Exploratory Laparotomy

Abdominal injury, acute diffuse peritonitis, acute upper gastrointestinal bleeding, abdominal mass, acute intestinal obstruction may consider this operation, but need to pay attention to some non-surgical means. Treatment of diseases: upper gastrointestinal bleeding, peritonitis, intestinal obstruction Indication Abdominal injury (1) There is obvious symptoms of peritoneal inflammation, abdominal cavity puncture to extract the contents of the gastrointestinal tract, or x-ray examination for pneumoperitoneum. (2) Hemorrhagic shock, abdominal puncture has no blood clotting fluid. (3) There is bleeding in the gastrointestinal tract or blood is drawn from the stomach tube. (4) Abdominal wall injury In the debridement, the lesion was found to be deep and the abdominal cavity. (5) The abdominal wall wound has gas, blood, urine, gastrointestinal contents or bile outflow. 2. Acute diffuse peritonitis (1) Diffuse peritonitis is diagnosed without limitation. (2) Although the signs of peritoneal irritation are not obvious, the exudate is confirmed by abdominal puncture, and the condition deteriorates rapidly after the onset. (3) In the process of non-surgical treatment of acute peritonitis, the following conditions occurred: the condition did not improve; the condition was aggravated; the body temperature gradually increased; the total number of white blood cells and neutral cells continued to increase; there was a tendency to shock. Peritonitis caused by the following reasons should be treated with non-surgical treatment: acute edematous pancreatitis without complications; primary peritonitis; female pelvic organ infection; retroperitoneal infection. 3. Acute upper gastrointestinal bleeding (1) combined with shock, non-surgical treatment of the condition is not improved. (2) Acute upper gastrointestinal bleeding, after three-lumen tube compression and blood transfusion, the bleeding was suspended, but there was bleeding after the three-lumen tube was compressed. (3) Acute upper gastrointestinal bleeding, when the non-surgical treatment is good, the treatment effect is unstable. (4) There have been many similar history of bleeding in the past. 4. Abdominal mass (1) There is a clear mass in the abdomen, and some of the edges are clear. The nature, location and extent of the mass cannot be determined by the relevant examination. (2) Abdominal mass was observed after short-term treatment, and the situation was not improved. (3) Abdominal masses have obvious symptoms, such as abdominal pain and fever, but they cannot be examined due to the condition, and they are urgently needed to be resolved. (4) Abdominal masses are mutated and cannot be examined as they should. All cases are suspected of having the following conditions, should not be operated, should be repeatedly checked, and then deal with the situation: ectopic kidney; polycystic kidney; polycystic liver; compensatory hepatomegaly; pregnancy uterus; bladder urinary retention; Fecal stones; intra-abdominal metastasis of advanced cancer; mesenteric lymph node tuberculosis; or chronic lymphadenitis. 5. Acute intestinal obstruction (1) acute intestinal obstruction, there are signs of peritonitis, suspected intestinal stenosis. (2) acute intestinal obstruction, combined with shock. (3) Acute intestinal obstruction, after treatment by non-surgical treatment, the condition has not improved, and even worse. (4) Acute intestinal obstruction, when it is not treated by non-surgical treatment, the effect is unstable. Preoperative preparation 1. Dehydrated patients should be infused with saline quickly to correct water and electrolyte imbalance. 2. In addition to infusion of normal saline, blood loss patients need to quickly supplement whole blood, plasma, dextran and other expansion agents. 3. Patients with long course of disease should be supplemented with potassium ions. 4. Gastrointestinal decompression, eliminate abdominal distension, to facilitate intraoperative operation and postoperative recovery. 5. Use antibiotics to prevent infection. 6. Calm and relieve pain, so that the patient's spirit is peaceful. 7. Prepare blood. 8. Abdominal trauma 1 When combined with shock, rapid blood transfusion; infusion should also be infusion. Blood transfusion and infusion should be taken through the upper extremity vein to prevent the inflow into the abdominal cavity when the vena cava is damaged. 2 Open trauma When the intestinal tract is removed, it should be protected by wet gauze and should not be returned to the abdominal cavity. 3 When the gunshot wound is only the entrance, it should be taken as an x-ray film to identify the location of the bullet and the shrapnel to determine what organs may be injured when the ballistic path passes. 