外科學(xué)第七版（The seventh edition of surgery）

外科學(xué)第七版(Theseventheditionofsurgery)

Chapterlaseptictechnique

Sterilization(Physics)-killsalllivingmicroorganisms

Disinfection(Chemistry)-antibacterialagainstpathogenic

microorganismsandharmfulmicroorganisms

Allmicroorganismsarenotrequiredtokill

Operatingrules

Sterilization,toxic,(surgicalinstruments/articles)

Highpressuresteammethod

Boilingmethod

Burningmethod

Drugimmersionmethod

Heavyformaldehydefumigation

Brusharm,upperarm10cm

Surgicalareadisinfection,incisionaround15cm,cleaning

centeroutside,infectionwound,outside.

Chapter2hydropowerbalance

Bodyfluid,water+solute(electrolyteandnonelectrolyte)

Bodyfluidbalance-acompositionthatisinarelatively

constantstate(dynamicequilibrium)

Bodyfluidvolume:adultmalesare60%,females50%,chiIdren

80%.

Fluid:Cinternalsolution(40%)

Cexternalfluid(20%)-plasma5%,interstitialfluid(15%

(functionalCexternalfluid,nonfunctionalCexternalfluid)

Cationicmg/Lanionicmg/L

Na+142CL103

K+5H2g27

Ca5HP04g22

Mg2was1

Two,theregulationofbodyfluidbalance

(1)waterbalance:kidneyregulation

(two)balanceregulationofelectrolytes;

Thenormalvalueof1,sodium142145mmol/L

Intake(ML)anddischarge(ML)

Drinkingwater,1000^1500,urine,1000^1500

Thefoodcontains700dungand150

Theoxidationoffoodrawwater300skinevaporation500

Breathe350

Total:2000?2500total:2000?2500

2,potassium(1)98%waslessincell(2)cellthaninouter

solution,butimportantin3.5~5.5mmol/L

(3)theabilityofkidneytoregulateK+isverylow

3,ClHC03(1)orthemutualcompensation

(2)[HCO3-]isthebaseforstoringalkaliandregulating

acid-basebalance

Three,themetabolicimbalanceofwaterandelectricity

(I)dehydration

1,hypertonicdehydration(primarydehydration)

(1)thelackofwater>serumsodiumfluidisNacellhypertonic

(2)thecauseofdiseaseisprofusesweatingandinsufficient

waterintake

(3)thebodyfluidiseasytochange

(4)clinicalmanifestation;

(5)treatment:(1)drinkingwater(2)staticinto5%Gor

0.45%GS;

2,hypotonicdehydration(chronicdehydration,secondary

dehydration)

(1)sodiumdeficiency>waterdeficiency,serumNa+cell,low

fluidinfiltration,celledema

(2)causeofdisease:1.Losingliquid;drinkingplentyof

boiledwater

(3)changeofvolumeofbodyfluid:cell,cellsolutionof

externalfluid

(4)clinicalmanifestations:(1)early130-140mmol/L;

Metaphase120-130mmol/L

Severe“120mmol/L”

(5)treatment:1.Moderatetomoderatesodiumdeficiency,5%GNS,

200t+dailyrequirement2000t

Severe3%~5%Nacl

3,isotonicdehydration(acutedehydration,mixeddehydration)

(1)surgeryisthemostcommonlyused,twosodiumloss,serum

Na+,osmoticpressureinthenormalrange

(2)causeofdisease:massivelossofdigestivejuice

(intestinalobstruction,peritonitis,vomiting)

(3)changeofbodyfluid

(4)clinicalmanifestation

(5)treatment:balancedsaltsolution3000,5000t;

Hypertonichypotonicinfiltration

Thirstwasevidentwithoutmildorobvious

Skinelasticitycanbeextremelypoor

Themucosaisdryanddry

Thepulseisslightlyfasterornormalfastfast

Thebloodpressurecanbenormalandlow

Verylittleurine,lessnormal(lessadvanced)

(two)lowpotassiumwhitemark

1serumpotassium<3.5mmol/L

2,etiology:(1)insufficientintake-long-termfasting

(2)excessiveloss-gastrointestinalfistula,vomiting,

diureticsandalkalosis

(3)abnormaldistribution-glucose+insulininput

3、clinicalmanifestation:

AbsenceofK+triad(1),lackofexpression,weaknessofmuscle

(2)abdominaldistension,decreasedbowe1sounds

(3)muffled,flattenedTwave,Uwave

4,treatment:(1)strivefororal

(2)seeurinarysupplementK+

ThesupplementofK+(3)concentrationisappropriate

(4)donotdripquickly

(5)controltotalamount;

