between the processes of breakdown and synthesis, and adrenal hyperfunction decreases. Entry into the body increased amounts nutrients creates conditions for the onset of the anabolic phase, characterized by the predominance of synthesis processes under the influence of hypersecretion of anabolic hormones (insulin, androgens, growth hormone). This phase continues until the body completely restores the pool of structural proteins and carbohydrate-fat reserves, after which the phase of increasing the patient’s weight begins.

In the first days, the patient is bothered by pain in the wound, general weakness, lack of appetite, and thirst. The temperature is within 37-38°C, there is moderate leukocytosis in the blood (9000 - 12,000) with a shift in the leukocyte formula to the left. Sometimes there is flatulence, difficulty urinating, associated with a forced position in bed or of reflex origin.

The patient's regimen depends on the nature of the surgical intervention. As a rule, bed rest is indicated for 2-4 days. In cases where the activation of patients for one reason or another is delayed, a measure to prevent postoperative complications is to treat. physical training.

Features of nutrition in P. items largely depend on the specific nature of the operation, the patient’s condition, etc. Feeding after operations that are not accompanied by opening of the lumen of the gastrointestinal tract. tract, usually begin on the 2nd day with small portions of liquid food. From the 5th-6th day, patients are gradually transferred to a general diet. Typically, the surgical wound is examined the day after surgery. When it heals by primary intention, the sutures on the neck can be removed on the 5th day, in other areas - on the 6-8th day. In weakened and cancer patients, the sutures are removed later, on the 11th -16th day.

With an uncomplicated course of P. p. general care(see) caring for the patient is reduced to turning him several times a day, straightening the folds in the linen, wiping the body camphor alcohol twice a day, performing passive movements in all joints, rinsing the mouth with sodium bicarbonate solution or furatsilin. According to indications, a general massage is performed. To prevent mumps, chewing gum and sucking lemon are recommended; to prevent pulmonary complications, activating the patient, exercise therapy, massage, and mustard plasters.

When the course of P. is smooth, cardiac medications, respiratory analeptics, and painkillers are prescribed. For pain relief in P., the DPA method has proven itself well - long-term epidural anesthesia (see Local anesthesia), which consists of introducing local anesthetic drugs (trimecaine, dicaine) into the epidural space. DPA interrupts the flow of patol, impulses from the operated organs, relieves pain sensitivity without inhibiting the cough reflex, and helps restore gastrointestinal motility. tract. To relieve pain after surgery, inhalation of oxygen with nitrous oxide using an intermittent flow apparatus is also used (see Inhalation anesthesia).

In order to correct the acid-base balance and conduct detoxification therapy, especially after major traumatic surgical interventions, intravenous infusions of solutions of glucose, electrolytes, blood substitute fluids, etc. are carried out in the P. point under constant laboratory control (see Infusion therapy ).

In P., physical therapy is widely used; it helps to normalize impaired body functions, primarily due to the general tonic effect of physical exercise. Breathing exercises improve ventilation of the lungs and reduce congestion in them, and reduce nausea. Movements in the hip joints stimulate intestinal motility and promote the release of gases. Peripheral blood circulation is improved due to movements in small joints. The use of physical exercise is a prevention of vein thrombosis, and also helps to accelerate the healing process of postoperative wounds, prevents the formation of adhesions, prepares the patient for full-fledged household and labor activity. The exercise therapy technique is based on the characteristics of the surgical intervention, the age and condition of the patient. If there are no contraindications (they can only be determined by the surgeon), treat. gymnastics is prescribed after thoracic operations within a few hours and the next day after abdominal operations. The exercise therapy technique includes 3 periods: early (before removal of sutures), late (before discharge from the hospital) and long-term (before restoration of working capacity).

In the first period, in the first three days, exercises are performed at a slow pace for all joints of the limbs. After abdominal surgery, the load on the muscles is limited abdominals. Light massage chest from the back helps eliminate stagnation, activation of blood and lymph circulation, improvement of breathing. Leg movements should be performed with incomplete amplitude, without lifting the feet from the bed (exercises in small joints are repeated 5-8 times, in medium and large joints 4-6, taking into account the body’s reaction). After operations on the chest organs, movement in the shoulder joint on the side of the operation is limited. Starting positions - lying on your back and on your side. Gradually, the total load is increased by performing new exercises. The duration of the lesson in the first period is 10-15 minutes. In the second period, exercises are carried out for everyone muscle groups, the amplitude of movements is gradually increased and brought to full. After operations on the abdominal organs, first of all, attention is paid to strengthening the abdominal muscles, after operations on the chest organs - to strengthening the muscles of the torso and restoring mobility in the shoulder joint on the operated side. Classes can be conducted in a physical therapy room, using exercises with objects (gymnastic sticks, dumbbells, etc.), on equipment (gymnastic wall, bench, etc.), as well as various types of walking. Each exercise is repeated 10-12 times, the duration of the session is 20-25 minutes. In the third period, general developmental exercises are introduced for all muscle groups. The intensity of the load increases even more, the duration of the lesson is 30-40 minutes. Along with the lesson, treat. Gymnastics includes measured walking (from 500 m to 2-3 km), as well as skiing, swimming, rowing, etc.

Physiotherapy is of great importance in P. p. In the first three days after surgery to reduce pain and to prevent the development of edema and hematoma, local hypothermia is prescribed for 20-30 minutes. with a break of 1-2 hours, 5 procedures. To activate mineral metabolism, increasing immunobiological processes in the normal course of P. p., after 7-10 days, general UV irradiation (see Ultraviolet radiation) is indicated according to an accelerated scheme in combination with calcium electrophoresis on the collar area. With the development of atonic intestinal paresis, electrical stimulation of the intestinal muscles is carried out (see Electrical stimulation) or the area of ​​the celiac plexus is affected by pulsed currents (see), ultrasound, microwaves. Urinary retention is an indication for high-frequency therapy (inductothermy, UHF therapy, microwaves, UV irradiation and paraffin applications to the bladder area.

The course of uncomplicated P. p. is characterized by a gradual and daily improvement in the patient’s condition. In cases where this process is delayed, one should first of all suspect the occurrence of certain complications.

Complicated postoperative period. Complications can occur after any operation, but more often they develop after major traumatic surgical interventions on organs chest cavity(lung resection, extirpation of the esophagus, etc.), and abdominal (gastrectomy, pancreaticoduodenectomy, resection of the stomach, liver, reconstructive operations on the gastrointestinal tract and biliary tract, etc.).

In the first hours or days after surgery, bleeding may occur (see), associated with insufficient hemostasis during surgery or due to the ligature slipping from a blood vessel. Particularly dangerous internal bleeding. At a later date, arrosive bleeding is possible, associated with the melting of the vessel wall by a purulent process.

Blood loss, as well as inadequate pain relief, contribute to the development of postoperative shock (see). The leading links in the pathogenesis of this complication are disorders of microcirculation in tissues and cell metabolism. If signs of shock appear (pallor of the skin, a grayish tint, cyanosis of the nails and lips, low rapid pulse, low blood pressure), the patient must be given absolute rest and warmed with heating pads; Intravenous and intra-arterial transfusion of blood and blood-substituting fluids, administration of hormones, vitamins, cardiac and analgesics, oxygen therapy are indicated.

Complications from the respiratory system include pulmonary atelectasis (see Atelectasis) and pneumonia (see Pneumonia). More often they occur after operations on the lungs, less often during surgical interventions on the abdominal organs; are usually detected on the 3-4th day after surgery. According to N. S. Molchanov (1971), atelectatic, aspiration, hypostatic, infectious and intercurrent pneumonia are observed in P. p. The severity of the course and prognosis of pneumonia depend on the extent of the lesion (unilateral or bilateral), the nature of the pneumonia (focal, confluent or abscess); it may also develop in the only lung present. In the wedge, the picture of postoperative pneumonia and atelectasis is dominated by symptoms of respiratory failure (see), expressed to varying degrees. The decisive factor in making a diagnosis is rentgenol, research. Treatment is complex - antibiotics, sulfonamides, oxygen therapy, etc. The use of sanitation bronchoscopy is effective (see).

Prevention of pulmonary complications - breathing exercises, early activation of the patient, cupping, mustard plasters. Complications from the larynx and trachea most often develop after intubation anesthesia. In these cases, UHF therapy (see), microwave therapy (see), as well as UV irradiation of the larynx, trachea and collar area are used.

Intestinal paresis is often observed. The most significant in the etiology and pathogenesis of the paretic state is considered to be a violation of the activity of the. n. p., innervating the intestines, disturbance of acetylcholine metabolism with inhibition of cholinergic systems, irritation of mechano- and chemoreceptors of the intestinal wall during its overstretching, deficiency of adrenal hormones, disorders of water-electrolyte (hypokalemia) and protein metabolism, etc. Treatment and prevention of paresis intestines are carried out taking into account all these pathogenetic mechanisms (see below).

A dangerous complication is hepatic-renal failure (see Hepato-renal syndrome), in the development of which the initial state of the liver plays a significant role. Most often it occurs in patients operated on for obstructive jaundice caused by cholelithiasis, cancer of the pancreaticoduodenal zone, cirrhosis of the liver, and less often - other diseases. Most early symptoms hepatic-renal failure- jaundice, tachycardia, hypotension and oliguria. Flatulence, partial retention of stool and gases, nausea, vomiting, regurgitation, and accumulation of large amounts of fluid in the stomach are observed. Brown, apathy, drowsiness, lethargy, confusion, delirium, motor agitation, euphoria, etc. Possible hemorrhagic diathesis in the form of subcutaneous hemorrhages, nosebleeds, bleeding gums, etc. The level of bilirubin, ammonia in the blood increases, residual nitrogen with a relatively low urea content. Treatment of hepatic-renal failure is complex: infusions of solutions of glucose, glutamate, calcium supplements, sodium bicarbonate, cocarboxylase, vitamins B6, B15, corticosteroids. In severe condition of the patient, hyperbaric oxygenation, hemodialysis, hemosorption, intraportal administration of drugs and oxygenated blood, including with the help of an arterioportal shunt, are indicated. To prevent hepatic-renal failure, the method of forced diuresis using Lasix and mannitol is used with adequate administration of fluids and salts.