9. Acute diffuse peritonitis 1 When the cause is unknown, the following tests are performed: serum amylase; abdominal puncture or peritoneal washing liquid examination; vaginal posterior sacral puncture examination; x-ray examination; electrocardiogram examination. 2 generally have symptoms of systemic poisoning and water, electrolyte disorders, should be positively corrected. 3 disable the enema. 10. Acute upper gastrointestinal bleeding 1 preoperative examination: liver function determination; sputum meal perspective, to understand the presence or absence of varicose veins in the esophagus; b ultrasound examination of liver, spleen and gallbladder; platelet count and out, clotting time; fiber gastroscopy. 2 for short-term non-surgical treatment: in addition to blood transfusion, intravenous administration of hemostatic drugs and vasoconstrictors; application of three-lumen tube compression to stop bleeding; through the gastrointestinal decompression tube flushing the gastric cavity, a good hemostasis effect on gastric bleeding lesions. 11. Abdominal mass 1 preoperative examination: gastrointestinal barium meal perspective; intravenous or retrograde pyelography; b-ultrasound; ct examination; endoscopy; related to abdominal angiography. 2 Intestinal preparation: 2 days before surgery, use slag-free diet, take laxative, clean enema before operation; oral neomycin, daily 2 ~ 4g, a total of 2 ~ 3 days; 3 The upper abdomen mass should be placed on the stomach tube, and the lower abdomen mass should be inserted into the catheter to empty the stomach and bladder to avoid obstructing the exploration. 12. Acute intestinal obstruction 1 Preoperative examination of serum potassium, sodium, chlorine, carbon dioxide binding force, x-ray abdominal plain film. 2 focus on correcting dehydration, acidosis and electrolyte imbalance. Surgical procedure 1. Position: supine position. 2. Incision selection: The general incision should be selected at the location closest to the lesion. The laparotomy of abdominal injury is usually performed by a midline incision, or a median side incision, or a transabdominal rectus incision, which is convenient for upward and downward extension when needed, or laterally expanding to both sides. For chest and abdomen joint injuries, such as chest and abdomen, surgery is required to make as much as possible a chest and abdomen joint incision, and it is appropriate to make an incision in the chest and abdomen. Avoid incision with a wound as much as possible to avoid infection or rupture of the incision. The laparotomy of acute peritonitis should use the right mid-abdominal rectus incision. The upper 1/3 of the incision is on the umbilicus and the lower 2/3 is below the umbilicus. The length of the incision is suitable for allowing the hand to enter the abdominal cavity, and then appropriately extended as needed. Exploratory laparotomy for acute upper gastrointestinal bleeding often involves a mid-abdominal or median side incision. If necessary, make a transverse incision or a combined chest and abdomen incision. The incision of the abdominal mass should be determined according to the location of the mass and the organs that may be involved. Generally, the median or median side incision is much more used than the transverse incision. When the right upper quadrant may involve the liver, it should also be prepared for a combined chest and abdomen incision. Exploratory laparotomy for intestinal obstruction is preferably performed with a median or right median approach. 3. Observation when incision of the peritoneum: When cutting to the peritoneum, it should be observed. Intra-abdominal hemorrhage often appears blue through the peritoneum; diffuse peritonitis has hyperemia and edema in the peritoneum. When incision of the peritoneum, attention should be paid to the presence or absence of gas escape, the presence or absence of fluid in the abdominal cavity, and the odor, color, quantity and nature of the effusion. If there is blood outflow, it means that there is a rupture of a substantial organ or blood vessel. In female patients, rupture of ectopic pregnancy should also be considered. If there is gas or gastrointestinal tract, there is a perforation of the hollow organ; If there is fecal odor, the lesions are mostly in the colon or appendix; if there is bile-like fluid overflow, it means that the biliary tract or stomach and duodenum have lesions; if there is rice soup-like liquid, it should be noted whether there is typhoid perforation or peritoneal tuberculosis in the ileum. If there is bloody pulpy fluid overflow in the abdominal cavity, there may be visceral blood circulation disorder (mesenteric vascular embolism, strangulated intestinal obstruction, ovarian cyst pedicle torsion, etc.). In addition, some liquids should be collected for smear and culture to identify pathogens and sensitivity to antibiotics. 