UNIVERSIDAD DE SAN MARTIN DE PORRES FACULTAD DE OBSTETRICIA Y ENFERMERÍA ESCUELA PROFESIONAL DE OBSTETRICIA
CURSO: CIRUGÍA E INSTRUMENTACIÓN EN OBSTETRICIA
PROFESORA
:
FLOR DE MARIA CHUMPITAZ SORIANO
CICLO
:
VI
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Lima-Perú
FACULTAD DE OBSTETRICIA Y ENFERMERIA ESCUELA DE OBSTETRICIA PLAN DE SESIÓN I.
II.
III.
INFORMACIÓN GENERAL: Asignatura : Cirugía e Instrumentación en Obstetricia Profesor : Flor de María Chumpitaz Soriano Tema Tema : Cirugía Cirugía.. Acto quirúrg quirúrgico ico.. Tiempos Tiempos fundame fundamental ntales es de la operación quirúrgica. Táctica y Técnica quirúrgica Sesión Nº : 2 CAPACIDAD DE LA SESIÓN Aplica conceptos generales y principios de la cirugía • • Clasifica los tipos de cirugía • Define acto quirúrgico: Táctica y técnica quirúrgica. • Determina los tiempos fundamentales de la Técnica quirúrgica • Enuncia algunos sufijos y trazos quirúrgicos CONTENIDOS Y/ O ACTIVIDADES:
I. LA CIRUGÍA La Cirugía es la rama de la medicina que tiene por objeto curar las enfermedades mediante procedimientos cruentos: secciones, punciones, extirpaciones y resecciones a través de intervenciones manuales. Cirugía es pues, sinónimo de trabajo manual y así fue interpretado hasta el siglo pasado en que el cirujano todavía obedecía las órdenes del medico clínico y ejecutaba las operaciones con su indicación y supervisión. Las operaciones quirúrgicas deben cumplir tres requisitos: la incisión no debe causar dolor; la hemorragia se debe cohibir, y la herida debe cicatrizar. La cirugía moderna ha tenido tenido un impulso impulso notabl notable e gracias gracias a la capacida capacidad d de asegurar asegurar la cicatri cicatrizac zación ión por medio medio de un tratamiento aséptico. Por tal motivo, la necesidad de asepsia es el elemento que regula la conducta de los cirujanos, es decir, el “ritual” de la operación, la forma de los instrumentos e incluso el diseño y la construcción de hospitales. El cirujano actual ha de poseer además de habilidad manual congénita y susceptible de perfeccionarse, un profundo conocimiento de toda la patología que, unido a la sagacidad,
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a) Cirugía General
b) Cirugía Externa
c) Cirugía Interna
d) Cirugía Mayor
e) Cirugía Menor
f) Cirugía Curativa
g) Cirugía Paliativa h) Cirugía de Reconstrucción
i) Cirugía Constructiva j) Cirugía Ablativa OTRAS: Cirugía electiva- Cirugía Cirugía de urgencia- Cirugía de emergencia.
PRINCIPIO QUIRURGICO 1. El paciente es el centro de toda atención 2. Prev Preven enir ir la la infe infecc cció ión n 3. Evita vitarr el dolor olor 4. Organi Organizac zación ión del equipo equipo quirúr quirúrgic gico o 5. Conduc Conducta ta dirigi dirigida: da: Cuida Cuidados dos a técnic técnica a de disecc disección ión 6. Manten Mantener er las activid actividades ades vital vitales es en optimas optimas condici condicione oness
II. ACTO QUIRÚRGICO Es un procedimiento cruento merced al conocimiento de la anatomía anatomía y fisiología humana, al desarrollo de la farmacología y el incesante esfuerzo para perfeccionar las técnicas de esterilización en la lucha permanente contra los gérmenes y su consecuencia inmediata: la infección en cirugía, al mejor control de los operados en las unidades de recuperación postoperatoria y de terapia intensiva.
Función Ejecutora del Acto Quirúrgico y Gesto Quirúrgico Curar o aliviar la enfermedad a través de la acción manual sobre los tejidos orgánicos con ayuda de instrumentos.
Gesto quirúrgi quirúrgico: co: los los movi movimi mient entos os inte integra grados dos de la mano mano del del ciru ciruja jano no con con el instrumento, en forma disciplinada en el espacio del campo operatorio y en el tiempo que dura la intervención quirúrgica.
Semiología Quirúrgica Estu Estudia dia sínto síntoma mass y signo signos, s, no se apar aparta ta de la semi semiol olog ogía ía de las las enfer enferme meda dades des “internas” o quirúrgicas, posibles de tratamiento médico.
Patología quirúrgica Estudia cada cada enfermedad, desde su etiología y sintomatología hasta el diagnóstico y tratamiento.
Clínica quirúrgica
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juntamente con los exámenes complementarios (análisis, etc) hace el diagnóstico para indicar una terapéutica quirúrgica y establecer un pronóstico sobre la base de los hallazgos y la evolución del problema.
OPERACIÓN QUIRURGICA El conj conjun unto to de disp disposi osici cion ones es,, tare tareas as y recur recurso soss técn técnic icos os que real realiz iza a un tipo tipo de personas con un propósito fundamental y practico: la intervención quirúrgica. La intervención quirúrgica antes de llevarse a cabo se traza un plan sobre la base del diagnóstico, localización del proceso, estado y hábito del paciente y vía de acceso más directa; es lo que se llama táctica quirúrgica. Se fundamenta en el conocimiento de fisiopatología y anatomía patológica. En cambio técnica quirúrgica, se refiere a los distintos tiempos operatorios realizados con limpieza, seguridad, suavidad y con el instrumento indispensable; se fundamenta en el dominio de la anatomía quirúrgica.
TIEMPOS FUNDAMENTALES FUNDAMENTALES DE LA TÉCNICA QUIRURGICA Hay dos elementos básicos en la práctica de la cirugía. El conocimiento de la anatomía, ya que toda operación exige una descripción detallada y lo más exacta posible del órgano sobre el cual ha de recaer la intervención y de la región en que dicho órgano se halla contenido. Por otro lado, durante el acto quirúrgico debe actuarse con movimientos sistemáticos y ordenados ordenados sobre aquellos tejidos y órganos, órganos, incidiéndolo incidiéndolos, s, separándolos separándolos,, extirpándolo extirpándoloss o reparándolos, de forma que no se lesionen sus componentes o estructuras. Estos procedimientos requieren instrumentos para su ejecución, como bisturís y tijeras, pinzas pinzas hemost hemostáti áticas cas,, separa separadore dores, s, aspira aspiradore dores, s, instru instrumen mentos tos de tracció tracción, n, porta porta agujas agujas y materiales de sutura. Los tiempos fundamentales de la técnica quirúrgica son: •
Corte, incisión o diéresis
•
Hemostasia
•
Exposición (separación, aspiración, tracción)
•
Disección
•
Sutura o síntesis
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procedimiento procedimiento se utilizan utilizan los instrumentos instrumentos de corte, considerándose considerándose como tales a los bisturís, tijeras, sierras, costotomos y gubias, entre otros. Estos instrumentos son de muy diversa forma y tamaño y ello depende básicamente del tipo de tejido a incidir, así como de la región anatómica que se interviene. Como en cualquier profesión, arte u oficio, sobre todo las de orden manual, se dispone de una serie de instrumentos indispensables para ejecutarla. En el caso de la cirugía, a través de la histor historia ia de la humanida humanidad, d, se han acumula acumulado do
una gran cantida cantidad d de instru instrumen mentos tos
altamente especializados, de aplicaciones muy diversas. En un momento clave será posible resolver una determinada situación quirúrgica solo si se cuenta con el recurso especifico, por lo que el conocimiento del instrumental permite al cirujano resolver situaciones propias de cada intervención quirúrgica. Para el tiempo de incisión se cuenta con el bisturí.
El BISTURÍ Es el principal de todos, sirve para establecer una solución de continuidad o sea la división terapéutica de los tejidos: •
Comunes, de uso corriente para apertura de pared y resto de la operación, empleados siempre en partes blandas
Especiales, para tiempos delicados, cirugía estética
De lámina cambiables
Cuchillos de amputación para tejidos óseos
Técnica para tomar el bisturí El bisturí se empuña para cortar los tegumentos, sosteniéndolos entre el pulgar y los dedos medio, anular y meñique, con apoyo sobre el lomo de la hoja. Al realizar el corte de la piel debe ejercerse presión uniforme y discreta, deslizando el filo con un movimiento decidido, sin titubeos. La sección de los tejidos subcutáneos se hará mediante pequeños cortes suaves, profundizando los planos. La Hemo Hemosta stasi sia a se irá irá reali realizan zando do a medi medida da que el bist bistur uríí avanz avanza, a, para para evit evitar ar la acumulación de sangre que entorpece la buena visión del campo operatorio y desangra innecesariamente al enfermo. Cuando se trata de abrir un absceso o drenar una cavidad, se emplea el bisturí de punta aguda.
