1. 2
Translation from the English language edition:
Schein’s Common Sense Emergency Abdominal Surgery edited by Moshe Schein paul N. Rogers - Ahmad Assalia Copyright © Springer-Verlag Berlin Heidelberg 2010
Springer is a part of Springer Science+Business Media All Rights Reserved
Moshe Schein, MD, FACS, FCS (SA), Attending Surgeon,
Marshfield Clinic, Ladysmith Center,
906 College Avenue,
Ladysmith, WI 54848, USA
schein.moshe@marshfieldclinic.org,
www.docschein.com
Paul N. Rogers, MBChB, MBA, MD, FRCS, Consultant General
and Vascular Surgeon, Department of Surgery,
Gartnaval General Hospital,
Glasgow, Scotland, UK
pn.rogers@btinternet.com
Ahmad Assalia, MD, FACS, Deputy Director and Chief of Advanced Laparoscopic
Surgery, Department of Surgery B, Rambam Health Care Campus.
Senior Lecturer in Surgery, Faculty of Medicine, Technion, Israeli Institute
of Technology,
Haifa, Israel
assaliaa@gmail.com
mTargmneli da mTavari redaqtori: medicinis akademiuri doqtori Teimuraz qemokliZe
redaqtori: medicinis akademiuri doqtori kaxaber kikviZe
samecniero redaqtori: medicinis mecnierebaTa doqtori, profesori merab kilaZe
stilisti: qeTevan nikolaiSvili
damkabadonebeli: boris sxirtlaZe

2. 445
qirurgiuli internetqseli (The SurgiNet)
aseTi idealuri da obieqturi (MMM) sxdoma bevrgan ar tardeba, rac umTavresad adgilobrivi
socialur-politikuri Semaferxebeli faqtorebis bralia. Tu Tqvens garemocvaSic asea, aman
SesaZloa Tqveni qirurgiuli ganaTleba daazaralos: rogorRa unda gaarCioT mtyuani da marTali?
wignebi da Jurnalebi sasargebloa, magram ganswavluli qirurgebis jgufis mier konkretuli
SemTxvevis eqspertul Sefasebas ver Secvlis. Tu Tqven gaqvT personaluri kompiuteri da
eleqtronuli misamarTi, SegiZliaT, SurgiNet-Si gaerTiandeT; es aris qirurgTa saerTaSoriso
forumi, romelsac SeuZlia, Tqven mier SeTavazebul nebismieri SemTxveva Riad da obieqturad
gaarCios. gindaT am saerTaSoriso MMM-Si monawileoba? gaugzavneT mesiji Toronto-el Dr. Tom
Gilas-s misamarTze tgilas@sympatico.ca an am wignis romelime redaqtors _ mschein1@mindspring.com.
daskvna
rogorc iciT, katis gatyaveba bevrnairad SeiZleba. advilia, iyoT sarkastuli da
movlenebs `reqtoskopidan~ uyuroT. Cveni sneuli avadmyofi da (MMM) sxdomisaken wamyvani
movlenebi Zalze rTulia, magram am qaosis ukan yovelTvisaa alali simarTle, romelic
unda gaaSiSvlo da gaacxado. uinston CerCilisa ar iyos, warmateba _ esaa unari,
warumateblobidan warumateblobamde enTuziazmiT ganagrZo svla.
`SURGINET miSvele, gexverwebi!~
wesisamebr, pacients is meore Secdoma klavs, pirvels rom mohyveba (Clifford K. Meador).
qirurgiaSi ori upatiebeli sircxvili arsebobs. pirveli didi Secdomaa, roca arasaWiro
operacia keTdeba, meore _ roca iseTi qirurgi akeTebs operacias, romelic am operaciisTvis
teqnikurad momzadebuli ar aris (Max Thorek, 1880-1960).
gamoTxovebis win madlobas mogaxsenebT wignis wakiTxvisaTvis!
vimedovnebT, mogewonaT Cveni patara wigni. neba mogveciT, dagemSvidoboT uinston
CerCilis 1941 wlis radiomimarTviT, romelic mieZRvna evropis dapyrobil xalxebs:
`Rame mSvidobisa, daisveneT da im dilisTvis moikribeT Zal-Rone, romelic
aucileblad gaTendeba. igi gaabrwyinebs simamacesa da simarTles, sikeTiT
gaasxivosnebs RirsebisTvis wamebuli yvela gmiris samares. ase dadgeba ganTiadi!~
Tqven, gadaudebeli daxmarebis qirurgebi, medicinis gmirebi xarT, ganTiadi
ibrwyinebs TqvenTvis!

3. 441
Sedegebi. garTulebebisa da
sikvdilianobis analizi
59
Moshe Schein
`didi~ operacia vargis (`janian~) pacientTan SesaZloa `patara~ aRmoCndes.
`patara~ operacia dauZlurebulTan SesaZloa `didi’’ aRmoCndes.
`didma~ qirurgma icis, rogor moargos operacia pacientsa da mis daavadebas.
kvlav da kvlav: qirurgiul sistemaSi cota ram Tu eZleva daviwyebas ise swrafad,
rogorc mkvdari pacienti (P.O. Nystrom).
imeds vitovebT, Tqveni bolo pacientebi problemebis gareSe gadaurCnen gadaudebel abdominur
operacias da mis Semdgom periods, magram, Cvenda samwuxarod, mTlianobaSi sikvdilianobisa da
garTulebebis maCvenebeli maRali rCeba. axla, roca qariSxali Cadga, is droa, davsxdeT da
ganvixiloT, ra gafuWda. rogorc Francis D. Moore-ma (1913-2001) Tqva: Tqven gWirdebaT iseTi
qirurgiuli gundi, romelic daupirispirdeba da Tvals gausworebs Secdomebs,
saxels daarqmevs maT da Zal-Rones ar daiSurebs maTi ganmeorebis Tavidan asacileblad.
garTulebebisa da sikvdilianobisadmi miZRvnili sxdoma
aseTi (Morbidity and Mortality Meeting _ MMM) sxdomis Catareba aucilebelia yvelgan,
sadac ki qirurgTa gundi muSaobs. es aris adgili, sadac Tqven da Tqvens kolegebs SegeZlebaT,
gaaanalizoT, imsjeloT, Tvali gadaavloT garTulebebisa da sikvdilis mizezebs. albaT gecnobaT
kliSe: `zogi qirurgi sakuTar Secdomebze swavlobs, zogi _ sxvisaze, zogi samudamod uswavleli
rCeba~. zemoxsenebuli sxdomis mizani am ukanaskneli variantis mospobaa. aseTi sxdomebi
regularulad imarTeba Tqvens departamentSi? Tu Tqven amerikul ganaTlebis sistemaSi xarT
asocirebuli, maSin yovelkvireulad mogiwevT am sxdomaze daswreba: mis gareSe sarezidento
programa akreditacias ver miiRebs. Cven viciT, rom msoflios sxva `qirurgiul kunWulebSi~
aseT sxdomebi ar tardeba, yvela uxeSi Secdoma da warumatebloba ifarcxeba. Tu aseTi
sxdomebi kidev tardeba sadme, saxeladRa SemorCa da maTze umetesad `saintereso SemTxvevebi~
da `warmatebuli operaciebi~ gamoaqvT. es ar aris swori. (MMM) konferenciebi imisTvis
imarTeba, rom obieqturad gaanalizdes Secdomebi da garTulebebi. vinmes dasasjelad da
kedelTan misayeneblad ki ara, aramed codnis SesaZenad da gasaumjobeseblad. rad gindaT erTi
da imave Secdomebis gameoreba? ase rom, yvelgan, sadac ki qirurgad imuSavebT, gamarTeT aseTi
(MMM) konferenciebi. da Tu `soloqirurgi~ xarT (patara qalaqSi marto muSaobT), bolos
da bolos, Tqven TviTon CautareT sakuTar Tavs.
(MMM) sxdomebis optimaluri formati
aseTi sxdomisTvis yovelkvira rutinulad unda gamoiyos saaTebi. yvela interni,
rezidenti da qirurgi regularulad unda eswrebodes mas. ganyofilebis nebismieri wevris
mier Catarebuli mkurnalobis Sedegad ganviTarebuli yvela garTuleba da sikvdilis
SemTxveva unda iqnes gamotanili. `garTuleba yvelasTvis garTulebaa~ _ ganurCevlad
imisa, triumfiT dasrulda Tu tragediiT, yvela monawile unda iyos warmodgenili.
aseTi (MMM) sxdoma demokratiuli forumia. bosisa Tu adgilobrivi `gigantis~ miqarva iseve
sainteresoa (Tu ufro metad ara), rogorc norCi rezidentis qmedeba. rezidentebma yvela detali
unda icodnen da winaswar gaivarjiSon prezentaciaSi. iqve unda iyos istoria da radiologiuri
kvlevebis monacemebi. miznad unda daisaxoT situaciaSi garkveva da sxvisi ganswavlis xelSewyoba.