4. Clear blood and exudate in the abdominal cavity: After entering the abdominal cavity, first use the aspirator to pump blood, gastrointestinal fluid or exudate in the abdomen. In the case of major bleeding, the bleeding should be controlled by hand pressure while the blood is being pumped. For example, when the liver ruptures, the hepatic hilum is pressed, and when the spleen ruptures, the tail of the pancreas is compressed. If so, it can reduce the amount of blood loss, save the patient's life, reveal the field, easy to explore and operate. 5. Exploration: After clearing the effusion or blood in the abdominal cavity, the intra-abdominal lesions can be explored. The location, steps and focus of the investigation can be determined according to the specific condition. The normal area should be explored first, and the ward should be explored. The investigation should be gentle and meticulous; special attention should be paid to the parts that are easily neglected, such as the posterior wall of the stomach, the small curvature of the stomach, the vicinity of the cardia, and the retroperitoneal part of the duodenum and colon. (1) The general abdominal exploration sequence is as follows: Liver: Slide your hand on the exposed liver surface, touch the toughness, and cooperate with the visual inspection to detect whether the liver is damaged, inflammation, cyst, cancer, hardening or stone. Esophageal hiatus: For patients with pain and swelling in the upper abdomen, it is necessary to explore the esophageal hiatus. Some patients with esophageal hiatal hernia may present these symptoms. First pull the left lobe of the liver to the upper right side with a hook and push the stomach flap to the lower left side with your hand to reveal the cardia. Then use the right finger to palpate whether there is an intra-abdominal organ through the esophageal hiatus into the chest cavity, pay attention to the presence or absence of tumors and inflammatory lesions; and pay attention to the left lobe of the liver with or without tumor and metastatic cancer lesions. Spleen area: patients with abdominal trauma should be routinely examined for the spleen area. The subperitoneal rupture of the spleen does not necessarily show hemorrhage in the abdomen. Only when the spleen is palpated, the subcapsular hemorrhage is found. At this time, spleen suture repair or resection should also be performed. In addition, it is necessary to check the lesions of the spleen of the colon with or without tumors. Stomach: Use the right hand to palpate the entire anterior wall of the stomach from the cardia to the pylorus, the size of the curve, the omentum and lymph nodes. Then make a mouth under the small omentum, and separate the gastric colon ligament from the big curvature of the stomach, and probe the posterior wall of the stomach and the stomach bed itself. Duodenum: Go to the right along the pylorus and explore the presence of ulcer lesions in the duodenal bulb. Penetrating ulcers often have heavier adhesions, and perforated ulcers are surrounded by pus and exudate. Biliary tract: first check the size and tension of the gallbladder, whether there is adhesion, edema, suppuration, gangrene, and whether there are stones in the cavity. Then, use the left hand to extend into the retina hole (winslow hole), palpate the thickness of the common bile duct, with or without stones, surrounded by swollen lymph nodes, adhesions or masses. Pancreas: Lift the transverse colon and press the head, body and tail of the pancreas at the base of the transverse mesenteric finger with your hand pointing upwards and backwards to understand the hardness, presence or absence of nodules and masses. The body part of the pancreas was examined at the incision of the gastric ligament. If necessary, the duodenal descending portion can be separated to reveal the head of the pancreas. Small intestine: After the transverse colon and its mesentery are pulled upward, the duodenal suspensory ligament (treitz ligament) is diagnosed, and the duodenal jejunum is presented. According to the condition, the ileocecal valve is inspected from the beginning of the jejunum. While examining the small intestine, check the corresponding mesenteric for blood circulation disorders. During the examination, the examined intestines should be returned to the abdominal cavity in time. Appendix and ascending colon: Pay special attention to the