Illustration of Surgical Procedures for Intern Physicians 1

Author: Chen Daojin
Editor:
Publisher:
Publishing Date: 2003-02-01
Features:
(1) Epidural anesthesia or subarachnoid anesthesia, supine position, slight external rotation of the affected limb.
(2) About 1.5 cm below the inguinal ligament, at the medial side of the femoral artery pulse, make a 4-6 cm incision parallel to the inguinal ligament. Incise the skin, subcutaneous tissue, and superficial fascia, stop bleeding, and protect the skin. At the inferomedial margin of the oval foramen, locate the great saphenous vein and separate its branches, generally separating 4-6 branches (Fig. 1-13-1, Fig. 1-13-2).
(3) Ligate and cut each branch, then ligate and suture the proximal end of the great saphenous vein with No. 4 silk thread at a distance of 0.5 cm from the femoral vein (Fig. 1-13-3).
(4) Do not ligate the distal end of the great saphenous vein temporarily. After inserting a vein stripper into the distal vein lumen, ligate it immediately to control bleeding (Fig. 1-13-3).
(5) Gradually push the stripper downward in the vein lumen. If resistance is encountered, slightly withdraw or advance while rotating. If significant resistance is felt, it may be a communicating branch. In such cases, make a small incision, separate the vein, and ligate it at both ends of the stripper head. Cut between the ligatures and slowly withdraw the stripper while compressing the, allowing the vein to be removed along with the stripper (Fig. 1-13-3, 4, 5, 6).
(6) Continue stripping the great saphenous vein from the second incision downward using this method. For excessively curved veins in the lower leg, directly incise the skin, excise the vein, and suture the skin.
I. Indications
1. Patients over 6 months old with recurrent abdominal wall hernias without conditions causing increased intra-abdominal pressure, such as urinary difficulties, ascites, or uncontrolled chronic cough.
2. Acute incarcerated hernias requiring immediate herniorrhaphy.
II. Preoperative Preparation
1. General patients should control conditions like cough or urinary tract infections before surgery.
2. For incarcerated hernias with intestinal obstruction, gastrointestinal decompression, fluid replacement, shock management, and antibiotics must be administered.
III. Anesthesia
Continuous epidural anesthesia can be used. General anesthesia is preferred for patients with insufficient blood volume.
Artificial Rupture of Membranes
Artificial rupture of membranes involves breaking the amniotic membrane with forceps or a needle to expel amniotic fluid, promoting fetal descent, stimulating cervical contractions, and facilitating cervical dilation. The procedure is most effective when the cervix is mature and the fetal head is engaged.
1. Indications
(1) Acute polyhydramnios with severe compression symptoms.
(2) Various pregnancy complications requiring induction, such as prolonged pregnancy or preeclampsia, with a cervical score ≥6.
(3) Prolonged pregnancy with a mature cervix (score ≥6) and engaged fetal head.
(4) Various pregnancies with a mature cervix (score ≥6) and engaged fetal head.
(5) Ineffective treatment of pregnancy complications with medication, such as severe preeclampsia, chronic nephritis, or diabetes.
(6) Vertex presentation with cervical dilation of 4-5 cm, weak contractions, and labor arrest without significant cephalopelvic disproportion.
(7) Confirmed intrauterine fetal death or fetal malformation, such as hydrocephalus or anencephaly.
(8) Multiparous women requiring induction for various reasons.
2. Contraindications
(1) Significant cephalopelvic disproportion or obstructed labor.
(2) Abnormal like transverse or breech presentation.
(3) Severe placental dysfunction.
3. Preoperative Preparation
Same as artificial stripping of membranes.
4. Procedure
(1) Vaginal examination to assess cervical dilation, cord presentation, and fetal station.
(2) First, dilate the cervical canal and strip the membranes with fingers. Then, with the right hand holding a toothed forceps, place the tip under the protection of the left index and middle fingers and insert it into the vagina, placing it on the amniotic sac surface. Break or puncture the membranes during contractions to prevent excessive rapid amniotic fluid leakage and amniotic fluid embolism (Fig. 5-4-4-1).
(3) If amniotic fluid flow is insufficient, enlarge the with fingers or slightly push the presenting part upward to allow fluid to drain.
(4) For polyhydramnios, use an amniotic sac puncture needle or long needle to pierce the membranes. The puncture point should be slightly above the cervical os level to allow amniotic fluid to flow along the needle. If a large amount of fluid gushes out, cover the cervical os with the hand to slow the flow and prevent sudden hypotensive shock, placental abruption, cord prolapse, or partial fetal delivery.
5. Key Points During Surgery
(1) Monitor fetal heart rate and blood pressure before and after membrane rupture.
(2) Check for cord presentation before membrane rupture. Do not remove the hand from the vagina until amniotic fluid flows out to prevent excessive leakage and assess for cord prolapse or partial fetal delivery.
(3) For polyhydramnios, allow amniotic fluid to drain slowly. When rupturing membranes in cases of partial placenta previa, palpate for a cystic sensation to confirm the membranes before proceeding to avoid placental injury and bleeding.
6. Postoperative Care
(1) Maintain vulvar hygiene.
(2) Closely monitor uterine contractions and fetal heart rate. If the presenting part is not fully engaged, restrict ambulation.
(3) For polyhydramnios treated with artificial rupture of membranes, collect the drained fluid to assess volume and color. If bloody fluid is present, check for signs of placental abruption.
(4) Uterine contractions typically begin within 1-2 hours after membrane rupture. If contractions are absent after 6 hours, add oxytocin to the intravenous infusion.
(5) If delivery has not occurred 12 hours after membrane rupture, administer antibiotics to prevent infection.
7. Major Complications
(1) Cord prolapse or partial fetal delivery.
(2) Hypotensive shock, placental abruption.
(3) Infection risk increases if membrane rupture persists for more than 12 hours.