database.json

[
{
"keys": [
"appendix",
"appendectomy",
"appendix removal"
],
"name": "Appendectomy",
"modes": {
"professional": "Appendectomy is the removal of the vermiform appendix. The patient lies on his back. An incision in the right iliac region, layer-by-layer access, ligation and removal of the appendix, suturing.",
"normal": "The appendix is removed through a small incision on the side of the abdomen. It is done under anesthesia, then stitched up."
},
"steps": [
{
"name": "Pain relief",
"description": {
"professional": "General anesthesia (intubation anesthesia) is performed. Propofol or sodium thiopental is administered intravenously for induction, then maintained with inhalational anesthetics (sevoflurane, isoflurane) through an endotracheal tube. Epidural anesthesia is possible if general anesthesia is contraindicated.\nInstruments: \n- 18G catheter (IV access) \n- 20 ml syringe (propofol/thiopental) \n- Macintosh laryngoscope No. 3-4 \n- 7.0–7.5 mm endotracheal tube\nTechnique: \n1. The anesthesiologist fixes the patient's head with his left hand, inserts the laryngoscope with his right hand (blade along the midline of the tongue). \n2. The tube is inserted under the control of vocal cords (angle 45°), connected to a ventilator. \n\nLogistics: \n- The used laryngoscope is placed on a separate table for processing. \n\nNuance: With epidural anesthesia, the Tuohy needle is inserted at the L3-L4 level at an angle of 60°.",
"normal": "Before the operation, the person is put to sleep. This is done through an injection into a vein - the drug puts the patient into a deep sleep. After that, the doctor inserts a special tube into the throat so that the person can breathe through the device. Everything happens carefully and quickly - the patient does not feel anything.\n📌 Interesting point: sometimes, instead of general sleep, anesthesia is given in the back - it completely turns off sensitivity in the lower part of the body."
  }
 },
 {
"name": "Incision",
"description": {
"professional": "A 5-7 cm long McBurney incision (a point on the border of the middle and outer third of the line connecting the navel and the anterior superior iliac spine). Layer-by-layer dissection of the skin, subcutaneous tissue, aponeurosis, muscles and peritoneum.\nInstruments: \n- Scalpel No. 15 (pencil grip) \n- Mikulicz clamps 2 pcs. \n- Electrocoagulator (cut mode, 30 W) \n\nTechnique: \n1. McBurney incision: 2 cm above the anterior superior iliac spine, length 5-7 cm. \n2. Subcutaneous tissue is coagulated, avoiding thermal burns to the skin. \n\nLogistics: \n- Scalpel after the incision — in the «dirty»tray. \n\nNuance: In case of obesity, a retractor is used for the edges of the wound.",
"normal": "On the right side of the abdomen, just above the hip, the surgeon makes a small incision — about 5–7 centimeters. First, the skin is cut, then the subcutaneous tissue. All bleeding areas are immediately cauterized with a special device so that there is no blood.\n📌 Interesting point: if a person is overweight, the skin can be slightly stretched with special hooks to improve access."
  }
 },
 {
"name": "Access",
"description": {
"professional": "Mobilization of the cecum, visualization of the appendix. Assessment of its condition, isolation from adhesions if necessary. Application of a clamp to the mesentery of the appendix.\nInstruments: \n- Metzenbaum scissors \n- Bilroth clamps 2 pcs. \n- Gauze swabs \n\nTechnique: \n1. The aponeurosis and muscles are dissected layer by layer (spread apart with blunt forceps). \n2. The peritoneum is lifted with tweezers, cut with the tips of the scissors upward. \n\nLogistics: \n- Bleeding vessels are coagulated immediately. \n\nNuance: With a retrocecal location of the appendix, the cecum is mobilized.",
"normal": "After the incision, the doctor moves deeper: pushes apart the muscles, lifts a thin film inside the abdomen (this is the peritoneum), and underneath it is already the intestine. Carefully, layer by layer, the surgeon finds the cecum and the appendix itself.\n📌 Interesting point: the appendix can hide behind the intestine. In this case, it has to be «pulled out» by carefully moving the intestine."
  }
 },
 {
"name": "Removal",
"description": {
"professional": "Ligation of the mesentery with absorbable suture material (vicryl), cutting off the appendix between two clamps. The stump of the appendix is immersed in the cecum with a purse-string and Z-shaped sutures.\nInstruments: \n- Kocher clamp \n- Vicryl thread 2-0 (ligature) \n- Appendicular clamp \n\nTechnique: \n1. The mesentery of the appendix is ligated, cut off. \n2. The stump is immersed with a purse-string suture (26 mm needle). \n\nLogistics: \n- The removed appendix is sent to a container for histology. \n\nNuance: In case of gangrene of the appendix, the mesentery is sutured separately.",
"normal": "When the appendix is found, the doctor carefully ties its base with threads, cuts off the appendix itself and tightly sutures the place where it was. It's like removing a broken faucet and plugging a pipe - so there are no leaks.\n📌 Interesting moment: removed appendix then they send it for inspection to make sure there is nothing dangerous inside."
  }
 },
 {
"name": "Suture",
"description": {
"professional": "Layer-by-layer wound suturing: peritoneum (catgut), muscles (vicryl), aponeurosis (polypropylene), subcutaneous tissue and skin (silk/absorbable sutures). Drainage if necessary.\nInstruments: \n- Mathieu needle holder \n- Monocryl 3-0 thread (skin) \n- Redon drainage (for peritonitis) \n\nTechnique: \n1. The peritoneum is sutured with catgut, the muscles - with vicryl. \n2. The skin is closed with an intradermal suture. \n\nLogistics: \n- Used needles - in a sharps container. \n\nNuance: The drainage is brought out through a separate puncture.\n⚠️ After the operation\n1. The person is usually sent home after 1-3 days.\n2. The suture heals for about a week.\n3. Sometimes the stomach may hurt - this is normal.",
"normal": "After everything inside is processed, the doctor stitches the incision back up. This is done in layers: first the internal tissues, then the muscles, and finally the skin. If there was an infection or pus during the operation, they can leave a special tube (drainage) so that the fluid can come out.\n📌 Interesting point: modern sutures can be self-absorbing - they do not need to be removed.\n\n⚠️ After the operation\n1. The person is usually sent home after 1-3 days.\n2. The suture heals for about a week.\n3. Sometimes your stomach may hurt — that's normal."
    }
   }
  ]
 },
{
"keys": [
"caesarean",
"caesarean section"
],
"name": "Caesarean section",
"modes": {
"professional": "Incision in the anterior abdominal wall, layer-by-layer access, incision in the uterus, extraction of the fetus, suturing. Performed under general anesthesia or epidural anesthesia.",
"normal": "The baby is taken out through an incision in the abdomen. Everything is done under anesthesia. The stitches are then removed."
},
"steps": [
{
"name": "Preparation",
"description": {
"professional": "Bladder catheterization, preparation of the surgical field. Choice of anesthesia: spinal/epidural (0.5% bupivacaine) or general anesthesia (propofol + succinylcholine for intubation). Monitoring vital signs.\nInstruments:\n- Foley catheter 16 Fr (for the bladder)\n- Antiseptic (chlorhexidine 2%)\n- 10 ml syringe (bupivacaine 0.5% for epidural anesthesia)\n- ECG monitor, pulse oximeter\n\nTechnique:\n1. Catheterization of the bladder (to avoid damaging it).\n- The catheter is inserted under sterile conditions and fixed to the thigh.\n2. Preparation of the surgical field:\n- From the xiphoid process to the pubis, with broad strokes.\n3. Anesthesia:\n- Epidural: an 18G Tuohy needle is inserted into the L3-L4 space.\n- General anesthesia: if urgent - intubation (propofol + succinylcholine). \n\nLogistics: \n- Used antiseptic wipes go into the «dirty» bin. \n\nNuance: During an emergency CS, catheterization is sometimes skipped.",
"normal": "Before the operation, a catheter is inserted into the woman's bladder - this is necessary so that it does not interfere and is not damaged during the operation. The abdomen is treated with an antiseptic - from the sternum to the pubis. Then anesthesia is administered: most often - an injection in the back, which turns off sensitivity below the waist. Sometimes, if everything is urgent, general anesthesia is given - the woman falls asleep completely. \n📌 Interesting point: even if everything is done urgently, doctors have time to prepare everything as needed in a couple of minutes."
  }
 },
 {
"name": "Incision",
"description": {
"professional": "Pfannenstiel incision (transverse above the pubis) or lower midline laparotomy. Layer-by-layer dissection: skin, subcutaneous tissue, aponeurosis, division of the rectus muscles, parietal peritoneum.\nInstruments:\n- Scalpel #20 (for skin)\n- Electrocoagulator (ValleLab, «cut/coagulation» mode)\n- Pean clamps (for subcutaneous vessels)\n\nTechnique:\n1. Pfannenstiel incision (transverse, above the pubis):\n - Dissect the skin and subcutaneous tissue.\n - Coagulate the vessels.\n2. Dissect the aponeurosis transversely with scissors, bluntly separate the muscles.\n\nLogistics:\n- Place the scalpel immediately into the «sharp» container after cutting the skin. \n\nNuance: During an emergency C-section, a lower midline incision is sometimes made (faster).",
"normal": "A horizontal incision in the lower abdomen about 10-15 cm long. The surgeon makes it just above the pubis. It looks like a small «seam» along the bikini line. The skin and tissues are carefully moved apart to reach the uterus. It is important to do everything in layers and as carefully as possible so as not to damage other organs.\n📌 Interesting point: during an emergency birth, a vertical incision can be made - this is faster, but more noticeable."
  }
 },
 {
"name": "Access",
"description": {
"professional": "Opening the vesicouterine fold of the peritoneum, lowering the bladder. Uterine incision in the lower segment (transverse according to Derfler) 10-12 cm long.\nInstruments: \n- Mayo scissors (curved) \n- Kocher clamps (2 pcs.) \n- Retractor (for retraction of the urinary bladder) \n\nTechnique: \n1. Vesicouterine fold: \n - Raise with tweezers, cut with scissors the tips upwards. \n2. The urinary bladder is lowered down with a swab. \n3. Uterine incision: \n - Transverse in the lower segment (according to Derfler) - length 10-12 cm. (as mentioned earlier) \n - Cut with a scalpel, then spread apart with fingers. \n\nLogistics: \n- Blood is aspirated with an electric suction pump. \n\nNuance: If the uterus does not contract well, the incision is made higher.",
"normal": "When the doctor reaches the uterus, he carefully moves the urinary bladder down so that it does not interfere. After this, an incision of approximately 10–12 cm is made on the uterus. Sometimes it is done with a scalpel, but more often with fingers, so that the tissue does not tear further than necessary.\n📌 Interesting point: the uterus is cut in its lower segment - there are fewer muscles there, and the suture heals better."
  }
 },
 {
"name": "Extraction",
"description": {
"professional": "Manual extraction of the fetus, cutting the umbilical cord. Introduction of oxytotin to contract the uterus. Removal of the placenta, revision of the uterine cavity.\nInstruments: \n- Obstetric forceps (if the head is deep) \n- Scissors (for the umbilical cord) \n- Syringe with oxytocin (10 IU intravenously) \n\nTechnique: \n1. Manually insert into the uterine cavity, find the head/pelvis of the fetus. \n2. Extract the baby, clamp and cut the umbilical cord. \n3. Oxytocin is administered immediately to contract the uterus. \n\nLogistics: \n- The fetus is handed over to the neonatologist. \n- The placenta is examined for integrity. \n\nNuance: In case of breech presentation, the baby is removed carefully by the legs.",
"normal": "The doctor carefully inserts his hand through the incision in the uterus and pulls out the baby. First, the head or legs (depending on the position). Then the umbilical cord is cut, and the newborn is immediately handed over to the pediatrician. The uterus is allowed to contract, for this purpose a special medicine is administered.\n📌 Interesting point: everything — from the first incision to the birth of the child — takes 2–4 minutes."
  }
 },
 {
"name": "Sewing",
"description": {
"professional": "Double-row suture on the uterus (vicryl), suturing of the peritoneum, layer-by-layer closure of the wound. Intraoperative bleeding prevention (ergometrine).\nInstruments:\n- Needle holder (for the uterus)\n- Vicryl 0 thread (two-row suture)\n- Catgut 2-0 (for the peritoneum)\n\nTechnique:\n1. The uterus is sutured in 2 layers:\n- First row — continuous suture.\n- Second row — immersion (for tightness).\n2. The peritoneum is sutured with catgut.\n3. The skin — with an intradermal suture (Monocryl 3-0).\n\nLogistics:\n- Used needles — in a «sharp» container.\n\nNuance: In case of bleeding, the vessels are additionally coagulated.",
"normal": "After the baby is extracted, the doctor sutures the uterus in two layers. Then he returns the bladder to its place, sutures all the layers back — muscles, skin. At the end, a neat cosmetic suture is applied. If everything went smoothly, the operation lasts about 40 minutes.\n📌 Interesting point: many modern sutures are self-absorbing and do not need to be removed."
    }
   }
  ]
 },
{
"keys": [
"tonsils",
"tonsillectomy"
],
"name": "Tonsil removal",
"modes": {
"professional": "Surgical removal of the palatine tonsils in chronic tonsillitis. Performed under anesthesia, with hemostasis.",
"normal": "Inflamed tonsils are removed under anesthesia. After this, the throat hurts for several days."
},
"steps": [
{
"name": "Pain relief",
"description": {
"professional": "Endotracheal anesthesia: premedication (midazolam), induction (propofol), muscle relaxants (rocuronium), intubation. Maintenance of anesthesia with sevoflurane. Local anesthesia is possible in adults (lidocaine 2%).\nInstruments: \n- Macintosh laryngoscope No. 3 \n- Endotracheal tube 6.5–7.0 mm \n- Syringe 10 ml (propofol) \n- Muscle relaxant (rocuronium) \n\nTechnique: \n1. Intubation: \n - The tube is inserted under the control of the laryngoscope (blade along the midline). \n - Fix it at a depth of 20–22 cm in adults. \n2. Anesthesia: \n - Maintained with sevoflurane (1.5–2%). \n\nLogistics: \n- The used laryngoscope is placed on the assistant's sterile table. \n\nNuance: In adults, local anesthesia is sometimes used (2% lidocaine with adrenaline).",
"normal": "The patient is given anesthesia - usually general, so that he does not feel anything. He will breathe through a tube in the throat during the operation. Everything happens quickly - the person falls asleep in a few seconds and wakes up after everything. \n📌 Interesting point: in adults, local anesthesia is sometimes given - they simply immobilize the throat."
  }
 },
 {
"name": "Fixation",
"description": {
"professional": "Installation of a mouth gag (McIver). Providing access to the tonsils. The patient is positioned on his back with his head thrown back.\nInstruments:\n- McIver mouth speculum\n- Tongue serrated retractor\n- Adrenaline swabs (1:100,000)\n\nTechnique:\n1. The mouth speculum is placed from left to right, fixing the jaws.\n2. The tongue is retracted with a retractor to open the view of the tonsils.\n\nLogistics:\n- The assistant controls the pressure of the mouth speculum (so as not to damage the teeth).\n\nNuance: With a small mouth, use a children's mouth gag.",
"normal": "The mouth is fixed with a special tool to access the tonsils. This is a special device that allows you to keep your mouth open. The tongue is fixed so that it does not interfere. This is necessary because the doctor must clearly see the tonsils and can work calmly. \n📌 Interesting point: there are special smaller versions of these devices for children."
  }
 },
 {
"name": "Removal",
"description": {
"professional": "Excision of tonsils with a capsule: cold method (scalpel, scissors) or thermal (electrocoagulation, coblation). Separation from the palatine arches with hemostasis.\nInstruments:\n- Cold instruments:\n- Scalpel #12\n- Metzenbaum scissors\n- Thermal:\n- Harmonic scalpel (Harmonic)\n- Electrocoagulator (25 W mode)\n\nTechnique:\n1. Cold method:\n- The tonsil is grasped with a clamp and cut off from the arches with a scalpel.\n- The lower pole is separated with scissors.\n2. Thermal method:\n- The harmonic scalpel cuts and coagulates simultaneously.\n\nLogistics:\n- The removed tonsils are placed in a container for histology.\n\nNote: It is important not to leave tissue in the niche (risk of relapse).",
"normal": "The doctor grasps the tonsils themselves and carefully cuts them off. This is done either with conventional surgical instruments (scalpel and scissors) or with modern devices that immediately cauterize the vessels. This helps reduce bleeding.\n📌 Interesting point: some clinics use a laser - the operation is faster and almost bloodless."
  }
 },
 {
"name": "Hemostasis",
"description": {
"professional": "Stopping bleeding: electrocoagulation, hemostatic sponges, ligation of large vessels. Control of the absence of bleeding.\nInstruments: \n- Electrocoagulator (needle tip) \n- Hemostatic sponges (Surgicel) \n- Ligatures (Vicryl 3-0) \n\nTechnique: \n1. Small vessels are coagulated pointwise. \n2. Large arteries are ligated. \n3. The tonsil bed is tamponed with a hemostatic sponge. \n\nLogistics: \n- Used tampons are counted (risk of forgetting in the throat!). \n\nNuance: In case of bleeding from the descending palatine artery, they are stitched.",
"normal": "After removal, the doctor carefully checks if there is any blood left. Cauterizes the vessels or puts special sponges that stop the bleeding. Everything is done carefully so as not to damage the surrounding tissue.\n📌 Interesting point: the sponges dissolve on their own after a few days."
  }
 },
 {
"name": "Control",
"description": {
"professional": "Revision of the tonsil bed, removal of tissue residues. Evaluation of hemostasis. Removing the mouth gag, transferring the patient to the ward.\nInstruments:\n- Flashlight for examination\n- Aspirator (to remove blood/saliva)\n- Suture material (if additional ligatures are needed)\n\nTechnique:\n1. Inspect the tonsil niches from different angles.\n2. Check for any tissue residue or bleeding vessels.\n\nLogistics:\n- Remove the mouth gag after complete hemostasis.\n\nNote: Before extubation, check for blood in the stomach (risk of aspiration).",
"normal": "The surgeon examines the wound again, makes sure everything is clean and dry. After that, the instruments are removed, and the patient is transferred to the ward. Your throat will hurt for 5-7 days - this is normal. You are not allowed to drink and eat right away, but gradually.\n📌 Interesting point: your voice may temporarily become hoarse, but it will pass."
    }
   }
  ]
 },
{
"keys": [
"gall",
"cholecystectomy"
],
"name": "Gallbladder removal",
"modes": {
"professional": "Laparoscopic cholecystectomy: CO2 insufflation, trocars, bladder isolation, clipping, extraction.",
"normal": "The gallbladder is removed through punctures. This is done with a camera and instruments inside the abdomen."
},
"steps": [
{
"name": "Insufflation",
"description": {
"professional": "Creation of pneumoperitoneum: CO2 is injected with a Veresh needle (pressure 12-14 mm Hg) through the umbilical access. Gas pressure control to ensure working space.\nInstruments:\n- 150 mm Veresh needle\n- CO₂ supply system (pressure 12-14 mmHg)\n- 10 mm 30° laparoscope\n\nTechnique:\n1. Make a puncture with a Veresh needle at the Calca point (1 cm above the navel)\n2. Connect the insufflation system - start with low pressure (8 mmHg), gradually increase\n3. Check for uniform distribution of gas in the abdomen\n\nLogistics:\n- After installing the first trocar, remove the needle and place it in a separate tray\n\nNote: In case of adhesions or previous operations, use the open Hasson approach.",
"normal": "Before starting, the doctor makes a puncture in the navel area and pumps carbon dioxide into the abdomen. This is necessary so that the stomach «inflates» a little, and the surgeon can easily see and work inside without affecting other organs.\n📌 Interesting point: free space appears inside - like a small dome."
  }
 },
 {
"name": "Trocars",
"description": {
"professional": "Installation of 3-4 trocars: 10 mm in the navel (camera), 5 mm in the epigastrium and right hypochondrium (instruments). An additional trocar is possible if necessary.\nInstruments:\n- Main trocar 10 mm (for the camera)\n- Additional trocars 5 mm (2-3 pcs)\n- Video laparoscopic stand\n\nTechnique:\n1. Trocars are installed at standard points:\n - Epigastric (for the working hand)\n - Right hypochondrium (for the assistant)\n2. Position of the \"American trapezoid\" - the surgeon is on the left of the patient\n\nLogistics:\n- Each trocar is fixed to the skin with a suture or a special fixator\n\nNuance: In case of obesity the injection points may shift.",
"normal": "They make several small punctures. Through these punctures (usually 3-4), a camera and instruments are inserted into the abdomen. The camera transmits the image to the screen. The doctor works looking at the monitor, like in a video game, but everything is real.\n📌 Interesting point: the camera magnifies the image 10-15 times - you can see the smallest details."
  }
 },
 {
"name": "Select",
"description": {
"professional": "Identification of the elements of the Calot triangle: cystic duct and artery. Dissection, mobilization of the gallbladder from the liver bed. Control of anatomy to prevent damage.\nInstruments:\n- Maryland dissector\n- Atraumatic clamp\n- Harmonic scissors\n\nTechnique:\n1. Find \"Calot triangle\" (between the cystic duct, artery and liver)\n2. Separate the cystic duct and artery\n3. Mobilize the gallbladder from the liver bed\n\nLogistics:\n- Periodically clean the instruments from carbon deposits\n\nNuance: In case of inflammation, the bottom of the bladder is first isolated (\"from top to bottom\").",
"normal": "The surgeon begins to search gallbladder with a camera. When he finds the bladder, he separates it from the liver. Then the surgeon isolates the duct (through which the bile flows) and the artery that feeds the bladder. All this is done with pinpoint precision - without haste, so as not to damage anything. \n📌 Interesting point: an important stage is «a critical look at the anatomy.» A mistake can damage the liver or ducts."
  }
 },
 {
"name": "Clipping",
"description": {
"professional": "Applying titanium clips to the cystic duct and artery. Cutting between the clips. Separating the bladder from the liver with a harmonic scalpel or electrocoagulation.\nInstruments:\n- Clip applicator (like Hem-o-lok)\n- Medium-sized clips (6-8 mm)\n- Laparoscopic scissors\n\nTechnique:\n1. Apply 2 clips to the duct and artery\n2. Cut between the clips\n3. Separate the bladder from the liver with a harmonic scalpel\n\nLogistics:\n- Immediately reload the used clip applicator\n\nNote: With a wide duct (>4 mm), it is better to apply sutures.",
"normal": "Artery and the duct is clamped with special clips - like small clothespins. After that, the bladder is carefully cut off. The place of disconnection is cauterized or treated so that there is no blood.\n📌 Interesting point: the clips remain inside forever - they are safe and do not interfere."
  }
 },
 {
"name": "Removal",
"description": {
"professional": "Removal of the bladder through the umbilical port in a special container (endobag). Revision of the bed, hemostasis. Removal of trocars, suturing of ports. Drainage as indicated.\nInstruments:\n- Endobag (container for removal)\n- Toothed clamp\n- Irrigator-aspirator\n\nTechnique:\n1. Place the bladder in the endobag\n2. Remove through the umbilical port\n3. Inspect the bed for bleeding\n4. Remove the trocars under visual control\n\nLogistics:\n- Large stones are crushed before removal\n\nNuance: A C-arm is needed for intraoperative cholangiography.\nKey safety points:\n1. A critical look at the anatomy - always identify:\n - Common bile duct.\n - Common hepatic artery.\n2. If in doubt - convert to open surgery.\n3. Drainage as indicated (inflammation, bleeding).",
"normal": "The bladder is placed in a small bag and pulled out through one of the punctures. Then they check if everything is clean inside, and sew up the small holes.\n📌 Interesting point: the person goes home the next day, and there are almost no traces."
    }
   }
  ]
 },
{
"keys": [
"tracheostomy",
"insertion of a tube into the trachea"
],
"name": "Tracheostomy",
"modes": {
"professional": "Creation of a breathing hole in the trachea when obstructed. An incision in the neck, access to the trachea, insertion of a tube.",
"normal": "They make a hole in the throat so that the person can breathe. They insert a tube."
},
"steps": [
{
"name": "Preparation",
"description": {
"professional": "Position the patient on his back with a bolster under the shoulders, extend the neck. Process the surgical field. Local anesthesia (lidocaine 2%) or continue artificial ventilation in an emergency.\nInstruments: \n- Syringe 10 ml with lidocaine 2% + adrenaline (1:100,000) \n- Scalpel No. 20 \n- Mosquito clamps (2 pcs.) \n- Tracheal hooks (single-toothed and blunt) \n\nTechnique: \n1. Patient position: \n - Head tilted back (roller under shoulders), neck in hyperextension. \n2. Anesthesia: \n - Infiltrate the skin and subcutaneous tissue along the midline (from the cricoid cartilage to the jugular notch). \n3. Marking: \n - Optimal level: 2-3 tracheal rings (below the cricoid cartilage). \n\nLogistics: \n- The assistant fixes the head to prevent displacement. \n\nNuance: In case of emergency tracheostomy, anesthesia may be omitted.",
"normal": "The patient is placed on his back, the head is tilted back. The neck area is treated with an antiseptic. Sometimes local anesthesia is used, but more often general anesthesia is used, especially if it is urgent.\n📌 Interesting point: the patient may have severe swelling or injury - then a tracheostomy saves lives."
  }
 },
 {
"name": "Incision",
"description": {
"professional": "A longitudinal incision of the skin 3-4 cm below the cricoid cartilage or a transverse incision between 2-3 tracheal rings. Dissection of the subcutaneous tissue, separation of muscles along the white line.\nInstruments: \n- Scalpel No. 20 (pencil grip) \n- Electrocoagulator (cut mode, 30 W) \n- Hemostatic clamps \n\nTechnique: \n1. Vertical incision (3-4 cm): \n - Dissect the skin, subcutaneous tissue, platysma. \n2. Horizontal incision (alternative): \n - Between the tracheal rings, if a long-term cannula is planned. \n\nLogistics: \n- The used scalpel is in a sharps container. \n\nNuance: In case of obesity, the incision is extended to 5 cm.",
"normal": "A small vertical or horizontal incision is made on the front of the neck. Then the muscles are carefully spread apart to get to the trachea - this is the tube through which air enters the lungs. \n📌 Interesting point: it is very important not to touch the thyroid gland, which is located nearby."
  }
 },
 {
"name": "Isolation of the trachea",
"description": {
"professional": "Identification of the cricoid cartilage and tracheal rings. Retraction of the isthmus of the thyroid gland upward or its intersection between clamps. Fixation of the trachea with hooks.\nInstruments:\n- Anatomical tweezers\n- Metzenbaum scissors\n- Muscle retraction hooks\n\nTechnique:\n1. Separate the muscles along the white line:\n- The sternohyoid and sternothyroid muscles are spread apart.\n2. Thyroid isthmus:\n- Retract the hook upward or cross between clamps.\n3. Expose the trachea:\n- Palpate the rings (make sure not to hit the thyroid cartilage).\n\nLogistics:\n- Bleeding vessels are coagulated immediately.\n\nNuance: If the thyroid gland is damaged, stitch it with catgut.",
"normal": "When the doctor reaches the trachea, he carefully separates it from the surrounding tissues - muscles, vessels and the thyroid gland. This is necessary to clearly see the cartilaginous rings of the trachea and not to damage anything important. \n📌 Interesting point: sometimes the trachea has to be \"hooked\" with a special hook to fix it before the incision - this makes it easier and safer to insert the tube."
  }
 },
 {
"name": "Tracheal incision",
"description": {
"professional": "Longitudinal incision between 2-3 rings or excision of a fragment of the anterior wall (window). Cricothyrotomy in emergency cases (incision between the cricoid and thyroid cartilages).\nInstruments: \n- Scalpel No. 11 (for the trachea) \n- Trousseau tracheodilator \n- Cricothyrotomy clamp (if urgent) \n\nTechnique: \n1. Fixation of the trachea: \n - The cricoid cartilage is fixed with a hook. \n2. Incision: \n - Transverse between 2-3 rings (length 1-1.5 cm). \n - Or fenestrated (a fragment of the anterior wall is excised). \n3. Aspiration: \n - Mucus and blood are removed from the lumen. \n\nLogistics: \n- Blood is aspirated immediately so that it does not get into the bronchi. \n\nNuance: In children, a fenestrated incision is not made (risk of stenosis).",
"normal": "When the doctor sees the cartilages of the trachea, he makes an incision in them or cuts out a small «window». A tube will then be inserted into this hole to allow the person to breathe.\n📌 Fun fact: in emergency cases, the incision can be made in just 30 seconds!"
  }
 },
 {
"name": "Insert the tube",
"description": {
"professional": "Installation of a tracheostomy cannula of the appropriate size (usually 6-8 mm), fixation with tapes around the neck. Connection to a ventilator or oxygen. Suturing the skin around the tube.\nInstruments: \n- Tracheostomy cannula (size 6-8 mm for adults) \n- Mandrin (guide) \n- Fixation tapes \n\nTechnique: \n1. Insertion of the cannula: \n - With the mandrin at an angle of 45°, then turn horizontally. \n2. Fixation: \n - With tapes around the neck (tied in a double knot). \n3. Connection to the ventilator: \n - Check the air flow (condensation on the tube walls). \n\nLogistics: \n- Leave the mandrin nearby in case of emergency replacement. \n\nNuance: Do not change the cannula for the first 24 hours (risk of loss of access).\n\nCritical points: \n1. Do not cut the 1st ring (risk of stenosis). \n2. In case of bleeding from the thyroid veins — press and coagulate. \n3. Always aspirate the contents of the trachea before inserting the tube.",
"normal": "The doctor inserts a special tube into the incision and secures it with tapes around the neck. They check if air passes. If everything is normal — they connect to the machine or give oxygen.\n📌 Interesting point: if everything is done correctly, the patient feels relief almost immediately.\nCare:\nAfter installation, the doctor makes sure that there is no infection and that the tube does not become clogged with mucus. It is periodically cleaned and changed if necessary.\n📌 Interesting point: the first tube replacement is done only after 24 hours - it cannot be done earlier."
    }
   }
  ]
 },
{
"keys": [
"ectopic",
"ectopic pregnancy"
],
"name": "Surgery for ectopic pregnancy",
"modes": {
"professional": "Removal of the affected fallopian tube or embryo from the tube laparoscopically. Hemostasis, control.",
"normal": "If the pregnancy is outside the uterus, an operation is performed to safely remove it."
},
"steps": [
{
"name": "Anesthesia",
"description": {
"professional": "General anesthesia: induction with propofol + fentanyl, intubation, maintenance with sevoflurane. In stable condition, spinal anesthesia (0.5% bupivacaine) is possible.\nInstruments:\n- 18G catheter for IV access\n- 7.0-7.5 mm endotracheal tube\n- Blood pressure monitor\n- 20 ml syringe (propofol)\n\nTechnique:\n1. Standard induction:\n- Premedication (midazolam 1-2 mg)\n- Propofol 2 mg/kg\n- Muscle relaxant (rocuronium 0.6 mg/kg)\n2. Intubation:\n - Macintosh laryngoscope #3\n - Fixation of the tube at 21 cm for women\n\nLogistics:\n- After intubation, the laryngoscope is placed in a tray for disinfection\n\nNuance: In case of hemorrhagic shock, the doses of drugs are reduced.",
"normal": "The woman is given general anesthesia so that she falls asleep. She will breathe through the tube under the control of the device. The doctor monitors the pulse, blood pressure, oxygen level - everything is under observation.\n📌 Interesting point: if the patient is in shock, the dose of drugs is reduced so as not to overload the heart."
  }
 },
 {
"name": "Laparoscopy",
"description": {
"professional": "Creation of pneumoperitoneum (CO2 up to 12-14 mm Hg), introduction of trocars: optical (10 mm umbilical) and 1-2 instrumental (5 mm in the iliac regions).\nInstruments:\n- Veresh needle 150 mm\n- Trocar 10 mm (optical)\n- Trocars 5 mm (2 pcs)\n- CO₂ insufflator\n\nTechnique:\n1. Pneumoperitoneum:\n - Puncture with a Veress needle at the Palmer point\n - Initial pressure 8 mm Hg.\n2. Installation of ports:\n - Umbilical - 10 mm\n - Left iliac - 5 mm\n - Suprapubic - 5 mm\n\nLogistics:\n- The first trocar is installed under visual control\n\nNuance: In case of massive hemoperitoneum, first - sanation.",
"normal": "A needle is inserted through the navel and carbon dioxide is pumped in to slightly «inflate» the abdomen. Then a camera and instruments are inserted. This is called laparoscopy — an operation performed through small punctures.\n📌 Interesting point: the belly rises like a tent — doctors can see everything inside."
  }
 },
 {
"name": "Isolation of the tube",
"description": {
"professional": "Revision of the pelvis: detection of the affected tube, assessment of its condition. In case of rupture — aspiration of blood, washing. Isolation of the tube from surrounding structures.\nInstruments:\n- Atraumatic clamp\n- Laparoscopic scissors\n- Aspirator-irrigator\n\nTechnique:\n1. Revision of the pelvis:\n - Evacuation of blood and clots\n - Determination of the localization of pregnancy\n2. Isolation of the tube:\n - The mesosalpinx is fixed with a clamp\n - The vessels are coagulated with a harmonic scalpel\n\nLogistics:\n- The assistant controls the aspirator\n\nNuance: In case of tubal abortion - a complete revision of the pelvic cavity.",
"normal": "The doctor examines the pelvic organs. Finds the fallopian tube in which the embryo is stuck. Carefully frees it from clots and blood. If the tube is badly damaged, it will have to be removed.\n📌 Interesting point: if everything is detected at an early stage, the tube can be saved."
  }
 },
 {
"name": "Removal",
"description": {
"professional": "Salpingectomy (tube removal) in case of rupture: clipping of the mesosalpinx, excision. Or salpingotomy (incision of the tube) with removal of the ovum in case of early diagnosis.\nInstruments:\n- Bipolar coagulator\n- Clip applicator\n- Endo bag\n\nTechnique:\n1. Coagulation and intersection:\n- Place of entry into the uterus\n- Mesentery of the tube\n2. Extraction:\n- In the endo bag through an expanded port\n- If large - morcellation\n\nLogistics:\n- Mandatory labeling of the drug for histology\n\nNuance: If you want to preserve fertility - salpingotomy.",
"normal": "The damaged tube or embryo is removed. It is important to stop the bleeding and not to damage adjacent organs. Everything is done with a coagulator and very thin instruments.\n📌 Interesting point: the removed tissues are sent to laboratory for examination."
  }
 },
 {
"name": "Sewing",
"description": {
"professional": "Hemostasis (coagulation, hemostatic sponges). Removal of trocars, suturing of ports. Drainage as indicated. Hemostasis control before completion.\nInstruments:\n- Laparoscopic needle holder\n- Vicryl 3-0 suture material\n- Redon 10 Fr drainage\n\nTechnique:\n1. Hemostasis control:\n- Coagulation of the tubal bed\n- Revision of the ovary\n2. Drainage:\n- Installation of drainage in the Douglas pouch\n3. Port suturing:\n - Umbilical aponeurosis - Vicryl 0\n - Skin - Monocryl 4-0\n\nLogistics:\n- Drainage is fixed with a separate suture\n\nNuance: If bleeding continues - conversion to laparotomy.\nCritical points:\n1. Mandatory revision of the contralateral tube.\n2. Monitoring the hCG level in the postoperative period.\n3. If the tube ruptures - active infusion therapy.",
"normal": "The surgeon examines the insides again, makes sure that there is no blood. If necessary, a drainage (a tube for liquid) is placed. After that, the instruments are removed and the punctures are stitched up.\n📌 Interesting point: such operations often save a woman's life - when a tube ruptures, every minute counts."
    }
   }
  ]
 },
{
"keys": [
"heart",
"bypass"
],
"name": "Coronary artery bypass grafting",
"modes": {
"professional": "Heart surgery: the chest is opened, the ICC is connected, the shunts are installed to bypass the blocked vessels.",
"normal": "The chest is opened and bypasses are created in the heart vessels."
},
"steps": [
{
"name": "Anesthesia",
"description": {
"professional": "General anesthesia: induction (propofol, midazolam, fentanyl), intubation, mechanical ventilation. Installation of invasive monitoring (arterial line, CVC). Connection of artificial blood circulation (artificial blood circulation).\nInstruments:\n- Arterial catheter 20G (radial artery)\n- Central venous catheter 8.5 Fr\n- Transesophageal echocardiography sensor\n- Mechanical ventilation apparatus with PCV mode\n\nTechnique:\n1. Induction:\n- Fentanyl 5-10 mcg/kg\n- Propofol 1.5-2 mg/kg\n- Rocuronium 0.6-1 mg/kg\n2. Preparing the bypasses:\n - Internal mammary artery (IMA) - isolated with Potts tweezers \n - Great saphenous vein - taken with a mobilizer \n\nLogistics:\n- IMA is placed in a heparinized solution \n\nNuance: In diabetes, arterial revascularization is preferable.",
"normal": "The patient is put to sleep. Connected to machines, catheters are inserted into the arteries and veins. Next - connection to the machine that will temporarily replace the heart and lungs.\n📌 Interesting point: the heart is stopped during the operation so that it does not interfere with the surgeon's work."
  }
 },
 {
"name": "Incision",
"description": {
"professional": "Median sternotomy: skin incision along the midline, dissection of the sternum with an oscillating saw. Separation of the wound edges with a retractor. Taking bypass grafts (internal mammary artery, great saphenous vein).\nInstruments:\n- Oscillating saw (blade thickness 0.3 mm)\n- Sternum retractor\n- Bone wax\n\nTechnique:\n1. Incision along the midline from the jugular notch to the xiphoid process\n2. Dissection of the sternum strictly in the center\n3. Stopping bleeding from the bone with wax\n\nLogistics:\n- The saw is cleaned after each pass\n\nNuance: For repeat operations - a cutter instead of a saw.",
"normal": "The doctor makes a vertical incision along the sternum and carefully saws the bone with a special saw. Then spreads the edges to get to the heart.\n📌 Interesting point: the bone is then connected with a wire - it remains inside forever and does not interfere."
  }
 },
 {
"name": "ICC",
"description": {
"professional": "Cannulation of the aorta and right atrium, connection to the ICC apparatus. Introduction of cardioplegic solution to stop the heart. Maintaining hypothermia 28-32 ° C.\nInstruments:\n- Aortic cannulas 22-24 Fr \n- Double-lumen venous catheter 32 Fr \n- Cardioplegic solution \n\nTechnique:\n1. Cannulation: \n- Aorta - purse-string suture 4-0 prolene \n- Right atrium - double purse-string \n2. Cardioplegia: \n - Antegrade (via the aortic root) \n - Retrograde (via the coronary sinus) \n\nLogistics:\n- ACT control >480 sec.",
"normal": "Before starting work on the heart, the surgeon connects the patient to the artificial circulation machine (ACM). This is a special \"pump\" that temporarily replaces the heart and lungs: \n1. Tubes are inserted into large vessels (aorta and vena cava) - through them, blood is taken from the body, saturated with oxygen and returned back. \n2. The machine starts working, and the heart is stopped using a special solution - now the surgeon can safely perform bypass surgery. \n📌 Interesting point: during the operation of the IR, the patient does not breathe on his own, and his temperature can be reduced to 28–32°C to protect the organs!"