Thrombosis is a serious complication of P. p. (see Thrombosis). The most common clinical occurrence is thrombosis of the veins of the extremities (see Thrombophlebitis), the main symptoms of which are pain along the veins, swelling of the limb and increased venous pattern. A special form of thrombotic complications in P. p. is thromboembolism of the pulmonary trunk and pulmonary arteries (see Pulmonary trunk, Embolism pulmonary artery). The leading cause of thrombus formation is a violation of the blood coagulation system (see), manifested in hypercoagulation. This is facilitated by the surgical trauma itself, when the cut changes hemostasis as a result of a violation vascular wall, blood loss, hypoxia, shifts in water-electrolyte balance, reaction of the sympathetic-adrenal system, thromboplastin release. Long-term bed rest in P. also contributes to thrombus formation. According to most scientists, hypercoagulation persists until 5-6 days after surgery and this period is considered the most thrombotic. There is also a point of view that, regardless of the type of surgical intervention, in the first 3-5 days. There is some activation of anticoagulant factors and inhibition of coagulation factors, and then the opposite phenomenon is observed. Assessing the blood coagulation system in terms of thrombus formation is difficult, because according to the coagulogram data (see), one can judge its condition only at the time of registration. Coagulogram indicators may change during pain relief, surgery, etc. However, studying a series of coagulograms before, during and after surgery, taking into account previous thrombophlebitis, inflammatory processes in the pelvis, the presence varicose veins veins of the lower extremities, disorders fat metabolism, concomitant cardiovascular diseases, age (over 50 years) helps to identify thrombotic patients for appropriate treatment. events. There are specific and nonspecific prevention of thrombosis. Specific prevention includes anticoagulant therapy (see Anticoagulants) - the use of direct-acting anticoagulants (heparin) and indirect action (neodicoumarin, phenylene, syncumar, etc.). Nonspecific prevention consists of daily massage, breathing exercises, elastic bandaging of the lower extremities, and early activation of the patient. The issue of preventing thrombosis is very complex and has not been completely resolved. Most researchers believe that anticoagulant prophylaxis should begin on the 1st - 2nd day after surgery; There is an opinion that from the 3-4th day.

Occasionally, in early P., hyperthermic syndrome develops (see), associated with toxic cerebral edema. Diagnosis usually does not cause difficulties. Treatment is craniocerebral hypothermia (see Artificial Hypothermia), spinal punctures, administration of amidopyrine. aminazine, pipolfen.

When a hematoma or inflammatory infiltrate forms in the p.p., UHF therapy is prescribed, which promotes the resorption of blood residues and reduces the likelihood of spread purulent inflammation. If the infiltrate does not resolve for a long time. Along with thermal effects, electrophoresis of iodine, dionine, and lidase is carried out. Ultrasound therapy provides a good absorption effect (see). Sometimes suppuration of the surgical wound occurs. In these cases, it is necessary to remove the stitches. separate the edges of the wound and drain it well. Irradiation of the surgical wound with short UV rays (3-5 times) also helps to clean the surgical wound. Further treatment carried out on the principle of treating purulent wounds (see Wounds, wounds).

The most formidable of inf. complications in P. p. is sepsis (see). More often it develops in emergency operated patients with acute diseases of the abdominal organs against the background of peritonitis or in case of failure of anastomotic sutures. It may develop after operations performed for purulent-inflammatory diseases (osteomyelitis, abscess, phlegmon). Treatment consists of eliminating the infectious focus, carrying out anti-inflammatory therapy, etc.

In complicated P., there is a disruption in the process of normalizing metabolism, which manifests itself in a prolongation of the catabolic phase, which can lead to exhaustion of the body and a slowdown in healing processes; Losing more than 40% of body weight is life-threatening. With prophylactic and treatment. The goal is vitamin therapy, providing the body with a sufficient amount of proteins, fats and carbohydrates, and in some cases, the use of anabolic hormones.

Postoperative psychoses - a type of acute symptomatic psychoses - usually develop in the nearest P. p. The classic description of the symptoms of postoperative psychoses belongs to S.S. Korsakov, Kleist (K. Kleist). Acute mental disorders occur in 0.2-1.6% of patients who have undergone abdominal surgery. They develop on days 2-9 after surgery and last from several hours to 2 weeks. The stereotype of the development of postoperative psychoses can be presented as follows: surgery - somatogenic asthenia - exogenous type of reaction (see Bongeffer exogenous types of reaction, vol. 10, additional materials); Sometimes the so-called occurrence may occur. transitional syndromes (see Symptomatic psychoses). Against the background of severe physical and mental asthenia with a predominance of symptoms of irritable weakness, syndromes of impaired consciousness most often develop such as delirium (see Delirious syndrome), often hypnagogic oneiroid (see Oneiroid syndrome), amentia (see Amentive syndrome), stunning (see .), less often twilight stupefaction (see); amnestic disorders, as well as convulsive syndrome, are possible. Relatively infrequently, the exogenous type of reactions is replaced by such transitional syndromes as hallucinatory-paranoid (see Paranoid syndrome), depressive (see Depressive syndromes), manic (see Manic syndromes), disorders in the form of derealization phenomena, disorders of already seen and never seen , as well as body schema disorders. The frequency of occurrence and characteristics of the wedge, the picture of acute mental disorders depend on the nature of the somatic disease and on which organ the operation was performed on. After heart surgery, mental disorders occur 2 times more often than during other abdominal surgical interventions, and develop, as a rule, in the form of an anxiety-depressive state; Cardiophobic phenomena, vital fear, derealization disorders, auditory hallucinations are typical; Syndromes of impaired consciousness are observed less frequently - Delirious, Oneiric, amentive. Mental disorders are accompanied by transient neurol symptoms. After operations on went.-intestinal. tract, acute paranoid occurs more often, and syndromes of impaired consciousness occur less frequently. After kidney transplantation in early P., delirious syndrome with a predominance of hypnagogic delirium may develop. Due to the lack of expression of psychomotor agitation, psychosis may remain unrecognized. The exception is delirious episodes with euphoria and significant psychomotor agitation against the background of polyuria (in the first days of transplant functioning). Short-term derealization disorders are also possible. Against the background of massive hormonal therapy used during transplantation for the purpose of immunosuppression, catatonic-oneiric and affective disorders sometimes develop. Against the background of crises of rejection, a state close to anxious-melancholy with vital fear, epileptiform seizures, is observed. Gynecological operations, in particular hysterectomy, are sometimes accompanied by psychogenic depression with suicidal thoughts. Clinically similar depressive psychoses of a psychogenic nature with melancholy, thoughts about the great severity of the disease, or depressive-paranoid phenomena with ideas about relationships can occur after operations for a malignant neoplasm of the larynx, after amputations of the mammary gland, limbs and other operations associated with serious cosmetic defects. Postoperative psychoses should be differentiated from exacerbations or manifestations of endogenous psychoses, alcoholic delirium (see Alcoholic psychoses, Manic-depressive psychosis, Schizophrenia). Both somatogenic and psychogenic factors are involved in the etiology of mental disorders after surgery. In the pathogenesis of mental disorders, the leading place is occupied by factors of toxicosis, hypoxia, allergic sensitization, shifts in ionic equilibrium, endocrine changes, patol. Interoception from injured organs and tissues. An important role belongs to the nature of the pathol, the process as a whole, the state of the compensatory capabilities of the brain, as well as premorbid personality characteristics. Due to the possibility of destructive tendencies and suicidal actions caused by psychosis, strict supervision of patients is necessary, which requires training of nursing staff. For the treatment of postoperative psychoses, according to indications, antipsychotics and tranquilizers can be used in combination with intensive therapy of the underlying pathology. Postoperative psychosis usually ends with complete mental recovery. Prognostically unfavorable is the change from delirium or oneiroid to amentive syndrome or its primary development.

Features of the postoperative period depending on the nature of the surgical intervention

Operations on the abdominal organs. P. p. after operations on the abdominal organs has three characteristic features: frequent development of bronchopulmonary complications, the need for parenteral nutrition, as well as paresis of the gastrointestinal tract. tract, which usually develops to one degree or another in almost all patients. Bronchopulmonary complications are caused by hypoventilation of the lungs due to restriction diaphragmatic breathing against the background of postoperative pain, flatulence, localization of the operation in the upper abdomen. Prevention of bronchopulmonary complications and their treatment - see above.

In cases where there is a violation of the motor-evacuation function of the gastrointestinal tract. tract is diagnosed before or during surgery, they resort to temporary gastrostomy on a Foley catheter (see Stomach, operations) or to various options intestinal intubation (see). Normalization of the motor-evacuation function of the intestines is also facilitated by early intake of liquid and food through the mouth, early getting up and exercise therapy, refusal of long-term use of drugs that slow down the passage of food masses through the gastrointestinal tract. tract.

After operations on the stomach, duodenum and small intestine, the first 2 days. the patient is on parenteral nutrition. On the 3rd day you are allowed to drink up to 500 ml of liquid (water, tea, fruit juices, broth and jelly). In the absence of stagnation in the stomach, from the 4th day, diet No. 1A is prescribed, excluding substances that are strong pathogens secretions, as well as mechanical, chemical and thermal substances that irritate the gastric mucosa (food is given only in liquid and mushy form). From the 7-8th day - diet “N” 1 or No. 5 (mechanically and chemically gentle diet): food is given in liquid and mushy form, denser food is given in boiled and finely pureed form (see Medical nutrition). In the first two to three days after surgery, gastric contents are aspirated through a tube 2 times a day; in subsequent days, gastric intubation is continued as indicated. Sitting and walking are allowed from 2-3 days. Sutures are removed on the 7-8th day, and in weakened patients - on the 12-14th day. Patients are discharged from the surgical department on the 8-15th day.

After operations on the gall bladder - cholecystectomy (see), cholecystostomy (see) - diet No. 5A is prescribed from the 2nd day. After creating biliodigestive anastomoses, the nutritional system is the same as after operations on the stomach and duodenum. If the course of P. p. is smooth, drainage from the abdominal cavity is removed on the 3rd day, tampons - on the 4th day, drainage from the common bile duct if its distal section is patency - on the 15-20th day. Sitting and standing are allowed after cessation of abdominal drainage. Depending on the nature of the surgical intervention, patients are discharged on the 10-25th day.

