[THE PROBLEM OF CHOOSING A METHOD FOR RECURRENT INGUINAL HERNIA REPAIR].

Inguinal hernia repair is the most popular surgery performed by general surgeons around the world. The recurrence rate with various inguinal hernia repair techniques is 15%. The use of laparoscopic techniques in the treatment of inguinal hernias has significant advantages over open surgery, since it can significantly reduce pain, achieve excellent cosmetic results and shorten the duration of hospitalizations. At the same time, the recurrence rate after using laparoscopic techniques reaches 8.9%. The aim of this work is to determine the optimal method of surgical intervention for recurrent inguinal hernias. In the period from 2007 to 2011, a comparative randomized study was conducted, included 82 patients with recurrent inguinal hernias. Initially, all 82 patients were operated using Liechtenstein method with polypropylene mesh. All 82 patients with recurrent inguinal hernias were divided into two groups, patients in group I were operated on using laparoscopic methods (TAPP), in group II, repeated hernioplasty was performed using a modified Lichtenstein technique. In group I, the duration of the operation was 87±12 minutes. There were no serious intraoperative complications in group I. In group II, the average duration of the operation was 112±15 minutes. Complications in group II: severe pain syndrome was observed in 29 patients (69%), seroma developed in 15 patients (35.7%), in 4 patients (9.5%) hernia recurrence was revealed. Thus, patients who have been operated on using laparoscopic methods have certain advantages in terms of the duration of the operation, the number of postoperative complications, the presence of pain syndrome, and most importantly, these patients do not have a recurrent hernia. The results of repeated interventions in patients with recurrent inguinal hernias who did not use mesh implants were analyzed. The results obtained show the advantage of laparoscopic methods in reoperations, which was accompanied by fewer complications and reccurences. A rather difficult problem of choosing the optimal method of re-interventions in patients with relapses after laparoscopic hernioplasty. In 16.7% of patients, repeated laparoscopic hernioplasty turned out to be impossible due to technical difficulties and they had to switch to open Lichtenstein plasty. At the same time, in almost half of patients with recurrent inguinal hernias, it was possible to successfully perform repeated laparoscopic hernioplasty with good immediate and long-term results.

STUDY OF INTRAOPERATIVE INDOCYANINE GREEN ANGIOGRAPHY EFFECTIVENESS FOR IDENTIFICATION OF PARATHYROID GLANDS DURING TOTAL THYROIDECTOMY.

Postoperative hypocalcemia is a common complication of thyroidectomy. This problem is most often associated with accidental devascularisation or excision of the parathyroid glands (PG). Aim was study near-infrared fluorescent imaging with intraoperative parathyroid gland indocyanine green angiography to help identify and preserve parathyroid glands during total thyroidectomy in order to avoid postoperative hypocalcemia. For period from 2017 to 2019 years, 58 patients in Odessa regional hospital were underwent total thyroidectomy. Indications for surgery were multinodular goiter (n=42), thyroid cancer (n=11) and Graves' disease (n=5). By randomization all patients were divided into two groups: in the first group, 28 patients underwent standard total thyroidectomy, in the second group 30 patients underwent near-infrared-assisted total thyroidectomy with indocyanine green (ICG) angiography. Parathyroid autofluorescence was detected using a near infrared/indocyanine green endoscopic system (Karl Storz, Germany). Serum calcium and parathyroid hormone levels were compared between the two groups of patients in 1, 7 -15 days after surgery and then 3, 6 months later. In the first group, on based of a visual assessment of the PG, autotransplantation the PG were conduct in only 4 cases (in 3 cases - one gland, in one case - 2 glands). In the second group, autotransplantation was performed in 11 patients (in 8 cases - one gland, in 2 cases - two, in one case - 3). The transient postoperative hypocalcemia was observed in 5 patients of the first group (17,86%) and in the 2 patients of second group (6,67%) on 5-10 postoperative days. In the first group 1 patient at 3 months after surgery had permanent hypocalcemia. Near-infrared fluorescent imaging with intraoperative parathyroid gland indocyanine green angiography is a safe and an easily repeatable method. This technique provides improved detecting and assessment of the perfusion of the PG. The need for autotransplantation of the PG can be determined more objectively using ICG imaging than simple visualization.

[LIVER CYSTIC ECHINOCOCCOSIS LAPAROSCOPIC TREATMENT EFFECTIVENESS].