4. 442
monawile qirurgis dacva da xelis dafareba saWiro ar aris, mis advokatobas aravin gTxovT.
damswreTa umetesobas sulelad nu CaTvliT; isini umalve grZnoben, rom simarTle iCagreba.
garTulebebis Sefaseba
roca SemTxveva moxsendeba, sxdomis Tavmjdomare diskusias im mizniT iwyebs, rom
konsesusi iqnes miRweuli. damTrgunveli siCumis dasarRvevad SegiZliaT erT-erT warCinebul
qirurgs mimarToT kiTxviT: `Cemo batono, Tu SeiZleba, gviTxariT, es pacienti Tavidanve
Tqveni meTvalyureobis qveS rom yofiliyo, Sedegi igive iqneboda?~ es xerxi gaalRobs
yinuls. xels Seuwyobs gulwrfel da farTo diskusias.
ra aris `namdvili garTuleba~? magaliTad, zogierTi qirurgi amtkicebs, rom
sisxlis iseTi danakargi, romelic hemotransfuzias ar saWiroebs, garTuleba ar aris; is
ubralod teqnikuri iaRliSia, rac yovelTvis `SeiZleba moxdes~.
mizezis Sefaseba: Secdoma gansjis dros moxda Tu teqnikaa braleuli? Tu operacias
terminaluri stadiis kibos mqone pacients gaukeTebT, es Wkvianur gadawyvetilebad ver
CaiTvleba. Tu reoperacia naRvlis buStis sareclidan sisxldenis gamo mogiwiaT, e. i. wina
operaciis dros hemostazis sakiTxSi teqnikuri Secdoma iyo daSvebuli. arsebobs iseTi
Secdomebic, romlebic xSirad Serwymulia da erTmaneTisgan ver gaacalkevebT: mwvave
mezenteriuli iSemiiT Sepyrobili pacienti imitom kvdeba, rom diagnozi metismetad gvian
daisva (araswori gansja) da Camoyalibebuli stomis Cavardnis gamo gamonadeni muclis
RruSi CaiRvara (teqnikuri Secdoma). xSirad Zalze Zneli gasarCevia, garTuleba (mag.,
anastomozis ukmarisoba) teqnikuri Secdomaa Tu pacientTan dakavSirebuli iseTi faqtorebis
brali, rogoricaa malnutricia da steroidebis xangrZlivi miReba.
sxva saqmea operaciis Sefaseba Carevis droulobisa da saWiroebis mixedviT. zogs Tu
metismetad gvian gahyavs an saerTod ar gahyavs pacienti saoperaciod, sxvebi metismetad adreul
an arasaWiro operacias akeTeben. erTni ver amCneven dazianebas da Zalze cotas `amoWrian~, meoreni
ki nametans moindomeben xolme. mavanma SesaZloa postoperaciuli abscesis gamo operacia daagvianos,
sxvam operacia maSin gaakeTos, roca perkutanuli drenirebac ikmarebda. yuradReba miaqcieT, rom
qirurgiul sazogadoebaSi `gamoparvas~ ufro mkacrad gansjian, vidre gadametebas. am
ukanasknels gagebiT ekidebian: `rac SegveZlo, gavakeTeT, magram ar gaamarTla!~
adgili hqonda Tu ara saeqimo gulgrilobas? Secdomebi (imedia, cota) ganuyofeli
nawilia nebismieri qirurgiuli praqtikisa, qirurgiul Secdomas is ar uSvebs, vinc
operacias ar akeTebs, magram saeqimo gulgriloba savalalo ramaa. Tu operacia imitom
gadaido, rom pasuxismgebelma qirurgma SabaT-kviras Tavi ar Seiwuxa an operaciis dros
qirurgi nasvami iyo, es gulgrilobis kargi magaliTia. roca romelime qirurgi Secdomebs
ganuwyvetliv imeorebs, iseT paradigmas avlens, romelic aseve gulgrilobad unda CaiTvalos.
SesaZlebeli iyo garTulebis an sikvdilis Tavidan acileba? rezidentebTan
Cven vaxalisebT saoperacio pacientebisTvis APACHE II-is qulaTa sistemis gamoyenebas.
dabali (10-ze naklebi) qulebi imaze miuTiTebs, rom sikvdilianobis navaraudevi maCvenebeli
Zalze mcire iqneba, maRali (>20) ki imas ar niSnavs, rom pacientis gadarCena SeuZlebeli
iyo. maRali riskisaa is, vinc umaRless qulebs da teqnikur ostatobas moiTxovs. iseTi
pacientebic arseboben, romlebic mcired uzustobasac ki ver gadaitanen.
vin aris pasuxismgebeli? (MMM) sxdoma sasamarTlo ar aris da misi mizani braleulobis
dadgena ar unda iyos, magram sxdomis Semdeg yvela damswrem unda icodes, rogor SeiZleboda
ukeT gakeTeba. dadanaSaulebas yvelanairad unda varidoT Tavi (garda gansakuTrebuli SemTxvevebisa,
romlebic, principSi, am sxdomis saqme arc aris); arc erTi sistema ar gaamarTlebs, romelic
xarisxis kontrolis nacvlad demonizacias daisaxavs miznad; adamianis buneba aseTia: simarTle
daimaleba da konfrontacia Tavidan iqneba acilebuli. samwuxarod, simarTle is aris, rom

5. 403
laparostomis daxurva
rogorc ki laparostoma Tavis saqmes gaakeTebs, misi daxurva unda daigegmos. arsebobs
(qirurgis arCevanidan da muclis lokaluri mdgomareobidan gamomdinare) ori gza: muclis
adreuli daxurva da kedlis mogvianebiTi rekonstruqcia.
muclis adreuli daxurva
adreuli daxurvisTvis optimaluri momenti metismetad xanmoklea da bolo operaciidan
daaxloebiT erT kviraSi dgeba. mere ukve aponevrozi lateralurad retraqcias iwyebs da
nawlavsa da muclis kedels Soris Sexorcebebi viTardeba. amis Semdeg SeuZlebelia
amoSverili organoebis mobilizacia da ukan, mucelSi Sebruneba _ viTardeba `dominirebis
kargva~ (loss of domain). aRarafers vityviT imaze, ra saTuo iqneba aponevrozis kideebis
Sua xazTan mitana. es amocana pirvel kviraSic ki metismetad did risksa da ZalisxmevasTanaa
dakavSirebuli. raRa Tqma unda, muclis adreuli daxurvis ganxorcielebadoba ramdenime
faqtoriT ganisazRvreba, maT Soris _ defeqtis zomiT, nawlavTa pareziT, fistulebis
arseboba-ararsebobiT. iSviaTad defeqti imdenad pataraa, rom aponevrozis kideebi advilad,
dauWimavad uaxlovdeba erTmaneTs (sakiTxavia, aseT dros saerTod iyo ki saWiro
laparostomia?!). mcire defeqtebis dros xSirad xerxdeba kanis mobilizacia da aponevrozis
gareSe misi gakerva. pacients Tiaqari rCeba, magram xelovnur masalas, rogoric ar
unda iyos is, mainc kani sjobia.
WeSmariti abdominuri katastrofis Semdeg laparostomiuli Wrilobebi metismetad
farToa, aqvs fiqsirebuli, SeWmuxnuli kideebi da Tan axlavs organoTa `dominirebis kargva~
(loss of domain). am viTarebasTan gasamklaveblad bolo dros xdeba gamogonili biomasalebis
komponentTa separaciis teqnika
swori kunTi
5 sm
10 sm
3 sm
nax. 52.2-3 komponentTa separaciis teqnika.
igive manevri keTdeba meore mxares.

6. 386
fistula muclis kedlis masStaburi defeqtiT
arcTu iSviaTad xdeba, rom gaJonvebisa da reoperaciebis Sedegad sabolood mravlobiTi
nawlavovani fistulebi Cndeba. es e. w. rTuli anu IV ti pis fistula is RvTis
risxvaa, romelsac Zalze maRali sikvdilianoba mosdevs (Cveni, Schein-isa da Decker-is 1991
wlis klasifikaciiT, I tipisaa zeda, foregut fistulebi, wvrilnawlavovani _ II tipisa,
xolo III tipisa _ msxvilnawlavovani). laparostomiuli strategiis popularobis
matebisdakvalad, aseTi fistulebi sul ufro xSirad gvxvdeba. nawlavovani xvrelidan
fistulis gamosasvlelamde distancias da peritonuli Rrus mdgomareobas mkurnalobis
SedegebisTvis sabediswero mniSnvneloba aqvs.
praqtikuli TvalsazrisiT saWiroa, erTmaneTisgan gavarCioT ori mdgomareoba:
IV-A fistulebi - es is scenaria, romelic gaJonvis adreul stadiaSi viTardeba;
fistula lokalizebulia muclis kedlis defeqtis siRrmeSi da iwvevs nawlavis SigTavsis
masStabur kontaqts peritoneumis angariSgasawev farTobze. Sedegad xdeba toqsikuri
produqtebis itensiuri Sewova, rasac mosdevs (adgilobrivi da sistemuri) anTebadi pasuxisa
da organoTa disfunqciis SenarCuneba. aseT situaciebSi aucilebelia reoperacia, raTa
gakeTdes eqsteriorizacia (an gamoTiSva gamonadenis defeqtidan mosaSoreblad). Tu arada
aseTi pacientebi bedis anabara rCebian; IV-A fistulebis mqoneTa naxevarze meti kvdeba.
IV-B ti pis fistula
kolinji
kolinji
Cirqi,
dabinZureba
IV-A ti pis fistula
IV-A ti pis fistulis gansxvaveba IV-B-gan
IV-B ti pis fistulebi - es gaJonvisTvis damaxasiaTebeli mogvianebiTi fenomenia:
muclis kedlis defeqtis zedapiris siaxloves fistulis `eqspozireba~ xdeba. is aseve
moixsenieba rogorc `kokori~ - fistula, romlis `bunagis~ centri Cakepil nawlavs ukavia.
ramdenadac peritoneumis Rru, wesisamebr, sufTaa da nawlavis SigTavsisgan izolirebuli,
pacients SIRS-i da sefsisi ar aReniSneba. aseTi fistulebis mkurnaloba friad
maxvilgonierebas moiTxovs.
mkurnaloba
misi ZiriTadi mizania, sicocxlisTvis uSualo safrTxis Semcveli IV- AA
ti pis fistula gamoTiSvis an eqsteriorizaciis gziT gadayvanil iqnes problemur,