TIJERAS Es otro otro instru instrume ment nto o para para corta cortar, r, y por por tant tanto, o, debe debe estar estar bien bien afil afilad ada; a; una una tije tijera ra estropeada secciona magullando y triturando los tejidos, estableciendo así las condiciones que propician la infección y retardan la cicatrización.
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Las rectas se emplean para seccionar tejidos superficiales, y las curvas en regiones profundas; profundas; las de extremidad extremidad aguda no se deben usar en la vecindad de órganos que pueden ser lesionados. En ningún caso, cuando se opera, se cerraran las hojas de la tijera sin tener a la vista sus extremidades. Las tijeras se emplean frecuentemente como instrumento de disección insinuando sus puntas cerradas entre los tejidos y separándolas sucesivamente para ir despejando la zona interesada (Metzenbaum)
Técnica de tomar las tijeras Para su mayor efectividad la tijera debe sostenerse introduciendo en sus anillos el pulgar y el anular; el dedo medio apoyándose en la rama por delante del anillo que aloja al anular y el índice con su pulpejo contra la articulación del instrumento. Para Para corta cortarr liga ligadur duras as,, sutur suturas as y mate materi rial ales es simi simila lare ress que que empl emplea ean n tije tijera rass de construcción sólida, de hojas fuertes y cortas; en ningún caso deben emplearse para esos trabajos otras tijeras ya que ello llevaría a estropear su filo.
Sufijos según maniobra quirúrgicas MANIOBRA
SUFIJO
Incisión
tomía
Punción
centsis
Incisión con abocamiento del órgano al exterior
ostomia
Extirpación
ectomía
Unión de dos órganos normalmente separados
anastomosis
Operaciones plásticas
plastía
Operaciones que mantienen un órgano en una situación determinada pexia Operación que inmovilizan órganos
desis
Sutura
rafía
Detención del curso de líquidos o materias orgánicas
stasis
Examen visual de órganos internos
oscopía
Trazos de incisión quirúrgica El trazo de una incisión debe seleccionarse en función de la circunstancia particular del enfermo que se está tratando.
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•
Longitudinales
•
Transversales
•
Diagonales En cuanto a su trazo pueden clasificarse como:
•
Rectas
•
Curvas
•
Mixtas
•
Semicirculares
•
Fusiformes Los trazos de incisión, según los pliegues cutáneos de inserción, que dan lugar a
cicatrices mas estéticas.
HEMOSTASIS Hemostasis es toda maniobra que se ejecuta para evitar o cohibir una hemorragia. Una hemostasis hemostasis adecuada es esencial para obtener buenso resulatdos. resulatdos. La insuficiente insuficiente cohibición cohibición de la hemorragia ocasiona una perdida de sangre innecesaria, y la formación de hematomas, cuya eventual infección contribuye de modo subtancial a la morbilidad post-operatoria. Algunas boquillas sangrantes de vasos pequeños suelen cerrarse en forma espontánea con gran rapidez.Los vasos sangrantes de mayor tamaño deben cerrarse con ligaduras y pinzamiento o suturas hemostáticas. Las pinzas hemostáticas son un instrumento de acero inoxidable a base dos ramas que se entrecruzan en su porción intermedia formando una articulación fija o desarmable; tienen un mango con dos anillos y los extremos convocados de las más variadas formas para coger los vasos. Unas tienen la extremidad ranurada sin dientes, como la pinza Kelly, y otras como las de Kocher tienen, además dientes en su extremidad. Cerca del anillo cada rama presenta, por su cara interna, unos que se enganchan recíprocamente al cerrar la pinza, impidiendo que esta se abra espontáneamente. De este modo, la presa que hace el instrumento sobre los tejidos se mantiene firmemente.
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ramas de la pinza de Kocher y las cierra sobre el vaso seccionado, de dos maneras: con toma de punta, cuando el eje de la pinza continua el eje del vaso; con toma de través, cuando el eje de la pinza se aplica perpendicular u oblicuo respecto del eje del vaso. La primera es una toma delicada que se puede hacer cuando el vaso está aislado y desnudo y tiene la ventaja de favorecer la cicatrización porque el tejido aprisionado es mínimo. Siemp Siempre re convi convien ene e hacer hacer hemos hemostas tasis is de los los dos dos cabos cabos del del vaso vaso para para evitar evitar la hemorragia secundaria por vía recurrencial. Si al colocar una pinza la hemorragia se detiene solo parcialmente, es porque la pinza esta mal colocada, en cuyo caso el cirujano deberá hacer la retoma vascular correctamente. Si un vaso se hallara en el campo operatorio, molestara al cirujano y su sección no acarreará inconveniente para el enfermo, se procede según una de las dos técnicas siguientes: se lo aisla, se lo levanta y se lo toma con dos pinzas de Kocher, a pocos milímetros una de otra, para cortarlo entre ellas y ligar cada uno de los cabos; se lo aisla, se lo levanta y se colocan dos ligaduras de 0,5 cm una de la otra, para cortarlo, finalmente, entre ellas.
OPERACIÓN PROPIAMENTE DICHA Separación Técnica operatoria que tiene la acción y efecto de mantener aparte o dividir órganos y tejidos. Impide mezclarse.
Instrumentos de separación Son instru instrument mentos os que separa separan n los labios labios de la herida herida operator operatoria ia o determ determinad inados os órganos y tejidos para facilitar el acceso y la visión del foco operatorio donde se efectuará la intervención intervención quirúrgica propiamente propiamente dicha. Estos instrumentos reciben el nombre genérico de Separadores. Por Separador de doble extremo angulado y punta roma. Modelo Parker. Son similares a los separadores de Farabeuf.
Tracción Es la acción de arrastre o estiramiento que se ejerce en una extremidad en dirección distal. Instrumentos de prehensión Son todos aquellos que toman firmemente los tejidos y órganos para ejercer tracción
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Son instrumentos que desecan, liberan los planos anatómicos de la zona operatoria.
Pinzas de disección Están constituidas por dos láminas alargadas de acero, unidas en uno de sus extremos y en el extremo opuesto ambas tienen pequeños dientes. La flexibilidad de sus ramas las mantienen abiertas. Sirven para coger provisionalmente los tejidos y “presentarlos”. Las hay delicadas, rectas, curvas y acodadas o bayoneta, especiales para tejidos delicados, mucosas (Farkas).
Técnica para sostener la pinza de disección Se sujetan entre el dedo pulgar, el índice y el dedo medio de la mano izquierda. Los dientes sirven para hacer presa en los tejidos y evitar que se deslicen sin tener que ejercer sobre ellos presión excesiva; se usan en combinación con el bisturí o tijeras en la disección. Son muy apropiadas para levantar y sostener la piel. No deben usarse sobre vasos y vísceras huecas.
Sonda acanalada Es un instrumento con un mango aplanado y de un cuerpo delgado con un surco en toda su extensión y con el extremo distal romo, tiene una función como la pinza de disección de presentar al cirujano los tejidos o planos de clivaje por donde debe efectuarse la disección. También se convierte en instrumento de exploración de cavidades, trayectos fistulosos y planos de clivajes, durante el curso de la disección.
OCLUSIÓN Técnica de cerrar o juntar un órgano o conducto. SÍNTESIS DE LOS TEJIDOS BLANDOS O SUTURA Una vez que el cirujano ha terminado la operación deberá establecer la continuidad de los los teji tejido doss a trav través és de los los cuale cualess se abrió abrió cami camino no para para lleg llegar ar al foco foco oper operat atori orio. o. Esta Esta
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♦
Seda o algodón ó nylon
Porta-Agujas son instrumentos destinados a sostener en su extremo distal una aguj aguja a de sutu sutura ra,, tien tienen en una una form forma a y cons constr truc ucci ción ón simi simila larr a la de las las pinz pinzas as ♦
hemostáticas de mediano tamaño distinguiéndose por que sus ramas son mas cortas y más anch anchas as en su extr extremo emo infer inferio ior, r, y medi median ante te estr estria iaci cion ones es transv transver ersa sale less fija fija firmemente a la aguja. Está establecido aplicar el porta-aguja en la mitad proximal al extremo romo para que una vez que ha penetrado la aguja a través del tejido se abra el porta-aguja porta-aguja y nuevamente nuevamente se cierre sobre el extremo extremo punzante para hacer hacer tracción y terminar de pasar la aguja. ♦
Agujas, son instrumentos de acero quirúrgico, que tienen tres segmentos
básicos: La punta, el cuerpo y el ojo. Hay dos clases principales: agujas rectas y agujas curvas, las agujas rectas son aplicables en toda clase tejido siempre y cuando sea posible posible una exposición exposición adecuada. adecuada. Cuando se trata trata de heridas operatorias operatorias de gran profundidad y con muy poco espacio es necesario recurrir a las agujas curvas las cuales se manejan con un porta-aguja. Las agujas deben ser de punta roma para la mayoría de tejidos con la sola excepción de aquellos tejidos de gran dureza que deben ser perforados con agujas cortantes. Ejemplo fascias gruesas, la piel, cartílago. ♦
Material de sutura, sirven para unión de los planos anatómicos y para realizar
la hemostasia perfecta, pueden ser de material absorbible y no absorbible. De las clases más importantes de material de sutura utilizado en cirugía han alcanzado gran aceptación, el catgut. ♦
Catgut simple de material absorbible (de 8 a 10 días desaparece), Catgut
crómico desaparece a un plazo más largo (20 días desaparece). Ácido poliglicólico es de material sintético absorbible (45 días desaparece). Seda o algodón ó nylon no se absorben y son perfectamente tolerados por el organismo, también el alambre inoxidable plateado o plata no son absorbibles absorbibles con gran uso en cirugía. ♦
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IV .FUENTE DE INFORMACIÓN Cirugía, Escuela de Medicina de La Habana, tomo I, editorial Pueblo y Educación MARTINEZ DUBOIS, Salvador; “Cirugía” , “Cirugía” , Mc Graw Hill Interamericana, México.
