MINISTRY OF HEALTH REPUBLIC OF UZBEKISTAN
TASHKENT MEDICAL ACADEMY
"APPROVED"
Vice Rector for academic affairs
of TMA Prof. Teshaev O.R.
___________________________
«27» august 2015y.
Department: FACULTY AND HOSPITAL SURGERY
Subject: FACULTY SURGERY
TOPIC:
ACUTE CALCULOUS CHOLECYSTITIS AND ITS COMPLICATIONS
Educational-methodical technology
(for teachers and medical students)
Tashkent-2015
Compiled by:
Professor Khakimov M.Sh.
Docent Berkinov U.B.
Assistant Sattarov O.T.
Technology training approved:
At the faculty meeting protocol number №1 of «27» august 2015y.
Subject: Acute calculous cholecystitis and its complications.
1. Model learning technology in the classroom
Time – 6 h
Number of students – 8-10 pers.
Practical session in the clinic and workshop
Form of lesson
using in this lesson "BLACK-BOX", "WEB".
Department of facultative and hospital surgery,
Venue classes
training room, dressing.
1. Introduction
Structure of the training
2. The practical part
sessions
- Supervision of patients
- Implementation of practical skills
- Discussion of the practical part
3. The theoretical part
- Discussion of the theoretical part
4. Assessment
- Self-esteem
- Evaluation of teacher
5. Conclusion teacher.
Assessment of Knowledge.
Providing questions relating to the next class.
The purpose of the lesson: clarifying the theme by showing the importance of
topics for the training of students, introducing students Acute calculous
cholecystitis and its complications, the reasons for their development, clinical
features, differential diagnosis, optimal methods of treatment, postoperative care,
rehabilitating patients.
Task of the teacher:
Learning outcomes:
1. To consolidate and deepen the The student should know:
students' knowledge about the - Diagnosis and differential diagnosis and
features clinics and course
complications;
Acute calculous cholecystitis - Interpretation of the results of instrumental
and its complications,.
diagnostic studies to substantiate the
2. Explain the principles of the
diagnosis and the choice of a rational
differential diagnosis.
treatment;
3. Students' skills of self- - Preoperative characteristics of this category
informed decision-making in
of patients;
the
appointment
of - Determine the nature of surgery and
rehabilitation for patients with
conservative treatment, to know their
surgical diseases
of
gall
characteristics;
bladder.
- To prevent complications during and after
4. Provide
students
the
surgery;
principles
of
prevention - To learn a special survey methods.
activities.
The student should be able to:
Perform practical skills to acquire some
Methods and techniques of
training
Learning tools
Forms of study
Conditions of learning
Monitoring and evaluation
practical skills in the examination of patients
with Acute calculous cholecystitis and its
complications, perform special techniques,
survey data of patients to determine indications
and contraindications for surgical interference.
Methods "BLACK-BOX" and "WEB", graphic
organizer – a conceptual table.
Manuals, training materials, slides, video and
audio, medical history.
Individual work, group work, collective.
Audience chamber, training room, operating
room, dressing.
Interpreting control: control issues, perform
educational tasks in groups.
2. Motivation
Instilling students with the need for timely development of adequate
operations to severe complications, and in their development, encountering
with the most informative and modern methods of diagnosis, surgical treatment,
meeting with potential complications of surgery and operating out during the
period of prevention, development of clinical thinking of students. The
development of the modern view of the problem issues from the perspective
of world medicine and general practice.
3. Intro-subject and inter-subject communication
Teaching this topic is based on the knowledge bases of students on anatomy,
normal and pathological physiology of circulation. Knowledge acquired during the
course will be used during the passage of gastroenterology, internal medicine and
other clinical disciplines.
4. The content of lessons
4.1. Theoretical part
Complicated calculous cholecystitis. Chronic inflammatory process in the
gall bladder is often associated with the development of various complications,
which can be divided into two groups (Scheme 1).