After operations on the large intestine (see Intestines), accompanied by the creation of a colon intestinal anastomosis, from the 2nd day a zero table is prescribed (the most gentle diet with the inclusion of easily digestible foods), fluid intake, as a rule, is not limited. From the 5th day, they are transferred to diet No. 1. From the 2nd day, for 5 days, the patient drinks 30 ml of Vaseline oil 3 times a day. Enemas are usually not prescribed. Management of patients with colostomies is carried out in the same way as after resection of the colon. If colostomy (see) is performed on an emergency basis, the intestine is opened as late as possible, when adhesions have formed between the removed intestine and the parietal peritoneum. In case of severe symptoms of intestinal obstruction (see), the removed intestine should be punctured with a thick needle or its lumen should be opened with an electric knife for 1 - 1.5 cm. In the absence of phenomena of increasing intestinal obstruction, the intestine is opened on the 2-4th day after the operation. Patients are discharged after colon surgery on days 12-20.

The most severe complication after operations on the abdominal organs is the failure of sutures placed on the wall of the stomach or intestines, and anastomoses between different parts of the gastrointestinal tract. tract. More often, failure of the esophageal and esophageal-gastric anastomoses is observed, less often of the gastrointestinal and colonic anastomoses; after resection of the stomach, failure of the sutures of the duodenal stump is observed.

Wedge, the picture of suture failure is different. Sometimes it manifests itself on the 5th-7th day with a sudden onset, accompanied by sharp pain in the abdomen, muscle tension in the anterior abdominal wall, symptoms of peritoneal irritation, collapsing condition. More often, starting from 3-4 days, they appear dull pain in the abdomen, usually without clear localization, the temperature rises to 38-39°, persistent paresis of the gastrointestinal tract. tract does not respond to conservative measures, symptoms of peritoneal irritation gradually increase. For the purpose of diagnosing insufficiency of sutures, rentgenol, a study with contrasting went.-intestinal. tract. In doubtful cases, a “groping” catheter is used, which is inserted into the abdominal cavity after removing one or two sutures from the surgical wound, as well as laparoscopy (see Peritoneoscopy). Treatment for failed sutures is surgical. Application of additional sutures to the area of ​​the defect in the wall of a hollow organ or anastomosis, even with peritonization of the suture line by a strand greater omentum, not always effective. Often re-applied sutures are cut through. In this regard, if the sutures on the small and large intestine fail, it is advisable to remove the corresponding section of the intestine to the abdominal wall; in other cases, one has to limit oneself to drainage of the abdominal cavity (see Drainage) and parenteral nutrition.

Insufficiency of sutures is the most common cause of postoperative peritonitis (see). Due to widespread use antibiotics wedge, the picture of postoperative peritonitis has changed. According to I. A. Petukhov (1980), postoperative peritonitis can be sluggish, atypical, with a blurred wedge, picture, and acute, reminiscent of perforation of hollow organs.

Early symptoms of peritonitis are a frequent small soft pulse that does not correspond to the temperature and general condition of the patient, increasing intestinal paresis, abdominal pain, tension in the muscles of the abdominal wall, agitation, anxiety, euphoria or, conversely, depression, insomnia, increasing dry mouth, thirst, hiccups , nausea and vomiting. Treatment is early relaparotomy, elimination of the source of infection, sanitation of the abdominal cavity and intestinal decompression.

In P. p. after intra-abdominal operations, especially on the stomach, pancreas and biliary tract, may develop acute pancreatitis(cm.). Its main causes are direct trauma to the pancreas during the intervention and impaired outflow from the bile ducts and pancreatic ducts. Typically, postoperative pancreatitis appears on the 3-4th day after surgery. Diagnosis of pancreatitis in P. p. is difficult, because it often develops against the background of a severe postoperative course and has an erased wedge picture. In these cases, dynamic monitoring of amylase levels in the blood and urine is important. Treatment of pancreatitis in P. p. is usually conservative: cytostatic and antienzyme drugs, novocaine blockades, forced diuresis, local hypothermia, antibiotics, etc. If signs of peritonitis or abscess formation appear, surgery is indicated; the purpose of the cut is to remove sequestered areas of the gland, local administration of enzyme inhibitors, drainage of the omental bursa and abdominal cavity.

A serious complication of P. p. is mechanical intestinal obstruction (see), the cause of the cut is most often adhesive process due to traumatization of the serous cover of the gastrointestinal tract. tract during surgery and restriction of intestinal mobility in places of damage. Early diagnosis presents significant difficulties, since the initial symptoms of mechanical intestinal obstruction and postoperative paresis of the gastrointestinal tract. tracts are very similar. However, persistent gas retention, bloating, rumbling in the intestines, cramping pain, etc. should alert the doctor. An increase in wedge, and rentgenol, signs of intestinal obstruction is an indication for relaparotomy. The operation is reduced to eliminating the obstruction and decompressing the stomach and intestines.

Features of the postoperative period in gynecological practice - see Caesarean section, Hysterectomy, Care for gynecological patients.

Orthopedic and traumatological operations. Many modern orthopedic and traumatological operations are a difficult intervention for the patient; they are accompanied by large blood loss and the need to immobilize bone fragments for long periods. Large blood loss is due to the fact that hemostasis in bone tissue is difficult, and the surgical wound is usually a large wound surface. Therefore, bleeding after surgery may continue long time. In P. p., the main task is to compensate for blood loss and normalize homeostasis (see Blood loss). Immobilization after orthopedic and traumatological operations is carried out using internal or external devices, including pins, plates (see Osteosynthesis), distraction-compression devices (see), plaster casts (see Plaster technique), etc. After osteoplastic operations (see Bone grafting), as a rule, relatively long-term immobilization is necessary for adaptation and reconstruction of bone grafts. Regardless of the method of immobilization, the patient must be in a forced position for some time (on his stomach, on his back, on his side or in another special position). After joint replacement (see Endoprosthetics), immobilization lasts minimum terms(1 - 2 weeks) or is completely absent, which is associated with the need for early movements of the operated limb.

In P., due to prolonged immobilization of bones and joints, contractures and stiffness can often develop. To prevent these complications, as well as to restore the functions of the musculoskeletal system, treatment is used. physical education. In the method of its application, two periods are distinguished - the period of immobilization of the damaged organ and the period after removal of the plaster cast. In the first period to lay down. gymnastics is prescribed for joints free from immobilization. After removing the plaster cast, restoration of the function of the affected organ begins. In some cases, special devices are used for this (see Mechanotherapy).

Neurosurgical operations. Uncomplicated P. p. is characterized by a gradual restoration of impaired brain functions caused by the main process. The criterion for assessing the patient's condition is his level of consciousness. If consciousness is not restored within several hours after the operation, one must think about a complication.

The nature of complications after craniocerebral operations is associated with disruption of the regulatory functions of the brain due to surgical trauma and additional, sometimes irreversible changes in its tissue. This is primarily manifested by dysfunction nerve cells and metabolic processes in them, damage to the blood-brain barrier (see), impaired cerebral circulation and liquor circulation processes. Symptoms of disturbances in the functioning of the cardiovascular system and respiration, water and electrolyte metabolism, functions of the pelvic organs and the musculoskeletal system are often observed.

Considering general state the patient, his level of consciousness, motor and mental activity, neurol, status, affective-emotional reactions, two states are distinguished: one is characterized by an excessive decrease in general activity, the other by its increase. Each of these conditions requires fundamentally various therapies, aimed either at activating and stimulating the cortical-subcortical-stem structures of the brain, or at reducing the overall level of its functioning sedatives or therapeutic and protective anesthesia. There are transitional options, in which the main areas of intensive care are combined.

Vascular therapy is aimed at normalizing vascular tone, vascular wall permeability, rheological properties of blood, microcirculation and includes the administration of vasoactive agents (sermion, etc.) and low molecular weight dextrans (reopolyglucin). Treatment measures aimed at normalizing liquor circulation depend on the nature of its violation. At intracranial hypertension resulting from an increase in the volume of one of the components of the contents of the skull (cerebrospinal fluid, blood or tissue fluid), the following treatment methods are used: to reduce the volume of cerebrospinal fluid - lumbar or ventricular drainage, carbonic anhydrase inhibitors, cardiac glycosides; to reduce blood volume - breathing exercises, massage, hyperventilation using artificial lung ventilation (ALV), hyperoxgenation, hypothermia; to reduce the excess volume of tissue water - glucocorticoid hormones, osmodiuretics, saluretics (see Hypertensive syndrome). For intracranial hypotension, medications are administered that stimulate cerebrospinal fluid production - caffeine, piracetam (nootropil), and improve microcirculation (see Hypotensive syndrome). To maintain respiratory function, oxygen therapy is used (see Oxygen therapy), and according to indications, mechanical ventilation. If mechanical ventilation continues for more than 2-3 days, tracheostomy is indicated (see). It should be performed as early as possible in patients who are in comatose, even with adequate breathing, as well as in the case of complete paralysis of the muscles of the pharynx and larynx.

Most typical complications: hematoma (see), ischemic hypoxia of the brain, sometimes caused by forced clipping of the great vessels during surgery, dislocation and herniation, cerebral edema. To eliminate them, methods of specific, pathogenetic therapy are used.

Surgeries on the spinal cord, depending on the level of its damage, are accompanied by varying degrees of respiratory and pelvic organ dysfunction. In case of uncomplicated P., treatment is reduced to reducing pain; in case of urinary retention, catheterization of the bladder. Complications include the development of respiratory failure, trophic disorders, infectious and inflammatory processes - pyelocystitis (see Pyelonephritis), infected bedsores (see).

After operations on peripheral nerves carry out therapy that improves nerve fiber trophism, eliminates swelling and inflammation.

