Preoperative preparation and postoperative period of gynecological patients

Each surgical operation affects the processes of vital activity of the organism as a whole. Along with physical trauma, one should also take into account the mental effects, pain, the effect on the body of narcotic substances, loss of fluid, electrolytes. Heat and many other moments. The success of the operation depends on:

• correct evaluation of indications and contraindications to surgical intervention;
• carefulness of examination of the patient and preoperative preparation;
• the choice of the method of anesthesia, the time and nature of the operation;
• techniques for performing the operation;
• therapeutic and prophylactic measures in the postoperative period.

[1], [2], [3]

Indications for surgical treatment

Indications for surgery can be absolute and relative.

Absolute indications are conditions directly threatening the life of a woman, accompanied by a picture of an acute abdomen (bleeding during ectopic pregnancy, rupture or perforation of the uterus, twisting the leg of the ovarian cystadenoma, rupturing the ulcer of the uterine appendages with the expiration of pus in the abdominal cavity and the development of peritonitis, etc.) or external bleeding (with malignant tumors of female genital organs, submucosal uterine myoma) with posthemorrhagic anemia.

An example of relative indications for surgical intervention can serve as the omission of the walls of the vagina and uterus, malformations of the genital organs, which do not cause concomitant complications, etc.

Selecting the method of operation

When choosing a possible method and the scope of surgical treatment, the following data are taken into account: the nature of the underlying disease, the presence of concomitant diseases, the age of the patient, the conditions of life and work, bad habits. In young women, in the absence of malignant tumors, organ-preserving surgeries are advisable. In women of menopausal age and in menopause, more radical operations are performed. Concomitant extragenital diseases, as well as the elderly patient's age, are an indication for a simpler, quicker and easier to perform operation. The surgical intervention plan can be changed during the operation. It depends on additional data obtained during the operation, as well as on the occurrence of complications (bleeding, collapse, shock, injury to neighboring organs, etc.).

For anesthesia in gynecological operations, both local (including epidural) and general anesthesia are used. There are a large number of narcotic, analgesic drugs, muscle relaxants, neurotropic drugs, ganglion blockers and antihistamines, which allow to carry out a modern anesthetic aid for a variety of operations and carry out management of vital body functions during surgical intervention.

Preoperative preparation

The duration of the preoperative period is determined by the nature of the underlying and accompanying diseases. In emergency operations, the duration of preoperative preparation is minimal. And with planned, especially in patients with severe concomitant diseases, it is calculated in days, sometimes weeks.

Preoperative examination

During the preoperative preparation, the general condition of the patient is clarified, the main diagnosis is clarified, the accompanying diseases are identified. The examination begins in out-patient conditions, which significantly shortens the patient's stay in the hospital before the operation. There is a volume of clinical and laboratory research, which is carried out by the patient regardless of the nature of the disease.

Scope of examination of gynecological patients before surgery

For small and diagnostic operations

• Clinical blood test.
• Clinical analysis of urine.
• Blood test for RW.
• The analysis of a blood on the form 50.
• Blood test for HBAG.
• Chest x-ray.
• Analysis of the vaginal smear for biocenosis.
• Analysis of cervical smear on atypia.

For abdominal surgery

• Clinical analysis of blood (platelets + time of incoherence).
• Clinical analysis of urine.
• Analysis of the rye on RW.
• The analysis of a blood on the form 50.
• The blood test is not HBAg.
• Chest x-ray.
• Information about sanation of the oral cavity.
• Analysis of the vaginal smear for biocenosis.
• Analysis of cervical smear on atypia.
• Biochemical blood test (total protein, bilirubin, glucose, ALT, ACT).
• Coagulogram (prothrombin).
• ECG.
• The therapist's conclusion about the absence of contraindications to surgical treatment.
• Data of diagnostic curettage (for tumors of the uterus)

When identifying concomitant diseases (chronic tonsillitis, bronchitis, caries, colpitis, endocervicitis, etc.), the patient must undergo appropriate treatment.

For the examination of gynecological patients, in addition to the usual ones, additional test methods are used (according to indications), the volume of which is determined by the underlying disease.