Scheme 1
Complications of calculous cholecystitis
peritoneal forms
obstructive forms
Phlegmonous cholecystitis
Obstructive cholecystitis
Gangrenous cholecystitis
(obstruction of the cystic duct,
Acute gallbladder empyema
gallbladder hydrops)
Perforative cholecystitis (perivesical Obstruction of the bile duct
infiltrate, perivesical abscess, localized (choledocholithiasis,
papillary
peritonitis, diffuse peritonitis)
stenosis, pancreatitis)
Such a division is conditional, because in clinical practice often there are cases
when we have the combined lesions of the gallbladder and bile ducts.
Peritoneal forms of cholecystitis characterized by the spread of the
inflammatory process over the entire thickness of the gallbladder wall and its
transition beyond.
Phlegmonous cholecystitis. The emergence of this form of cholecystitis
promote microbial factor and violation of evacuation function of the gallbladder.
Inflammatory process quickly captures the entire thickness of the gallbladder wall
that leads to purulent impregnation and its output infection beyond the gallbladder.
The clinical picture of phlegmonous cholecystitis characterized by acute onset
of the disease. Patient after errors in diet there are strong pain in the right upper
quadrant with typical irradiation along the right phrenic nerve. Accompanied by
recurring pain, vomiting and increased body temperature to 38-39 ° C.
Patients with phlegmonous cholecystitis behave restlessly. Language they dry,
the coated. Upper abdomen behind in the act of breathing. On palpation of the
abdomen marked soreness and muscle tension in the right upper quadrant.
Symptom of Ortner - Grekov sharply positive. There is a positive symptom of
Mussy (pain when pressing your finger over the right clavicle between ne-anterior
legs sternoclavicular-nipple muscle). Despite the presence of muscular protection,
many patients can palpate enlarged, hard and painful gall bladder or perivesical
infiltrate. In peripheral blood detected increased (up to 15000-18000) white blood
cell count with leukocyte shift to the left.
The disease usually progresses with the increase of local or systemic effects of
peritonitis.
Gangrenous cholecystitis - the most severe form of acute cholecystitis,
accompanied by the development of local or general peritonitis. This form of
cholecystitis often caused by the progression of abscess inflammation in the
gallbladder wall. According to some authors, necrosis of the gallbladder wall
promotes thrombosis of the main trunk or branches of the individual cystic artery.
Other researchers believe gangrene of the gallbladder wall consequence of a severe
infection with hyperergic allergic sensitization of the patient.
The clinical picture of gangrenous cholecystitis in many ways resembles the
clinical picture abscess cholecystitis, but with more severe intoxication organism:
pointy facial features, high body temperature, repeated vomiting, dry tongue. On
examination of the abdomen revealed a right upper quadrant of peritoneal irritation
symptom (symptom of Shchetkin - Blumberg).
If gangrenous cholecystitis around the gallbladder has no time to form
distinguishes infiltrate, symptom of Shchetkin- Blumberg determined in all parts of
the abdomen.
Outcomes of acute cholecystitis. When acute inflammation in the gallbladder
occurs on the background of the blockade of the cystic duct, may develop acute
gallbladder empyema (accumulation of pus in the lumen of the gallbladder). In
patients with acute empyema of the gallbladder, despite conducted anti-
inflammatory treatment, remains high body temperature, accompanied by chills
and sweating. Often detected light yellow skin and sclera, continued nausea and
vomiting. In the right upper quadrant defined by an enlarged, hard and painful gall
bladder or inflammatory infiltrate. Symptom of Ortner – Grekov is sharply
positive. The picture shows the white blood purulent inflammation (pronounced
leukocytosis, increased ESR), appear in the urine protein cylinders, red blood cells
- the signs of toxic nephritis.
Perforative cholecystitis is a consequence of abscess or gangrenous
inflammation of the gallbladder wall. As a result of necrosis of the gallbladder wall
its infected contents come out. When the contents of the gallbladder may extend
into the free peritoneal cavity, causing the development of peritonitis general or in
a cavity bounded by an inflammatory infiltrate in the lumen or soldered to the
gallbladder hollow body.