Operations on the organ of vision. After abdominal operations on the eyeball (antiglaucomatous operations, cataract extraction, cataract extraction with implantation of an artificial lens, corneal transplantation, etc.), patients, as a rule, within 10-12 hours. After the operation they are on bed rest. You are allowed to get up and walk from the next day. After operations for retinal detachment (see) - strict bed rest (up to 6 days). Sutures from the conjunctiva are removed no earlier than after 7 days. after operation. Supramid sutures placed on the cornea after cataract extraction and keratoplasty are removed no earlier than after 4-5 weeks. Drug therapy includes the prescription of mydriatics (1% atropine solution, 0,25% scopolamine solution, 1% solution of homatropine, 10% solution of mezaton, 0.1% solution of adrenaline in drops, applications) to prevent the development of iritis, iridocyclitis. After keratoplasty, corticosteroid therapy is indicated to suppress the incompatibility reaction. In the presence of inflammatory exudate in the moisture of the anterior chamber of the eyeball, broad-spectrum antibiotics are used (under the conjunctiva, intramuscularly, intravenously).

Surgical trauma is accompanied by the release of prostaglandins, which contribute to the development of iritis and retinal edema in the macular zone (Erwin's syndrome), and therefore, on the eve or on the day of surgery, it is advisable to prescribe and continue taking medications that block the synthesis of prostaglandins (indomethacin and etc.).

The management of patients after implantation of an artificial lens depends on the principle of its fixation in the eye. When intrapupillary fixation of Fedorov-Zakharov iris-clins lenses is performed, the administration of mydriatics can cause significant dilation of the pupil and lead to dislocation and dislocation of the intraocular lens into the anterior chamber of the eyeball or into the vitreous body, which can cause the development of severe complications. With extrapupillary fixation of iris lenses proposed by M. M. Krasnov, intracapsular implantation of an artificial lens by B. N. Alekseev, the management of patients is the same as after cataract extraction. Complications in P. p. may include the development of iridocyclitis (see). In such cases, corticosteroids are prescribed in drops (dexazone, prednisolone, cortisone) or in the form of subconjunctival injections (dexazone, hydrocortisone). For hemorrhage in the anterior chamber of the eyeball (see Hyphema), subconjunctival injections of fibrinolysin, alpha-chymotrypsin, papain and other proteolytic enzymes or the introduction of these drugs in the form of electrophoresis are effective.

The cause of the occurrence in P. of small anterior chamber syndrome (see) with an increase or decrease in intraocular pressure is: relative pupillary block; combination of relative pupillary block with cyclolenticular block (malignant glaucoma), which develops on the operating table in eyes with a closed anterior chamber angle with the patient’s tendency to hypertensive crisis; ciliochoroidal detachment in eyes with significant filtration of fluid under the conjunctiva after anti-glaucomatous operations or external filtration in case of ruptures of the conjunctival flap, filtration along the conjunctival suture, as well as along the corneal suture during cataract extraction and through corneal transplants (see). Relative pupillary block is eliminated by prescribing mydriatics.

With the development of malignant glaucoma (see), lens extraction is indicated. External filtration is eliminated by applying additional sutures, suturing a silicone filling (tape) or a silicone lens. In case of prolonged absence of the anterior chamber of the eyeball (for 5-6 days), ciliary sclerotomy (see Sclera) is indicated with restoration of the anterior chamber with sterile solutions through a valve puncture of the cornea.

Features of the postoperative period in children. The nature of P. p. in children is determined by anatomical and physiological. characteristics of a growing organism. These features are most pronounced in newborns and early childhood, although they persist to varying degrees throughout the entire period of formation of the body. In P. p., pain relief plays an important role, since in children, especially in early childhood, the response to injury is always hyperergic in nature, and therefore the pain factor can cause diffuse disruption of all vital functions, primarily gas exchange and blood circulation. To prevent pain, children are administered intramuscularly with analgin, promedol, sometimes in combination with fentanyl, diphenhydramine, and aminazine. Doses depend on the age of the child. Epidural anesthesia is effective (see Local anesthesia). In some cases, the pain syndrome is well relieved by acupuncture (see Acupuncture, Reflexotherapy).

In P. p., homeostasis disturbances are the most dangerous in children, since the immaturity of compensatory mechanisms and the lack of necessary thermogenesis exclude the possibility of adequate self-regulation and correction of violations of basic vital functions. First of all, it is necessary to eliminate circulatory disorders that are associated with hypovolemia. This is due to the child’s relatively greater need for blood volume per unit of body weight (mass) and the danger of even “small” blood loss. Thus, a decrease in circulating blood volume by 12-14% in a newborn child is equivalent in its negative effect on the body to a loss of 20% of blood volume in an adult. Hypovolemia is corrected by transfusion of red blood cells, group blood, plasma, albumin, and polyglucin. To relieve spasm of arterioles, a glucozone-caine mixture and Droperidol are used. After this, it is advisable to administer strophanthin, cocarboxylase, 20% calcium pantothenate solution, and ATP in age-specific dosages.

One of the features of P. p. in newborns and young children is the danger of a violation of the temperature balance, which is associated with imperfection of their thermoregulation. Opening the chest or abdomen, intestinal eventration, and intravenous fluids during surgery can lead to hypothermia. To prevent hypothermia, newborns are operated on special heated tables or covered with heating pads. The temperature in the operating room should be at least 24-26°. Intravenous fluids should be warmed to room temperature. From the operating room, children are transported covered and covered with heating pads or in special incubators.

Hyperthermia is no less dangerous. Increased body temperature St. 39.5° can lead to seizures, cerebral swelling and even fatal outcome. In P. p., hyperthermia is more often associated with infectious and inflammatory complications.

To eliminate hyperthermic syndrome, the child is cooled with a fan, opened, wiped with alcohol or ether, the stomach and rectum are washed with cold water, cooled solutions are administered intravenously, etc. If there is no effect, injections of amidopyrine, analgin, aminazine in age-appropriate dosages are indicated .

To maintain normal acid-base balance, correction of hemodynamic disorders, gas exchange, temperature balance and effective pain relief are carried out. In cases where these conditions are met, but metabolic acidosis still occurs, 4% sodium bicarbonate solution is administered intravenously, the amount of which is calculated by the formula: base deficiency (BE) X 0.5 X body weight. Metabolic alkalosis is eliminated by intravenous administration of potassium chloride.

Most often in P. p. there is a violation of breathing and gas exchange (see Respiratory failure). Children need more oxygen per unit of body weight than adults. At the same time, as a result of the comparative narrowness of the upper respiratory tract, the horizontal position of the ribs, the high position of the diaphragm, the relatively small size of the chest and the weakness of the respiratory muscles, the child’s respiratory system experiences significant stress. Naturally, airway obstructions, inflammation and swelling of the mucous membranes, painful hypoventilation, restrictive breathing disorders, trauma to the chest wall and lung tissue in a child lead to gas exchange disturbances faster than in an adult (see). Free airway patency is ensured by the correct position of the child in bed (elevated head end of the bed, the child should lie on the healthy, non-operated side), aspiration of contents from the oropharynx and tracheobronchial tree, prolonged nasal intubation.

Hypoxemia is corrected by inhalation of warm and humidified oxygen at a concentration of 40-60% using a mask, nasal catheters, or in an oxygen tent. Spontaneous breathing with increased expiratory resistance is very effective for the prevention and treatment of respiratory disorders in children. This method is indicated for low partial pressure of oxygen, pulmonary edema, aspiration pneumonia, “shock” lung, and also for the prevention of microatelectasis. Increased airway resistance is beneficial for hypoventilation associated with postanesthesia depression and during the transition from mechanical ventilation to spontaneous breathing. Mechanical ventilation (see Artificial respiration) is indicated in cases where spontaneous breathing is absent or impaired to such an extent that it is unable to ensure gas exchange. The criteria for assessing the degree of respiratory failure and transfer to mechanical ventilation are the level of partial pressure of oxygen 50-45 mm Hg. Art. and below, the level of partial pressure of carbon dioxide is 70 mm Hg. Art. and higher.

To prevent pneumonia and atelectasis, percussion massage is performed, cupping and physiotherapeutic procedures are useful.

In early childhood, due to age-related imperfections in kidney function, the introduction of large quantities of liquids, especially saline solutions, is dangerous.

Features of the postoperative period in elderly and senile patients

The main feature of P. p. in patients over the age of 60 years is its relatively more severe course, which is due to a decrease in the function of the respiratory and cardiovascular systems, a decrease in the body's resistance to infection, and a deterioration in the regenerative abilities of tissues. Often, surgical trauma leads to an exacerbation of obvious or latent concomitant pathology - diabetes mellitus, kidney disease, liver disease, etc. With age, the vital capacity of the lungs decreases, the maximum ventilation of the lungs is significantly reduced, the drainage function of the bronchi is disrupted, which contributes to the occurrence of atelectasis (see Atelectasis) and pneumonia (see Pneumonia). Due to this special meaning acquire respiratory and lay down. gymnastics, massage, early activation of patients, prescription of bronchodilators. In the first 3-5 days. after surgery, periodic inhalations of nitrous oxide with oxygen are used using an intermittent flow anesthesia machine (see Inhalation anesthesia). This event helps relieve pain, improve coughing and, unlike drugs, does not depress respiratory center. Due to the phenomena of atherosclerosis (see), cardiosclerosis (see) often observed in older people and the limitation of the compensatory capabilities of the heart muscle, they are necessarily prescribed cardiac glycosides. To improve coronary blood flow in patients with chronic, coronary heart disease (see), intensain, isoptin, B vitamins, nicotinic acid, etc. are indicated.

Due to significant age-related changes in the blood coagulation system, hypercoagulation predominates in patients of this group, which becomes more pronounced after operations, especially for malignant neoplasms and acute inflammatory processes of the abdominal organs. Preventive measures include treatment of heart failure, thrombolytic therapy and early activation of patients.

In the prevention of pulmonary, cardiovascular and thromboembolic postoperative complications, long-term epidural anesthesia has acquired a significant role (see Local Anesthesia), thanks to which patients maintain high motor activity, adequate external breathing and good orientation.

A decrease in the compensatory capabilities of an aging body determines the need for more frequent studies of acid-base balance and electrolyte balance in order to timely and adequately correct them.

Due to the decrease in acid-enzymatic and motor function of the stomach and intestines, elderly people in P. are prescribed an easily digestible, gentle and high-calorie diet.

In elderly patients, suppuration of the surgical wound often occurs, which often occurs without characteristic signs of inflammation, which requires more careful monitoring of the wound. For suppuration, methyluracil and pentaxyl are widely used, and proteolytic enzymes are used locally, in the wound.

