[Strategy for maintaining mesh implants in infected postoperative wounds of anterior abdominal wall]

Treatment of infected mesh implants of anterior abdominal wall is a complex problem in the absence of a unified approach. Traditional method involving surgical debridement of the site of infection with removal of mesh implant is associated with many risks and potential complications. This review is devoted to peculiarities of paraprosthetic infection, possible preserving the implant and methods of treating wound infection avoiding removal of endoprosthesis. Requirements for preservation of mesh implant and key role of vacuum therapy are emphasized.

[Diagnosis and treatment of patients with abdominal trauma]

OBJECTIVE

To improve the results of diagnosis and treatment of patients with abdominal injuries through a wider introduction of laparoscopic methods.

MATERIAL AND METHODS

We analyzed 3556 patients with concomitant abdominal injuries. All patients had damage to several organs and systems. Laparoscopy was performed in 1962 patients, laparotomy without previous laparoscopy - in 1594 patients.

RESULTS

Laparoscopy found no abdominal injuries in 25.7% of patients, other 13.7% of patients required no surgery and follow-up was indicated. In 60.7% of patients, injuries required surgical correction. Among these lesions, 26.6% of injuries were successfully eliminated using laparoscopic approach. In some cases, more than one injury was corrected. Indications for laparotomy were overestimated in 30.2% of patients who underwent open surgery without previous laparoscopy.

CONCLUSION

There is a tendency to decrease in the number of open and laparoscopic procedures for concomitant abdominal trauma over time that is associated with widespread introduction of modern diagnostic methods and accumulation of experience. Laparoscopy should be preferred for diagnosis of abdominal injuries in patients with concomitant trauma and no contraindications. This approach diagnoses no injuries or their mild nature in 39.3% of cases. Moreover, laparoscopy effectively eliminates certain lesions in 26.6% of cases.

[Surgical anatomy of the right portal vein]

OBJECTIVE

To study the features of surgical anatomy of intrahepatic segments of right portal vein.

MATERIAL AND METHODS

The results of 260 histological examinations including sectional (n=60) and clinical (n=200) surveys were analyzed. Anatomical analysis implied assessment of organometric characteristics including liver weight, length, width and thickness of right and left lobes, division angles of portal vein, the number of branches, length and diameter of the vessels. Clinical examination was based on analysis of splenoportograms and X-ray direct portal venograms. Patients were divided into three groups according to their body type (dolichomorphic, mesomorphic, brachymorphic).

RESULTS

Anatomical and clinical surveys confirmed the differences in metric characteristics of portal vascular system depending on the body type. There was medial angulation of the median fissure under 70-85º (78.0±3.4°) in dolichomorphic and mesomorphic patients. Right angle between the median fissure and lower liver surface was observed in brachymorphic subjects. Portal vein division into the branches of the first order to the right of the median fissure was found in 49 cases. Median or left-sided division was noted in other cases. In most cases (n=219), right portal vein dichotomously divided into the right paramedian and right lateral branches. Portal trifurcation was detected in 2.3% of cases, medial translocation of the right paramedian branch - in 1.1% of cases.

CONCLUSION

Right liver lobe surgery may be associated with certain technical difficulties due to variable anatomy of the right portal vein. Anatomical and atypical liver resections should be preceded by preoperative identification of individual anatomical variations of the main liver vessels. Contrast-enhanced computed tomography is optimal method for this purpose.

[Anatomical features and biomechanical properties of the diaphragm in pathogenesis of hiatal hernia]

OBJECTIVE

To study changes of diaphragm and esophageal-diaphragmatic junction depending on age and constitutional features.

MATERIAL AND METHODS

We studied changes of diaphragm and esophageal-diaphragmatic junction depending on age and constitutional features by using of 40 cadaveric specimens (people aged 19-75 years).

RESULTS

Esophageal-aortic ligament is observed rarer with age. This ligament is poorly developed in brachiomorphic body type while diaphragmatic-cardiac ligament is generally absent as a rule. This is a predisposing factor for weakening this area. It was revealed that reduced strength and elasticity (especially esophageal-aortic and esophageal-diaphragmatic ligaments) is one of the key factors in the development of hiatal hernia. It is especially relevant for brachiomorphic body type, the 2^nd mature and elderly age. The 2^nd mature period is associated with reduced diameter and kinking of great arteries, that leads to 1.5-2 times decrease of arterial capacity of the diaphragm. Therefore, hiatal hernia repair using own tissues may be insufficient and accompanied by recurrence in persons with brachiomorphic body type in the 2^nd mature period.

CONCLUSION

Analysis of biomechanical data and anatomical features of the diaphragm may be useful to predict recurrent hiatal hernia.