Hyperkalemia

(1)serumK+>5.5mmol/L;

(2)manifestation:asthenia,flaccidparalysis,bradycardia,

andTwaveapex

Hypocalcemia

1,serumcalciumislessthan2mmol/L(8mg/dl)

2,theetiologyofacutepancreatitis,intestinalfistula,

parathyroidinsufficiency

3,N-M=excitatorymouthnumbnessfoottwitchChwsteksign(+)

Trouseau(+)sign

4,treatment:makeupCa2+

(I)maintenanceofacid-basebalance

Normalbloodweaklyalkaline:PHis7.35-7.45

1.Bloodbuffersystem:Hco3":H2co3=20:1

2,theregulationofthelungs:C02discharge,speeduporslow

down

3,theregulationofthekidney:H+discharge

(two)substitutionofacid

1,causeperitonitis,shock,intestinalfistula,intestinal

obstruction

2:Performance:deepbreathing,breath,ketoneflavor,facial

flushing,oftenaccompaniedbydehydrationsymptoms

3,treatment:(1)correctdehydration

(2)C02,CP<35vol/dl,HCO3-<10mmol/larealkaline

Intravenousinjectionofsolution(NaHco3,THAM)

(three)substitutebase

1,etiology:pyloricobstruction,intothelye,lowK+blood,

diuretic(lowalowK+alkalosis)

2,performance:handandfootconvulsions,alkalineurineor

abnormalacidicurine

C02CPfreeG2+:pHHCO5

3,treatment:enterNS,5%GNS,fillK+

Respiratoryobstruction,emphysema,pneumonia,pulmonary

trauma,ventilation

(five)callingalkali

HyperventilationorARDSprecursorreducesC02excretionby

ventilator

Anionbarrier,P043-3,S042-5

Chapter3transfusion

Autotransfusion

Bloodcomponentpreparation:bloodcomponentproducts

Bloodtransfusionreaction:1,feverreaction:causeheat

source,slowdropfever

2,allergicreactions:allergic,antiallergic

3,hemolyticreaction:bloodtypedoesnotmatch

Performance:(1)afterenteringmorethan10ml,chills,high

fever,dyspnea,lowbackpain

(2)hemoglobinuria,oliguria,oliguria,andacuterenal

failure

(3)hemolyticjaundice(4)delayedhemolysis,1-2Wafterblood

transfusion;

Treatment:stoptransfusion,preservekidney(Hbdissolve

crystal,preventrenaltubuleembolism),resistshock

Chapter4shock(shock)

First,theconcept:effectivecirculationofblood,easyto

organizebloodflowinsufficiency,cellmetabolicdisorder

Cellfunctionimpaired

Two.Classification:(1)hypovolemicshock

Hemorrhagicshock,hemorrhagicshock

(two)emotionalshock,highpowertype(highrank,low

resistancetype,warmshock)

Lowpowertype(lowrank,highresistancetype,coldshock)

Three,commonlyusedindicators:thepresenceofshock,

SBP<90mmHg,pulsepressure<20mmHg

Earlyshock,<30ml/h<shockcorrection,oliguria,<400t/24h,

oliguria,<100t/24h

Centralvenouspressure(CVP),5~10cmH20

CVP<5cmH20,insufficientbloodvolume,CVP>15cmH20heart

dysfunction

Pulmonarycapillarywedgepressure(PCWP)

Chaptersanesthesia(anethesia)

Cardiopulmonaryresuscitation,CPR,CPCR

Chapter6tumor

First,theincidence:lung,stomach,milk,liver,intestines

-thecity,stomach,liver,lung,food,intestines-Rural

Two.Classification:whetherthereisinfiltration,growthor

metastasisaccordingtothedegreeofhistological

differentiation

Three,etiology:Occupation-asbestos,radiation,benzene

Biologicalfactors-viruses,bacteria(stomach,liver,

lymphoma,nasopharynx)

Lifestyle-tobaccoleaves(lungs,pancreas,bladder,kidney),

nitrates,fungi(stomach,liver),aflatoxin,Aspergillus

flavus,etc..

