Amputation

Amputation is the delete operation peripheral parts of the body. Usually, amputation imply the destruction of part of a limb by crossing all tissues, including bone, what distinguishes amputation from assertequal (see).
Most often amputation is used as the only or the last resort of life of patients with malignant tumors, gangrene limbs, traumatic toxicityis not curable local infectious process. Amputation is indicated for severe trauma to the limbs, especially the destruction of vessels and nerves, when fully and permanently lost the ability to use the limb. There are amputation primary (primary evidence, for example due to the extensive damage to the limbs, especially the destruction of vessels and nerves), secondary (secondary indications, for example in the case beyond the secondary stop bleeding), early (in the first three days after the injury), late (about chronic purulent processes, deformation) and repeated, or reamputation (see).

amputation
Fig. 1. Amputation hips on Pirogov: 1-3 - operation stages. Fig. 2. Amputation in a circular way cuff. Fig. 3. Amputation of the femur and tibia patchwork way: 1 - cut front and back flaps; 2 - cut one front flap. Fig. 4. Leykoplastyrb stretching of the skin after the amputation. Fig. 5. Osteoplastic amputation according to Pirogov: 1 - cut; 2 - prepisovanie heel bone; 3 - stump.

Preparation of the patient to amputation includes (according to indications) replenish blood loss, activities to combat shock, intoxication and other Treatment of the operative field is conducted on the eve of the day operations with superimposed on a limb sterile bandages and again on the operating table. Preferred anesthesia, but can be applied casing and intraosseous procaine anesthesia, if not contraindicated a tourniquet (obliterating atherosclerosis, anaerobic infection). The level of amputation should ensure sufficient efficacy, however, we must seek to maintain the maximum length of the stump. When tumors operate within obviously healthy tissues, inflammatory processes sometimes have to operate within inflamed, but always viable tissues. Operate more with imposed harness. If contraindications to the tourniquet produce a preliminary ligation large vessels centrally level of amputation or finger pressure.
Soft tissue cut a circular incision, or cut flaps. When circular simultaneously, or guillotine, the method used in case of emergency, all the soft tissue is cut in one plane immediately to the bone. When duhomenko the way first, cut the skin, subcutaneous tissue and the fascia, then on the edge of the decrease in the skin, muscles to bones. When each body position the way amputation (N. I. Pirogov) after dvuxmestnogo dissection of soft tissues to the bone strongly pulling them up and on the edge of the skin again cross the muscles (Fig. 1). This method provides safe shelter of the end of the bone and soft tissues. When poor muscle array or weak contractility of muscles used in a circular way cuff (Fig. 2). More advantageous in some forms of severe injuries, as well as for prosthetics patchwork ways amputation (Fig. 3). The flaps cut with a scalpel from the skin and muscles, or of skin tissue and the fascia more often on the front surface of the leg.
Regardless of how amputation bone perejivayut saw, in some cases cross (with amputation of the finger) pliers for 2-4 mm below the section of the periosteum. After ligation of vessels silk and crossing razor pre-shot 2% solution novokaina nerves remove the harness and complete stop bleeding. The edges of the cut bones grind file. The stump wound sutured, and in the corners on two days impose graduates of the rubber glove. On a stump impose a plaster of Paris splint is placed, which prevents the development of contractures in the joint and provides peace. The next day after the surgery make the dressing, graduates are removed. Sutures are removed on 12-14 day. Prosthetics possible after healing wounds and disappearance of oedema. Pre-stump prepare massage and medical gymnastics.
If you do not exclude the possibility of wound infection, it is temporarily closed with stitches or impose 2-3 guides seam. In these cases, to prevent the contraction of the skin produce traction (Fig. 4).
The greatest support function of the stumps of lower extremities is achieved osteoplastic amputation. Filing bones cover autograft bone or cut with a flap of soft tissues (N. I. Pirogov), or free. Osteoplastic amputation according to Pirogov (Fig. 5) was the prototype other osteoplastic amputations. Osteoplastic amputation should be finished blind stitch wounds. A set of tools for amputation - see Surgical instruments. Cm. also Stump, Prosthetics.