The main goal of the research was to study echinococcosis liver cyst laparoscopic treatment's effectiveness. The retrospective analysis of liver echinococcosis cyst surgical treatment in the period from 2003 to 2013 years was conducted. 348 patients underwent surgical treatment, among them 283 patients - laparoscopic procedure, 65 - open surgery. Medial age was 42,3±7,9 years. Female - 214, male - 134. 249 patients underwent laparoscopic partial (conservative) cystectomy, 34 - laparoscopic radical cystectomy with liver resection, 3 (1%) - conversion. 47 patients underwent partial (conservative) cystectomy using open approach. 18 - radical cystectomy using either typical or atypical hemihepatectomy. A long term analysis of 226 (79,8%) patients in a period from 6 month to 7 years was conducted. Comparison of the results revealed the advantage of laparoscopic operations. It was manifested in less blood loss, duration of the procedure, pain syndrome, and a smaller number of bed-days. Infections of the residual cavity after open surgery were twice as much comparing to ones after laparoscopic surgery. Complications after open surgery were significantly higher than after laparoscopic procedures due to postoperative wound infections. After open surgery frequency of echinococcosis recurrence was higher than after laparoscopic one (8,5% vs 2,5%) (р<0,05). Nowadays it is possible to say that treatment of choice of noncomplicated liver echinococceal cysts is laparoscopic one. Correctly made laparoscopical procedure has a good long term results, few postoperative compications, less frequent recurrences and the excellent cosmetic effect. From the principles of radical surgical treatment's point of view laparoscopic approach is the same as an open surgery.

Laparoscopic management of large hiatal hernia: mesh method with the use of ProGrip mesh versus standard crural repair.

BACKGROUND: Primary repair of large hiatal hernia is associated with a high recurrence rate. The use of mesh can lead to a reduce of recurrence rate. Despite this reduction, the type of mesh used and the placement technique are controversial. In our study, we used a new type of non-absorbable, self-fixating mesh to reinforce the cruroplasty. The aim of the present study was to compare the long-term results of laparoscopic treatment of large hiatal hernia with mesh reinforcement versus simple crura repair. METHODS: This study was performed on 98 gastroesophageal reflux disease patients who underwent Nissen fundoplication with mesh-augmented crura repair and fundoplication with standard crura repair. We used non-absorbable laparoscopic self-fixating mesh by ProGrip™. All patients were separated into the mesh group (n = 50) and non-mesh group (n = 48). The groups were evaluated according to the following criteria: dysphagia, patients' symptomatic outcome judgment according to The Gastroesophageal Reflux Disease-Health Related Quality of Life (GERD-HRQL) questionnaire and patients' satisfaction, hiatal hernia recurrence according to upper endoscopy and a barium contrast swallow study. Follow-up was completed in 95 (97%) patients with a mean follow-up duration of 54 months (range 12-62 months). RESULTS: Mean operative time was not significantly different (p = 0.30302). During the 48 months of follow-up, one recurrence occurred in the mesh group and eight recurrences appeared in the non-mesh group (p = 0.027). Patient satisfaction was significantly higher in the mesh group (p = 0.004). The mesh group had a more significant improvement in GERD-HRQL score (p < 0.0001) compared to the non-mesh group. CONCLUSION: In conclusion, this study confirms that laparoscopic repair of large hiatal hernias is effective and durable over a long period of time. Reinforcement of crura repair with ProGrip™ mesh is safe and can prevent anatomical recurrences.

[BALLOON DILATATION IN COMBINATION WITH A DOSED PAPILLOTOMY IN THE TREATMENT OF DIFFICULT FORMS OF CHOLEDOCHOLITHIASIS].

Results of treatment was studied in 2008 - 2015 yrs in 57 patients, suffering "difficult stones" (choledocholithiasis), in whom a dosed papillotomy in combination with the balloon dilatation. The advantages of application of combined dosed endoscopic papillosphincterotomy and balloon dilatation, comparing with complete endoscopic papillosphincterotomy, while treating "difficult stones" of common biliary duct, were established. Application of the procedure have guaranteed a good access through the duodenal papilla magna and have permitted to perform the calculi extraction in a less traumatic way, what have promoted its function preservation, and reduction of a postoperative complications rate, the patients' stationary treatment duration, and the remote complications rate. Using questionnaire SF-36, the quality of life was analyzed in patients, in whom in remote period the duodenal papilla magna function was preserved.

Randomized controlled trial comparing laparoscopic greater curvature plication versus laparoscopic sleeve gastrectomy.