Given the cyclical hormonal changes that occur in the female body, a favorable time for surgery is considered the first days after the end of menstruation. Scheduled operations should not be performed during menstruation.

Preparation of the patient for surgery

The duration and nature of preoperative preparation may vary depending on the general condition of the patient, underlying and concomitant diseases, and age.

Before the operation, an assessment of the functional state of the vital systems of the body and their reserve capabilities is carried out. Scheduled operation is performed against a background of stable compensation and remission of concomitant diseases.

Evaluation of the cardiovascular system consists in the analysis of the contractility of the myocardium, changes in the vascular system as a whole and in its individual basins (small circle of blood circulation, vessels of the brain, myocardium). When revealing pathological changes, preoperative preparation of the patient is made in the conditions of therapeutic hospital (separation).

When assessing the respiratory system, attention is drawn to the manifestation of chronic diseases. Prevention of postoperative complications includes physiotherapeutic measures aimed at normalizing external respiration. According to the indications, medication is used to restore the patency and drainage function of the respiratory tract.

Preparation of the gastrointestinal tract requires special attention. Preliminary sanitation of the oral cavity and nasopharynx is carried out. Diet in the pre-operative period should be high in calories, but not abundant. The bowel should be emptied daily. On the eve of the operation, all patients are treated with a cleansing enema. Laxatives for the preparation for surgery are currently prescribed rarely, because as a result of their action, acidosis and intestinal paresis can develop. When preparing patients for operations on the intestines (ruptures of the third degree crotch, intestinal-vaginal fistulas) 2 days before the operation, a laxative is prescribed, and on the eve and on the day of the operation they put a cleansing enema.

Preparation of the liver. The restriction of food on the day of operation and after it leads to a significant expenditure of glycogen, therefore it is recommended to inject glucose immediately before the operation and during the intervention. A persistent violation of the basic functions of the liver is a contraindication to the operation.

Preparation of patients for vaginal operations. The operation is performed under normocoenosis or an intermediate type of vaginal biocenosis. With dysbiotic and / or inflammatory processes, therapy aimed at restoring normal microflora is carried out. In the presence of pressure sores, tampons with fatty ointments or emulsions, sea buckthorn oil are used, and dosage forms containing estriol are administered. Since treatment of pressure sores takes a long time, it is recommended that it be performed on an outpatient basis.

General preparation. The doctor is obliged to conduct psycho-preventive preparation of the patient, explain to her the nature of the forthcoming operation, to strengthen confidence in the successful outcome of surgical intervention. Within a few days before the operation, Bechterew's medicine or tranquilizers (trioxazine, chlordiazepoxide, or elenium, etc.) are prescribed. The result of general preoperative preparation is obtaining written informed consent of the patient for surgical intervention. On the eve of the operation, under the recommendation of an anesthesiologist, premedication begins.

The patient has the right to refuse to carry out the operation right up to the very beginning.

Contraindications to surgical treatment

When deciding on the question of surgical treatment, contraindications to surgery must be considered. These include, in particular, severe diseases of the cardiovascular system, diseases of the respiratory system, liver, kidneys and other organs and systems that severely disrupt the general condition of the body and its compensatory and adaptive mechanisms. However, in a number of cases of providing emergency care for life indications, it is necessary to perform the operation, despite the existing contraindications. Contraindications to routine operations in gynecological patients are usually concomitant acute infectious diseases (influenza, acute respiratory diseases, etc.), pyoderma, pressure sores on the vaginal part of the cervix, inflammation of the vaginal mucosa (before vaginal operations).