  }
 },
 {
"name": "Shunts",
"description": {
"professional": "Anastomosis overlay: proximal (to the aorta) and distal (to the coronary artery below the stenosis). Use of 6-0/7-0 Prolene. Checking the patency of the grafts.\nInstruments:\n- Minimally invasive retractor\n- Needle-tipped electrocautery\n- Hem-o-lok vascular clips\n\nTechnique for the IAA:\n1. Isolation from the subclavian artery to the distal end\n2. Coagulation of the side branches at 20 W\nTechnique for the vein:\n1. Endoscopic harvesting (EVH)\n2. Distal ligation with 6-0 prolene \n\nLogistics:\n- The shunts are marked for identification.",
"normal": "New vessels are sewn onto the heart - one end is connected to the aorta, the other to the heart arteries. The blood will now follow new paths and feed the heart as it should.\n📌 Interesting point: the work is almost like jewelry - the sutures are made with threads thinner than a hair."
  }
 },
 {
"name": "Sewing",
"description": {
"professional": "Disabling the ICC, restoring cardiac activity (defibrillation if necessary). Installing drains. Stitching the sternum with wire, suturing the wound layer by layer.\nInstruments:\n- Microsurgical scissors \n- DeBakey tweezers \n- 7-0 prolene suture material \n\nTechnique:\n1. Distal anastomoses: \n - LAD → IAA (end-to-side) \n - OB → VNA (side-to-side sequentially) \n2. Proximal (on disconnected aorta): \n - 4.0-4.5 mm punch \n - 6-0 Prolene suture \n\nLogistics:\n- Doppler patency check. \n\nICC disconnection\nTechnique: \n1. Gradual flow reduction \n2. Decannulation after hemodynamic stabilization \n3. Placement of temporary epicardial pacemakers \n\nMonitoring:\n- TEE for LV function.\n- Suture bleeding.",
"normal": "The heart is restarted. The doctor checks if everything is working. The sternum is brought together, sutures and a bandage are applied. After that, the patient is transferred to intensive care.\n📌 Interesting point: after such an operation, the heart literally gets a second life."
    }
   }
  ]
 },
{
"keys": [
"hemorrhoids",
"hemorrhoid removal"
],
"name": "Hemorrhoidectomy",
"modes": {
"professional": "Removal of internal/external hemorrhoids with tissue excision. Hemostasis, control.",
"normal": "Hemorrhoids are removed surgically so that they do not bleed or hurt."
},
"steps": [
{
"name": "Pain relief",
"description": {
"professional": "Spinal anesthesia (0.5% bupivacaine) or general anesthesia. The patient is positioned on his back with his legs brought to the stomach (lithotomy). Treatment of the perianal area.\nInstruments:\n- Spinal catheter 25G (for bupivacaine 0.5%)\n- Proctologic speculum\n- Rectal retractor\n\nTechnique:\n1. Patient position - lithotomy or on the side\n2. Spinal anesthesia - level L3-L4\n3. Treatment of the perianal area with chlorhexidine\n\nLogistics:\n- After anesthesia, the needle is immediately disposed of in a sharps container\n\nNote: In case of allergy to local anesthetics - general anesthesia.",
"normal": "The patient is given anesthesia - general or spinal (injection in the back). Then it is placed in a comfortable position so that the doctor can work calmly in the anal area.\n📌 Interesting point: with good anesthesia, a person does not feel anything at all."
  }
 },
 {
"name": "Selections",
"description": {
"professional": "A rectal speculum for visualizing nodes. Grasping the node with a clamp, its traction. Excision of the mucosubcutaneous flap over the node while preserving the anal epithelium.\nInstruments:\n- Allis clamp 3-4 pcs.\n- Electrocoagulator with a needle tip\n- Rectal speculum with backlight\n\nTechnique:\n1. Alternate fixation of nodes with Allis clamps\n2. Marking the excision boundaries\n3. Coagulation of small vessels\n\nLogistics:\n- Used clamps are passed to an assistant for cleaning\n\nNuance: With combined hemorrhoids, they start with the internal nodes.",
"normal": "The doctor examines the inside of the rectum with a special mirror. Finds enlarged hemorrhoids, grabs them with instruments and marks them for removal.\n📌 Interesting point: hemorrhoids are not a tumor, but simply dilated veins."
  }
 },
 {
"name": "Excision",
"description": {
"professional": "Ligation of the node leg at the base (Milligan-Morgan ligature method) with excision. Or the use of hardware hemorrhoidopexy (stapler). Coagulation of vessels.\nInstruments:\n- Scalpel No. 11\n- Metzenbaum scissors\n- Vicryl 3-0 suture material\n\nTechnique:\n1. V-shaped incision at the base of the node\n2. Ligation of the node pedicle\n3. Excision with preservation of the anal epithelium\n\nLogistics:\n- The removed nodes are sent for histology\n\nNuance: There should be ≥1 cm of skin between the remaining flaps.",
"normal": "The doctor cuts off the nodes. At the same time, he/she ligates the vessels to prevent bleeding. Everything is done carefully so as not to damage healthy tissue and maintain normal function.\n📌 Interesting point: remove only severely inflamed and prolapsed nodes - the rest can «calm down» on their own."
  }
 },
 {
"name": "Hemostasis",
"description": {
"professional": "Thorough hemostasis: electrocoagulation, hemostatic sponges (Spongostan), ligatures. Control of the absence of bleeding in the bed of the removed nodes.\nInstruments:\n- Bipolar coagulator\n- Hemostatic sponges (Surgicel)\n- Tampons with adrenaline\n\nTechnique:\n1. Step-by-step coagulation of the bed\n2. Application of hemostatic sponges\n3. Bleeding control for 3 minutes\n\nLogistics:\n- Counting the tampons used\n\nNote: In case of profuse bleeding - suturing with 4-0 Vicryl.",
"normal": "The removal site is checked: all vessels are cauterized or covered with special sponges. This is important - even a small drop of blood can cause problems later.\n📌 Interesting point: for control, doctors sometimes put a tampon with medicine inside."
  }
 },
 {
"name": "Control",
"description": {
"professional": "Revision of the surgical field, checking the patency of the anal canal. Insertion of a tampon with ointment (Levomekol). Application of an aseptic dressing.\nInstruments:\n- Gas outlet tube\n- Ointment tampons (Levomekol)\n- Self-absorbable suture material\n\nTechnique:\n1. Insertion of a gas vent tube\n2. Application of ointment tampons\n3. Suturing wounds if necessary\n\nLogistics:\n- Fixation of drainage with a plaster.\n\nPostoperative protocol:\n1. Pain relief:\n- Ketorolac 30 mg IV\n- Paracetamol 1 g every 6 hours\n2. Dressings:\n- Daily with ointment dressings\n3. Stool:\n- Laxatives on the 3rd day\n\nComplications:\n- Bleeding (1-3%)\n- Urinary retention (5-10%)\n- Stenosis of the anal canal (rare)",
"normal": "At the end, a tube can be inserted into the anus to remove gases. A bandage is applied. The patient is sent to the ward, where he will recover.\n📌 Interesting point: there is almost no pain if everything is done correctly. The main thing is the doctor's accuracy and adherence to the regimen after."
    }
   }
  ]
 },
{
"keys": [
"rhinoplasty",
"rhinoplasty"
],
"name": "Rhinoplasty",
"modes": {
"professional": "Correction of bone/cartilage structures of the nose. Open or closed technique.",
"normal": "Surgery to change the shape of the nose. Often done for the sake of appearance."
},
"steps": [
{
"name": "Anesthesia",
"description": {
"professional": "General anesthesia (propofol + sevoflurane) or local anesthesia (lidocaine with adrenaline for vasoconstriction). Nasal packing with adrenaline to reduce bleeding.\nInstruments:\n- 5 ml syringe with 2% lidocaine + 1:100,000 adrenaline\n- Surgical marker\n- 27G needle for infiltration\n\nTechnique:\n1. Infiltration anesthesia:\n- 4 injection points at the base of the nose\n- 2 ml in the columella\n- 1 ml along the bridge of the nose\n2. Markings:\n- Incision line along the columella\n- Tip correction boundaries\n\nLogistics:\n- Used needles - in a sharps container\n\nNote: Adrenaline reduces bleeding by 40%.",
"normal": "The doctor gives injections with anesthesia around the nose to relieve pain. Sometimes general anesthesia is given. Then they draw with a special pen where the incision will be and which parts need to be corrected.\n📌 Interesting point: the more precise the markings, the more natural the result."
  }
 },
 {
"name": "Access",
"description": {
"professional": "With open rhinoplasty: an incision along the columella (the partition between the nostrils) with lifting of the skin flap. With closed rhinoplasty - access through the nostrils without external incisions.\nInstruments:\n- Scalpel No. 15\n- V-shaped scissors\n- Double-pronged hook\n\nTechnique:\n1. Incision along the columella:\n - 45° angle to create a step\n - Length 4-5 mm\n2. Soft tissue detachment:\n - Skin flap is lifted\n - Lower lateral cartilages are isolated\n\nLogistics:\n- Bleeding vessels are coagulated immediately\n\nNuance: Subcutaneous fat is preserved for a natural contour.",
"normal": "The surgeon makes a small incision between the nostrils or inside the nose. Then carefully separates the skin from the bones and cartilages to open the «frame» of the nose.\n📌 Interesting point: all manipulations are done through tiny holes that heal without a trace."
  }
 },
 {
"name": "Correction",
"description": {
"professional": "Hump resection (osteotomy), correction of the tip of the nose (cartilage plastic surgery), septoplasty for a deviated septum. Modeling new contours using autologous cartilage or implants.\nInstruments:\n- Osteotome 8 mm\n- Diamond rasp\n- Hammer 50 g\n\nTechnique:\n1. Hump resection:\n- With an osteotome from top to bottom\n- 3-4 precise blows with a hammer\n2. Osteotomy:\n- Lateral - through 2 mm incisions\n- Medial - through a rhinotrache\n\nLogistics:\n- Bone chips are collected for possible use\n\nNuance: With thin skin - minimal resection.\n\nTip grafting:\n\nInstruments:\n- Gerald tweezers\n- PDS 5-0 suture material\n- Templates for cartilage\n\nTechnique:\n1. Dome correction:\n - Resection of 2-3 mm of the cartilage edge\n - Suture technique for narrowing\n2. Strengthening:\n - Autocartilage from the septum\n - Fixation with through sutures\n\nLogistics:\n- The remaining cartilage is preserved in saline\n\nNuance: With thick skin - more aggressive correction.",
"normal": "Now work with cartilage and bones begins. The doctor can remove the hump, narrow the nose, raise the tip. It all depends on the patient's wishes and the capabilities of the anatomy.\n📌 Interesting point: often use the patient's own cartilage from the septum to strengthen the shape."
  }
 },
 {
"name": "Fixation",
"description": {
"professional": "Implementation of internal sutures (catgut), fixation of the septum with splints. Installation of an external plaster or thermoplastic splint to maintain the new shape.\nInstruments:\n- Silicone splints\n- Merocel tampons\n- Thermoplastic splint\n\nTechnique:\n1. Internal fixation:\n- Tampons with antibiotic\n- Splints are fixed with a suture\n2. External fixation:\n - Splint in the shape of the new nose\n - Fixation for 7-10 days\n\nLogistics:\n- Checking the symmetry before applying the splint.",
"normal": "Everything that has been changed is fixed with sutures and internal plates. Then an external bandage is applied so that the nose keeps its shape in the first days.\n📌 An interesting point: in order for everything to «take root», the patient must not touch the nose for at least 2 weeks."
  }
 },
 {
"name": "Control",
"description": {
"professional": "Final assessment of symmetry and shape. Nasal tamponade (removed after 1-2 days). Prescribing antibiotics and painkillers.\nPostoperative protocol\n1. Cooling:\n - Cold compresses for 48 hours\n2. Medicines:\n - Cefazolin 1 g 2 times a day\n - Ketorolac 10 mg for pain\n3. Dressings:\n - Removal of tampons on the 2nd day\n - Removal of stitches on the 7th day\n\nComplications:\n- Septal hematoma (1-3%)\n- Asymmetry (5%)\n- Respiratory failure (rare)",
"normal": "Checking the result, applying tampons and dressings, completing the operation. The surgeon checks the symmetry, stops the bleeding, applies a dressing. The patient is given recommendations and sent home in a few hours (or the next day).\n📌 Interesting point: the final result is visible only after 6-12 months, when everything heals."
    }
   }
  ]
 },
{
"keys": [
"amputation"
],
"name": "Limputation amputation (hip level)",
"modes": {
"professional": "Limb removal due to injury/ischemia. Stump formation, hemostasis, infection prevention.",
"normal": "Part of the arm/leg is cut off if it cannot be saved. Then a form is made for the prosthesis."
},
"steps": [
{
"name": "Anaesthesia",
"description": {
"professional": "General anesthesia (propofol + fentanyl + muscle relaxants) or conduction (for example, brachial plexus block during arm amputation). Prevention of thrombosis (heparin). Also, marking is performed:\nInstruments:\n- Surgical marker\n- Tape measure\n- Doppler device for assessing blood flow\n\nTechnique:\n1. Determining the level of amputation:\n- Minimum length of the femoral stump - 12 cm from the greater trochanter\n2. Marking the flaps:\n- The anterior flap is 2-3 cm longer than the posterior flap\n- Total length = 1.5 femoral diameters\n\nLogistics:\n- Marking is confirmed by the senior surgeon\n\nNuance: In case of diabetes, 2 cm is added to the calculated length.",
"normal": "Full anesthesia or pain relief is performed on the limb being operated on only. Then the doctor determines exactly where the leg needs to be amputated. The site is marked with a marker so that a prosthesis can be installed later. Everything is done taking into account the anatomy and future rehabilitation.\n📌 Interesting point: the higher the amputation, the more difficult the recovery, but sometimes there is no choice."
  }
 },
 {
"name": "Incision",
"description": {
"professional": "Planning stump flaps: longer palmar/anterior flap. Skin, subcutaneous tissue and fascia incision. Ligation of main vessels (silk/vicryl). This is called soft tissue processing.\nInstruments:\n- Scalpel #20\n- Electrocoagulator (Spray mode, 40 W)\n- Kocher clamps 6 pcs.\n\nTechnique:\n1. Skin incision:\n- Semicircular anterior flap\n- Short oblique posterior\n2. Muscles are crossed 5 cm distal to the bone level\n3. Nerves:\n - Pull by 2 cm and cut with a scalpel\n - Treat with 96% alcohol\n\nLogistics:\n- Bleeding vessels are ligated immediately\n\nNuance: The sciatic nerve is treated separately (high risk of neuroma).",
"normal": "Under anesthesia, the doctor makes incisions on the skin and muscles. Veins and arteries are immediately ligated to prevent blood loss. Nerves are also carefully treated so that they do not hurt later.\n📌 An interesting point: each layer of tissue is treated differently - even in such a serious operation there is a subtlety."
  }
 },
 {
"name": "Removal",
"description": {
"professional": "Sawing the bone with an oscillating saw with a smooth edge processing. Nerve transection with their shortening and immersion in soft tissue to prevent neuromas. Muscle processing.\nInstruments:\n- Oscillating saw with cooling\n- Bone file\n- Bone wax\n\nTechnique:\n1. The periosteum is separated 0.5 cm distal to the cut level\n2. Cut at an angle of 45° to smooth the anterior edge\n3. Edge processing:\n- Sharp protrusions are rounded off with a file\n- The medullary canal is closed with wax\n\nLogistics:\n- Bone chips are removed with an irrigator\n\nNote: For osteoporosis, special saws with fine teeth are used.",
"normal": "The bone is sawed off with a special saw. Sharp edges are smoothed. The bone canal is closed with wax to prevent bleeding and reduce pain.\n📌 Interesting point: the surgeon does everything so that the stump is comfortable for the future prosthesis."
  }
 },
 {
"name": "Stump formation",
"description": {
"professional": "Myoplasty (suturing muscles over the bone) or myodesis (fixation of muscles to the bone). Wound drainage. Suturing the skin without tension, forming a rounded stump suitable for prosthetics.\nInstruments:\n- Mathieu needle holder\n- Vicryl suture material No. 0\n- Redon 14 Fr drainage\n\nTechnique:\n1. Myodesis:\n - Muscles are sutured over the bone\n - Fascia - with a separate suture\n2. Drainage:\n - 2 drains are installed\n - Fixed with separate sutures\n3. The skin is sutured without tension\n\nLogistics:\n- Deep sutures - Vicryl №0\n- Skin - monofilament 3-0\n\nNuance: In case of vascular pathology, drains are left for 5-7 days.",
"normal": "The muscles are sutured so that they lie well on the bone. The skin is closed with a neat suture. A tube (drainage) is often placed to prevent fluid accumulation.\n📌 Interesting point: the shape of the stump is the key to a quality life after amputation."
  }
 },
 {
"name": "Bandaging",
"description": {
"professional": "Applying an aseptic bandage, sometimes a compression bandage. Immobilization of the stump (for example, with a splint). Bleeding control, antibiotics and analgesics.\nInstruments:\n- Compression cover\n- Hard bandage\n- Protective cap\n\nTechnique:\n1. Application of a hard bandage:\n - In the first 24 hours - without a prosthesis\n - Then - compression hosiery\n2. Prevention of contractures:\n - Daily exercise therapy from the 3rd day\n - Extension position\n\nLogistics:\n- First dressing change after 48 hours\n\nPain relief protocol\n| Drug | Regimen | Duration |\n|----------------|---------------------|----------------------|\n| Ketorolac | 30 mg IV | Every 8 hours (3 days)|\n| Gabapentin | 300 mg | 2 times a day (month) |\n| Nerve block | 0.5% bupivacaine | Intraoperative |\n\nComplications:\n- Phantom pain (70% in the first month)\n- Contracture (15%)\n- Infection (5-8%)",
"normal": "After the surgery, the patient undergoes dressing changes, receives pain relief and begins exercise therapy. It is very important to start moving as soon as possible so that the muscles do not atrophy.\n📌 Interesting point: phantom pain is not a fiction. They are really felt, and they need to be worked with."
    }
   }
  ]
 },
{
"keys": [
"craniotomy",
"craniotomy",
"brain surgery"
],
"name": "Craniotomy",
"modes": {
"professional": "Surgical opening of the skull to access the brain. Performed for tumors, hematomas, epilepsy. Includes marking, burr hole, bone flap removal, work with the dura mater (DMA).",
"normal": "A «window» is cut in the skull to get to the brain. It is done in case of serious illnesses or injuries. After the operation, the bone is sometimes returned to its place."
},
"steps": [
{
"name": "Marking and incision",
"description": {
"professional": "Access planning using neuronavigation (MRI/CT data). Marking the skin with a marker along the expected boundaries of the bone flap. Processing the surgical field. Skin incision with a #10 scalpel followed by electrocoagulation of the vessels. Formation of a cutaneous-aponeurotic flap.\nInstruments:\n- Neuronavigation system (e.g. StealthStation)\n- Scalpel #10\n- Electrocoagulator (Spray mode, 40 W)\n- Soft tissue hooks (e.g. Fish)\nTechnique:\n1. The incision line is drawn along the border of the scalp.\n2. Hemostasis of the subcutaneous tissue vessels — bipolar coagulation.\n3. Detachment of the flap from the periosteum — by blunt dissection.\nLogistics:\n- Used markers are disposed of in a «sharp» container.\nNuance: For frontal tumors, the incision is made behind the hairline (cosmetic effect).",
"normal": "The doctor draws on the head where the incision will be (often in a semicircle, like a «lid»). The skin is carefully cut and moved aside. The bleeding is stopped by cauterization.\n📌 Interesting point: sometimes a 3D map of the brain is used to accurately hit the desired area."
  }
 },
 {
"name": "Burner hole",
"description": {
"professional": "Making an initial hole in the skull using a burr (e.g. Anspach or Midas Rex). Positioning at the “key point” (usually over an intact sinus). Irrigation with saline to cool the bone. Insertion of a dural hook to protect the dura mater.\nInstruments:\n- Pneumatic burr with diamond tip\n- Dural hook (3 mm wide)\n- Irrigator with cooling\nTechnique:\n1. The burr is held at a 45° angle to the bone.\n2. The first hole is in the Cronlein zone (safe point).\n3. Depth control — until the «blue» (TMO) appears.\nLogistics:\n- The shavings are aspirated immediately (risk of embolism).\nNuance: Low speeds (10,000 rpm) are used for osteoporosis.",
"normal": "A small hole is drilled in the skull with a special «drill». The doctor makes sure not to touch the brain under the bone. They constantly pour saline solution on it so that there is no overheating.\n📌 Interesting point: the skull bone smells burnt — like hair after a hairdresser."
  }
 },
 {
"name": "Osteoplasty",
"description": {
"professional": "Enlargement of the hole with a craniotome (for example, Gigli saw or craniotome) with the formation of a bone flap. Detachment of the TMO from the inner surface of the bone with a raspatory. Extraction of the flap and its preservation in a sterile saline solution with an antibiotic.\nInstruments:\n- Craniotome with a 5 mm burr\n- Penfield raspatory No. 1\n- Bone wax for hemostasis\nTechnique:\n1. The sawing line is drawn between the burr holes.\n2. The bone flap is lifted by the periosteum.\n3. The dura mater is separated from the bone, avoiding tears.\nLogistics:\n- The flap is marked (for example, «left fronto-parietal»).\nNuance: In case of metastases, the bone may not be returned (risk of relapse).",
"normal": "The bone is sawed between the holes like a «door». It is carefully removed and placed in a sterile solution. Now the brain is visible through the dense film (TMO).\n📌 Interesting point: the bone can then be screwed back with titanium plates - like a construction set."
  }
 },
 {
"name": "Dura mater opening",
"description": {
"professional": "Incision of the dura mater (TMO) with a #11 scalpel, followed by spreading the edges with microtweezers. Coagulation of meningeal vessels. Fixation of the TMO to the edges of the wound with sutures (nylon 4-0).\nInstruments:\n- Microscalpel #11\n- Bipolar coagulator (power 15 W)\n- Prolene 6-0 suture material\nTechnique:\n1. Incision of the TMO - along an avascular line (avoiding the sinuses).\n2. The edges of the membrane are moved away with hooks.\n3. The arachnoid membrane is preserved (if possible).\nLogistics:\n- Used needles - in a sharps container.\nNuance: With high ICP, the incision is made slowly (risk of dislocation).",
"normal": "The thin membrane over the brain is cut. The blood is cauterized. Now the surgeon can see the brain itself - it looks like a walnut, but it pulsates.\n📌 Interesting point: the brain does not hurt - it has no pain receptors!"
  }
 },
 {
"name": "The main stage (depending on the pathology)",
"description": {
"professional": "Options:\n1. **Tumor**: ultrasound aspiration (CUSA), vascular coagulation, urgent histology.\n2. **Hematoma**: clot evacuation, bipolar hemostasis.\n3. **Aneurysm**: clipping with microscopic titanium clips.\nInstruments:\n- Ultrasonic aspirator (CUSA)\n- Microscope (e.g. Zeiss OPMI Pentero)\n- Sugita or Yasargil clips\nTechnique:\n1. Work is performed in a «dry» field (irrigation with saline).\n2. ICP control - mannitol or ventriculostomy.\n3. Neuromonitoring (EEG, M-responses).\nLogistics:\n- The removed tissue is sent for histology.\nNuance: With glioblastoma, 5-ALA is used to illuminate the tumor.",
"normal": "Now the surgeon does what it all started for: removes the tumor, removes the thrombus or «fixes» the vessel. Everything is under a microscope - the slightest mistake is dangerous.\n📌 Interesting point: sometimes the brain is «illuminated» with a special substance to see the tumor borders."
  }
 },
 {
"name": "Suture",
"description": {
"professional": "Dura mater suturing with a continuous suture (Prolene 4-0). Fixation of the bone flap with titanium plates and screws. Drainage of the epidural space (Jackson-Pratt drainage). Layered suturing of soft tissues.\nInstruments:\n- Microneedle holder\n- Titanium plates (1.5 mm)\n- Drainage 10 Fr\nTechnique:\n1. The dura mater is sealed with fibrin glue.\n2. The bone flap is fixed with at least 4 screws.\n3. The aponeurosis is sutured with Vicryl 0.\nLogistics:\n- The remaining bone chips are removed with an irrigator.\nNuance: In case of cerebral edema, the bone may not be placed (decompressive craniotomy).",
"normal": "The brain is covered with a shell, the bone is screwed back (if possible). Drainage is placed, the skin is sutured.\n📌 Interesting point: titanium plates do not interfere with MRI and do not jingle at the airport!"
    }
   }
  ]
 },
{
"keys": [
"meningioma",
"brain tumor",
"meningioma removal",
"neurosurgery"
],
"name": "Meningioma removal",
"modes": {
"professional": "Radical removal of a benign tumor growing from the cells of the arachnoid membrane (arachnoid endothelium). Stages: access to the dura mater, tumor devascularization, separation from the brain, resection with attachment site capture (Simpson Grade I-II). Control of sinuses and arteries is critical.",
"normal": "A benign tumor that has «stuck» to the meninges is removed. The operation is complex, but usually successful. After it, the brain is returned to its place, as if nothing had happened."
},
"steps": [
{
"name": "Neuronavigation and access",
"description": {
"professional": "Access planning with neuronavigation (based on MRI with contrast). Skin marking according to tumor projection. Choice of craniotomy (frontal-temporal, parasagittal, etc.). Skin incision, formation of a cutaneous-aponeurotic flap while preserving the feeding vessels.\nInstruments:\n- Neuronavigation system (StealthStation, BrainLab)\n- Scalpel #15\n- Bipolar coagulator (20 W)\n- Fish or Budde retractors\nTechnique:\n1. Incision along the hairline (for a cosmetic effect).\n2. Hemostasis of the scalp arteries - clipping or coagulation.\n3. Detachment of the periosteum with a raspatory.\nLogistics:\n- Bone chips are preserved for possible plastic surgery.\nNuance: For parasagittal meningiomas - control of the superior sagittal sinus (risk of thrombosis).",
"normal": "The surgeon looks at a 3D map of the brain and marks where the incision will be. The skin is carefully folded back to reach the skull.\n📌 Interesting point: sometimes the incision is made along the hairline - the scar is not visible later."
  }
 },
 {
"name": "Craniotomy",
"description": {
"professional": "Burner hole in the «key point» (outside the tumor projection). Osteoplastic craniotomy using a craniotomy (e.g. Midas Rex with a 5 mm burr). Separation of the dura mater from the bone with a Penfield #3 raspatory. Preservation of the bone flap in warm saline with cefazolin.\nInstruments:\n- Pneumatic burr (Anspach or Midas Rex)\n- Dural hook\n- Bone wax\nTechnique:\n1. Sawing the bone 1-2 cm beyond the tumor.\n2. Stopping bleeding from diploic veins with wax.\n3. Marking the flap (e.g. «right parietal»).\nLogistics:\n- Shavings are aspirated to prevent embolism.\nNuance: In case of bone invasion - resection of hyperostosis (risk of relapse).",
"normal": "A «window» is cut out in the skull around the tumor. The bone is preserved - it will be put back.\n📌 Interesting point: the cranial bone smells burnt - like shish kebab, but this is normal!"
  }
 },
 {
"name": "Opening the dura mater and devascularization",
"description": {
"professional": "Incision of the dura mater with a #11 scalpel in the avascular zone. Coagulation of the meningeal vessels feeding the tumor. Separation of the dura mater from the arachnoid membrane. Gradual devascularization of meningioma with bipolar (15-25 W).\nInstruments:\n- Microscalpel #11\n- Bipolar forceps (e.g. Malis)\n- Microscissors (e.g. Yasargil)\nTechnique:\n1. Incision of the dura mater along the tumor perimeter.\n2. Coagulation of vessels at the base of the meningioma.\n3. Separation of the arachnoid plane by blunt dissection.\nLogistics:\n- Used needles - in a sharps container.\nNuance: In case of sinus invasion - decision on resection/plastic surgery (risk of blood loss).",
"normal": "The surgeon opens the dura mater of the brain and closes the vessels that feed the tumor.\n📌 Interesting point: the tumor sometimes «sticks» off the brain, like a mushroom from a tree."
  }
 },
 {
"name": "Tumor removal (Simpson Grade I-II)",
"description": {
"professional": "Delicate dissection of the tumor from the brain tissue while preserving the pial vessels. Enucleation of the meningioma core with an ultrasonic aspirator (CUSA). Resection of the dura mater at the site of tumor attachment (Simpson Grade I). In case of bone invasion — aggressive resection (Simpson Grade II).\nInstruments:\n- Ultrasonic aspirator (CUSA, 30% power mode)\n- Microforceps (e.g. Rhoton No. 6)\n- Prolene 6-0 suture material\nTechnique:\n1. Aspiration of the tumor center to reduce the volume.\n2. Gradual separation of the capsule from the brain.\n3. Resection of the dura mater with the capture of 1-2 cm of healthy tissue.\nLogistics:\n- The sample is sent for urgent histology.\nNuance: In case of convexital meningiomas — control of motor zones (neuronaviation + corticography).",
"normal": "The tumor is shelled out, like the pulp from a nut, and removed. The place where it was attached is cauterized or excised.\n📌 Interesting point: meningiomas are often «kind» — they do not grow into the brain, but simply press it."
  }
 },
 {
"name": "Dura mater plastic surgery and cranioplasty",
"description": {
"professional": "Closure of the dura mater defect with autocartilage/artificial membrane (DuraGen). Sealing with sutures (Prolene 5-0) + fibrin glue. Return of the bone flap with fixation with titanium plates. Drainage of the subgaleal space.\nInstruments:\n- Artificial dura mater (DuraGen or Neuro-Patch)\n- Titanium microplates (1.0 mm)\n- Jackson-Pratt 10 Fr drainage\nTechnique:\n1. Plastic surgery of the dura mater defect with a patch.\n2. Fixation of the bone with at least 4 screws.\n3. Checking the tightness (Valsalva test).\nLogistics :\n- The tumor remains are disposed of as biological waste.\nNuance: For large defects - cranioplasty with a titanium mesh.",
"normal": "The hole in the shell is covered with a «patch», the bone is put back in place and screwed with titanium screws.\n📌 Interesting point: titanium is not magnetic - you can do an MRI after the operation."
  }
 },
 {
"name": "Completion and monitoring",
"description": {
"professional": "Layer-by-layer wound suturing. Application of an aseptic dressing. Monitoring of neurological status (motor functions, speech). MRI in the first 24 hours to assess the radicality of the removal. Prevention of seizures (levetiracetam) and edema (dexamethasone).\nInstruments:\n- Vicryl 2-0 suture material (aponeurosis)\n- 4-0 monofilament (skin)\n- Neuromonitoring sensors (NIM)\nPostoperative protocol:\n1. ICP monitoring (if there was edema).\n2. Antibiotics (ceftriaxone 2 g/day).\n3. Activation on the 2nd day.\nComplications:\n- Venous infarction (5% with sinus damage).\n- Liquorrhea (3%).\n- Relapse (7% over 10 years).",
"normal": "The wound is sutured, the patient is transferred to the ward. The first days they check that there is no cerebral edema.\n📌 An interesting point: if the tumor was large, the brain gradually «straightens out» - like a ball after pressure."
    }
   }
  ]
 },
{
"keys": [
"trigeminal neuralgia",
"Jeanette decompression",
"MVD",
"neurosurgery"
],
"name": "Microvascular decompression of the trigeminal nerve",
"modes": {
"professional": "Microsurgical separation of a vessel (artery/vein) compressing the trigeminal nerve root in the cerebellopontine angle. Stages: retromastoid approach, opening of the dura mater, identification of the «vessel-nerve» conflict, installation of a Teflon protector. Control of the superior cerebellar artery (SCA) loop is critical.",
"normal": "An operation that relieves «lightning» facial pain. The surgeon finds the vessel that is pressing on the nerve and places a «spacer» between them. The pain disappears instantly!"
},
"steps": [
{
"name": "Positioning and approach",
"description": {
"professional": "Patient position on the side (healthy side down). Fixation of the head in a three-point Mayfield holder. Linear incision (5-6 cm) behind the mastoid process. Retromastoid craniotomy (3x3 cm window) using a pneumatic burr (Anspach). Opening the mastoid air cells to access the sigmoid sinus.\nInstruments:\n- Midas Rex craniotome with a 4 mm burr\n- Double-pronged soft tissue hook\n- Bone wax\nTechnique:\n1. 1 cm skin incision behind the auricle.\n2. Coagulation of the occipital artery.\n3. Bone flap-preserving craniotomy.\nLogistics:\n- Bone chips are preserved for possible reimplantation.\nNote: If the sigmoid sinus is high, the incision is shifted posteriorly.",
"normal": "The patient is placed on his side, the head is fixed in a special holder. A small incision is made behind the ear and a hole is «drilled» in the skull.\n📌 Interesting point: the bone will be put back in place later — it will take root!"
  }
 },
 {
"name": "Dura mater opening and access to the cerebellopontine angle",
"description": {
"professional": "Dura mater (DMA) incision with a #11 scalpel. DMA edges fixation with sutures (4-0 silk). Gradual CSF irrigation to lower the cerebellum. Insertion of a retractor (e.g. Greenberg) with pressure control (max. 20 mmHg). Identification of the superior petroclival angle.\nInstruments:\n- #11 micro scalpel\n- Soft-bladed retractor\n- Irrigator with heated saline\nTechnique:\n1. DMA incision in the shape of the letter «T».\n2. Aspiration of cerebrospinal fluid to reduce ICP.\n3. Search for the trigeminal nerve (V pair) by anatomical landmarks.\nLogistics:\n- Used needles - in a container for sharp objects.\nNuance: In case of a narrow anatomical window - partial resection of the lateral part of the cerebellum (rare).",
"normal": "The surgeon opens the meninges and carefully moves the cerebellum to find the trigeminal nerve.\n📌 Interesting point: the brain «floats» in fluid - it is pumped out to make it easier to work."
  }
 },
 {
"name": "Identification of the «vessel-nerve» conflict",
"description": {
"professional": "Microscopic visualization (magnification ×10-40) of the trigeminal nerve root in the entry zone into the bridge (REZ, root entry zone). Search for a compressing vessel (usually the SMA loop, less often the anterior inferior cerebellar artery (AICA) or vein). Dissection of arachnoid adhesions with microscissors.\nInstruments:\n- Operating microscope (Zeiss OPMI Pentero)\n- Yasargil microscissors\n- Rhoton microtweezers No. 5\nTechnique:\n1. Separation of the vessel from the nerve with a blunt dissector.\n2. Coagulation of the satellite veins with a bipolar (10 W).\n3. Preparation of a pocket for the protector.\nLogistics:\n- Arachnoid adhesions are sent for histology.\nNuance: In case of venous compression - coagulation of the vein (be careful - risk of trunk ischemia!).",
"normal": "Under the microscope, the surgeon finds the vessel that is pressing on the nerve (often a tortuous artery).\n📌 Interesting point: the nerve can be «pressed» into the brainstem, like a boot print in the snow."
  }
 },
 {
"name": "Installing a Teflon protector",
"description": {
"professional": "Fixing the vessel in a new position using a Teflon sponge (e.g. Teflon Felt). The pad is placed between the vessel and the nerve, avoiding kinking the artery. Checking for tension. Additional fixation with fibrin glue (Tisseel).\nInstruments:\n- Teflon sponge (size 5×10 mm)\n- Microholder for the protector\n- Fibrin glue\nTechnique:\n1. Forming a Teflon «hammock» around the vessel.\n2. Checking the pulsation of the artery after displacement.\n3. Fixation with glue to prevent migration.\nLogistics:\n- Teflon residues are disposed of as non-biological waste.\nNuance: In case of multiple vessels, protectors are installed in a cascade.",
"normal": "A soft Teflon «gasket» is inserted between the vessel and the nerve. It is like a pillow - it protects the nerve from pressure.\n📌 Interesting point: Teflon is the same material as in non-stick frying pans!"
  }
 },
 {
"name": "Completion and control",
"description": {
"professional": "Repeated revision of the decompression zone. Suturing of the dura mater with a sealed suture (Prolene 5-0). Return of the bone flap with fixation with titanium plates. Drainage of the subcutaneous space (Redon drainage 10 Fr). Layered wound suturing.\nInstruments:\n- Mathieu needle holder\n- Titanium microplates (1.0 mm)\n- Drainage with active aspiration\nPostoperative protocol:\n1. MRI to rule out hematoma.\n2. Pain relief (paracetamol + tramadol).\n3. Monitoring neurological status (corneal reflex!).\nComplications:\n- Liquorrhea (2%).\n- Nerve damage (1%).\n- Relapse (5% over 5 years).",
"normal": "The wound is sutured, the bone is put back in place. After a couple of days, the patient already forgets about the pain!\n📌 An interesting point: if the operation is done correctly, the pain disappears immediately - as if by magic."
    }
   }
  ]
 },
{
"keys": [
"hydrocephalus",
"VPSh",
"brain shunting",
"neurosurgery"
],
"name": "Ventriculoperitoneal shunting",
"modes": {
"professional": "Installation of a shunt system for the outflow of cerebrospinal fluid from the ventricles of the brain into the abdominal cavity. Stages: craniotomy, ventricular catheter, subcutaneous tunnel, peritoneal catheter, valve adjustment. The angle of insertion of the catheter into the ventricle and checking the patency of the system are critical.",
"normal": "An operation that «drains» excess fluid from the brain into the abdomen. A tube with a valve is inserted so that the pressure in the head does not jump. After this, the headache stops, and the patient can think straight again!"
},
"steps": [
{
"name": "Planning and marking",
"description": {
"professional": "Determining the point of insertion of the ventricular catheter (usually the right atrium of Kocher: 1 cm anterior to the coronary suture, 2.5 cm lateral to the midline). Marking the skin with a marker along the trajectory of the shunt: from the frontal region to the abdomen (hypochondrium or pelvis). Preparing the surgical field.\nInstruments:\n- Neuronavigation (in complex cases)\n- Surgical marker\n- Template for measuring the length of the catheter\nTechnique:\n1. The entry point into the ventricle is at the intersection of the lines: 10 cm from the nasion, 3 cm from the midline.\n2. The trajectory of the subcutaneous tunnel is from the parotid region to the epigastrium.\nLogistics:\n- Checking the length of the catheter according to the table (patient's height/age).\nNote: For children under one year old, the insertion point is 1 cm in front of the fontanelle.",
"normal": "The surgeon marks on the head and abdomen where the «tubes» will be laid.\n📌 Interesting point: in children, the shunt is placed through the fontanelle - it is still soft!"