The clinical picture of perforation of the gallbladder is largely dependent on
the phase of development of the inflammatory process in the gall bladder, the
period from the onset of the disease and the degree of formation of adhesions
around the gallbladder (from forming separates infiltration). Perforation of the
gallbladder wall and hit its contents into the free peritoneal cavity is manifested by
a sudden intensification of pain in the upper abdomen with simultaneous
deterioration of general condition of the patient. In the foreground the clinical
picture of acute general peritonitis.
If perforation of the gallbladder wall occurs in mature separates the abdominal
cavity infiltration, the picture of the limited peritonitis, subhepatic abscess.
Perforation of the hollow body (stomach, duodenum or colon) leads to the
formation of internal biliary fistula. In some cases, getting calculus in the
duodenum and its promotion through the intestines can cause the development of
acute intestinal obstruction gallstone.
Obstructive forms cholecystitis characterized by a partial or complete
blockage of the main bile ducts, which can be a cause of gallstone, released in
hepatic bile duct from the gallbladder (choledocholithiasis), or inflammation (scar)
process, which occurs in the distal bile duct due to damage its mucous shells small
stones, extending into the duodenum (stenosis of major duodenal papilla). The
clinical picture of obstructive forms of cholecystitis manifests the development of
jaundice and acute cholangitis. Since the blockade of the distal bile duct can cause
inflammation in the pancreas, some cases of cholecystitis, accompanied by bile
duct blockage, proceed as choletcystopancreatitis.
The most frequent symptom in the main bile duct obstruction is jaundice
(icterus) - condition of the body, accompanied by staining sclera, mucous
membranes and skin yellow, resulting from increasing the amount of bilirubin in
the blood of the patient. Since hyperbilirubinemia in complicated calculous
cholecystitis occurs at biliary obstruction, jaundice is mechanical in nature, which
is characterized by an increase in the total amount of bilirubin in the blood due to
its direct fraction.
Main bile duct obstruction leads to stagnation in their bile (bile hypertension)
and expand their diameter (cholangioectasia). Stagnation of bile in the biliary
system is accompanied by morphological changes in the liver and a violation of its
functions. Liver failure is still considered the most common and serious
complication of mechanical obstruction of the bile ducts and in 50% of cases the
cause of death of patients in the postoperative period.
Jaundice in cholelithiasis, usually appears after the onset of pain in the right
upper quadrant, which are characteristic forms of cholecystitis pain. In a study of
patients have found clinical picture of acute cholecystitis.
Violation of the outflow of bile into the duodenum, occurs against the
backdrop of an acute inflammatory process in the gall bladder, leading to the
development of inflammation and in the bile ducts - acute cholangitis.
Morphological changes in the wall of the bile duct with acute cholangitis may be
presented by catarrhal, phlegmonous or gangrenous inflammation.
Clinical picture of acute cholangitis is characterized by signs of general
intoxication. The main symptom of acute cholangitis is a high temperature (up to
39-40 ° C), accompanied by chills, profuse sweating at night. Patients complain of
nausea, vomiting, lack of appetite. In the peripheral blood revealed leukocytosis
with a shift to the left leukocyte, erythrocyte sedimentation rate increases. The
close anatomical and functional relationship of the biliary system and pancreas
contributes to the fact that in acute cholecystitis in the inflammatory process
involves the pancreas. There are three points of view on the mechanism of
inflammatory-process in the pancreas in acute cholecystitis (cholecystitis,
pancreatitis):
1) infected bile reflux into the pancreatic duct occlusion with stone major
duodenal papilla, edema or stenosis of the major duodenal papilla in patients with
common bile duct and ampulla for pancreatic ducts;
2) the spread of inflammation of the gallbladder with the pancreas through the
blood and lymph vessels;
3) violation of the evacuation of pancreatic juice blockade major duodenal
papilla.