BACKGROUND: Laparoscopic greater curvature plication (LGCP) is a new restrictive bariatric procedure, which has a similar restrictive mechanism like laparoscopic sleeve gastrectomy (LSG) without potential risk of leak. Aim of the study was to compare 2-year outcomes of LSG and LGCP. METHODS: Multicenter prospective randomized trial was started in 2010. A total of 54 patients with morbid obesity were allocated either to LGCP group (n = 25) or LSG group (n = 27). Main exclusion criteria were: ASA > III, age > 75 and BMI > 65 kg/m(2). There were 40 women and 12 men, and the mean age was 42.6 ± 6.8 years (range 35-62). Data on the operation time, complications, hospital stay, body mass index loss, percentage of excess weight loss (%EWL), loss of appetite and improvement in comorbidities were collected during the follow-up examinations. RESULTS: All procedures were completed laparoscopically. The mean operative time was 92.0 ± 15 min for LSG and 73 ± 19 min for LGCP (p > 0.05). The mean hospital stay was 4.0 ± 1.9 days in the LSG group and 3.8 ± 1.7 days in LGCP group (p > 0.05). One year after surgery, the mean %EWL was 59.5 ± 15.4 % in LSG group and 45.8 ± 17 % in LGCP group (p > 0.05). After 2 years, mean %EWL was 78.9 ± 20 % in the LSG group and 42.4 ± 18 % in the LGCP group (p < 0.01). After 3 years, mean %EWL was 72.8 ± 22 in the LSG group and only 20.5 ± 23.9 in the LGCP group (p < 0.01). Loss of feeling of hunger after 2 years was 25 % in LGCP group and 76.9 % in the LSG group (p < 0.05). The comorbidities including diabetes, sleep apnea and hypertension were markedly improved in the both groups after surgery. CONCLUSION: The short-term outcomes demonstrated equal effectiveness of the both procedures, but 2-year follow-up showed that LGCP is worse than LSG as a restrictive procedure for weight loss.

[СOMPARISON OF LAPAROSCOPIC CRURORAPHY AND PLASTY, USING LIGHTWEIGHT NET TRANSPLANT IN LARGE HIATAL HERNIAS: REMOTE RESULTS OF PROSPECTIVE RANDOMIZED INVESTIGATION].

Two procedures of laparoscopic plasty of large hiatal hernias (HH): cruroraphy (group I) and a two­layered plasty, using lightweight partially absorbable net (LPAN) Ultrapro (group II) were compared in prospective randomized investigation. The results of treat* ment were studied in terms from 24 to 27 mo, (24.4 ± 0.72) mo at average. The pure symptomatic anatomical recurrences rate, including those in conjunction with function* al recurrences, were trustworthily less in group II; duration of functional dysphagia (without stricture) did not differ in the groups trustworthily. Тhus, in large HH a two­lay* ered plasty conduction, using LPAN, permits to reduce the anatomical recurrences rate, not enhancing the complications rate, and it may be considered the operation of choice.

[Possibilities of laparoscopic gastric resection for gastrointestinal stromal tumors].

Possibilities of laparoscopic technologies application while surgical excision of gas- trointestinal stromal tumors (GIST) were analyzed. In 2000 - 2015 yrs in the clinic 28 patients were operated on for gastric GIST. In 10 of them laparoscopic gastric resec- tion with tumor (in 3 - the tumor excision in borders of nonaffected tissues, in 4 - gas- tric fundus resection or stapler resection of a great curvature together with tumor, in 3 - transgastric excision of the tumor, using staplers) surgery was done. The disease recurrence in 2-5 yrs follow-up was absent. Laparoscopic operations has advantage over open interventions while preserving oncological radicalism.

[FUNCTIONAL PLASTIC OF ANTERIOR ABDOMINAL WALL HERNIAS].

In order to improve the treatment efficacy of postoperative anterior abdominal wall hernias the method of plastic with restoration of anatomical and physiological properties of the muscles of the anterior abdominal wall was used. After the intervention by the improved method, regardless of the location of the hernia defect yielded promising results for the conservation of anterior abdominal wall muscle function in 75% of cases completely restored functional ability of muscles recti abdomini.

[RANDOMIZED CONTROLLED COMPARATIVE INVESTIGATION OF EFFICACY OF LAPAROSCOPIC PLICATION OF BIG GASTRIC CURVATURE AND LAPAROSCOPIC SLEEVE GASTRECTOMY].