[4], [5], [6], [7], [8]

Complications in the postoperative period

The most formidable postoperative complication is bleeding. It can occur when the ligature is slipping from the vessel, from a vessel that was not ligated during the operation, with purulent fusion of the vessel wall, as well as from small vessels when the coagulation and anticoagulation systems are violated. The clinical picture of internal bleeding is characterized by pallor of the skin and mucous membranes, dyspnea, collapsoid state, frequent small pulse, lowering of arterial pressure. To clarify the diagnosis of internal bleeding, a vaginal examination is necessary. If there is liquid blood in the abdominal cavity, then the bulging of the posterior vaginal vault is usually determined. In the case of retroperitoneal bleeding, hematoma is palpated (most often between the leaves of the broad ligament of the uterus). With percussion, a free fluid in the abdominal cavity or blunting of sound over the hematoma is determined. To clarify the diagnosis is possible in the conduct of ultrasound and MRI of the abdominal cavity, which reveals a free fluid in the abdominal cavity. The presence of internal bleeding is an indication for repeated intubation for the bandaging of bleeding vessels. Bleeding with the formation of a hematoma can be from the vessels of the anterior abdominal wall: In this case, the ligation of the bleeding vessel and the removal of blood clots are shown. With bleeding after vaginal operations, diagnosis is easier, because there is external bleeding. To stop it, ligation of the vessels or tamponade of the vagina is performed.

Shock and collapse are serious complications of the postoperative period. Shock occurs after prolonged and traumatic operations accompanied by massive blood loss. In the pathogenesis of its development, the leading role belongs to violations of hemodynamics and all vital functions of the body. Clinically, the shock manifests itself in the oppression of the psyche, apathy while maintaining consciousness, a small frequent pulse, pale skin, the appearance of cold sweat, lowering of temperature and blood pressure; can be observed oliguria or anuria. At the same time, the metabolism is disrupted, acidosis occurs, the number of red blood cells increases, the volume of blood decreases.

The collapse is due to the primary lesion of the vascular system and is accompanied first by a violation of hemodynamics, and then changes in the central nervous system. Collapse is characterized by the following clinical symptoms: loss of consciousness, general weakness, severe pallor, cyanosis, cold sweat, frequent and small, sometimes arrhythmic pulse, frequent shallow breathing, lowering of blood pressure.

Treatment for shock and collapse should be started immediately. The patient must be transferred to the Trendelenburg position (inclination angle about 15 °). The main method of treatment is jet transfusion of blood-substituting fluids to stabilize hemodynamics. From blood-substituting liquids, it is better to introduce low-molecular, saline solutions, a solution of hydroxyethylated starch, since they last longer in the vascular bed and stabilize blood pressure. At the same time, it is recommended to administer corticosteroids. To improve cardiac activity, cardiac glycosides are used. When phenomena of decompensated acidosis is recommended intravenous sodium bicarbonate.

Anuria is a serious complication of the postoperative period. Its causes may be shock and collapse, accompanied by a decrease in arterial pressure and reflex spasm of renal vessels, severe anemia of the patient, blood transfusion, Rh-incompatible or ABO system, septic infection. Injury or ligation of the ureters. The treatment of anuria is determined by its etiology and must be started immediately.

Postoperative pneumonia is observed after prolonged operations, with delayed sputum, aspiration of gastric contents, atelectasis and congestion in the lungs, as well as lung infarction. Pneumonia most often occurs in people with chronic diseases of the respiratory system, in the weakened elderly and senile patients. In the treatment of postoperative pneumonia, an important role is played by the correct administration of antibiotics (respectively, the sensitivity of microbial flora). The use of anticoagulants of indirect action (neodicumarin, phenylin, syncumar, etc.) is shown in the individually selected dosage.

The paresis of the intestine, which occurs from 2-3 days postoperative period, and intestinal obstruction, which develops on the 4th-5th day, are characterized by cramping pains in the abdomen, nausea, vomiting, delay of gases and stool. Subsequently, the peristalsis stops, the pulse becomes more frequent, the temperature rises and the general condition of the patient worsens. With fluoroscopy of the abdominal cavity in the vertical position, the patient is determined by gas bubbles with horizontal levels of liquid below them (Clauber's bowls). It is recommended to carry out intestinal paresis therapy for drainage and gastric lavage, and for the injection of proserin intramuscularly. To stimulate the peristalsis of the intestine, hypertensive and, if necessary, siphon enemas are made. When confirming the diagnosis of mechanical intestinal obstruction, surgery is indicated.