  }
 },
 {
"name": "Ventricular catheter",
"description": {
"professional": "A burr hole in the skull (5 mm in diameter) with a craniotome. Puncture of the ventricle with a catheter with a guidewire at an angle of 90° to the bone (for the lateral ventricle - direction to the conditional point «between the eyebrows»). Depth control (4-6 cm in adults) via cerebrospinal fluid drainage.\nInstruments:\n- Craniotome with a 4 mm cutter\n- Ventricular catheter (e.g. Codman)\n- Catheter mandrin\nTechnique:\n1. Insert the catheter until you feel a «gap» (penetration into the ventricle).\n2. Connect a manometer to measure ICP (normal: 5-15 mmHg).\n3. Fix the catheter to the periosteum with sutures (Prolene 4-0).\nLogistics:\n- The cerebrospinal fluid is sent for analysis (protein, cellular composition).\nNote: For small ventricles, use ultrasound navigation.",
"normal": "A hole is drilled in the skull and a catheter is inserted into the brain at a right angle. As soon as clear fluid starts flowing out of the tube, you've hit the right spot!\n📌 Interesting point: the depth of insertion is like the length of a matchbox (4-6 cm)."
  }
 },
 {
"name": "Subcutaneous tunnel",
"description": {
"professional": "Formation of a tunnel from the ear area to the abdomen using a tunnelizer (for example, Passport). The catheter is passed under the skin, avoiding compression areas (clavicle, ribs). The valve (e.g. Medtronic Strata) is fixed to the aponeurosis in the retroauricular region.\nInstruments:\n- Tunnelizer with an oval tip\n- Valve holder\n- Catheter length measure\nTechnique:\n1. Skin incision in the retroauricular region and epigastrium.\n2. Passing the «reflection» tunnelizer (so as not to damage the vessels).\n3. The valve is fixed to the temporal muscle.\nLogistics:\n- Excess catheter is cut off, leaving a 10 cm margin.\nNote: In women, bypass the mammary gland to prevent necrosis.",
"normal": "A «tunnel» for the tube is made under the skin from the head to the abdomen. The valve (like a button behind the ear) regulates the flow of fluid.\n📌 Interesting point: the tube is passed in such a way that it is not pinched when the patient sits or bends over."
  }
 },
 {
"name": "Peritoneal catheter",
"description": {
"professional": "Mini-laparotomy (2 cm incision) in the right hypochondrium. Insertion of a catheter into the abdominal cavity under visual control. Checking the outflow of cerebrospinal fluid (drop test). Fixation of the catheter to the peritoneum (Vicryl 3-0).\nInstruments:\n- 5 mm trocar\n- Laparoscopic camera (in complex cases)\n- Vicryl suture material\nTechnique:\n1. The catheter is passed into the small pelvis (in adults) or the right subdiaphragmatic pocket (in children).\n2. Position control — no resistance when flushing with saline.\nLogistics:\n- The excess length of the catheter is placed in a «ring» in the abdominal cavity.\nNuance: In case of adhesions — catheter installation under laparoscopic control.",
"normal": "The tube is inserted into the abdomen through a small incision. There, the liquid will be sucked in, like water in a sponge.\n📌 Interesting point: in children, the catheter is sometimes inserted into the heart (ventriculoatrial bypass)."
  }
 },
 {
"name": "Check and completion",
"description": {
"professional": "System patency test: flushing with sterile saline (0.9% NaCl) under pressure. Valve adjustment (if programmable) according to preoperative ICP data. Layer-by-layer wound suturing. X-ray control of catheter position.\nInstruments:\n- 10 ml syringe with saline\n- Valve programmer (eg Sophysa)\n- X-ray machine (for intraoperative control)\nPostoperative protocol:\n1. CT scan of the head after 24 hours.\n2. Antibiotics (cefazolin 1 g ×3 days).\n3. Limitation of physical activity for 2 weeks.\nComplications:\n- Infection (3-5%).\n- Shunt dysfunction (10% in the first year).\n- Hyperdrainage (rare).",
"normal": "They check that fluid flows freely through the tube. The valve is adjusted to the patient's pressure.\n📌 Interesting point: modern valves can be adjusted with a magnet without cutting the skin!"
    }
   }
  ]
 },
{
"keys": [
"glioblastoma",
"brain tumor",
"neurosurgery",
"glioma resection"
],
"name": "Glioblastoma removal",
"modes": {
"professional": "Maximum radical resection of a malignant glial tumor (IV degree according to WHO) using intraoperative neuronavigation, fluorescent labeling of 5-ALA and intraoperative MRI. Control of tumor boundaries and preservation of functional areas of the brain (corticography, neuromonitoring) are critical.",
"normal": "Removal of an aggressive brain tumor with an attempt to capture all of its «tentacles». The surgeon illuminates the tumor with a special substance so as not to affect the healthy brain."
},
"steps": [
{
"name": "Preoperative preparation",
"description": {
"professional": "3 hours before surgery: oral administration of 5-aminolevulinic acid (5-ALA, 20 mg/kg). Skin marking according to neuronavigation data (MRI with tractography). Patient positioning in the supine/lateral position with head fixation in Mayfield. Prevention of cerebral edema (mannitol 1 g/kg IV).\nInstruments:\n- Neuronavigation station (BrainLab, StealthStation)\n- Three-point head holder\n- Intraoperative MRI system (if available)\nTechnique:\n1. Combining MRI data with the navigation system.\n2. Marking the projection of the tumor and functional zones (speech, motor).\nLogistics:\n- Monitoring the level of 5-ALA in the plasma.\nNuance: If localized in the speech zone - awake-craniotomy planning.",
"normal": "The patient is given a «magic pill» that makes the tumor glow under blue light. The surgeon studies a 3D map of the brain to accurately plan the incision.\n📌 Interesting point: sometimes the operation is done «on awakening» so as not to affect the speech zones!"
  }
 },
 {
"name": "Craniotomy",
"description": {
"professional": "Linear/arc-shaped skin incision preserving the feeding vessels. Burr hole with a craniotome (5 mm burr). Osteoplastic craniotomy with the formation of a bone flap (size 2 cm larger than the tumor borders). Hemostasis of the bone edges with wax.\nInstruments:\n- Pneumatic burr (Anspach or Midas Rex)\n- Bone wax\n- Dural hooks\nTechnique:\n1. Sawing the bone while preserving the periosteum.\n2. Control of the position of the sinuses (at parasagittal tumors).\nLogistics:\n- The bone flap is stored in antibiotic-saline solution.\nNuance: In case of bone invasion — hyperostosis resection.",
"normal": "A «window» is cut out in the skull to get to the tumor. The bone is preserved — it will be put back.\n📌 Interesting point: the tumor can grow into the bone, then part of it is also removed."
  }
 },
 {
"name": "Opening the dura mater and visualizing the tumor",
"description": {
"professional": "Incision of the dura mater with a #11 scalpel in the avascular zone. Fixation of the edges with sutures (4-0 silk). Turning on blue light (405 nm) to activate 5-ALA fluorescence (the tumor glows pink). Marking the boundaries using neuronavigation data.\nInstruments:\n- Microscope with a fluorescence module (Zeiss Pentero 900)\n- Ultrasonic aspirator (CUSA EXcel)\n- Bipolar coagulation (Malis, 15 W)\nTechnique:\n1. Fluorescence confirms the tumor area (100% specificity).\n2. Ultrasound navigation to determine the depth.\nLogistics:\n- Collection of material for urgent histology.\nNote: If there is no luminescence, neuronavigation control is used.",
"normal": "Under blue light, the tumor turns pink - like a neon sign. This helps the surgeon avoid damaging the healthy brain.\n📌 Interesting point: 5-ALA makes the tumor visible only under special light!"
  }
 },
 {
"name": "Tumor resection",
"description": {
"professional": "Tumor enucleation with an ultrasonic aspirator (CUSA) while preserving the pial vessels. Gradual coagulation of tumor tissue with a bipolar. Control of boundaries by fluorescence and neuronavigation. When close to functional zones — corticography and direct electrical stimulation.\nInstruments:\n- CUSA (frequency 28 kHz, aspiration 60%)\n- Rhoton microforceps No. 4\n- Neuromonitoring (NIM Eclipse)\nTechnique:\n1. Resection from the center to the periphery.\n2. In case of invasion into the ventricle — stop to prevent dissemination.\n3. Motor evoked potential monitoring.\nLogistics:\n- Tumor tissue is sent for histology and molecular analysis (MGMT, IDH1).\nNuance: If the motor cortex is affected, subtotal resection is performed while preserving the functional island.",
"normal": "The tumor is «sucked out» with a special ultrasound device that breaks it into small pieces. The vessels are cauterized.\n📌 An interesting point: if the tumor is near the area responsible for movement, the surgeon can leave a thin layer to avoid paralysis."
  }
 },
 {
"name": "Radicality monitoring",
"description": {
"professional": "Intraoperative MRI (if available) to assess residual tumor. Repeated fluorescence under blue light. Hemostasis of the tumor bed with a hemostatic sponge (Surgicel). Installation of a capsule with carmustine (Gliadel) upon agreement with the oncologist.\nInstruments:\n- Intraoperative MRI (BrainSuite)\n- Hemostatic sponges (Floseal, Surgicel)\n- Implantable capsule with a chemotherapy drug\nTechnique:\n1. MRI control 30 minutes after resection.\n2. Additional resection in case of residual tumor.\nLogistics:\n- Recording of data for postoperative radiation therapy.\nNuance: With localization in functional zones, residual tumor volume is acceptable (STR, subtotal resection).",
"name": "After removal, an MRI is done right in the operating room to check if there is any tumor left. Sometimes a «tablet» with a chemotherapy drug is placed in the tumor bed.\n📌 Interesting point: modern technologies allow scanning the brain during surgery!"
  }
 },
 {
"name": "Completion",
"description": {
"professional": "Sealed suturing of the dura mater (Prolene 4-0). Return of the bone flap with fixation with titanium plates. Drainage of the epidural space (Redon drainage 10 Fr). Layered suturing of the wound.\nInstruments:\n- Titanium plates and screws (1.5 mm)\n- Drainage with active aspiration\n- Vicryl suture material 2-0\nPostoperative protocol:\n1. CT scan after 2 hours to exclude hematoma.\n2. Dexamethasone 4 mg ×4 times a day (edema prevention).\n3. Start of radiation therapy in 2-4 weeks.\nComplications:\n- Neurological deficit (15-20%).\n- Infection (3-5%).\n- Relapse (100% within 2 years without adjuvant therapy).",
"normal": "The bone is put back in place, the wound is sutured. Radiation and chemotherapy begin in a couple of weeks.\n📌 Hard fact: glioblastoma always comes back, but surgery prolongs life for years."
    }
   }
  ]
 },
{
"keys": [
"epilepsy",
"lobectomy",
"hippocampectomy",
"neurosurgery",
"focal cortical dysplasia",
"callosotomy"
],
"name": "Surgical treatment of epilepsy",
"modes": {
"professional": "Radical removal of the epileptogenic zone (temporal/frontal lobectomy, selective amygdalohippocampectomy) or disconnection of pathological neural networks (callosotomy). Stages: intraoperative EEG, corticography, neuronavigation, functional mapping. Control of the preservation of functional zones (speech, motor) is critical.",
"normal": "Surgery, which stops epileptic seizures. The surgeon removes or «disables» the area of the brain where the seizures originate. Most often, the temporal lobes are operated on."
},
"steps": [
{
"name": "Preoperative mapping",
"description": {
"professional": "Video-EEG monitoring (3-7 days), high-resolution MRI (3T), PET, functional MRI (speech/motor areas). Implantation of subdural grids or depth electrodes if the data do not match. Wada test to assess hemisphere dominance for speech.\nInstruments:\n- Stereotactic system (FrameLink, BrainLab)\n- Depth electrodes (DIXI Medical)\n- Intraoperative neurophysiological monitoring (Natus)\nTechnique:\n1. Accurate definition of the epileptogenic zone based on ictal/interictal EEG data.\n2. Tractorography to assess proximity to conduction pathways.\nLogistics:\n- Comparison of EEG, MRI, and clinical semiotics of seizures.\nNuance: In case of bilateral hippocampal damage — decision on sequential surgeries.",
"usual": "Before the surgery, the patient lives with electrodes on the head for a week to «catch» the seizure on the EEG. They do an MRI and speech tests.\n📌 Interesting point: sometimes electrodes are temporarily implanted in the brain to accurately determine the lesion."
  }
 },
 {
"name": "Craniotomy and approach",
"description": {
"professional": "Positioning: on the side (with temporal approach) or on the back (frontal lobe). Fixation of the head in Mayfield. Arcuate skin incision (temporal approach: from the zygomatic arch to the parietal tubercle). Craniotomy 4x4 cm with preservation of the bone flap. Opening of the dura mater in the avascular zone.\nInstruments:\n- Pneumatic burr (Midas Rex with a 5 mm burr)\n- Double-pronged soft tissue hooks\n- Microscope (Zeiss OPMI Pentero)\nTechnique:\n1. For temporal lobectomy — access through the middle temporal gyrus.\n2. For frontal resection — bypass Broca's area.\nLogistics:\n- The bone flap is stored in warm saline with an antibiotic.\nNote: For callosotomy — parasagittal approach with preservation of the paracentral lobules.",
"normal": "The skull is opened above the problem area. In temporal lobe epilepsy, the incision goes from the temple to the crown.\n📌 Interesting point: the bone is always returned to its place - it takes root as if it were native."
  }
 },
 {
"name": "Intraoperative EEG and corticography",
"description": {
"professional": "Application of electrodes to the cortex (subdural strips/grid). Recording of interictal activity. Direct electrical stimulation (1-5 mA) for mapping speech/motor zones. Marking of functionally significant areas with sterile markers.\nInstruments:\n- Cortical electrodes (Ad-Tech Medical)\n- Ojemann stimulator (Natus)\n- Neuronavigation with fMRI data integration\nTechnique:\n1. Stimulation with a step of 5 mm (frequency 50 Hz, duration 1 ms).\n2. Motor response control (face, arm, leg).\nLogistics:\n- Mapping of the Broca/Wernicke area in the dominant hemisphere.\nNote: Plasticity is possible in children under 5 years old - resection in the dominant hemisphere with caution.",
"normal": "The brain is «listened» to with electrodes and checked which areas are responsible for speech and movement.\n📌 An interesting point: during stimulation, the patient can start talking or moving their hand - this helps the surgeon not to touch important areas."
  }
 },
 {
"name": "Resection of the epileptogenic zone",
"description": {
"professional": "**Temporal lobectomy**: removal of the anterior 3-4 cm of the temporal lobe (non-dominant hemisphere) or 2-3 cm (dominant). **Amygdalohippocampectomy**: transcortical approach through the middle temporal gyrus to the hippocampus. **Frontal resection**: neuronavigation-guided removal of cortical dysplasia.\nInstruments:\n- Ultrasonic aspirator (CUSA EXcel, 30% power)\n- Bipolar forceps (Malis, 10 W)\n- Rhoton microforceps #3\nTechnique:\n1. Gradual aspiration of the cortex while preserving white matter.\n2. In hippocampectomy — control of pial vessels (risk of brainstem damage).\nLogistics:\n- Samples are sent for histology (FCD I-III according to Blumcke).\nNuance: In mesial temporal sclerosis — mandatory hippocampal resection.",
"normal": "The surgeon removes the area of the brain where seizures originate. In temporal epilepsy, this is the tip of the temporal lobe and the hippocampus (it looks like a seahorse).\n📌 Hard fact: the hippocampus is «memory», but after its removal the patient forgets only the last 1-2 years."
  }
 },
 {
"name": "Callosotomy (in generalized epilepsy)",
"description": {
"professional": "Dissection of the corpus callosum (anterior 2/3 in tonic-clonic seizures or 100% in Lennox-Gastaut syndrome). Access through the interhemispheric fissure. Step-by-step coagulation and incision with microscissors. Control of the safety of the pericallosal arteries.\nInstruments:\n- Microscope with ×20-40 magnification\n- Yasargil microscissors\n- Bipolar coagulation (15 W)\nTechnique:\n1. Separation of the hemispheres with a blunt retractor.\n2. Gradual dissection of the corpus callosum fibers.\nLogistics:\n- Intraoperative ultrasound to control the depth.\nNuance: In case of Lennox-Gastaut syndrome — additional subpial resection.",
"normal": "The «bridge» between the hemispheres of the brain is cut so that the seizures do not spread.\n📌 Interesting point: after this operation, the patient can write with his left hand without realizing it («alien hand» syndrome)."
  }
 },
 {
"name": "Completion and postoperative control",
"description": {
"professional": "Repeat intraoperative EEG to assess epileptiform activity. Hermetic suturing of the dura mater (Prolene 4-0). Fixation of the bone flap with titanium plates. Subdural space drainage (Redon 10 Fr drainage).\nInstruments:\n- Titanium plates (1.0 mm)\n- Drainage with active aspiration\n- Vicryl 2-0 suture material\nPostoperative protocol:\n1. Video-EEG monitoring 24-48 hours.\n2. MRI after 72 hours to assess radicality.\n3. Gradual withdrawal of antiepileptic drugs (after 6-12 months).\nComplications:\n- Hemianopsia (with resection of the occipital lobe).\n- Transient aphasia (10-15%).\n- Hydrocephalus (rare).",
"normal": "The wound is sutured, the patient is transferred to the ward. The attacks may disappear immediately or after several months.\n📌 Good news: 70% of patients live without attacks after surgery!"
    }
   }
  ]
 },
{
"keys": [
"microdiscectomy",
"herniated disc",
"lumbar",
"neurosurgery",
"nerve decompression"
],
"name": "Lumbar microdiscectomy",
"modes": {
"professional": "Microsurgical removal of a herniated disc with decompression of the spinal nerve root. Stages: paramedian approach, hemilaminectomy, foraminotomy, removal of a herniated disc under the control of an operating microscope. Control of the integrity of the dural sac and the nerve root is critical.",
"normal": "An operation that removes the «pinching» of a nerve due to a herniated disc in the lumbar region. The surgeon removes the hernia through a small incision, and the leg pain goes away almost immediately."
},
"steps": [
{
"name": "Positioning and marking",
"description": {
"professional": "The patient is positioned on his stomach with a bend in the lumbar region (the «knees-chest» position). Skin marking based on intraoperative fluoroscopy data: projection of the affected segment (usually L4-L5 or L5-S1). Treatment of the surgical field. Infiltration anesthesia (1% lidocaine with adrenaline).\nInstruments:\n- X-ray C-arm\n- 22G spinal needles\n- Surgical marker\nTechnique:\n1. Determining the level using an X-ray (control by the iliac crest).\n2. Marking a 3-4 cm long incision 1.5 cm from the midline.\nLogistics:\n- Checking the level of anesthesia before the incision.\nNuance: In case of obesity (BMI> 35) — increasing the incision length to 5 cm.",
"normal": "The patient is placed on his stomach, with a pillow under the lower back. The sore spot is marked with an X-ray and the incision line is drawn.\n📌 Interesting point: the incision is so small that the scar is almost invisible!"
  }
 },
 {
"name": "Access to the spine",
"description": {
"professional": "Incision of the skin, subcutaneous tissue and lumbosacral fascia. Blunt separation of the muscles (multifidus and longissimus) using dilators. Installation of a tubular retractor (e.g. METRx). Hemilaminectomy with Kerrison nippers (size 2-3 mm) with exposure of the yellow ligament.\nInstruments:\n- Tubular retractor (diameter 18-20 mm)\n- Kerrison nippers (1-3 mm)\n- Electrocoagulator (Valleylab, 20 W)\nTechnique:\n1. Bipolar coagulation of epidural veins.\n2. Resection of the lower edge of the overlying vertebral arch.\nLogistics:\n- Bone fragments are disposed of as biological waste.\nNuance: In case of facet joint hypertrophy — partial facetectomy.",
"normal": "Through the incision, the surgeon moves the muscles apart like curtains and gets to the vertebra. Using special «nippers» he removes part of the bone to see the nerve.\n📌 Interesting point: the muscles are not cut - they are simply moved aside, so the recovery is fast."
  }
 },
 {
"name": "Disc herniation removal",
"description": {
"professional": "Excision of the yellow ligament (ligamentotomy). Identification of the dural sac and root. Mobilization of the root medially (in case of medial hernia) or laterally (in case of foraminal hernia). Discectomy with a microcoagulator and pulp forceps. Hemostasis control with a bipolar.\nInstruments:\n- Microsurgical forceps (Pituitary rongeurs)\n- Penfield dissector No. 4\n- Binocular microscope (magnification ×10-16)\nTechnique:\n1. Incision of the fibrous ring with a scalpel No. 11.\n2. Removal of hernial material and degenerative nucleus pulposus.\n3. Revision of the spinal canal for sequesters.\nLogistics:\n- The removed material is sent for histology.\nNuance: In the case of a massive adhesive process, a dural protector is used.",
"normal": "The surgeon finds the nerve and carefully moves it to the side. The hernia is pulled out with small forceps, like a splinter.\n📌 Interesting point: the hernia looks like on a piece of chewing gum — soft and sticky."
  }
 },
 {
"name": "Root decompression and control",
"description": {
"professional": "Checking the freedom of the root with passive movements. Foraminotomy for stenosis of the intervertebral foramen (with Kerrison pliers 1 mm). Washing the wound with sterile saline. Installation of a hemostatic sponge (Surgicel). Intraoperative test for segment stability (if instability is suspected — transpedicular fixation).\nInstruments:\n- Nerve hook\n- Irrigator with warm saline\n- Hemostatic sponge (Gelfoam)\nTechnique:\n1. Palpation of the root with a hook — it should move freely.\n2. Checking for the absence of disc fragments in the epidural space.\nLogistics:\n- Fixation of the retractor by an assistant during revision.\nNuance: In case of recurrent hernias — use of adgeolysis (hyaluronidase).",
"normal": "The surgeon checks that the nerve lies freely in its «bed». If necessary, he widens the opening through which the nerve exits the spine.\n📌 An interesting point: after releasing the nerve, the patient immediately feels that the pain goes away."
  }
 },
 {
"name": "Completion of the operation",
"description": {
"professional": "Removal of the retractor. Layer-by-layer suturing of the wound: fascia (Vicryl 2-0), subcutaneous tissue (Vicryl 3-0), skin (monofilament 4-0). Application of a sterile dressing. Extubation and transfer to the ward.\nInstruments:\n- Mathieu needle holder\n- Suture material (absorbable/non-absorbable)\n- Sterile wipes\nPostoperative protocol:\n1. Activation after 2-3 hours.\n2. Pain relief (paracetamol + NSAIDs).\n3. Discharge on the 2-3 day.\nComplications:\n- Liquorrhea (1-2%).\n- Hernia recurrence (5-10%).\n- Root injury (0.5%).",
"normal": "The muscles are returned to their place, the incision is sutured. After a couple of hours, the patient can already get up.\n📌 Good news: 90% of patients forget about leg pain immediately after surgery!"
    }
   }
  ]
 },
{
"keys": [
"laminectomy",
"spinal stenosis",
"spinal decompression",
"neurosurgery",
"spinal surgery"
],
"name": "Laminectomy",
"modes": {
"professional": "Surgical decompression of the spinal canal by removing the vertebral arch (lamina) and spinous process. Indications: spinal stenosis, spinal cord compression, tumors. Stages: access, resection of bone structures, decompression of the dural sac, stabilization (if necessary).",
"normal": "Surgery that widens the «narrow» spinal canal to release the compressed spinal cord and nerves. After this, the patient can walk again without pain."
},
"steps": [
{
"name": "Positioning and approach",
"description": {
"professional": "The patient is positioned on his stomach with a lumbar arch (knees-chest position). Skin markings according to fluoroscopy data: projection of the affected segments (usually L3-L5). A midline skin incision 8-10 cm long. Layer-by-layer dissection of the subcutaneous tissue and lumbosacral fascia.\nInstruments:\n- Scalpel No. 20\n- Electrocoagulator (Valleylab, 30 W)\n- Retractors (e.g., Taylor or Williams)\nTechnique:\n1. Midline incision from the spinous process of the overlying to the underlying vertebra.\n2. Detachment of paravertebral muscles from spinous processes and arches subperiosteally.\nLogistics:\n- Bleeding vessels are coagulated with bipolar.\nNuance: During cervical laminectomy - fixation of the head in Mayfield with slight flexion.",
"normal": "The patient is placed on his stomach, placing a cushion under the lower back. The surgeon makes an incision along the spine and carefully moves the muscles to the sides.\n📌 Interesting point: the muscles are not cut - they are «peeled off» from the bone, like the peel of an orange."
  }
 },
 {
"name": "Resection of bone structures",
"description": {
"professional": "Removal of spinous processes with Liston nippers. Resection of the lamina with a high-speed burr (e.g. Midas Rex with a 4 mm burr) or Kerrison rongeurs (size 2-3 mm). Control of the integrity of the dural sac. Facetectomy if necessary.\nInstruments:\n- Liston rongeurs\n- Pneumatic rongeur (Midas Rex)\n- Kerrison rongeurs (2-3 mm)\nTechnique:\n1. Initial resection at the base of the spinous process.\n2. Gradual removal of the lamina from the caudal to the cranial direction.\n3. Control of the resection depth to avoid damaging the dural sac.\nLogistics:\n- Bone fragments are preserved for possible plastic surgery.\nNuance: In case of hypertrophy of the facet joints - partial resection of the medial sections.",
"normal": "The surgeon removes the bone «wings» of the vertebrae (spinous processes and arches) to make room for the spinal cord.\n📌 Interesting point: the bone is sometimes preserved - it can be used for plastic surgery."
  }
 },
 {
"name": "Decompression of the dural sac and roots",
"description": {
"professional": "Excision of the yellow ligament (ligamentotomy). Microsurgical decompression roots: dissection of adhesions, removal of osteophytes. Revision of the spinal canal for disc herniation or tumors. Washing the wound with warm saline.\nInstruments:\n- Microforceps (Pituitary rongeurs)\n- Penfield dissector No. 4\n- Binocular loupe (×3.5)\nTechnique:\n1. Careful separation of the yellow ligament from the dural sac.\n2. Blunt mobilization of the roots.\n3. Removal of compressive factors (osteophytes, hernias).\nLogistics:\n- Hemostasis of epidural veins with bipolar (15 W).\nNuance: In case of pronounced adhesions — use of dural protector.",
"normal": "The surgeon releases the spinal cord and nerves, removing everything that compresses them: ligaments, bone spurs (osteophytes), hernias.\n📌 Important: nerves are as delicate as live wires — they are easy to damage!"
  }
 },
 {
"name": "Stabilization (if necessary)",
"description": {
"professional": "In case of segment instability or multiple resections — transpedicular fixation (CD Horizon system or similar). Installation of titanium screws in the vertebral pedicles and their connection with rods. Decortication of the remaining bone structures to stimulate fusion.\nInstruments:\n- Transpedicular screws (diameter 5.5-6.5 mm)\n- Rods (diameter 5.5 mm)\n- X-ray C-arm to control the position of the screws\nTechnique:\n1. Screw insertion point: junction of superior articular process and transverse process.\n2. Insertion angle: 10-15° medially in the lumbar region.\n3. Depth control by X-ray.\nLogistics:\n- Checking the position of the screws with intraoperative fluoroscopy.\nNuance: In case of osteoporosis, use cement screws.",
"normal": "If a lot of bone is removed, the spine is strengthened with titanium screws and rods.\n📌 Interesting point: the screws are screwed into the «pedicles» of the vertebrae - these are the strongest places."
  }
 },
 {
"name": "Completion of the operation",
"description": {
"professional": "Hemostasis (Surgicel, bone wax). Installation of drainage (Redon 10 Fr). Layered suturing of the wound: fascia (Vicryl 2-0), subcutaneous tissue (Vicryl 3-0), skin (monofilament 4-0). Application of a sterile dressing.\nInstruments:\n- Drainage with active aspiration\n- Mathieu needle holder\n- Suture material\nPostoperative protocol:\n1. Activation after 6-12 hours.\n2. Pain relief (NSAIDs + weak opioids).\n3. Wearing a corset for 4-6 weeks (with fixation).\nComplications:\n- Cerebrospinal fluid leakage (1-3%).\n- Segment instability (5-10%).\n- Infection (1-2%).",
"normal": "The wound is sutured, leaving drainage for 1-2 days. The patient can get up after a few hours.\n📌 Good news: 80% of patients report a decrease in leg pain immediately after surgery!"
    }
   }
  ]
 },
{
"keys": [
"spondylodesis",
"spinal fusion",
"spinal stabilization",
"interbody corporodesis",
"TLIF",
"PLIF"
],
"name": "Spinal fusion",
"modes": {
"professional": "Surgical stabilization of the spinal segment with the creation of a bone block. Methods: PLIF (posterior), TLIF (transforaminal), ALIF (anterior). Stages: discectomy, installation of a cage with a bone graft, transpedicular fixation. The angle of cage installation and the compression force are critical.",
"normal": "An operation that «fuse[s]» diseased vertebrae into a single block using metal structures and a bone graft. After this, the spine stops «walking» and hurting."
},
"steps": [
{
"name": "Access to the spine",
"description": {
"professional": "**Posterior approach (TLIF/PLIF)**: Midline incision 8-12 cm. Subperiosteal detachment of the paravertebral muscles to the facet joints. Resection of the spinous process and vertebral arch (if necessary). **Anterior approach (ALIF)**: Incision along the left rectus abdominis muscle. Retroperitoneal approach to the spine with vascular mobilization.\nInstruments:\n- Electrocoagulator (Force Triad, 30 W)\n- Bone raspators (Cobb, Hohmann)\n- Retractor (e.g. Williams for posterior approach)\nTechnique:\n1. For TLIF — partial facetectomy to access the disc.\n2. For ALIF — identification of the aortic bifurcation and iliac vessels.\nLogistics:\n- Marking the surgical level with a C-arm X-ray.\nNote: For ALIF in men — risk of retrograde ejaculation (damage to the superior hypogastric plexus).",
"normal": "The surgeon makes an incision on the back (less often on the abdomen) and carefully moves the muscles aside to reach the vertebrae.\n📌 Interesting point: with anterior access, the intestine is temporarily moved aside - it then returns to its place!"
  }
 },
 {
"name": "Discectomy and bed preparation",
"description": {
"professional": "Full discectomy with pulp forceps. Resection of the endplates with a burr (for example, Midas Rex with a ball attachment) to the bleeding bone (puncture bleeding). Washing the disc space with antibiotic-saline. Measuring the depth and height of the bed.\nInstruments:\n- Disc forceps (Pituitary rongeurs)\n- Burr with a 5 mm ball attachment\n- Calibration probes (in 1 mm increments)\nTechnique:\n1. Removal of the disc up to the fibrous ring along the perimeter.\n2. Decortication of the endplates without destroying the cortical layer.\n3. Formation of grooves for the cage (with TLIF).\nLogistics:\n- The removed disc is sent for histology.\nNuance: In osteoporosis - minimal resection of the endplates.",
"normal": "The surgeon removes the damaged disc between the vertebrae and clears the space down to the «bleeding» bone - this is necessary for better fusion.\n📌 Important: the space is measured like a tailor - so that the cage (implant) fits perfectly."
  }
 },
 {
"name": "Installation of a cage and bone graft",
"description": {
"professional": "Implantation of a cage (PEEK, titanium or ceramics) with bone chips (autograft from the iliac crest or allograft). In TLIF - installation of the cage at an angle of 45° through the foraminal window. Compression of the cage during fixation with rods.\nInstruments:\n- Cage (dimensions 8-14 mm high, 22-30 mm long)\n- Implant holder\n- Mallet for final seating\nTechnique:\n1. Filling the cage with bone chips (mixed with BMP-2 if necessary).\n2. Control of the cage position with an X-ray (should not protrude beyond the disc).\n3. With TLIF — cage rotation in the frontal plane to restore lordosis.\nLogistics:\n- The remaining chips are placed in the side pockets.\nNuance: With ALIF — use of cages with a large lordosis angle (10-15°).",
"normal": "A «cage» with bone chips is placed in the cleared space. Over time, the chips grow together into a single block.\n📌 Interesting point: bone chips can be taken from the patient's pelvis — there they are like a «spare part»."
  }
 },
 {
"name": "Transpedicular fixation",
"description": {
"professional": "Installation of screws into the vertebral pedicles (diameter 5.5-7.5 mm). Position control with a C-arm: the screw must pass through the pedicle without going beyond it. Installation of rods (diameter 5.5-6.5 mm) with compression. Fixation with contrast agents.\nInstruments:\n- Pedicle probes (gearshift)\n- Stylet for thread cutting\n- Torque wrench (1.5-2 Nm)\nTechnique:\n1. Entry point: junction of transverse process and superior articular process.\n2. Insertion angle: 5-10° medially in the lumbar region.\n3. Depth: 80% of the pedicle length on the x-ray.\nLogistics:\n- Screw stability test (no «toggle»).\nNuance: In osteoporosis - cement augmentation (PMMA).",
"normal": "The vertebrae are fastened with titanium screws and rods - like scaffolding.\n📌 Important: screws are screwed into the strongest parts of the vertebra — the pedicles."
  }
 },
 {
"name": "Decortical fusion and additions",
"description": {
"professional": "Decortical fusion of the remaining bone structures (arches, transverse processes) with a burr to stimulate fusion. Placing bone chips in the lateral grooves. If necessary, installing an interspinous stabilizer (e.g. Coflex).\nInstruments:\n- High-speed burr (Anspach)\n- Bone forceps (Leksell)\n- Bone cement syringe (for osteoporosis)\nTechnique:\n1. Removing the cortical layer down to the spongy bone.\n2. Formation of a «bed» for the shavings between the transverse processes.\nLogistics:\n- The shavings are mixed with a collagen sponge (for fixation).\nNuance: With PLIF, the installation of interbody cages is mandatory paramedian.",
"normal": "The surgeon «scratches» the bone around to stimulate the growth of new tissue. Everything is sprinkled with bone shavings - like a fertilizer for fusion.\n📌 Interesting point: sometimes an additional «spring» is placed between the spinous processes for unloading."
  }
 },
 {
"name": "Completion",
"description": {
"professional": "Hemostasis (Surgicel, Floseal). Drainage installation (2 drains with ALIF). Layered suturing: fascia (Vicryl 0), subcutaneous tissue (Vicryl 2-0), skin (monofilament 3-0). Application of a sterile dressing.\nInstruments:\n- Jackson-Pratt drain (10 Fr)\n- Mathieu needle holder\n- Absorbable suture material\nPostoperative protocol:\n1. Corset (TLSO) for 3 months.\n2. Limitation of twisting/bending for 6 weeks.\n3. CT control after 3/6/12 months.\nComplications:\n- Pseudoarthrosis (5-15%).\n- Cage migration (3%).\n- Neighboring segment syndrome (10% over 5 years).",
"normal": "The wound is sutured, leaving drains. After 1-2 days, the patient gets up in a corset.\n📌 Good news: titanium structures last a lifetime - they do not need to be replaced!"
    }
   }
  ]
 },
{
"keys": [
"intracranial hematoma",
"epidural hematoma",
"subdural hematoma",
"intracerebral hemorrhage",
"decompressive trepanation",
"emergency neurosurgery"
],
"name": "Removal of intracranial hematoma",
"modes": {
"professional": "Emergency surgical intervention to evacuate blood accumulation in the cranial cavity with brain decompression. Options: resection trepanation for intracerebral hematomas, osteoplastic trepanation for epi-/subdural hematomas. Critical control of the bleeding source (meningeal vessels, parenchymal arteries) and assessment of the dislocation of brain structures is precise.",
"normal": "Urgent surgery to remove a blood clot from the skull after trauma or stroke. The surgeon removes the blood clot that is pressing on the brain, saving the patient's life."
},
"steps": [
{
"name": "Emergency diagnostics and preparation",
"description": {
"professional": "CT of the head without contrast (determination of the type of hematoma, volume, displacement of midline structures). Preparation of the operating room: neurosurgical kit, oscillatory saw, autotransfusion kit. Intubation, mechanical ventilation, correction of coagulopathy (vitamin K, FFP if INR> 1.5). Patient position depending on location: supine (frontal hematomas), lateral (temporal).\nInstruments:\n- Perfusion apparatus (Cell Saver)\n- Neuronavigation (for elective cases)\n- Emergency craniotomy kit\nTechnique:\n1. Volume calculation using the ABC/2 formula (for intracerebral).\n2. Hematoma projection marking using CT slices.\n3. ICP monitoring (mannitol 1 g/kg for signs of dislocation).\nLogistics:\n- Simultaneous preparation of two surgical teams for bilateral hematomas.\nNote: For a subdural hematoma with a thickness of >10 mm - emergency surgery within 4 hours.",
"normal": "The patient is immediately taken to a CT scan - the image will show where the blood has accumulated. In the operating room, instruments are prepared while the patient is anesthetized.\n📌 Life fact: with an epidural hematoma, every minute counts - the «golden hour» for surgery."
  }
 },
 {
"name": "Decompressive trepanation",
"description": {
"professional": "Linear skin incision (for epidural - above the injured artery, for subdural - a large arcuate one). Burr hole with a trepanner (1 cm below the lower edge of the hematoma). Expansion of the trepanation window to 5x5 cm with Kerrison nippers. For intracerebral hematoma - resection trepanation with removal of the bone flap.\nInstruments:\n- Oscillating saw (Anspach)\n- Kerrison nippers (3-5 mm)\n- Arc cutter (for bone flaps)\nTechnique:\n1. In case of epidural hematoma - the first opening is above the site of the artery rupture (usually the middle meningeal).\n2. In case of subdural - trepanation at the point of maximum clot thickness.\n3. In case of intracerebral - trepanation above the projection of the hematoma + 2 cm.\nLogistics:\n- The bone flap during resection is stored in an antibiotic solution.\nNuance: In case of severe cerebral edema - the trepanation window is widened to 10 cm.",
"normal": "The surgeon cuts a «window» in the skull directly above the blood clot. In urgent operations, the bone may not be put back so that the brain can swell.\n📌 Important: the size of the hole is like the palm of an adult."
  }
 },
 {
"name": "Hematoma evacuation",
"description": {
"professional": "Step-by-step removal of clots: for epidural - detachment from the dura mater with a raspatory, for subdural - irrigation and aspiration, for intracerebral - microsurgical technique with bipolar coagulation. Control of the source of bleeding: clipping of meningeal vessels, coagulation of parenchymal arteries.\nInstruments:\n- Aspirator with adjustable pressure (factory 200-300 mmHg)\n- Bipolar forceps (Malis, 20 W)\n- Microsurgical clips (Yasargil, 5 mm)\nTechnique:\n1. Epidural: coagulation of the middle meningeal artery at the foramen spinosum.\n2. Subdural: lavage of the cavity with warm saline until the water is clear.\n3. Intracerebral: removal along the border with the edematous zone (without affecting the «penumbra»).\nLogistics:\n- The volume of removed blood is measured for replenishment.\nNuance: In case of organized subdural hematoma - excision of the capsule.",
"normal": "The blood clot is removed with a special suction. The bleeding vessel is pressed or «glued». In case of intracerebral hemorrhages, they work like jewelers - under a microscope.\n📌 Fact: old hematomas (2-3 weeks) become dense, like rubber - they are cut out in pieces."