FACULTAD DE OBSTETRICIA Y ENFERMERIA ESCUELA DE OBSTETRICIA PLAN DE SESIÓN I
II
III
INFORMACIÓN GENERAL: Asignatura : Cirugía Obstétrica e Instrumentación Profesor : Flor de María Chumpitaz Soriano Tema : Quirófano Sesión Nº : 3 CAPACIDAD DE LA SESIÓN Describe las instalaciones del quirófano y sus áreas . Explica la importancia importancia de los accesorios de sala de operaciones .
CONTENIDOS
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Las medidas que se emplean para evitar o prevenir esta posibilidad de entrada son múlti múltipl ples es y parte parte de ella ellass compr compren ende den n el dise diseño ño del área área dond donde e debe deben n efec efectu tuar arse se las las intervenciones quirúrgicas.
Diseño arquitectónico del área de quirófanos Las salas de operaciones estarán localizadas en una zona: 1. Acce Accesi sibl ble e a los los servi servici cios os de paci pacient entes es quir quirúr úrgi gicos cos inte intern rnad ados os,, serv servic icios ios de urge urgenc ncia ias, s, unidad de cuidados intensivos y departamento de servicios auxiliares del diagnóstico, etc. 2. Aleja ejada de los servicios donde nde
se
encuentren
pacient entes
con enfe nfermeda edades
infectocontagiosas o áreas sépticas o muy concurridas. 3. Apartada Apartada en el hospital hospital para evitar evitar el tránsit tránsito o de personas personas ajenas ajenas a través través de ella. ella. El número de quirófanos requeridos se establece en función de varios factores: Cantidad y duración de operaciones programadas, tipo de especialidad con que cuenta el hospital, hospital, pero fundamentalmente fundamentalmente por el número de camas quirúrgicas, quirúrgicas, calculando calculando una sala de operaciones por 20 camas censables. El diseño de los quirófanos sigue dos principios fundamentales: 1. Establ Establece ecerr un filtro filtro a los factore factoress de contam contamina inació ción n que pudiera pudieran n introduci introducirse rse en el área quirúrgica a través de personas, materiales, objetos e incluso el aire. 2. Sepa Separa raci ción ón de las las área áreass sépt séptic icas as y asép aséptitica cass dent dentro ro de la sala sala
de opera operaci cion ones es,,
permitiendo así la práctica de una buena técnica que evite la contaminación. El área de quirófanos se divide en tres zonas o áreas principales de restricción progresiva para eliminar fuentes de contaminación: 1
Z
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mediante rodilleras o es electrónico y funciona mediante fotoceldillas, al igual las jaboneras. Estos Estos lava lavado doss de acero acero inoxi inoxida dable ble debe deben n ser sufi sufici cient entem ement ente e profu profund ndos os para para evit evitar ar salpicaduras y la salida del agua a través de un tubo curvo y elevado que permite efectuar el lavado manteniendo los antebrazos en posición vertical. También se incluyen los portacepillos, o bien cepillos desechables que llevan integrado el jabón. El área gris también incluye la sala de recuperación postoperatoria. Debe contar con el equipo básico que consta de: esfigmomanómetros, estetoscopios, unidades de oxígeno y aspiración, colocadas cerca de las camillas, un gabinete de medicamentos de urgencia, carro de paro cardíaco, equipo de traqueotomía, monitores electrocardiografía y desfribiladores, además de un gabinete de enfermería y estante para ropa. La central de equipos y esterilización es el lugar donde se almacenan los instrumentos quirúrgicos, la ropa y demás utensilios estériles. Allí se preparan y esterilizan los bultos que son almacenados almacenados en una vitrina guardaestéril guardaestéril adyacente a la sala de operaciones, operaciones, rotulando rotulando en la parte exterior qué equipo contiene y la fecha de la esterilización; que conservará su vigencia dos semanas como máximo; de no utilizarse en ese lapso tendrá que esterilizarse nuevamente. En el cuarto de anestesia se ubican los carros o cajas metálicas que contienen el equipo básico de anestesiología, como laringoscopios, pilas, conectores, mascarillas y sondas endotraqueales, previamente esterilizadas y algunos medicamentos propios de la anestesia, también debe contar con una gaveta de seguridad para narcóticos, etc; es decir medicamentos sobre los que existe un estricto control para su uso . En el cuarto de rayos X se estaciona el aparato portátil y el revelador automático de las placas que se toman en el transoperatorio.
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No se const constru ruye yen n repi repisa sass o sali salient entes es que que pued puedan an albe alberga rgarr polv polvo. o. Las salas salas de operaciones estarán desprovistas de ventanas.
Piso Debe ser resistente al agua y conductor de corriente para evitar la acumulación de cargas electrostátic electrostáticas as que puedan provocar chispas. chispas. Las esquinas deben ser redondeadas redondeadas para facilitar el aseo.
Ventilación La concentración de partículas y bacterias en el aire debe ser similar a cuartos estériles que se utilizan en las industrias de alta tecnología. Estas concentraciones bajas se alcanzan cambiando cambiando el aire de la sala de 20 a 25 veces cada hora y haciendo pasar el flujo de aire que penetra por filtros de alta eficacia para partículas en aire, los cuales eliminan 99.97% de las partículas mayores de 0.3 micras de diámetro. Las Las bact bacteri erias as prese presente ntess en el aire aire de la sala sala de oper operaci acione oness está están n unid unidas as con partículas: descamación, polvo, pelusas, y gotas secas (saliva, secreciones nasales). Aunque la sala de operaciones y el aire que penetra en ella pueden estar muy limpios, el número de partículas viables aumenta sustancialmente en cuanto entra el personal debido a descamación, descamación, pelusa pelusa y otras partículas, partículas, en las cuales se dispersan dispersan por la turbulencia turbulencia aérea que produce el movimiento del personal y fuentes de calor como las lámparas. El mejoramiento del ambiente en la sala de cirugía se obtiene principalmente con un personal bien entrenado, que usa el pijama quirúrgico correctamente, que transita sólo lo indispensable dentro del quirófano, que habla lo menos posible durante la intervención y que se apega a las normas de asepsia y antisepsia establecidas. Las recomendaciones actuales para la ventilación de las salas de operaciones indican
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Iluminación La iluminación equilibrada en la sala sala de operaciones proporciona al cirujano una visión clara del campo quirúrgico, evita forzar la vista y permite una iluminación adecuada a la circulante y al anestesiólogo. Tanto la iluminación en el área operatoria como la general en la sala debe ser flexible, ajustable y controlable. La relación entre la brillantez del sitio quirúrgico, la periferia del mismo y el perímetro del quirófano debe ser 5:3:1. Se recomienda que la brillantez de la iluminación general sea hasta de 70 bujías por metro. Las fuentes de iluminación no deben causar destellos o reflejos indeseables. La cantidad de luz necesaria durante la intervención quirúrgica varía según el cirujano y el sitio operatorio. Otros aspectos de la iluminación de la sala de operaciones que se sabe varían según el cirujano, la especialidad y el procedimiento son los siguientes: ♦
La distancia focal
♦
La dirección del dispositivo luminoso
♦
La posibilidad de disminuir las sombras
♦
El tamaño del campo quirúrgico
♦
La capacidad para cambiar la posición del foco de iluminación en condiciones
estériles.
Aparatos de calefacción En niños, ancianos y pacientes quemados resulta de especial importancia mantener la tempe tempera ratu tura ra corp corpora oral,l, en virt virtud ud de que que todo todoss esto estoss paci pacien entes tes tiene tienen n trast trastor orno noss de la
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Es de forma rectangular, está construida de acero inoxidable y se utiliza como recurso de apoyo a la circulante y al anestesiólogo. ♦
Mesa De Mayo
Es una mesa de altura variable, con una barra de soporte apoyada en una base. Posee un marco para una charola rectangular de acero inoxidable que se coloca arriba y en sentido transversal al paciente, a una altura conveniente del campo quirúrgico. Se emple emplea a para para colo colocar car los instrum instrumen ento toss que que serán serán
de uso uso conti continuo nuo durant durante e la
intervención.