Postoperative peritonitis develops due to infection of the abdominal cavity and is characterized by rigidity and soreness of the anterior abdominal wall, expressed by symptoms of irritation of the peritoneum, frequent pulse, high fever, nausea, vomiting and severe general condition of the patient. At the present time, the eroded course of peritonitis is typical: a relatively satisfactory condition of the patient remains, there are no or slightly expressed symptoms of irritation of the peritoneum, there is no nausea and vomiting. Listening to the peristalsis of the intestine, there is an independent chair. In peripheral blood, leukocytosis, a shift to the left in the leukocyte formula, an increase in ESR are noted. Treatment of peritonitis operative - relaparotomy, removal of the focus of infection and wide drainage of the abdominal cavity. Important components of treatment are antibacterial, desensitizing, anticoagulant and general restorative therapy. In severe purulent peritonitis, peritoneal dialysis is performed.

Thrombosis and thrombophlebitis in the postoperative period most often occur in the veins of the lower limbs and pelvis. The development of these complications contributes to obesity, varicose veins of the lower extremities, previous thrombophlebitis, cardiovascular failure. Signs of thrombosis are pain in the extremities, swelling, fever, soreness during palpation along the vessels. In the treatment of thrombosis, complete rest, elevated limb position, administration of antibiotics and anti-coagulants of direct and indirect action are necessary.

Suppuration of the operating wound is observed more often in patients operated on for malignant neoplasms of genital organs and purulent processes of the uterine appendages. With the development of infection in the area of the operating wound, there are pains, infiltration of tissues. Hyperemia of the skin, the temperature rises. In such cases, several seams should be removed in order to create conditions for the discharge of the separated, treat the wound with hydrogen peroxide, introduce a drain moistened with 10% sodium chloride solution. Daily it is necessary to do dressings and toilet wounds.

A rare complication is the complete divergence of the edges of the wound and the prolapse of the intestinal loops - an event. When overlapping secondary seams about the event in the abdominal cavity, drains are introduced to drain the contents and introduce antibiotics.

[9], [10], [11],

Prevention of infectious complications

Postoperative wound infections worsen the results of surgical treatment, prolong the duration of hospitalization and the cost of inpatient treatment. One of the effective approaches to reducing the frequency of postoperative suppuration, along with the improvement of surgical techniques and the observance of rules of aseptic and antiseptic, is antibiotic prophylaxis. Rational antibiotic prophylaxis in certain situations can reduce the incidence of postoperative infectious complications from 20-40% to 1.5-5%. At present, the expediency of antibiotic prophylaxis in surgical operations is beyond doubt.

Antibiotic prophylaxis, unlike antibiotic therapy, implies the appointment of an antibacterial agent in the absence of an active infectious process and a high risk of infection in order to prevent its development. Preventive use of antibiotics is their administration to microbial contamination of the operating wound or the development of wound infection, and also in the presence of signs of contamination and infection, when the primary treatment is surgical intervention, and the purpose of the antibiotic is to minimize the risk of wound infection.

Depending on the risk of postoperative infectious complications, all surgical interventions are divided into 4 categories.

Characteristics of transaction types

Conditional characteristic	Features of intervention
"Clean"	Non-traumatic planned operations without signs of inflammation that do not affect the oropharynx, respiratory tract, gastrointestinal tract or genitourinary system, as well as orthopedic operations, mastectomy, strumectomy, hernia repair, phlebectomy in patients without trophic disorders, joint replacement. Arthroplasty, operations on the aorta and arteries of the extremities, heart surgery
"Conditionally clean"	Pure operations with the risk of infectious complications (planned operations on the oropharynx, digestive tract, female genitalia, urological and pulmonological operations without signs of concomitant infection), phlebectomy in patients with trophic disorders, but without trophic ulcers, repeated intervention through a "clean" wound during 7 days, submerged osteosynthesis with closed fractures, urgent and urgent operations. By twisting the criteria included in the group "clean", blunt injuries without a rupture of hollow organs
"Contaminated"	Operative interventions on the biliary and genitourinary tract in the presence of infection, on the gastrointestinal tract with a high degree of its contamination, surgery for violation of asepsis or in the presence of an inflammatory process (but not purulent inflammation). Operations for traumatic injuries. Penetrating wounds, treated for 4 h
"Dirty"	Operative interventions on known infected organs and tissues, with concomitant or previous infection, wounds or perforation of the gastrointestinal tract, procto-gynecological operations, penetrating wounds and traumatic wounds treated after 4 hours, phlebectomy in patients with trophic disorders and ulcers, operations with purulent inflammation on infected tissues