7. 371
maT distribucias veweviT. ileuss Tu veraferi uyo, kevis ReWva nerwyvs mainc moadens
sawols mijaWvuls, piris Rrus gausufTavebs da gunebas gamoukeTebs (am mizniT pawawa
doza Sotlandiuri viskic rom mowrupos, araferi daSavdeba).
saqmes davubrundeT: Tu postlaparotomiuli pacienti mexuTe dRes parezisa da
gauvalobis niSnebs amJRavnebs, imis gasarkvevad, ra saxisaa airebis dagroveba, Cven muclis
mimoxilviT rentgenologiur kvlevas girCevT. Tu rentgeni ileuss an gauvalobas gvaeWvebinebs,
diagnozis gasarCevad iqneb gastrografinis micemam da Tvalis midevnebam ivargos.
V postoperaciuli dRe muceli
gadaberilia, gazebze ver gadis
mimoxilviTi rentgenografia
kontrasti kolinjSi
gadadis, klinika miileva
laparaskopuli
gauvaloba? parezi?
kompiuteri
kontrastiT
ara
ki
testireba gastrografiniT
nawlavis CaWedva
troakaris adgilSi
klinikuri
`sefsisi”? ieWve
kerZo mizezi
ara
muclis gaxsna
lokaluri ganakveTiT
konservatuli
mkurnaloba
ki
gauvaloba
kompiuteri
kontrastiT
10-12 dReSi ar gaumjobesda?
parezi
reoperacia
strangulacia?
umkurnale
mizezs
mkurnalobis algoriTmi
gaxangrZlivebuli ileusis klinikuri suraTi Tu romelime zemoT CamoTvlil
intaabdobinur mizezs gafiqrebinebT, problemis aRmosaCenad naCvenebia muclis kompiuteris
Catareba kontrastirebiT (oraluri gastrografiniT da ara bariumiT!). zogjer
gastrografins problemis moxsnac SeuZlia. Tu gastrografini msxvil nawlavamde ver
mivida, es wvrilnawlavovan gauvalobaze mianiSnebs. postoperaciuli periodis sawyis

8. 327
40
mucelSida wnevis sindromi
Moshe Schein
qirurgiaSi fiziologia mefea, anatomia _ dedofali. Tqven SegiZliaT, ufliswuli
iyoT, _ ra Tqma unda, Tu gansjis unari SegwevT.
amerikis SeerTebuli Statebis erovnul dResaswaulze, madlierebis dRes, milionobiT
ojaxSi `madlian~ indaurs kargad gamovteniT xolme sxvadasxva ingredientiT (Cemi indauri
daCurTulia Turquli bardiT, nivriT, qondriT) da ojaxur Tavyrilobaze geaxlebiT. kidev
kargi, am veeba frinvelebs ase mWidrod sikvdilis Semdeg gamotenian, Torem ra eSvelebodaT,
sicocxleSive rom mohqceodnen ase?! frinveli jer frenas veRar SeZlebda, mere TandaTan
hipoventilacia ganuviTardeboda, araqaTi gamoecleboda da suls ganutevebda. sikvdils
miawerdiT cud filtvebs, beber guls, Turqul bardas da nivris mier gamoyofil toqsinebs
an, ukidures SemTxvevaSi, anesTeziologs. realuri mizezi, romelic pirvelxarisxovani
mecnieruli monacemebiT aris dasabuTebuli, prozaulze metia: intraabdominurma wnevam
moimata da mucelSida hi pertenziam abdominuri kompartmentsindromi gamoiwvia.
marTla arsebobs abdominuri kompartmentsindromi?
dResdReobiT yvelaferi imaze miuTiTebs, rom momatebuli mucelSida wneva arRvevs fiziologiasa
da organoTa funqcionirebas. ukuefeqtebze damyarebuli rTuli SedegebiT intraabdominuri
wneva gadaecema mimdebare sivrceebsa da Rruebs, amcirebs wuTmoculobas, zRudavs filtvebis
ventilacias, aqveiTebs Tirkmelebis funqcias da organoTa sisxlmomaragebas, zrdis cerebrospinur
wnevas (nax. 40.1). Tu ramis eWvi grCebaT, roca kidev mogiwevT reoperaciis gakeTeba marTviT
sunTqvaze myofi mucelgadaberili mZime avadmyofisTvis, sTxoveT anesTeziologs, sasunTq gzebSi
wnevas daakvirdes. maSinve dainaxavT, rogor ecema es wneva, rogorc ki relaparotomias gaakeTebT.
momatebuli mucelSida wnevis (paT)fiziologiuri Sedegebi
izrdeba
sisxlis saSualo wneva
guliscema
CasunTqvis maqsimaluri (pikuri) wneva
Torakalur-plevruli wneva
centraluri venuri wneva
filtvis kapilarebis CaWirxvnis wneva
qveda Rru venis wneva
Tirkmlis venis wneva
sisxlZarRvTa sistem. winaaRmdegoba
wuTmoculoba
venuri ukudena
organoTa sisxlmomarageba
kuWis lorwovanis pH
Tirkmelebis sisxlmomarageba
glomerulebis filtraciis maCvenebeli
cerebrospinuri siTxis wneva
muclis kedlis damyoloba
mcirdeba
ucvlelia
_
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9. 309
nax. 37.2-3 kolinjis
mravlobiTi
perforaciebi; aivpozitiuri pediatriuli
pacienti
citomegalovirusuli
kolitiT.
`eqimbaSis~ tradiciuli oyna
afrikul tomebSi aseTi ram gavrcelebulia. Tu saoyne (muti) `medikamentebs~ toqsikuri
nivTierebebi daemata, Sedegi SesaZloa iyos koroziuli dazianeba, qsovilebis nekrozi da
perforacia da mogvianebiTi striqturebi (nax. 37.2-4). swor nawlavze mxolod meqanikurma
mani pulirebamac ki SesaZloa gamoiwvios travma an manekrozebeli fasciiti. daxocili
gesliani xoWoebis (Coleoptera) dafqviT miRebuli eqstraqti (Cantharidin) Tirkmelebis
mwvave ukmarisobas iwvevs.
dakvirvebam aCvena, rom vidre gastroenteritis gamo saavadmyofoSi moxvdeba,
afrikeli bavSvebis umetesobas tradiciuli Samanuri oyna aqvs gakeTebuli.
iseTi SemTxvevebic xSiria, rom yvelaferi am bangs braldeba da realuri daavadeba
gamoeparebaT xolme.
`hei, eqimo modi sxvas vkiTxoT azri. macade Cems `Sangomas~-s vurekav~

10. 300
wvrilnawlavovani gauvaloba muclis tuberkulozis yvelaze xSiri garTulebaa da
gamowveulia sanaTuris striqturiT, mucelSida SexorcebebiT an xaWoseburad gadagvarebuli
limfuri kvanZebis zewoliT sanaTurze. klasikurad miiCneva SemTxveva, roca srul gauvalobamde
pacienti anamnezSi nawlavovani gauvalobis ganmeorebiT (e. w qvemwvave) Setevebs aRniSnavs. am
dros, marTalia, zogierTi qirurgi tuberkulozis sawinaaRmdego medikamentebs niSnavs da
amjobinebs, erTi Tvis ganmavlobaSi elodos Sedegs, SesaZloa, avadmyofoba aseT konservatul
reJims ar daemorCilos da mainc saoperacio gaxdes. operaciis dros arcTu iSviaTad
waawydebiT sqel da mWidro Sexorcebebs (nax. 37.1-1), romlebic orTabrZolaSi yvelaze
fenomenalur qirurgsac ki gamoiwvevda. Tu ver umklavdebiT, warmatebis sawindari
moTmineba da dasaxmareblad Tqvenze gamocdilis xmoba iqneba. abdominuri tuberkulozis
arsebobis Sesaxeb eWvs aRZravs xaWosmagvari SigTavsis limfuri kvanZebi, fetviseburi gamonayari
nawlavsa da jorjalze da wvrilnawlavovani striqturebi (nax. 37.1-2, 37.1-3). aseT dros
nax. 37.1-1 Sexorcebebi muclis tuberkulozis dros.
nax. 37.1-2 fetvismagvari tuberkulomebi nawlavisa da jorjlis zedapirze