The clinical picture of acute cholecystopancreatitis presented as symptoms of
gallbladder and bile ducts, and pancreas. Patients complain of pain in the right
upper quadrant or epigastrium, often radiating to the back and having herpes
character. Often, pain radiating to the left shoulder girdle - the left-hand-frenikus
symptom. Vomiting in cholecystopancreatitis is resistant agonizing character. The
body temperature of 38-39 C.
Abdominal palpation patients feel pain at the point of the gallbladder and
pancreas area location - above the navel. With deep palpation to the left and above
the navel is often possible to detect pulsations weakening of the abdominal aorta a positive sign of the Resurrection. Involvement in the inflammatory process of the
tail of the pancreas appears the onset of symptoms of Mayo-Robson (onset of pain
on palpation in the left costal-vertebral angle). Already in the first hours of the
disease in patients with cholecystopancreatitis determined increase in blood
amylase and urine diastase. In peripheral blood leukocytosis and high
aneosynophilia.
Diagnostics of calculous cholecystitis and its complications is based on a
comprehensive examination of the patient with the help of special methods of
research used in the preoperative period and during surgery. In recent years, the
main method of a special study to identify the pathological process in the
gallbladder, extrahepatic bile ducts in the pancreas and is ultrasound imaging. With
the help of this study can be found in the gall bladder stones and set the form of
inflammation of the gallbladder (Figure 3).
Fig. 3. Ultrasound tomography in acute cholecystitis:
a - catarrhal form;
b - form of abscess;
с - gangrenous form (perforation of wall)
It reveals the pathological process is localized in the hepatic bile duct, a major
duodenal papilla and in the pancreas (Figure 4).
Fig. 4. The ultrasonic tomogram at choledocholithiasis (A) stenosis of papilla
Fateri (B), the bile duct stricture (C):
a - a stone; b - the bile duct; c - zone of stenosis; d - zone of stricture
Identify the pathological process in the gall bladder and bile ducts by using the
X-ray examination, which is carried out through a number of methods:
I. Indirect contrasting of the biliary system.
1. Simple plain radiography of the liver and extrahepatic bile ducts.
2. Excretory cholecystocholangiography:
a) oral; b) intravenously.
II. Direct contrasting of the biliary system.
1. Percutaneous cholecystocholangiography under laparoscopic control.
2. Percutaneous transhepatic cholangiography under fluoroscopic
guidance.
3. Percutaneous transhepatic cholangiography
under ultrasound
guidance.
4. Endoscopic retrograde cholangiography
5. Fistulo - cholecystocholangiography.
6. Operating cholecystocholangiography.
Technique of X-ray studies based on indirect (excretory) contrasting of the
biliary system, now almost does not apply, since their low informative. As for the
X-ray inspection techniques, which are based on direct contrasting of the biliary
system, they are used in patients with mechanical obstruction of the biliary tract
(with obstructive jaundice). As the contrast agents are used 25-30% solutions of
water-soluble iodine preparations (cardiotrast, Diodon, biligrafine, bilignost et al.).
Percutaneous puncture of the biliary system, followed by conducting them in
contrast solution can be performed under laparoscopic control (percutaneous
transvesical cholecystocholangiography - Figure 5);
Fig. 5. Percutaneous laparoscopic cholecystocholangiography.
Under X-ray or ultrasound - percutaneous transhepatic cholangiography.
Direct contrasting extrahepatic bile ducts may retrograde introduction of these
contrasting solution at endoscopy of the duodenum (endoscopic retrograde
cholangiography).
In cases where in the preoperative period can not be clearly determined the
status of the extrahepatic bile ducts, to identify choledocholithiasis and papillary
stenosis of extrahepatic bile ducts examined during operation is used operating
cholangiography (Figure 6).
Fig. 6. Roentgenograms in the direct contrasting of bile ducts:
a - a stone in the bile duct
b – stenosis at terminal part of the common bile duct;
During surgery to examine the bile duct, you can use special fiberscope
(choledochoscopy). This examination reveals inflammation in the wall of the bile
duct (cholangitis), as well as to detect not removed concrements.
Treatment of calculous cholecystitis and its complications.