The regenerative properties of tissues in older people are reduced, so it is recommended to remove their sutures on the 9th - 10th day, and in cancer patients - on the 11th - 16th day after surgery.

Bibliography: Aripov U. A., Avakov V. E. and Nisimov P. B. Metabolic disorders in patients with postoperative intoxication psychoses, Anest. and resuscitation, No. 3, p. 55, 1979; Bairov G. A. and Man-k and N. S. Surgery of premature infants, L., 1977; Dedkov a E. M. and Lukomsky G. I. Prevention of postoperative thromboembolism, M., 1969, bibliogr.; Isakov Yu. F. and Doletsky S. Ya. Pediatric surgery, M., 1971; Kovalev V.V. Mental disorders in heart defects, p. 117, M., 1974; Makarenko T. P., Kharitonov L. G. and Bogdanov A. V. Management of the postoperative period in general surgical patients, M., 1976; Malinovsky N. N. and Kozlov V. A. Anticoagulant and thrombolytic therapy in surgery, M., 1976; Manevich A. Z. and Salalykin V. I. Neuroanesthesiology, M., 1977; M and I t V. S. et al. Gastric resection and gastrectomy, p. 112, M., 1975; M e-n i y l o in N. V. and V o y c e x about v-s k i y P. P. Blood loss during injuries and surgical interventions on bones, Blood transfusion and blood substitutes, Complications, Orthop, and traumat., No. 2, p. 72, 1978, bibliogr.; Microsurgery of the eye, ed. M. M. Krasnova, p. 20, M., 1976; Multi-volume guide to surgery, ed. B.V. Petrovsky, vol. 1, p. 226, M., 1962; Molchanov N. S. and Stav with Kaya V. V. Clinic and treatment of acute pneumonia, L., 1971; Fundamentals of Gerontology, ed. D. F. Chebotareva, p. 399, M., 1969; Pantsyrev Yu. M. ii Grinberg A. A. Vagotomy for complicated duodenal ulcers, With. 61, M., 1979; Panchenko V. M. Coagulation and anticoagulation system in the pathogenesis and treatment of intravascular thrombosis, M., 1967; Petrovsky B.V. and Guseinov Ch.S. Transfusion therapy in surgery, M., 1971; Petukhov I. A. Postoperative peritonitis, Minsk, 1980, bibliogr.; Popova M. S. Mental disorders that occur in patients after partial resection of the larynx, in the book: Klin, and organizational. aspects of psychiatry, ed. A. B. Smulevich, p. 150, Ulyanovsk, 1974; Guide to eye surgery, ed. M. L. Krasnova, p. 101 and others, M., 1976; Guide to clinical resuscitation, ed. T. M. Darbinyan, M., 1974; Guide to Emergency Abdominal Surgery, ed. V. S. Savelyeva, p. 61, M., 1976; Ryab'ov G. A. Critical conditions in surgery, M., 1979; Smirnov E. V. Surgical operations on the biliary tract, p. 211, L., 1974; S olovyov G. M. and Radzivil G. G. Blood loss and regulation of blood circulation in surgery, M., 1973; Handbook of physiotherapy, edited by A. N. Obrosov, p. 258, M., 1976; Struchkov V. I. Essays on general and emergency surgery, M., 1959; Struchkov V.P., Lokhvitsky S.V. and Misnik V.I. Acute cholecystitis in the elderly and old age, With. 66, M., 1978; T e about d o-resku-Ekzarku I. General surgical aggression, trans. from Romanians, Bucharest, 1972; Wilkinson A. W. Water-electrolyte metabolism in surgery, trans. from English, M., 1974; Surgery of the elderly, ed. B. A. Korolev and A. P. Shirokova, Gorky, 1974; Shabanov A.N., Tselibeev B.A. and Sharinova S.A. Mental disorders in connection with surgical operations, Sov. med., No. 1, p. 64, 1959; Shalimov A. A. and Saenko V. F. Surgery of the stomach and duodenum, p. 339, Kyiv, 1972; Shanin Yu. N. et al. Postoperative intensive care, M., 1978, bibliogr.; Sh m e l e in and V. V. Cataract, M., 1981, bibliogr.; Barker J. Postoperative care of the neurosurgical patient, Brit. J. Anaesth., v. 48, p. 797, 1976; Marsh M. L., Marshall L. F. a. Shapiro H. M. Neurosurgical intensive care, Anesthesiology, v. 47, p. 149, 1977.

T. P. Makarenko; B. N. Alekseev (ph.), 3. X. Gogichaev (ur.), O. I. Efanov (physiot.), V. P. Illarionov (physicist), I. V. Kliminsky ( abd. chir.), R. N. Lebedeva (cardiography, chir.), N. V. Menyailov (trauma), V. A. Mikhelson (det. chir.), E. B. Sirovsky (neurosir.), M. A. Tsivilko (psychiatrist).

The postoperative period begins from the moment the operation is completed and continues until the patient’s ability to work is restored.

During this period of time, a set of measures is carried out aimed at preventing and treating complications, as well as promoting the processes of reparation and adaptation of the body to the anastomo-physiological relationships created by the operation.

There are immediate and long-term postoperative periods.

The immediate period begins from the end of the operation until the patient is discharged from medical institution. Remote period occurs outside the hospital and is used for the final elimination of general and local disorders caused by the operation. They are often associated with impaired intestinal function and the existence of various types of colostomies. This period is also called the rehabilitation period.

In the immediate postoperative period, the most critical period is the early period - the first 1-2 days. At this time, those changes in the activity of organs and systems that are a direct consequence of surgical trauma and pain relief are most pronounced. This set of changes creates a state of operational stress.

Factors of surgical intervention - psycho-emotional stress, direct tissue injury and the symptomatic effect of anesthetics - cause activation of subcortical autonomic centers in the central nervous system. The stress reaction is realized through the tension of the sympathetic-adrenal and adrenocortical systems, and the direct executor of their commands is the circulatory system as a whole.

All these initially appropriate adequate compensatory mechanisms, with significant strength and duration, lead in the first hours and days after surgery to a new pathological condition, characterized by oxygen debt (hypoxia), metabolic acidosis, hypovolemia, hypokalemia, etc.

The earliest manifestations of operational stress, when humoral disorders have not yet occurred, are characterized by cardiac function. It is its indicators that need to be monitored especially carefully in the first hours.

Subsequently, operational stress goes through several successive stages:

1) stage of afferent impulse;
2) stimulation of subcortical autonomic centers and cerebral cortex;
3) activation of the sympathetic-adrenal and pituitary-adrenal systems;
4) stress restructuring of blood circulation;
5) metabolic disorders and hypoxia.

The duration of the first two stages is calculated in negligibly small periods of time. The third stage requires a little more time, but is also calculated in minutes. The appearance of disturbances in humoral homeostasis requires considerable time.

An important task in the early postoperative period is constant monitoring of the patient's condition. Monitoring is required, including emission computed tomography (ECG), electroencephalography (EGG), study of peripheral circulation (plethysmography, rheography). For the purpose of operational monitoring of the patient’s condition, special computerized systems are used that exist and continue to be developed.

Objective criteria for assessing the severity of stress are also based on determining indicators of humoral homeostasis (PH, BE, XL, etc.). All these methods of continuous monitoring can only be carried out in the intensive care unit. Here there is an opportunity to provide adequate treatment.

The main method of treatment in the early postoperative period is sufficient pain relief. It begins during anesthesia and is aimed primarily at preventing pathological impulses in the central nervous system. It is important to provide pain relief in the next few hours and days after surgery.

This is achieved by prescribing narcotic analgesics. In addition, various combinations with neuroleptoanalgesics can be used. Regional and local anesthesia should be widely used: epidural anesthesia, blockades, electrosleep, etc.

In addition, the goals of therapy in the early postoperative period are to maintain cardiac activity and systemic circulation, external respiration function, combat hypoxia, hypovolemia, disturbances of water-electrolyte balance, metabolism and acid-base balance.

In the future, depending on how successfully these problems were solved, the course of the postoperative period can be uncomplicated or complicated.

Uncomplicated postoperative period

The catabolic phase is characterized by the following changes. Immediately after surgery, due to an increase in the intensity of metabolic processes, the body's need for energy and plastic material increases, but this need cannot be satisfied due to the limited supply of nutrients. Therefore, it is provided by the internal reserves of the body by stimulating catabolic processes with hormones (catecholamines and glucocorticoids).

As a result, the excretion of nitrogenous wastes in the urine increases, a negative nitrogen balance occurs, hypoproteinemia is observed, and an increase in free fatty acids in blood. Disorders of carbohydrate metabolism are manifested by postoperative hyperglycemia due to increased formation of glucose from glycogen and increased gluconeogenesis.

Hyperkalemia resulting from hyperfunction of the adrenal glands and increased breakdown of proteins causes the development of postoperative acidosis. Then metabolic alkalosis develops very quickly due to hypovolemia, hypochloremia, and hypokalemia. This phase is characterized by a decrease in the patient's body weight.

During the transition phase, a balance occurs between the processes of breakdown and synthesis, and adrenal hyperfunction decreases.

The anabolic phase is characterized by the predominance of synthesis processes under the influence of hypersecretion of anabolic hormones (insulin, androgens, growth hormone). This phase continues until the body completely restores the pool of structural proteins and carbohydrate-fat reserves, after which the phase of increasing body weight begins.

In the early postoperative period, the patient should be provided with bed rest during the first two days. In this case, it is important to maintain minimal physical activity with the help of therapeutic exercises. It promotes adequate respiratory function, prevention of postoperative congestive pneumonia, and rapid normalization of blood circulation in the muscles. Early physical activity is an effective method for preventing gastrointestinal paresis.

Early physical activity should begin in bed. To do this, it is advisable to place the patient in a position with the head end raised and the lower limbs bent at the knees. For 2-3 days, in the absence of complications, early rising should be recommended, initially short-term, and then longer as the patient’s condition improves.

Transfusion therapy plays an important role in the intensive care system in the postoperative period. Its main objectives are maintaining the balance of fluids and ions, parenteral nutrition and intensive symptomatic therapy. In the early postoperative period, fluid deficiency is observed.