11. 294
SidsiT daavadebuli pacientebi 1
36
Sai Sajja
Moshe Schein
SidsiT dasnebovnebulebs SesaZloa mwvave apendiciti daemarToT.
adamianis imunodeficitis virusiT inficireba (aiv) da misi gardauvali Sedegi,
SeZenili imunodeficitis sindromi (Sidsi), jandacvis sayovelTao problemas warmoadgens.
amasTan, igi cvlis damkvidrebuli qirurgiuli mkurnalobis praqtikasac. medicinis
miRwevebTan erTad ufro da ufro imatebs aseTi pacientebis sicocxlis xangrZlivobac
da, amrigad, sadac ar unda muSaobdeT, didia albaToba, aseTi pacientebis qirurgiuli
mkurnaloba mogiwioT. ramdenadac, am wignSi aRwerili qirurgiuli mkurnalobis ZiriTadi
principebi SidsiT inficirebulebzec vrceldeba, aqcents am populaciisTvis specifikur
sakiTxebze davsvamT.
daavadebis xasiaTi
es pacientebi warmodgebian daavadebis ganviTarebis mravalferovani speqtriT, virusis
asimptomuri tarebiT dawyebuli, damTavrebuli Sorswasuli SidsiT (Tanmxlebi oportunistuli
infeqciis CaTvliT).
CD4+ ujredTa raodenobis mixedviT, virusmatareblebi Semdeg kategoriebad iyofian:
 sawyisi stadia _ CD4+-is raodenoba aRemateba 500 ujred/ml-s;
 Sualeduri stadia _ CD4+-is raodenobaa 200-499 ujredi/ml;
 Sorswasuli stadia _ CD4+-is raodenobaa 50-200 ujredi/ml;
 terminaluri stadia _ CD4+-is raodenoba 50 ujred/ml-ze naklebia (miuxedavad
imisa, arsebobs, Tu ara, daavadebis simptomebi an sxva Tanmxlebi daavadeba). Tu sisxlis erT
ml-Si CD4+ ujredTa raodenoba 200-ze naklebia, mdgomareoba ganisazRvreba rogorc
Sidsi. garda amisa, roca oportunistuli infeqciebisa da simsivneebis grZeli siidan
romelime viTardeba, virusis matarebeli pacienti SidsiT daavadebulTa kategoriaSi unda
gadaiyvanoT.
muclis tkivili
aseT pacientebTan muclis tkivili da kuWnawlavismxrivi araspecifikuri Civilebi Zalze
xSiria, amitom klinikuri Sefaseba gaZnelebulia. amasTan, ufro didia im daavadebaTa sia, romlebTanac
diferenciuli diagnozis gatarebaa saWiro. leikocitebis raodenobas, rac Cveulebriv populaciaSi
Zalze faseulia, amjerad ver endobi, radgan saZiebel daavadebas leikopenia uZRoda win. xSirad
Tanmxlebia centraluri nervuli sistemis infeqcia, rac kidev ufro arTulebs muclis tkivilis
gaanalizebas. antivirusuli medikamentebi xSirad qronikul abdominur simptomebsa da mwvave
pankreatits iwvevs. mkurnalobis gegmis safuZvlebs ayalibebs Semdgomi: anamnezis kargad Segroveba,
Sidsis stadirebis gansazRvra, oportunistuli infeqciisa da antiretrovirusuli Terapiis
efeqturobis amocnoba, mimoxilviTi rentgenokvlevebisa da laboratoruli testebis sruli
mainc, ratom daeTmo aiv-sa da Sidss calke Tavi? kargad viciT, rom zogierTi daavadebis `modaSi Semotanis~ tendencias mxolod Cven
ar vkicxavT. maT Soris yvelaze TvalSisacemia Sidsi da ZuZus kibo. aseT pacientebs ufro metad TanaugrZnoben, vidre sxva, Cveulebrivi
sneulebebiT daavadebulebs. ubralod, es Tavi imis aRiarebaa, rom am pacientebs qirurgiuli mkurnalobis sxvagvarad morgeba sWirdebaT da ara
zemoxsenebuli dasanani tendenciiT damatebiTi gulisxmiereba (redaqtorebi).

12. 290
nax. 35.2 invaginaciis ultrabgeriTi niSani. marcxniv: `cru Tirkmeli~ _
sigrZivi Wrili. marjvniv: `samizne wreebi~ _ ganivi Wrili.
nax. 35.3 bariumis hidrostatuli oyniT invaginaciis bolomde Casworebis
radiologiuri monitoringi (marjvena qvemo suraTze kontrasti wvril
nawlavSia Sesuli).
gangrenis SesaZlebloba aReniSnebaT, laparotomia dauyovnebliv unda gaukeTdeT. sawyis
etapze, roca peritoniti gamoxatuli ar aris, invaginacia SeiZleba gaswordes pnevmaturi
an hidrostaturi wneviT, rentgenis an ultrabgeriTi kontroliT. Tu arsebobs eWvi
perforaciis Taobaze, wyalSi xsnadi kontrasti ufro usafrTxoa, vidre bariumi. gasworebis
mcdeloba umetesad warmatebiT gvirgvindeba, Tumca qirurgisa da radiologis SeTanxmebul
muSaobas moiTxovs (nax. 35.3).

13. 271
gadaudebeli situaciebi ginekologiaSi
33
Bernard Cristalli
Moshe Schein
ginaxavs odesme iseTi ginekologi, vinc darwmunebiT ityvis, rom `mwvave muclis~
mizezi ginekologiuri daavadebaa da ara mwvave apendiciti? (Moshe Schein)
ginaxavs odesme iseTi qirurgi, vinc darwmunebiT ityvis, rom qalebTan `menjis
mwvave muclis~ mizezi qirurgiulia problemaa da ara ginekologiuri? (B. Cristalli).
saxelganTqmuli ingliseli mwerali da eqimi Somerset Maugham-i (1874-1965) werda:
`qali is arsebaa, romelic dReSi erTxel Sardavs, kuWSi kviraSi erTxel gadis, menstruacia
TveSi erTxel aqvs, weliwadSi erTxel mSobiarobs da yovelTvis, roca ki SesaZlebloba
eZleva, kavdeba seqsiT~. dRes am politikur koreqtulobas moklebul winadadebas veRar
dawer, magram neba rom gvqonoda, Cven mas davurTavdiT ramdenime komentars `qvemoT
mucelSi tkivilis~ Sesaxeb.
zogad qirurgs mSobiarobis miReba iSviaTad uwevs, magram didia albaToba, gadaudebel
ginekologiur problemebs Seejaxos. reproduqciuli asakis qalebSi muclis mwvave tkivili
Zalian xSiria. aseTi tkivili, Tu `qirurgiuli~ ar aris, ginekologiuri unda iyos. Tqveni
kolega ginekologebi ZiriTadad kai ti pebi ki arian, magram maTi Tvalsawieri menjs ar
scdeba (rasakvirvelia,
garda doqtori Cristalli-sa); sanam mwvave apendicits ar
gamoricxavT, menjSi mwvave situaciis `ginekologiurad~ gamocxadebas moeridebian.
zogjer operacias akeTeb TiTqosda mwvave apendicitis gamo da ginekologiur problemas
waawydebi. unda icodeT, rogor gaumklavdeT mas.
ginekolegebsa da meanebTan urTierTobis bednierebis kidev erTi mizezi saerTo orsuli
pacientia. rogorc cnobilia, orsulobas TavisTavadac SeuZlia gamoiwvios muclis tkivili
da, imavdroulad, SeuZlia Secvalos qirurgiuli daavadebis Cveulebrivi suraTi. es diagnozis
dasmas arTulebs. kidev erTi mniSvnelovani gamowvevaa travmirebuli pacienti. am gamocemaze
Cven doqtor Berni Cristalli-Tan, parizel ginekologsa da meanTan, erTad vmuSaobdiT, ase rom,
siamovnebiT warmovadgenT am Tavis Casworebul da gafarToebul variants (redaqtorebi).
`zogad qirurgs damiZaxeT!~

14. 244
anoreqtaluri midamos
gadaudebeli qirurgia
29
Luis A. Carriquiry
vwvalobT da vixocebiT Cvens sakanalizacio da madrenirebel sistemaSi gaCenili
defeqtebis gamo (William A. Lane, 1856-1943).
ratom SevitaneT am gamocemaSi Tavi gadaudebeli anoreqtaluri situaciebis Sesaxeb?
yvelaze martivi pasuxi iqneboda, rom es, ubralod, anatomiis gamo gakeTda _ swori nawlavi
abdominuri organoa. anusi mkacrad abdominurad ver CaiTvleba, Tumca miekuTvneba Soriss,
romelic latu sensu muclis Rrus fskeria. magram mTavari mizezi pragmatulia _ morigeobebze
gadaudebel anoreqtalur situaciebs zogadma qirurgma unda mixedos da uzrunvelyos am
xSiri daavadebis optimaluri mkurnaloba.
jer ganvixiloT analuri areSi tkivilis sami ZiriTadi mizezi:
 mwvave naxeTqi;
 mwvave perianaluri hematoma (hemoroiduli kvanZebis CaWedva _ mTrg.);
 perianaluri abscesi (paraproqtiti _ mTrg.).
`es ra babasilia, miSveleT, ra iqneba!~
marTalia, arc erTi maTgani ar aris sicocxlisTvis saSiSi, magram maT dauyovnebliv unda
miexedos, raTa pacients tkivili da stresi Seumsubuqdes. vinaidan TiToeuli maTganiT gamowveuli
tkivili defekaciis aqtTan mimarTebiT damaxasiaTeblad icvleba, diagnozis diferenciacia
advilia da mas pacientis gasinjvamdec mixvdebiT. Semdeg pacients sinjavT, rac uaRresad
mtkivneuli reqtaluri gasinjvis gareSec SeiZleba gakeTdes: gverdulad wamoawvineT pacienti
an mdgomares sTxoveT, win gadaixaros, Tqven ki ukan daujeqiT, nazad gadauwieT dundulebi da
daaTvaliereT Sorisis midamo _ ase advilad SeamCnevT mwvave perianalur hematomas da mwvave
naxeTqs, zogjer _ perianealur abscessac ki. Tu verafers xedavT, CaTvaleT, rom perianalur
abscesTan gaqvT saqme da ise moiqeciT, rogorc qvemoT iqneba aRwerili.