In identifying of calculous cholecystitis it’s need to raise the question about
the indications for surgical treatment. Tactics to perform early surgery for
calculous cholecystitis is based on the fact that even in uncomplicated forms of the
disease morphological changes in the wall of the gallbladder suggest persistence of
the pathological process. In addition, at 30-40% of patients with calculous
cholecystitis in the pathological process there is involved the extrahepatic bile
duct, duodenal papilla large and pancreas. Against the background of chronic
inflammation in the gallbladder may develop a malignant tumor. Therefore, early
surgery is intended to prevent the development of complications calculous
cholecystitis.
So far, surgeons are not formed a consensus on the timing of the operation in
complicated forms of calculous cholecystitis (acute inflammation of the
gallbladder). Some of them consider it necessary to perform surgery in the early
hours of admission to hospital. Others recommend to handle patients after acute
inflammation subsided phenomena and perform pre-operative rehabilitation of the
bile ducts. This point of view in the conditions of use of ultrasound, which allows
us to observe the dynamics of inflammation in the gallbladder wall under the
influence of anti-inflammatory therapy should be considered more rational.
Emergency surgery should be performed only in those cases when acute
cholecystitis revealed a picture of diffuse peritonitis.
If the timing of performing surgery surgeons argue that on the surgical
approach their opinion united - in the surgical treatment of patients with calculous
cholecystitis is necessary to remove the gallbladder and remove all the
complications of the extrahepatic bile ducts and the major duodenal papilla.
Removal of the gallbladder (cholecystectomy) is performed as a wide
laparotomy access, and by means of minimally invasive interventions laparoscopic cholecystectomy or cholecystectomy from mini-access.
To eliminate the pathological processes, which are in the extrahepatic bile
duct, usually produce autopsy lumen of the bile duct (choledochotomy). Most
often, the lumen of the bile duct is exposed longitudinal section of its wall in
supraduodenal department. After opening the lumen of the bile duct stones were
removed from it (choledocholithotomy) and produce the removal of papillary
stenosis (transcholedocheal papillosphincterotomy). Convinced of the complete
elimination of pathological processes biliary tract, bile duct wall wound sutured
tightly with unresponsiveness suture using a precision technique seam (sewn fabric
wall of the bile duct, located above the duct mucosa). In some cases
choledochotomy can be completed or external drainage of the bile duct by a Tshaped
latex
drainage
or
formation
biliodigestive
anastomosis
(choledochoduodeno- or choledochojejunoanastomosis). In cases where there is a
papillary stenosis or stone prejudiced in his vial perform transduodenal
papillosphincterotomy followed by removal of the stone.
The introduction of the surgical practice of endoscopic surgery has
significantly changed the surgical approach with calculous cholecystitis and its
complications. Currently, the operation of choice in calculous cholecystitis is
laparoscopic cholecystectomy. During laparoscopic cholecystectomy can be
performed and choledocholithotomy that ends overlay blind stitch the wound
channel. To eliminate choledocholithiasis or papillary stenosis preoperatively
performed endoscopic transduodenal papillosphincterotomy and lithoextraction.
4.2. New teaching technologies used in this lesson "Black-box", "Web":
USE OF THE “BLACK BOX”.
The method provides for joint activities and active participation in the
classroom each student, the teacher works with the entire group.
Each student takes out a "black box" issue. (Options of questions are
attached). Students are required to detail the reasons for his answer.
To think about each answer the student is given 3 minutes. Then discuss the
answers, given in addition etiopathogenesis, clinical course. At the end of the
method of teacher comments on your answer is correct, its validity, the activity
level of students.
This methodology promotes student speech, forming the foundations of
critical thinking as In this case, the student learns to assert his view, analyze
responses band members - participants of the contest.
USING "WEB".
Steps:
1. Previously students are given time to prepare questions on the passed
occupation.
2. Participants sit in a circle.
3. One of the participants is given skein of thread, and he sets his prepared
question (for which he must know the full answer), hold the end of the filament
coil and transferring to any student.