Due to the increased secretion of aldosterone and audiuretin, fluid is lost, sequestered in the wound, and accumulates in the stomach and intestines. Therefore, fluid replacement is necessary. In this case, they proceed (with normal hydration of the patient) from a dose of 1.5 l/m2 or 35-40 ml per 1 kg of patient weight. This maintenance dose does not take into account losses. To this dose should be added daily diuresis, losses through the intestines and gastric tube, wound and fistulas.

If there is an increased excretion of nitrogenous wastes in the urine, and we monitor this by the specific gravity of urine, the amount of fluid administered should be increased. So, if the density of urine increases to 1025, then you need to additionally introduce an average of up to 500.0 ml of liquid.

However, the tasks of infusion therapy in the postoperative period are much broader than restoring fluid deficiency. With the help of infusions, it is possible to correct natural postoperative disorders of vital functions - disturbances in circulatory homeostasis, ineffective hemodynamics, disturbances in water-electrolyte homeostasis, protein deficiency, shifts in the coagulation properties of the blood. In addition, infusion therapy provides parenteral nutrition and treatment of complications that arise.

To simply replenish fluid losses, it is advisable to use basic solutions: isotonic solution sodium chloride, 5% glucose solution in isotonic solution. A continuous intravenous infusion is performed. The injection rate is 70 drops/min, i.e. 3 mg/kg body weight/hour or 210 mg/hour with a body weight of 70 kg for a glucose solution in excess solution.

For an isotonic sodium chloride solution, the average daily dose is 1000 ml with continuous intravenous infusion at a rate of 180 drops/min (550 mg/hour for a body weight of 70 kg). If stress is overcome after colon surgery total the transfused fluid on the first day of the postoperative period is 2500 ml or more.

If renal function is intact, potassium ions should be added to these solutions. In particular, we widely use a solution of ionosteril Na 100 containing a sufficient amount of potassium. In general, to cover the body's needs in case of impaired water-electrolyte metabolism in the postoperative period, basic polyionic solutions containing electrolytes, a sufficient amount of physiologically free water, and carbohydrates should be used.

The approximate composition of such solutions should be as follows: 1 liter of solution containing Na+ - 1.129 g; K+ - 0.973 g; Mg++ - 0.081 g; Cl- - 1.741 g; H2PO4 - 0.960 g; lactate - - 1.781 g; sorbitol - 50.0 g. Depending on changing needs, the composition may change, in particular, glucose, fructose, a complex of vitamins are added, the concentration of potassium and other ions is changed.

For alkalosis, Darrow's solution, containing 2.36 g of Na+ per 1 liter of liquid, can be very useful; 1.41 g K+; 4.92 Cl-. At metabolic acidosis infusions of corrective solutions containing sodium hydrogen carbonate are indicated (up to 61.01 g of HCO3 per 1 liter of liquid).

As already mentioned, in the postoperative period the daily need for calories and proteins increases significantly. To reduce protein catabolism, it is necessary to administer concentrated solutions of glucose, xylitol and levulose with or without electrolytes. Infusion of combinations of these sugars (for example, combistiril from Fresenius) avoids the disorders associated with the use of only high-percentage glucose solutions.

To replace protein deficiency, protein hydrolysates and other plasma replacement solutions have long been used. Currently, preference is given to solutions of amino acids. These solutions may contain, in addition to a set of basic amino acids, electrolytes and vitamins. Fat emulsions and high-calorie sugar solutions are also used for parenteral nutrition.

Restoration of surgical blood loss

However, the use of blood transfusions is associated with a certain risk for patients associated with the development of known complications, the transmission of infectious diseases (hepatitis, AIDS, etc.), and deterioration of the rheological properties of blood. There is also a danger of remetastasis in patients with tumor diseases. Therefore, attempts to replace blood transfusions should be considered justified.

For this purpose it is proposed:

1. long-term preoperative collection of blood or plasma from the patient several weeks or months before the planned operation;
2. intraoperative autotransfusion of one’s own blood;
3. carrying out acute preoperative normovolemic hemodilution.

For obvious reasons, the first two methods of autohemotransfusion cannot be used in patients with colon cancer. The third is comparatively simple. However, it is contraindicated in weakened patients with signs of anemia and hypovolemia.

In these cases, to compensate for blood loss, we resort to small-volume blood transfusions, combined with transfusion of colloidal solutions to replace the volume. A moderate controlled hemodilution is created, in which the hematocrit level should not be reduced below 30-35%.

Infusion therapy is also an important element of the system for preventing various complications. In particular, the use of solutions that normalize the rheological properties of blood (antiplatelet agents, low molecular weight dextrans, etc.) is aimed at preventing postoperative circulatory disorders. The use of cardiac glucosides and other agents that provide an inotropic effect on the myocardium. The result is an increase in cardiac output.

In the postoperative period, patients with colon cancer often develop a hypercoagulable state. A number of researchers interpret it as thrombotic. In this regard, prophylactic use of anticoagulants was suggested. However, at present there is no reason to unambiguously regard the state of hypercoagulation as the cause of inevitable postoperative thrombosis.

A.N. Filatov wrote in 1969: “... the use of the most advanced research methods has now made it possible to determine hypercoagulation in a patient, while the doctor still cannot decide whether this hypercoagulation will cause a blood clot in the examined patient or whether it is only a transient condition that does not threaten thrombus formation in the patient.” vessels."

In modern conditions, one should distinguish between intravascular coagulation and prethrombosis with hypercoagulation phenomena. The prethrombotic state is caused by damage to the vascular wall, slow blood flow, changes in its protein composition, viscosity and others rheological factors, and not just hypercoagulation.

The identification of the prethrombotic state with hypercoagulation is erroneous, because prethrombosis is dangerous due to several factors, among which hypercoagulation may not be of decisive importance. That is why the prevention of thrombosis should not consist only of influencing postoperative hypercoagulation. Prevention and treatment of prethrombosis are multivalent.

They should include agents that reduce the functional activity of platelets (hydrochlorine, acetylsalicylic acid); low molecular weight dextrans. The use of heparin should be considered very useful in patients with risk factors for thrombosis (age, concomitant vascular and blood diseases, traumatic intervention).

Heparin acts as a coagulation inhibitor in vivo and in vitro in three ways:

1) inhibits thrombin, thromboplastin, factors V, VII, IX, Xa, XI, XII, as well as fibrin formation;
2) activates the lysis of fibrin and fibrinogen;
3) inhibits platelet aggregation.

To prevent thrombosis in high-risk groups, subthreshold doses of heparin are used (5000 units every 8-12 hours). Selective administration of high doses of heparin should be used for signs of pathological hypercoagulability, especially when a positive or severe positive reaction for fibrinogen.

An important concern of the doctor in the postoperative period is to restore the function of the gastrointestinal tract. Various methods have been proposed to prevent gastric and intestinal paresis.

Unimpeded movement of intestinal contents can be achieved various modes nutrition throughout the postoperative period. Enteral nutrition, in the absence of complications, can be carried out already from the second day after surgery.

At first, it is allowed to take a moderate amount of liquid (sweet tea, jelly, juices), then broth, liquid cereals, pureed vegetable soups and purees. From 5-6 days it is possible to take regular light food - boiled fish, steamed meat cutlets, cottage cheese, fruits, etc.

Most surgeons consider it advisable to prescribe laxatives after colon surgery. This desire is justified, since liquid feces pass unhindered through the anastomosis without causing excessive pressure on the suture line.

As a rule, castor oil or a 10-15% solution of magnesium sulfate is used. In our practice, we increasingly use oil laxatives such as olive, sunflower, corn, and castor oil.

Therapy with these laxatives is a continuation of postoperative bowel preparation. However, it is less important after operations for cancer of the right half of the colon.

The functions of the gastrointestinal tract are restored after surgery the faster the sooner the environment in which the patient is located becomes familiar to him.

Prevention of purulent-inflammatory complications

An uncomplicated postoperative period occurred in 370 patients after radical operations in patients with colon cancer, which amounted to 84.3%. Various complications developed in 85 patients (18.7%). The nature of these complications can be judged from Table 18.3. Some patients had several complications simultaneously.

Table 18.3. Frequency and nature of postoperative complications after radical surgery for uncomplicated colon cancer

One of the complications that begins to develop during surgery is postoperative shock. It may be caused by surgical trauma or blood loss. It is especially often observed during abdominal-anal resections of the rectosigmoid region.

Prevention of this complication is ensured by adequate pain relief. The most common type is combined inhalation anesthesia. The introduction of novocaine solution into the root of the mesentery and retroperitoneal space also helps prevent postoperative shock.

IN Lately Spinal and epidural anesthesia is becoming increasingly common, especially in severe patients with concomitant diseases. Prevention of bleeding is ensured by careful hemostasis and careful treatment of organs and tissues during surgery.

Acute cardiovascular failure develops especially often in patients with concomitant diseases of the cardiovascular system. This should be taken into account during preoperative preparation.

Complications from the respiratory system are quite common. Particularly dangerous are those that are accompanied acute respiratory failure (ARF). ARF after surgery is rarely associated with a decrease in the huge diffusion surface of the lungs (60-120 m2). Rather, it is due to its ineffective functioning. One of the main causes of early acute respiratory failure is blood loss and associated massive blood transfusions.

As a result, impaired microcirculation, embolism with fat droplets, spasm, and thrombosis develop in the pulmonary microvessels. The so-called parenchymal ARF is formed (decrease in Pa O2 with normal or reduced Pa CO2). By the end of the immediate postoperative period, acute respiratory failure comes to the fore, caused by a change in the nature, quantity and evacuation of sputum, as well as inflammatory edema of the mucous membrane of the respiratory tract.

They arise due to exposure to gas mixtures, intubation, and hidden aspiration of gastric contents. Due to mechanical and chemical damage to the ciliated epithelium, the natural mechanisms of cleansing the tracheobronchial tree are insufficient. Intense production of bronchial mucus leads to mucoid obstruction of the bronchi.

Clearance of the tracheobronchial tree by coughing is also impaired due to injury to the respiratory muscles, changes in its functional state (hypotonicity) and postoperative pain. As a result of a complex of these reasons, as well as due to the activation of microbial flora against the background of a decrease in immune protective reactions, pneumonia develops.