Four,indicators:alkalinephosphataseE(AKP):liverCaand

osteosarcoma,blockingyellow

LDH:hepaticCaandmalignantlymphoma

Careinoembryonicantigen(CEA):colon,stomach,lung,milk,Ca

2embryonicantigen(AFP):hepaticCa,embryonaltumor

Chapter?surgicalnutrition

Energyrequirement:104.6KJ(25KCal)/Kg.d

Protein:18/kg.d~,nitrogen,0.15g/kg.d

(I)parenteralnutrition(PN)glucose;

Fatemulsion10%,fatmilkcontainingheat4.18KJ(IKcal/ml)

Compoundaminoacidsolution

Electrolytes,vitamins,traceelementsandcompoundnutrient

solution(3Lbag)(ww.medkaoyan.com)

Complication:technique:blood,pneumothorax,airembolism

Metabolic:electrolytedisorders,hyperglycemia,hypoglycemia

Hyperosmolarnonketoticcoma,bloodglucoseconcentration,

40mmo/Ll

Hypertonicdiuresis:water:intravasculardischargeinthe

tissues

Celldehydration,N,cell,mention,coma

Infection:catheterinfection

(two)enteralnutrition(EN);

Conformstothephysiologicalprocessandpromotestheliver

andintestinalmucosafunction

Concentration:24%energy4.18Kg(Ikcal/ml)

Inputs:mouth,nasalfeeding,jejunum

Complications:aspiration,abdominaldistentionanddiarrhea

Indications:gastrointestinalfunctionisnormal,intakeis

not,gastrointestinaldysfunction,gastrointestinalfistula,

gastrointestinalfunctionisnormal,butotherorgansarenot

normal.

ExogenousinfectionofChapters

Sepsis-asurgicalinfectioncharacterizedbysystemic

inflammatoryresponse,suchastemperature,respiration,and

circulatorychanges

Sepsissyndrome-

Systemicinflammatoryresponsesyndrome:thetemperatureis

higherthan38DEGCorlessthan36degreesCelsius,heartrate

90beats/min

Pa02<32mmng>20beats/minbreathing

WBCcount:>12*109/Lor<4*109/C

Orimmaturegranulecell<10%

Erysipelas:meshlymphangitis(intradermal)lymphadenitis

cellulitis:furuncleandcarbuncle.

Tetanus:tetanustoxininjection,exotoxin,automaticimmune

Temporarytreatment:passiveimmunity,TAT

Clinicalsymptoms:systemicsymptoms,dizziness,fatigue

Twitchmusclesandorder

Chapter9multipleorgandysfunctionsyndrome

(mlatiple,oraan,dysfuntion,syndrome,MODS)

Heartfailure,ARF,ARDS,lungfailure

Peripheralcirculationshock,brain,gastrointestinal,stress

ulcer

ChapterlOburns(Burn)

Severityindex:light,moderate,severe

Estimationofburnarea:thenewninepointsmethodandthepalm

method

Burndepth:Idegrees,superficial2nddegree,deepsecond

degreeandthirddegreeburn

Burnpatients:1,exudateperiod(shockphase)

2,deepfeeling(2-3weeksafterinjury)

3,repairperiod:Idegrees,superficialseconddegree

self-healingskingraftingfusionrepair

Treatment:bodyfluidtherapy,24hafterinjury,1%,2degrees,

3degrees,1.5ml/kg,BWcrystaladhesive=2:1,plusbasicwater

5%GDD200ml

Chapterllneckdisease

I.appliedanatomyofthethyroidgland

Two.Secretionandregulationofthyroxine

Three、thyroidadenoma

Nodulargoiter:multiplenodules,follicularorcystic

bleeding,thyroidpreparationshavesomeutility,indications:

secondaryhyperthyroidism,malignantchange,compression

symptoms

Four.Hyperthyroidism

(1)mainsymptoms:

(two)diagnosis:T3,T4,TSH;

(four)treatment;medicine,radioactiveiodine131;operation;

preparationoforaliodinebeforeoperation.FNaylor

hydrochloride(propranolol)

Surgery:anesthesia,cervicalplexus,generalanesthesia,

Duringoperation:thethyroidgland,theinnercapsuleandthe

innermembrane:oneisAandtheotherisclosetothenail(N

onthethroat)

UnderaA-shippedoffa(antithroatN)

Resectionof80~90%

Complication:pharynxpharynxthroattwoNinternalvoicelow

-theupperNbranchofthelarynx

Hoarseness-laryngealNasphyxia

Five.ThyroidCa

PapillaryglandCa:30-45yislowevil

FollicularglandCa:50y,evilinabout

Bloodmetastasis,lungandliverbone33%,lymphnode

metastasis10%

UndifferentiatedCa:70y,highevil

MedullaryCa:calcitoninsecretioncell,serumcalciumdown

Six、chroniclymphthyroiddisease(Joe'sdisease,Hashimoto

thyroiditis)

Autoimmunedisease:30-50yearsold

Diagnosis:antithyroglobulinPrantibody(TG),antithyroid

microsomalantibody(TM)

Treatment:exceptformalignantdiseases,includinglymphoma,

long-termthyroidpreparationsareeffective.