appendix when acute peritonitis. First find the ileocecal area, look for the appendix to the cecum, and you can see the appendix. Then, explore the ascending colon and pay attention to the right kidney and right ureter with or without lesions. Transverse colon and omentum: lift the omentum and the transverse colon upwards, check the omentum for necrosis or metastasis, sometimes the omentum and other organs are stuck, and also need to check for possible internal hemorrhoids and intestinal obstruction. Wait. From the liver to the spleen, the transverse colon was examined for tumor, stenosis or obstruction. Colon, colon and rectum: focus on the presence or absence of stenosis, obstruction, mass, inflammatory lesions and diverticulum, and at the same time explore the left kidney and ureter. Bladder, uterus, and appendages: The surgeon puts the hand into the pelvis and examines the bladder. Women must check the uterus, fallopian tubes and ovaries; in the case of suspected ectopic pregnancy, the attachment must be checked. (2) Abdominal trauma exploration principle: If there is a large amount of bleeding in the abdominal cavity, the source of the bleeding should be searched first, the bleeding should be controlled, and then the other organs should be explored step by step by the bleeding organ. If there is no bleeding in the abdominal cavity, but there is gastrointestinal content and gas spillover, first explore the gastrointestinal tract, and then explore the various organs. The general order is to first probe the stomach, duodenum, biliary tract, pancreas, jejunum, ileum, colon, rectum, bladder, etc., then check the liver and spleen, and finally explore the pelvic organs and retroperitoneal organs. (3) Points for attention in the exploration of acute peritonitis: the normal area should be explored first, and finally the ward should be explored. The omentum often adheres to the severe lesions, and the abscess is mostly located at the lesion. Saponification points on the omentum and mesentery are characteristic manifestations of acute pancreatitis; if there is congestion of the intestinal wall, hypertrophy of the edema, and expansion of the intestine, the possibility of intestinal obstruction should be considered. (4) Steps for the exploration of acute upper gastrointestinal bleeding: 1) First check if it is a gastroduodenal ulcer or esophageal varices bleeding. After entering the abdominal cavity, check for ascites, whether the liver and spleen are normal. Initially determine whether there is esophageal varices. Then from the stomach pylorus along the stomach size to the Tuen Mun to detect the presence or absence of ulcers, this is the most direct way to determine the bleeding of gastroduodenal ulcer. Ulcers that are easily negligent are in the posterior wall of the stomach, the cardia, and the bottom of the stomach. If necessary, they should enter the small omental sac and probe from the posterior wall of the stomach. A gastric ulcer that penetrates the posterior wall of the stomach into the pancreas can only be discovered in this case. From the pylorus to the Tuen Mun Department, you can find the bleeding caused by gastric cancer, which is one of the common causes of upper digestive bleeding. 2) When the above detection is negative, the biliary tract should be explored. When there is bleeding in the biliary tract, it often has a gallbladder and a common bile duct that is full of blood. Biliary hemorrhage can be determined by puncture and taking blood or bloody bile from the gallbladder or common bile duct. Pay attention to the puncture of the common bile duct should not be too deep, so as not to accidentally enter the vein, causing judgment errors. 3) Ulcers can occur in the duodenal bulb or in other parts of the duodenum. Therefore, if the biliary exploration is negative, all duodenum should be explored. The method is to cut the peritoneum on the outside of the descending part of the duodenum and separate into the posterior side of the descending part; by cutting the right side of the root of the transverse mesenteric, the horizontal part of the duodenum can be revealed; the depth of the lower part of the horizontal part can reach the horizontal part. rear. This can find out whether there are ulcers, tumors or diverticulum in the first, second and third segments of the duodenum. These can all be the cause of major bleeding. 4) Upper jejunum lesions of the duodenal suspensory ligament (tuberculosis, tumor, diverticulum, ectopic pancreas, etc.). Sometimes it is also the cause of major bleeding in the upper digestive tract and cannot be missed. 