Trípode Se usa para colocar las soluciones que se administran al enfermo por vía endovenosa Cubeta de patada Es de acero inoxidable; se coloca sobre carretillas que facilitan su desplazamiento con el pie. En estas cubetas se depositan los materiales de desecho durante la intervención quirúrgica.
Lámpara quirúrgica Son medias esferas metálicas cuya concavidad refleja en dirección convergente hacia la región anatómica los haces luminosos de uno o varios focos cuya propiedad es generar más luz con menos calor. Estas lámparas están sujetas al techo y tienen la facilidad de poderse mover en varios
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Es un generador de radiofrecuencia de 500 watts que se usa para cortar y coagular tejidos. Este elemento también también representa un riesgo por lo que requiere estrecha vigilancia.
Unidad de rayo láser Los equipos de rayo láser producen energía potencialmente dañina, que han llegado a ocasionar lesiones tanto al paciente como al personal, incluyendo quemaduras cutáneas, daño a la retina, lesiones por incendio de las sondas endotraqueales, etc. Su uso requier requiere e adaptar adaptar algunas algunas modificaci modificaciones ones en el diseño diseño del quiróf quirófano ano.. Las paredes y el techo no deberán ser reflejantes y el equipo utilizado en el campo quirúrgico no ser inflamable, alejando del mismo torundas de algodón, gasas, apósitos y objetos plástico. Ante Antess de usar usarlo, lo, el pers person onal al médi médico co y param paramédi édico co deber deberá á tener tener entre entrenam namie ient nto o especializado, y al momento de la intervención contar con chaleco y lentes especiales para su protección.
Unidad de rayos x
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de mascarillas facial y tubos endotraqueales de diferentes tamaños (2.5, 3 y 3.5 mm), laringoscopios, catéteres venosos y arteriales. •
Carro de anestesia, con material específico para hacer anestesia.
•
Material tocúrgico para realizar el parto.
Equipo quirúrgico El equipo operatorio puede definirse como el dos o más personas que trabajan juntas para llenar las necesidades de salud de un enfermo en un medio específico. Las responsabilidades y funciones de cada miembro del departamento quirúrgico están claramente definidas por escrito en las normas del quirófano o el manual de procedimientos del hospital. Estas normas están visibles y escritas para clarificar la descripción del trabajo y
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Cada individuo del grupo del quirófano tiene la responsabilidad de conocer y practicar los principios básicos de las técnicas de asepsia incluyendo buena salud y limpieza personal
IV
FUENTE DE INFORMACIÓN • BEREY BEREY Y KONNT, KONNT, “Técnica “Técnica de Quirófano Quirófano “ Editorial Editorial Interamericana Interamericana MC Graw Hill. Séptima Edición. 1995 • GANDSAS MARIO, “Fund Funda amentos ntos de Enfer fermería Quir uirúrg úrgica e Instrumentación”, Editorial Ateneo, Cuarta Edición.
FACULTAD DE OBSTETRICIA Y ENFERMERIA ESCUELA DE OBSTETRICIA PLAN DE SESIÓN I
INFORMACIÓN GENERAL:
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una sola operación, pero en la práctica el personal quirúrgico lleva a cabo varias operaciones, que que es el plan plan de cirug cirugía ía por un día. día. Entre Entre una una y otra otra oper operac ació ión n se limpi limpia a el suelo suelo del del quirófano, se esterilizan de nuevo los instrumentos y se cambia la lencería quirúrgica. Las transgresiones transgresiones posibles posibles en la técnica técnica aséptic aséptica a pueden llevarse llevarse al mínimo mínimo si se se ordena a los pacien pacientes tes de dicha lista lista de cirugí cirugía a
para para que en primer primer lugar se hagan hagan las operacio operaciones nes
“limpi “limpias” as”.Cu .Cuanto anto mayor sea el número número de pacient pacientes es que se operen, operen, mayores mayores serán las posibi posibilid lidades ades de error error.. La asepsia asepsia
depend depende e de la discipli disciplina na
person personal al y de la atención atención
cuidadosa cuidadosa a todos los detalles, no del uso de antibióticos antibióticos han desterrados desterrados en parte el peligro de las infecciones en las heridas. Sin embargo, es mínima su función como medio para evitar la contaminación de las incisiones, que se logra solo por atención al paciente, el personal, los objetos inanimados y el aire.
FUENTES DE INFECCIÓN La causa más importante de que una herida herida no cicatrice como debiera normalmente es la infección. Los microorganismos llegan a los tejidos durante la operación o los cambios de
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desplazándose hacia la periferia. El lavado de la piel en el sitio de la incisión se hace con
agua y jabón conteniendo hexaclorofeno, luego se seca y se trata con tintura de mercurocromo o timerosal. La zona debe debe ser lo suficientem suficientemente ente grande grande como para para incluir incluir toda la incisión incisión y la zona zona de trabaj trabajo o adyace adyacente, nte, de tal forma que el médico médico y la enferme enfermera ra puedan puedan maniob maniobrar rar durante la intervención sin tocar la piel no estéril. Se recomienda como antiséptico el etanol al 70% ( por volumen) excepto en piel delicada, como los genitales y cerca de los ojos, y en niños; en vez de etanol etanol puede utiliza utilizarse rse cetrimi cetrimida da al 1% ( 10 g / L), y también también cabe cabe recurrir recurrir a la solución yodada al 2,5 % en etanol (25g (25g // L) Con el progreso de la química aparecieron, diferentes antisépticos que trataban de unir un alto poder bactericida con una mayor tolerancia por los tejidos, como el yodo. El empleo de la Tintura de yodo al 2% es el mayor porcentaje de esterilidad produce. La tintura de yodo debe emplearse tiñendo la piel del paciente paciente y dejándola dejándola en contacto contacto con la misma misma durante durante 5 minutos minutos,, quitan quitando do después después el exceso de alcoho alcohol,l, especialm especialmente ente en los Pliegues donde la falta de evaporación hace que sea más irritante este producto.
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Colocación de los guantes Después de la desinfecci desinfección ón y el secado de las manos con una compresa compresa estéril, estéril, el cirujano, pasa al quirófano para colocarse el delantal. Cuando la enfermera destapa el tambor de guantes y ofrece al equipo el número requerido se procederán al calzado calzado de guantes con la siguiente técnica: con la mano izquierda se los toma y despoja de las gasas que lo envuelven; se los toma por los puños puños volcados volcados con los dedos de la mano mano izquierda. izquierda. En esta forma se presenta presenta la embocadura embocadura del guante derecho derecho para que los cuatro últimos últimos dedos de la mano
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elegidos elegidos según la preferencia preferencia personal del cirujano cirujano como por ejemplo la tintura de yodo, la tintura de merthiolate al 1/1000, mercurio cromo, etc. b) El campo campo operator operatorio io se delimita delimita con cuatro cuatro campos campos pequeño pequeños, s, fijando fijando cada cada ángulo de unión a la piel por medio de las llamadas PINZAS DE CAMPO tipo VACKAUS que terminan en dos extremos puntiagudos; el resto del paciente y toda la mesa de operaciones ase cubre con campos estériles de grandes dimensiones. De los miembros miembros del equipo quirúrgico, quirúrgico, el cirujano, cirujano, sus asistentes asistentes y su instrumentista, instrumentista, son los que están en directo contacto con la zona operatoria y por eso luego del lavado de
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que cons consis iste te en la solu soluci ción ón de cont contin inui uida dad d de la Incisi Incisión ón o Apert Apertura ura, que superficie superficie del organismo organismo para obtener obtener acceso a la lesión quirúrgic quirúrgica a a tratar; se a)
realiza de la superficie a la profundidad de las estructuras orgánicas en un solo block o por planos. El instrumental es a base de instrumentos cortantes como por ejemplo el bisturí, las tijeras, las legras.