Amputation (from lat amputatio - clipping) is an operation to remove a peripheral unit or other authority. Practically, when people talk about the amputation involve the removal of a limb or distal segments of its produced by crossing the bones that makes amputation from assertequal (see).
The readings. Most often amputation is used as the only or the last means of saving the life of the patient. Living testimony to A. are: malignant tumor of limb gangrene its major parts, local infection is not curable and threaten the patient from generalized infection, intoxication, amyloidosis, etc.; severe injuries of the extremities. In the latter case there are indications of primary (extensive damage, especially with the breaking of the vessels and nerves that make limb unviable) and secondary (threatening infectious complications, ischemic gangrene, which could not be secondary stop the bleeding, and others). Accordingly, and amputation injuries divided into primary and secondary.
Not for health reasons A. produce when fully and permanently lost the ability to use a limb, so it becomes useless, preventing appendage (coarse, corrigirutee deformation, serious and incurable neurotrophic lesions)and for dry gangrene of the most distal departments (for example, the fingers) as accelerating treatment operations. A. concerning chronic purulent processes, deformation, paralysis called late. Repeated amputation often called reputatsia (see).
Preparation of the patient for urgent A. includes (according to indications) replenish blood loss, shock and detoxification of the event. Before planning a amputation may need a blood transfusion, introduction tonics, insulin and diet therapy, etc. Treatment of the operative field carried out before the operation with superimposed on foot sterile bandages and again on the operating table after the tourniquet is applied.
Anesthesia: preferred anesthesia, but in many cases A. may be done under casing or intraosseous anesthesia. The latter, however, requires the tourniquet is applied, which is not always valid (obliterating endarteritis, anaerobic infection).
The level of amputation should ensure sufficient efficacy; on the other hand, need to strive for the maximum length of the stump. A. planned, especially for tumors, produce within unchanged tissues. When an emergency A. this rule is often necessary to break, operating in the tissues, already inflamed, though viable. Operation within necrotic tissue (if frostbite IV degree) is called how agressively to debride (see). Previously proposed standard levels amputation now are not considered.
Harness impose proximal level A., but not closer than 15-20 cm from the future section, otherwise retraction crossed muscles, he can slip into the wound. When A. the root limbs imposed harness must be fixed, circling it around your waist or chest (see Harness hemostatic)If the impossibility of application of tourniquet produce a preliminary ligation of the arterial vessels; you can perform an amputation and with fingertip pressure line.
The technique. Dissection of soft tissues produce circular incision, or cut flaps. When circular simultaneously, or guillotine, the way all the soft tissue is cut in one plane, right to the bone. The method is used only in emergency A. and then only in cases where it is necessary to maximally reduce the time of surgery (anaerobic infection, severe shock). When duhomenko the way first, cut the skin to the subcutaneous tissue and fascia, then on the edge of the decrease in the skin, muscles to bones. When each body position method (cone amputation N. I. Pirogov) after dvuxmestnogo cut to the bone greatly retard the soft tissue up (proximal) and on the edge of the skin again cross the muscles (Fig. 1). This method is the best of the pie. It provides safe shelter of the end of the bone and soft tissues. The defect of his trauma (twice crossing muscles and especially nerve trunks). When insufficient contractility of muscles used in a circular way cuff (Fig. 2). The skin with circular amputations cut distal to the expected level filing bones at a distance equal to 1/6 of the length of a circle segment, adding 2-4 cm on airway skin, more pronounced on flexor surface.
More profitable for prosthetics patchwork ways (Fig. 5, 1, 2). Pieces of the plan, and then cut with a scalpel from the skin and muscles, or of skin tissue and the fascia. In the lower third of the forearm and leg amputation knife usually pierce all the soft tissue through at the base of the flap and cut out his sawing motion, coming from the depths to the surface. The total length of the flap must be equal to the diameter of the leg. Patches (or flap) calculated so that the scar was on the outside surface stump (on the brush - in the rear, at the hip - back and so on).