Laparoscopic plication (LP) of gastric big curvature (GBC) constitutes a new bariatric restrictive procedure, which has mechanism quite similar to that of a laparoscopic sleeve gastrectomy (LSG), but without danger for the sutures insufficiency development. The efficacy and safety of LSG and LP GBC were compared. Analysis of complications, the body mass (BM) index loss, an extra BM loss, an appetite loss, severity of the concomitant diseases course was conducted in accordance to results of the repeat examination. In 2 yrs the loss of extra BM have constituted the loss of an extra BM, accordingly, (42.4 ± 18) and (78.9 ± 20)%; in 3 yrs - (28.5 ± 23) and (72.8 ± 22)%. Thus, LP GBC is less effective, then LSG, in the treatment of morbid obesity.

[Videothoracoscopic atypical pulmonary resection, using various surgical technologies].

Atypical videothoracoscopic pulmonary resection was conducted in 943 patients, using mechanical and electrowelding suture. Various variants of the intervention conduction are adduced. Duration of the patients stationary treatment have constituted at average 6.1 days, lethality--0.6%, complications have occurred in 38 (4%) patients.

[Tactic of surgical treatment of complex rectal fistula].

The experience of the examination and treatment of 646 patients for different forms of complex rectal fistula (CRF) summarized. A working classification of the CRF with regard to their complication was developed and implemented. A differentiated approach has allowed greater use sphincter-preserving methods to improve functional outcome, quality of life, reduce the duration of the disability period and frequency of patients disability.

[A new classification of hiatal hernias, based on analysis of far remote results of laparoscopic plasty].

The results of operative treatment of 787 patients, suffering hiatal hernia (UH), were analyzed. Depending on the hiatal foramen square the patients were divided into three groups: with a small, large and giant hernias. In large HH a cruroraphy conduction causes a trustworthy more recurrence rate, than in small HH. In large HH the alloplasty performance secures lesser recurrence rate, then in cruroraphy conduction, although the dysphagia rate is bigger. While performing original method the dysphagia rate is minimal in comparison with such, when polypropylene transplant is used for plasty. In a giant HH alloplasty is complicated by trustworthy enhanced recurrence rate (19%), than in large HH, trusting neccessity to elaborate a new methods of correction. Basing on results of a factorial analysis made, concerning an accordance of the hiatal defect square with the recurrence rate in the groups of patients, there was established, that the division levels (10 and 20 cm2) for establishing the HH classification strictly parallels the recurrence rate in each class determined by the authors.

[Prophylaxis of injuries of biliary ducts in laparoscopic cholecystectomy: clinical recommendations of Ukrainian association of specialists for miniinvasive, endoscopic and laser technologies].

Wide introduction of laparoscopic cholecystectomy (LCHE) caused during last 20 years a significant enhancement of rate of the biliary ducts injuries (BDI). Taking into account the experience gained in performing of more than 40,000 operations of LCHE in a leading clinics, including such in a technically complex situations, as well as experience of more than 500 operations performance for BDI, clinical recommendations, based on principles of a substantiality medicine were elaborated. More than 100 sources of foreign and domestic literature were analyzed, summarizing the results of more than 150,000 operations of LCHE, special attention was drawn to the sources I (meta-analysis and prospective randomized investigations) and II (systematic reviews, thoroughly planned prospective comparative investigations) levels of substantiality. Every paragraph is accompanied by a certain level of a recommendation strength (RS, A-C). It is necessary to follow these recommendations strictly today.

Laparoscopic repair of hiatal hernias: new classification supported by long-term results.

BACKGROUND: Mesh repair may decrease the recurrence rate but bears risk of esophageal complications. This study aimed to analyze the long-term results of laparoscopic hiatal repair depending on hiatal surface area (HSA). METHODS: The results from 658 procedures were analyzed. Group 1 had 343 patients with HSA smaller than 10 cm(2) (small hernias), for whom primary crural repair was performed. Group 2 had 261 patients with HSA size 10-20 cm(2) (large hernias), for whom primary crural repair (subgroup A) or mesh repair (subgroup B) was performed. Group 3 had 54 patients with HSA larger than 20 cm(2) (giant hernias), for whom only mesh repair was performed. RESULTS: The mean follow-up period was 28.6 months (range, 10-48 months). Primary repair results in a higher recurrence rate for large hernias (11.9 %) than for small hernias (3.5 %) (p = 0.0016). For large hernias, the original method of sub-lay lightweight partially absorbable mesh repair provides a lower recurrence rate than primary repair (4.9 % vs 11.9 %; p = 0.0488) and a comparable dysphagia rate (2.1 % vs 2.2 %; p = 0.6533). For giant hernias, mesh repair results in a higher recurrence rate than for large hernias (20 % vs 4.9 %; p = 0.0028). The analysis of variance (ANOVA) HSA recurrence ratio confirmed the correctness of the chosen threshold levels (10 and 20 cm(2)) for subdividing hernias into three classes according to the new classification. CONCLUSIONS: The authors advise routine measurement of HSA and use of relative classification, primary suturing as the optimal repair for small hernias, the original technique of sub-lay lightweight partially absorbable mesh repair as the apparent best treatment for large hernias, and the original technique for giant hernias, which provides results corresponding to those reported in the literature, although these results require improvement.