Operación propiamente dicha. Es la etapa importante y donde se emplea la gama mas variada del instrumental se ejecuta con instrumentos que facilitan el
b)
diagnóstico, la exposición del foco operatorio y del tejido enfermo, maniobras
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Instrumentos de hemostasia Las manos del cirujano cirujano son las mejores armas armas hemostáticas hemostáticas para la identificaci identificación ón y control del punto sangrante en la herida operatoria. Una hemorragia de gran magnitud puede ser temporalmente detenida en forma instantánea por simple presión digital. La pinza hemostática es un instrumento de acero inoxidable a base de dos ramas que se entrecruzan entrecruzan en su su porción porción intermedia intermedia formando formando una articul articulación ación fija fija o desarmable desarmable
y que
tiene un mango con dos anillos y los extremos con bocados de las más variadas formas para
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clamp quedan quedan colocadas en forma alterna alterna ejerciendo ejerciendo una presión uniforme uniforme sobre
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terminación de la pinza y donde están implantados en su superficie interna un gran
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Entre el material quirúrgico necesario consideramos a todos aquellos instrumentos que
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♦
Instrumentos de SINTESIS Y MATERIAL DE SUTURA,
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de la incisión. Deberán evitarse los golpes dolorosos durante el pasaje de los instrumentos. Un
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INDICACIONES Está indicado en la segunda fase del trabajo de parto, cuando la cabeza no esta muy baja. Esta técnica se aplica aplica cuando no se puede realizarse una una anestesia peridural peridural y la anestesia general resulta peligrosa para la paciente. Es necesario remarcar que el bloqueo de pudendos no permite una manipulación obstétrica invasiva ; por ello , sólo debe aplicarse en caso de instrumentación baja con presentaciones en cuarto plano, bien apoyadas sobre el suelo pélvico y con la rotación ya efectuada. POSICION DE LA PACIENTE Y EQUIPO Se coloca a la paciente en posición de litotomía con los brazos a lo largo del cuerpo y los pies sujetos a la pierneras. Se localiza mediante palpación palpación la tuberosidad isquiática y se marca con una cruz su borde medial inferior en caso de emplear la vía transperineal. Es indispensable disponer con el equipo de reanimación básico, básico, con el objeto de afrontar cualquier complicación que pudiera surgir durante el procedimiento. EQUIPO BASICO PARA EL BLOQUEO DE PUDENDOS Tres tallas estériles Aguja de 20mm (20 G) para la vía transperineal Aguja de 90mm (22 G) con protector Iowa o Kobak para la vía transvaginal. Dos jeringas de 20ml con la solución anestésica que se inyectará. Gasas estériles. Batea Solución para asepsia Anestésico local Dos pares de guantes. DESCRIPCIÓN DE LA TÉCNICA Preparación quirúrgica de lavado de manos, colocación de guantes y disposición de equipo estéril, se realiza asepsia vulvar y perineal con solución desinfectante y entallado de la zona; se debe evitar las soluciones alcohólicas que pueden provocar quemazón. En las dos vías de abordaje del nervio pudendo se bloquea el nervio por fuera del ligamento sacroespinoso y por debajo de la espina ciática. VIA TRANSPERINEAL Esta indicada cuando la presentación de la cabeza fetal ocupa la vagina e imposibilita el abordaje transvaginal. Se identifica la zona palpando la tuberosidad isquática, isquática, si se utiliza la mano derecha, introducirá el dedo índice de la izquierda preferiblemente en la vagina por ser más aséptica y si utiliza la mano izquierda, introducirá la mano derecha. Se practica anestesia dérmica o habón cutáneo en el punto señalado por una “X” con una aguja de 20 G-40 mm perpendicular a la piel y a través del habón cutáneo practicado. Se avanza lentamente la aguja a través través de la fosa isquiática y se mantiene mantiene en todo momento el dedo en la fosa para guiar la aguja hacia la tuberosidad isquiática, que se encuentra a una profundidad de 2,5-3,8 cm del plano cutáneo, según la la corpulencia de la gestante. Una vez que se alcanza la espina ciática, y previa aspiración, se inyecta de 5-7 ml de la solución anestésica; de esta manera , se bloquea el nervio pudendo inferior que es la rama del nervio cutáneo femoral posterior. A continuación, se avanza la aguja 1 cm más hasta alcanzar el ligamento sacroiliaco, lo cual se percibe mediante un “clic”; se inyectan entonces previa nueva aspiración otros 5-7 ml de la solución anestésica, para bloquear el nervio hemorroidal inferior. Por ultimo, se repite la técnica para el contrario cambiándonos previamente los guantes. VIA TRANSVAGINAL Es importante valorar el estado de dilatación, así como la altura de la presentación para determinar la posible duración del parto y la aplicabilidad de la técnica, técnica, ya que tanto una duración excesiva como una presentación demasiado baja contraindican el bloqueo de
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plástico semirígido, para evitar pellizcar la mucosa vaginal o las pequeñas arrugas que forman los guantes. El empleo de estas agujas ha ha desplazado casi totalmente a las agujas de Kobak o Iowa. Una vez que la aguja contacta con la espina ciática, se avanza con cuidado a través de la mucosa hasta que la punta se ancla en el ligamento sacroespinoso; en este punto se depositan previa aspiración 5-7 ml de la solución anestésica. Luego, se avanza muy lentamente lentamente hasta percibir la pérdida brusca de resistencia, lo cual indica indica que la aguja ha pasado al otro lado del ligamento y descansa en el mismo plano del nervio y los vasos; en este momento, se inyectan otros 5-7 ml de anestésico, previa aspiración cuidadosa y mantenida. Este bloqueo es imposible realizarlo cuando el parto está muy avanzado y la la cabeza fetal, muy baja. La vía transvaginal es más segura y fiable , ya que la aguja tiene que atravesar menos espesor de tejido, lo cual hace la técnica técnica más fácil, segura y precisa.Existe menos riesgo de de hematomas del perineo y menos riesgo de perforación del recto.
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FACULTAD DE OBSTETRICIA Y ENFERMERIA ESCUELA DE OBSTETRICIA PLAN DE SESIÓN I
INFORMACIÓN GENERAL Asignatura Profesor Tema
II • • • • •
III
: : :
Cirugía Obstétrica e Instrumentación Flor de María Chumpitaz Soriano Ampliación del canal del parto: Episiotomía Accidentes del canal del parto. Episiorrafía Reparación de los accidentes del canal del parto. Sesión Nº : 11 CAPACIDAD DE LA SESION Define episiotomía y tipos de ampliación del canal del parto Determina el momento de la episiotomía Diagnostica los tipos de desgarro en el perineo Explica la técnica de episiorrafía Sutura el perineo y región vulvo`perineal. CONTENIDOS Y/ Y/ O ACTIVIDADES
I. EPISIOTOMÍA Etimológicamente, la palabra episiotomía se deriva de la forma prefija griega epision, que significa vulva, y tomé, también del griego, que quiere decir corte. Es pues, una “incisión quirúrgica del orificio vulvar en el momento del desprendimiento de la parte fetal, para evitar que produzca espontáneamente espontáneamente un desgarro desgarro grave del perineo”. De acuerdo acuerdo con la definición definición que trae el diccionario de terminología de ciencias medicas, la palabra episiotomía es la mas aceptada y la mas utilizada desde los comienzos de la obstetricia. A pesar de que los términos perineotomía perineotomía y vagino-perine vagino-perineotomia otomia dan una idea mas completa completa del procedimiento procedimiento quirúrgico quirúrgico que se realiza; el uso y la costumbre, nos obliga continuar con la palabra episiotomía. La episiotomía se realiza con fines profilácticos para ampliar la parte inferior de la vagina, la vulva y el perineo y de esta manera, facilitar la salida del feto. La incisión quirúrgica efectuada por el operador es un corte nítido, lineal y anatómico en contraposición con el desgarro, en el cual, es difícil controlar su forma de extensión. El acortamiento del segundo periodo del parto y sus efectos sobre el feto, ha sido un punto muy discutido en los últimos tiempos tiempos al analiza analizarr el parto parto fisiol fisiológic ógico o o natural natural,, pero pero de todas todas maneras maneras,, la episio episiotom tomía ía disminuye la duración del expulsivo. Se puede asegurar que la principal indicación de la episiotomía se cumple cuando se atiende el parto de una primigesta y en estos casos, siempre debe realizarse. También se recomienda cuando se requiere la aplicación de un fórceps o cuando el
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Tipos De acuerdo con la dirección del corte, se conocen la mediana, la mediolateral y la lateral. Esta ultima no se menciona por antiestética, antianatómica y antifuncional y porque el sangrado es mayor. Es difícil encontrar dos personas que realicen una episiotomía con su correspondien correspondiente te reparación, en forma exactamente exactamente igual. Sin embargo, antes de hablar sobre la técnica, se anotan las ventajas y desventajas de la mediana y la mediolateral.
Mediana 1. Su cier cierre re se se hace hace con con mayor mayor facili facilidad. dad. 2. Su cica cicatr triz izac ació ión n es es mej mejor or 3. El dolor dolor es es menor menor durant durante e el puerper puerperio io 4. Los resul resultad tados os anatóm anatómico icoss posteri posteriores ores son son mejores mejores 5. La pérdi pérdida da de sangr sangre e es es men menor or 6. Desde el punto punto de de vista vista funcional funcional,, produce produce menos menos dispare dispareunia unia 7. El desga desgarro rro del del esfín esfínter ter anal anal y aun del del recto recto,, es mayor. mayor.