15. 229
profuzuli `qvemoTa~
gastroduodenuri sisxldena
27
Per-Olof Nyström
sadac ar unda waawydeT intensiur sisxldenas, upirvelesad, gaxsovdeT, rom es
Tqveni sisxli ar aris.
profuzulia sisxldena, Tu is Tavisi intensivobiT hemodinamikurad
mniSvnelovania, ar Cerdeba da dRe-RameSi, sul cota, 4 erTeuli sisxlis
transfuzias moiTxovs.
sabednierod, msxvili nawlavidan WeSmaritad profuzuli sisxldena iSviaTia. TiTqmis
yoveli `qvemoTa~ sisxldena TavisTavad miileva da hemodinamikurad umniSvneloa, magram,
iseve rogorc nebismieri gastrointestinuri sisxldena, ubralo ramed manamde ar unda
CaiTvalos, sanam misi SeCereba dinamikuri dakvirvebiT ar dadasturdeba.
sisxldenis wyaroebi
kolinjis manifestirebuli sisxldenis dros sisxldenis wyarosa da mizezis zustad
dadgena umetesad verc ki xerxdeba (maSinac ki, roca avadmyofs miRebis dResve utareben
kolonoskopias). xSirad sisxldenis mizezad manamde cnobil paTologias moiazreben.
mogvianebiT, roca sisxldenis epizodi miiwureba, sadiagnostiko damuSavebam (gamokvlevebma)
SesaZloa retrospeqtulad gamoavlinos manamde ucnobi paTologia.
qvemoTa sisxldenis mizezebi (CamoTvlilia sixSiris gauTvaliswineblad)
 simsivne
 nawlavis anTebiTi daavadeba
 divertikulozi-divertikuliti
 iSemiuri koliti
 sisxlZarRvovani paTologia _ angiodisplazia
 buasili
 operaciis Semdgomi (maT Soris anastomozidan)
 Meckel-is divertikuli
 infeqcia
Cveni mokle komentari aseTi sisxldenis wyaros garkvevaSi dagexmarebodaT: simsivne,
kibo iqneba Tu keTilTvisebiani polipi, iSviaTad iwvevs intensiur sisxldenas, magram
xSirad sisxldena farulia, rasac mniSvnelovan anemiamde mivyavarT. swori nawlavis kibodan
sisxldena, rogorc wesi, manifestirebulia. vidre diagnozi reqtoskopiiT ar gairkeveva,
anemiam SesaZloa intensiuri sisxldena gvaeWvebinos. aseTi pacienti anamnezSi tenezmebs da
ganavalTan erTad mciredi sisxldenis epizodebs aRniSnavs. nawlavis anTebiTi daavadebisas
sisxldena TiTqmis arasodes aris daavadebis pirveli simptomi da iSviaTadaa intensiuri.
aseT pacientTa umravlesobasTan diagnozi cnobilia da sisxldena asocirebulia

16. 195
mwvave mezenteruli iSemia
23
Moshe Schein
Paul N. Rogers
ucnauri ramaa sisxlZarRvovani qirurgia. yvelafers rom Tavi davaneboT, is iavarqmnilis
aRdgenaa (Cid dos Santos).
mezenteruli sisxlZarRvebis okluzia ganixileba iseT mdgomareobad, roca diagnozis
dasma SeuZlebelia, prognozi _ uimedo, mkurnaloba _ uSedego (A. Cokkins, 1921).
romeli Tqvengani ar gamouZaxebiaT Terapevtebsa da saswrafo daxmarebis ganyofilebis
eqimebs xanSi Sesul pacientebTan `mezenteruli iSemiis“ gamosaricxad. am dros, rogorc
wesi, gxvdebaT mkvnesare avadmyofi gaurkveveli CivilebiT mucelSi da misi istoriis
anakinZi, romelic Tqvenze mets iwonis. `mezenteruli iSemiis gamoricxva“ _ saTqmelad
ufro advilia, vidre saqmnelad.
mwvave mezenteruli iSemia, rogorc wesi, zeda mezenteruli arteriis auzis daavadebaa.
ase rom, upiratesad wvrili nawlavi ziandeba, magram SeiZleba iyos CaTreuli aswvrivi
kolinjic, romelsac sisxliT igive arteria amaragebs. kolinjis izolirebuli iSemia, romelic
gacilebiT iSviaTi daavadebaa, calke iqneba ganxiluli `iSemiuri kolitebis~ TavSi.
problema
problema wvrili nawlavis sisxlmomaragebis uecari Semcirebaa, rac male Sua mucelSi
tkivils iwvevs. Tu mkurnalobis gareSe darCa, procesi TandaTanobiT CaiTrevs nawlavis
kunTovan Sres. mxolod ramdenime saaTis Semdeg, roca serozac daziandeba, iCens Tavs
peritoniumis gaRizianebis niSnebi.
neba gviboZeT, simartivisTvis mwvave mezenteruli iSemia sam saxeobad warmovadginoT,
romlebic daaxloebiT Tanabari sixSiriT gvxvdeba:
Trombuli: Cveulebisamebr, mwvave arteriuli Trombozi zeda mezenteruli arteriis
Sesasvlels Wedavs, iwvevs mTeli wvrili nawlavis da aswvrivi kolinjis Rrma iSemias
(auzi, romelic am arteriiT maragdeba).
emboluri: axlomdebare wyarodan emboluri masebis gamofrqvevis gamo (gulidan _
winagulovani fibrilaciis, miokardis infarqtis, daavadebuli sarqvlis, aortidan _
aTerosklerozis an anevrizmis gamo). emboli, wesisamebr, am arteriis dasawyisSi iWedeba,
magram ara kolinjis Sua arteriis gamoyofamde. amdenad, mlivi nawlavis ufro proqsimuli
maryuJebi, iseve rogorc ganivi da (albaT) aswvrivi kolinji, narCundeba. embolebi midrekilia
fragmentirebisken, distalurad migrirebs da alag-alag wvrili nawlavis iSemias iwvevs.
araokluziuri: `Semcirebuli nakadis~ gamo (Tuki emboli da Trombozi gamoiricxa).
Tumca sagulisxmoa, rom mis gamSvebad da xelSemwyobad mezenteruli sisxlZarRvebis
aTerosklerozi moiazreba. es `Semcirebuli nakadi~ Sedegia gulis dabali wuTmoculobisa
(mag., kardiogenuli Sokis dros), cudi mezenteruli sisxlmomaragebisa (mag., intraabdominuri
hi pertenziis dros) da spazmisa (vazopresorebis miReba), magram umetesad sicocxlisTvis
saSiSi paTologiebis fonze am faqtorebis kombinacia xdeba.
wvrili nawlavis iSemia SeiZleba gamoiwvios mezenteruli venebis Trombozmac. am
nozologiis niSnebi da mkurnaloba radikalurad gansxvavdeba zemoxsenebuli sami scenarisgan
da mogvianebiT calke iqneba ganxiluli.
saqme is aris, rom, saxelmZRvaneloebisgan gansxvavavebiT, klinikur praqtikaSi mezenteruli
iSemia maSin amoicnoba, roca nawlavis gangrena ukve dawyebulia. am dros sistemuri

17. 177
wvrilnawlavovani gauvaloba
21
Moshe Schein
kliftonis dakidebuli xididan gadaxtoma naklebad saxifaToa, vidre operaciaze uaris
Tqma maSin, roca nawlavovani gauvalobisgan igvemebi (Fredrick Treves, 1853-1923).
wvrilnawlavovan gauvalobas dRemde yvelaze xSirad Tiaqrebi da operaciis Semdgomi
Sexorcebebi iwvevs, iSviaTad _ sxva meqanikuri mizezic: gadaylapulis gaWedva (magaliTad,
bezoaris), avTvisebiani an anTebadi procesi (Crohn-is daavadeba), invaginacia. TiaqrebiT
gamowveul wvrilnawlavovan gauvalobas momdevno TavSi ganvixilavT, xolo operaciis
Semdgom adreul da paralizur ileuss _ ufro mogvianebiT, aq ki SevexebiT wvrilnawlavovan
gauvalobas `umanko muclis~, invaginaciis, simsivnis, sxivuri enteritisa da naRvlovani
kenWebis SemTxvevaSi. saerTod, gauvalobis mizezad tuberkulozic ganixileba, magram am
Tavis udidesi nawili SexorcebiT wvrilnawlavovan gauvalobas mieZRvneba.
Sir William Osler-i (1849-1919) ambobda, diagnostikuri siduxWiridan gamosavali nawlavTa
Sexorcebaao. WeSmaritad, ganurCevlad meqanizmisa, gauvalobis 2/3-ze metis mizezia iatrogenuli
(e.i. qirurgiuli saqmianobis Sedegad ganviTarebuli) adhezia. icodeT, geTayva, rom
laparoskopiuli qirurgiis eraSi zogierTma pacientma adre gadatanili qirurgiuli Carevis
Sesaxeb informacia SesaZloa arc ki gadmoalagos. mag., iseTi banaluri laparoskopiuli
operaciis Semdeg, rogoricaa milebis ligireba, darCenili nawiburi xSirad SeumCnevelia.
banaluri kia, magram mas SeeZlo daetovebina erTi SexorcebiTi zonari, romelic srul
wvrilnawlavovan gauvalobas gamoiwvevda. isic unda gaiTavisoT, rom muclis zeda
(suprakolonuri) sarTulis Carevebi ufro naklebadaa dakavSirebuli SexorcebiT gauvalobasTan,
vidre qveda (infrakolonuri) sarTulisa. da bolos, vinaidan Tqven Terapevti ar xarT,
albaT ar gWirdebaT imis Sexseneba, rom Sexorceba TiTqmis arasodes (qirurgiaSi
arasodes Tqva `arasodes~) iwvevs msxvilnawlavovan gauvalobas.
dilema
wvrilnawlavovani gauvaloba Zalze xSirad (naxevarze met SemTxvevaSi mainc, Tu
ufro metad ara) eqvemdebareba konservatiul (araoperaciul) mkurnalobas, magram
konservatiuli mkurnalobis daJinebam SesaZloa daagvianos nawlavis komprometaciis
(strangulaciis) amocnoba, rac metismetad zrdis sikvdilianobasa da avadobas. ase rom,
seriozul gamowvevas warmoadgens Semdegi sakiTxebis gadawyveta: romel avadmyofebs sWirdebaT
gadaudebeli laparotomia mosalodneli an arsebuli strangulaciis gamo? rodisaa sawyisi
konservatiuli mkurnaloba swori da usafrTxo? yavlgasuli Segoneba _ `gauvalobis
dros mzes arc Casvla acalo da arc amosvla~ zogs jer kidev rom akeria pirze, sxva
gamudmebiT mcdelobaSia, operacia sul mTlad aicilos Tavidan.
am kiTxvebze pasuxi gaidlainebiT unda iyos ganmtkicebuli, magram jer ramdenime
termins movfinoT naTeli.
gansazRvrebebi
`martivi~ obstruqcia: nawlavi blokirebuli, kompresirebuli an Semogrexilia, magram
sisxlZarRvovani momarageba ar aris darRveuli.
strangulacia-obstruqcia: nawlavis obstruirebuli (gadaketili) segmentis
sisxlmomarageba darRveulia.