  }
 },
 {
"name": "Hemostasis and decompression",
"description": {
"professional": "Thorough hemostasis: Surgicel tamponade, bone wax for bleeding from diploic veins, fibrin glue (Tisseel) for parenchymal bleeding. In case of severe edema - durotomy with plastic surgery with autocartilage/artificial membrane. Drainage of the subdural space (Redon 10 Fr drainage).\nInstruments:\n- Hemostatic sponges (Surgicel, Floseal)\n- Drainage system (Jackson-Pratt)\n- Dural patches (DuraGen)\nTechnique:\n1. Hemostasis control when blood pressure rises to 140 mm Hg.\n2. Checking brain pulsation after hematoma removal.\n3. If necessary - resection of non-viable brain tissue.\nLogistics:\n- Drainage is connected to a system with low negative pressure (50-70 mm Hg).\nNuance: In case of malignant edema - leaving a bone flap (decompressive hemicraniectomy).",
"normal": "Every drop of blood is stopped with special sponges. If the brain is very swollen - the membrane is expanded with a «patch».\n📌 Important: after removing the clot, the brain should start pulsating - this is a sign of success." 
  }
 },
 {
"name": "Completion of the operation",
"description": {
"professional": "In osteoplastic trepanation - return of the bone flap with fixation with titanium plates. In decompressive - suturing of the dura mater without tension, suturing of the temporal muscle to the aponeurosis. Layered suturing of the wound: galea (Vicryl 0), subcutaneous tissue (Vicryl 3-0), skin (stapler/monofilament).\nInstruments:\n- Titanium microplates (1.5 mm)\n- Stapling device (for skin)\n- Castroviejo needle holder\nPostoperative protocol:\n1. CT control after 2 hours.\n2. Maintaining SBP 120-140 mm Hg.\n3. Prevention of seizures (levetiracetam).\nComplications:\n- Hematoma recurrence (5-15%).\n- Posttraumatic hydrocephalus (10%).\n- Epilepsy (20-30% with intracerebral hematomas).",
"normal": "The bone is returned to its place (if possible) and fixed with titanium plates. Neat stitches are applied to the skin. After 2 hours, a repeat CT scan will show whether new blood has accumulated.\n📌 Good news: 70% of patients return to normal life after timely surgery!"
    }
   }
  ]
 },
{
"keys": [
"artificial valve",
"valve replacement",
"aortic valve",
"mitral valve",
"cardiac surgery",
"valve replacement"
],
"name": "Implantation of an artificial valve (aortic/mitral)",
"modes": {
"professional": "Cardiac surgical replacement of a damaged heart valve with a mechanical or biological prosthesis. Access through sternotomy, connection of the ICC, excision of the native valve, fixation of the prosthesis, disconnection of the ICC with restoration of cardiac activity. Control of anticoagulation and prevention of embolism are critical.",
"normal": "Surgery to replace a «broken» heart valve with an artificial one. It is done through an incision in the sternum, connected to a heart-lung machine. After installing the valve, the heart is restarted. The patient lives with it for decades!" 
},
"steps": [
{
"name": "Anesthesia and access",
"description": {
"professional": "General anesthesia: induction (propofol + fentanyl), muscle relaxants (rocuronium), intubation. Installation of invasive monitoring (arterial line, CVC, TEE). Median sternotomy: incision from the jugular fossa to the xiphoid process, dissection of the sternum with an oscillating saw. Bone wax hemostasis.\nInstruments:\n- Oscillating saw (blade thickness 0.3 mm)\n- Sternum retractor (Finochietto)\n- EchoCG sensor (for valve monitoring)\nTechnique:\n1. Incision of the skin and subcutaneous tissue with an electrocoagulator.\n2. The sternum is sawed strictly along the midline, avoiding pleural cavities.\nLogistics:\n- Blood is aspirated into the Cell Saver system for reinfusion.\nNuance: For repeat surgeries, a cutter is used instead of a saw (risk of heart damage).",
"normal": "The patient is given general anesthesia, a breathing tube is inserted. The sternum is cut in the center - it's like «opening the door» to the heart.\n📌 An interesting point: the bone is then fastened with titanium staples - they remain forever!"
  }
 },
 {
"name": "Connection to the artificial blood vessel",
"description": {
"professional": "Cannulation of the aorta and right atrium. Heparin administration (300-400 U/kg), ACT >480 sec. Connection to the artificial blood vessel (ABV). Cardioplegic solution (cold Custodiol or blood with potassium) to stop the heart.\nInstruments:\n- Aortic cannula 20-22 Fr\n- Double-lumen venous catheter 32 Fr\n- Cardioplegic system (Del Nido)\nTechnique:\n1. The aorta is cannulated above the sinuses of Valsalva.\n2. Venous drainage is through the right atrium.\n3. Cardioplegia is introduced into the aortic root (antegrade) or coronary sinus (retrograde).\nLogistics:\n- Blood temperature control (28-32°C).\nNuance: In case of aortic calcification — axillary artery cannulation.",
"normal": "The heart is connected to an «artificial heart» (ICC device), which will pump blood instead of it. The organ itself is stopped with a cold solution — as if «put to sleep» for the duration of the operation.\n📌 Important: such an operation cannot be performed without ICC!"
}
},
{
"name": "Valve excision",
"description": {
"professional": "Aortic/left atrium incision (for mitral valve). Excision of native valve leaflets, decalcification of the fibrous ring. Revision of subvalvular structures (chords, papillary muscles). Collection of material for histology.\nInstruments:\n- Mezzenbaum scissors (for aorta)\n- Decorticator (for calcium)\n- Pulse irrigator (saline + heparin)\nTechnique:\n1. Aortic access: transverse incision 1 cm above the commissures.\n2. Mitral access: through the interatrial septum or left atrium.\n3. Calcium is removed sharply, avoiding perforation.\nLogistics:\n- Removed tissues sent for histology (to rule out endocarditis).\nNuance: In case of mitral stenosis, revision of the chords is mandatory.",
"normal": "The Surgeon opens the aorta or atrium, cuts out the old valve and cleans the area from calcium (like «scraping off scale»).\n📌 Hard fact: calcium makes the valve stony - it must be removed completely!"
  }
 },
 {
"name": "Implantation of the prosthesis",
"description": {
"professional": "Fixation of an artificial valve (mechanical/biological) with sutures (Ethibond 2-0) or rapid-deployment system. For mechanical - mandatory anticoagulation (INR 2.5-3.5). Checking the mobility of the leaflets, tightness.\nInstruments:\n- Prosthesis (e.g. Carpentier-Edwards or On-X)\n- Needle holder (for circular suture)\n- Leaflet tester (for mechanical valves)\nTechnique:\n1. 12-20 separate sutures with gaskets (pledgets) are applied.\n2. The prosthesis is «put» in place, the knots are tightened.\n3. Leak test - introduction of saline solution into the left ventricle.\nLogistics:\n- The valve size is determined by the template (sizer).\nNuance: If the aortic ring is small, plastic surgery (expansion) is possible.",
"normal": "A new valve (metal or animal tissue) is sewn with threads that do not dissolve. The mechanical one has clicks, the biological one lasts 10-15 years.\n📌 Interesting point: the surgeon checks the valve by pouring water - like a plumber!"
  }
 },
 {
"name": "Completion",
"description": {
"professional": "Aortic/atrial closure (Prolene 4-0). Decannulation of the ICC, administration of protamine (1:1 to heparin). Starting the heart with defibrillation (10-20 J) or adrenaline. Placement of drains (mediastinal + pericardial). Stitching the sternum with wire (6-8 staples).\nInstruments:\n- Defibrillator (internal electrodes)\n- Blake drain 28 Fr\n- Bone staples (titanium)\nTechnique:\n1. EchoCG control for regurgitation/stenosis.\n2. The sternum is fixed with double-twisted wire.\n3. The subcutaneous tissue is sutured in layers.\nLogistics:\n- Check for bleeding before closure.\nPostoperative protocol:\n1. Mechanical ventilation for 2-6 hours.\n2. Anticoagulants (warfarin for mechanical valves).\n3. EchoCG before discharge.\nComplications:\n- Bleeding (5%).\n- Conduction block (requires pacemaker).\n- Endocarditis (1%).",
"normal": "The heart is started with a shock or medications. The sternum is secured with wire, drains are left for 1-2 days.\n📌 Good news: modern valves last 20+ years, and patients live a full life!"
    }
   }
  ]
 },
{
"keys": [
"aortic aneurysm",
"aortic replacement",
"aortic stenting",
"aortic rupture",
"vascular surgery",
"open aortic surgery"
],
"name": "Surgery for aortic aneurysm",
"modes": {
"professional": "Surgical removal of aortic aneurysm with replacement of the affected area with a synthetic prosthesis or endovascular stent graft. Access depends on the location (laparotomy/thoracotomy), control of the proximal and distal edges of the aneurysm, reimplantation of aortic branches is mandatory. Control of spinal cord and abdominal organ ischemia is critical.",
"normal": "An operation that saves from a «bomb» in the abdomen or chest - an aneurysm (a dangerous widening of the aorta). The surgeon either opens the abdomen/chest to replace the damaged area with an artificial tube, or inserts a stent through a puncture in the thigh. After this, the aorta becomes strong again and does not threaten to rupture."
},
"steps": [
{
"name": "Anesthesia and access",
"description": {
"professional": "General anesthesia: intubation anesthesia (propofol + fentanyl + muscle relaxants), invasive monitoring (arterial line, CVP, TEE). The patient is positioned on the back (for abdominal aneurysm) or on the side (for thoracoabdominal). Access: midline laparotomy (for infrarenal aneurysm) or left thoracotomy (for thoracic region).\nInstruments:\n- Electrocoagulator (Valleylab, 40 W)\n- Retractor (Omni-Tract for laparotomy)\n- Scalpel #20\nTechnique:\n1. For abdominal access — incision from the xiphoid process to the pubis.\n2. For thoracotomy — incision along the 6th intercostal space with dissection of the diaphragm.\nLogistics:\n- Preparation of the Cell Saver system for blood reinfusion.\nNote: If the aneurysm ruptures — temporary clamping of the aorta until the abdominal cavity is opened.",
"normal": "The patient is sedated and connected to devices that monitor blood pressure and heart rate. The incision is made either in the center of the abdomen (if the aneurysm is in the abdominal aorta) or between the ribs (if in the thoracic aorta). It's like «opening the hood» to access the body's main «pipe».\n📌 Important: during an emergency operation (if the aneurysm is already rupturing), the surgeon can clamp the aorta before the incision - to stop catastrophic bleeding."
  }
 },
 {
"name": "Aortic mobilization and clamping",
"description": {
"professional": "Isolation of the aorta proximal and distal to the aneurysm. Clamping with DeBakey or Satinsky clamps. In case of infrarenal aneurysm - control of the renal arteries. Administration of heparin (5000 IU intravenously). In case of thoracoabdominal aneurysm - reimplantation of the intercostal arteries for prevention of spinal cord ischemia.\nInstruments:\n- Vascular clamps (DeBakey, Fogarty)\n- Penfield dissector No. 4\n- Ultrasound Doppler (to assess blood flow)\nTechnique:\n1. Proximal clamping - below the celiac trunk (for infrarenal aneurysm).\n2. Distal - above the bifurcation (for a tubular prosthesis) or on the iliac arteries (for a bifurcation one).\nLogistics:\n- The clamping time should not exceed 30 minutes (risk of kidney/intestinal ischemia).\nNuance: In case of aortic calcification - careful application of clamps to avoid plaque fragmentation.",
"normal": "The surgeon finds healthy areas of the aorta above and below the aneurysm and applies «clamps» to them - like shutting off water before repairing a pipe. If the aneurysm is close to the kidneys, their arteries are also carefully protected.\n📌 Interesting point: during surgery on the thoracic aorta, small arteries that feed the spinal cord can be sewn up to avoid paralysis!"
  }
 },
 {
"name": "Aneurysm resection and prosthetic replacement",
"description": {
"professional": "Longitudinal aortotomy, removal of thrombotic masses and calcifications. Resection of the aneurysm wall while preserving the posterior semicircle (with open technique). Anastomosis: proximal (end-to-end) and distal (end-to-end or bifurcation prosthesis). Suture material - prolene 3-0 or 4-0.\nInstruments:\n- Vascular prosthesis (Dacron, diameter 16-22 mm)\n- Castroviejo needle holder\n- Suture pads (pledgets) to strengthen anastomoses\nTechnique:\n1. The prosthesis is sutured with a continuous suture to the proximal edge of the aorta.\n2. The distal anastomosis is formed after decompression (removal of air/thrombi).\n3. With a bifurcation prosthesis, it is sequentially sutured to the iliac arteries.\nLogistics:\n- Checking the tightness of the anastomoses with an injection of heparinized saline.\nNuance: With endovascular stenting (EVAR) - access through the femoral arteries and installation of the stent graft under X-ray control.",
"normal": "The aneurysm is opened, blood clots and calcium are removed (like «cleaning a blockage»). An artificial «tube» made of durable material (Dacron) is sewn in its place. If the aneurysm is large, a «tee» with branches for the iliac arteries is installed.\n📌 A visual moment: the prosthesis is sewn on so tightly that the surgeon checks the stitches by pouring saline solution in — like looking for a leak in a bicycle tube!"
  }
 },
 {
"name": "Reimplantation of branches and restoration of blood flow",
"description": {
"professional": "For thoracoabdominal aneurysms — reimplantation of the celiac trunk, superior mesenteric and renal arteries into the prosthesis (the «island» technique or separate anastomoses). Decompression of the aorta before removing the clamps. Control of distal blood flow with Doppler.\nInstruments:\n- Bulb aspirator (to remove air emboli)\n- Vascular clips (Hem-o-lok)\n- Thermography (to assess organ perfusion)\nTechnique:\n1. Sequential opening of clamps: first proximal, then distal.\n2. In EVAR — control of the stent graft position on angiography.\nLogistics:\n- Renal ischemia time — no more than 40 minutes.\nNuance: In case of stent «leakage» (endoleak) — installation of additional components or conversion to open surgery.",
"normal": "If the aneurysm has affected the arteries that feed the intestines or kidneys, they are «transplanted» into a new prosthesis. Blood flow is restored in stages: first the «upper» clamp is opened, then the «lower» ones.\n📌 Life hack: surgeons use ultrasound to make sure blood is flowing to all organs - like a plumber checks the water pressure!"
  }
 },
 {
"name": "Completion and control",
"description": {
"professional": "Hemostasis (Surgicel, TachoSil), drainage (Jackson-Pratt drainage). Layer-by-layer suturing of the laparotomy/thoracotomy wound. For EVAR - removal of introducers and suturing of femoral approaches. Intraoperative angiography or ultrasound to exclude endoleaks.\nInstruments:\n- 28 Fr drainage\n- Suture material (PDS for aponeurosis, Monocryl for skin)\n- Angiograph (for EVAR)\nPostoperative protocol:\n1. CT angiography after 24 hours.\n2. Monitoring of diuresis, intestinal ischemia markers (lactate).\n3. Lifelong observation (in case of EVAR — annual CT).\nComplications:\n- Spinal cord ischemia (paralysis — 5-10% in thoracoabdominal aneurysms).\n- Prosthesis thrombosis (1-3%).\n- Endolitis (stent leakage — 15-20%).",
"normal": "After checking the sutures for leaks, the wound is sutured, leaving drains. If the surgery was endovascular (through punctures), only a small suture will remain on the thigh.\n📌 Important: even after a successful surgery, the patient regularly undergoes CT scans to make sure that the aneurysm is not «leaking». Modern stents require lifelong monitoring!"
    }
   }
  ]
 },
{
"keys": [
"pericardiectomy",
"constrictive pericarditis",
"cardiac tamponade",
"heart surgery",
"pericardial removal",
"cardiac decompression"
],
"name": "Pericardiectomy",
"modes": {
"professional": "Radical pericardial removal in constrictive pericarditis or recurrent effusions. Access: median sternotomy or left thoracotomy. Steps: cardiac mobilization, layer-by-layer excision of the pericardium while preserving the phrenic nerves, hemostasis control. Control of right ventricular function after decompression is critical.",
"normal": "An operation to free the heart from its «shell» - a thickened or inflamed sac around the heart (pericardium). The surgeon carefully removes the dense membrane from the heart that prevents it from beating normally. After this, the heart can again freely fill with blood and function fully."
},
"steps": [
{
"name": "Anesthesia and access",
"description": {
"professional": "General anesthesia: intubation (double-lumen tube during thoracotomy), invasive monitoring (arterial line, central venous pressure, transesophageal echocardiography). Position: supine (for sternotomy) or on the right side (for thoracotomy). Access: median sternotomy (more common) or left thoracotomy (5th intercostal space).\nInstruments:\n- Oscillating saw (for sternotomy)\n- Retractor (Finochietto for thoracotomy)\n- Electrocoagulator (Valleylab, 30 W)\nTechnique:\n1. For sternotomy - incision from the jugular fossa to the xiphoid process.\n2. In thoracotomy - an incision from the parasternal line to the mid-axillary line.\nLogistics:\n- Preparing the Cell Saver system for blood reinfusion.\nNuance: In previous surgeries - using an ultrasonic scalpel (Harmonic).",
"normal": "The patient is sedated and connected to a ventilator. The surgeon makes an incision either in the center of the sternum (as in bypass surgery) or between the ribs on the left. This is like opening a «door» to the heart to get to its dense membrane.\n📌 Important: if the patient has had previous heart surgeries, the surgeon acts especially carefully - like a sapper defusing a mine."
  }
 },
 {
"name": "Opening the pericardium and mobilizing the heart",
"description": {
"professional": "Identification and preservation of the phrenic nerves. Longitudinal opening of the pericardium in the avascular zone. Gradual separation of the pericardium from the epicardium: first on the anterior surface, then laterally. In case of constrictive pericarditis - excision of calcified areas.\nInstruments:\n- Metzenbaum scissors\n- Penfield dissector #4\n- Ultrasonic scissors (Harmonic)\nTechnique:\n1. Initial pericardial incision - 2 cm above the diaphragm.\n2. Mobilization from the left ventricle to the right (to avoid overloading the RV).\n3. In case of dense adhesions - sharp dissection method.\nLogistics:\n- Marking the phrenic nerve with a silicone loop.\nNuance: In case of damage to the coronary arteries - immediate suturing with 6-0 Prolene.",
"normal": "The surgeon finds and carefully moves aside the nerve that controls the diaphragm (so that the patient can breathe normally after the surgery). Then he begins to remove the pericardium from the heart - like peeling an orange, peeling it slice by slice.\n📌 Interesting point: they always start from the left side - if they start from the right, the suddenly freed heart may not cope with the load! "
  }
 },
 {
"name": "Radical removal of the pericardium",
"description": {
"professional": "Excision of the pericardium: anteriorly - from the aortic root to the diaphragm, posteriorly - to the pulmonary veins, laterally - to the phrenic nerves. In constrictive pericarditis - complete removal (including the diaphragmatic surface). Hemostasis with bipolar (15 W).\nInstruments:\n- DeBakey forceps\n- Bipolar coagulation (Malis)\n- Vascular clips (Hem-o-lok)\nTechnique:\n1. Sequential separation of the pericardium by blunt and sharp means.\n2. Special attention is paid to the areas of the atrial appendages and vena cava.\n3. Myocardial bleeding control - Surgicel tamponade.\nLogistics:\n- The removed pericardium is sent for histology.\nNuance: During tamponade - preliminary puncture of the pericardium to stabilize hemodynamics.",
"normal": "The surgeon removes the pericardium from all sides of the heart - from the front, back and sides, leaving only small areas near important vessels. This is similar to removing the wrapper from a ball that has dried and prevents it from inflating.\n📌 Important: when the last section is removed, the heart immediately begins to beat more freely - doctors literally see how it breathes a sigh of relief."
  }
 },
 {
"name": "Hemostasis control and drainage",
"description": {
"professional": "Thorough hemostasis of the pericardial bed (Surgicel, TachoSil). Installation of drains: into the pericardial cavity (24 Fr) and pleural cavity (during thoracotomy). Checking the integrity of the phrenic nerves. Leak test with increased pressure in the breathing circuit.\nInstruments:\n- Blake drain\n- Hemostatic sponges (Floseal)\n- Nerve stimulator (to check the diaphragm)\nTechnique:\n1. Washing the cavity with warm saline.\n2. Checking the diaphragm excursion during nerve stimulation.\n3. The drainage is fixed to the skin with a separate suture.\nLogistics:\n- Counting napkins and instruments before closing.\nNuance: If the pleura is damaged, additional drainage is installed.",
"normal": "After removing the pericardium, the surgeon carefully checks for bleeding areas on the heart (using special «patches» made of absorbable cellulose). Then he places drainage tubes - one will drain fluid from the pericardium, the other (if access was through the chest) - from the pleural cavity.\n📌 A visual moment: to check if the diaphragm nerve is damaged, the surgeon can lightly «tickle» it with an electrical stimulator - the diaphragm twitches, as if from hiccups!" 
  }
 },
 {
"name": "Wound closure and postoperative care",
"description": {
"professional": "Layer-by-layer suturing: sternum - with steel wires (for sternotomy), muscles - Vicryl 0, subcutaneous tissue - Vicryl 2-0, skin - with 3-0 monofilament. For thoracotomy - suturing of intercostal muscles leaving drainage.\nInstruments:\n- Bone nippers (for sternum modeling)\n- Wire (5-6 staples for sternotomy)\n- Suture material (PDS, Monocryl)\nPostoperative protocol:\n1. Mechanical ventilation for 2-4 hours (with stable hemodynamics).\n2. Monitoring of central venous pressure and diuresis (risk of acute right ventricular failure).\n3. EchoCG after 24 hours to assess function heart.\nComplications:\n- Acute heart failure (15-20%).\n- Bleeding (3-5%).\n- «Free heart» syndrome (hyperdynamic function - rare).",
"normal": "The sternum is fastened with titanium staples (which remain forever), the muscles and skin are sutured with absorbable threads. After the operation, the patient is left on a ventilator for several hours until the heart adapts to the new state.\n📌 Amazing fact: sometimes the heart, freed from the squeezing «shell», begins to work too actively - this is called «free heart syndrome», and doctors are prepared for such a development of events."
    }
   }
  ]
 },
{
"keys": [
"ASD",
"atrial septal defect",
"congenital heart defect",
"ASD closure",
"cardiac surgery",
"endovascular closure of ASD"
],
"name": "Atrial septal defect (ASD) closure",
"modes": {
"professional": "Surgical or endovascular correction of a congenital defect in the septum between the atria. Options: open surgery on a stopped heart with patch plasty (auto- or synthetic) or endovascular installation of an occluder (Amplatzer, Gore Cardioform). Control of the defect edges and prevention of embolism are critical.",
"normal": "Surgery to «patch a hole» in the wall between the upper chambers of the heart. In children and adults, the defect can be closed either through an incision in the chest or through a puncture in the thigh - without opening the heart! After this, the blood stops mixing, and the heart works like new."
},
"steps": [
{
"name": "Access and preparation",
"description": {
"professional": "**Open method**: Median sternotomy, connection to the ICC. **Endovascular method**: access through the femoral vein, passing a catheter into the right atrium. Intraoperative TEE to measure the size of the ASD and assess the edges.\nInstruments:\n- Sternotome (for open access)\n- Introducer 10-12 Fr (for endovascular)\n- TEE sensor\nTechnique:\n1. With open access - cannulation of the aorta and vena cava.\n2. With endovascular - angiography to visualize the defect.\nLogistics:\n- For the endovascular method: selection of an occluder 2-4 mm larger than the diameter ASD.\nNuance: If the margins are insufficient (<5 mm) — only open surgery.",
"normal": "**If the surgery is open**: The surgeon cuts the sternum and connects the patient to the artificial blood circulation machine (ACM). **If the method is endovascular**: A thin tube (catheter) is inserted through a puncture in the groin and carried to the heart.\n📌 Interesting: the size of the «hole» is measured with ultrasound right during the surgery — like a tailor takes measurements!"
  }
 },
 {
"name": "Visualization and assessment of the defect",
"description": {
"professional": "In case of open surgery: opening the right atrium, revision of the ASD (localization, size, presence of the inferior vena cava valve). In case of endovascular surgery: control of the position of the conductor through the defect into the left atrium (the «loop» technique).\nInstruments:\n- Cardioscope (for open access)\n- Angiograph (for endovascular)\n- Measuring balloons (for sizing)\nTechnique:\n1. In case of secundum ASD - assessment of the distance to the aorta, pulmonary veins.\n2. In case of sinus venosus type - planning of reimplantation of the pulmonary veins.\nLogistics:\n- Stock of occluders of different sizes (+ reserve method).\nNuance: In case of multiple defects - combined strategy.",
"normal": "The surgeon examines the «hole»: if it is small (up to 30 mm) and located in the center, an occluder can be placed through a catheter. If the edges are thin or the defect is of a complex shape, an open operation with a patch will be required.\n📌 Important: sometimes there is more than one «hole» - then they close everything, like patches!"
  }
 },
 {
"name": "Defect closure",
"description": {
"professional": "**Open method**: Excision of the ASD edges, suturing (for defects <10 mm) or pericardial/PTFE patch plasty (5-0 Prolene suture). **Endovascular**: delivery of the occluder through a catheter, sequential opening of the discs in the left and right atria.\nInstruments:\n- Amplatzer Septal occluder\n- Castroviejo needle holder (for open)\n- Delivery Sheath\nTechnique:\n1. For open surgery — continuous suture with pledgets.\n2. In case of endovascular — control of the occluder position on echocardiography before release.\nLogistics:\n- Stability test: slight twitching of the occluder with a catheter.\nNuance: In case of primary ASD (AV canal) — only open plastic surgery.",
"normal": "**Open method**: The surgeon stitches up the hole with a strong thread (like darning socks) or sews on a patch of pericardial tissue. **Endovascular**: an «umbrella» is inserted through the catheter — it opens on both sides of the septum, tightly sealing the defect.\n📌 Visual moment: the occluder resembles two mesh «plates» that press the hole from both sides!"
  }
 },
 {
"name": "Control and completion",
"description": {
"professional": "Tightness check: in case of open surgery — injection of saline into the left atrium, in case of endovascular surgery — transesophageal echocardiography with contrast. Removal of air from the heart cavities. Drainage (with open access). Suturing wounds.\nInstruments:\n- Contrast agent (for echocardiography)\n- Needle for air aspiration\n- Redon 16 Fr drainage\nTechnique:\n1. In case of open surgery — suturing the atrium with a double-row suture.\n2. In endovascular surgery — removal of the delivery system.\nLogistics:\n- X-ray control of the occluder position before completion.\nNuance: Additional correction in case of residual shunt.",
"normal": "The surgeon checks for leaks: in open surgery, he pours saline into the heart (like looking for a hole in a bicycle tube), in endovascular surgery, he does an ultrasound with contrast.\n📌 Important: if the «umbrella» is not positioned correctly, it can be adjusted or even replaced!"
  }
 },
 {
"name": "Postoperative management",
"description": {
"professional": "**Open surgery**: mechanical ventilation for 2-4 hours, drainage monitoring, echocardiography after 24 hours. **Endovascular**: activation after 6 hours, echocardiography before discharge. Antiplatelet agents (aspirin 3-6 months).\nPostoperative protocol:\n1. In case of open surgery — corset for 1 month (for sternum fusion).\n2. ECG monitoring (risk of blockade in case of marginal defect).\n3. Repeated echocardiography after 1, 6 and 12 months.\nComplications:\n- Residual shunt (5% in case of endovascular method).\n- Occluder embolization (0.5%).\n- Atrial fibrillation (10-15% in adults).",
"normal": "After open surgery, the patient spends 1-2 days in intensive care, after endovascular surgery — gets up in the evening! «Thinning» tablets are prescribed for 6 months (to prevent blood clots from forming on the occluder).\n📌 Good news: children after such an operation run around a week later as if nothing had happened!"
    }
   }
  ]
 },
{
"keys": [
"pacemaker",
"pacemaker implantation",
"pacemaker",
"cardiac surgery"
],
"name": "Pacemaker implantation",
"modes": {
"professional": "Surgical installation of a pacemaker (pacemaker) to correct bradyarrhythmia. Stages: access to the subclavian vein, insertion of electrodes into the heart cavity, formation of a subcutaneous bed for the generator, testing of stimulation parameters. Control of the position of the electrodes and the stimulation threshold is critical.",
"normal": "Through a small incision under the collarbone, thin wires are inserted into the heart, and a «battery» is implanted under the skin. It sends impulses if the heart beats abnormally. The operation is almost painless and the patient can go home the next day."
},
"steps": [
{
"name": "Preparation and anesthesia",
"description": {
"professional": "Treatment of the surgical field (left/right subclavian region) with chlorhexidine 2%. Local anesthesia: infiltration of lidocaine 1% with adrenaline (1:100,000). ECG monitoring (leads II and V1), non-invasive blood pressure, pulse oximetry. Antibiotic prophylaxis (cefazolin 1 g IV 30 min before incision).\\nInstruments:\\n- Syringe 10 ml with needle 22G (lidocaine)\\n- Antiseptic wipes\\n- ECG electrodes\\nTechnique:\\n1. Infiltration of the skin and subcutaneous tissue along the line of the future incision.\\n2. Monitoring the heart rate and rhythm on the monitor.\\nLogistics:\\n- Used needles - in a container for sharp objects.\\nNuance: In case of allergy to lidocaine - articaine 4%.",
"normal": "The patient is placed on his back, the skin below the collarbone is treated with «iodine». Several injections with anesthetic are given - the area will go numb. Sensors are glued to the chest to monitor the heartbeat.\n📌 Interesting point: if the patient is worried, they can give a sedative, but more often everything goes without it - it will not hurt!"
  }
 },
 {
"name": "Puncture of the subclavian vein",
"description": {
"professional": "Puncture of the subclavian vein with an 18G needle using the Seldinger method (angle 30° to the skin, direction to the sternoclavicular joint). Checking the aspiration of venous blood. Insertion of a 0.035 inch guidewire under fluoroscopic control. Tissue expansion with a 7 Fr. dilator. Installing the introducer.\\nInstruments:\\n- Vein puncture needle (18G, 70 mm long)\\n- 0.035 J-type guidewire\\n- Dilator with 7 Fr introducer\\n- Fluoroscopic apparatus (C-arm)\\nTechnique:\\n1. Vein puncture 1 cm below the collarbone.\\n2. The guidewire is advanced to the superior vena cava (ECG or X-ray control).\\nLogistics:\\n- Checking the free movement of the guidewire before dilation.\\nNuance: If unsuccessful, alternative access is through the axillary vein.",
"normal": "Through a tiny puncture under the collarbone, the doctor inserts a thin «wire» into the vein and advances it toward the heart. Everything is controlled by X-ray in real time.\n📌 Interesting point: the patient does not feel how the conductor moves through the vein - veins do not have pain receptors!" 
  }
 },
 {
"name": "Inserting electrodes",
"description": {
"professional": "Inserting stimulating electrodes through the introducer: ventricular (into the right ventricle) and atrial (into the right atrium). Fixation with an active (screw) or passive (with «antennae») mechanism. Fluoroscopic control of position (ventricular electrode - at the apex, atrial - in the atrial appendage).\\nInstruments:\\n- Ventricular electrode (e.g. Medtronic 4076)\\n- Atrial electrode (e.g. Medtronic 4574)\\n- Stylet for shaping the electrode\\n- Stimulation threshold meter\\nTechnique:\\n1. The ventricular electrode is inserted through the tricuspid valve.\\n2. The atrial electrode is bent in the shape of «J».\\nLogistics:\\n- Testing the electrodes before fixation.\\nNuance: In case of atrial fibrillation - only the ventricular electrode (VVI mode).",
"normal": "Through a tube in a vein, the doctor passes thin wires into the heart: one into the upper chamber (atrium), the other into the lower (ventricle). The tips of the electrodes «catch» the wall of the heart.\n📌 Interesting point: the wires are flexible, like spaghetti, but their position is checked with an X-ray - so that everything is perfect!"
  }
 },
 {
"name": "Parameter testing",
"description": {
"professional": "Measuring the stimulation threshold (voltage at which the heart responds with contraction), impedance (resistance) and sensitivity (registration of its own rhythm). Optimal parameters: threshold <1.0 V, impedance 300-1000 Ohm, sensitivity >2.0 mV. Correction of the electrode position if the values are unsatisfactory.\\nTools:\\n- ECG analyzer (e.g. Medtronic 2290)\\n- Temporary external stimulator\\n- Testing cables\\nTechnique:\\n1. Stimulation with a gradual decrease in voltage until capture is lost.\\n2. Sensitivity testing in the «demand» mode.\\nLogistics:\\n- Recording the parameters in the protocol.\\nNuance: At a high threshold — replacing the electrode or choosing a new fixation location.",
"normal": "The doctor turns on the stimulator and checks how the heart responds to weak impulses. The screen shows that the heart «listens» to the device.\n📌 Interesting point: if the parameters are not ideal, the electrode will be adjusted a little - it's like adjusting an antenna for a clear signal!"
  }
 },
 {
"name": "Formation of the bed and fixation of the generator",
"description": {
"professional": "Formation of a subcutaneous pocket for the generator between the pectoralis major and deltoid muscles. Hemostasis by bipolar coagulation. Fixation of electrodes to the generator (screw connection). Placing the generator in the pocket, layer-by-layer suturing of the wound.\\nInstruments:\\n- Pocket clamp (metal retractor)\\n- Bipolar coagulator (15 W)\\n- Suture material (Vicryl 2-0 - fascia, Monocryl 4-0 - skin)\\nTechnique:\\n1. The pocket is created bluntly (with a clamp or finger).\\n2. The generator is fixed to the muscle with a suture (Prolene 2-0).\\nLogistics:\\n- Check for the absence of bending of the electrodes.\\nNuance: With thin skin - placement of the generator under the muscle.",
"normal": "A «pocket» is formed under the skin below the collarbone, where the stimulator itself is placed - a flat box the size of a matchbox. The wires are connected to it, like cords to a TV. The incision is stitched up - the seam is almost invisible.\n📌 Interesting point: you can feel the generator with your hand, but it does not even interfere with sleeping on this side!"
  }
 },
 {
"name": "Completion and control",
"description": {
"professional": "Fluoroscopic control of the position of the electrodes and the generator. Application of an aseptic dressing. Activation of the pacemaker in DDD mode (or VVI in AF). Prescription of antibiotics (cefazolin 1 g ×2 days), pain relief (paracetamol 500 mg).\\nInstruments:\\n- Fluoroscopy in two projections (AP + lateral)\\n- Pacemaker programmer (for setting parameters)\\n- Sensor for checking the generator operation\\nPostoperative protocol:\\n1. X-ray control after 24 hours.\\n2. Limitation of arm movements for 7 days.\\n3. Sutures are removed on the 10th day.\\nComplications:\\n- Hematoma of the bed (3-5%).\\n- Dislocation electrode (1-2%).\\n- Infection (0.5-1%).",
"normal": "They do a final x-ray to make sure everything is in place. They put a bandage on and give you a reminder: don't raise your arm for a week, avoid magnets. In a month, the pacemaker is checked.\n📌 Good news: modern pacemakers work for 8-10 years, and replacement is even easier than the first installation!"
    }
   }
  ]
 },
{
"keys": [
"heart transplant",
"heart transplant",
"donor heart",
"orthotopic transplant",
"cardiac surgery"
],
"name": "Heart transplant",
"modes": {
"professional": "Replacement of the recipient's damaged heart with a donor organ. Stages: donor heart collection (conditioning, cardioplegia, excision), transportation in preservative solution, recipient preparation (sternotomy, ICC connection), orthotopic implantation (biatrial or bicaval anastomosis), heart start-up. Critical: ischemia time (<4 h), ABO compatibility, HLA typing, rejection prevention.",
"normal": "The most complex «heart repair»: the diseased organ is replaced with a healthy one from a donor. The operation lasts 6-8 hours, requires perfect coordination between surgeons, anesthesiologists and transplantologists. A new heart begins to beat in the patient's chest, giving him a second chance at life."
},
"steps": [
{
"name": "Donor heart harvesting",
"description": {
"professional": "Donor stage: After confirmation of donor brain death, hemodynamic support is provided (norepinephrine, vasopressin). Laparotomy/sternotomy. Heparin administration (300 U/kg). Canification of the aorta and pulmonary artery. Infusion of cardioplegic solution (Custodiol HTK or Stanford) at t=4°C. Cardiac excision: intersection of the superior/inferior vena cava, aorta, pulmonary veins. Immersion of the organ in a sterile container with preservative solution and ice.\\nInstruments:\\n- Cardioplegic solution (1000 ml)\\n- 14 Fr catheters (aorta, PA)\\n- Metzenbaum scissors for cutting vessels\\n- Thermally insulated container (with t-sensor)\\nTechnique:\\n1. The aorta is clamped, cardioplegia is introduced into the aortic root.\\n2. The heart is removed with the «cuff» from the atria and great vessels.\\n3. Time from circulatory arrest to extraction — <30 min.\\nLogistics:\\n- The container is marked with: blood type, donor weight, collection time.\\nNote: For long-distance transport, a perfusion machine (OCS Heart) is used.",
"normal": "The heart is taken from a donor who has been declared brain dead, but the body is supported by machines. Surgeons inject a special «preservative» into the organ, stop it and carefully extract it. The heart is placed on ice and urgently taken to the recipient's hospital - every minute counts!\n📌 Hard fact: no more than 4 hours for the whole thing, otherwise the organ will die."
  }
 },
 {
"name": "Preparing the recipient",
"description": {
"professional": "Recipient: Median sternotomy. Insertion of catheters into the aorta and vena cava. Connection to the artificial blood circulation (ABG) machine. Maintenance of hypothermia (28–32°C). Removal of the affected heart: transection of the aorta, PA, atria (leaving the posterior walls for anastomoses). Bed hemostasis.\\nInstruments:\\n- Oscillating saw (for the sternum)\\n- Cannulas for ABG (24 Fr — aorta, 32 Fr — vena cavae)\\n- Scalpel No. 20 + Potts scissors\\nTechnique:\\n1. Anastomosis of the superior/inferior vena cavae to the ABG cannulas.\\n2. Resection of the recipient heart, preservation of the atrial appendages.\\n3. Antifibrinolytic therapy (tranexamic acid).\\nLogistics:\\n- Parallel monitoring of the donor heart (telephone communication with the transport team).\\nNuance: In case of pulmonary hypertension - risk of acute right ventricular failure.",
"normal": "While the donor heart is on the way, the patient is prepared: the sternum is cut, connected to the device that replaces the heart and lungs. The diseased heart is carefully cut out, leaving only the «pockets» of the atria - a new one will be sewn to them later.\n📌 Interesting point: the body is cooled to 28°C - this slows down the metabolism and protects the organs."
