tailieunhanh - Ebook Farquharson’s textbook of operative general surgery (9/E): Part 2

(BQ) Part 2 book “Farquharson’s textbook of operative general surgery” has contents: Emergency laparotomy, surgery of intra-abdominal malignancy, classic operations on the upper gastrointestinal tract, operative management of upper gastrointestinal disease, gallbladder and biliary surgery, and other contents. | 14 EMERGENCY LAPAROTOMY Introduction Emergency laparotomy for non-traumatic haemorrhage Emergency laparotomy for peritonitis Intraoperative dilemmas in the acute abdomen 233 233 234 237 INTRODUCTION An exploratory laparotomy is carried out in conditions where the need for an operation is recognized but where a definitive diagnosis cannot be made until the abdomen is opened. Whenever possible, however, an attempt should be made to arrive at an accurate, or at least a provisional, diagnosis before surgery. This not only allows the surgeon to plan the optimum surgical approach to the problem, but may also indicate an intra-abdominal pathology which would be more satisfactorily managed by non-operative means. Most exploratory laparotomies are performed in the emergency situation, where the value of exhaustive investigations has to be balanced against any deterioration which may occur in the patient’s general condition during the inevitable delay. A short delay, during which both active resuscitation and preliminary investigations are performed, is however usually beneficial as surgery on severely shocked or septic patients carries a high mortality. Intensive preoperative resuscitation has the potential to improve physiological status, and reduce the risk of perioperative death, but unfortunately deterioration can also occur. Cardiovascular stability, and adequate tissue perfusion, may not be attainable in the presence of continuing haemorrhage, and as total blood loss rises, coagulopathy may develop. Tissue already compromised by strangulation, or excessive dilatation, may infarct with resultant perforation and sepsis, and absorption of toxic products from any dead tissue will also continue (see Chapter 11). The timing of surgery is therefore very important. The surgeon, aware of the deteriorating intra-abdominal situation, is often impatient to operate on a patient unfit for major intervention. The anaesthetist, in contrast, may strive too long to optimize a patient .