Mediolateral 1. Su cier cierre re se se hace hace con con mayor mayor dificul dificultad tad 2. Su cica cicatri trizac zación ión puede puede ser ser defe defectu ctuosa osa.. 3. El dolo dolorr es mas mas frecuen frecuente te duran durante te el puer puerperi perio o 4. Los resultados resultados anatómicos anatómicos posteriores posteriores son más deficientes deficientes 5. La pérd pérdid ida a sang sanguí uínea nea es may mayor or 6. Desde el el punto de de vista funcion funcional, al, la dispare dispareunia unia se present presenta a con mayor mayor frecuencia frecuencia 7. El desga desgarro rro del del esfín esfínter ter anal anal y aun del del recto recto es menor menor Es difícil decir cual de las dos es mejor. El estudiante de pregrado y el médico que se inicia como especialista especialista debe conocer y poner en practica los dos tipos de episiotomía, episiotomía, con la supervisión adecuada, antes de inclinarse por cualquiera de las dos. Como puede observarse, la principal ventaja de la mediolateral sobre la mediana es la disminución de los desgarros perineal y rectal.
Aspecto Anatómico Solamente se mencionan algunos detalles anatómicos relacionados con la episiotomía y su reparo posterior. Los músculos y las aponeurosis del perineo tienen la misma disposición en la mujer que en el hombre. La diferencia se encuentra en el músculo transverso profundo. Además, en la mujer existen dos orificios: la uretra y la vagina, localizados en una porción
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Plano Profundo El principal músculo es el elevador del ano con sus porciones que se comportan como músculos músculos diferentes. Son el pubiococcíge pubiococcígeo o y el ileococcígeo, ileococcígeo, toman sus nombres de los sitios de inserción. Tienen una función constrictora sobre la vagina y el ano.
Plano Medio El transverso profundo es mas largo en la mujer que en el hombre y se une firmemente en el centro, en una zona tendinosa; la cual esta situada en el espacio triangular recto vaginal, comprendido entre la parte perineal del recto y la vagina. El esfínter externo de la uretra termina en la parte inferior, en el tejido conectivo denso que une estrechamente la uretra y la vagina.
Plano Superficial Este plano esta constituido por cinco músculos. El esfínter externo del ano se localiza en el triángulo rectal del perineo. Los cuatro restantes ocupan el triángulo urogenital y son: el transverso superficial, el isquiocavernoso, el bulbocavernoso y el constrictor de la vagina. Este ultimo, produce la contracción de la vagina y es el causante del vaginismo inferior. Las aponeurosis acompañan a los músculos en su recorrido y también se dividen en superficial, media y profunda o endopelvia. Esta es la más importante. Los músculos y aponeurosis que constituyen el piso pélvico, tiene un significado valioso en la filosofía sexual, por lo cual, la atención que se brinde a la madre durante el parto y la correcta ejecución de la episiotomía y sutura posterior, redundaran en un beneficio desde este punto de vista.
II. TÉCNICA Si la episiotomía se hace demasiado temprano, la pérdida sanguínea puede ser mayor. Pero si se efectúa muy tarde, no cumple con uno de los objetivos, cual es conservar el piso pélvico por que los músculos ya han sufrido estiramiento y aun ruptura de muchas fibras que el operador no puede observar. Cuando el parto es espontáneo, el momento mas adecuado para realizar el corte es el encajamiento profundo de la presentación, pero antes de abombarse o distenderse el perineo y sin que se halla dilatado el anillo valvular. Cuando se aplica un fórceps, se recomienda efectuarla antes de iniciar la maniobra; para que el corte sea nítido, pero cuando se esta seguro de extraer el feto por vía vaginal. La ventaja ventaja e hacer incisión incisión primero se sobrepone sobrepone a la pérdida sanguínea ligeramente ligeramente superior. A continuación se anotan los pasos para realizar una episiotomía mediana. La habil habilid idad ad se adqui adquiere ere desp después ués de efect efectua uarr vari varias as veces veces la técni técnica ca,, pero pero el
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1) Se separan separan los los labios labios con los los dedos dedos índice índice y medio medio de la mano contra contraria ria a la que sostiene la tijera y se identifica el plano muscular. 2) La punta punta de la tijera tijera se introduc introduce e en la línea línea media media de la región mucocutá mucocutánea. nea. 3) La orientación orientación de de la tijera tijera debe ser ser de forma forma oblicua oblicua en dirección dirección al recto. recto. En dicho dicho sitio se inicia el corte. 4) La tijera tijera toma un sentido sentido horizont horizontal al alejándola alejándola del del recto y con movimiento movimiento de de cierre y apertura de las ramas, se avanza lentamente hasta una profundidad que varia entre 6 y 9 cm. 5) Después Después de alcanzar alcanzar la profundida profundidad d deseada, deseada, se retira retira la tijera tijera y se realiza realiza un corte de la mucosa vaginal, el tejido conectivo y la porción muscular y aponeurótica. Posteriormente se continúa con el corte de la región perineal.
III. LESIONES DEL CANAL DEL PARTO DESGARROS Es una de las principales causas de hemorragia postparto. Pueden ocurrir como consecuencia de un parto precipitado, expulsivo mal conducido, tamaño exagerado del feto, tejidos rígidos y aplicación incorrecta de fórceps. Se localiza principalmente en el cuello, en la vagina o en el perineo. Se deben sospechar cuando el útero se encuentra bien contraído después de la expulsión de la placenta y el sangrado por vagina es significativo. La recomendación de revisar el canal del parto después de toda intervención durante el expul expulsi sivo vo,, es una una medi medida da preve preventi ntiva va del choq choque ue hipov hipovol olémi émico co que que se pres presen enta ta como como consecuencia de la hemorragia. Además, se pueden detectar algunas laceraciones que sin provocar hemorragia pueden ser la causa de posteriores alteraciones del cuello tales como: cervicitis y ectropión.
Cervicales La mayoría de las veces se localizan en las comisuras y pueden ser pequeños o extensos de acuerdo a la causa. Así, cuando el fórceps se aplica sin estar el cuello en la dilatación completa o si una de las cucharas se coloca incorrectamente, la profundidad del
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disección larga y suficiente gasa, son necesarios para efectuar la revisión del cuello en el postpar postparto to inmedi inmediato ato.. Con las pinzas pinzas se va recorr recorriend iendo o el cuello cuello sujeta sujetando ndo sus bordes bordes y frac fracci cion onánd ándolo oloss
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preferencialmente las comisuras. Después de localizar el sitio y la extensión, se procede a la sutura. En este sentido, algunos consideran que una laceración menor de 2.5 cm que no sangre, no es necesario corregir, sin embargo, la cicatrización posterior del cuello es mejor cuando se suturan todos los desgarros por pequeños que ellos sean. El material de sutura por lo general es el catgut cromado 00 y el cierre se puede efectuar con puntos separados o continuos según la extensión y la intensidad de la hemorragia. El cierre debe comenzar un poco por detrás del ángulo superior del desgarro hasta el borde del cuello.
Vaginales Se produce cuando no se conduce bien el expulsivo en un parto espontáneo, la episiotomía es insuficiente para el grado de rigidez de los tejidos o el tamaño del feto o se aplica incorrectamente un fórceps.
Perineo Las causas de los desgarros perineales son iguales a las que causaron las lesiones vaginales. Existen en ocasiones algunas condiciones desfavorables en la constitución del perineo que facilitan los desgarros a pesar de la experiencia de la persona que atiende el parto. Esto se observa en la extracción de algunos fórceps cuando hay rigidez del tejido muscular. Se clasifican en 4 grados así: I.
Comp Compro rome mete te sol solo o la piel piel y los los teji tejido doss sup super erfifici cial ales es sin sin int inter eres esar ar el el mús múscu culo lo
II. II.
Adem Además ás de de la la piel piel y los los tej tejid idos os supe superfi rfici cial ales es está están n com compro promet metid idos os los los mús múscu culo loss del perineo
III. III.
Se exti extien ende de a los los mús múscu culo loss per perin inea eale less y al al esf esfín ínte terr del del ano ano
IV. IV.
Adem Además ás de de compr comprom omet eter er las las ante anteri rior ores es estru estruct ctura uras, s, exi exist ste e lesi lesión ón de de la muc mucos osa a rectal, no importa importa su extensión.
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Después de la expulsión de la placenta, se aplica una solución antiséptica en la vagina y el perineo, se limpian y separan los extremos del esfínter anal. El cierre de la mucosa rectal y anal se efectúa con catgut cromado 00 o 000 con puntos separados, a una distancia de medio centímetro entre uno y otro para facilitar el adosamiento de los bordes. Este primer plano se debe debe reforz reforzar ar con unos puntos puntos que se coloca colocan n en la fascia fascia rectovagi rectovaginal. nal. Enseguid Enseguida a se aproximan los extremos retraídos del esfínter anal y se colocan 2 o 3 puntos separados de catgut cromado 00 pasados a través del músculo y de su fascia. Los músculos elevadores del ano se suturan por puntos separados y finalmente se aproximan el transverso profundo y el superficial del perineo. El resto de la sutura es igual a la de una episiotomía mediana.
