1. Surgical approach
The first stage consists of adequate exposure of the diseased organ so that the surgeon can freely perform the main part of the work. A correctly chosen incision determines the surgeon's comfort and the patient's safety.
Three key requirements apply to any approach:
- Proximity to pathology: the incision must be located as close as possible to the zone of interest.
- Adequate exposure: the wound must be wide enough for free manipulation of instruments.
- Minimal trauma: tissues should be damaged as little as possible.
Classic examples of wide exposures are opening of the abdominal cavity (laparotomy), the chest (thoracotomy), and craniotomy.
Modern sparing approaches:
- Mini-approaches. The length of the incision is only 3–4 cm. Working through such a small "window" requires specialized surgical instruments and high-quality local illumination.
- Laparoscopic technique. Instead of a single incision, 3–4 tiny punctures about 1 cm long are made. Wide tubes—trocars—are inserted through them. Gas is insufflated into the cavity (e.g., abdominal or pelvic) to create a working space. The operation is performed with micro-instruments under video camera guidance. The main advantage of this method is rapid rehabilitation: the patient can get up as early as the second day, and discharge and return to work occur in one to two weeks. Typical examples: removal of the gallbladder (cholecystectomy), appendix, or ovarian cyst.
> Important rule: Operations from miniature approaches require virtuosic instrument handling and extensive clinical experience. Beginning surgeons are strongly advised to use wide approaches, as they guarantee full exposure and reduce the risk of fatal errors.
2. Surgical procedure
This is the culmination, the main stage of the operation for which it was undertaken. It represents the surgeon's direct impact on the pathological focus. This can be the opening of an abscess, or the complete or partial removal of a diseased organ (appendix, stomach, gallbladder).
Interestingly, there are exceptions in surgery: sometimes the first stage (approach) is simultaneously the second (procedure). A classic example of such a coincidence is a simple tissue incision for adequate drainage of cellular spaces in case of a purulent infection.
There are many special types of surgical procedures depending on the ultimate goal:
- Puncture (punctio) — performing a puncture of a cavity or organ.
- Biopsy — targeted excision of a small tissue fragment for subsequent histological analysis.
- Resection — excision of a part of an organ along its length (e.g., gastric resection).
- Amputation — removal of a peripheral, distal part of an organ or limb (amputation of the lower leg, supravaginal amputation of the uterus).
- Extirpation — radical, complete removal of an organ along with its surrounding tissues (extirpation of the rectum or uterus with appendages).
- Anastomosis creation — formation of an artificial connection (stoma) between hollow structures, for example, a vascular or gastroenteroanastomosis.
- Plasty — surgical elimination of tissue defects using the patient's own biological or artificial materials (as in inguinal canal repair).
- Transplantation — transplantation of an entire organ or complex of tissues from a donor to a recipient.
- Prosthetics — replacement of a destroyed organ or its fragment with an artificial analogue (e.g., hip joint replacement).
3. Completion of the operation
The final stage of the surgical intervention, often called the "exit from the operation." The absence of postoperative complications and a favorable outcome for the patient directly depend on how meticulously it is performed.
At this stage, the surgeon is obligated to:
- Restore anatomical tissue relationships. If the operation was in the abdominal cavity, peritonization is performed (restoration of peritoneal integrity); if in the chest, pleuritization.
- Install drains. If necessary, the wound is dried, and special tubes are left for fluid outflow.
- Suture the wound. Tissues are sutured strictly in layers, in the same order in which they were incised during the surgical approach stage.
Briefly: answers to topical questions
What instruments are used to create a laparoscopic approach?
Trocars and a Veress needle are used to create a laparoscopic approach.
- Trocars — wide tubes with a diameter of 5 mm and 10 mm (for the telescope), which are inserted through small incisions.
- Veress needle — used for gas insufflation and establishing pneumoperitoneum before inserting the first trocar.
What types of interintestinal anastomoses exist?
There are four main types of interintestinal anastomoses by type of connection:
- end-to-end;
- side-to-side;
- end-to-side;
- side-to-end.
When naming an anastomosis, the more proximally located organ is indicated first, followed by the more distally located one. In a side-to-side anastomosis, the stumps are closed tightly, and the loops are positioned isoperistaltically.
What types of sutures are used for layered closure of a surgical wound?
Various types of sutures are used for layered closure of a surgical wound:
- interrupted;
- continuous;
- Multanovskiy locking stitch;
- mattress.
If the subcutaneous adipose tissue is thick, sutures are first placed on the deep layer (catgut or fine silk/nylon), followed by silk sutures on the skin.
What are the contraindications for laparoscopic surgery?
Contraindications for laparoscopic surgery are divided into absolute, relative, and contraindications for elective interventions.
- Absolute — hemorrhagic shock, decompensated cardiovascular and respiratory diseases, uncorrectable coagulopathy, hepatic-renal failure, and conditions precluding the Trendelenburg position.
- Relative — polyvalent allergy, diffuse peritonitis, severe adhesions, late pregnancy, and large uterine myomas.
- For elective surgeries — acute infectious and cold-like diseases occurring less than 4 weeks prior to the intervention.
What types of tissue and organ transplantation exist?
Types of transplantation are classified depending on the source of the transplanted tissues or organs.
- Autologous transplantation — the donor and the recipient are the same person.
- Isogeneic transplantation — transplantation between genetically identical monozygotic twins.
- Syngeneic transplantation — the donor and the recipient are first-degree relatives.
- Allogeneic transplantation — transplantation of tissues from one human to another.
- Xenogeneic transplantation — transplantation of organs or tissues from an animal to a human.
- Prosthetic replacement — use of synthetic materials and inorganic substances.
The "E-P-C" rule (Exposure, Procedure, Closure) helps to remember the three stages.
Class and exam questions
What is the difference between resection and amputation?
Resection is the removal of a portion of an organ along its length (e.g., removal of part of the stomach while preserving gastrointestinal tract continuity), whereas amputation is the severance of a peripheral part (e.g., a lower extremity).
Why beginners must not use mini-approaches?
Working in a confined space (through a 3–4 cm incision) requires perfect instrument handling and vast experience. Wide incisions provide better exposure, which is critically important for patient safety when surgery is performed by a beginner.
Can the approach and the procedure be the same action?
Yes, in purulent surgery. For example, when a surgeon makes an incision to open and drain an abscess in a fascial space, the incision itself (exposure) already achieves the therapeutic goal (procedure).
What else to study on this topic
- Topographic anatomy of the anterior abdominal wall during laparotomy
- Types of surgical instruments for exposure and wound closure
- Principles of gastroenteroanastomosis formation
- Methods of wound drainage at the stage of surgical completion
- Technique of endoscopic suturing during laparoscopy
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