SURGICAL TACTICS FOR LARGE AND GIANT ESOPHAGEAL HIATAL HERNIA

The  OBJECTIVE  is to improve  the  results of surgical  treatment of patients with large  and  giant  EHH. MATERIAL AND METHODS.  We  present our  experience of surgical  treatment of 25  patients with large  and  giant  EHH, who  underwent laparoscopic  interventions according to  the  original  technique, which  consisted in the  method of plasty  of esophageal hiatus:   the   mesh  implant   was   installed   and   fixed  in  the   posterior  mediastinum  above  the   diaphragm.  RESULTS. Intraoperative  bleeding  was   noted   in  2  (8  %)  patients,  which  did  not  require   conversion.  In  the  near   postoperative period,   no  complications  were  noted.   In  the  long-term   periods from  1  to  5  years, there   was  no  recurrence of  EHH and  complications associated  with the  use   of mesh implant.  CONCLUSION.  Videoendosurgical  interventions  are  the operations  of  choice  in  the  treatment  of  patients  with  large  and  giant  EHH.  The  most  effective  method  of  plasty for  large  and  giant  EHH  is  the  combined plasty  of  the  esophageal hiatus   by  a  mesh implant  in  combination  with  a posterior  cruroraphy,  with  the  installation   and   fixation  of  the  mesh implant  in  the  posterior mediastinum above  the cruses of diaphragm.

[Vacuum-therapy in complex treatment of epithelial coccygeal course]

AIM

To analyze the outcomes in patients with epithelial coccygeal course (ECC) after original vacuum-therapy.

MATERIAL AND METHODS

The study included 61 patients with ECC. Patients were divided into 3 groups: 22 patients underwent ECC excision followed by wound closure by Donati, ECC excision with following wound management with ointment swathes was used in 19 cases, vacuum-therapy of open wound was conducted in 20 patients.

RESULTS

In group 1 hospital-stay was 11±1.9 days (ranged 3-20, Me=11), time of complete wound healing - 14.9±4.9 days (ranged 8-49, Me=12.5), early postoperative complications were observed in 5 (22.7%) patients, recurrence - in 3 (13.6%) cases. In group 2 hospital-stay was 13.7±2.6 days (ranged 3-25, Me=15), time of complete wound healing - 74±5,7 days (ranged 35-112, Me=57,0), early postoperative complications were observed in 2 (10.5%) patients, recurrence - in 1 (5.3%) case. In group 3 hospital-stay was 13.9±2.3 days (ranged 5-24, Me=15), time of complete wound healing - 31.1±2.7 days (ranged 15-39, Me=31.0), complications and recurrences were absent.

CONCLUSION

Vacuum therapy improves surgical results compared with conventional treatment.

[The extended endarterectomy from the femoral-popliteal arterial segment]

32 patients with atherosclerosis obliterans of lower limbs stage 2-4 were operated on according to the authorized method of arterial reconstruction in the absence of the suitable autologous transplant vessel (vena saphena magna). The efficacy of the procedure, thrombosis frequency and reocclusion were analyzed. Algorythm of postoperative use of low-molecular heparin in combination with antithrombicytic drugs and desaggregants had been worked out.

[Laparoscopic fibrocholedochoscopy in surgical treatment of choledocholythiasis]

Method of trocar fibrocholedochoscopy and lithotomy was worked out and applied in 16 patients with cholelithiasis complicated with choledocholythiasis. Application of given technique allows improving of choledocholythiasis diagnostics and treatment. One-stage endovideolaparoscopic surgical treatment with troacar fibrocholedochoscopy and lithotomy allow retaining of sphincteric apparatus of major duodenal papilla and avoiding open surgical methods.

[Distinctive features of trocar laparoscopic fibrocholedochoscopy and lithotomy in cholecystocholedocholithiasis surgery]

An analysis of results of surgical treatment of 16 patients with an cholecystocholedocholithiasis who had undergone troacar laparoscopic fibrocholedochoscopia. In conclusion it is staled, that this method can be provided in most of patients and guarantees good postoperative results.

[Videoendosurgical diagnosis and treatment of abdominal injuries in combined trauma]

Experience with videolaparoscopy in 1332 patients with combined abdominal trauma is analyzed. The original method of diagnosis of traumatic abdominal multitraumas in shock patients was proposed and patented. Diagnostic and treatment algorithm for hemoperitoneum in patients with abdominal multitrauma based on USE or CT data on liquid in the abdominal cavity has been developed. Videolaparoscopy helped to avoid open surgery in 73.3% patients with dominating abdominal trauma.

[Balloon compression hemostasis in injuries of parenchymatous organs]

Balloon compression method of hemostasis in injuries of parenchymatous organs is described. Developed device consists of inflatable balloon and double-lumen tube for drainage of abdominal cavity and filling of balloon with air. Hemostasis is achieved due to inflation of balloon and pressure on injured surface. Parameters of pressure and time of compression were determined in experimental study. This device can be used both in open and video-assisted laparoscopic surgeries. Described method was used in 29 patients (22 of them underwent laparoscopic surgery and in 7 patients the device was applied during laparotomy). This method permits to achieve reliable sutureless hemostasis, to control hemostasis and pressure on the wound, to drain abdominal cavity.

[Laparoscopic surgeries in acute cholecystitis]

Results of 2035 laparoscopic cholecystectomies for acute cholecystitis and its complications were analyzed. Indications and contraindications are clarified. Some technical features made the procedure easier in perivesical infiltration and adhesive process in the upper abdominal cavity. Efficacy and safety of intrasurgical cholangiography are validated. Method of drainage of the common hepatic duct by Holsted-Pikovsky was used. Surgical algorithm adjusted to pathological changes of extrahepatic bile ducts revealed during intrasurgical cholangiography was developed that permits to apply widely mini-invasive technologies.