Antibiotic prophylaxis is indicated for all "conditionally clean" and "contaminated" operations. In pure operations, prevention is carried out in cases where the potential infection poses a serious threat to the life and health of the patient, and if the patient has risk factors for the development of postoperative infections, which include:

• age over 70 years;
• eating disorders (obesity or malnutrition);
• cirrhosis of the liver;
• renal failure, heart failure;
• diabetes;
• alcoholism or drug addiction;
• malignant neoplasms;
• congenital or acquired immunodeficiency states;
• treatment with corticosteroids or cytostatics;
• antibiotic therapy before surgery;
• blood transfusion;
• blood loss;
• - the duration of the operation is more than 4 hours;
• - lengthy hospitalization before surgery.

Management of patients in the postoperative period

Any surgical intervention has a pronounced stressor effect on the patient's body. The components of surgical stress are:

• emotional-mental status of the patient;
• an operation that includes pain, mechanical and blood loss.

Management of patients in the postoperative period largely determines the success of surgical treatment, since it is known that no matter how skillfully the operation has been performed, there is always the possibility of complications up to fatalities. Preventive maintenance of complications in the postoperative period should be spent at patients arriving on planned surgical treatment still at an out-patient stage with attraction of experts of adjacent specialties. The "risk group" for the occurrence of complications includes patients with obesity, anemia, varicose veins, with clinical signs of cardiovascular, pulmonary, renal and other systems and organs, and older women.

The duration of the early postoperative period in gynecological patients takes 7-10 days. The duration of the late postoperative period with its uncomplicated course is limited to three months after surgical treatment.

The early postoperative period is characterized by a decrease in daily diuresis, which is caused by sodium retention in the blood serum and relative hypokalemia and hypercaliuria, which persist until the 6th day of the postoperative period. Hypoproteinuria, imbalance of protein fractions of blood also appear until the end of the first week of the postoperative period, which is associated with the adrenocorticoid phase of catabolism.

The rise in body temperature in the first week of the postoperative period is a physiological reaction of the body to the absorption of the products of the decomposition of injured tissues, blood and a wound secretion. In elderly and elderly women, leukocytosis and a temperature reaction are less pronounced than in young patients.

Preventive maintenance of thromboembolic complications in the postoperative period includes carrying out of nonspecific measures and specific prophylaxis. To nonspecific prevention include:

• early activation;
• bandage of the shins immediately before the operation with elastic bandages.

Specific prevention is given to patients with obesity, varicose veins, chronic thrombophlebitis, cardiovascular insufficiency. The prevention begins 2 hours before the operation and includes the use of heparin and its low-molecular derivatives (fractiparin, kleksan, etc.), in the postoperative period, the administration of these drugs lasts 6-7 days.

Treatment and rehabilitation

Therapy and rehabilitation in the postoperative period are divided into 4 stages.

At the first stage, the patient is in the intensive care unit. At the heart of intensive observation lies the early detection of symptoms that indicate an unfavorable course of the postoperative period or about inadequate responses of the patient to therapeutic actions, which helps to prevent the emergence of critical states.

Intensive monitoring in the Department of Anaesthesiology and Reanimation (UAR) or in the intensive care unit (ICU) differs from the traditional in continuity and focus and can be visual, laboratory, monitor and combined.

For each patient in the UAR and ICU, an hourly monitoring map with a list of appointments is generated. In them, during the observation time of the patient in the department after 1-3 h, they record the respiratory, circulatory, body temperature, diuresis, catheter discharge and drainage rates, take into account the volume of injected and withdrawn fluid.

Visual observation is one of the simplest and most accessible, applicable in any conditions. An experienced doctor and a nurse are able to catch the smallest changes in the functions of external systems of vital activity of the organism. At the same time, special attention is paid to the patient's behavior, color and temperature of the skin, frequency and depth of breathing, participation in auxiliary muscles, the presence of cough, the character of sputum.