5) When the above tests are all negative, the stomach should be cut open to explore the stomach. The incision in the anterior wall of the stomach should be larger. If there is a large amount of blood in the stomach, the emptying should be quickly exhausted, and the incision of the stomach wall should be pulled open with a tractor to make most of the stomach clearly visible. If the bleeding has not stopped at the time of exploration, you can see the blood rushing out from the bleeding area. If you can't directly see the bleeding point, you can first determine whether the bleeding is from the cardia or the pylorus direction to further check the bleeding up or down. Esophageal varices bleeding, blood can continue to flow from the cardia into the stomach, showing that the submucosal varicose veins at the cardia are as thick as the little finger, similar to the anal fistula. You should also pay attention to whether there are lacerations, ulcers or tumors caused by vomiting in the cardia. Fingers can be detected by the cardia extending into the lower end of the esophagus. In addition to ulcers in the stomach, hemorrhagic lesions are also caused by hemorrhagic gastritis, stress ulcers and arteriosclerosis caused by arteriosclerosis. 6) When there is no problem in the lower end of the esophagus and in the stomach, the duodenum can be examined through the pylorus. Use your fingers to enter the duodenum through the pylorus, and use another finger to check the outside. Can also be inserted into the duodenum through a pylorus through a pyloric catheter, exhausted blood, and then suction to determine the location of the bleeding, clear the site and then open the anterior wall of the duodenum to find bleeding lesions. It can also be examined by pyloric insertion of a fiber choledochoscope. 7) Ectopic pancreas is one of the causes of bleeding that is easily detected. The ectopic pancreas is located under the mucosa, the appearance is slightly higher than the surrounding area, the color is lighter and softer, and it is easy to be neglected when the bleeding stops, so it must be carefully searched. (5) Method of exploration of abdominal mass: The purpose of the exploration is to determine the nature and source of the mass, the relationship between the mass and the surrounding organs or tissues, and whether it can be removed. Before performing local exploration, you can explore nearby or related parts as needed to avoid focusing your attention on the local area and ignoring important changes around you. Malignant tumors should be checked for liver metastasis, and there is no metastasis before or after the rectum. When it is found that there are multiple metastatic malignant tumors, local deep exploration should not be conducted. If the mass of the mass is large and involves a wide range, it is impossible to find out the source, the relationship with the organ and whether it can be removed, but it can quickly find out the activity, cystic or substantial of the mass; The essence is hard (mainly fibrous tissue), soft (slurry can be sucked out by thick needles); there is no gap between the surrounding tissue; the nature of the mass and the surrounding blood supply is rich; whether there are important tissues connected to it, such as the upper right The duodenal ligament of the abdomen, the superior mesenteric artery in the middle and upper abdomen, the abdominal aorta and inferior vena cava in the middle abdomen, the ureter on both sides, and the radial artery in the lower abdomen. The above organizations should avoid damage during exploration. After identifying the above, you can decide whether further exploration is needed. Further exploration begins with the marginal part of the unimportant organization, gradually expanding and approaching the deep and inner sides. In the following cases, the mass can not be removed: the mass wrapped around the abdominal aorta or inferior vena cava, can not be separated; surrounded by mesenteric artery, vein, can not be separated; surrounded by hepatoduodenal ligament or invasion of the liver can not be separated; Partially invade the surrounding abdominal wall and there is no gap to separate. When exploring a large tubular tissue, it is necessary to determine whether it is a blood vessel. If you can't recognize whether a large blood vessel is a blood vessel that supplies a mass, you should first use a finger squeeze or a non-invasive clamp to temporarily block it to observe the intestinal blood flow or distal blood supply. Cut off the ligation. If the mass invades the ureter or iliac vessels, complete resection may be considered when necessary and the following conditions: the contralateral kidney is normal, the ureteral defect can be replaced with the intestine, and an artificial