4. A student who receives skein, answers the question (in this party, who
asked him, commented on a response) and passes the baton on the
issue. Participants continue to ask questions and answer them until everything will
be in the web.
5. Once students have completed all the questions, a student holding a roll,
returning his party, from whom he received the issue, while asking his question,
and so on, until the "unwinding" of the coil.
Note: To prevent the students who should be attentive to each answer,
because they do not know who to throw skein.
4.3. Analytical part
Situational problem:
Patient after a fatty meal had pain in the right upper quadrant, the yellowness
of the skin.
I. Your diagnosis :
A. Mechanical jaundice. *
B. colitis
V. gastritis
G. miolgiya
D. arthrosis
5. Practical part
Performed of mission on the practical knowledge (to shepherd of differential
diagnostics and grounded conclusion diagnosis, appointed corresponding diet and
planning therapy, USI).
1. HOLD DIFFERENTIAL DIAGNOSIS AND JUSTIFY THE FINAL
DIAGNOSIS.
Purpose: To educate and carry out a differential diagnosis to justify a
definitive diagnosis.
Fully
Not
№
Activity
implemented
fulfilled
correctly
1. List the disease, clinical symptoms, which are
0
25
similar to the disease.
2. Make a differential diagnosis of major clinical
0
35
syndromes.
3. On the basis of complaints, medical history,
0
40
objective data and results of laboratory and
instrumental examinations, as well as differential
diagnosis to put a definitive diagnosis.
Total
№
1.
2.
3.
4.
5.
6.
0
100
2. APPOINT APPROPRIATE DIET AND PLANNED TREATMENT.
Purpose: The treatment of the disease and to achieve remission.
Fully
Not
Activity
implemented
fulfilled
correctly
The study of the characteristics of medical tables on
0
10
Pevsner.
The right choice of dietary table in accordance with
0
10
the diagnosis.
Assessment of usefulness of the diet
0
20
In accordance with the diagnosis, disease severity
0
20
and stage of the appointment of primary therapy.
In accordance with the diagnosis, disease severity
0
20
and stage of the appointment of symptomatic
therapy.
Prophylactic measures.
0
20
Total
0
100
3. THE TECHNIQUE TUBING OF STOMACH.
Purpose: to the prophylactic of aspics by the stomach contents, to preparing
of stomach to operation.
Not
Fully implemented
№
Activity
fulfilled
correctly
1 Calm patient, explain manipulation
0
10
2 Get on of surgical thumb .
0
10
3 Measurement distention from the
0
10
mouth until stomach.
4 Put on of the stomach tube by the
0
10
nose.
5 Suck content of stomach with
0
10
helping hypodermic Jane.
6 Fixation tube with bandage and
0
10
banding around of the face of patient.
7 Bathe tube with physiological
0
10
solution and periodic moved of tube
for prophylactic adhesion to mucus
of stomach.
8 Repetitively suck until full cleaning
0
10
of stomach
9 Estate of medical instruments to
0
10
dez.solution
10 Get off surgical thumb and estate of
0
10
to dez.solution .
Total
0
100
6. The form control of knowledge
1. Spoken;
2. Written;
3. Answer to situation problem;
4. Demonstration of the reclaim practical knowledge.
№
7. Criteria for evaluating the current control
Evaluation
Progress in %
The level of student knowledge
1
96-100%
Perfect
“5”
2
91-95%
Perfect
“5”
3
86- 90%
Perfect
“5”
4
81-85%
Well
“4”
5
76-80%
Well
“4”
Complete the correct answer to the questions.
Summarizes and
makes
decisions, creative thinking, self-analyzing.
Solve situational problems correctly, with a
creative approach, with full justification for the
answer.
Actively and creatively participate in interactive
games, the right to make informed decisions and
summarize, analyze.
Complete the correct answer to the questions.
Creative thinking, self-analyzing.
Solve situational problems correctly, with a
creative approach, the rationale for the answer.
Actively and creatively participate in interactive
games, the right decision makers.