Bone, as a rule, cross-cut saw, sometimes (when the amputation of fingers) - cutters. When A. lower leg tibia perejivayut on the Foundation layer of the skin flap, peroneal 1.5 - 2 C above tibial; the bones of the forearm cross on one level in a position that average between pronation and supination. Crossing bones always need to make a few proximal section plane of the muscles that pull the retractor. The periosteum is cut with a scalpel and shift raspatory in the distal direction; bone perejivayut on 2 - 4 mm distal section of the periosteum and separate the removed part of the leg. Otrabativaut the cut ends of the main and smaller (but visible) vessels, seize their clip and by slightly pulling out of the muscles, are ligated silk. Then remove the harness, put the clamps on the bleeding small vessels as identify and stitch them together with catgut with the muscle tissue. After hemostasis, grind file edge filing bones. Bone marrow is not scoop. This technique of processing of a bone (option messaggistica method Bunge) to the greatest extent prevents development of leaf osteonecrosis and education of osteophytes (see Stump). The ends of the major nerves carefully extracted from tissues throughout 4-5 cm, enter the thin needle 1% solution novokaina, tight infiltrating them nerve, and cut it in one swift movement of the blade safety razors. Vessels nerve tied up separately thin catgut. For the prevention of end navrom leading to kaupallisesti phantom pain, suggested many ways (tubal stump nerve silk, injection of alcohol or 5% solution of formaldehyde and others), but they are not reliable; the most important is wound healing by primary intention. If you have confidence in aseptica during and after the re-test reliability of hemostasis stump wound sutured. We must remember that part of the small vessels begin to bleed only a few minutes after removal of the loom.
Some authors (G. C. BPO, N. N. Dei Priori, N. P. Novachenko and others) recommend to sew muscles over OPROM bones, connecting antagonists; and others (M. S. Usevich, V. G. Vainshtein) sew only the fascia and the skin tissue, indicating that the muscles and without seams are attached to the bone surface, providing active mobility stump, and that is sewn over OPROM bone muscle tissue is injured and forms scars, spinaudio bone to the skin. However, if the level of amputation there are many tendons, the antagonists to make appropriate. In the corners are sewn wounds impose on two days strips of rubber; stump fix the plaster of Paris splint is placed until the sutures are removed. Further treatment - see the Stump, Prosthetics. If you do not exclude the possibility of wound infection (especially in the military field conditions), it is left open in the calculation of the subsequent imposition of delayed primary or early secondary sutures (see the Wounds, wounds). In these cases, to reduce shrinkage of soft tissues impose traction end stump through leukoplast (Fig. 9) or silk threads made through the edge of skin wounds. During the development of the stump wound infection treatment, as if infected wounds.
The greatest support function of the stumps of lower extremities is achieved osteoplastic amputation. With this method, first developed Nieroba (1852), filing bones cover autograft bone or cut with a flap of soft tissues, or free. A. according to Pirogov (Fig. 6)has served as the prototype of operations Gritti - Szymanowski (Fig. 3 : 1-3), the Sabaneev (Fig. 4). Yu Yu Dzhanelidze A. when the diaphysis hip used free graft taken from the tubular part of the remote bones. The transplant saw through and placed sideways on, respectively modeled late filing (Fig. 7). You can close filing bones and a wide fascia of the thigh - the flap on the leg (Fig. 8) or free, which soon metaplasia in bone (G. I. Lukyanov). As a replacement for bone plastics and proposed other ways: plastic tendons, periosteum, as the application filing bone "gravel" (N. A. Bogoraz), various bio-stimulants (gluten-streptocide, sodium fluoride, osteoblast and others). In the experiment good results from the shelter filing a blood clot with bone gravel in the case of nylon fabric. Osteoplastic amputation must be completed blind stitch wounds.