vascular of equal size can replace the radial artery. When separating a lump, the most difficult, dangerous, and unsure part should be left for final treatment. In this way, even if most of the mass has been separated and finally found to be inoperable, the surgery can be stopped, otherwise the mass can not be removed and the important tissue has been damaged, which can make the operation in a difficult situation. Larger masses, often in the process of exploration and separation, gradually recognize the relationship with the surrounding organs or tissues, and gradually clear the possibility of resection. It is often not until the separation is completed that the source of the mass is determined when the lump is removed. Some lumps can be clearly defined after exposure, without exploration, such as pancreatic pseudocyst, hepatic cyst, gallbladder hydrops, etc., according to the condition, the necessary surgical treatment. Sometimes the nature of the mass is clear, there is no adhesion around, and it is still necessary to explore to determine whether it can be removed. If the liver cancer is to be detected, the contralateral hepatic lobe and each hepatic portal are negative. (6) Exploring the acute intestinal obstruction: 1) When the peritoneum is dissected, if there is a small amount of grass yellow clear liquid, it may be caused by swelling of the intestinal lumen, lymphatic and venous return; if there is bloody and odorous liquid in the abdominal cavity, the strangulated intestinal obstruction should be considered. Exist; if there is gas in the abdominal cavity, and there are feces and mites, it can be judged that the intestinal necrosis is undoubted. After laparotomy, look for the site of obstructive lesions, the signs are: the heavier the expansion of the intestine, the more obvious the change in color; the junction of the inflated and collapsed intestines. When searching, apply a warm saline gauze pad around the incision, gently inscribe the intestine tube one by one, and explore the swelling and discoloration more and more until the main lesion is found. The intestinal wall can become brittle due to inflammation, and it is easy to be torn. Therefore, the operation should be gentle, not strong, and the intestines of the narrowed necrosis should be more careful. When the main part of the lesion is fixed in the abdominal cavity and can not be revealed or proposed outside the incision, the proximally inflated intestine should be decompressed for further exploration. Due to the exploration, the intestines outside the incision should not be too much, so as to prevent the amount of liquid in the intestine from being too large, the pulling of the mesentery is pressed against the edge of the incision, which seriously hinders the venous return, and the intestinal wall can thus become purple-black. The bowel decompression should be performed quickly and the intestinal effusion should be aspirated. 2) When obstruction is caused by adhesion, the adhesion must be separated first. When separating the adhesion, apply the sharpener, do not damage the serosal layer of the intestine, and bluntly separate the fingers to break the intestinal wall. 3) Because of the twisting and nesting of the intestines, it is best to take out the incision and then handle it. Never tear the brittle bowel wall. If the intestinal fluid enters the abdominal cavity, it can often cause severe shock. 4) When it is found that the intestine is twisted, it should be quickly reset in the opposite direction. The direction and the degree of twist should be distinguished to avoid aggravation or incomplete reduction. 5) After the lesion is removed, due to the temporary obstruction of the intestinal blood supply and suspected necrosis, it should be coated with warm cocaine water wet gauze pad, and the mesentery is blocked with procaine (0.25% procaine in the mesenteric root) 100 to 200 ml), etc., after 3 to 5 minutes, observe the change in color, the recovery of peristalsis, and whether the artery supplying the intestine is beating. Unless it returns to normal, it should be removed if it is suspicious. 6) Where there is colon expansion, suspected and colonic obstruction, you can first observe the cecum, the middle part of the transverse colon and the sigmoid colon. The lesion should be between the swollen intestine and the normal intestine. If between the cecum and the middle part of the transverse colon, the ascending colon and the transectal liver should be explored. When the transverse colon and the sigmoid colon are between the spleen and the descending colon. 7) In addition to the common causes of obstruction, the rare causes should not be overlooked, such as incarceration, incarceration of intestinal wall, and incarceration of various internal hemorrhoids. 