Intensive therapy and prevention of postoperative ARF should include a number of measures. First of all, it is necessary to restore bronchial and bronchiolar patency, airiness of respirators and maintain the lungs in an expanded state.

It is necessary to prescribe drugs that cause thinning of sputum, facilitating its separation, eliminating bronchiospasm. It is very useful inhalation therapy using steam-oxygen mixtures, essential oils, mucolytics, proteolytic enzymes.

In order to enhance the mechanisms of sputum separation (detergent action), well-known expectorant mixtures are used, containing a decoction of ipecac, thermopsis, iodides, as well as detergent surfactants (tacholiquin, admovone, etc.).

Bronchospasm can be relieved with aminophylline, novodrinum and their analogues. Increased ventilation of the lungs can be achieved with the help of respiratory analeptics (ethimizole, etefil, meclofenoxate). Breathing stimulation can only be effective with adequate pain relief.

Due to bacterial contamination and activation of automicroflora, especially in the presence of a chronic inflammatory focus in bronchial tree, shown antibacterial therapy using antibiotics.

As can be seen from Table 18.3, after operations for colon cancer, the proportion of purulent-septic complications is high. The source of infection in the wound, abdominal cavity, and soft tissues of the abdominal wall is the tumor, surrounding tissues and intestinal contents. The most serious complication is postoperative peritonitis. It may be associated with failure of the sutures of the intestinal anastomosis or the sutured intestinal stump.

Prevention of this complication should be carried out during surgery by the correct choice of anastomosis site, suturing technique, careful assessment of the sufficiency of blood circulation of the anastomosed sections of the intestine, and preoperative preparation of the intestine. It appears that improving these preventive measures remains an urgent task.

Functional intestinal obstruction

Intestinal stasis is the initial phase of postoperative functional intestinal obstruction. It is accompanied by bloating, a feeling of fullness in the abdomen, difficulty breathing, and moderate tachycardia.

The progression of functional intestinal obstruction is characterized by the next phase - intestinal paresis. This condition is accompanied by a high position of the diaphragm, increased bloating and pain, increased tachypnea and tachycardia (up to 130-140 beats per minute). The calm state is replaced by periods of excitement. Irreversible loss of fluid, water, and nutrients leads to severe disturbances in cellular metabolism. BCC, cardiac output, and blood pressure decrease. Neurological disorders appear.

Fermentation processes are enhanced by the upward migration of colon microflora. Bacterial toxins, endotoxins, prostaglandins, as well as histamine and lysosomal enzymes accumulate, which further suppress the contractility of the muscles of the intestinal walls and cause capillary paresis.

As a result, microcirculation of the intestinal walls, secretion and absorption in the intestine are further disrupted. The sensitivity and excitability of enteroreceptors and contraction pacemakers are inhibited and, as a result, the intestinal permeability function is inhibited. A sharp change in the composition of intestinal contents negatively affects cavity and membrane digestion, disrupts the transport of nutrients, and increases intraintestinal pressure.

As a result, pathological changes of all types of homeostasis develop in an avalanche manner, characterizing the terminal phase of functional intestinal obstruction - enterorrhagia, which becomes the cause of death of the patient.

Treatment of this postoperative complication should be comprehensive and include measures aimed at combating hypoxia, hypovolemia, and hypokalemia, which aggravate intestinal paresis.

These measures include oxygen therapy, pain relief, rapid restoration of bcc and normalization of rheological properties of blood, elimination of vascular spasm, restoration of water-electrolyte balance. Sympathetic hypertonicity is reduced with the help of cholinomimetics or direct stimulation of the intestinal muscles.

For early stimulation of motor skills, anticholinesterase drugs are used - prozerin, nivalin; intravenous administration of hypertonic solutions of sodium chloride, sorbitol. Reflex stimulation of peristalsis can be carried out using various enemas. Electrical stimulation is used less frequently intestinal peristalsis through the skin.

Therapeutic effect

With a delayed effect, ganglion blockade is supplemented with α-adrenolytics: aminazine at a dose of 0.2 mg/kg or pyrroxane at a dose of 0.3 mg/kg every 10-12 hours. Other options for sympathetic blockade are less preferable, including perinephric and other types of novocaine blockades.

Their effect is insignificant and short-lived with a significant risk of complications. At the same time, the clinical effect of prolonged epidural anesthesia in the postoperative period should be highly appreciated.

As already mentioned, functional intestinal obstruction in the postoperative period leads to isotonic dehydration. During the day, reverse resorption of about 8 liters of digestive secretions is limited, and up to 4 liters of liquid is bound due to edema of the intestinal wall. Therefore, an important part of treatment is infusion therapy. Its objectives are to replenish fluid losses, correct potassium deficiency, bicarbonate deficiency and other water-electrolyte imbalances.

If intestinal paresis persists despite intensive therapy, you should definitely think about intraperitoneal complications, peritonitis, mechanical intestinal obstruction, eventeration, etc. These complications require urgent relaparotomy.

Yaitsky N.A., Sedov V.M.

Collapse

Removal of the uterus and appendages is perhaps one of the most serious and difficult operations in gynecology. It can cause quite a lot of complications, and in addition, it is characterized by a long and difficult recovery period, during which various restrictions apply to many areas of life. But it is precisely careful adherence to the doctor’s recommendations at this stage that can significantly speed up recovery from the disease, recovery after the procedure and improve the quality of life. This material describes how the postoperative period goes after removal of the uterus, what features it has, and what recommendations should be followed at this stage of treatment.

Duration

How long does the patient’s rehabilitation actually take after such an intervention? To some extent, this is influenced by its method and volume. For example, if the uterus and appendages were removed, then the recovery period can be up to two months, and if only the organ cavity itself, then up to six weeks or one and a half months.

It is customary to distinguish between early and late rehabilitation periods. By early we mean the first three days after surgery, with the first 24 hours having the maximum value. By late we mean the entire remaining period - up to one and a half to two months.

Fast recovery

How to quickly recover after hysterectomy? There are no express methods of recovery after this intervention. This intervention is quite serious and extensive, accompanied by hormonal changes in the reproductive system. And also, the symptoms of the disease that required amputation of the organ have their own effects. Therefore, the recovery period after removal is normally long and is accompanied, to the greatest extent in the first weeks, by a deterioration in well-being.

Taking into account individual characteristics body, recovery after removal of the uterus may go a little faster or a little slower, but there will still not be a significant difference. And even if your health improves after 2-3 weeks, this does not mean that you should stop following the doctor’s recommendations.

Within 24 hours after the laparotomy was performed, it is necessary to maintain bed rest. It takes a lot of time just to come out of anesthesia. You shouldn't sit down or get up, even to go to the toilet. Although by the end of the first day, carefully, with the help of your hands, it is already acceptable to turn over on your side. Only liquid food is allowed.

First 72 hours

Over time, it is necessary to increase physical activity. At this stage, the patient should already be half-sitting in bed, getting up to go to the toilet, and turning over on her side. You should still eat liquid and semi-liquid food, and by the third day, begin to include easily digestible regular food. It is important to control your bowel movements to avoid constipation and gas formation.

These days, treatment is already being carried out after removal of the uterus - broad-spectrum antibiotics are taken to avoid infection.

It is necessary to pay attention to your general condition - a high temperature after the procedure at this stage may be a sign of an inflammatory process.

One and a half to two months

About a week after the abdominal surgery was performed, antibiotic treatment ends. Often, at this stage, hormone treatment may be prescribed to facilitate menopause (if the ovaries are removed). At the same stage, consultations with a psychologist are prescribed, if necessary.

The patient can eat regular food, but it is important that it is healthy and natural and does not cause constipation or gas. Bed rest is moderate during the first two weeks. Then it can be canceled, but physical exertion should be avoided.

Rehabilitation after hysterectomy excludes saunas, steam baths, and any overheating. You cannot swim in natural bodies of water; you can maintain hygiene using a shower.

What should you do at this stage? It also depends on the type of intervention. Depending on it, the patient may be given additional instructions for rehabilitation.

Subtotal hysterectomy

Perhaps the simplest procedure is hysterectomy, with a short postoperative period. With such an intervention, only the body of the organ is removed, the neck and appendages remain unaffected. The duration of the rehabilitation period is about one and a half months, the scar is small, hormonal treatment is not required.

Total hysterectomy

The uterus and cervix are removed, without appendages. The duration of the recovery period is approximately the same; you can return to sexual activity no earlier than after two months. Hormonal treatment is also not required.

Hysterosalpingo-oophorectomy

Not only the body of the organ is removed, but also the appendages - the ovaries and fallopian tubes. Extirpation of the uterus and appendages is a fairly difficult operation, requiring a long, up to two months, rehabilitation period. Scheme of the procedure in the photo in the material.

Radical hysterectomy

The entire organ is removed. Rehabilitation has the same features as for total hysterectomy.

Intimate life

During the entire recovery period after hysterectomy, it is advisable to abstain from intimate life. Although in many ways this can only be determined based on the method by which the intervention was carried out. For example, if only the uterine cavity is removed and the vagina and cervix are completely preserved, doctors allow you to resume sexual activity after a month or a month and a half. If the cervix and upper third of the vagina were removed, the period of abstinence may be longer, since the suture may be injured after the intervention.

Thus, during the first five weeks, sex is prohibited. After this period, you should consult with a specialist on this issue. This is true for any period after abdominal surgery for hysterectomy – consult your doctor before resuming sexual activity.

Sport

When can you exercise after a hysterectomy? This question can only be answered taking into account the type and intensity of loads. On initial stages recovery after any procedure physical activity there should be a minimum. After the first week of rehabilitation, therapeutic exercises can be added, which prevents the formation of adhesions, etc. After completing the full rehabilitation period, you can again engage in gymnastics and aerobics in moderate amount and without excessive loads and strength exercises.

You can also start doing fitness no earlier than 2 months after the intervention, and only with the permission of the attending physician. Concerning professional sports, bodybuilding - the time to start such exercises must be discussed with the doctor separately, since the nature of the load, the nature of the intervention, the speed and characteristics of healing play an important role.

