Рассказывать о здешней хирургии можно долго, но самая главная отличительная её черта заключается в том, что все врачи вообще, а хирурги в частности, постоянно учатся. Учатся так, как никто из нас в России не учился. Это и немудрено, от этой учёбы и её результатов зависит в конечном итоге их благосостояние. Каждый резидент ежегодно сдаёт несколько экзаменов, практических и теоретических. Самый основной - это ABSITE. От баллов, набранных на этом экзамене часто зависит его место в резидентуре.

Экзамен идёт 5 часов, в нём около 200 вопросов. Здесь дано только объяснение по теме, сама формулировка вопроса и пять ответов (только один из которых является правильным) - это секрет Американского колледжа хирургов. Мы хотим опубликовать эту информацию для тех из вас, кто планирует перебраться сюда и попытать счастья в американской медицине. После каждого вопроса дано указание на источник информации. Нам кажется, что эти вопросы будут полезны специалистам любых специальностей.

Обратите внимание на сокращения, они здесь очень распространены.

Если у вас есть вопросы, вы можете поместить их на наш   Форум

Ниже два примера, остальное вы можете скачать с нашего сайта (ссылки справа)

Treatment of Complications of Reduction of Incarcerated Inguinal Hernia.
The danger of incarcerated inguinal hernias is protrusion of a hollow viscus outside its normal environment through a ring of variable size. If the viscus becomes caught by the ring and cannot be reduced, it is by definition incarcerated. If, in addition blood flow to or from the protruding viscus is compromised, the process of strangulation begins, with ultimate necrosis of the bowel, if left unattended. Incarcerated hernias are difficult to differentiate from those, in which the strangulating process has begun and therefore are considered to be surgical emergencies. Incarcerated hernias may or may not cause intestinal obstruction, but essentially all hernias involving bowel that reach the stage of vascular compromise do cause the signs and symptoms of intestinal obstruction.

There are two exceptions, namely, Richter's hernia - i.e., one side of the bowel wall is involved, and Littre's hernia, i.e., the incarceration and strangulation of Meckel's diverticulum. In all patients with signs and symptoms of intestinal obstruction, all potential hernia sites must be visualized and palpated, and contrariwise, all patients with incarcerated or strangulated hernia should be carefully reviewed for the presence of intestinal obstruction.

Femoral, indirect inguinal, and umbilical hernias are more likely to cause strangulation of bowel because these sacs have smaller necks that tend to be surrounded by rings of rigid tissue.
Direct inguinal hernias usually have a broad neck. Recognition of impending or actual strangulation is extremely important, since emergency measures (operation) are indicated. Pain in the region of the hernial swelling and particularly tenderness to palpation are ominous signs. Sudden change from a state of hernial reducibility to irreducibility and discoloration of the tissues over the swelling are additional signs of strangulation. Without signs of strangulation, an incarcerated hernia of short duration may be carefully reduced by gentle but firm pressure upon the swelling.

It is possible to reduce the bowel content from its extracavitary position but not release the bowel from the peritoneal sac, i.e., reduction en masse. Thus, one must observe the patient for a period following reduction to ensure restoration of normal bowel activity.

Sabiston, Textbook of Surgery, 14th Ed., pp 1139.

Treatment of Small Bowel Obstruction (SBO)
Obstruction occurs when there is a physical barrier or functional failure, an ileus, to the normal transit of intestinal contents. The majority is secondary to post-op adhesion (64-79%), hernia (15-25%), and tumors (10-15%). Classically, the cardinal symptoms are crampy abdominal pain, obstipation, vomiting and abdominal distention. In addition, there may be tenderness, fever, leukocytosis, and tachycardia. These additional findings are suggestive of infection or infarction - complications of small bowel obstruction. Early radiographic studies are the most important diagnostic maneuver. The presence of air/fluid levels and its pattern helps the surgeon distinguish between a partial or complete obstruction and ileus. Partial SBO are frequently resolved without surgical intervention.

The management of bowel obstruction is individualized but the common principles are: correction of metabolic abnormalities, gastrointestinal decompression by a nasogastric tube, intravenous hydration and perioperative antibiotic coverage.

If there is a complete obstruction, proper and timely surgery is essential. This may involve lysis of adhesions, resection and/or bypass of an obstructing lesion, an enterotomy to remove a foreign object, or the formation of an ileostomy/colostomy proximal to the obstruction.

Schwartz, 6th Edition, pp 1028-1031