A great help in assessing the patient's condition is observed by the functional state of the organs (the shape and degree of bloating, his participation in the act of breathing, the condition of dressings in the area of a postoperative wound, the presence of signs of internal or external bleeding, and the tension of the muscles of the anterior abdominal wall). Nausea, regurgitation, vomiting deserve attention. The ability to determine the recovery time of the motor function of the intestine (the appearance of peristalsis, the escape of gases and stool).

The use of monitor devices greatly facilitates the process of monitoring patients and increases their informativeness. The monitoring technique allows for constant monitoring of the respiratory function (respiratory rate, respiratory volume, minute breathing volume, saturation, CO2 content), blood circulation (number of heartbeats, arterial and central venous pressure, ECG, pressure in the heart cavities), central nervous system EEG), thermoregulation (body temperature). The use of computer technology makes it possible not only to recognize in a timely manner the acute violations of vital functions of the body, but also to eliminate them.

Visual and monitoring monitoring does not exclude the value of laboratory diagnostics. The express laboratory allows to study many indicators and includes the determination of hemoglobin and hematocrit, circulating blood volume, coagulogram, oxygen-base state, blood gases, plasma electrolytes and erythrocytes, degree of hemolysis, total protein level, functional kidney and liver, etc. A number of these indicators should be studied in dynamics as intensive therapy is carried out, including at night.

For the prevention of postoperative complications, it is extremely important in the early postoperative period:

• adequate anesthesia with the use of narcotic and non-narcotic analgesics;
• elimination of hypovolemia;
• early expansion of the motor regime.

At the second stage the patient is in the general department. It monitors the condition of postoperative sutures, the continuation of the therapy begun, as well as the prevention and diagnosis of purulent-inflammatory complications manifested, as a rule, on the 6th-7th day of the postoperative period.

From a clinical point of view, the most accessible and reliable indicator of the diagnosis of postoperative purulent-inflammatory complications (PGVO) is the definition of the leukocyte index of intoxication (LII). The leukocyte index of intoxication, proposed in I941 by J. Ya. Kalf-Kalifom:

(s.y. + 2 p.y. + 3 jun. + 4 mielots.) (Plasma, class + 1) / (monocytes + lymphocytes) (eosinophils + 1)

Normally, this figure is from 0.5 to 1.5. An increase in the index characterizes the increase in the inflammatory response. Various modifications of LII are still widely used in clinical practice.

A new approach to diagnosis and prognosis of the HMHO can be the use of the leukocyte blood formula as an integral indicator reflecting the characteristics of the neurohumoral reaction of the body to stresses of different strength. According to L.H. Garkavi (1990), the reactions of acute and chronic stress are caused by the action of a strong stimulus. Irritants of weak strength cause the reaction of training, and irritants of strength are reactions of calm and increased activation. Adverse reactions include reactions of stress, training and activation that occur with desynchronization phenomena, which indicates a decrease in the natural resistance of the organism and a worsening of the clinical course of the disease.

One of the traditional methods of preventing HBV is currently intraoperative antibiotic prophylaxis.

To date, in the surgical practice, experience has been gained in the use of immunomodulating drugs for the prevention of PGVO (thymolin, thymogen, interleukin). It indicates the possibility of increasing the natural defense mechanisms of the macroorganism and, thereby, controlling the course of the postoperative period.

Today, immunotherapy is represented not only by preparations of natural or synthetic origin. Various physicochemical factors, such as ultrasound, magnetic field, extracorporeal methods of detoxification, needle and laser puncture, also apply to full-fledged immunotherapy.

To improve the immunoreactivity and improve the healing of the surgical wound in gynecologic patients, transfusions of laser irradiated and ultraviolet autobloods are used.

At the third stage the patient is observed in the women's consultation at the place of residence. A great emphasis is placed on the conduct of physiotherapeutic procedures and resorption therapy.

The fourth stage involves carrying out rehabilitation measures for women in a specialized sanatorium. In addition to general restorative treatment, patients may be prescribed balneotherapy, mud therapy according to indications.