Seven,parathyroidhormoneinto

Feedbackregulation

Ca2+:=Ca2+

Parathyroidhormone(PTH+calcium)=stimulationinhibition

decreases

Antiparathyroidhormone(calcitonin)inhibitedthe

stimulationupdown

Primaryhyperparathyroidism:solitaryadenoma80%,adjacent

glandCa1%

Multiplehyperplasia12%

Clinicalfeatures:urinarycalculi-alkalineurine,calcium

stones

Osteoporosis-decalcification

Thetumorwasresectedand1/4wasretainedduringhyperplasia

Chapterl2breastdisease

Acutemastitis

(1)etiology:accumulationofmilk-milkbacteriainvasion-

skinlesions,nippledepression

(two)treatment:theuseofdrugs

Disable:

2.breastcystichyperplasiaandmilkCadistinguish,except

malignantchange,femaleHantagonism

3.-20-25y15breastfibroadenoma,30

4.intraductalpapilloma,40-45y,malignanttransformation

rate6-8%

5.breastCa:local,Cooper,lig,dimplesign*"

Blockageoflymphnodes:"cinnamon"sign"

Lymphaticdrainage:popliteal,subclavian,supraclavicular

Sternal

Milkroom

Deepsettoliver(rectussheath,liver,sickle1igament)

Hematogenousmetastasis,lung,boneandliver

Incidence:45-55Yurbanfemalefirst

Physicalexamination：

Diagnosis:mammography,needleaspiration,freezing

TNMstaging:0-2cm-5cm,TO,Tl,T2

Aslongasthereislymphnodemetastasis,thatis,IIphase

SimilarbreastCa:radiotherapyandreoperation

Treatment:trends,modifiedradicalmastectomy+combined

therapy

Retentionofmilkandsentinellymphnode

Endocrine:ER,PRthree,benzenechloraminemorethan2years

Chapter13externalabdominalhernia

1.Etiology:lowerabdominalwallstrength,

Increasedintra-abdominalpressure,cough,constipation,

dysuriathreemajorfactors

Ascites,pregnancy,etc

Two,anatomy:theherniasac,neck,body,hernia,hernia

triangle

Three,type:easytocomplextype,complextype,incarceration,

strangulation

Slidinghernia,herniaofintestinalwall,retrograde

incarceratedhernia,Litterhernia(Mecke11diverticulum)

Four,directinguinalhernia:identification:(40-50ymore

women)

Five,nonoperativetreatment:1yearsold,infirm,truss

Trendsinsurgicaltreatment:Bassini,Shouldice,Mcvayplasty

Tension-freelaparoscopy

Thetreatmentofincarceratedherniastrangulation:no-also

satisfied,preventintestinalobstruction

Thereisstrangulation-resection

Chapterl4abdominalinjuries(abslominal,injury)

Sharpinstrumentinjury-whethertopenetratetheabdominal

wallanddecidewhethertoopentheabdomenornot

Thefirstisbluntinjury-diagnosis

Hollowvisceraofparenchymalorgans

Laboratorydiagnosis:WBCHbstarchE

X-raygas

Treatment:spleen,allcolon-ostomy,liversuture,small

intestine-suture,cut,kiss

Sutureanddrainageofpancreas

Chapterl5ileus(intestinal,obstmcfion)

Intestinalcontentsdonotpassthroughtheintestinessmoothly

Etiology:(1)mechanicalintestinalobstruction:

1,intestinalcavityfilling,polyp,intussusception,

gallstone,fecallump,fecalstone

2,intestinalitselflesions,tumoratresia

3.Extraintestinalcompression:adhesions,hernias,and

tumors

Pathogenesis:simpleintestinalobstruction

Completeintestinalobstruction

Strangulatedintestinalobstruction

High,middleandlowobstruction

Closedloopintestinalobstruction

Diagnosis:(1)symptoms:abdominalpain,abdominaldistension,

vomiting,stopdefecation,exhaust

(2)ask:isthereanyobstruction?Ormechanicalparalysis

simpleorstrangulation

Highorlow;acompleteorincompletecause:

(3)signs:surgicalparalysis,peristalsis,incarcerated

hernia,abdominalpain,tenderness,bowelsounds,rectal

examination

(4)influencestudy:(1)gas-liquidplane;ringfolds;colon

bags;centerorallround

(3)mechanicalorparalysis(4)circularoverlaying,spring

shape,gobletintussusception(5)volvulus

(two)strangulatedintestinalobstruction

Continuousaggravationofintermittentabdominalpain,

abdominaldistension,asymmetry,WBCcountup

Foundbloodyfluid:vomitdischargeorperitonealpuncture

solution

X-rayisnotanarcorswellingoftheintestinalloop

Treatment:(1)gastrointestinaldecompression

IVinfusion:correctwaterandelectrolytedisorders

(2)operationmethod:adhesionexcisionorrelease

Distalintestinalobstructionanastomosis

Intestinalfistula

(three)adhesiveileus:historyofsurgery,inflammation,or

trauma

Manyaresimple,fewarenarrow

(four)intussusception:abdominalpain,bloodystool,X-ray,

massspringshapedcup

(five):inthehistoryofmotionofvolvulusinyoungadults

withsatiation

Volvulusofthesigmoidcolonismorecommonintheelderlyand

constipation

Beaklikex

Surgicaltreatmentisrequired,andnonoperativetreatmentcan

beperformedforcolonicvolvulus

TheintestinalmembraneAinfarctionsymptomsisnotobvious,

butWBC==

Ascarisintestinalobstruction:goodhairinchildren,

abdominaldistensionisnotobvious,abdominalmuscleisnot

tense

Chapter16portalhypertension

Anatomyandphysiology:13-24cmH2o

Thereare4communicatingbranchesoftheportalVandthe

cavityV:

Two、pathology:90%livercirrhosisafterlivertype

Splenomegaly,hypersplenism(WBC:PTC)-blood

Communicatingbranchdilatation-1owergastricvarices,V

bleeding

AscitesportalVhighpressuredecrease,increase,lymphatic

capillaryfiltrationpressureincrease

LowPrInter,colloidosmoticpressuredecreases

Aldosteroneincreases

Gradingofliverfunction(Childclassification)

ABC

Whiteclear(whitePR)>3530-35<30reactionlowestminimum

Ascitesisfew,easytocontrol,difficulttocontrol

Three,treatment:(1)themostcommoncomplicationsof

gastrointestinalbleeding

Surgicaltreatment:shuntanddevascularization

Devascularization-doesnotaffecthepaticinflowshunt-

reducesportalVpressure

Chapterl7hepaticCa(HCCandsecondarytwo)

Liversymptoms:AFP=400ug/LBUS(b)

Hepatectomy;hepaticAinfusionchemotherapyembolization

therapy

Chepter18biliarytractdisease

Anatomicphysiology:thegallbladdertriangle(Calottriangle)

MRCPcanshowtheeffectsofthewholebiliarytract

PTCpercutaneoustranshepaticcholangiography

PTCDpercutaneoustranshepaticbiliarydrainage

Acuteobstructivesuppurativecholangitis(AOSC)

Charcot'striad:upperabdominalpain,chills,highfever,

jaundice

Reyonld'pentalogyofS:tripleshock++neuropsychiatric

symptoms

Cysticductstones,compression,commonbileduct,Mirizzi

syndrome

Downhere

Cholecystitis,cholangitis,jaundice-embeddedhepaticduct

Two.GallbladderCa

(a)etiology:1,gallbladderstones70%98%coexist

2、tumorlikepolyp-gallbladderlikelesion

(1)tumorinternaladenoma,glandCA

(2)nonneoplasticpolyps:inflammatorypolyps,cholesterol

polyps

(two)clinicalmanifestation:1,cholecystitisorstonelike

symptom2,imaging

(three)treatment:surgicalresection

Theposteriorneckdifference,1yearsurvivalrate,stone

interest,andporcelaingallbladdertreatment

Threebileductca:

HilarbileductCA:upper1/3segment,accountingfor50-75%

Themiddleandlowereachaccountfor10-20%

Clinicalpresentation:painlessjaundice

Pruritusofskin,sclera,yellow

Treatment:resection:theuppersegmentisnoteasytocut,

palliativereliefobstruction

Roax-en-U-Y-tubeinterventionalstent

Chepter19pancreaticdisease:

Anatomyandphysiology:common