The questions covered completely, but there
are inaccuracies in the answer 1/2.
Independently analyzed. Inaccuracies in solving
situational problems, but with the right approach.
Actively involved in interactive games, make the
right decisions.
The questions covered in full, but there is
a 3/2 inaccuracies, errors.
Into practice, understand the essence of the issue,
says confidently, is a faithful representation.
Case solved the
problem
correctly,
but
the rationale for not fully answer.
Actively involved in interactive games, make
decisions correctly.
Correct, but incomplete coverage of the issue.
Understands the issue, says confidently, is a
faithful representation.
6
71-75%
7
66-70%
8
61-65%
9
55-60%
10
50-54%
Actively involved in interactive games.
On case studies gives a partial solution.
Well
Correct, but incomplete coverage of the issue.
Understands the issue, says confidently, is a
“4”
faithful representation.
On case studies gives a partial solution.
Satisfact The correct answer to half the questions.
ory
Understands
the issue, says
confidently,
“3”
is accurate representations only on individual
issues topics.
Case solved the problem correctly, but there is
no justification response.
Satisfact The correct answer to half the questions.
ory
Says uncertainly is accurate
“3”
representations only on individual issues topics.
Mistakes in solving situational problems.
Satisfact Reply with errors on half of the questions.
ory
Says uncertainly, is partial view on the subject.
“3”
Case solved the problem incorrectly.
Unsatisfa The correct answer to the third set of questions.
ctory “2” Situational problems solved correctly if the
11
46-49%
Unsatisfa
ctory “2”
12
41-45%
Unsatisfa
ctory “2”
13
36-40%
Unsatisfa
ctory
wrong approach.
The
correct answer
to
the fourth set of
questions. Situational problems solved correctly
if the wrong approach.
Lighting fifth of the questions correctly.
Gives incomplete and partially
incorrect
answers to questions.
Lighting 1/10
of questions at the
wrong approach.
“2”
14
31-35%
Unsatisfa To the questions are not answers.
ctory “2”
8. Chronological map of lessons
№
Steps of lessons
1. Introductory word teacher (study subjects).
2. Discussion topics practical lessons,
assessment of baseline knowledge of
students with new educational technologies
(small groups, case studies, business games,
slides, videos, etc.).
Forms of the
lessons
The survey, an
explanation
Duration
in min. of
90
5
25
3. Summing up the discussion.
4. Providing students with visual aids and
giving explanations to them.
5. Self-study students in mastering skills.
6. Clarification of the extent to which lessons
objectives on the basis of developed
theoretical knowledge and practical
experience on the results and taking into
account this evaluation activities of the
group.
7. Conclusion of the teacher on this lesson.
Assessment of the students on a 100 point
system and its publication. Cottage set on
the next class (a set of questions).
5
10
Oral interview,
written survey,
testing, checking
the results of
practical work,
discussion debate.
Information,
questions for selfstudy.
15
25
5
9. Control questions
1. Define cholangitis
2 . The main cause of jaundice .
3 . The main diagnostic methods choledocholithiasis .
4 . Classification of AC and its complications.
5 . Indications for conservative treatment of complications AC.
6. Indications for surgical treatment of complications AC.
7. The general principle of surgical treatment for complications AC.
8. Recommending literature
I. Fundamentally:
1. Surgical diseases. Sh.I. Karimov. Tashkent 2011 .
2. Surgical diseases. Sh.I. Karimov, N.Shamirzaev, Tashkent, 1995.
5. Surgical diseases. M.I.Kuzin, Moscow 2002.
6. Operation to the internal organs. Voylenko I. GEOTAR. Moscow. 2000.
7. The preparatory surgery Yu.L.Shevchenko. Sanct-Petersburg. 2000.
II. Additionally:
8. J. H. Davis Clinical Surgery. St. Louis: C. V. Mosby Co., 2007.
9. Dinarello, C. A., Cannon, J. G., and Wolff, S. M. New concept on the
pathogenesis of fever. USA, 2008.
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