8) When the lesion is found, the exploration can only be completed when the normal intestinal segment and the swollen intestine segment of the lesion are seen to the lesion. 6. Treatment of lesions (1) For patients with abdominal injuries, the location, extent and extent of the injury should be determined and disposed of. Spleen rupture and spleen suture repair or resection; liver rupture suture repair, wedge resection or hepatic resection, if the patient's condition does not allow liver resection and other methods can not stop bleeding, hepatic artery ligation can be performed; Repair or resection; severe colon injury should be performed first. (2) For patients with peritonitis, eliminating the source of inflammation is a major aspect of treatment. Such as appendicitis, Meckel diverticulitis should be removed as much as possible; cholecystitis, cholangitis should be sputum drainage; gastrointestinal perforation should be suture repair or resection. If it is primary peritonitis, the pus should be aspirated as much as possible, the abdominal cavity should be cleaned, and cigarettes should be placed in the lower abdomen. (3) Upper gastrointestinal bleeding should be sutured or resected according to the cause of bleeding to achieve the purpose of stopping bleeding. 1) Unresectable ulcer bleeding, simple suture can not guarantee no longer bleeding, should be removed as far as possible outside the gastrointestinal tract, and covered with surrounding tissue ulcers, plus partial resection of the stomach to ensure no longer bleeding. 2) Esophageal varices bleeding in the bottom of the stomach for vascular ligation, the recent effect is not certain, should be added splenectomy or gastric transection. 3) Biliary hemorrhage after the common bile duct drainage surgery to stop bleeding, but the effect is not certain. If there is a large amount of blood in the gallbladder, the gallbladder should be removed while the common bile duct is drained, and the hepatic artery should be ligated. 4) bleeding from the cardia or high-grade small-bend ulcer, the upper end of the stomach should be performed. The abdominal incision should be changed into a chest-abdominal incision. The diaphragm is cut open, the lesion is removed, and the stomach is lifted into the chest to match the lower end of the esophagus. If the probe is negative, blind abdominal resection is not enough, because superficial ulcers, hemorrhagic gastritis and other lesions often spread throughout the stomach, the removal of part of the body can not stop bleeding. If the lesion is not within the scope of resection, it will not be able to stop bleeding. Blind resection will increase the unnecessary burden of the patient and make the already critical condition worse. If necessary, vagus nerve cutting and pyloric angioplasty can be performed, and the effect can be observed. (4) For the treatment of abdominal masses, the process of actually separating the masses is the process of excision. After the exploration is completed, the tumor can be removed or the disease that has been confirmed can be removed, or the operation can be stopped without clearing the tumor. For the surrounding tissue connected to the mass, when it is damaged during the exploration and separation process, it should be treated according to the principle that it can be supplemented and replenished. If the common bile duct or ureter is damaged and cannot be end-to-end anastomosis, a free segment of the intestine can be used instead. If the blood vessel is damaged and the end end is not matched, the artificial blood vessel can be used instead. (5) patients with intestinal obstruction should be treated according to the cause of the disease, such as adhesion loosening, nesting and returning, torsion reduction, internal hemorrhoids and repair, tumor resection caused by obstruction or clear necrotic bowel resection. Due to the severe extensive adhesive intestinal obstruction caused by multiple operations, small intestine folding should be considered after separation of adhesions and obstruction. All small intestinal necrosis is most difficult to treat due to total small intestine torsion. If it is indeed necrotic, only the resection can temporarily save the life, and then according to the survival of the small intestine tube for reverse surgery, or artificial sphincter surgery. In order to ensure that the repaired and resected anastomosis of the intestine is well healed, the decompression of the intestine should be considered. The proximal end of the gastrointestinal decompression tube can be passed through the pylorus, from the upper to the intestine requiring decompression; the lower end of the intestine can be inserted into the stomach. The intestinal decompression tube is introduced into the intestinal tube requiring decompression through the ileocecal valve to ensure that the local part does not swell and rupture into a sputum. All aphids in the small intestine should be removed through a decompression or pushed into the colon to prevent the anastomosis from being broken due to aphid activity. 