[The method of miniinvasive operation for varicosely-changed veins of gastric fundus].

The laparoscopic operation method was elaborated for prophylaxis arrest of hemorrhage, originated from varicosely-changed (VCH) veins of gastric fundus. Dissection and clipping of a. gastri-ca sinistra is performed and VCH gastric vein is transsected. After gastric fundus mobilization a laparoscopic suturing apparatus is applied on him and the fundus became resected. Additionally the sutures made of nonabsorbable threads are applied above the mechanical sutures line. The method was applied in 2 patients, suffering VCH gastroesophageal veins. Application of the proposed operative intervention method have permitted to reduce significantly the occurrence rate of purulent-septic complications. While follow-up prolong 24 - 30 months the hemorrhage recurrence was not revealed. Application of modem videoendoscopic methods of operation for VCH gastric veins permits to improve significantly the operation results and safety, to reduce the patients stationary treatment time.

[A new method of gastric shunting for treatment of patients with morbid obesity].

The gastric shunting (GSH) method, permitting to control the patients body mass more effectively and promoting complete remission of diabetes mellitus type II, was elaborated. In 2008 - 2009 yrs 29 patients (9 men, 20 women) were operated on for morbid obesity, using shunting interventions. In 21 patients (the first group) a standard GSH was performed, in 8 (second group)--a modified operation. In 18-24 mo the excessive patient's body mass in patients of the first group have reduced by 62.8%, of the second group--by 89.3%. Complete compensation of diabetes mellitus type II with rejection from insulin and other antidiabetic preparations was achieved in 4 patients of the first group and in all--in the second group. Resistence for insulin have had lowered in patients of both groups, including in the first group--in 1,4 times, in the second group--in 3.2 times. Thus, preliminary results accurately demonstrate, that application of a modified GSH method is more effective, concerning the patients body mass reduction and achievement of complete compensation of diabetes mellitus type II.

[Possibilities of improving of videothoracoscopic operations for spontaneous pneumothorax].

A 15-years experience of videothoracoscopic operations in the treatment of 616 patients, suffering spontaneous pneumothorax, was summarized. The methods of videothoracoscopic operations, depending on the volume and localization of pathological process in pulmonary tissues, were depicted. The stages of endoscopic surgical intervention for spontaneous pneumothorax were analyzed. The disease recurrence, while using videothoracoscopic operations, have occurred in 3.6% of patients. All the patients are alive.

Laparoscopic common bile duct exploration versus open surgery: comparative prospective randomized trial.

The aim of the study was to analyse safety and benefits of laparoscopic common bile duct (CBD) exploration compared to open. Prospective randomized trial included a total of 256 patients with CBD stones operated from 2005 to 2009 years in a single center. There were two groups of patients: group I-laparoscopic CBD exploration (138 patients), group II-open CBD exploration (118 patients). Patient comorbidity was assessed by means of the American Society of Anesthesiology (ASA) score; i.e. ASA II-109 patients, ASA III-59 patients. Bile duct stones were visualized preoperatively by means of US examination in 129 patients, by means of ERCP in 26 patients, by magnetic resonance cholangiopancreatography in 72 patients. Preoperative evaluation was done through medical history, biochemical tests and ultrasonography. There was no statistical significant difference between 2 groups of patients. No mortality occurred. The mean duration of laparoscopic operations was 82 min (range, 40-160 min). The mean duration of open operations were 90 min (range, 60-150 min). Mean blood loss was much less in laparoscopic group than in open group (20 ± 2 vs. 285 ± 27 ml; p < 0.01). Postoperative complications were observed is nine patients of laparoscopic group and in 15 patients in open group (p < 0.01). There were 102 attempts to perform transcystic exploration of CBD. External drainage was used in 25 (32.8%) patients with transcystic approach. Conversion to laparotomy was performed in two patients. Open operations were performed in 118 patients with choledocholithiasis. External drainage was used in 85% of patients. Morbidity in open group was higher (12.7%) than in laparoscopic group (6.5%). Laparoscopic CBD exploration can be performed with high efficiency, minimal morbidity and mortality. Laparoscopic procedures have advances over open operations in terms of postoperative morbidity and length of hospital stay.