18. 140
mwvave pankreatiti
19
Moshe Schein
muclis Rrus organoebs Tuki RvTis risxva ram SeiZleba daemarTos, yvelaze
saSineli mwvave pankreatitia (Berkeley Moynihan, 1865-1936).
RmerTma pankreasi ukan imitom gadado, rom qirurgebi xaTabalaSi ar gabmuliyvnen.
redaqtoris winasityvaoba
am gamocemaSi mwvave pankreatitis qirurgiuli mkurnalobis Sesaxeb dasawerad moviwvieT
Mayo-s klinikis doqtorebi, batonebi Sarr-i da Barton-i. vinaidan am nozologiis mkurnaloba
naklebad agresiuli da invaziuri gaxda, is moiTxovs TiToeuli pacientisadmi individualur
midgomas da iseTi multidisciplinuri jgufis yuradRebas, romelSic iqnebian qirurgi, radiologi,
endoskopisti da reanimatologi. Mayo-s klinikis mier mowodebuli mravalmxrivi midgomis
koncefciis safuZvelze, mwvave pankreatitis garTulebuli formis mqone pacienti, Tu
SesaZlebelia, ar unda darCes saxlSi an raionul hospitalSi _ is unda gadaigzavnos
iseT centrSi, sadac mas ukeTes mkurnalobas SeTavazeben. magram realur cxovrebaSi,
romelsac Tqven, mkiTxvelebi eweviT, yvela aseT pacients Mayo-s klinikaSi an adgilobriv
sauniversiteto hospitalSi ver gadagzavniT. amdenad, mniSvnelovania, rom zogadi qirurgi, sadac
ar unda muSaobdes igi, swvdebodes am mravalwaxnaga daavadebis sirTules.
doqtorebis Sarr-isa da Barton-is naSromis gacnobamde sabaziso koncefciebis teqsts
gagacnobT.
pankreatitis Setevebi umetesad susti an zomieria da TavisTavad ganicdis regress.
wignis am nawilSi pankreatitis garTulebebi ufroa Tavmoyrili, romlebic metwilad
konservatiul da damxmare mzrunvelobas moiTxovs.
ZiriTadi sakiTxebi
daavadebis xasiaTi
mwvave gaurTulebeli pankreatiti erTkviriani daavadebaa. Tu Svid dReSi avadmyofi ar
gamojanmrTelda da pankreasis anTebis lokaluri da sistemuri niSnebi kvlavac SeimCneva,
garTulebis momwifeba unda ivaraudo. Tu maT ganviTarebasa da mkurnalobisadmi klinikur
midgomas kvirebis mixedviT ganixilav, am garTulebaTa gageba Zalze gaadvildeba.
klasifikacia
mwvave gaurTulebel pankreatits gadaudebeli qirurgi iSviaTad sWirdeba, magram mZime
pankreatitma, SesaZloa, uamrav garTulebas, infeqciursa Tu nekrozuls, daudos saTave. am
garTulebaTa ricxvSia:
I kvira _ anTebadi flegmona; mkurnaloba yovelTvis araoperaciulia.
II kvira _ pankreasuli an peri pankreasuli nekrozi; mkurnaloba (rogorc wesi)
araoperaciulia.
III kvira _ inficirebuli (pankreasuli da peri pankreasuli) nekrozi _ movixsenioT
inficirebad; mkurnaloba operaciulia.
IV kvira _ procesis dasasruli: pankreasuli abscesi, fsevdokista, inficirebuli
fsevdokista.

19. 118
sisxldena gastrointestinuri traqtis
zeda sarTulebidan _ `zemoTa sisxldena~
(da portuli hi pertenzia)
17
Moshe Schein
`me imaze swrafad movkurcxlav, vinc Cemi sayvareli kuWis naxevris amokveTas
mi pirebs Tormetgojas pawawina wylulis mosarCenad~ (Charles H. Mayo, 1861-1939).
`mezobeli Tormetgojas wylulis samkurnalod ZiriTadad janmrTeli kuWis amokveTa
Zalian hgavs siCqaris kolofis xmauris Sesamcireblad Zravis amoRebas ~ (Francis D.
Moore, 1913-2001).
Cveni rezidentobisas, 80-ian wlebSi, kvira ar gavidoda, Tormetgojadan an kuWis
wylulidan sisxldenis gamo operacia ar gakeTebuliyo. gadaudebeli wesiT Catarebuli
rezeqciebi, antrumeqtomiebi, Rerovani da seleqtiuri vagotomiebi Cveni yveli da puri iyo.
cvlilebebi TandaTan daiwyo. jer H2 receptorebis antagonistebi gaCnda, maT protonuli
tumbos inhibitorebi moyva, mere helokobaqteriis sawinaaRmdego Terapia gamoCnda, mere _
sisxldenis endoskopiurad kupirebis novatoruli meTodebi. Sedegad, iq, sadac vmuSaobT
(iq mainc!), zemoTa gastrointestinuri sisxldena iSviaToba gaxda da misdami Cveni midgomac
Seicvala. Tu Tqven iq moRvaweobT, rasac `ganviTarebad samyarod~ moixsenieben da sadac
wylulis sawinaaRmdego Tanamedrove medikamentebi Znelad xelmisawvdomia, SesaZloa wylulidan
sisxldenis Zvelebur gamovlinebebs SeeCexoT da masTan gasamklaveblad tradiciuli meTodebis
gamoyeneba dagWirdeT.
didi albaTobaa, ufro da ufro gauucxovdeT `zemoTa sisxldenebis~ qirurgiul
mkurnalobas, amitom unda mogvisminoT!
problema
`zemoTa sisxldenebi~ daavadebis keris treicis iogis proqsimulad arsebobas
gulisxmobs. Tumca saxelmZRvaneloebSi aTasnairi mizezia CamoTvlili, avadmyofTa umetesobas
sisxli sdis Tormetgojas an kuWis qronikuli wylulidan, portuli hi pertenziis
garTulebebidan (igulisxmeba saylapavis varikozi an hipertenziuli gastropaTia, romelTa
Sesaxeb mogvianebiTac visaubrebT) da kuWis lorwovanis mwvave dazianebis gamo (stresuli
wyluli da sxva terminebiT gamoxatuli TiTqmis igive daavadebebi). eroziuli gastriti
alkoholisa da analgetikebis erTdrouli an cal-calke miRebisas viTardeba (aspirini
nabaxusevze). stresis mqone pacientebTan profilaqtikis mizniT wylulis sawinaaRmdego
medikamentebis rutinuli gamoyenebis fonze kuWis lorwovanis mwvave dazianeba ukve gaiSviaTda.
stresmiRebul pacientebs sisxldena xSirad gaaqtiurebuli qronikuli peptikuri wylulidan
ewyebaT. sisxldenis wyaro SeiZleba iyos Mallory-Weiss-is naxeTqebic kardioezofaguri
Sesaxsrebis doneze, rac, rogorc wesi, gamowveulia slokiniT, xveliTa da RebinebiT, anda
Dieulafoy-s daavadeba _ kuWis lorwqveSa sisxlZarRvovani anomalia. zogadad, mizezad gvevlineba
etiologiuri faqtorebis kombinaciis varianti, damokidebuli kontingentze, romelic hospitalSi
xvdeba da im garemos socialur Cvevebze, sadac muSaoba giwevT.
klinika
daavadeba vlindeba hematomezisiT (axali sisxliT Rebineba), melenamezisiT (yavis
naxarSismagvari Rebineba) an meleniT. hematoCezia (axali an Seucvleli, arakuprisferi
sisxlis gamosvla swori nawlavidan) daavadebis keris treicis iogis distalurad arsebobaze

20. 85
muclis revizia: paTologiis moZebna
11
Moshe Schein
nurasodes gaaCereb kans Sensa da diagnozs Soris.
(gvesmis, rom es qirurgiuli aforizmi Zvelia da saTayvano, magram diagnozis
angariSmiucemlad gamodevneba arafers gvargebs!)
pirveli da mTavari qirurgiaSi Tvalebia, momdevno da naklebi _ TiTebi, ukanaskneli da
umciresi ki ena (Humphrey George Murray, 1820-1896)
arcTu iSviaTad, muclis gaxsnisas qirurgma icis, ra daxvdeba iq. am SemTxvevaSi
klinikur suraTsa da gamokvlevebs is pirdapir mihyavs paTologiuri adgilisken. qirurgi
peritoniumis gaRizianebis niSnebis mixedviT gadawyvets operacias da varaudobs, rom
muceli sisxliT an CirqiT iqneba savse, magram zogjer diagnozi laparotomiis Semdegac
gaurkveveli rCeba. rogorc wesi, qirurgi moisazrebs diagnozs, magram yovelTvis mzadaa
moulodnelobisTvis. amitom aris gadaudebeli abdominuri qirurgia amaRelvebeli da momTxovni:
katastrofa mudam karsaa momdgari da Relav, SegiZlia Tu ara, Rirseulad Seeba mas.
muclis revizia
laparotomia aratravmuli mizeziT (gauvaloba, anTeba, peritoniti) da laparotomia
travmuli sisxldenis gamo sagrZnoblad gansxvavdeba erTmaneTisgan, Tumca, miuxedavad
gansxvavebuli klinikuri garemoebebisa, daTvalierebis dros aucilebelia ori principuli
safexuris gavla:
 im konkretuli paTologiis amocnoba, risTvisac operacia daigegma;
 peritoneumis Rrus rutinuli revizia.
amrigad, gaxseniT peritoneumi. axla ras apirebT? Tqveni moqmedeba imazea damokidebuli,
`ra qeni, eqimo, veraferi naxe?~
ramdenad eqstremaluria viTareba, rogoria paTologiuri procesis meqanizmi (spontanuria
Tu travmuli), sawyisi monacemebi (sisxli, Cirqi, dabinZuraba). rac ar unda naxoT, imoqmedeT
Semdegi prioretitebis mixedviT:

21. 75
ojaxi, eTika, informirebuli Tanxmoba
da iuridiuli sakiTxebi
8
James C. Rucinski
aba, eqimo, ras ityvi, Cemo eqimo? (Philip Roth)
nu cruob, Senc ici da mec vici, rom vkvdebi, nuRar momatyueb mainc!
(Leo Tolstoy, 1828-1910)
Tu ginda, momakvdav kacs gaugo, unda waikiTxo Leo Tolstoy-s `sikvdili ivan iliCisa~.
roca gareT qari zuzunebs, SesaZloa saswrafo daxmarebis ganyofilebaSi (Emergency)
dagiZaxon da Tavad moxvdeT sruliad ucnobi xalxis mRelvarebisgan atexil qarbuqSi –
mogiwioT imis axsna, rom maT sayvarel adamians gadaudebeli operacia sWirdeba da saoperacio
ukve mzadaa.
informirebuli Tanxmobis mopoveba _ es aris adamianis (vaWarkaciviT) dainteresebis
unaris, eTikuri problemis gadawyvetisa da fsiqologiuri mzrunvelobis praqtikuli
gamovlena. amasTan erTad, is gulisxmobs sakuTari gamocdilebisa da mkurnalobis gegmis
bazarze gamotanasac. is moiTxovs gadawyvetilebis misaRebad pacientisa da misi axloblebis
mokavSireebad gadmobirebas. informirebuli Tanxmoba, romelic ufro kanonierebis gamoxatulebaa,
amasTanave, pacientis, Tqveni kolegebisa da sakuTari Tavis winaSe eTikuri valdebulebebis
aRebasac moiTxovs.
marifaTianoba
SeTavazebuli mkurnalobis axsna daiwyeT imave sityvebiT, rogoriTac Tqvens araeqim
naTesavs auxsnidiT. aRuwereT operaciis mosalodneli sargebeli da alternatiuli
mkurnalobis SesaZlo Sedegebi. SeTavazeT ramdenime scenari. magaliTad aviRoT sigmis
kibo da gauvaloba. misi mkurnalobis varianti konservatulic SeiZleba iyos, rac TiTqmis
ueWvelad miiyvans pacients nel da Znel sikvdilamde. sapirispiro variantia operaciiT
swrafi gamojanmrTeleba didxans kargad yofnis SansiT. operaciis Tanmxlebi garTulebebi
da sikvdilianoba, recidivebi da sxva potenciuri siZneleebi sadRac SuaSi unda iyos.
mTavaria, Tqven TviTon gjerodeT Tqveni SeTavazebuli gegmisa. Tu ase ar aris da gegma
`zemodan~ aris nakarnaxevi, maSin pasuxismgebels sTxoveT, `molaparakeba~ Tavad gamarTos.
pacientsa da mis ojaxTan Tavi gaasaReT eqspertad da mecnierad, romelsac esmis sxvisi
gasaWiri da rTuli problemis mogvarebaSi maTTan erTad monawileobs. daurTeT dagegmili
operaciis yvelaze metad mosalodneli garTulebebis aRwera saerTo monacemebisa da konkretuli
pacientis gaTvaliswinebiT. mag., sikvdilianobis riski hemikoleqtomiis dros SeiZleba umniSvnelod
CaiTvalos, magram xandazmulebSi Tu gauvaloba da hi poproteinemiaa, yoveli meoTxe
SesaZloa mokvdes. auxseniT ZiriTadi operaciis Semdgomi garTulebebis, infeqciis, sisxldenis,
hemotransfuziis Tanmxlebi problematikis, cudi Sexorcebisa da sikvdilianobis Sesaxeb,
mere axseneT dagegmili Carevis specifikuri garTuleba. magaliTad, naRvlis saerTo sadinris
dazianeba laparoskopiuli qolecisteqtomis dros. aucilebelia, yvela masStaburi gadaudebeli
Carevis win xazi gausvaT ganmeorebiTi operaciis SesaZleblobas imisda mixedviT, ra dagxvdebaT
operaciaze da rogor ganviTardeba Semdeg movlenebi. es didi SeRavaTi iqneba TqvenTvis, Tu
reoperacia marTlac gaxda saWiro da ojaxis wevrebTan `konfrontacia~ mogiwiaT. isini
mixvdebian, rom ganmeorebiTi operacia ufro mkurnalobis gagrZelebas warmoadgens, vidre
garTulebas. patar-patara garTulebebis CamoTvlam, mag., iseTebisa, rogoricaa flebiti

22. 46
muclis radiologiuri gamokvlevebi
5
Moshe Schein
Sai Sajja
Hans Ulrich Elben
aSkaraa diagnostikuri problematikis Secvla
da es cvlilebebi yoveldRe xdeba
_ ratom unda vendoT garTulebul kvlevas?
xelebis, yurebisa da Tvalebis gareSe
beCavdeba qirurgi, araferi rCeba!
`mwvave muceli riTmebSi~ (Zachary Cope, 1881-1974)
sxvadasxva specialobis eqimebis mier `mwvave muclis~ Sesaxeb miRebul gadawyvetilebaTa
mravalgvaroba aSkarad miuTiTebs problemis araerTgvarovan xedvaze. radiologis gamWoli
mzera yvelafers xedavs, Tumca saWiroze metis danaxviskenaa midrekili, Tanac yovelTvis
ar esmis imis klinikuri mniSvneloba, rasac xedavs. saswrafo daxmarebis ganyofilebis
(Emergency room, ER) eqimi bevrs verafers xedavs da rasac xedavs, mis mniSvnelobasac ver
xvdeba. maT mxolod is adardebT, sad daawvinon pacienti. es qirurgebs sakuTari Tavis
amara gvtovebs. Cven, daavadebis bunebis ukeTesad codniTa da operaciiswina dakvirvebis
radiologiuri monacebTan Sejerebis unariT SeiaraRebulni, yvelaze ukeT vkiTxulobT
abdominur gamosaxulebebs. Cven ukve vimsjeleT abdominuri gamokvlevebis rolze `mwvave
muclis~ SefasebaSi. am TavSi Cven SevecdebiT mogawodoT praqtikuli rCevebi imis Taobaze,
Tu rogor `uyuroT~ gamosaxulebebs da ras miamgvanoT isini yvelaze metad.
muclis mimoxilviTi rentgeni
Moshe Schein
samwuxarod, am martiv, iaf da usafrTxo gamokvlevas TandaTan enacvleba saswrafo
kompiuteruli tomografia, romelsac gacilebiT meti gamosxiveba aqvs. arada, mimoxilviT
abdominur rentgenze erTi Tvalis SevlebiT ramdeni ramis gageba SegeZloT?!
airis saxeebi mucelSi
Tavisufali airi mucelSi
Tavisufali airi (pnevmoperitoneumi) mucelSi yvelaze ukeT gulmkerdis rentgenis
pacientis mdgomare poziciaSi gadaRebisas Cans, Tumca Cveulebriv muclis rentgenzec
SeiZleba iqnes nanaxi. roca gulmkerdis rentgenograma normaluria da organos perforaciis
Taobaze eWvi grCebaT, marcxena gverdze wolisas gadaRebulma lateralurma suraTma
SeiZleba aCvenos pnevmoperitoneumi (nax. 5.1).
Cvevad gqondeT, eZeboT ati puri airi mucelSi. amis wyalobiT zogjer Tvalis erTi
SevlebiTac dasvamT diagnozs. biliarul xeSi airis arseboba (pnevmobilia) (nax. 5.2) an
qolecistoenterofistulis an biliodigestiuri anastomozis arsebobaze mianiSnebs, an
kidev, ufro xSirad, odis spinqteris endoskopiuri kveTis Sedegia. RviZlSida sanaRvle
gzebSi airi centralurad grovdeba, maSin roca RviZlis periferiis airi ufro karis
venaSi Tua. airi karis venaSi (nax. 5.3) aRwevs nawlavis kedlis gaWolviT, rogorc wesi
mezenteruli iSemiis an mwvave kolitis dros da iSviaTad _ pileflebitis dros. Cveulebriv,
karis venaSi airi Cndeba nawlavebis iSemiuri dazianebis dros, roca airis intramurulad
SeRweviT viTardeba nawlavis pnevmatozi (nax. 5.4).