  }
 },
 {
"name": "Implantation of a donor heart",
"description": {
"professional": "Biatrial method (Shumway): Anastomosis of the donor's left atrium to the recipient's atrial remnant with a continuous suture (Prolene 4-0). Then the right atrium. Anastomosis of the aorta and pulmonary artery. Deaeration through a puncture in the aorta. Gradual disconnection of the ICC.\\nInstruments:\\n- Prolene 4-0 suture material (with atraumatic needle)\\n- Atrium holders (Satinsky)\\n- Irrigator with warm saline\\nTechnique:\\n1. Left atrial anastomosis is the first (most important).\\n2. The aorta is connected end-to-end (check for leaks).\\n3. Starting the heart: defibrillation (10–20 J) or spontaneous rhythm.\\nLogistics:\\n- The ischemia time of the donor heart should be <240 min.\\nNuance: If the sizes do not match, pericardial adaptation or atrial plastic surgery.",
"normal": "The new heart is sewn on «in parts»: first the left atrium, then the right, then the aorta and pulmonary artery. After the last suture, the organ is filled with blood, removing air bubbles. Then comes the moment of truth: the heart is started with an electric shock or it “comes to life” on its own.\n📌 An exciting moment: the first contraction of the donor heart in the new chest - the surgeons freeze, watching the rhythm."
  }
 },
 {
"name": "Completion and start",
"description": {
"professional": "Hemodynamic control: Inotropic support (epinephrine 0.05 mcg / kg / min, milrinone). EchoCG assessment of contractility, exclusion of right ventricular hypertrophy. Installation of temporary epicardial electrodes for stimulation. Mediastinal drainage (2 drains). Sternum suturing with wire (Steel 5).\\nInstruments:\\n- EchoCG sensor (via esophagus)\\n- Pleurovac 28 Fr drains\\n- Bone wax for hemostasis\\nTechnique:\\n1. Gradual reduction of ICC flow with stable BP.\\n2. In case of right ventricular failure — NO inhalation.\\n3. Rejection prevention: methylprednisolone 500 mg IV.\\nLogistics:\\n- Myocardial biopsy after 7 days (rejection assessment).\\nNote: In case of bleeding — protamine sulfate administration (1 mg per 100 U of heparin).",
"normal": "The heart is neglected, but the patient is not yet safe. Doctors adjust the medications so that the organ takes root, install drains to drain fluid, and stitch the sternum with titanium wire.\n📌 Important: the first day is in intensive care, where blood pressure, rhythm, and oxygen levels are checked every 30 minutes."
  }
 },
 {
"name": "Postoperative protocol",
"description": {
"professional": "Days 1–3: mechanical ventilation, monitoring of central venous pressure, diuresis, and troponin. Immunosuppression (tacrolimus, mycophenolate mofetil). Infection prevention (cefepime + fluconazole).\\n7 days: Endomyocardial biopsy (catheter through the jugular vein). Adjustment of immunosuppressant doses.\\n1 month: Assessment of cardiac function (EchoCG, MRI), transition to oral medications.\\nComplications:\\n- Acute rejection (15–20% in the first year).\\n- Infections (cytomegalovirus, fungi).\\n- Coronary artery disease of the donor heart (after 5 years).\\nInstruments:\\n- Endomyocardial biopsy biopsy\\n- Immunosuppressive monitors (tacrolimus blood levels)\\nNuance: Lifelong ban on grapefruit (interacts with tacrolimus).",
"normal": "The first days are in intensive care: the heart «gets used» to the new body, and the patient receives shock doses of anti-rejection drugs. A week later - a biopsy: a tiny piece of the heart is taken through a vein in the neck to check if the body is attacking it.\n📌 Hard and fast rule: always take pills now and avoid grapefruits (they ruin the medicine!)"
    }
   }
  ]
 },
{
"keys": [
"labyrinth surgery",
"MAZE",
"atrial fibrillation",
"radiofrequency ablation",
"cardiac surgery"
],
"name": "Labyrinth surgery (MAZE) for atrial fibrillation",
"modes": {
"professional": "Surgical elimination of atrial fibrillation (AF) by creating linear scar blocks in the myocardium of the atria to interrupt pathological electrical re-entry circuits. Options: classic «cut-suture» (Cox-Maze III) or ablation methods (radiofrequency, cryo-, laser). Stages: access through median sternotomy/thoracoscopy, isolation of pulmonary veins, creation of ablation lines, suturing of the left atrial appendage. Control of impulse conduction and prevention of thromboembolism are critical.",
"normal": "An operation that «draws a maze» on the heart so that chaotic electrical signals during atrial fibrillation can no longer run through the atria. After this, the heart beats evenly again. Often done simultaneously with valve replacement or bypass."
},
"steps": [
{
"name": "Anesthesia and access",
"description": {
"professional": "General anesthesia: induction with propofol (2 mg/kg), fentanyl (5 mcg/kg), muscle relaxant (rocuronium 0.6 mg/kg). Intubation, mechanical ventilation with PEEP 5 cm H2O. Monitoring: invasive BP, TEE, 12-lead ECG. Access: median sternotomy (when combined with other surgeries) or right mini-thoracotomy (for isolated MAZE).\\nInstruments:\\n- Oscillating saw (for the sternum)\\n- 5 mm thoracoscopic ports (for mini-access)\\n- Transesophageal echocardiogram sensor\\nTechnique:\\n1. With sternotomy - cannulation of the aorta and vena cava for ICC.\\n2. With thoracoscopy - one-lung ventilation (collapse of the right lung).\\nLogistics:\\n- ECG electrodes are applied taking into account future ablation lines.\\nNuance: With COPD, the time of one-lung ventilation is minimized.",
"normal": "The patient is sedated, a tube is inserted into the trachea for breathing. If the operation is combined with valve replacement, the sternum is cut; if MAZE is done separately, a small incision is made under the right armpit.\n📌 Interesting point: during the operation, the heart can be stopped and connected to a heart-lung machine (CLM)."
  }
 },
 {
"name": "Pericardial incision and cardioplegia",
"description": {
"professional": "Longitudinal dissection of the pericardium in front of the phrenic nerve. Canification aortic (22 Fr cannula) and vena cava (32 Fr double-lumen cannula). Clamping of the aorta, introduction of crystalloid cardioplegia (4°C) into the aortic root. Myocardial temperature <15°C. Additionally: injection of cardioplegia into the coronary sinus (retrograde).\\nInstruments:\\n- Aortic clamp (Fogarty)\\n- 9 Fr cardioplegic catheter (for the coronary sinus)\\n- Myocardial temperature sensor\\nTechnique:\\n1. Cardioplegia is introduced under a pressure of 200–300 mmHg.\\n2. Ischemia monitoring: ECG in ST-analysis mode.\\nLogistics:\\n- Every 20 minutes — repeat dose of cardioplegia.\\nNuance: In case of left ventricular hypertrophy — add lidocaine to cardioplegia.",
"normal": "The heart is freed from the outer shell (pericardium), connected to the ICC apparatus and an «ice» solution is administered to stop it. This gives the surgeon time for precision work.\n📌 Important: the heart «sleeps» for no more than 90 minutes - otherwise the risk of damage increases."
  }
 },
 {
"name": "Creating a «labyrinth» (ablation lines)",
"description": {
"professional": "Classic MAZE (scissors-suture):\\n- Incisions in the left/right atria according to the Cox-Maze III scheme.\\n- Suturing with a continuous suture (Prolene 4-0) with the creation of electrical barriers.\\nAblative methods:\\n- Radiofrequency (RF, 60–80°C): bipolar clamp (AtriCure) around the pulmonary veins.\\n- Cryoablation (-60°C, 2 min): CryoFlex probe (Medtronic) on the posterior wall of the left atrium.\\nRequired lines:\\n1. Pulmonary vein isolation (circular).\\n2. Line from left appendage to mitral valve.\\n3. Line in right atrium (interatrial septum).\\nInstruments:\\n- Bipolar ablator (eg, AtriCure Gemini)\\n- Cryoprobe (eg, Medtronic CryoConsole)\\n- 4-0 PTFE suture (for appendage isolation)\\nTechnique:\\n1. Ablation is performed until local biopotential drops to <0.1 mV.\\n2. Block test: atrial stimulation to confirm isolation.\\nLogistics:\\n- Ablation map (documentation of all lines).\\nNuance: In case of persistent AF — additional ablation of the autonomic ganglia.",
"normal": "The surgeon «draws» a network of lines on the atria using freezing (cryo) or heating (radiofrequency). These scars become walls that block chaotic impulses. The pulmonary vein orifices are necessarily isolated — this is the main source of failures!\n📌 Interesting point: the lines look like a maze — hence the name of the operation."
  }
 },
 {
"name": "Left atrial appendage closure",
"description": {
"professional": "Resection or occlusion of the left atrial (LA) appendage to prevent thromboembolism. Methods:\\n- Suture: Double PTFE 4-0 suture with intussusception of the auricle.\\n- Clipping: Installation of a titanium clip (AtriClip).\\n- Stapling device: Stapler 45 mm (for thoracoscopy).\\nInstruments:\\n- Stapling device (eg, Endo GIA)\\n- Atraumatic clamp (for fixing the auricle)\\nTechnique:\\n1. Before suturing - aspiration of blood from the auricle to exclude blood clots.\\n2. Checking the tightness of the suture using TEE.\\nLogistics:\\n- The removed auricle is sent for histology.\\nNuance: In case of a blood clot in the auricle - preliminary anticoagulation (heparin).",
"normal": "The LA auricle is a «sac» where blood clots often form during AF. It is either sutured or cut off to reduce the risk of stroke.\n📌 Important: after the surgery, the patient still takes anticoagulants temporarily - the heart needs to heal."
  }
 },
 {
"name": "Finishing and starting the heart",
"description": {
"professional": "Deaeration through a puncture in the aorta. Removal of the aortic clamp. Starting the heart: defibrillation (10-20 J) or spontaneous restoration of rhythm. Inotropic support (dobutamine 5 mcg / kg / min). Evaluation of sinus rhythm by ECG. Installation of temporary epicardial electrodes. Drainage of the mediastinum. Sternum suturing (Steel 5 wire) or thoracotomy access.\\nInstruments:\\n- Defibrillator with internal plates\\n- Epicardial electrodes (eg Medtronic 6500)\\n- Pleurovac 28 Fr drainage\\nTechnique:\\n1. In case of AF after start-up — cardioversion 50–100 J.\\n2. Test for conductivity of ablation lines (atrial stimulation).\\nLogistics:\\n- Inotropes are administered through a central venous catheter.\\nNuance: In case of pulmonary edema — emergency ultrafiltration.",
"normal": "The heart is filled with blood, removing air bubbles, and started. If it does not «wake up» on its own, an electric shock is used. Then the rhythm is checked — it should be smooth! Titanium staples are inserted into the sternum and the wound is sutured.\n📌 An exciting moment: the correct sinus rhythm is visible on the monitor for the first time — it means the labyrinth is working!"
  }
 },
 {
"name": "Postoperative protocol",
"description": {
"professional": "Days 1–3: Mechanical ventilation (with sternotomy), ECG monitoring, TEE. Antiarrhythmics (amiodarone 1.2 g/day). Anticoagulants (heparin → warfarin, target INR 2–3).\\n7 days: Holter monitoring. Assessment of sinus node function.\\n1 month: Stress EchoCG, discontinuation of antiarrhythmics with stable rhythm.\\nComplications:\\n- Bleeding (5–10%).\\n- Sick sinus syndrome (3–5%).\\n- Recurrent AF (10–15% in the first year).\\nInstruments:\\n- Holter monitor (3-channel)\\n- INR meter to monitor warfarin\\nNote: With bradycardia — temporary pacemaker; with persistent — permanent.",
"normal": "The first days — in intensive care: the heart «learns» to work with new conduction pathways. If the rhythm gets out of order, amiodarone is given. After a month, tests are done: if everything is fine, the patient forgets about the antiarrhythmia pills.\n📌 Good news: 85% of patients after MAZE live AF-free for 10+ years!"
    }
   }
  ]
 },
{
"keys": [
"stenting",
"coronary arteries",
"endovascular stenting",
"angioplasty",
"cardiac surgery"
],
"name": "Endovascular stenting of coronary arteries",
"modes": {
"professional": "A minimally invasive procedure to restore blood flow in the coronary arteries by installing a stent. Includes catheterization, angiography, balloon dilation and stenting under X-ray control. The choice of stent (BMS, DES) and anticoagulation control are critical.",
"normal": "A tube with a balloon and stent is inserted through a puncture in the arm or groin to open a blocked artery in the heart. Surgery without incisions - the patient is conscious."
},
"steps": [
{
"name": "Preparation and access",
"description": {
"professional": "Preparation of the surgical field (wrist artery or femoral). Local anesthesia (lidocaine 1%). Puncture of the artery with an 18G needle, insertion of an introducer 6-7F. Installation of an arterial hose for pressure monitoring. Administration of heparin (70 U/kg) to prevent thrombosis.\nInstruments:\n- Seldinger needle\n- Introducer with cuff\n- 0.035 guide catheter\nTechnique:\n1. Puncture of the artery at an angle of 45°.\n2. Insertion of the guide catheter to the ascending aorta.\n3. Fixation of the introducer with a suture.\nLogistics:\n- ACT (activated clotting time) control>250 sec.\nNuance: With radial access - Allen test to check collateral blood flow.",
"normal": "The patient's arm or groin is treated, and an anesthetic injection is given. A plastic tube is inserted through a tiny puncture - this is the «entrance» for the catheter.\n📌 Interesting point: the patient is awake and can look at the screen, where his arteries are visible!"
  }
 },
 {
"name": "Angiography",
"description": {
"professional": "Selective coronary artery catheterization (Judkins Left/Right catheters). Contrast administration (iodine-containing, for example, Ultravist). Fluoroscopy in 4 projections: LAO, RAO, cranial, caudal. Evaluation of the degree of stenosis according to the TIMI classification.\nInstruments:\n- 5F angiographic catheter\n- Automatic contrast injector\n- C-arm with digital subtraction analysis\nTechnique:\n1. Recording a «movie» in DICOM format.\n2. Measuring the diameter of the artery and the length of stenosis (QCA analysis).\nLogistics:\n- The contrast dose does not exceed 4 ml/kg.\nNuance: In case of chronic occlusion - search for the «tail» contrast.",
"normal": "A contrast agent is injected through a catheter and an X-ray video is taken. The screen shows where the artery is narrowed or blocked.\n📌 Important: the contrast may cause a feeling of warmth - this is normal!"
  }
 },
 {
"name": "Balloon dilation",
"description": {
"professional": "Insertion of a 0.014\" guidewire beyond the stenosis area. Installation of a balloon catheter (size 1:1 to the artery). Inflation of the balloon (pressure 8-16 atm) for 30-60 sec. Control of recanalization using contrast. In case of resistant stenosis - use of «cutting» balloons (Scoring/Cutting).\nInstruments:\n- Semi-compatible balloon (Monorail)\n- Inflator with manometer\n- Guidewire with hydrophilic coating\nTechnique:\n1. Balloon positioning using marks.\n2. Gradual inflation to minimize dissection.\nLogistics:\n- The balloon is used only after confirming the intraluminal position.\nNuance: In case of calcification — rotational atherectomy (Rotablator).",
"normal": "A thin balloon is inserted to the narrowing site, inflated — the artery expands. Sometimes a balloon with «blades» is used if the plaque is too hard.\n📌 Fact of life: the balloon deflates, but the stent remains — like a spring in a shirt!"
  }
 },
 {
"name": "Stenting",
"description": {
"professional": "Stent selection (length +2 mm to the lesion, diameter according to the reference). DES (with medication) at high risk of restenosis. Positioning under X-ray. Inflating the stent balloon to the nominal pressure. Stent apposition control (OCT/IVUS if necessary).\nInstruments:\n- Stent system (e.g. Xience Alpine)\n- Intracoronary ultrasound (IVUS)\n- Optical coherence tomography (OCT)\nTechnique:\n1. «Open cell design» for side branches.\n2. Postdilation with a non-compliant balloon (18-28 atm).\nLogistics:\n- Checking the proximal/distal edge («landing zones»).\nNuance: For bifurcations - the «T-stenting» technique.",
"normal": "A stent is a metal mesh that is opened in the artery. It remains there forever, keeping the vessel open.\n📌 Fun fact: modern stents are coated with a drug that prevents re-narrowing."
  }
 },
 {
"name": "Completion",
"description": {
"professional": "Repeat angiography to assess TIMI 3 blood flow. Removal of the guidewire and introducer. Hemostasis: radial access - compression bracelet; femoral - Angio-Seal device or manual compression for 15 min. Prescription of dual antiplatelet therapy (aspirin + clopidogrel / ticagrelor).\nInstruments:\n- Hemostasis device (TR Band)\n- Peripheral suture device (Perclose)\n- Pressure sensor (if left)\nPostoperative protocol:\n1. ECG monitoring for 24 hours.\n2. Activation after 2-6 hours.\n3. Discharge in 1-2 days.\nComplications:\n- Restenosis (5-10% for DES).\n- Stent thrombosis (<1%).\n- Access site hematoma (3%).",
"normal": "After the procedure, a pressure bandage is applied to the arm or groin. The patient can get up in a few hours!\n📌 Good news: the surgery reduces the risk of heart attack by 70%."
    }
   }
  ]
 },
{
"keys": [
"Ross procedure",
"aortic valve replacement",
"pulmonary autograft",
"cardiac surgery",
"heart defect"
],
"name": "Ross procedure",
"modes": {
"professional": "Replacement of the diseased aortic valve with an autograft from the patient's own pulmonary valve, followed by implantation of the homograft in the pulmonary position. Stages: sternotomy, connection of CPB, pulmonary valve harvesting, implantation in the aortic position, pulmonary valve replacement. Control of coronary arteries and autograft geometry is critical.",
"normal": "The surgeon replaces the diseased aortic valve with a healthy valve from the patient's own pulmonary artery, and puts a donor valve in its place. The operation is complex, but allows you to avoid lifelong medication."
},
"steps": [
{
"name": "Anesthesia and access",
"description": {
"professional": "Induction of general anesthesia: propofol (2 mg / kg), fentanyl (5 mcg / kg), rocuronium (0.6 mg / kg). Tracheal intubation, connection of mechanical ventilation. Installation of invasive monitoring (arterial line, CVP, TEE). Median sternotomy: skin incision from the jugular notch to the xiphoid process, dissection of the sternum with an oscillating saw. Hemostasis of the bone edge with wax.\nInstruments:\n- Oscillating saw with a protective cover\n- Sternum retractor\n- Bone wax\nTechnique:\n1. Incision along the midline with preservation of the sternoclavicular ligaments.\n2. Layer-by-layer dissection of tissues to the periosteum.\n3. Control of bleeding from the sternal arteries.\nLogistics:\n- Used saw blades are immediately disposed of.\nNuance: In children under 10 years old - partial sternotomy to preserve the growth of the sternum.",
"normal": "The patient is given general anesthesia through a tube in the trachea. The surgeon cuts the sternum in the center - from the base of the neck to the solar plexus. The edges are spread with a special dilator, opening access to the heart.\n📌 Important: after the surgery, the bone will be connected with titanium staples - they will remain forever, but do not interfere with MRI."
  }
 },
 {
"name": "Connecting the CPB",
"description": {
"professional": "Cannulation of the aorta (cannula 20-24 Fr) and right atrium (double-lumen cannula 32-36 Fr). Connection to the artificial circulation (AC) machine. Start of perfusion. Introduction of cardioplegic solution (Custodiol 20 ml/kg) into the aortic root after clamping. Cooling the patient to 28-32°C.\nInstruments:\n- Fogarty aortic clamp\n- Cannulas for CPB with turbulent flow\n- Thermoregulation system with heat exchanger\nTechnique:\n1. Proximal anastomosis of the cannula to the ascending aorta.\n2. Venous drainage through the right atrium.\n3. ACT control >480 sec.\nLogistics:\n- The perfusionist controls the flow of 2.4 l/min/m².\nNuance: In case of aortic calcification - canification of the iliac arteries.",
"normal": "Tubes are inserted into the aorta and right atrium, connected to a device that temporarily replaces the heart and lungs. The heart is stopped with a special solution - now the surgeon can work on the motionless organ.\n📌 Interesting: body temperature drops to 28°C - it's like hibernation to protect the brain."
  }
 },
 {
"name": "Pulmonary valve harvesting",
"description": {
"professional": "The pulmonary trunk is incised 5 mm above the valve. Microsurgical isolation of the valve with a section of the pulmonary artery (15-20 mm cone). Preservation of the integrity of the leaflets and the fibrous ring. Orientation marking (6-0 Prolene commissural sutures). Irrigation in cold saline.\nInstruments:\n- McPherson micro scissors\n- Freer dissector\n- Irrigator with cardioplegia 4°C\nTechnique:\n1. Identification of the left coronary artery to prevent damage.\n2. Resection of the valve as a single block with the muscular ring.\n3. Control for the absence of calcification of the leaflets.\nLogistics:\n- The autograft is stored in an ice solution.\nNuance: In the case of a bicuspid pulmonary valve, the decision on the modification of equipment.",
"normal": "The surgeon carefully cuts out the patient's healthy pulmonary valve together with the «sleeve» from the artery. The valve is placed in a cold solution - like an organ for transplantation.\n📌 Important: the valve is marked with threads to avoid confusing the top and bottom during installation."
  }
 },
 {
"name": "Implantation in the aortic position",
"description": {
"professional": "Resection of the aortic valve with preservation of the coronary orifices. Preparation of the aortic ring (decalcification if necessary). Fixation of the autograft with a continuous 5-0 Prolene suture. Reimplantation of the coronary arteries into the «neoaorta» (island inclusion technique). Leak test at 100 mmHg.\nInstruments:\n- Hegar calibration probes\n- Castroviejo needle holder\n- PTFE suture material\nTechnique:\n1. Commissure triangulation for symmetry.\n2. Formation of a «tongue» for the coronary orifice.\n3. Test for the absence of paravalvular regurgitation.\nLogistics:\n- Autograft ischemia time <90 min.\nNuance: In Marfan syndrome - additional strengthening of the ring.",
"normal": "The diseased aortic valve is removed, the site for the new one is cleared. The patient's pulmonary valve is sutured in its place, precisely aligning all the «petals». The coronary arteries, like water pipes, are reconnected to the new structure.\n📌 The tricky part: the slightest misalignment of the valve will cause a leak - a delicate job!"
  }
 },
 {
"name": "Pulmonary valve replacement",
"description": {
"professional": "Implantation of a cryopreserved homograft (or bioprosthesis) in the pulmonary position. Anastomosis of the pulmonary artery trunk with a continuous 5-0 PDS suture. Removal of air emboli from the heart chambers. Gradual warming of the patient. Starting the heart with defibrillation (10-20 J) if necessary.\nInstruments:\n- Homograft with a matching size (±2 mm)\n- Electrocardioverter-defibrillator\n- 25G deaeration needle\nTechnique:\n1. Distal anastomosis first - for precise alignment.\n2. Maintaining the length of the homograft to prevent compression.\n3. Monitoring the valve function with intraoperative echocardiography.\nLogistics:\n- The homograft is defrosted in 3 stages over 30 minutes.\nNuance: In children, a «growth suture» is left along the anterior wall.",
"normal": "A donor valve or bioprosthesis is installed in place of the removed pulmonary valve. Everything is carefully stitched and checked for leaks. The heart is filled with blood, removing air bubbles - like when bleeding the brakes in a car.\n📌 A miracle: when the heart is started, the new valve immediately starts working!"
  }
 },
 {
"normal": "Completion of the operation",
"description": {
"professional": "Decannulation after stabilization of hemodynamics. Installation of drains (mediastinal and pleural). Suturing the sternum with wire (8-10 threads). Layer-by-layer closure of the wound. Connection to a temporary pacemaker for AV block. Transesophageal echocardiography control.\nInstruments:\n- Blake 19Fr drain\n- 5 mm steel wire for the sternum\n- Implantable pacemaker electrode\nPostoperative protocol:\n1. Inotropic support (epinephrine 0.02-0.1 mcg/kg/min).\n2. Anticoagulation (heparin 300 U/kg/day).\n3. CT scan after 48 hours to evaluate the homograft.\nComplications:\n- Bleeding (5%).\n- Blockade of the conduction pathways (3%).\n- Autograft regurgitation (1% per year).",
"normal": "The tubes from the CPB are removed, the heart starts working on its own again. Drains for fluid are placed in the chest. The sternum is fastened with titanium wire - like a plumbing clamp. In 5-7 days, the patient can breathe without pain!\n📌 The main thing: this valve will grow with the child and does not require replacement."
    }
   }
  ]
 },
{
"keys": [
"lobectomy",
"removal of a lobe of the lung",
"lung cancer",
"thoracic surgery",
"video-assisted lobectomy"
],
"name": "Lung lobectomy",
"modes": {
"professional": "Radical removal of a lobe of the lung in case of malignant or benign lesions. Stages: thoracotomy / VATS access, isolation of the lobe, treatment of vessels and bronchus, lymph node dissection, drainage. Control of the pulmonary arteries and anastomoses is critical.",
"normal": "Surgery to remove one lobe of the lung, most often in case of cancer. The surgeon removes the affected area, preserving the healthy parts of the lung."
},
"steps": [
{
"name": "Anesthesia and positioning",
"description": {
"professional": "Dual-lumen intubation for separate lung ventilation. Position on the healthy side with a cushion under the chest. Monitoring: invasive BP, TEE, SpO2. Prophylactic antibiotic therapy (cefazolin 2 g IV).\nInstruments:\n- Double-lumen tube 37-39 Fr\n- Bronchoscope for position control\n- Neuromonitoring sensors\nTechnique:\n1. Checking the lung isolation with an apnea test.\n2. Fiberoptic repositioning of the tube in case of collapse.\nLogistics:\n- Marking the blood pressure level on the dependent arm.\nNuance: With VATS - the «swimmer» position with arm abduction.",
"normal": "The patient is placed on his side, a special tube is inserted into the trachea so that one lung can be disconnected during surgery. This gives the surgeon space to work.\n📌 Important: before the surgery, it is imperative to check how the patient tolerates the disconnection of one lung - a breathing test is done."
  }
 },
 {
"name": "Surgical approach",
"description": {
"professional": "Anterolateral thoracotomy along the 5th intercostal space (length 10-15 cm) or VATS (3 ports + utility incision). Dissection of the muscles: latissimus dorsi, anterior serratus, intercostal. Introduction of a retractor with gradual opening. Revision of the pleural cavity.\nInstruments:\n- Finochetto rib retractor\n- Thoracoscope 10 mm 30°\n- Harmonic scalpel\nTechnique:\n1. In VATS - the camera is in the 7th intercostal space along the midaxillary line.\n2. Protection of the intercostal nerve by blunt dissection.\nLogistics:\n- Hemostasis with an electrocoagulator in the «spray» mode.\nNuance: For tumors >5 cm - conversion to open surgery.",
"normal": "The surgeon makes an incision between the ribs (or several small punctures in VATS). The muscles are carefully moved apart, the ribs are slightly spread apart with a special instrument - like opening curtains.\n📌 Interesting: with VATS access, the operation is performed through 3-4 holes, looking at the monitor screen - like in a computer game, but for real!"
  }
 },
 {
"name": "Isolation of the lobe",
"description": {
"professional": "Division of the interlobar fissure: blunt dissection along the avascular plane, treatment of vascular adhesions with bipolar. Identification of the elements of the root of the lobe: artery, vein, bronchus. Sequential processing: first arterial branches, then venous, finally - bronchus.\nInstruments:\n- Maryland dissector\n- Stapling device (Echelon 60)\n- Hem-o-lok clips\nTechnique:\n1. In case of upper lobectomy on the right - isolation of truncus anterior.\n2. Mobilization of the azygos vein if necessary.\nLogistics:\n- Marking the direction of resection using CT navigation.\nNuance: In case of inflammation - intrapericardial processing of vessels.",
"normal": "The surgeon finds the border between the lobes of the lung - like separating the layers of a cake. The vessels and bronchus feeding the affected lobe are carefully isolated.\n📌 A difficult moment: the pulmonary arteries are very thin - like spaghetti, they are easy to damage, so they work with jewelry precision."
  }
 },
 {
"name": "Processing of vessels and bronchi",
"description": {
"professional": "Ligation and intersection of pulmonary arteries (Prolene 4-0 suture material or staplers). Ligation of pulmonary veins (Echelon stapler or clips). Intersection of the lobar bronchus 5 mm distal to the carina (Endo GIA 3.5 mm stapler). Checking the tightness of the bronchial stump with a test with saline.\nInstruments:\n- Bronchial stapler with a blue cassette\n- Vascular stapler (white cassette)\n- Irrigator with warm saline\nTechnique:\n1. Arteries are treated proximal to the veins.\n2. The bronchus is crossed at a 45° angle to maintain its shape.\nLogistics:\n- The removed vessels are checked for the presence of two rows of staples.\nNote: If the bronchus is short - hand suture PDS 3-0.",
"normal": "Each vessel is clamped with a stapler - like a paper clip, then crossed. The bronchus (air «tube») is also blocked and cut off, checking that there is no air leakage.\n📌 Important: if the bronchus is too short, the surgeon sutures it manually - this requires special skill."
  }
 },
 {
"name": "Lymphatic dissection",
"description": {
"professional": "Removal of lymph nodes of stations 7, 10, 11 (for NSCLC). Isolation of packets from the bifurcation of the trachea to the phrenic nerve. Marking of groups of lymph nodes separately for histology. Hemostasis of lymphatic vessels with clips.\nInstruments:\n- LigaSure bipolar forceps\n- Metzenbaum scissors\n- Lymph node containers\nTechnique:\n1. Complete mediastinal dissection for cancer.\n2. Preservation of the recurrent laryngeal nerve.\nLogistics:\n- Separate marking of «subcranial» nodes.\nNote: At stage N2 - intraoperative consultation with an oncologist.",
"normal": "The surgeon removes all the lymph nodes around the lung - this is where cancer spreads first. They are marked and sent for urgent analysis.\n📌 Critical: if tumor cells are found in the nodes, an extension of the operation may be required."
  }
 },
 {
"name": "Completion of the operation",
"description": {
"professional": "Revision of the bed for hemostasis (especially the intercostal arteries). Installation of two drains: anterior - to the dome, posterior - to the diaphragm. Layered suturing: intercostal muscles (Vicryl 2-0), subcutaneous tissue, skin (stapler or subcuticular suture). Connecting the drains to the active aspiration system (-20 cm H2O).\nInstruments:\n- Pleurovac 28 Fr drain\n- Absorbable mesh (for rib resection)\n- Hegar needle holder\nPostoperative protocol:\n1. X-ray immediately after surgery.\n2. Analgesia: epidural catheter + Paracetamol.\n3. Activation after 4-6 hours.\nComplications:\n- Bronchial fistula (1-2%).\n- Bleeding (3%).\n- Atelectasis (15%).",

"normal": "The lung is carefully straightened, checking for air leaks. Two drainage tubes are inserted into the chest - they will remove air and fluid. The ribs are brought back together, the muscles and skin are stitched up. After 1-2 days, the drains are removed, and after a week the patient can breathe almost normally!\n📌 Good news: the remaining lobes of the lung will expand over time and take over the work of the removed part."
    }
   }
  ]
 },
{
"keys": [
"pneumonectomy",
"lung removal",
"lung cancer",
"thoracic surgery",
"lung extirpation"
],
"name": "Pneumonectomy",
"modes": {
"professional": "Radical removal of the entire lung with the main bronchus, pulmonary vessels and lymph node dissection. Indications: central cancer with damage to the main bronchus, tumors with invasion of the pulmonary veins/arteries. Critical stages: treatment of the main pulmonary artery, sealing of the bronchial stump, control of the mediastinum.",
"normal": "Complete removal of one lung in advanced tumors or severe injuries. After the operation, the remaining lung gradually takes over the entire respiratory function." 
},
"steps": [
{
"name": "Anesthesia and access",
"description": {
"professional": "Double-lumen intubation with bronchoscope position control. Position on the healthy side with a cushion under the chest. Monitoring: invasive BP, CVP, BIS, gas analysis. Posterolateral thoracotomy along the 5th intercostal space with resection of the 5th rib (length 15-20 cm). Insertion of a rib spreader.\nInstruments:\n- Double-lumen tube 39-41 Fr\n- Liston rib scissors\n- Finochetto retractor\nTechnique:\n1. Rib resection 2 cm lateral to the paravertebral line.\n2. Drainage of pleural fluid before deployment.\nLogistics:\n- Extracorporeal membrane oxygenation (ECMO) readiness.\nNuance: For tumors >10 cm, transsternal access is possible.",
"normal": "The patient is placed on his side, a special breathing tube is inserted to work with only one lung. The surgeon makes a large incision along the ribs, sometimes removing one rib for better access.\n📌 Important: before the operation, it is imperative to check how the remaining lung copes with breathing - special tests are done."
  }
 },
 {
"name": "Lung mobilization",
"description": {
"professional": "Dissection of the pulmonary ligament. Isolation of the main bronchus to the tracheal bifurcation. Separation of the lung from the mediastinum with ligation of small vessels. Treatment of the pulmonary artery: isolation extrapericardial or intrapericardial (for central tumors).\nInstruments:\n- Debakey dissector\n- LigaSure bipolar forceps\n- Satinsky vascular clamps\nTechnique:\n1. For right-sided pulmonectomy - mobilization of the azygos vein.\n2. Control of the left recurrent nerve for left-sided.\nLogistics:\n- Marking the tumor borders with surgical clips.\nNuance: In case of growth into the pericardium - resection of the pericardial window.",
"normal": "The surgeon carefully separates the lung from all attachments, like freeing the root of a tree from the ground. The main vessels and the bronchus are isolated especially carefully - they are large, like a garden hose.\n📌 A difficult moment: the nerve responsible for the voice runs nearby - it must be preserved at any cost!" 
  }
 },
 {
"name": "Pulmonary artery treatment",
"description": {
"professional": "Ligation and transection of the main pulmonary artery: double ligature proximally (silk 0) + distal stapler (Echelon 60 mm). Alternatively, hand suture with 4-0 Prolene. Intrapericardial approach - pericardial opening anterior to the phrenic nerve.\nInstruments:\n- Vascular stapler with white cassette\n- Castroviejo needle holder\n- Pericardial scissors\nTechnique:\n1. Proximal control of the artery before mobilization.\n2. Suture strength test by increasing pressure.\nLogistics:\n- Readiness of 5-0 vascular suture material.\nNuance: In case of arterial calcification - use of Teflon pads.",
"normal": "The pulmonary artery, the main «pipe» that carries blood to the lung, is clamped and cut. First, strong knots are applied, then it is cut.\n📌 Critical: if the artery is damaged, severe bleeding can begin, so the surgeon always keeps spare sutures on hand." 
  }
 },
 {
"name": "Pulmonary vein transection",
"description": {
"professional": "Isolation of the superior and inferior pulmonary veins extrapericardially or together with the atrial appendage (in case of tumor invasion). Application of a Satinsky clamp to the atrium. Dissection of the veins with 3-0 Prolene suturing in a double-row suture. Control of the tightness of the suture with an adrenaline swab.\nInstruments:\n- Satinsky clamp 45 mm\n- Polypropylene thread 3-0\n- ValleyLab electrocoagulator\nTechnique:\n1. In case of invasion into the atrium - resection using a vascular stapler.\n2. Mandatory check for blood clots in the appendage.\nLogistics:\n- Hemostasis with bipolar in 25 W mode.\nNuance: With left-sided surgery - risk air embolism through an open ear.",
"normal": "The pulmonary veins that return blood to the heart are carefully cut and stitched up. Sometimes part of the heart wall has to be removed - like stitching up a hole in an air mattress.\n📌 Important: before cutting, check for blood clots - they can get into the heart." 
  }
 },
 {
"name": "Processing of the main bronchus",
"description": {
"professional": "Mobilization of the bronchus to the carina. Application of a bronchial stapler (blue cassette) 5 mm distal to the bifurcation. Intersection of the bronchus with a #11 scalpel. Sealing the stump with 3-0 Prolene (braided suture). Pleuralization with a mediastinal pleural or pericardial flap.\nInstruments:\n- Bronchial stapler TA 30\n- Schumacher needle\n- Pleural flap on a pedicle\nTechnique:\n1. Control of the stump length (no more than 1 cm).\n2. Tightness test under water at a pressure of 30 cm H2O.\nLogistics:\n- Sanitation of the stump with a povidone-iodine solution.\nNuance: With a right-sided operation - risk bend of the left main bronchus.",
"normal": "The main bronchus - the «breathing tube» - is compressed with a special stapler, cut off and carefully sutured. The suture site is covered with a «patch» from the surrounding tissue.\n📌 Vital: if the suture is not airtight, air will escape into the chest cavity - like a punctured chamber."
  }
 },
 {
"name": "Lymph node dissection and completion",
"description": {
"professional": "Extended lymph node dissection: paratracheal, bifurcation, subcarinal nodes (stations 2R, 4R, 7, 8, 9). Mediastinal hemostasis with argon-enhanced coagulation. Installation of two drains: anterior - to the pleural dome, posterior - to the diaphragm. Layered suturing with thoracoplasty (resection ribs are reimplanted with titanium plates).\nInstruments:\n- Titanium lymphatic clips\n- ForceTriad argon coagulator\n- MatrixRIB rib plates\nPostoperative protocol:\n1. Mechanical ventilation in PCV mode for the first 12-24 hours.\n2. Epidural analgesia for 5 days.\n3. Bronchoscopy on the 3rd day.\nComplications:\n- Bronchial fistula (3-5%).\n- Pleural empyema (7%).\n- Postpneumonectomy space syndrome (10%).",
"normal": "The surgeon removes all the lymph nodes in the mediastinum - like uprooting the roots of a weed. The chest is closed, sometimes reinforced with titanium plates. Two drainage tubes are left for monitoring.\n📌 Rehabilitation: the first few days the patient breathes through a ventilator, but after a week the remaining lung begins to work for two!"