HEMATOMAS Se presentan ocasionalmente y pueden ser de tal magnitud que desencadenan un choque hipovolémico además del dolor tan molesto en las primeras horas del postparto. La mayoría de las veces ocurre por la laceración de un vaso sin lesión visible de los tejidos adyacentes. Se presentaba con mayor frecuencia cuando se aplicaba el bloqueo paracervical o pudendo. También se puede deber a una presión excesiva de la presentación sobre la vagina y las estructuras pélvicas de soporte. La aplicación de fórceps cuando se acompaña de una rotación o queda muy ajustado en la vagina. Casi siempre el hematoma se forma gradualmente cuando la sangre estravasada se acumula en los tejidos de la pelvis. La paciente experimenta un dolor a medida que crece el hematoma y manifiesta la sensación de un peso en la región recto perineal con deseos de defecar. El diagnóstico se hace con la inspección y la palpación recto-vaginal. De acuerdo con la anatomía de las distintas fascias del piso pélvico se pueden dividir en: vulva, vaginal y rectroperitoneal.
Vulvar Poco tiempo después del parto y cuando ya la paciente se encuentra en la habitación, se queja de un dolor intenso localizado en la región vulvo-vagina vulvo-vaginal.l. A la inspección inspección se observa observa
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Vaginal El diagn diagnós óstitico co se confi confirm rma a por la insp inspec ecci ción ón y la palp palpac ació ión. n. Casi Casi siemp siempre re esta esta localizado por debajo de la mucosa vaginal y es una continuación de la perineorrafía. Es preciso abrir la vagina, drenar el hematoma y reconstruir la zona afectada.
Retroperitoneal Es el más grave y ocurre en las primeras horas del postparto. Se presenta como una comp complilica caci ción ón de un desgar desgarro ro cerv cervic ical al extens extenso o que que no fue fue sutu sutura rado do adec adecuad uadam amen ente. te. Ocasionalmente tiene lugar en las primíparas después de un parto normal. La lesión de la arteria uterina o de una de las ramas del tronco anterior de la arteria hipogástrica, puede ser la causa de esta variedad de hematoma. El diagnóstico se sospecha por el intenso dolor abdominal, el estado de choque y la palpación de una masa localizada a nivel de los ligamentos anchos.
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Reparación de la episiotomía Es necesario resaltar que el borde medial del componente vaginal de la episiotomía es mas largo que el lateral, puesto que en la episiotomía se corta un cilindro, cuya porción lateral esta fijada a la pared pélvica, mientras que la medial cuelga libremente. Al reparar la episiotomía, cada punto dado con la aguja debe hacerse avanzar algo mas en el borde medial que en el lateral. Esto permite conseguir una mejor coaptación de los bordes vaginales, el anillo himeneal y la horquilla perineal.
Sutura de la episiotomía Episiorrafía o Perineorrafía: El cierre de la herida debe ser muy cuidadoso, es decir, plano por plano, con los instrumentos y materiales necesarios para la colpoperinorrafía. El momento oportuno de realizarla es variable, para unos inmediatamente después del parto, aprovechando la anestesia; para otros después que se ha expulsado la placenta. En el primer caso, se presenta el inconveniente de que la sangre oscurece el campo; se contiene con un gran tapón de gasa atado con con hilo largo, que servirá para no olvidarlo. En el segundo caso, la ventaja es que ya no hay sangre en el campo y que la sutura no estará expuesta a desgarros por la necesidad de nuevas maniobras en el momento de ser expulsada la placenta.
Material de sutura Es recomendable catgut simple 0, 00. El catgut cromado es útil para puntos profundos cuando se han interesado los elevadores.
Técnica Se entreabre bien los labios vulvares y los bordes de la herida, se hace hemostasia y comienza la sutura con puntos separados o puntos continuos por el ángulo superior de la herida de la mucosa y de su fascia. El último hilo en la sutura de la mucosa se coloca en los puntos donde el circulo himeneal ha sido seccionado. En lo sucesivo se hace la sutura de los músculos perineales con puntos separados, con
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Postoperatorio Después de lavar cuidadosamente la herida y el perineo se le protege con solución antiséptica. Al higienizar se evitara friccionarla para no perturbar el tenue proceso fribroplático que que prod produc ucir irá á una una cica cicatr triz iz elást elástic ica a o, al menos menos sóli sólida da.. Cual Cualqui quier er fall falla a dejara dejara la vulv vulva a entreabierta, entreabierta, con todas sus consecuencias consecuencias:: infecciones infecciones cervicales endometriales endometriales o anexiales, anexiales, prolapsos, esterilidad, alteraciones de la sensibilidad y, aun la frigidez.
V. ACCIDENTES DE LAS PARTES BLANDAS DURANTE DURANTE EL PARTO: Tratamiento suturas cervicales La sutura debe realizarse inmediatamente después del desgarro Existen tres maniobras para que la traquelorarrafia no sea dificultosa: 1. Comprimir el útero a través de la pared abdominal hacia el exterior de la pelvis. 2. Tomar el labio anterior del cuello con una pinza y traccionarlo hacia fuera de la vagina. 3. Tomar el labio posterior (previa colocación de las valvas o sin ellas) y traerlo con fuerza hacia fuera. De esta manera el desgarro se visualiza en casi toda su totalidad. Se coloca una valva separando la pared vaginal del lado del desgarro y se procede a la sutura por puntos separados no mas de 0,5 cm uno del otro, o mediante surjet contínuo o punto pasado. Es recomendable comenzar la sutura por la parte no desgarrada del cuello, por encima del ángulo superior de la herida, debido de que allí se halla el vaso retraído.
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Suturas perineales Se empieza la sutura inmediatamente después del alumbramiento, puesto que la herida no está aún contaminada. •
Es conveniente revisar antes el cuello del útero y la vagina
•
En el desgarro 1ro. y 2do. Grado se utiliza anestesia local, puntos separados
que afronten todo el espesor de la herida, lo importante es no dejar espacios “muertos”. •
En el desgarro de 3er. Grado, se utiliza anestesia general. Se procede por
plano; teniendo cuidado de reparar previamente los casos de esfínteres externo •
En el desgarro de 4to. Grado implica una cuidadosa preparación y hemostasia
de la pared rectal y del esfínteres del ano. •
En el desgarro central del periné se secciona el puente representado por la
horquilla.
Técnica Se inicia con el cierre de los planos profundo en el cual queda incluido los músculos (puntos separados). La aproxi aproximac mación ión de los múscul músculos os bulbo bulbo caverno cavernoso so y transve transverso rso superfi superficial cial debe realizarse con mucho cuidado sin presionar demasiado los bordes. Después de terminar la reconstrucción de los músculos, se toma la aguja que se había dejado sobre la región supera púbica y se inicia el cierre de la piel por medio de la sutura subdérmica o en todo caso con los puntos separados. Desgarro de 1er. Grado ---------------------- Puntos separados (piel y tejidos superficiales)
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-
5to. Plano ------------------ piel ------------------------------------ puntos separados
Afecta la pared del recto. Llegamos a este diagnóstico de 1er, 2do, 3er, 4to grado a través de la palpación mediante tactos: vaginales y rectales. El cier cierre re inco incorr rrect ecto o favo favore rece ce la cicat cicatri riza zaci ción ón defe defect ctuo uosa sa y pued puede e ser ser caus causa a de dispareunia; formándose también hematomas que producen mucho dolor y facilitan la infección.
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FACULTAD DE OBSTETRICIA Y ENFERMERIA ESCUELA DE OBSTETRICIA PLAN DE SESIÓN I
II
III
FORMACIÓN GENERAL: Asignatura : Cirugía Obstétrica Menor e Instrumentación Profesor : Flor de María Chumpitaz Soriano Tema : Heridas Sesión Nº : 12 CAPACIDAD DE D E LA SESION -Identifica las heridas quirrúrgicas -Clasifica las heridas según como surgen y según contaminación CONTENIDOS Y/ O ACTIVIDADES
I. HERIDAS Por herida se entiende la intersección de la continuidad anatómica y funcional del tejido vivo con lesión celular en alguna región superficial o profunda del cuerpo, causada por agresión micro o microscópica, programada o no. Las heridas son lesiones de los tejidos blandos, en las que la piel esta abierta y se hallan expuestos diferentes tejidos internos. Producen hemorragia, frecuentemente desarrollan infección y a veces perdida de la función por sección de nervios o tendones, implican la rotura, laceración, incisión perforación o daño de alguna zona u órgano del cuerpo.
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Las heridas de las extremidades, cuello o cara permiten un diagnóstico de la lesión más sencillo que una herida abdominal. El riesgo de la infección, es mayor cuando la herida se encuentra en comunicación con la cavidad oral por ser éste un medio contaminado, al igual que la región perineal
Profundidad: Hay diferencia diferencia en la profundi profundidad dad de las las
heridas así, por ejempl ejemplo, o, una una herida herida de 2
cms. de profundidad en el ángulo anterior del cuello que en la región glútea, pues en la primera fácilmente se pueden lesionar lesionar estructuras vasculares importantes que provoquen la muerte del paciente, mientras que en la segunda sólo lesionará músculo.