7. Clean the abdominal cavity: After the organ damage treatment, the blood, intestinal fluid, feces, tissue fragments, foreign bodies, etc. in the abdominal cavity should be removed as much as possible, and then the abdominal cavity should be flushed with isotonic saline until the rinsed saline is clarified, and as far as possible Suck the water. When washing, pay attention to the underarms, colonic sulcus and pelvic cavity, etc., do not allow the accumulation of dirty liquid. If the abdominal cavity is not heavy, the abdominal cavity can be washed with saline. If the abscess has formed in the abdominal cavity, or the inflammation has been limited, the saline will not be washed after the pus is exhausted to avoid spreading the infection. Regarding the application of antibiotics in the abdominal cavity, if the abdominal cavity is lightly polluted or there is no damage to the hollow organ, it is not necessary to infuse antibiotics. However, if the intra-abdominal contamination is serious, or there is damage to the hollow organ, especially in the case of colon injury, a low concentration of antibiotic solution can be placed into the abdominal cavity after end-operative intra-abdominal surgery, such as cephalosporins or aminoglycosides, dissolved in physiological saline. Instill into the abdominal cavity, or rinse the abdominal cavity with 1% metronidazole solution. After the patient with peritonitis clears the pathogen, if the condition allows, try to absorb the pus and clean the abdominal cavity. Abdominal flushing and intra-abdominal application of antibiotics are carried out in accordance with the above principles. 8. Abdominal drainage: patients with abdominal trauma in the following cases must be placed in abdominal drainage: 1 liver injury; 2 after splenectomy; 3 biliary tract injury; 4 hollow organ injury, especially rupture of extraperitoneal cavity; 5 injury There is more than bleeding; 6 sutures may be healed, or may form a sputum. For patients with peritonitis, most patients need abdominal drainage after operation. The indications are: 1 inflammatory lesions that cannot be removed, such as those who can not be removed by perforation of the appendix; 2 the lesion has been removed, but the suture is not due to obvious inflammation changes in the surrounding tissue. Prison, may be leaking; 3 infection after retroperitoneal (including incision of the pancreas or duodenum); 4 finite local abscess formation in the peritoneum; 5 gastrointestinal tract anastomosis and anastomotic suspected leakage By. After the large lump that has adhesion to the surrounding area is removed, the part should also be placed in drainage. The drainage strips may depend on the organ being damaged, the nature of the fluid flowing out of the abdominal cavity, and the extent of contamination. For bile sputum, small intestine fistula, and pancreatic fistula, which may form a large amount of digestive juice, double cannula can be placed under the armpit, under the liver or in the pelvis to continue to attract, or a soft hose with a larger diameter can be used for drainage; Peritonitis, which is less polluted and has been treated as a source of disease, can be drained by cigarettes. The drainage strip should be drawn at the other side of the abdominal wall, and should not be led out through the original wound or the exploration incision. The drainage port should be large enough that the drainage strip should be fixed to the abdominal wall with sutures or fixed with a safety needle to prevent it from coming out or sliding into the abdominal cavity. 9. Incision suture: Generally, the incision should be sutured in one stage. Those with mild contamination of the incision can be washed with saline and sutured. If the incision is seriously polluted, the wound is irrigated or extracutaneously or subcutaneously, or the rubber sheets are drained at both places, and the incision is sutured. For anemia, hypoproteinemia, intra-abdominal infection, elderly, critically ill patients, it is estimated that patients with poor postoperative healing may be added as extraperitoneal incision sutures to avoid postoperative wound rupture.

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