    }
   }
  ]
 },
{
"keys": [
"pleural drainage",
"thoracostomy",
"pleural drainage",
"pneumothorax",
"hemothorax",
"pleurisy"
],
"name": "Pleural drainage",
"modes": {
"professional": "An invasive procedure for inserting a drainage tube into the pleural cavity to remove air (pneumothorax), blood (hemothorax), or exudate (pleurisy). Includes local anesthesia, puncture, insertion of a Bulau drain, or connection to an aspiration system.",
"normal": "When air or fluid accumulates in the chest, interfering with breathing, the doctor inserts a special tube between the ribs. All excess is removed through it, and the lung straightens out again." },
"steps": [
{
"name": "Preparation and positioning",
"description": {
"professional": "Choosing the access point: for pneumothorax - 4-5 intercostal space along the midclavicular line, for effusion - 7-8 intercostal space along the posterior axillary line. Patient position: sitting with a forward bend (for effusion) or lying on the healthy side (for injury). Treating the field with an antiseptic in wide strokes (from the sternum to the spine). Marking the injection site according to ultrasound/X-ray data.\nInstruments:\n- Ultrasound machine with a linear sensor\n- Skin marker\n- Sterile tray with napkins\nTechnique:\n1. Palpation of the ribs to identify the intercostal space.\n2. Ultrasound control of the depth of effusion/air.\n3. Full-thickness infiltration of anesthetic walls.\nLogistics:\n- Check the function of the aspirator before starting.\nNuance: In case of tension pneumothorax - immediate puncture with a 14G needle in the 2nd intercostal space.",
"normal": "The patient is seated on the bed so that he hugs the pillow and leans slightly forward - this way the ribs move apart. The doctor finds the desired intercostal space (usually between the 4-5 rib under the arm) and treats the skin with a cold antiseptic.\n📌 Important: before the injection, an ultrasound is done - like an «underwater locator» it looks for fluid accumulation."
  }
 },
 {
"name": "Anesthesia",
"description": {
"professional": "Layered infiltration anesthesia: skin (1% lidocaine 3-5 ml), subcutaneous tissue, intercostal muscles, parietal pleura. A 22G needle 40 mm long is inserted along the upper edge of the rib (avoiding the vascular-nerve bundle). Aspiration test when advancing - air/liquid appears when entering the cavity.\nInstruments:\n- 10 ml syringe with a 22G needle\n- 1% lidocaine or 0.5% bupivacaine\n- Test tube for effusion analysis\nTechnique:\n1. Anesthesia is started from the skin to the pleura.\n2. «Fan» technique - 3 intercostal spaces are blocked.\n3. Depth control by tissue resistance.\nLogistics:\n- Any remaining anesthetic is disposed of in a «sharp» container.\nNote: For children, the dose is calculated as 3 mg/kg lidocaine.",
"normal": "Several injections of anesthetic are given - first superficially, then deeper, right down to the pleura. The doctor may ask you to hold your breath so as not to accidentally injure the lung.\n📌 Interesting: an area the size of a palm is anesthetized - then the installation of the tube will be painless."
  }
 },
 {
"name": "Incision and access",
"description": {
"professional": "A 1.5-2 cm transverse skin incision with a #11 scalpel. Blunt separation of the subcutaneous tissue with a mosquito clamp. Puncture of the intercostal muscles with a trocar or Pean clamp along the upper edge of the rib. Digital revision: a finger is inserted into the wound to confirm the position in the pleural cavity and separate the adhesions.\nInstruments:\n- Scalpel #11 with a depth limiter\n- Blunt Kelly clamp\n- Trocar 28-32Fr (for planned drainage)\nTechnique:\n1. The incision is strictly perpendicular to the skin.\n2. «Tunneling» through the muscles at an angle of 45°.\n3. Digital control before inserting the drainage.\nLogistics:\n- The used trocar is immediately washed.\nNuance: In case of adhesions, the access is expanded to 3 cm.",
"normal": "The surgeon makes a small incision (like for an earring), then carefully spreads the muscles between the ribs with a blunt instrument. An important point is that he inserts his finger into the incision to make sure that he has entered the pleural cavity exactly.\n📌 Sensation: the patient may feel pressure, but not pain."
  }
 },
 {
"name": "Drainage placement",
"description": {
"professional": "Insertion of a 24-32Fr drainage tube (for blood - 36Fr) 10-15 cm into the pleural cavity. When using a trocar, remove the stylet after positioning. Fixation of the tube to the skin with a 1-0 silk suture. Connection to the Bulau system (underwater valve) or an electric aspirator (-20 cm H2O). Application of an occlusive dressing.\nInstruments:\n- Chest drain with side holes\n- Suture set with needle holder\n- System with Heimlich valve\nTechnique:\n1. Direction of the tube in case of pneumothorax - to the apex of the lung.\n2. In case of effusion — to the posterior costophrenic angle.\n3. X-ray position control after installation.\nLogistics:\n- The drainage is fixed with a “safety” suture.\nNuance: In children — soft drains 12-16Fr are used.",
"normal": "A flexible tube (as thick as a finger) is inserted through the incision and advanced inside. In case of pneumothorax — to the top of the lung, in case of fluid — down, like a “hose” to the deepest point. The tube is sewn to the skin with a thread so that it does not fall out, and connected to a jar of water or a suction device.\n📌 Visualization: air bubbles or a stream of liquid are visible in the jar — this means the drainage is working!"
  }
 },
 {
"name": "Control and fixation",
"description": {
"professional": "X-ray/ultrasound immediately after the procedure. Monitoring the volume of discharge (dangerous >1500 ml/day). Flushing the drainage with 0.9% NaCl if blocked. Daily treatment of the insertion site. Auscultation of the lungs for straightening.\nInstruments:\n- X-ray machine (portable)\n- Sterile wipes with chlorhexidine\n- 20 ml syringe for flushing\nTechnique:\n1. Marking the fluid level on the drainage jar.\n2. Checking the water fluctuation in the system.\n3. Clamping the drainage during transportation.\nLogistics:\n- Change the aseptic dressing every 24 hours.\nNote: With long-term drainage - prevention of empyema (ceftriaxone 1 g/day).",
"normal": "After the procedure, an X-ray is taken to check whether the lung has straightened. Nurses measure the volume of outflowing fluid daily and flush the tube with saline if it becomes clogged.\n📌 Important: Always keep the drainage can below chest level - otherwise the fluid may «leak» back!"
  }
 },
 {
"name": "Drainage removal",
"description": {
"professional": "Indications: cessation of air/fluid inflow (>24 h), lung straightening on x-ray, discharge volume <100 ml/day. Preparation: pain relief, premedication (morphine 2-4 mg IV). Rapid removal of the tube on exhalation with simultaneous application of an occlusive dressing. Control x-ray after 2 hours.\nInstruments:\n- Suture scissors\n- Vaseline wipes\n- Steri-Strips patch\nTechnique:\n1. Changing the drainage ligation within 2 hours to assess for recurrence.\n2. «Jerky» removal in one go.\n3. Sealing the wound with an ointment dressing.\nPostoperative protocol:\n1. Pain relief (paracetamol + ketorolac).\n2. Breathing exercises from the first day.\n3. Discharge 24-48 hours after removal.\nComplications:\n- Subcutaneous emphysema (15%).\n- Recurrence of pneumothorax (5%).\n- Infection (3%).",
"normal": "When the lung has recovered, the tube is removed: the doctor asks you to take a deep breath and hold it, and then quickly removes the drainage. A tight bandage is applied to the wound - like a «patch» on a punctured ball.\n📌 Advice: after removal, it is better to lie on this side for 2 hours - this way the wound will close more reliably."
    }
   }
  ]
 },
{
"keys": [
"simpatectomy",
"hyperhidrosis",
"endoscopic thoracic sympathectomy",
"ETS",
"sweating palms",
"autonomic nervous system"
],
"name": "Endoscopic thoracic sympathectomy (ETS)",
"modes": {
"professional": "Surgical interruption of the sympathetic trunk at the level of the thoracic ganglia for the treatment of hyperhidrosis, Raynaud's syndrome or phantom pain. Performed videoendoscopically through mini-accesses with clipping, resection or ablation of nerve nodes.",
"normal": "Surgery against excessive sweating of the hands or face - through small punctures in the armpits, the doctor «disconnects» the nerve nodes responsible for the sweat glands. The result is dry palms on the day of surgery."
},
"steps": [
{
"name": "Preparation and positioning",
"description": {
"professional": "General anesthesia with double-lumen intubation (lung isolation). Patient position on the back with arms spread at 90°. Marking of access points: 3rd intercostal space along the midaxillary line (5 mm for the camera) and 5th intercostal space along the anterior axillary line (3 mm for instruments). Treatment of the field with an antiseptic.\nInstruments:\n- Double-lumen endotracheal tube\n- Thoracoscope 5 mm 30°\n- Needles for CO₂ insufflation\nTechnique:\n1. Collapse of the lung on the side to be operated on.\n2. Control X-ray to identify the rib level.\n3. Hyperhidrosis test (iodine-starch test).\nLogistics:\n- Mark of the surgeon's dominant hand (right-handed/left-handed).\nNuance: In case of obesity — increase insufflation pressure to 8 mmHg.",
"normal": "The patient is placed on his back, arms spread out like a «cross». Anesthesia is administered through a special tube — one lung is temporarily disconnected for work. The skin in the armpits is treated with iodine and «targets» for punctures are drawn.\n📌 Important: before the operation, the palms are lubricated with iodine and starch — sweaty areas turn purple so that the surgeon knows exactly which nerves to block."
  }
 },
 {
"name": "Creation of pneumothorax",
"description": {
"professional": "The pleural cavity in the 4th intercostal space is punctured with a Veresh needle. CO₂ insufflation (pressure 4-6 mmHg) for lung collapse. Insertion of a 5 mm trocar under visual control. Examination of the pleural cavity: identification of the sympathetic trunk (a cord with ganglia along the heads of the ribs).\nInstruments:\n- Veress needle with a protective valve\n- Insufflator with gas heating\n- Thoracotrocar with obturator\nTechnique:\n1. Puncture strictly along the upper edge of the rib.\n2. Control of the depth by the «failure» of resistance.\n3. Visualization of the sympathetic chain — a pearly white structure.\nLogistics:\n- EtCO₂ monitoring (not >45 mmHg).\nNuance: In case of adhesions — an additional 3rd port.",
"normal": "Carbon dioxide is injected through a tiny puncture — it gently pushes the lung back, freeing up space for work. The surgeon inserts a camera and sees the nerve chain — it looks like a white cord running along the spine.\n📌 Amazing: the entire operation takes place through holes less than a centimeter — like a game of Tetris inside the chest!"
  }
 },
 {
"name": "Identification of the sympathetic trunk",
"description": {
"professional": "Visualization of ganglia: T2 (for palms), T3-T4 (for face), T5 (for armpits). Separation of the chain from the intercostal veins (often anastomosed with the azygos vein). Coagulation of transverse communicants. Test stimulation with an electrosurgical hook (if there is doubt about identification).\nInstruments:\n- Maryland electrosurgical hook\n- Bipolar forceps\n- Atraumatic dissector\nTechnique:\n1. Dissection along the axis of the trunk without damaging the pleura.\n2. Control of bleeding from the venous plexuses.\n3. Marking the target ganglia with a clip.\nLogistics:\n- Recording of video surgery for documentation.\nNuance: In case of atypical anatomy, search in relation to the costal heads.",
"normal": "The surgeon finds the necessary «nodes» of the nerve chain - for the palms, this is the level of the second rib, for the face, the third. Nerves are carefully separated from small vessels - like wires are stripped of insulation. Sometimes they are tested with electricity - if the palm of your hand sweats on the monitor, it means that this is the right node.\n📌 Subtlety: one wrong step - and you can touch important veins going to the heart!"
  }
 },
 {
"name": "Denervation",
"description": {
"professional": "Intervention options:\n1. Clipping with titanium clips (reversible in case of complications).\n2. Radiofrequency ablation (50-70 ° C, 30 sec).\n3. Resection of the trunk segment (histological control).\nMandatory T3-T4 sympathectomy for palmar hyperhidrosis. Hemostasis control. Checking pupil dilation (Horner's syndrome with T1 damage).\nInstruments:\n- Clip applicator with 5 mm titanium clips\n- RF generator with a needle electrode\n- Endoscopic scissors\nTechnique:\n1. Clips are applied to the trunk + 1 cm distally.\n2. For ablation - circular treatment of a 5 mm zone.\n3. The removed fragment is sent for histology.\nLogistics:\n- The number of clips is recorded in the protocol.\nNuance: In case of Raynaud's syndrome — additional T2 sympathectomy.",
"normal": "The chosen method of «disabling» the nerves:\n• The gold standard is titanium clips (like microscopic clothespins).\n• Or «cauterization» with a radiofrequency beam.\n• In rare cases, a section of the nerve is cut out.\n📌 The result is visible immediately: your palms become dry and warm right on the operating table!"
  }
 },
 {
"name": "Completion",
"description": {
"professional": "Lung reinflation under visual control. Removal of trocars under video observation. Suturing of ports with absorbable suture 3-0. Drainage is not required. Application of aseptic stickers. Extubation in the operating room.\nInstruments:\n- Monocryl suture material\n- Skin stapler\n- Pneumatic system for reinflation\nTechnique:\n1. Control of complete lung expansion.\n2. Aspiration of residual gas through the port.\n3. Cosmetic intradermal suture.\nLogistics:\n- Checking the pupils for symmetry.\nNuance: In case of subcutaneous emphysema - X-ray control.",
"normal": "The lung is filled with air again, like a balloon. The punctures are sealed with a special plaster - no stitches are needed, the marks are almost invisible. In 30 minutes the patient is already in the ward and can eat.\n📌 Fact: 95% of people say goodbye to sweaty palms forever!"
  }
 },
 {
"name": "Postoperative monitoring",
"description": {
"professional": "X-ray after 2 hours to exclude pneumothorax. Assessment of compensatory hyperhidrosis (back, abdomen). Cold palm test. Discharge after 24 hours. Limitation of physical activity for 7 days.\nPostoperative protocol:\n1. Pain relief - ketorolac 30 mg / day.\n2. Breathing exercises from the 1st day.\n3. Follow-up examination after 1 month.\nComplications:\n- Compensatory hyperhidrosis (50%).\n- Horner's syndrome (1-3%).\n- Pneumothorax (2%).\n- Neuralgia (5%).",
"normal": "After the operation, an X-ray is taken to check for air in the chest. The puncture site may hurt for the first few days, but this can be relieved with regular pills.\n📌 Important to know: 50% of patients experience increased sweating of the back or thighs - this is the price to pay for dry palms."
    }
   }
  ]
 },
{
"keys": [
"pneumothorax",
"spontaneous pneumothorax",
"thoracoscopy",
"pleural cavity",
"thoracic surgery"
],
"name": "Surgery for spontaneous pneumothorax",
"modes": {
"professional": "Surgical treatment of spontaneous pneumothorax, including drainage of the pleural cavity, resection of bullae and pleurodesis. Stages: VATS access, lung revision, treatment of pathological areas, drainage. Control of air leakage and prevention of relapse are critical.",
"normal": "Surgery for sudden accumulation of air in the chest cavity. The surgeon removes the bubbles in the lung and creates conditions for the lung to stick to the chest wall, preventing recurrence."
},
"steps": [
{
"name": "Emergency diagnosis and preparation",
"description": {
"professional": "Chest X-ray or CT to confirm the diagnosis and assess the volume of the pneumothorax. Puncture of the thoracostomy cavity in case of tension pneumothorax. Operating room preparation: videothoracoscopic set, tissue suturing machine, drainage systems. Single- or double-lumen intubation depending on the method.\nInstruments:\n- 5 mm 30° thoracoscope\n- 5 and 10 mm trocars\n- 14G puncture needle\nTechnique:\n1. In case of tension pneumothorax - immediate decompression in the 2nd intercostal space.\n2. Port markings for VATS: safety triangle.\nLogistics:\n- Emergency thoracotomy kit at the ready.\nNote: For smokers - preparation for possible resection.",
"normal": "The patient is given an urgent X-ray to see how much air has accumulated around the lung. In severe cases, the air is first pumped out with a thick needle - it's like deflating a tire.\n📌 Important: smokers are at risk - their lungs are often covered with weak bubbles (bullae)."
  }
 },
 {
"name": "Drainage of the pleural cavity",
"description": {
"professional": "Installation of a Bulau drainage: a 2 cm skin incision in the 4-5 intercostal space along the midaxillary line. Blunt isolation to the pleura. Insertion of a 20-28 Fr drainage tube towards the apex. Fixation with a suture and connection to the active aspiration system (-20 cm H2O).\nInstruments:\n- Argyle 24 Fr drainage\n- Pean clamp\n- Silk 2-0 suture material\nTechnique:\n1. Digital revision of the pleural cavity before inserting the drainage.\n2. Control of the drainage position with an X-ray.\nLogistics:\n- Sterile Heimlich valve in the system.\nNuance: With subcutaneous emphysema - additional drainage.",
"normal": "A flexible tube is inserted through a small incision under the armpit, which is connected to a jar of water. Air bubbles in the jar indicate that the system is working.\n📌 A visual moment: when the lung straightens out, the bubbles in the drainage stop - like in an aquarium filter."
  }
 },
 {
"name": "Videothoracoscopically access (VATS)",
"description": {
"professional": "Position on the healthy side with arm abduction. Creation of 3 ports: camera - 7th intercostal space along the midaxillary line, instrumental - 3rd and 5th intercostal spaces along the anterior axillary line. CO2 insufflation (8 mm Hg) to improve visibility. 360° lung inspection.\nInstruments:\n- 10 mm thoracoport\n- HD telescopic camera\n- Insufflator with gas heating\nTechnique:\n1. The first trocar is inserted using the «open» method.\n2. Inspection of the apex of the lung first.\nLogistics:\n- Position of the operating team: surgeon in front, assistant in the back.\nNuance: In case of adhesions - an additional 4th port.",
"normal": "Through three punctures (as for laparoscopy) a camera and instruments are inserted. A little gas is pumped into the chest cavity - this moves the tissues apart, giving the surgeon an overview.\n📌 Interesting: transparent bubbles on the lung are clearly visible on the monitor - like bunches of grapes."
  }
 },
 {
"name": "Resection of bullae and lung treatment",
"description": {
"professional": "Identification of bullae (usually the upper lobe). Clipping the base of the bulla with vascular clips. Resection with a mechanical stapler (Endo GIA 45 mm, blue cassette). Irrigation of the bed with saline to check for leaks. Coagulation of small bullae with an argon coagulator.\nInstruments:\n- Endostapler with triplex staples\n- 5 mm clip applicator\n- Argon-reinforced coagulator\nTechnique:\n1. Resection with 5 mm of healthy tissue capture.\n2. Leak test at 30 cm H2O pressure.\nLogistics:\n- The removed bullae are sent for histology.\nNuance: For giant bullae - the «kapitoshka» technique.",
"normal": "The surgeon finds the bubbles and cuts them off with a special stapler, which immediately stitches the tissue. The cut site is checked by pouring saline solution - if there are bubbles, then there is an air leak.\n📌 Important: the stapler places three rows of titanium staples - like in an office stapler, but for human tissue."
  }
 },
 {
"name": "Pleurodesis",
"description": {
"professional": "Mechanical treatment of the parietal pleura: with a windlass or electrocoagulation until capillary bleeding occurs. Application of talc suspension (4 g of sterile talc) through a sprayer. Control of uniform distribution over the entire surface.\nInstruments:\n- Pleural brush\n- Talc insufflator\n- Electrosurgical generator\nTechnique:\n1. Treatment from the dome to the diaphragm.\n2. Talc is sprayed under visual control.\nLogistics:\n- Aspiration of excess talc after 5 min exposure.\nNuance: In case of talc allergy - chemical pleurodesis with doxycycline.",
"normal": "To make the lung «stick» to the chest wall, the surgeon treats the inner surface of the chest with a special mesh or sprays sterile talc - like powder.\n📌 Surprisingly: talc causes controlled inflammation, which creates strong adhesions."
  }
 },
 {
"name": "Completion of the operation",
"description": {
"professional": "Lung reimplantation under video camera control. Installation of a second 20 Fr drainage along the posterior axillary line. Removal of trocars under visual control. Layered suturing of ports. Fixation of drains with separate sutures. Connection to the Pleurovac system.\nInstruments:\n- Blake 20 Fr drainage\n- Absorbable suture material\n- Atraumatic needle\nPostoperative protocol:\n1. X-ray control after 2 hours.\n2. Analgesia: NSAIDs + local blockades.\n3. Removal of drains if there is no leak for >24 hours.\nComplications:\n- Persistent leak (5%).\n- Pleural empyema (1%).\n- Relapse (3% after VATS).",
"normal": "The drainage tubes are fixed with sutures, the punctures are sealed. A control X-ray is taken after 24 hours - if the lung has straightened and there is no air leak, the tubes are removed.\n📌 Good news: after VATS, patients go home on the 3-4th day and quickly return to active life!"
    }
   }
  ]
 },
{
"keys": [
"VATS",
"videothoracoscopy",
"thoracoscopic surgery",
"minimally invasive lung surgery",
"pleural biopsy"
],
"name": "Videothoracoscopy (VATS)",
"modes": {
"professional": "Minimally invasive endoscopic intervention in the pleural cavity through 3-4 ports. Indications: pleural biopsy, resection of pulmonary nodes, treatment of pneumothorax, sympathectomy. Control of bleeding and adequate ventilation of one lung are critical.",
"normal": "Surgery through small punctures in the chest with a video camera. Used to diagnose and treat lung and pleural diseases without large incisions."
},
"steps": [
{
"name": "Anesthesia and positioning",
"description": {
"professional": "Double-lumen intubation (37-39 Fr) for separate lung ventilation. Position on the healthy side with a cushion under the chest (in case of pneumothorax - on the back). Monitoring: capnography, SpO2, invasive BP. Lung isolation test (collapse of the operated lung).\nInstruments:\n- Bronchoscope for intubation control\n- Double-lumen endotracheal tube\n- Neuromonitoring sensors\nTechnique:\n1. Checking the tube position with a fiberscope\n2. Collapsed lung on the side of the operation\nLogistics:\n- Readiness for emergency thoracotomy\nNuance: With adhesions - gradual collapse of the lung",
"normal": "The patient is placed on his side, a special tube is inserted into the trachea so that one lung can be disconnected. This gives the surgeon space to work.\n📌 Important: before the operation, check how the patient tolerates the disconnection of one lung - do a breathing test."
  }
 },
 {
"name": "Creating ports",
"description": {
"professional": "Formation of 3-4 ports (5-12 mm): a chamber in the 7th intercostal space along the midaxillary line, instrument ports in the 4th and 5th intercostal spaces. A pneumothorax is created with a Veresh needle (CO2 pressure 8-10 mm Hg). Trocars are inserted under visual control.\nInstruments:\n- Trocars 5/10/12 mm\n- Veresh needle\n- CO2 insufflator\nTechnique:\n1. The first port is a safe zone (safety triangle)\n2. Trocar insertion control with a torcoscope\nLogistics:\n- Ports are fixed to the skin with sutures\nNuance: In case of adhesions - open technique according to Hasson",
"normal": "The surgeon makes 3-4 small incisions (5-12 mm) between the ribs. A camera and instruments are inserted through them. Carbon dioxide is pumped into the chest to create space for work.\n📌 Interesting: the first puncture is made in the «safe triangle» - an area where there are no large vessels."
  }
 },
 {
"name": "Revision of the pleural cavity",
"description": {
"professional": "Systematic examination: costal pleura, diaphragm, mediastinum, visceral pleura. Detection of adhesions, tumor nodes, pathological fluid. Collection of effusion for cytology/microbiology. Separation of adhesions with a harmonic scalpel.\nInstruments:\n- Thoracoscope 30° 10 mm\n- Harmonic scalpel\n- Aspirator-irrigator\nTechnique:\n1. Methodical examination by quadrants\n2. Biopsy of suspicious areas\nLogistics:\n- Marking of biopsy specimens by localization\nNuance: In case of hemothorax - search for the source of bleeding",
"normal": "The surgeon examines the entire chest cavity through the camera - the lungs, diaphragm, costal surface. If there are adhesions (scar bridges), they are carefully separated. Fluid or pieces of tissue are taken for analysis.\n📌 Important: in case of cancer, it is immediately determined whether the tumor can be removed in a minimally invasive way."
  }
 },
 {
"name": "The main stage (depending on the pathology)",
"description": {
"professional": "1. For pleural biopsy: taking 3-4 samples from different areas with endoscopic forceps. 2. For bullectomy: resection of bullae with Endo GIA stapler (blue cassette). 3. For sympathectomy: coagulation of the sympathetic trunk at the R3-R4 level. 4. For tumors: marking the node with a radioisotope for further resection.\nInstruments:\n- Endoscopic forceps\n- Stapling apparatus\n- Electrocoagulator\nTechnique:\n1. For bullae - resection with capture of healthy tissue\n2. In case of biopsy - taking a full sample\nLogistics:\n- Hemostasis control after each stage\nNuance: In case of bleeding - switch to manual suture",
"normal": "Depending on the problem: remove blisters on the lung (bullae) in case of pneumothorax, cut nerves in case of hyperhidrosis (heavy sweating), take pieces of the tumor for analysis.\n📌 Technical point: all incisions and sutures are made with special suturing devices - like a mini-stapler."
  }
 },
 {
"name": "Drainage and completion",
"description": {
"professional": "Revision for hemostasis (especially intercostal vessels). Installation of 24-28 Fr drainage through the lower port under visual control. Connection to the active aspiration system (-20 cm H2O). Layer-by-layer suturing of ports. Control X-ray in the operating room.\nInstruments:\n- Pleurovac chest drain\n- Vicryl suture material\n- C-arm X-ray machine\nTechnique:\n1. Fixing the drain with a double suture\n2. Checking the straightening of the lung\nLogistics:\n- The drain is removed when the discharge is <100 ml/day\nNuance: In case of prolonged exudation - connection of the Heimlich system",
"normal": "After all manipulations, a drainage tube is inserted into the chest through one of the punctures. It is connected to a jar of water to allow air and liquid to come out. The incisions are sutured with a cosmetic suture.\n📌 Good news: the drainage is usually removed after 1-2 days, and the stitches are almost invisible."
  }
 },
 {
"name": "Postoperative care",
"description": {
"professional": "Activation after 4-6 hours. Pain relief: NSAIDs + local block. Breathing exercises from the first day. Control X-ray after 24 hours. Removal of drainage in the absence of air/blood. Discharge on the 3-5th day.\nInstruments:\n- Spirometer for exercise therapy\n- Portable X-ray machine\n- Thoracic belt\nPostoperative protocol:\n1. Antibiotics 24 hours\n2. Analgesics according to the scheme\n3. Physiotherapy\nComplications:\n- Subcutaneous emphysema (8%)\n- Persistent fistula (1%)\n- Atelectasis (5%)",
"normal": "In just a few hours, the patient can get up and walk. Breathing exercises with a special device are mandatory.\n📌 Rehabilitation: in a week you can return to normal life, and in a month - even play sports!"
    }
   }
  ]
 },
{
"keys": [
"enucleation of mediastinal tumor",
"thoracic surgery",
"thymoma",
"mediastinal neuroma",
"video-assisted surgery"
],
"name": "Enucleation of mediastinal tumor",
"modes": {
"professional": "Microsurgical removal of mediastinal neoplasm with preservation of the capsule. Indications: benign thymomas, neuromas, teratomas. Stages: access to the mediastinum, isolation of the tumor from critical structures (main vessels, trachea, nerves), hemostasis, drainage. Critical control of the phrenic and recurrent nerves.",
"normal": "A surgery to remove a tumor in the chest between the lungs, where the main vessels and nerves pass. The surgeon shells the tumor like a nut, without damaging the surrounding tissue."
},
"steps": [
{
"name": "Anesthesia and positioning",
"description": {
"professional": "General endotracheal anesthesia with mechanical ventilation. Supine position with a cushion under the shoulder blades (for anterior mediastinum) or on the side (for posterior mediastinum). Monitoring of venous pressure through a catheter in the subclavian vein. Insertion of a urinary catheter. Thrombosis prevention (heparin 5000 U).\nInstruments:\n- Double-lumen endotracheal tube\n- Central venous catheter\n- Invasive blood pressure sensor\nTechnique:\n1. For tumors >5 cm - arterial line in the radial artery.\n2. Preparedness for emergency sternotomy in case of bleeding.\nLogistics:\n- Marking the tumor projection on the skin using CT.\nNote: In case of myasthenia - avoid muscle relaxants.",
"normal": "The patient is placed on his back, placing a pillow under the thoracic region - this expands the space between the ribs. General anesthesia is administered and a special tube is inserted into the trachea for artificial respiration.\n📌 Important: for tumors near the heart, an emergency blood transfusion device is always prepared."
  }
 },
 {
"name": "Surgical approach",
"description": {
"professional": "Anterior mediastinum: partial sternotomy (upper for thymomas) or VATS (3 ports). Posterior mediastinum: thoracotomy along the 4th-5th intercostal space. Dissection of the mediastinal pleura along the phrenic nerve. Visualization of the tumor in the capsule.\nInstruments:\n- Oscillating sternum saw\n- Thoracoscope 10 mm 30°\n- Finochetto rib retractor\nTechnique:\n1. For VATS - camera in the 5th intercostal space along the midaxillary line.\n2. Protection of the internal thoracic artery during sternotomy.\nLogistics:\n- Intraoperative ultrasound to determine the boundaries.\nNuance: In case of invasive thymomas - readiness for thymectomy.",
"normal": "To access the tumor, the surgeon either partially dissects the sternum (as when opening a door) or makes 3-4 small incisions between the ribs for a video camera and instruments.\n📌 Interesting: the phrenic nerve, which controls breathing, is highlighted with a bright blue ribbon - it cannot be damaged!"
  }
 },
 {
"name": "Tumor isolation",
"description": {
"professional": "Blunt isolation of the capsule with a Penfield dissector. Gradual separation from the pericardium (with anterior mediastinum) or the spine (with posterior). Coagulation of feeding vessels with a 15 W bipolar. Identification and preservation of the brachiocephalic veins, superior vena cava, and recurrent laryngeal nerve.\nInstruments:\n- Harmonic scalpel\n- DeBakey atraumatic clamps\n- Metzenbaum scissors\nTechnique:\n1. Starting the isolation from the least vascularized pole.\n2. Using hydrodissection (saline + adrenaline).\nLogistics:\n- Marking the tumor orientation with 6-0 sutures.\nNuance: In case of cystic lesions - aspiration of the contents with an 18G needle.",
"normal": "The tumor is carefully «peeled» from the surrounding tissues, as if peeling an orange, without damaging the capsule. Particular care is taken near large veins and nerves - they are wrapped in soft protective tapes.\n📌 A tricky part: some tumors stick to the pericardium — then the surgeon uses an «electric scalpel» that cuts and cauterizes at the same time."
  }
 },
 {
"name": "Processing of feeding vessels",
"description": {
"professional": "Clipping of arterial branches from the internal mammary artery with titanium clips. Ligation of venous tributaries into the superior vena cava (Prolene 5-0 suture). Control of tumor bed hemostasis with a hemostatic sponge (Surgicel). Checking the integrity of the pleura.\nInstruments:\n- Clip applicator with medium clips\n- Suture material with an atraumatic needle\n- Floseal hemostatic matrix\nTechnique:\n1. Suturing vessels «in two layers» with a diameter of> 3 mm.\n2. Use of argon-enhanced coagulation on the pericardium.\nLogistics:\n- Counting the number of installed clips.\nNuance: If the pleural cavity is damaged - install additional drainage.",
"normal": "The blood vessels feeding the tumor are clamped with tiny titanium clips and crossed. The area where the tumor was is treated with a special «hemostatic sponge» - it dissolves in 2-3 weeks.\n📌 Important: if the pleural cavity (lining of the lung) is opened, the surgeon immediately inserts an additional drainage tube."
  }
 },
 {
"name": "Tumor extraction",
"description": {
"professional": "Placing the preparation in an endobag. Expansion of one of the ports to 3-4 cm for extraction (for VATS). For large tumors - morcellation in a container. Urgent histological examination. Revision of the bed for the absence of residual tissue.\nInstruments:\n- EndoCatch endocontainer\n- Morcellator with a protective cover\n- Sterile measuring cup\nTechnique:\n1. Avoid contact of the tumor with the wound edges.\n2. Photographic recording of the stages for the protocol.\nLogistics:\n- Weighing the tumor indicating the volume.\nNote: In case of teratomas, be careful with the contents (risk of infection).",
"normal": "The tumor is placed in a special container bag and removed through the largest puncture (or through an incision in the sternum). If the formation is too large, it is crushed inside the bag, like crushed ice for cocktails.\n📌 Critical: the contents of cystic tumors should not get into the wound - this can cause inflammation!"
  }
 },
 {
"name": "Completion of the operation",
"description": {
"professional": "Installation of drainage in the mediastinum (24 Fr) through a separate puncture. Layered suturing: sternum - with stainless steel wire, muscles - Vicryl 0, skin - intradermal suture. Connecting the drainage to the active aspiration system (-10 cm H2O).\nInstruments:\n- Pleurovac drainage\n- Liston bone nippers\n- Mathieu needle holder\nPostoperative protocol:\n1. X-ray/CT after 2 hours.\n2. Pain relief: epidural anesthesia + Ketorolac.\n3. Removing the drainage if the discharge is <100 ml/day.\nComplications:\n- Horner's syndrome (1%).\n- Bleeding (2%).\n- Chylothorox (rare).",
"normal": "A drainage tube is inserted into the mediastinum to remove blood and lymph. The sternum is secured with titanium staples, the muscles and skin are sutured with absorbable threads. After 4-6 hours, the patient is allowed to drink, and after 24 hours - to get up.\n📌 Good news: most of these tumors are benign, and surgery provides a complete cure!"
    }
   }
  ]
 },
{
"keys": [
"tracheal tumor resection",
"tracheal surgery",
"tracheal stenosis",
"thoracic oncology",
"circular tracheal resection"
],
"name": "Tracheal tumor resection",
"modes": {
"professional": "Radical removal of a tracheal tumor with circular or wedge resection, restoration of airway continuity. Stages: intubation of the tumor, access, mobilization of the trachea, resection with histological control of the edges, end-to-end anastomosis. Control of blood supply and anastomosis tension is critical.",
"normal": "Surgery to remove a tumor in the trachea (breathing tube) with subsequent suturing of healthy areas. Restores normal breathing and prevents suffocation."
},
"steps": [
{
"name": "Complex intubation",
"description": {
"professional": "Conscious induction (sedation + local anesthesia). Flexible bronchoscopy to assess patency. Intubation through the tumor with a narrow tube (6.0-6.5 mm) or above it. Alternative: high-frequency jet ventilation. Monitoring: SpO2, EtCO2, invasive BP.\nInstruments:\n- 4.2 mm video bronchoscope\n- Parker Flex-Tip tubes\n- HFJV device\nTechnique:\n1. «Sliding» intubation under visual control.\n2. Backup tracheostomy for critical stenosis.\nLogistics:\n- Readiness for extracorporeal membrane oxygenation (ECMO).\nNuance: For subglottic tumors - intubation through a stoma.",
"normal": "The riskiest stage! A tube is inserted into the patient's trachea directly through the tumor - like a thread through a narrow eye of a needle. This is done very carefully so as not to block the remaining lumen.\n📌 Emergency option: if the tumor almost completely blocks the trachea, they can immediately make an opening in the neck (tracheostomy)."
  }
 },
 {
"name": "Surgical approach",
"description": {
"professional": "Cross incision above the jugular notch + median sternotomy (for tumors of the lower third). Dissection of the band muscles of the neck. Isolation of the trachea from the cricoid cartilage to the bifurcation. Preservation of the lateral vascular bundles (risk: damage to the recurrent nerves).\nInstruments:\n- Colorado-tip electrocoagulator\n- Tracheal retractors\n- Nerve stimulator\nTechnique:\n1. With cervical access - hyperextension of the neck on a bolster.\n2. Mobilization of the trachea no more than 1 cm on each side.\nLogistics:\n- Marking the tumor with staples before resection.\nNuance: With carcinoids - avoid palpation of the tumor (risk of bronchospasm).",
"normal": "The surgeon makes an incision at the base of the neck and/or dissects the sternum. The trachea is freed from surrounding tissues, like a wire is cleaned of insulation.\n📌 Caution: the nerves that control the voice pass nearby - damage to them will make the voice hoarse forever."
  }
 },
 {
"name": "Tumor resection",
"description": {
"professional": "Circular resection (max. 5 cm in adults): transverse incisions above and below the tumor. Wedge resection for small lesions. Urgent histological examination of the edges. Lymph node dissection of the paratracheal nodes. Protection of the distal section with a sterile tube.\nInstruments:\n- Tracheal scissors with an angled blade\n- Cryoapplicator for urgent biopsy\n- Endotracheal tube for distal ventilation\nTechnique:\n1. Resection with the capture of 1 cm of healthy tissue in cancer.\n2. Preservation of the posterior membranous portion during wedge resection.\nLogistics:\n- The tumor is removed as a single block with tissue.\nNuance: In case of adenoid cystic cancer — frozen sections of all edges.",
"normal": "The surgeon cuts out a section of the trachea with the tumor, leaving clean edges — as when cutting off a damaged hose. The sections are sent for urgent analysis to make sure that the entire tumor has been removed.\n📌 Life hack: if a large section needs to be removed, the trachea is “stretched” with special balloons before the operation — then the remaining ends are easier to connect."
  }
 },
 {
"name": "Tracheal anastomosis",
"description": {
"professional": "Connection of the ends of the trachea with PDS 3-0 sutures: first the posterior membranous portion (continuous suture), then the anterior cartilaginous (separate interrupted sutures). Tension relief: submental suture to sternum, tongue root mobilization. Leak testing with saline under 30 cm H2O.\nInstruments:\n- Castroviejo needle holder\n- Absorbable suture material\n- Bronchoscope for control\nTechnique:\n1. Sutures through cartilage without mucosal capture.\n2. Knots outside to minimize granulomas.\nLogistics:\n- Use of a surgical microscope during reconstructions.\nNuance: In diabetes, add fibrin glue.",
"normal": "The ends of the trachea are sutured like the sleeves of a suit - first the back wall with a continuous suture, then the front wall with separate stitches. To prevent the sutures from coming apart, the patient's head is fixed in a bent position with a special collar.\n📌 Important: each suture must be perfectly straight - the slightest fold will cause scarring and new stenosis."
  }
 },
 {
"name": "Completion of the operation",
"description": {
"professional": "Drainage of the anterior mediastinum (Blake 19Fr drainage). Layered suturing with muscle repositioning. Fixation of the chin to the sternum with a «straitjacket» bandage (reduces tension). Extubation in the operating room with a stable anastomosis.\nInstruments:\n- Active drainage system\n- Mental suture made of 2-0 nylon\n- Rigid Philadelphia collar\nPostoperative protocol:\n1. Bronchoscopy on the 1st and 3rd days.\n2. Parenteral nutrition for 5 days (immobilization of the neck).\n3. CT after 1 month.\nComplications:\n- Anastomotic dehiscence (5%).\n- Granulomas (8%).\n- Restenosis (12% with radiation therapy).",
"normal": "After checking the tightness of the suture, drainage is placed and the wound is sutured. The patient is given a special collar that does not allow the neck to straighten for 2 weeks - the sutures should heal without tension.\n📌 Amazing: most patients breathe on their own on the day of surgery — the trachea heals very quickly!"