Agente agresor La importancia radica en el daño tisular que provoque. Una herida por arma blanca o vidrio será lineal, mientras que por bala, o aplastamiento, tendrá gran daño de tejido con pérdida de sustancia, severa contaminación, mayor tendencia a la infección, lo cual hace más difícil su manejo y pronóstico.
Anatomía La localización de una herida y su profundidad permiten determinar cuales son las estructuras anatómicas mas probablemente afectadas. La cantidad y espesor del tejido celular subcutáneo varían de acuerdo con la región del cuerpo y el grado de obesidad. Cuanto mayor es el grosor del tejido celular subcutáneo, mayor es el riesgo de infección, porque la capacidad de este tejido para defenderse de la invasión
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Son aquellas en que existe rotura visible en la piel o en la membrana mucosa. Ellas se subclasifican a su vez según el tipo de extensión de la herida a) Abrasiones, Abrasiones, Escoriacione Escoriaciones, s, Arañazos Arañazos O Raspaduras: Raspaduras: b) Cort Cortes es E Inc Incis isio ione ness c) Punz unzadur adura as d) Dav Davuls ulsion iones 2.
Heridas Cerradas
Se producen en la parte interior del cuerpo, por lo que no existe una lesión lesión externa en la piel que sangre. Puede haber hemorragias por oídos, nariz y boca. a) Herida Heridass cerrad cerradas as leve levess – Cont Contusi usiones ones b) Heri Herida dass cerr cerrad adas as grav graves es
II.
POR EL EL GR GRADO DE DE CO CONTAMINACION 1. Herida Limpia 2.
Herida Limpia Contaminada
3
Herida Ex Extensamente Co Contaminada
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Las personas personas con lesiones lesiones múltiples múltiples (politraumati (politraumatizadas) zadas) necesitan tratamiento tratamiento multidisciplinario, que coordina une persona. Los traumatismos múltiples pueden afectar todos los aparatos y sistemas corporales.
Heridas Quirúrgicas El tratamiento tratamiento aséptico aséptico de una herida es un intento intento de evitar la contaminación contaminación por bacterias de las fuentes de infección como el paciente, personal, los objetos inanimados y el aire, durante la operación y en la primera semana o días ulteriores de la cicatrización.- Los métodos modernos para evitar la infección en las heridas “limpias” incluyen también el uso de técnicas técnicas quirúrgicas quirúrgicas cuya finalidad finalidad es es hacer que que la herida herida no constituy constituya a un medio para para la disección limpia limpia y neta hemostasis hemostasis adecuada adecuada y proliferación bacteriana: manejo suave, disección aposición precisa de los bordes
sin tensión cuando se cierra la herida . Es imposible
eliminar por completo las bacterias del campo quirúrgico, pero las medidas asépticas prácticas permiten reducir el riesgo de contaminación a un nivel aceptable.
Manejo de heridas contaminadas
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Manejo de heridas infectadas Una herida se considera infectada si: a) Sus Sus borde bordess están están enro enroje jeci cidos dos b) Sus Sus borde bordess está están n edema edemato toso soss c) Se incr increm ement enta a el dol dolor or loc local al d) Hay Hay produc producci ción ón de pus pus e) No ha tenido atención atención sino hasta después de 24 horas horas de producida. producida. Este tipo de heridas se trata con reposo del área afectada y curaciones diarias con gasas humedecidas con agua oxigenada, solución de Dakin (solución de hipoclorito de sodio) o suero fisiológico solamente. El cambio de curación debe ser diario o cada 12 horas, porque así la herida se debrida y se limpia. La herida con estas curaciones cicatriza sola por segunda intención en un periodo de
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Carro de curaciones Es una mesa de 1 o 2 pisos, en la cual se halla todo lo necesario para una curación: soluciones antisépticas: instrumental, gasas y apósitos. El piso inferior del carro esta destinado a recibir el material que ha sido utilizado y que se considera contaminado o sucio. En un balde se hecha el material descartable. Procedimientos 1. Descub Descubrir rir la región región que ha de curars curarse, e, si existier existiera a la posibi posibilid lidad ad de mojar la cama cama con con secr secrec ecio ione ness o dura durant nte e el lava lavado do de la heri herida da,, se debe debe prot protege eger r convenientemente. 2. Retirar Retirar las telas telas adhesiv adhesivas as que fijan fijan la curaci curación, ón, hacién haciéndol dolo o en forma forma rápida rápida o empleando una solvente para ablandar el adhesivo. 3. Abrir Abrir un paquete paquete con instrume instrumental ntal.. No debe tocarse tocarse la superfic superficie ie interna interna del papel, que esta esterilizada. 4. El paqu paquet ete e de gasa gasass abie abiert rto o corr correc ecta tame ment nte e se colo coloca ca sobr sobre e el carr carro o de curaciones o al extraerlo del recipiente hacerlo con pinzas para no contaminar a los
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FACULTAD DE OBSTETRICIA Y ENFERMERIA ESCUELA DE OBSTETRICIA PLAN DE SESION I
II
INFORMACIÓN GENERAL: Asignatura : Cirugía Obstétrica Menor e Instrumentación Profesor : Flor de María Chumpitaz Soriano Tema : Inflamación- Infección quirúrgica. Sesión Nº : 13 CAPACIDAD DE LA SESIÓN Establece diferencias entre Inflamación y de la Infección Quirúrgica • Identifica las infecciones quirúrgicas. •
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b. Exud Exudac ació ión. n. Es la sali salida da del del plas plasma ma por por los los espa espaci cios os entr entre e las las célu célula lass endo endote telilial ales es de los los capi capila lares res,, esto esto se da por por la acci acción ón de polip polipép éptitidos dos vasoactivos o quininas. Esta se manifiesta por tumor y dolor.
Mediadores químicos de la inflamación 1. Amin Aminas as vas vasoac oactiva tivas: s: his histami tamina na y sero seroto toni nina na 2.
Proteasas plasmáticas:
Sistema de las kininas (Bradikinina y kalicreina) Sistema del complemento (fragmento de C3, C5, C567).
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citocinas) influyen en la expresión de superficie y la intensidad de fijación de estas moléculas de adhesión.
Inflamación séptica aguda Es un conjunto de síntomas locales en los tejidos por la penetración de gérmenes patógenos que alteran y destruyen las células.
Etiología y patogenia
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Esto da lugar a un tumor o aumento de volumen del área afectada, constituyéndose los signos cardinales de la inflamación. Los elementos del plasma, al pasar al espacio intersticial, destienden las mallas del tejido conectivo separando sus elementos celulares y fibras; al irritar mecánica o químicamente las terminaciones sensitivas nerviosas producen el dolor.
Marginación de los leucocitos Si observamos al microscopio un vaso capilar en un área de inflamación aguda, nos
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Efectos sistémicos de la inflamación Cualqui Cualquiera era que haya haya sufrid sufrido o una faringi faringitis tis o cualqui cualquier er infecci infección ón respira respirator toria ia ha experimentado los efectos sistémicos de la inflamación aguda. La fiebre es una de las manifestaciones más prominentes sobre todo si la inflamación es secundario de la infección. En conjunto estos efectos sistémicos se conoce como reacciones de fase aguda. Además Además de fiebre fiebre hay aumento aumento en el sueño sueño de hondas hondas lentas lentas,, dismin disminuci ución ón del apetito, apetito, incr increm emen ento to en la degr degrad adac ació ión n de las las prot proteí eína nas, s, hipo hipote tens nsió ión n y otra otrass alte altera raci cion ones es
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La primera lleva glóbulos blancos a la zona afectada que ayudan a destruir y eliminar sustancias extrañas como bacterias y las células tisulares destruidas. Las histamina, junto con otras sustancias, sustancias, aumenta la permeabilida permeabilidad d de las paredes capilares capilares y ello permite que pasen al área líquidos, proteínas y leucocitos. También se activan los mecanismos de coagulación, de tal forma que los líquidos se coagulan y “tapian” las áreas lesionadas. Típica Típicamen mente, te, en un proceso proceso inflam inflamato atorio rio hay cinco cinco caminos caminos observa observable bles: s: calor, calor, enrojecimiento, dolor, tumefacción y limitación de la función. El enrojecimiento se debe a la dilatación de los vasos sanguíneos y el aumento consiguiente del riesgo a esa región.
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Esta consiste en:
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Si la infección se produce por la perforación de una víscera sin traumatismo externo, la
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Tres mecanismos de sostén acompañan de forma constante a estas intervenciones:
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debilid debilidad ad estruc estructur tural. al. El epitel epitelio io de superfi superficie cie no llega llega a recubri recubrirr el área infectad infectada a y la
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The world’s largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world’s largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world’s largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world’s largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world’s largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world’s largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world’s largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
The world’s largest digital library
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.