Example of a daily routine

Rehabilitation after surgery is faster with the correct daily routine. You need to sleep more - in the first 7 days after the procedure you need to sleep as much as you want. Then it is recommended to sleep for at least 8 hours, but you can’t sleep for more than 10 hours either, since at this stage you shouldn’t lie down too much. Physical activity is needed to avoid blood stagnation and the formation of adhesions. That is, bed rest should still be observed, but not excessively - taking into account sleep, you should spend 13-15 hours a day in bed, the rest of the time it is better to sit, walk, and do simple, non-stressful household chores.

Starting from the second week, walks are shown. At first, short ones - 15-20 minutes each. Over time, their duration can be increased to one hour in good weather. Every day you need to do therapeutic exercises for 10-15 minutes.

Diet example

As already mentioned, for the first three days it is better to eat fairly light food - natural vegetable broths and purees. Then you can gradually introduce food of normal consistency, and by the end of 5-6 days the patient should switch to a general diet. Although food should meet the requirements of a healthy diet, it is necessary to avoid fried, fatty, canned, smoked, and also sweets, preservatives and dyes. For example, the diet could be like this:

1. Breakfast – rolled oats porridge, egg, black tea;
2. Late breakfast – fruit, cottage cheese;
3. Lunch – soup with vegetable or chicken/meat broth, lean beef with rice, rosehip broth;
4. Afternoon snack – vegetable/fruit salad or yogurt;
5. Dinner – white fish with fresh or stewed vegetables, tea.

In general, after surgery to remove the uterus, you must adhere to the rules of a healthy diet, eat small meals, and do not overeat. The calorie content of the diet should remain at the same level.

Consequences

Consequences after removal of the uterus in the recovery period are possible if the rules for its passage are violated, as well as with certain characteristics of the body. For example, complications such as:

1. Depression, nervous breakdowns, other complications of an emotional and psychological nature;
2. Bleeding due to poor healing of sutures or stress on them;
3. Suture endometriosis is a condition in which the endometrium begins to form on the peritoneum (extremely rare);
4. Infection of the blood or peritoneum, neighboring organs during the operation manifests itself precisely during this period;
5. Long-term and persistent pain syndrome that develops when nerve trunks are damaged;
6. An inflammatory process, temperature after removal of the uterus is a sign of it;
7. Attachment of viruses and infections, fungi, as a result of reduced local immunity;
8. Some deterioration in the quality of sexual life, which usually disappears after hormonal therapy;
9. Decreased libido, which is also regulated by hormones;
10. Possible problems with the intestines, constipation;
11. Symptoms of early menopause when not only the cavity is removed, but also the ovaries.

Moreover, after abdominal surgery, which was performed under general anesthesia, complications after anesthesia can always arise. But they appear already in the first 24 hours after the procedure.

Conclusion

Regardless of the method used to remove the organ, a properly conducted recovery period is no less important than careful preparation for the intervention and its high-quality implementation. It is now that healing occurs, and it depends on it whether the patient will be bothered by the consequences of this intervention in the future. For example, if the postoperative period after removal of the uterus is carried out correctly, then adhesions will not form, which can subsequently cause pain, the scar will smooth out more or less aesthetically, etc.

The prospect of surgical intervention frightens many: operations are associated with a risk to life, and even worse - to feel helpless, to lose control over own body, trusting the doctors for the duration of the anesthesia. Meanwhile, the work of a surgeon is only the beginning of the journey, because the result of treatment half depends on the organization recovery period. Doctors note that the key to success is the right attitude of the patient himself, who is ready to work on himself in close cooperation with specialists.

Features of postoperative rehabilitation

Rehabilitation therapy has many goals. These include:

• prevention of possible complications of the operation;
• relieving pain or restrictions in mobility;
• acceleration of recovery and psychological recovery after illness;
• return of the patient to an active healthy life.

At first glance, nothing complicated - it may seem that the human body itself is capable of recovering from a serious illness or traumatic surgical intervention. Many patients naively believe that the most important thing in the postoperative period is healthy sleep and good nutrition, and the rest will “heal itself.” But that's not true. Moreover, self-medication and carelessness regarding rehabilitation measures sometimes nullify the efforts of doctors, even if the initial outcome of treatment was assessed as favorable.

The fact is that the recovery of patients after operations is a full-fledged system of medical measures, the development of which is carried out by a whole science, rehabilitation. The civilized world has long abandoned the idea of ​​providing patients with complete rest for a long time after surgery, because such tactics aggravate the patient’s condition. In addition, with the introduction of minimally invasive operations into medical practice, the emphasis of rehabilitation has shifted from healing the skin in the scar area to restoring the body’s full functioning already on the second or third day after the intervention.

During the period of preparation for surgery, you should not get hung up on thoughts about the intervention itself, this will lead to unnecessary worries and fears. Rehabilitation specialists advise thinking in advance about what you will do once you regain consciousness on the first day after surgery. It is useful to take a player, book or tablet computer with your favorite movie with you to the hospital, which will help you take your mind off unpleasant feelings and tune into a positive mood.

Competent organization of the recovery period after surgery is especially important for elderly patients who are more difficult to tolerate surgical interventions. In their case, the feeling of helplessness and forced limitation of mobility often develops into severe depression. Elderly people sometimes endure pain and discomfort until the end, embarrassed to complain to medical personnel. A negative psychological attitude interferes with recovery and leads to the fact that after surgery the patient will never fully recover. Therefore, the task of relatives is to think in advance about how the rehabilitation period will go, to choose a suitable clinic and doctor responsible for the rapid recovery and well-being of the elderly person.

Rehabilitation period after surgery

The length of recovery after surgery depends on many factors. The most significant of these is the nature of the operation. So, even a person with good health After minor spinal surgery, it will take at least 3–4 months to return to full life. And in the case of major abdominal surgery, the patient will have to adhere to a strict diet for several years to prevent the formation of adhesions. A separate discussion concerns operations on joints, which often require numerous sessions of physiotherapy and therapeutic exercises aimed at returning lost functions and mobility of the limb. Well, after emergency interventions for a stroke or heart attack, the patient sometimes has to recover for many years in order to regain the ability to be independent and work.

The complexity of the operation is far from the only criterion for the duration of rehabilitation. Doctors pay attention Special attention on the age and gender of the patient (women, as a rule, recover faster than men), the presence of concomitant diseases, bad habits and level physical training before surgery. A person’s motivation to recover is also important - that’s why good rehabilitation centers employ psychologists along with doctors.

Methods for restoring the body after surgery

The arsenal of rehabilitation therapy includes an impressive number of methods, each of which has its own strengths and weak sides. Most patients in the postoperative period are recommended to use a combination of several prescriptions, simultaneously recording what exactly brings great benefit for health in each specific case.

• Medications . Pharmacological support is an important aspect of comfortable recovery after surgery. Patients are prescribed painkillers, as well as vitamins and adaptogens - substances that increase vitality(ginseng, eleutherococcus, pantocrine and other remedies). After some types of interventions, special medications are prescribed: during neurological operations, patients are often prescribed Botox therapy - injections of botulinum toxin that relieve muscle spasms, reducing tension in various parts of the patient's body.
• Physiotherapy implies beneficial influence physical factors(heat, water, electric current, etc.) on the human body. She is recognized as one of the most safe methods treatment in modern medicine, but requires a competent approach and careful recording of the result. Experienced specialists in laser therapy, electromyostimulation and diadynamic therapy are in great demand today, because they help speed up wound healing, relieve inflammation and reduce pain after any type of surgery.
• Reflexology . This rehabilitation method involves influencing biologically active points on the human body using special needles or “cigars” (mox). He is classified as alternative medicine, but the effectiveness of reflexology has been repeatedly confirmed in the practical activities of many rehabilitation centers.
• Exercise therapy (physical therapy) useful both for people who have undergone surgery on bones and joints, and for patients recovering from cardiac surgery or stroke. A structured system of regular exercise helps not only on a physical level, but also psychologically: the joy of movement returns to a person, mood improves, and appetite increases.
• Mechanotherapy , despite its similarity with exercise therapy, refers to an independent method of rehabilitation of patients after surgery. It involves the use of exercise equipment and special orthoses that facilitate the movements of weakened patients and people with disabilities. physical capabilities. In medicine, this method is gaining increasing popularity due to the introduction of new, improved devices and devices into practice.
• Bobath therapy - a technique aimed at eliminating spasticity (stiffness) in the muscles. It is often prescribed to children with cerebral palsy, as well as adults who have suffered acute disorder cerebral circulation. The basis of Bobath therapy is the activation of movements by stimulating the patient’s natural reflexes. In this case, the instructor uses his fingers to influence certain points on the body of his student, which tones the functioning of the nervous system during classes.
• Massage prescribed after many surgical operations. It is extremely useful for older people suffering from diseases of the respiratory system, who spend a lot of time in a horizontal position. Massage sessions improve blood circulation, enhance immunity and can become a transitional stage that prepares the patient for active rehabilitation methods.
• Diet therapy not only allows you to create the right diet in the postoperative period, but also plays a role in the formation of healthy habits in the patient. This rehabilitation method is especially important for the recovery of patients after bariatric surgery (surgical treatment of obesity), people suffering from metabolic disorders, and debilitated patients. Modern rehabilitation centers always ensure that the menu for each patient is compiled taking into account his individual characteristics.
• Psychotherapy . As you know, the development of many diseases is influenced by the thoughts and mood of the patient. And even high quality health care will not be able to prevent relapse of the disease if a person has a psychological predisposition to poor health. The task of a psychologist is to help the patient understand what caused his illness and get ready for recovery. Unlike relatives, a psychotherapy specialist will be able to make an objective assessment of the situation and apply modern methods treatment, if necessary, prescribe antidepressants and monitor the person’s condition after completion of rehabilitation.
• Occupational therapy . The most painful consequence of serious illnesses is the loss of the ability to self-care. Ergotherapy is a set of rehabilitation measures aimed at adapting the patient to normal life. Specialists working in this field know how to restore self-care skills to patients. After all, it is important for each of us to feel independent from others, while loved ones do not always know how to properly prepare a person after surgery for independent actions, and are often overprotective of him, which hinders proper rehabilitation.

Rehabilitation - difficult process, however, you should not consider it an impossible task in advance. Experts recognize that the main attention should be paid to the first month of the postoperative period - timely initiation of actions to restore the patient will help him develop the habit of working on himself, and visible progress will be the best incentive for a speedy recovery!