    }
   }
  ]
 },
{
"keys": [
"thoracotomy",
"opening the chest",
"lung surgery",
"thoracic surgery",
"open chest surgery"
],
"name": "Thoracotomy",
"modes": {
"professional": "Surgical access to the chest cavity through the intercostal space or by resecting the rib. Main types: post-terolateral, axillary, anterior. It is used for operations on the lungs, heart, esophagus and mediastinum. Requires separate ventilation of the lungs and control of hemostasis of the intercostal vessels.",
"normal": "Surgery to open the chest to access the lungs, heart or other organs. The surgeon makes an incision between the ribs to reach the desired area."
},
"steps": [
{
"name": "Preparation and anesthesia",
"description": {
"professional": "Intubation with a double-lumen tube for separate lung ventilation. Position the patient on the healthy side with a cushion under the chest (for post-terolateral access). Preparation of the surgical field from the clavicle to the 12th rib. Placement of a urinary catheter and an arterial line.\nInstruments:\n- Double-lumen endotracheal tube\n- Bronchoscope for positioning\n- 20G arterial catheter\nTechnique:\n1. Lung isolation test (collapse of the operated lung).\n2. Preventive antibiotic therapy (cefazolin 2 g).\nLogistics:\n- Marking the blood pressure level on the dependent arm.\nNuance: In case of aortic pathology - a catheter in the right radial artery.",
"normal": "The patient is placed on his side, a special breathing tube is inserted, which allows one lung to be disconnected during surgery. This gives the surgeon space to work.\n📌 Important: before the operation to check how the patient tolerates the disconnection of one lung - they do a test compression of the bronchus."
  }
 },
 {
"name": "Surgical incision",
"description": {
"professional": "Skin incision along the V-VI intercostal space from the paravertebral line to the midclavicular. Layer-by-layer dissection: skin, subcutaneous tissue, latissimus dorsi muscle, serratus muscle. Electrocoagulation of bleeding vessels. Isolation of the intercostal space while preserving the vascular-nerve bundle.\nInstruments:\n- Scalpel No. 20\n- Valleylab electrocoagulator\n- Muscle hooks\nTechnique:\n1. Incision along the upper edge of the underlying rib.\n2. Blunt detachment of the periosteum with a raspatory.\nLogistics:\n- Used gauze swabs are counted.\nNuance: In repeated operations - access through the old scar field.",
"normal": "The surgeon makes an arcuate incision 15-20 cm long from the back to the armpit. He dissects the skin, subcutaneous fat and muscles layer by layer, exposing the ribs.\n📌 Interesting: the incision is often made along the bra line in women - so that the seam is less noticeable."
  }
 },
 {
"name": "Entrance to the chest cavity",
"description": {
"professional": "Dissection of the intercostal muscles along the upper edge of the rib. Introduction of a retractor (Finochetto) with gradual spreading of the ribs by 10-15 cm. Revision of the pleural cavity for adhesions. In case of dense adhesions - careful blunt separation with a finger. Hemostasis of damaged vessels with clips.\nInstruments:\n- Rib retractor with ratchet\n- Metzenbaum scissors\n- Hemostatic clips\nTechnique:\n1. Entry into the pleura in the posterior section (the layer is thinner there).\n2. Control of the intercostal nerve.\nLogistics:\n- Change the retractor every 30 minutes to prevent neuropraxia.\nNuance: With osteoporosis - risk of rib fracture during retractor.",
"normal": "The surgeon carefully separates the muscles between the ribs, then inserts a special retractor, which gently pushes the ribs apart. It's like opening blinds - the view of the lung gradually opens up.\n📌 Important: expand slowly to avoid breaking the ribs, especially in elderly patients."
  }
 },
 {
"name": "The main stage of the operation",
"description": {
"professional": "Depending on the goal: lobectomy (ligation of lobar vessels and bronchus), pleurectomy (separation of the pleura from the chest wall), removal of a mediastinal tumor (isolation of the formation from vital structures). Control of hemostasis by bipolar coagulation. Drainage of the surgical field.\nInstruments:\n- Satinsky vascular clamps\n- Ultrasonic dissector\n- Pool aspirator\nTechnique:\n1. During lobectomy - the sequence «artery-vein-bronchus».\n2. During pleurectomy - preservation of the endothoracic fascia.\nLogistics:\n- Labeling of preparations for histology.\nNuance: In case of cancer - mandatory mediastinal lymph node dissection.",
"normal": "Depending on the purpose of the operation, the surgeon can: remove part of the lung, remove a tumor, treat a purulent focus or perform other manipulations. Bleeding is monitored at all times and important structures are preserved.\n📌 A difficult moment: when working near the heart or large vessels, every movement must be precise - like a sapper."
  }
 },
 {
"name": "Drainage and suturing",
"description": {
"professional": "Installation of two drains (28-32 Fr): apical - for air, basal - for fluid. Layered suturing: intercostal muscles (Vicryl 2-0), latissimus dorsi (PDS 0), subcutaneous tissue (Vicryl 3-0), skin (stapler or subcuticular suture). Fixation of drains with stay sutures.\nInstruments:\n- Pleurovac chest drains\n- Mathieu needle holder\n- Skin stapler\nTechnique:\n1. Drainage is performed through a separate puncture.\n2. Sealing of sutures with a test with saline solution.\nLogistics:\n- Checking drains for fluctuations during breathing.\nNuance: In emphysematous patients - an additional pleural suture.",
"normal": "After completion of the main part, two plastic tubes are inserted into the chest - one removes air, the other liquid. The muscles and skin are sutured in layers.\n📌 Important: drains are left for 2-3 days, they are removed when the lung has fully expanded and air stops leaking."
  }
 },
 {
"name": "Postoperative management",
"description": {
"professional": "Transfer to the intensive care unit with SpO2, blood pressure, and diuresis monitoring. X-ray control 1 hour after surgery. Pain relief: epidural anesthesia + PCA pump. Activation after 4-6 hours with breathing exercises. Removal of drains in the absence of air/effusion (<100 ml/day).\nInstruments:\n- Analgosedation device\n- Incentive spirometer\n- Mobile X-ray machine\nPostoperative protocol:\n1. Antibiotics 24-48 hours.\n2. Low molecular weight heparins 7 days.\n3. Daily dressing.\nComplications:\n- Atelectasis (15-20%).\n- Bleeding (3%).\n- Persistent pain syndrome (8%).",
"normal": "After the operation, the patient is transferred to the intensive care unit, where breathing and drainage are monitored. After a few hours, help to sit up and start breathing deeply - this prevents complications.\n📌 The main thing: despite the pain, you need to cough and breathe deeply - this way the lung will straighten out faster!"
    }
   }
  ]
 },
{
"keys": [
"pleurodesis",
"pleural effusion",
"malignant pleurisy",
"thoracoscopy",
"pleural adhesion"
],
"name": "Pleurodesis",
"modes": {
"professional": "A surgical procedure for obliteration of the pleural cavity in case of recurrent effusions. Methods: mechanical (pleurectomy), chemical (talc, doxycycline) or combined. Stages: drainage of effusion, treatment of the pleura, drainage. Control of aerostasis and adequate pain relief are critical.",
"normal": "A procedure that «glues» the pleural layers together to prevent fluid accumulation in the lungs. Most commonly performed for cancer or persistent pneumothoraces."
},
"steps": [
{
"name": "Preparation and anesthesia",
"description": {
"professional": "General anesthesia with double-lumen intubation or local anesthesia for VATS. Position on the healthy side with arm abduction. Establishment of peripheral/central venous access. Premedication: fentanyl 1-2 mcg/kg, midazolam 1-2 mg. SpO2, ECG, BP monitoring.\nInstruments:\n- Thoracoscopic set\n- Pleurovac drainage system\n- Infusomat for anesthetics\nTechnique:\n1. Lung isolation test during intubation.\n2. Puncture of effusion under ultrasound navigation.\nLogistics:\n- Preparation of 2-3 liters of warm saline.\nNuance: For local anesthesia - add 1% lidocaine to the trocar insertion points.",
"normal": "The patient is placed on his side, general anesthesia or local anesthesia is administered. If a double-lumen tube is used, one lung is temporarily disconnected - this gives the surgeon space to work.\n📌 Important: before the operation, be sure to remove the maximum amount of fluid through the puncture - this makes it easier to see the pleural cavity."
  }
 },
 {
"name": "Drainage of the pleural cavity",
"description": {
"professional": "Thoracentesis along the midaxillary line in the 6-7 intercostal space (for VATS - 10 mm trocar). Aspiration of effusion with an electric suction pump. Inspection of the cavity: assessment of the degree of lung collapse, presence of adhesions, tumor nodes. Collection of fluid for cytology/biochemistry.\nInstruments:\n- 5-12 mm trocars\n- Aspirator with adjustable pressure\n- Containers for analysis\nTechnique:\n1. Puncture of the «safe triangle»: between the anterior serratus, latissimus dorsi muscles and the 5th rib.\n2. Control of the absence of damage to the diaphragm.\nLogistics:\n- The volume of removed fluid is recorded (often 1-2 l).\nNuance: In case of hemorrhagic effusion - lavage until «clear waters».",
"normal": "A tube is inserted through a small incision or puncture and all accumulated fluid is removed. The surgeon examines the cavity through a camera - looking for tumor nodes or areas of inflammation.\n📌 Interesting: sometimes cancer cells are found in the fluid - this helps to clarify the diagnosis."
  }
 },
 {
"name": "Pleura treatment",
"description": {
"professional": "Chemical pleurodesis: spraying 4-5 g of sterile talc (or doxycycline 500 mg in 100 ml of saline). Mechanical: pleural abrasion with a hard brush/gauze. Combined: talc after pleurectomy. Control of complete lung straightening under a pressure of 20 cm H2O.\nInstruments:\n- Talc applicator (spray system)\n- DeVilbiss thoracoscopic brush\n- Electrocoagulator for hemostasis\nTechnique:\n1. In VATS - treatment of all sections (apical, diaphragmatic).\n2. Uniform distribution of the sclerosant.\nLogistics:\n- Talc exposure time is 10 min.\nNuance: In case of mesothelioma - additional photodynamic therapy.",
"normal": "The most important stage! Sterile talc (like baby powder) is sprayed into the cavity - it causes inflammation and «sticking» of the pleural sheets. An alternative is special chemical solutions or even mechanical «sanding» of the pleura.\n📌 Important: the lung must be completely straightened before applying talc - otherwise there will be no effect."
  }
 },
 {
"name": "Drainage and sealing",
"description": {
"professional": "Installation of two 28-32 Fr drains: apical (for air) and basal (for liquid). Connection to the active aspiration system (-20 cm H2O). Checking the tightness with a suture around the drains. Layer-by-layer suturing of wounds. Fixing the drains with sutures/adhesive tape.\nInstruments:\n- Pigtail drain\n- Prolene 2-0 suture material\n- Oasis vacuum system\nTechnique:\n1. Drainage is carried out through a separate puncture.\n2. Control of air bubbles.\nLogistics:\n- Daily recording of the volume of discharge.\nNuance: In case of ongoing pneumothorax - Heimlich system.",
"normal": "Two tubes are inserted into the chest: one removes air, the other - the remaining fluid. They are connected to a vacuum system - like a vacuum cleaner. The puncture sites are carefully sutured.\n📌 Note: drains can be left in place for several days until the lung has fully straightened."
  }
 },
 {
"name": "Postoperative control",
"description": {
"professional": "X-ray immediately after surgery. Pain relief: NSAIDs + opioids (tramadol 50 mg every 6 hours). Drains are removed when the daily volume is <100 ml and there is no air. Antibiotic therapy (ceftriaxone 1 g / day for 3 days). Control CT after 7 days.\nInstruments:\n- Portable X-ray machine\n- Infusomat for analgesia\n- Pleural biopsy system\nPostoperative protocol:\n1. Breathing exercises from the 1st day.\n2. Activation after 4-6 hours.\n3. Ultrasound if relapse is suspected.\nComplications:\n- Empyema (2-3%).\n- ARDS (with talc) <1%.\n- Recurrence of effusion (5-10%).",
"normal": "Immediately after the operation, they take an X-ray to check how the lung has straightened out. The drains are removed when air and fluid stop coming out (usually after 2-3 days).\n📌 Good news: in 90% of patients after pleurodesis, effusion no longer accumulates for months!"
    }
   }
  ]
 },
{
"keys": [
"cholecystectomy",
"gallbladder removal",
"laparoscopic cholecystectomy",
"gallstone disease",
"gastrointestinal surgery"
],
"name": "Cholecystectomy",
"modes": {
"professional": "Surgical removal of the gallbladder by laparoscopic or open method. Main stages: access, isolation of the cystic duct and artery, mobilization of the gallbladder, hemostasis. Critical point - identification of the triangle of Calot.",
"normal": "Surgery to remove the gallbladder, most often due to stones. It is done through small punctures (4 holes) - the patient recovers in 2-3 days."
},
"steps": [
{
"name": "Preparation and anesthesia",
"description": {
"professional": "General endotracheal anesthesia with muscle relaxation. Supine position with the head end down (anti-Trendelenburg) and left rotation. Insertion of a nasogastric tube with an overfilled stomach. Treatment of the surgical field from the xiphoid process to the pubis.\nInstruments:\n- Macintosh laryngoscope No. 3\n- Endotracheal tube 7.0-7.5 mm\n- Chlorhexidine-based antiseptic\nTechnique:\n1. Preoxygenation with 100% oxygen for 3 minutes\n2. Induction with propofol (2 mg/kg) + fentanyl (1-2 mcg/kg)\nLogistics:\n- Airway pressure control <12 mm Hg.\nNuance: In case of obesity (BMI>35) - intubation with a video laryngoscope.",
"normal": "The patient is placed on his back, slightly tilting the table so that the legs are above the head. General anesthesia is administered - the person falls asleep and does not feel anything. The abdomen is treated with an antiseptic - from the sternum to the pubis.\n📌 Important: before the operation, be sure to check for allergies to anesthesia drugs!"
  }
 },
 {
"name": "Creation of pneumoperitoneum",
"description": {
"professional": "Veresh needle puncture at Calca point (1 cm above the navel). CO2 insufflation to a pressure of 12-14 mm Hg. Control of uniform gas distribution. Insertion of the first 10 mm trocar under visual control. Installation of a 30° laparoscope.\nInstruments:\n- 150 mm Veresh needle\n- Insufflator with gas heating\n- Trocar with a safety valve\nTechnique:\n1. «Suspended drop» test to confirm the intraperitoneal position\n2. Gradually increase the pressure from 8 to 14 mm Hg.\nLogistics:\n- CO2 consumption no more than 30-40 l per operation\nNuance: In case of adhesions - open access Hasson.",
"normal": "Carbon dioxide is pumped into the stomach through a puncture in the navel - the stomach inflates like a balloon. This is necessary so that the surgeon can see and work. Then a camera is inserted - now everything is visible on the screen.\n📌 Interesting: the gas is not harmful and is completely eliminated after the operation!"
  }
 },
 {
"name": "Insertion of trocars",
"description": {
"professional": "Installation of working ports under visual control: epigastric (10 mm), right subcostal (5 mm), additional in the left subcostal region if necessary. The «American trapezoid» position - the surgeon is on the left, the assistant is on the right of the patient.\nInstruments:\n- Trocars with fixing cuffs\n- Videolaparoscopic stand\n- Maryland instruments and atraumatic clamps\nTechnique:\n1. Epigastric port - 3 cm below the xiphoid process\n2. Right subcostal - along the midclavicular line\nLogistics:\n- Fixation of trocars to the skin with sutures\nNuance: During pregnancy - displacement of ports upward.",
"normal": "They also do 2-3 punctures (each 5-10 mm) in different places of the abdomen. Instruments are inserted through them: one «holds» the liver, the other works. The surgeon sits and looks at the screen, where everything is magnified 10 times!\n📌 Important: the instruments move like chopsticks - only forward-backward, left-right."
  }
 },
 {
"name": "Isolation of the elements of the Calot triangle",
"description": {
"professional": "Identification of the cystic duct, artery and hepatic duct. Blunt separation of the peritoneum. Dissection of the cystic artery (diameter 1.5-2 mm) with clipping with titanium staples. Mobilization of the neck of the gallbladder.\nInstruments:\n- Bipolar coagulation (LigaSure)\n- Clip applicator (Hem-o-lok)\n- Laparoscopic scissors\nTechnique:\n1. «Skeletization» of the cystic duct\n2. «Critical view» control - 100% identification of structures\nLogistics:\n- Clips are applied 2 at the proximal and distal ends\nNuance: In case of atypical anatomy - intraoperative cholangiography.",
"normal": "The surgeon finds a «safety triangle» - between the bile duct, artery and liver. Here you need to work very carefully! The artery is clamped with clips - like small clothespins.\n📌 Caution: if you mix up the ducts, you can damage the common bile duct - this is a serious complication."
  }
 },
 {
"name": "Cutting off and removing the gallbladder",
"description": {
"professional": "Intersection of the cystic duct and artery between clips. Separation of the gallbladder from the liver bed with a harmonic scalpel (mode 3). Hemostasis of the liver bed with argon-enhanced coagulation. Removal of the bladder in an endocontainer through the umbilical port.\nInstruments:\n- Harmonic scalpel (Harmonic)\n- Endo bag (Endo Catch)\n- Irrigator-aspirator\nTechnique:\n1. Cutting off from the liver from the neck to the bottom\n2. For large stones - crushing in a container\nLogistics:\n- Container volume 10-15 mm\nNuance: In case of bladder perforation - sanitation with 0.05% chlorhexidine.",
"normal": "The gallbladder is cut off from the duct and carefully «peeled off» from the liver with a special instrument that immediately cauterizes the vessels. Then it is placed in a special bag and removed through the navel.\n📌 Interesting: if the stones are very large, they can first be crushed right in the bag!"
  }
 },
 {
"name": "Completion of the operation",
"description": {
"professional": "Revision of the bed for hemostasis. Drainage as indicated (Blake 19Fr drainage into the subhepatic space). Removal of trocars under visual control. Suturing the aponeurosis of 10 mm Vicryl 0 ports. Application of intradermal sutures. Intraoperative cholangiography if in doubt.\nInstruments:\n- Absorbable suture material\n- Dermabond dermal glue\n- C-arm for cholangiography\nPostoperative protocol:\n1. Activation after 4-6 hours\n2. Pain relief: Paracetamol + NSAIDs\n3. Discharge on the 1-3 day\nComplications:\n- Damage to the common bile duct (0.3-0.5%)\n- Bleeding (0.2%)\n- Bile leakage (1%)",
"normal": "The surgeon checks for bleeding, washes the abdomen. The punctures are sutured - 1-2 sutures on the navel, the rest are almost invisible. After 2 hours you can drink, in the evening - get up.\n📌 Good news: you can live a normal life without a gallbladder - the liver itself regulates the secretion of bile!"
    }
   }
  ]
 },
{
"keys": [
"gastrectomy",
"stomach removal",
"stomach cancer",
"total gastrectomy",
"subtotal resection",
"oncosurgery"
],
"name": "Gastrectomy (total/subtotal)",
"modes": {
"professional": "Radical removal of the stomach (total) or part of it (subtotal) with D2 lymph node dissection for malignant neoplasms. Includes mobilization of the stomach, intersection of vessels, reconstruction of the gastrointestinal tract (esophagojejunostomy/gastrojejunostomy), drainage.",
"normal": "Surgery for complete or partial removal of the stomach for cancer or severe ulcers. The surgeon creates a new pathway for food from the esophagus directly into the intestine."
},
"steps": [
{
"name": "Anesthesia and access",
"description": {
"professional": "Induction of general anesthesia: propofol (2 mg/kg), fentanyl (3-5 mcg/kg), rocuronium (0.6 mg/kg). Tracheal intubation, placement of a nasogastric tube. Central venous access (subclavian vein). Supine position with a cushion under the lower back. Upper midline laparotomy from the xiphoid process to the umbilicus (+ left bypass if necessary) or laparoscopic access (5 trocars).\nInstruments:\n- Laparotomy set\n- Harmonic scalpel (LigaSure)\n- Laparoscope 10 mm 30°\nTechnique:\n1. In case of laparoscopy - pneumoperitoneum up to 12 mm Hg.\n2. Revision of the abdominal cavity for metastases (liver, peritoneum).\nLogistics:\n- Marking the edges of the incision with protective napkins.\nNuance: In case of obesity (BMI> 35) - extension of the incision to the pubis.",
"normal": "The patient is put under deep anesthesia, a tube is inserted into the stomach through the nose. The surgeon makes a large incision from the sternum to the navel (or several small punctures in case of laparoscopy). First, they check for metastases in other organs.\n📌 Important: before the incision, the abdomen is treated with iodine - as before an injection, but over a larger area."
  }
 },
 {
"name": "Laparotomy and revision",
"description": {
"professional": "Upper midline laparotomy from the xiphoid process to the navel (if necessary - bypassing it on the left). Revision of the abdominal cavity: liver, peritoneum, para-aortic lymph nodes. Determination of resectability. Installation of a retractor (for example, Omni-Tract).\nInstruments:\n- Valleylab electrocoagulator (60 W 'Spray' mode)\n- Liver retractor\n- Harmonic ultrasonic scissors\nTechnique:\n1. With total gastrectomy - the incision is extended to 5 cm below the navel.\n2. Cytological washing from the peritoneum if carcinomatosis is suspected.\nLogistics:\n- Marking the resection edges in the subtotal variant.\nNuance: In case of early cancer - minimally invasive access is possible (laparoscopy/robot).",
"normal": "The surgeon makes a vertical incision from the sternum to the navel. A special dilator lifts the costal arch to open access to the stomach. First, they check for metastases in the liver and peritoneum - the course of the operation depends on this.\n📌 Important: in the early stages of cancer, surgery can be performed through punctures (laparoscopy)."
  }
 },
 {
"name": "Mobilization of the stomach",
"description": {
"professional": "Intersection of the gastrocolic ligament while preserving the omental arcades. Ligation of the right gastroepiploic artery at the head of the pancreas. Isolation of the lesser omentum with clipping of the left gastric artery at the point of origin from the celiac trunk. Mobilization of the duodenum (in case of total gastrectomy).\nInstruments:\n- LigaSure bipolar forceps\n- Titanium vascular clips\n- Pean dissector\nTechnique:\n1. In case of subtotal resection - preservation of the right gastroepiploic artery.\n2. Isolation of the stomach from the pancreas by blunt dissection.\nLogistics:\n- Marking of the proximal border (at least 5 cm from the tumor).\nNuance: In case of invasion of the pancreas - resection of the tail of the gland.",
"normal": "The surgeon carefully separates the stomach from the surrounding organs. The vessels feeding the stomach are clamped with titanium clips and crossed. Be especially careful when working with the pancreas, as it can be easily damaged.\n📌 A tricky part: if the tumor has grown into neighboring organs, some of them will also have to be removed."
  }
 },
 {
"name": "Lymph node dissection D2",
"description": {
"professional": "Removal of lymph node stations 1-12a (for total gastrectomy) or 1-7 (for subtotal). Complete isolation of the celiac trunk, common hepatic and splenic arteries. Preservation of the vagus nerves if possible. Separate marking of lymph node groups for histology.\nInstruments:\n- Metzenbaum scissors with microengraving\n- Nerve stimulator\n- Containers for lymph nodes with separate cells\nTechnique:\n1. Layer-by-layer isolation of tissue along the arteries.\n2. Coagulation of lymphatic vessels to prevent lymphorrhea.\nLogistics:\n- The minimum number of removed lymph nodes is 15.\nNote: In case of metastases in the lymph nodes of the 16th station - palliative volume.",
"normal": "All lymph nodes around the stomach and large vessels are removed - this is where cancer primarily metastasizes. They are carefully sorted by zone and sent for urgent analysis.\n📌 Important: sometimes «hidden» metastases are found - then the surgical plan changes."
  }
 },
 {
"name": "Resection and reconstruction",
"description": {
"professional": "In case of total gastrectomy: intersection of the esophagus above the cardia, the duodenum below the pylorus. Formation of the Roux-en-Y esophagojejunostomy (with an EEA 25 mm stapler or a PDS 4-0 hand suture). In case of subtotal: leaving a 3-5 cm gastric stump, side-to-side gastrojejunostomy.\nInstruments:\n- OrVil round stapler\n- GIA 60 mm linear stapler\n- PDS II suture material\nTechnique:\n1. Length of the afferent loop 40-60 cm.\n2. Intussusception of the staple line with a seromuscular suture.\nLogistics:\n- Checking the anastomosis for leaks with methylene blue.\nNuance: In case of obesity - interintestinal anastomosis 100 cm distal.",
"normal": "The stomach is completely or partially removed. The esophagus is directly connected to the small intestine - either «end to end» using a circular stapler, or sutured to the side of the intestine.\n📌 Interesting: the new «stomach» will stretch over time and will be able to accumulate food."
  }
 },
 {
"name": "Drainage and closure",
"description": {
"professional": "Installation of two drains: in the stomach bed (left subphrenic) and at the anastomosis (through the jejunal loop). Layered suturing of the laparotomy wound: aponeurosis (Prolene 0), subcutaneous tissue (Vicryl 3-0), skin (stapler/subcuticular suture). Application of an aseptic dressing.\nInstruments:\n- Jackson-Pratt 19 Fr drain\n- Mathieu needle holder\n- Skin Stapler\nPostoperative protocol:\n1. Tube feeding from the 1st day.\n2. Contrast study of the anastomosis on the 5-7th day.\n3. Vitamin B12 for life.\nComplications:\n- Anastomotic failure (3-5%).\n- Dumping syndrome (20%).\n- Anemia (100% without replacement therapy).",
"normal": "Drainage tubes are placed in the abdominal cavity to drain the fluid. The incision is sutured with strong threads that will dissolve on their own. The next day, they begin to administer nutritional mixtures through a tube.\n📌 The main thing: after removing the stomach, you will have to inject vitamin B12 for life - it can no longer be absorbed."
    }
   }
  ]
 },
{
"keys": [
"gastroscopy",
"polyp resection",
"polypectomy",
"endoscopy",
"Gastrointestinal tract"
],
"name": "Gastroscopic resection of a polyp",

"modes": {
"professional": "Endoscopic removal of gastric mucosal neoplasms using a diathermic loop or biopsy forceps. Includes visualization, marking, resection, and hemostasis. Control of resection depth is critical if invasive growth is suspected.",
"normal": "A flexible tube with a camera and special instruments is inserted through the mouth to cut off suspicious growths in the stomach. No incisions - only discomfort when swallowing the tube."
},
"steps": [
{
"name": "Patient preparation",
"description": {
"professional": "Premedication: intravenous midazolam (1-2 mg) and fentanyl (50-100 mcg). Irrigate the throat with 10% lidocaine spray. Place the mouthpiece. Position on the left side with the chin to the chest. Monitor SpO₂ and ECG.\nInstruments:\n- Endoscopic mouthpiece\n- Aspiration pump\n- IV sedation system\nTechnique:\n1. Aspiration risk assessment (Mallampati scale).\n2. «Thumb method» to control the depth of sedation.\nLogistics:\n- Check the readiness of the resuscitation equipment.\nNote: During pregnancy - only superficial sedation.",
"normal": "The patient is given a sedative injection and their throat is treated with an anesthetic spray. A plastic mouthpiece is inserted between the teeth - it will protect the teeth and the endoscope itself.\n📌 Important: you cannot eat for 8 hours before the procedure - otherwise food particles may get into the lungs!" 
  }
 },
 {
"name": "Insertion of the gastroscope",
"description": {
"professional": "Careful insertion of the endoscope (diameter 9-10 mm) through the esophagus under visual control. Air insufflation to straighten the folds of the stomach. Systematic examination: antrum, body, fundus, cardia. Photographic recording of the polyp (size, shape, stem/base).\nInstruments:\n- Video gastroscope with narrow-band imaging (NBI)\n- CO₂ insufflator\n- Irrigation channel\nTechnique:\n1. Insufflation pressure control <15 mm Hg.\n2. Use of water to clean the mucosa.\nLogistics:\n- Marking of biopsy sites in the protocol (clockwise).\nNuance: In case of esophageal strictures, use a pediatric gastroscope.",
"normal": "The doctor carefully inserts a flexible tube through the mouth - you need to make a swallowing motion to help it pass into the esophagus. A little air is supplied to the stomach to straighten out the folds.\n📌 An unpleasant moment: for the first 20 seconds it seems impossible to breathe - but this is a reflex, breathing is maintained through the nose!" 
  }
 },
 {
"name": "Marking and preparing a polyp",
"description": {
"professional": "Lifting the polyp by injecting a saline solution with adrenaline (1:10,000) into the submucosal layer. Marking the borders with electrocoagulation (soft mode 15 W). Assessing the depth of invasion using EUS (endoscopic ultrasound) for formations >1 cm.\nInstruments:\n- Injection needle 23G\n- Electrocoagulator with a needle tip\n- Mini ultrasound sensor 12 MHz\nTechnique:\n1. Injection at 4 points around the polyp.\n2. Creating a «hydraulic cushion» for safety.\nLogistics:\n- Measuring the distance to the pyloric section.\nNuance: If GIST is suspected, refuse biopsy before resection.",
"normal": "The doctor «draws» a safe zone around the polyp: first, he injects a solution to lift it (like when a dentist gives an injection into the gum), then marks the boundaries with weak electric shocks.\n📌 Smart technology: ultrasound at the tip of the endoscope checks whether the polyp has grown deep into the wall."
  }
 },
 {
"name": "Polyp resection",
"description": {
"professional": "Polyp capture with a diathermic loop (size 2-3 cm) followed by coagulation (mixed mode 30 W cutting/40 W coagulation). An alternative for small polyps (<5 mm) is cold biopsy with forceps. Removal of the specimen through the mouth using a trap mesh.\nInstruments:\n- Snare loop made of titanium nickelide\n- Biopsy forceps with a needle\n- Dormia nylon mesh\nTechnique:\n1. Capture of the polyp stalk by 1/3 from the base.\n2. Gradually tightening the loop with coagulation.\n3. «Trap method» to prevent loss of the specimen.\nLogistics:\n- Recording the coagulation time (not >5 sec per approach).\nNuance: If the stalk is thick, preliminary clipping is required.",
"normal": "The polyp is captured with a thin wire loop, like a lasso. A weak electric current is applied while simultaneously squeezing, resulting in a «cut-cauterization». The removed polyp is caught in a special basket to be extracted and sent for analysis.\n📌 Important: if the polyp is large, they may first apply a mini-clip, like a paper clip on a bleeding vessel."
  }
 },
 {
"name": "Hemostasis and control",
"description": {
"professional": "Coagulation of vessels in the bed with argon plasma (flow 1 l/min, power 40 W). Application of hemostatic clips (type Resolution) for arterial bleeding. Irrigation of the bed with sucralfate suspension. Repeated examination after 5 minutes to exclude delayed bleeding.\nInstruments:\n- Argon plasma coagulator\n- Clip applicator with a rotary mechanism\n- Syringe with sucralfate\nTechnique:\n1. «Point» coagulation mode.\n2. Clipping according to the «sandwich» principle.\n3. Test with insufflation up to 20 mm Hg.\nLogistics:\n- Counting the used clips.\nNuance: During coagulation in the antral section - peristalsis control.",
"normal": "The removal site is treated with a «plasma torch» - it is painless, the patient feels only slight warmth. If blood oozes, micro staples are placed. At the end, the wound is washed with a medicinal gel.\n📌 Follow-up examination: the doctor waits 5 minutes to make sure that the bleeding will definitely not resume."
  }
 },
 {
"name": "Completion of the procedure",
"description": {
"professional": "Aspiration of air and gastric contents. Careful removal of the endoscope with visual control of the esophagus. Observation for 2 hours using sedation. Histological examination of the preparation according to the Vienna classification protocol.\nInstruments:\n- Aspiration catheter\n- Biopsy container with formalin\n- Pulse oximeter\nPostoperative protocol:\n1. Fasting for 2 hours, then cold liquid.\n2. Proton pump inhibitors for 4 weeks.\n3. Control gastroscopy in 3-6 months.\nComplications:\n- Bleeding (1.5%).\n- Perforation (0.3%).\n- Aspiration (0.1%).",
"normal": "The doctor pumps air out of the stomach - this will reduce discomfort after the procedure. After 30 minutes, you can drink water, after 2 hours - light food.\n📌 The main rule: if you experience sharp pain or vomiting with blood - call the doctor immediately! The results of the polyp analysis will be ready in 5-7 days."
    }
   }
  ]
 },
{
"keys": [
"herniorrhaphy",
"inguinal hernia",
"umbilical hernia",
"femoral hernia",
"hernioplasty",
"laparoscopic surgery"
],
"name": "Herniorrhaphy (inguinal, umbilical, femoral)",
"modes": {
"professional": "Surgical elimination of a hernial defect with plastic surgery of the hernial orifice. Options: open technique (according to Lichtenstein, Sapezhko) or laparoscopic (TAPP, TEP). The choice of mesh implant and technique for closing the defect is critical.",
"normal": "Surgery to reduce the protrusion and strengthen the weak spot in the abdominal wall with a special mesh. It is performed through a small incision or punctures."
},
"steps": [
{
"name": "Anesthesia and access",
"description": {
"professional": "Choice of anesthesia: local (0.5% lidocaine) for small hernias, spinal or general anesthesia for complex cases. Marking the surgical field taking into account the type of hernia: inguinal - above the inguinal ligament, umbilical - periumbilical, femoral - below the inguinal fold. Antiseptic treatment from the xiphoid process to the pubis.\nInstruments:\n- Scalpel No. 15\n- Farabeuf hooks\n- Valleylab electrocoagulator\nTechnique:\n1. For inguinal hernia - incision parallel to the inguinal ligament.\n2. For umbilical - crescent-shaped incision below the navel.\n3. In case of femoral hernia - access through the femoral canal.\nLogistics:\n- The boundaries of the hernial orifice are marked before dissection.\nNuance: In children under 5 years old - only suturing of the defect without mesh.",
"normal": "The patient is given an injection in the back or general anesthesia. The surgeon marks the incision site: for an inguinal hernia - in the fold between the abdomen and thigh, for an umbilical hernia - around the navel, for a femoral hernia - just below the groin. The skin is treated with iodine, as before the injection.\n📌 Important: with local anesthesia, the patient may feel a pulling sensation, but not pain."
  }
 },
 {
"name": "Isolation of the hernial sac",
"description": {
"professional": "Layer-by-layer tissue dissection to the aponeurosis. Identification of the hernial sac in the fatty tissue. Careful separation from surrounding structures (spermatic cord in men, round ligament of the uterus in women). Opening the sac, revision of the contents (omentum, intestine).\nInstruments:\n- Mikulicz clamps\n- Cooper scissors\n- Atraumatic tweezers\nTechnique:\n1. In case of strangulated hernia - assessment of intestinal viability (color, peristalsis, vascular pulsation).\n2. Resection of non-viable omentum.\n3. Immersion of organs back into the abdominal cavity.\nLogistics:\n- Strangulated tissues are checked with warm napkins for 5 minutes.\nNuance: In case of sliding hernia - special care with the bladder wall.",
"normal": "The surgeon cuts the skin and muscles, finds the «hernial sac» - this is like an inverted pocket of the peritoneum. Carefully frees it from adhesions. If there is an intestine inside, he checks to see if it has turned blue (a sign of strangulation).\n📌 It's scary, but true: if there is strangulation, part of the intestine can be removed if it «suffocated» without a blood supply."
  }
 },
 {
"name": "Plastic surgery of hernial orifices",
"description": {
"professional": "Suturing the defect with a non-absorbable thread (Prolene 2-0) for small sizes. For large defects - implantation of a polypropylene mesh (size 4-5 cm larger than the hernial orifice). Fixation of the mesh with sutures or a stapler (during laparoscopy). Methods:\n- According to Lichtenstein (inguinal)\n- According to Sapezhko (umbilical)\n- According to Bassini (femoral)\nInstruments:\n- Grid 15x10 cm (light weight)\n- Herniostapler\n- Hegar needle holder\nTechnique:\n1. The mesh is stitched «overlapping» with a margin of 3 cm.\n2. In case of inguinal hernia - bypass the spermatic cord.\n3. Control of the absence of tissue tension.\nLogistics:\n- The mesh is cut out according to an individual shape.\nNuance: In case of laparoscopy - preperitoneal placement of the mesh.",
"normal": "The weak spot is strengthened like a patch: either the edges are pulled together with strong threads (if the hole is small), or covered with a mesh made of synthetic material. Over time, the mesh grows through the tissues and becomes part of the body.\n📌 Amazing: the mesh can be placed even through punctures (laparoscopy) - then the scars are almost invisible!"
  }
 },
 {
"name": "Drainage and suturing of the wound",
"description": {
"professional": "Installation of silicone drainage (Redon 10Fr) for large hernias. Layered suturing: aponeurosis (Prolene 0), subcutaneous tissue (Vicryl 3-0), skin (intradermal suture Monocryl 4-0). Pressure bandage for 24 hours. With laparoscopy - suturing of only ports 5 mm or more.\nInstruments:\n- Drainage with a flotation valve\n- Suture material with an atraumatic needle\n- Skin stapler (at the patient's request)\nTechnique:\n1. Hemostasis control before closure.\n2. In case of inguinal hernia - checking the blood supply to the testicle.\n3. Formation of a cosmetic suture.\nLogistics:\n- The meshes used are registered in the card.\nNuance: In obese patients - additional fixation of the mesh with fibrin glue.",
"normal": "If there was a lot of damage - a tube is inserted to drain the fluid for 1-2 days. The muscles are sutured with strong threads that will dissolve in six months. The skin is sutured with a beautiful cosmetic suture - after healing, a thin white strip will remain.\n📌 Life hack: after surgery, it is better to wear compression underwear - it hurts less."
  }
 },
 {
"name": "Postoperative care",
"description": {
"professional": "Activation after 4-6 hours. Pain relief (paracetamol + NSAIDs). Antibiotic prophylaxis (cefazolin 1 g). Removal of stitches on the 7-10th day. Limitation of physical activity for 1 month. Follow-up examination after 1 month with ultrasound.\nInstruments:\n- Ultrasound machine with a linear sensor\n- Thermometer for temperature monitoring\n- Tonometer\nPostoperative recommendations:\n1. Wearing a bandage for 3-4 weeks.\n2. Elimination of constipation (lactulose).\n3. Gradual increase in activity.\nComplications:\n- Seroma (10-15%).\n- Relapse (1-3% with mesh).\n- Chronic pain (0.5-2%).",
"normal": "You can get up carefully in the evening. It hurts to laugh and cough for the first 3 days - it is better to press a pillow to your stomach. The stitches will be removed in a week, and in a month you can return to the gym.\n📌 Important: if your temperature suddenly rises or the suture turns red, see a doctor immediately, it could be an infection!"