23. 24
mTavari filosofia
1
Moshe Schein
Paul N. Rogers
Ahmad Assalia
qirurgi operaciis mkeTebeli Terapevtia.
`sibrZne mxolod tanjvaSi modis~ (Aeschylus, Agamemnon).
axla, roca am wigns xelSi iRebT da furclavT, mTel msoflioSi aTasobiT qirurgi
ebrZvis abdominur katastrofas. brZolis veli SeiZleba iyos londonis saswrafo daxmarebis
Tanamedrove departamenti da msxverplisTvis gankuTvnili Selaxuli sadgomi an saeqimo
karavic afrikaSi, Tumca suraTi yvelgan erTnairia: Tqven winaSea tkivilisagan gatanjuli
pacienti. sanerviulo Tavze sayrelia _ ar iciT diagnozi, ar iciT, mkurnalobis romeli
variantia saukeTeso da xarT Tu ara misi Semsrulebeli. es universaluri scenari XXI
saukuneSic ki ar gamoirCeva originalurobiT da iseTive Zvelia, rogoric Tavad qirurgia.
vidre Tqven saqmianobT, yovelive ise nela icvleba, rom SesaZloa, yuradRebac ver miaqcioT.
diax, Tqveni hospitali Tanamedrove medicinis flagmania, Tqven gadaudebeli daxmarebis
samsaxurs gamarqafebuli aqvs ukve xelovnebis nimuSad qceuli kompiuteruli da magniturrezonansuli tomografiis manqanebi, Tumca praqtikuli TvalsazrisiT arc araferi Secvlila
_ axlac Tqven orni xarT qveyanaze: Tqven da Tqveni pacienti (xSirad ki mTeli `sistemac~
Tqven winaaRmdegaa) da mxolod Tqven unda SeeWidoT swori gegmis Sedgenisa da misi
Sesrulebis urTules amocanas.
gadaudebeli abdominuri paTologiebis `saukeTeso~ mkurnaloba
upriania gadaudebeli abdominuri qirurgi qveiTi jaris oficers SevadaroT. misgan
Sorsaa is yuradReba da xotba, romliTac kardio da neiroqirurgebi arian garemoculni.
`iazrovne, rogorc qveiTma jariskacma...~

24. 7
It is useful to compare the emergency abdominal surgeon to an infantry officer
(Dr. Moshe Schein).
„upriania, gadaudebeli abdominuri qirurgi qveiTi jaris oficers SevadaroT“
(doqtori moSe Saini).
naSroms vuZRvni Cems vaJs, ioane qemokliZes _ qveiTi jaris momaval
oficers, daviT aRmaSeneblis saxelobis samxedro akademiis iunkers, aseve mis
megobrebsa da maswavleblebs.
mTargmnelisagan
(doqtor Sainis stilSi)
sasargeblo rCeva qarTvel mecnierebs: SeeCvieT sakuTar Targmanebze namdvili avtoris
gvaris miweras da im kacisa mainc mogeridoT, Tavis Sedevrs „sparsuli“ da „qarTulad
naTargmanebi“ rom uwoda.
aseve, gaiTvaliswineT, rom me arc qarTuli enis eqsperti var da arc, miT umetes,
inglisurisa. am ormag yulfSi Tavis gayofa sabWouri da postsabWouri qirurgiis
bedkrulobam maiZula.
safuZvliani eWvi maqvs _ am qveynad uamravi adamiani mxolod imitom dadis cocxali,
rom maTi mkurnali eqimi doqtor moSe Sainis am WeSmaritad mecnierul wigns gaecno da
mis Wkvianur dakvirvebebs eziara. didi imedi maqvs, aseTi adamianebis ricxvi am Targmanis
gamoqveynebis Semdeg saqarTveloSic gaizrdeba.
wignis meore gamocemis Targmanze muSaoba maSin daviwye, rodesac mesamis gamosvlamde
1-2 weliRa iyo darCenili. vcdilobdi, ise gadmomeqarTulebina, rom wminda akademiur
mxaresTan erTad avtoris gulisTqma da ganwyobac gadmomeca. es xSirad TiTqosda qarTul
samedicino wreebSi miRebuli metyvelebis gamoyenebiT ufro xerxdeboda (yovel SemTxvevaSi,
vcdilobdi, ,,nanuCoba“ ar gamomsvloda). am xnis ganmavlobaSi erTxelac ar Camixedavs
pirveli gamocemis rusul TargmanSi _ Tanamedrove qarTuli samedicino leqsika isedac
savsea Sori gziT daRlili, gaukuRmarTebuli kalkebiT. egeb, lingvisturi siduxWiridan
gamosavali qarTuli enis wiaRSi Zieba da laTinizmis originalSi Wvreta yofiliyo („ara
viqm, codna ras margebs, filosofosTa brZnobisa“!). ... momiteveT Cemi STabeWdilebebis
aseTi gulwrfeli aRiareba..., magram inglisur-qarTuli (da sxva qarTuli leqsikonebis)
umetesoba ver pasuxobs drois gamowvevebs. magaliTad, leqsikonSi SedarebiT rTuli
sityvis Ziebis Sedegebs Tu kargad daukvirdebi, imas ufro mixvdebi, ra ewera rusulqarTul leqsikonSi aTeulobiT wlis win, vidre mocemuli sityvis Tanamedrove inglisur
mniSvnelobas. mravali problema iCens Tavs qarTul samedicino enaSic... da, mgoni, Tanamedrove
sasaubro Tu literaturul qarTulSic. gulistkiviliT unda aRvniSno isic, rom sakuTari
produqciis gasasaReblad eqimebis gulis gawvrilebiT dakavebuli da araracionalur
mkurnalobasaviT momravlebuli samedicino (da farmacevtuli) firmebidan arc erTs ar
gamouxatavs survili am wignis gamosacemad raime saxis Sewevnisa (etyoba, kargad ician
maT Sesaxeb am wignis avtoris azri).
wignis avtoris stilis SenarCunebis mizniT, komentarisTvis movixmob wignis qarTuli
gamocemis redaqtors, medicinis akademiur doqtors, gadaudebeli daxmarebis qirurgs
kaxaber kikviZes: `wignis am gamocemaSi bevri mniSvnelovani Tavia damatebuli, rac
Tanamedrove medicinis moTxovnebiTaa gamowveuli. wigni warmoadgens avtoris cocxal da
Tavisufal, Tumca Zalian maRalprofesiuli donis saubars mkiTxvelTan. vfiqrobT, igi
daainteresebs rogorc axalgazrda, aseve gamocdil qirurgebs. SesaZloa gansakuTrebiT am
ukanasknelT, radgan wignSi bevri iseTi konservatuli (qirurgia xom Zalian konservatul
mecnierebad iTvleba) dogmaa Seryeuli Tu dangreuli, romelic TiTqosda xelSeuxeblad
miiCneoda. magaliTisTvis qirurgiis amerikuli Tanamedrove qrestomaTiis Semqmnelisa da
avtoritetis Schwartz-is mosazrebis mkiTxvelis samsjavroze gamotanac kmara. wignSi
detaluradaa aRwerili muclis Rrus gadaudebeli qirurgiuli paTologiebis klasikuri

25. 11
avtoris winasityvaoba qarTuli gamocemisaTvis
Zvirfaso qarTvelo megobrebo,
es SedarebiT „dabalteqnologiuri“ da „araformaluri“ wigni, romelic 2000 wels
pirvelad daistamba inglisur enaze, dRemde aRiarebiT sargeblobs mTel msoflioSi. wigni
ukve Targmnilia espanur, rusul, italiur, Cexur, polonur da Cinur enebze, axla ki
gansakuTrebuli kmayofilebiTa da siamayiT mivesalmebi Cveni wignis gamocemas qarTul
enazec.
Tqven winaSe guldawyvetiT unda vaRiaro, rom arasdros vyofilvar saqarTveloSi.
miuxedavad amisa, kargad vuwyi, rom mis xalxs didebuli uZvelesi da Tanamedrove qirurgiuli
tradiciebi aqvs. msoflios mraval qveyanaSi mogzaurobam da ucxoel qirurgebTan farTo
urTierTobiT SeZenilma gamocdilebam damarwmuna, rom TumcaRa erovnuli, eTnikuri,
kulturuli da enobrivi sazRvrebi Cven, qirurgebs, erTmaneTisgan gvyofs, qirurgiis saerTo
siyvaruli da pacientebisadmi absoluturi erTguleba gvaduRabebs. es sulac ar aris
gasakviri, radgan adamianis anatomia TbilisSic isaa, rac viskonsinis StatSi mdebare Cems
mSobliur qalaqSia; mwvave apendiciti helsinkisa da israelSi erTmaneTisgan didad ar
gansxvavdeba, xolo qirurgi, romelic saqarTvelos qalaq soxumSi SuaRamisas operacias
ukeTebs avadmyofs sisxlmdeni peptikuri wylulis gamo, bevri ramiT hgavs Tavisi kolegas,
romelic Sotlandiur glazgoSi imave problemasTan gamklavebas cdilobs. amitomac aris,
rom qirurgebi mTel msoflioSi TavianT Tavs am patara wignis suliskveTebasa da SinaarsTan
aigiveben. imedi maqvs, Cemo Zvirfaso qarTvelo megobrebo, sxvebiviT, Tqvenc mogewonebaT es
wigni.
wignis mesame gamocemis Tanaavtorebis, pol rojersisa da ahmad asalias saxeliT,
minda madloba gadavuxado doqtor Teimuraz qemokliZes qarTul enaze misi TargmnisaTvis.
„Cveulebrivi qirurgiuli teqstis“ Targmna SedarebiT advilia, magram kilos, ganwyobisa da
„qirurgiuli iumoris“ gadaTargmna guliani, natifi da kargad Camoyalibebuli qirurgis
pirovnul Tvisebebs saWiroebs. swored im Tvisebebs, romlebic ase TvalsaCinod gamoavlina
doqtorma Teimuraz qemokliZem am proeqtis ganxorcielebisas.
kidev erTxel gamovTqvam imeds, rom es wigni mogewonebaT da rames SegZenT. didad
dagifasebT, Tu, Tqvens STabeWdilebebs am eleqtronul misamarTze gamiziarebT:
mosheschein@gmail.com.
moSe Saini
marfildis klinika
viskonsinis Stati, aSS
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