    }
   }
  ]
 },
{
"keys": [
"laparoscopic resection of the sigmoid colon",
"diverticulitis surgery",
"colorectal surgery",
"sigmoid removal",
"intestinal laparoscopy"
],
"name": "Laparoscopic resection of the sigmoid colon",
"modes": {
"professional": "Minimally invasive removal of the affected area of the sigmoid colon with the formation of anastomosis. Indications: diverticulitis, tumors, intestinal obstruction. Stages: CO2 insufflation, bowel mobilization, vessel intersection, resection, anastomosis with a circular stapler.",
"normal": "The surgeon removes the diseased section of the intestine in the shape of the letter S (sigma) through 4 small incisions and sutures the healthy ends with a special device. Recovery after this operation is 2 times faster than with the open technique."
},
"steps": [
{
"name": "Anesthesia and positioning",
"description": {
"professional": "General endotracheal anesthesia with muscle relaxation. Catheterization of the bladder and placement of a nasogastric tube. The patient is positioned in a modified Lloyd-Davies position (lower limbs on supports, table tilted 15° head down). Treatment of the surgical field from the xiphoid process to the pubis.",
"normal": "The patient is sedated and placed in a special position: the legs are raised, like in a gynecological chair, and the head is slightly lower than the pelvis. This is necessary for the intestines to shift and for the surgeon to work more comfortably. An antiseptic is applied to the abdomen - from the sternum to the hips."
  }
 },
 {
"name": "Insufflation and trocars",
"description": {
"professional": "Creation of pneumoperitoneum with a Veress needle (CO2 pressure 12-14 mm Hg). Installation of a 5-mm optical trocar 2 cm above the navel. Insertion of a 30° laparoscope. Under visual control, the working ports are installed: a 12-mm trocar in the right iliac region, a 5-mm trocar in the right hypochondrium and left iliac region.",
"normal": "Carbon dioxide is pumped into the abdomen through a puncture near the navel - the abdomen inflates like a balloon. This creates space for work. Then a camera is inserted and 3 more punctures are made for the instruments - all no more than 1 cm. The main «working» puncture is on the lower right side of the abdomen - through it remove the intestine."
  }
 },
 {
"name": "Mobilization of the sigmoid colon",
"description": {
"professional": "Identification of the left ureter and iliac vessels. Dissection of the peritoneum along the white line of Toldt. Mobilization of the sigmoid colon with preservation of the superior hemorrhoidal arteries. Intersection of the sigmoid vessels after clipping (Hem-o-lok) at 1 cm from the bifurcation of the aorta.",
"normal": "The surgeon finds the intestine, which looks like the letter S (this is the sigma). Carefully separates it from the surrounding tissues, as if freeing the roots of a plant. He works especially carefully near the ureter - the tube that goes to the kidney. The vessels feeding the intestine are clamped with titanium clips and crossed."
  }
 },
 {
"name": "Resection and anastomosis",
"description": {
"professional": "Application of linear suturing devices (Endo GIA 60 mm) to the proximal and distal sections. Resection of the intestine between the suture lines. Extraction of the preparation through the expanded port in a protective endobag. Formation of an end-to-end anastomosis with a circular stapler (EEA 28-31 mm) with tightness control.",
"normal": "The diseased section of the intestine is stitched on both sides with a device that simultaneously cuts and staples. The removed intestine is placed in a special bag and pulled out through a slightly enlarged puncture. Then the ends of the intestine are connected «groove to groove» using a circular stapler - the device shoots two rows of titanium staples in the shape of a circle."
  }
 },
 {
"name": "Control and drainage",
"description": {
"professional": "Checking the anastomosis for leaks (air test under tamponade with saline solution). Hemostasis revision. Installation of drainage in the pelvic cavity through a separate puncture. Layer-by-layer suturing of ports 10 mm or more. De-sufflation of CO2 under pressure control.",
"normal": "Air is pumped into the anastomosis through the anus - if there are no bubbles in the pelvis, then the suture is airtight. A thin drainage tube is inserted into the pelvis - it will remove any discharge. All punctures are sutured except one - drainage is left through it. Gas is pumped out of the abdomen, monitoring the pressure on the monitor."
  }
 },
 {
"name": "Postoperative care",
"description": {
"professional": "Patient activation after 6 hours. Start of oral fluid intake after peristalsis. Drainage removal on the 2nd-3rd day if there is no discharge. Discharge on the 5th-7th day if the course is uncomplicated. Control colonoscopy after 3 months.",
"normal": "Already in the evening on the day of surgery, you can sit up and drink water. The next day you are allowed to get up - this prevents adhesions. The drainage is removed when fluid stops being released. The patient usually returns home after a week.\n📌 Main advice: for the first 2 months, follow a diet without coarse fiber so that the anastomosis heals perfectly!"
    }
   }
  ]
 },
{
"keys": [
"splenectomy",
"spleen removal",
"laparoscopic splenectomy",
"open splenectomy",
"hematology"
],
"name": "Splenectomy",
"modes": {
"professional": "Surgical removal of the spleen in case of injuries, hematological diseases or tumors. Performed laparoscopically (90% of cases) or openly. Critical stages: ligation of the splenic artery, mobilization of the spleen while preserving the pancreas, prevention of bleeding.",
"normal": "Surgery to remove the spleen through small punctures (laparoscopy) or an incision. After the operation, the person lives normally, but requires special vaccinations and observation."
},
"steps": [
{
"name": "Anesthesia and positioning",
"description": {
"professional": "General endotracheal anesthesia with muscle relaxation. The patient is positioned on the right side with a cushion under the ribs (laparoscopy) or on the back (open access). A nasogastric tube and a urinary catheter are inserted. Prophylactic antibiotic therapy (cefazolin 2 g IV).\nInstruments:\n- Intubation tube 7.0-8.0 mm\n- Salem Sump probe 18Fr\n- Foley catheter 16Fr\nTechnique:\n1. For laparoscopy - tilt the table 45° to the right lateral position.\n2. CO₂ pressure control no higher than 12 mm Hg.\nLogistics:\n- Mandatory vaccination 2 weeks before the planned surgery (Pneumo-23, Menactra, Hiberix).\nNuance: In case of idiopathic thrombocytopenic purpura (ITP) - preoperative immunoglobulin G.",
"normal": "The patient is put to sleep and placed on the right side, placing a pillow under the left hypochondrium. Thin tubes are inserted into the stomach and bladder - this is temporary.\n📌 Important: before the surgery, vaccinations against dangerous infections are mandatory - without a spleen, the body becomes more vulnerable."
  }
 },
 {
"name": "Access (laparoscopic/open)",
"description": {
"professional": "Laparoscopy: 4 ports (10 mm at the navel, 5 mm in the epigastrium and 2 in the left hypochondrium). Open access: incision along the left midclavicular line from the costal arch to the umbilicus. In case of injury - midline laparotomy. CO₂ insufflation up to 12 mm Hg. Visualization of the spleen and surrounding organs.\nInstruments:\n- Trocars 5/10/12 mm\n- Laparoscope 30° 10 mm\n- Harmonic scalpel (Harmonic)\nTechnique:\n1. First trocar according to Hasson (open technique).\n2. In case of adhesions - an additional port in the right hypochondrium.\nLogistics:\n- Used gas is filtered through the AirSeal system.\nNuance: In case of splenomegaly (>20 cm) - hybrid technique with mini-laparotomy.",
"normal": "The surgeon makes 4 small incisions (0.5-1 cm) for the camera and instruments. The abdomen is filled with carbon dioxide - this creates space for work. In an open operation, a 10-15 cm incision is made on the left under the ribs.\n📌 Interesting: an enlarged spleen sometimes has to be «crushed» in a special bag in order to remove it through a small incision."
  }
 },
 {
"name": "Spleen mobilization",
"description": {
"professional": "Dissection of the splenophrenic ligament. Gradual separation of the spleen from the stomach (short gastric vessels) and colon. Ligation of the splenic artery at the upper edge of the pancreas (clipping or harmonic scalpel). Control of the tail of the pancreas.\nInstruments:\n- LigaSure bipolar forceps\n- Clip applicator (Hem-o-lok)\n- Aspirator-irrigator\nTechnique:\n1. «Anterograde» approach - first the artery, then the vein.\n2. Coagulation of short gastric vessels from caudal to cranial.\nLogistics:\n- Marking the spleen poles for histology.\nNuance: In portal hypertension - initial ligation of the artery reduces blood loss by 40%.",
"normal": "The surgeon carefully «frees» the spleen by cutting the ligaments that hold it in place. The vessels are clamped with titanium clips or «sealed» with an ultrasonic scalpel.\n📌 Be careful: the pancreas is «hiding» nearby - it cannot be damaged!"
  }
 },
 {
"name": "Ligation of vessels and removal",
"description": {
"professional": "Final intersection of the splenic artery and vein after double clipping. Extraction of the spleen in an endobag (after morcellation during laparoscopy). Inspection of the bed for bleeding. Installation of drainage at the tail of the pancreas.\nInstruments:\n- EndoCatch 15 mm endobag\n- Morcellator (for splenomegaly)\n- Jackson-Pratt 10Fr drainage\nTechnique:\n1. The artery is ligated 1 cm from the hilum of the spleen.\n2. The vein is closer to the pancreas to prevent thrombosis.\nLogistics:\n- The removed organ is sent for urgent histology in case of tumors.\nNuance: In case of ITP - additional search for additional lobules.",
"normal": "The main vessels of the spleen are ligated with strong threads and crossed. The organ is placed in a special bag and removed - during laparoscopy it can be pre-minced.\n📌 Important: Always check for any extra small spleens - they can grow back!"
  }
 },
 {
"name": "Hemostasis control and completion",
"description": {
"professional": "Thorough coagulation of the splenic bed with an argon-enhanced coagulator. Application of a hemostatic sponge (Surgicel). Layer-by-layer suturing of wounds. With open access - suturing of the diaphragmatic surface with separate sutures. Final revision of the abdominal cavity.\nInstruments:\n- Argon plasma coagulator (ForceTriad)\n- Floseal hemostatic matrix\n- Ultrasonic scissors (Thunderbeat)\nTechnique:\n1. Hemostasis control when CO₂ pressure decreases to 8 mmHg.\n2. The drainage is brought out through a separate puncture.\nLogistics:\n- Counting instruments and gauze pads before closing.\nNuance: With thrombocytopenia <50×10⁹/l - intraoperative transfusion of platelet concentrate.",
"normal": "The surgeon checks every millimeter of the surgical area - even a small bleeding is dangerous. Finally, a drainage tube is inserted and the incisions are sutured.\n📌 Note: after the operation, the patient spends 24 hours in intensive care under observation."
  }
 },
 {
"name": "Postoperative care",
"description": {
"professional": "Monitoring hemoglobin and platelets every 6 hours. Prevention of thrombosis (low molecular weight heparin from 12 o'clock). Antibiotic therapy 24-48 hours. Removal of drainage if discharge <30 ml/day. Scheduled vaccination in 14 days (pneumococcus, meningococcus, Haemophilus influenzae).\nInstruments:\n- CTG machine (during pregnancy)\n- Nebulizer for atelectasis prevention\n- Compression stockings\nPostoperative protocol:\n1. Activation after 4-6 hours.\n2. Diet: table #1 on the first day.\n3. Ultrasound control on the 3rd day.\nComplications:\n- Bleeding (1-2%).\n- Thrombocytosis> 1000×10⁹/l (30%).\n- Overvige sepsis (lifelong risk).",
"normal": "The first days, blood tests are monitored - platelets can «soar» to huge numbers. Wearing a «No spleen» bracelet is mandatory - this is important for doctors in emergency cases.\n📌 The main rule: at any temperature above 38°C - urgently to the hospital, this could be a life-threatening infection!"
    }
   }
  ]
 },
{
"keys": [
"nephrectomy",
"kidney removal",
"laparoscopic nephrectomy",
"open nephrectomy",
"urology"
],
"name": "Nephrectomy (kidney removal)",
"modes": {
"professional": "Surgical removal of the kidney due to tumors, terminal hydronephrosis or trauma. Approaches: laparoscopic (transperitoneal/retroperitoneal) or open (lumbotomy). Control of the renal vessels and preservation of the integrity of adjacent organs are critical.",
"normal": "Surgery to remove a diseased or damaged kidney through small incisions (laparoscopy) or one large incision (open method). After the operation, you can live with one healthy kidney."
},
"steps": [
{
"name": "Anesthesia and positioning",
"description": {
"professional": "General endotracheal anesthesia with muscle relaxation. Catheterization of the urinary bladder. Patient position: for laparoscopy - on the side with a cushion under the costal arch (flex position), for open surgery - on the side with the lumbar region extended. Treatment of the surgical field from the xiphoid process to the pubis.\nInstruments:\n- Foley catheter 16Fr\n- Roller for fixing the position\n- Electrodes for neuromonitoring\nTechnique:\n1. CVP control for tumors >7 cm.\n2. Prevention of pressure point bedsores.\nLogistics:\n- Before laparoscopy — marking of ports under X-ray.\nNuance: In case of obesity (BMI> 35) — enhanced patient fixation.",
"normal": "The patient is given general anesthesia and a tube is inserted into the bladder. The patient is laid on the healthy side, with a cushion placed under the lower back — this makes the diseased kidney «more accessible». The skin is treated from the chest to the groin.\n📌 Important: special belts are used during laparoscopy to prevent the patient from moving during the operation."
  }
 },
 {
"name": "Access to the kidney",
"description": {
"professional": "**Laparoscopic**: 4 ports (5-12 mm) along the pararectal line. CO₂ insufflation up to 12-14 mm Hg. Dissection of the peritoneum along the Toldt line. **Open**: Lumbotomy (10-15 cm incision from the 12th rib to the iliac crest). Layer-by-layer dissection: skin, subcutaneous tissue, muscles (latissimus, external oblique, internal oblique, transverse).\nInstruments:\n- Hasson trocars (first port)\n- Harmonic ultrasonic scissors\n- Bookwalter retractor\nTechnique:\n1. With laparoscopy — identification of the ureter as the first landmark.\n2. With open access — preservation of the subcostal nerve.\nLogistics:\n- Used trocars are immediately washed.\nNuance: With adhesions — start dissection from the «free» zones.",
"normal": "**Laparoscopy**: The surgeon makes 3-4 small incisions (0.5-1 cm), inserts a camera and instruments. The abdomen is inflated with gas — like a balloon — to create space to work. **Open method**: A 10-15 cm incision on the side — the surgeon spreads the muscles manually, like drawing aside curtains.\n📌 Interesting: during laparoscopy, the kidney is then removed through an incision in the lower abdomen — in women, it can be made along the bikini line."
  }
 },
 {
"name": "Isolation of the kidney",
"description": {
"professional": "Mobilization of the colon (left side — descending colon, right — ascending colon). Identification and ligation of the ureter (Hem-o-lok clips). Gradual dissection of the renal pedicle: first the artery (posterolateral), then the vein (anteromedial). Adrenal gland separation in upper pole tumors.\nInstruments:\n- Bipolar coagulation (LigaSure)\n- Medium-Large clip applicator\n- Aspirator-irrigator\nTechnique:\n1. «No touching» the tumor (in oncology).\n2. «Artery-vein-ureter» sequence.\nLogistics:\n- Ureteral marking for the pathologist.\nNuance: In case of varicocele — additional ligation of the testicular vein.",
"normal": "The surgeon carefully moves the intestines, finds the ureter (looks like a white cord) and clamps it. Then he looks for the main «wires» of the kidney — the artery and vein. They need to be ligated first to prevent bleeding.\n📌 A tricky part: the artery is usually hidden behind the vein — they are ligated separately with titanium staples."
  }
 },
 {
"name": "Vessel ligation",
"description": {
"professional": "Double clipping of the renal artery (proximally — 3 clips, distally — 2). Intersection between the clips. Similar treatment of the vein (in case of tumors — first the vein to reduce blood filling). Additional suturing of the vessel stump with 4-0 prolene for a diameter of >7 mm.\nInstruments:\n- Titanium clips (Hem-o-lok ML)\n- Echelon vascular stapler\n- Prolene suture material\nTechnique:\n1. Control of abdominal aortic pulsation during left-sided nephrectomy.\n2. In case of vein thrombosis - preliminary ligation.\nLogistics:\n- The removed clips are taken into account for the X-ray.\nNuance: In case of arterial aneurysm - proximal control before isolation.",
"normal": "The renal artery and vein are clamped with special «clamps» (clips) and cut. If the vessels are wide, they are additionally stitched with surgical threads that do not dissolve.\n📌 Important: before cutting, the surgeon checks three times that these are the renal vessels, and not, for example, the mesenteric artery! "
  }
 },
 {
"name": "Kidney extraction",
"description": {
"professional": "Placing the kidney in an endo bag. During laparoscopy - expansion of one of the ports to 4-6 cm (in women - through the vagina). Morcellation is contraindicated in cancer. Revision of the bed for hemostasis (especially the adrenal gland and lumbar veins). \nInstruments: \n- Endo Catch endo bag (15 mm) \n- Morcellation clamp (only for benign processes) \n- Surgicel hemostatic sponge \nTechnique: \n1. For large tumors — extraction in two stages (first the tumor, then the kidney).\n2. Monitoring the integrity of the capsule during extraction.\nLogistics:\n- Tumors >7 cm are fixed with formalin before histology.\nNuance: During pregnancy — minimization of manipulations with the uterus.",
"normal": "The separated kidney is placed in a special container bag. During laparoscopy, it is pulled out through a slightly widened incision — in women, sometimes through the vagina, so that the scar is not visible.\n📌 Shocking fact: a healthy kidney is the size of a fist, but a kidney with hydronephrosis can be the size of a football!"
  }
 },
 {
"name": "Completion",
"description": {
"professional": "Installation of drainage in the kidney bed (silicone 19Fr). Layered suturing: for laparoscopy — port aponeurosis 10 mm or more (Vicryl 0), skin (Dermabond glue); for open access — muscles (PDS 1), subcutaneous tissue (Vicryl 2-0), skin (stapler or subcuticular suture).\nInstruments:\n- Jackson-Pratt drain\n- Fascia stapler\n- 35 mm skin stapler\nPostoperative protocol:\n1. Analgesia: paracetamol + NSAIDs ± tramadol.\n2. Drainage removal if discharge is <50 ml/day.\n3. Creatinine control after 24 hours.\nComplications:\n- Bleeding (1-3%).\n- Pneumothorax (if the pleura is damaged).\n- Intestinal paresis (5%).",
"normal": "A drainage tube is inserted inside - it removes the ichor for 1-2 days. The muscles and skin are sutured with absorbable threads. After laparoscopy, the stitches are almost invisible - only 3-4 small dots remain.\n📌 Good news: after 2-3 days you can eat regular food, and after a month you can exercise (but without lifting weights)."
    }
   }
  ]
 },
{
"keys": [
"intestinal obstruction",
"obstruction surgery",
"intestinal resection",
"emergency surgery",
"laparotomy"
],
"name": "Intestinal obstruction surgery",
"modes": {
"professional": "Emergency surgical intervention to eliminate a mechanical obstruction in the intestinal lumen. Includes laparotomy, abdominal revision, elimination of the cause of obstruction (dissection of adhesions, resection of necrotic areas, removal of a tumor/foreign body), intestinal decompression and restoration of passage. Critical is monitoring the viability of the intestine and preventing sepsis.",
"normal": "Emergency surgery when the intestine «blocks» and stops working. The surgeon finds the problem area (adhesions, tumor, volvulus), removes the blockage and removes damaged tissue. If you delay, the intestine may rupture and peritonitis."
},
"steps": [
{
"name": "Emergency preparation",
"description": {
"professional": "Infusion therapy (crystalloids 20-30 ml/kg) to correct dehydration. Placement of a nasogastric tube to decompress the stomach. Antibiotic prophylaxis (ceftriaxone 2 g + metronidazole 500 mg IV). Laboratory monitoring: lactate, electrolytes, leukocytes. ECG and abdominal X-ray in 2 projections («Kloyber cups»).\nInstruments:\n- 7 Fr central venous catheter\n- 18 Fr Salem Sump probe\n- Intraoperative lavage aspiration device\nTechnique:\n1. Infusion to CVP 8-12 mm Hg.\n2. Aspiration of gastric contents before intubation.\n3. Diuresis monitoring (>0.5 ml/kg/h).\nLogistics:\n- Prepare 2 abdominal drainage tubes.\nNote: In case of fecaloid — urgent start of broad-spectrum antibiotics.",
"normal": "The patient is given an IV drip to combat dehydration, antibiotics are administered. A tube is passed through the nose into the stomach — it pumps out the accumulated fluid and gases, reducing the pressure.\n📌 Important: if the X-ray shows «arches» and «cups», this is a clear sign of obstruction!"
  }
 },
 {
"name": "Laparotomy",
"description": {
"professional": "Midline incision from the xiphoid process to the pubis (length 15-20 cm). Layered dissection: skin, subcutaneous tissue, aponeurosis, peritoneum. Evacuation of effusion (sending for bacterial culture). Revision of the abdominal cavity according to the algorithm «from the ligament of Treitz to the ileocecal angle». Evaluation of color, peristalsis and pulsation of the mesenteric vessels.\nInstruments:\n- Scalpel No. 20\n- Electric knife with the «Spray» function\n- Bookwalter retractor\nTechnique:\n1. The incision is bypassed from the navel on the left for better healing.\n2. In the case of an adhesive process, the entrance to the abdominal cavity in «clean» zone.\n3. Fixation of the wound edges with sterile towels.\nLogistics:\n- Gloves are changed after contact with necrotic intestine.\nNuance: If ischemia is suspected - ultrasound of the mesenteric blood flow.",
"normal": "The surgeon makes a long incision in the center of the abdomen - from the sternum to the pubis. There may be cloudy fluid inside (a sign of inflammation). The intestine is swollen, like an inflated hose.\n📌 Shock fact: with volvulus, the intestine can be black - this means that the tissue has already died!"
  }
 },
 {
"name": "Search and elimination of the cause",
"description": {
"professional": "In case of adhesive obstruction - careful dissection of adhesions with Metzenbaum scissors. In case of volvulus - detorsion (untwisting) of the intestine with an assessment of viability. In case of tumor — mobilization of the affected segment with resection of 10 cm proximally and 5 cm distally. In case of hernia — dissection of the strangulating ring.\nInstruments:\n- Soft intestinal clamps (Doyen)\n- TA or GIA stapler\n- Thermolaparoscopic film to protect the intestine\nTechnique:\n1. Decompression of the intestine through a probe before manipulations.\n2. Viability test: color, pulsation, peristalsis, Doppler signal.\n3. In case of necrosis — resection within healthy tissue.\nLogistics:\n- Marking of the oral and aboral ends before resection.\nNuance: In case of tumor — urgent histology of the resection edges.",
"normal": "The surgeon finds the problem area: it can be dense adhesions (like a web), twisted intestine or a tumor. Adhesions are cut, the volvulus is untwisted. If the intestine is damaged, it is removed.\n📌 Life hack: to check if the intestine is alive, it is poured with warm saline solution - healthy tissue turns pink and begins to move!"
  }
 },
 {
"name": "Resection and anastomosis",
"description": {
"professional": "Applying intestinal clamps at the resection border. Cutting off the non-viable segment. Forming an end-to-end anastomosis with a double-row suture (internal - vicryl 3-0, external - silk 4-0). An alternative is hardware anastomosis with a circular stapler (size 25-29 mm). Checking the tightness by air insufflation.\nInstruments:\n- EEA suturing device\n- Hegar needle holder\n- PDS II suture material\nTechnique:\n1. «Golden rule»: anastomosis width >2 cm.\n2. Mesentery suturing with hemostasis (5-0 prolene vessel ligation).\n3. Drainage of the anastomosis area.\nLogistics:\n- Instrument change after contact with the intestinal lumen.\nNuance: In case of peritonitis — stoma formation (Hartmann operation).",
"normal": "The damaged part of the intestine is cut off, and the healthy ends are sutured. It's like repairing a torn hose: the edges are cleaned and connected in two layers — the inner one will dissolve itself, the outer one will be removed by the doctor.\n📌 Important: after suturing, the surgeon checks the seam by inflating it with air - if there are no bubbles, then the connection is airtight!"
  }
 },
 {
"name": "Decompression and sanitation",
"description": {
"professional": "Intraoperative nasointestinal intubation with a 120 cm long probe (installation behind the anastomosis). Abdominal cavity lavage with 8-10 liters of warm saline with an antiseptic (chlorhexidine 0.05%). Installation of drains in the small pelvis and subdiaphragmatic space. Layer-by-layer suturing of the laparotomy wound, leaving a «plug» for relaparotomy if necessary.\nInstruments:\n- Baker 18 Fr decompression probe\n- AquaStream lavage system\n- Redon 10 Fr cigar drains\nTechnique:\n1. Manual decompression of the intestine from the contents before the anastomosis.\n2. Control revision of all peritoneal pockets.\n3. Suturing the aponeurosis with non-absorbable thread (Prolene 0).\nLogistics:\n- Counting napkins and instruments before closure.\nNuance: In case of massive contamination - temporary closure of the abdominal cavity with a mesh.",
"normal": "The intestine is washed from the inside with a long probe, removing stagnant contents. The abdominal cavity is «rinsed» with saline until the water becomes clear. Drains are installed - tubes for draining fluid.\n📌 Important: sometimes the abdomen is deliberately not completely sutured - if a repeat revision is needed."
  }
 },
 {
"name": "Postoperative management",
"description": {
"professional": "Transfer to the intensive care unit. Continuation of antibiotic therapy for 5-7 days (meropenem 1 g x 3 times a day). Monitoring of drainage secretions (amylase, bilirubin). Gradual restoration of nutrition: from the 3rd day - parenteral, from the 5th - enteral through a tube, from the 7th - orally. Daily dressing with suture treatment. Removal of drains on the 4th-5th day.\nInstruments:\n- Infusomat for parenteral nutrition\n- Ultrasound machine for abscess monitoring\n- Dressing set with silver-containing dressings\nPostoperative risks:\n1. Anastomotic failure (3-5%).\n2. Adhesions (15%).\n3. Recurrence of obstruction (7% over 5 years).\nDischarge criteria:\n- Passage of stool and gases.\n- Normalization of leukocytes.\n- No pain on palpation.",
"normal": "The patient is in intensive care for the first few days - he receives nutrition through a vein. The drains are monitored for leakage (if bile appears, this is an alarm sign). As soon as the intestines «wake up» (begin to rumble), give water, then broth.\n📌 A good sign: the first independent stool means that the operation was successful!"
    }
   }
  ]
 },
{
"keys": [
"coagulation of anal fissure",
"treatment of anal fissure",
"radio wave coagulation",
"proctology",
"surgery of the anal canal"
],
"name": "Coagulation of anal fissure",
"modes": {
"professional": "A minimally invasive procedure of radio wave or laser coagulation of chronic anal fissure in order to eliminate sphincter spasm and stimulate healing. Includes anesthesia, rectoscopy, coagulation of the edges of the fissure and the bottom with the formation of a scab. An alternative to surgical sphincterotomy.",
"normal": "Painless cauterization of the anal fissure with a special device. It is done in 15 minutes, after which the wound heals without scars."
},
"steps": [
{
"name": "Preparation and anesthesia",
"description": {
"professional": "Cleansing enema 2 hours before surgery. The patient is positioned on the left side with the knees drawn up to the stomach. Treatment of the perianal area with an antiseptic (chlorhexidine 0.05%). Conduction anesthesia: infiltration of 2% lidocaine with adrenaline (1:200,000) along the fissure and in the projection of the sphincter. Anesthesia control after 5 minutes.\nInstruments:\n- 5 ml syringe with 25G needle\n- Anoscope with backlight\n- Rectal speculum\nTechnique:\n1. Layer-by-layer infiltration from the skin to the submucosal layer.\n2. Blocking the genital nerve in case of posterior fissure.\nLogistics:\n- Check sensitivity with tweezers before starting.\nNuance: In case of allergy to lidocaine - articaine 4%.",
"normal": "The patient is given a cleansing enema and placed on his side in the «fetal position». Anesthetic is injected around the anus - the injections are almost not felt, because the area is already inflamed. After 5 minutes they check - if everything is numb, you can begin.\n📌 Important: this is a local anesthetic, you remain conscious, but you do not feel anything!"
  }
 },
 {
"name": "Rectoscopy and fissure assessment",
"description": {
"professional": "Insertion of an anoscope with lubricant gel. Visualization of the fissure (typical location is 6 o'clock on the dial). Assessment of the depth, presence of a «sentinel tubercle» and hypertrophied anal papilla. Measurement of the length (usually 1-2 cm). Photo fixation for documentation.\nInstruments:\n- Rigid anoscope 30°\n- Digital endoscopic camera\n- Calibration probe\nTechnique:\n1. Inspection of the entire circumference of the anal canal.\n2. Differentiation from tumors and fistulas.\nLogistics:\n- Disinfection of optics after each use.\nNuance: When combined with hemorrhoids - simultaneous coagulation of nodes.",
"normal": "The doctor inserts a thin tube with a flashlight (like a small telescope) to examine the crack. Most often, it is located at the bottom, like the number 6 on a clock face. Its length is measured - usually no more than a little fingernail.\n📌 Interesting: sometimes they find a «bump» at the edge of the crack - this is the skin's reaction to chronic inflammation."
  }
 },
 {
"name": "Radio wave coagulation",
"description": {
"professional": "Device settings (Surgitron or similar): power 3.5-4.5 W, «coagulation» mode. Step-by-step treatment: first the bottom of the crack, then the edges with the capture of 2 mm of healthy tissue. The depth of action is up to the muscular layer of the sphincter. Formation of a white scab without charring. Coagulation of the hypertrophied papilla, if present.\nInstruments:\n- Radio wave generator\n- Needle electrode 0.1 mm\n- Smoke aspirator\nTechnique:\n1. Movements from the center to the periphery.\n2. Control of the depth by the change in tissue.\n3. Minimization of thermal damage.\nLogistics:\n- Cooling of the electrode with saline.\nNuance: In case of sphincter spasm - additional pneumatic dilation.",
"normal": "With a thin electrode, similar to a needle, the doctor «draws» along the crack. A slight hissing is heard - this is the radio waves cauterizing the tissue. The main thing is not to miss a millimeter, but also not to touch healthy areas. A whitish crust is formed - like after a burn.\n📌 Don't panic: it's painless, you'll feel just a slight warmth!"
  }
 },
 {
"name": "Hemostasis control and completion",
"description": {
"professional": "Irrigation of the wound with cold saline. Checking for bleeding under magnification. Application of ointment (Levomekol 5% or Proctozan). Insertion of a rectal suppository with anesthetic (Anestezol). Application of a sterile gauze bandage with an antiseptic.\nInstruments:\n- Ice-cold saline 4°C\n- Atraumatic tampons\n- Rectal suppositories with lidocaine\nTechnique:\n1. Tightness test during straining.\n2. Digital examination (only with adequate anesthesia).\nLogistics:\n- Disposal of disposable tips.\nNuance: For deep cracks - leave a drainage strip.",
"normal": "The wound is washed with a cold solution - check for bleeding. Then an anesthetic suppository is inserted and a bandage with ointment is applied.\n📌 Important: the bandage should be changed as needed after the first visit to the toilet — the doctor will give detailed instructions."
  }
 },
 {
"name": "Postoperative recommendations",
"description": {
"professional": "Purpose: 1) Sitz baths with chamomile 3 times a day; 2) Diet with fiber 30 g / day; 3) Laxatives (Lactulose 15 ml in the morning); 4) Pain relief (Nimesulide 100 mg 2 times a day). Examination after 7 days. Ban on lifting weights for 1 month. Prognosis: healing in 2-3 weeks in 92% of patients.\nTools:\n- Patient information\n- Dressing kit\n- Stool diary\nTechnique:\n1. Monitoring healing using photo reports.\n2. Correction of therapy in case of oozing.\nLogistics:\n- Telephone for emergency consultations.\nNuance: In case of relapse - consider the option of Botox.",
"normal": "After the procedure you need to: 1) Do warm baths 3 times a day (just sit in a basin with chamomile decoction); 2) Drink a lot of water and eat prunes so that the stool is soft; 3) Use pain-relieving ointment for the first 3 days. The pain will go away in 2 days, and complete healing - in 2 weeks.\n📌 The main thing: no alcohol or spicy food for a month — otherwise the crack will return!"
    }
   }
  ]
 },
{
"keys": [
"hemorrhoids",
"hemorrhoid removal",
"hemorrhoidectomy",
"proctology",
"Milligan-Morgan operation"
],
"name": "Hemorrhoidectomy",
"modes": {
"professional": "Radical excision of hemorrhoids with ligation of vascular pedicles. Options: open (without wound suturing), closed (with mucosal plastic surgery), submucosal (according to Parks). Hemostasis and preservation of the anal sphincter are critical.",
"normal": "Surgical removal of dilated venous nodes in the rectum. Relieves pain, bleeding and prolapse of «cones». After the operation 2-3 days of discomfort, but forever."
},
"steps": [
{
"name": "Preparation and anesthesia",
"description": {
"professional": "Bowel cleansing (2 enemas with an interval of 1 hour). Patient position in a gynecological chair or on the side with knees adducted. Spinal anesthesia (0.5% bupivacaine 3 ml) or intravenous anesthesia. Treatment of the perianal area with an antiseptic (chlorhexidine 0.05%). Rectal speculum for visualization of nodes.\nInstruments:\n- Anoscope with lighting\n- Syringe with a 25G needle for anesthesia\n- Rectal speculums of the «wing» type\nTechnique:\n1. Infiltration of lidocaine with adrenaline around the nodes.\n2. Marking the excision zones with a marker.\n3. Anal reflex control (with spinal anesthesia).\nLogistics:\n- Used needles are immediately placed in a sharps container.\nNote: During pregnancy, only local anesthesia.",
"normal": "The patient is given an enema to cleanse the intestines. They are laid on their side with their legs tucked up or in a special chair. The lumbar region is anesthetized (an injection in the back) - the lower part of the body goes numb, but consciousness is preserved. The doctor treats the skin with an antiseptic and inserts a dilator with a flashlight into the anus.\n📌 Important: with local anesthesia, slight pulling may be felt, but there will be no pain."
  }
 },
 {
"name": "Excision of external nodes",
"description": {
"professional": "Capture of the node with an Allis clamp. V-shaped incision of the skin at the base of the node with a #11 scalpel. Isolation of the node to the vascular pedicle. Ligation of the pedicle with absorbable thread (Vicryl 3-0). Cutting off the node above the ligature. Coagulation of small vessels with bipolar.\nInstruments:\n- Allis serrated clamp\n- Scalpel with a narrow blade\n- Bipolar forceps\nTechnique:\n1. Maintaining «skin bridges» between wounds (minimum 1 cm).\n2. Deep ligation of the pedicle at the internal sphincter.\n3. Forming a «pear-shaped» wound for drainage.\nLogistics:\n- Removed nodes are sent for histology.\nNuance: In case of thrombosed nodes, first evacuate the thrombus.",
"normal": "The surgeon grasps the «lump» with a special clamp and cuts it out with a triangular flap. The blood vessels at the base are tied with a self-dissolving thread - like tying a bag. The knot itself is cut off, and the wound is left open or carefully sutured.\n📌 Illustrative moment: areas of healthy skin are always left between the wounds - this will prevent narrowing of the anus."
  }
 },
 {
"name": "Removal of internal nodes",
"description": {
"professional": "Insertion of an anal retractor. Grasping the node with an anal clamp. Excision of the mucosa above the node with an electrocoagulator. Ligation of the pedicle at the base (hemorrhoidal artery) with muscle suturing. Suturing the mucosal defect with 4-0 catgut or leaving an open wound.\nInstruments:\n- Fergusson retractor\n- Electrocoagulator with a needle tip\n- Hegar needle holder\nTechnique:\n1. Capture of the node with the capture of 1 cm of healthy mucosa.\n2. Coagulation in the «cut» mode (30 W) to minimize bleeding.\n3. Immersion suture to prevent ligature fistulas.\nLogistics:\n- Change of blades after each node.\nNuance: With hypertrophy of the anal papillae - simultaneous resection.",
"normal": "Using a speculum-expander, find the internal nodes above the dentate line. Each node  stitches at the base, where the feeding vessels pass, then excised. The wound is either stitched up in a «herringbone» pattern or left to heal on its own - this depends on the technique.\n📌 A sore point: internal nodes are usually more sensitive, so they are removed especially carefully."
  }
 },
 {
"name": "Hemostasis and plastic surgery",
"description": {
"professional": "Wound toilet: removal of clots, coagulation of bleeding vessels. Installation of hemostatic sponges (Surgicel) in the bed of the nodes. In the closed technique - suturing of wounds with 3-0 catgut to form a «star». Drainage for extensive interventions (glove graduate).\nInstruments:\n- Hemostatic sponge with thrombin\n- Anastomotic stapler (for circular resection)\n- Penrose drainage\nTechnique:\n1. Layer-by-layer coagulation of the node bed.\n2. «Tightening» of the mucous membrane to prevent prolapse.\n3. Digital examination to control narrowing.\nLogistics:\n- Counting gauze balls to avoid leaving any.\nNuance: With concomitant anal fissure - dosed sphincterotomy.",
"normal": "The doctor carefully checks all wounds - cauterizes bleeding vessels, removes tissue residues. A sponge with a hemostatic drug is inserted into the anal canal. If the operation is extensive, a thin rubber tube may be left to drain the fluid.\n📌 Post-op life hack: on the first day, apply an ice pack through the bandage - this reduces swelling."
  }
 },
 {
"name": "Dressing and rehabilitation",
"description": {
"professional": "Applying an ointment dressing (Levomekol 5%) with a hydroactive coating. Installing a gas outlet tube for 2 hours. Purpose: analgesics (Ketorolac 30 mg intramuscularly), laxatives (Lactulose 30 ml / day), sitz baths with chamomile from the 3rd day. Monitoring urination (catheterization if there is a delay).\nInstruments:\n- Rectal swab with lidocaine\n- Mepore self-adhesive bandage\n- Bedpan with antiseptic\nPost-operative protocol:\n1. First dressing after 24 hours.\n2. Diet: broth, fermented milk products for 3 days.\n3. Full activity in 7-10 days.\nComplications:\n- Bleeding (1-3%).\n- Wound suppuration (2%).\n- Acute urinary retention (15%).",
"normal": "After the operation, a tampon with an anesthetic and anti-inflammatory drug is inserted into the anus. A spacious gauze bandage is applied - not pressing, but absorbing discharge. The first 3 days are prescribed a low-slag diet (so as not to injure the wounds), then gradually return to normal nutrition.\n📌 Main advice: for the first 2 weeks, you can not strain - to ease the stool, give mild laxatives."
      }
    }
  ]
 }
]