[Surgical treatment of complex incisional hernia]. / Khirurgicheskoe lechenie patsientov so slozhnoi posleoperatsionnoi ventral'noi gryzhei.

There is no generally accepted incisional hernia classification. To categorize incisional hernias, the European Hernia Society (EHS) proposed their classification based on the measurement of three parameters - location, dimension of hernia gate and recurrence. Unfortunately, this classification does not consider the «loss of the domain¼ of 20% or more, local complications including trophic ulcer or fistula of anterior abdominal wall. Moreover, implantation of mesh after previous hernia repair, obesity and other clinical factors are also not considered. Thus, surgeons have recently allocated patients with complex incisional hernia in a separate group. There is no clear definition of this term. There are no clinical guidelines on the management of patients with these hernias, and the choice of optimal surgical treatment remains individual. The authors present a patient with complex incisional hernia. Surgical strategy is described.

[Surgical treatment of enterocutaneous fistulas in patients with ventral incisional hernia]. / Khirurgicheskoe lechenie naruzhnykh kishechnykh svishchei v posleoperatsionnykh gryzhakh.

OBJECTIVE: To determine the optimal surgical treatment in patients with enterocutaneous fistulas combined with ventral incisional hernia. MATERIAL AND METHODS: There were 24 patients with enterocutaneous fistulas combined with ventral incisional hernia. Enterocutaneous fistula was noted in 19 cases, enteroatmospheric fistula - in 5 patients. RESULTS: Simultaneous fistula closure and abdominal wall repair were performed in 14 patients (mesh repair in 5 cases and local approximation of tissues in 9 cases). Postoperative complications occurred in 8 patients, hernia recurrence in long-term period developed in 7 people. Two-stage closure of abdominal wall defect was carried out in 10 patients. Fistula closure was followed by edge-to-edge anterior abdominal wall repair in 5 cases, skin edges were approximated by interrupted sutures or open wound management was performed. There were no postoperative complications and hernia recurrence in this group. CONCLUSION: Surgical treatment of patients with enterocutaneous fistulas combined with hernia should be performed in two stages, i.e. enterocutaneous fistula closure with subsequent hernia repair.

[Abdominal wall repair after total resection of desmoid fibroma in a patient with diabetes mellitus type 1]. / Rekonstruktsiya perednei bryushnoi stenki posle radikal'noi rezektsii desmoidnoi fibromy na fone sakharnogo diabeta 1-go tipa.

Desmoid fibroma (DF) is a rare connective tissue tumor comprising about 0.03-0.13% of all neoplasms. DF has a low potential for malignant transformation, but it is characterized by aggressive course and unfavorable prognosis. The main contingent of patients consists of women of reproductive age. Despite the nearly two-century history of study, there are certain unsolved problems including endocrine problems associated with this disease. We report a 30-year-old female with DF and diabetes mellitus type 1. Total resection of the affected right rectus abdominis muscle was performed in a single block with aponeurotic sheath and peritoneum after normalization of carbohydrate metabolism. Muscular aponeurotic defect 27�10 cm was closed after separation of abdominal wall structures and implantation of polypropylene prosthesis. There are no X-ray and clinical signs of DF recurrence or postoperative hernia after 8 months.

[Massive localized lymphedema of anterior abdominal wall]. / Massivnaya lokalizovannaya limfedema perednei bryushnoi stenki.

Massive localized lymphedema (MLL) is a rare disease observed in people with morbid obesity. MLL is easily confused with soft tissue sarcoma. Therefore, MLL is sometimes called as pseudosarcoma in the literature. MLL was initially described by G. Farshid and S. Weiss in 1998. However, etiology of MLL is still unknown despite certain relationships with injuries, operations and hypothyroidism. Since the term «MLL¼ was introduced only 20 years ago, there are no reliable statistical data on the prevalence of MLL. According to the World Health Organization data (2016), 13% of the adult world population are obese. Therefore, the risk of MLL is increased in these people. Thigh is the most common site of lesion. Abdominal wall lesion is rare and can cause diagnostic difficulties due to large dimensions and appearance. We report a 50-year-old obese woman with MLL of anterior abdominal wall. She experienced discomfort while walking and sleeping due to giant MLL of anterior abdominal wall that significantly reduced quality of life. Removal of MLL (weight 22160 g) was followed by favorable cosmetic and functional outcome. Analysis of differences between MLL and soft tissue sarcoma in the era of «obesity epidemic¼ is valuable for correct diagnosis and treatment of this rare complication. This report is the first case of MLL, registered in Russia. In our opinion, this is associated with insufficient awareness of physicians about this complication of obesity. We hope our observation will help clinicians to identify and treat this complication.

[Hybrid repair of postoperative ventral hernia]. / Gibridnaia metodika lecheniia posleoperatsionnoi ventral'noi gryzhi.

AIM: To develop new technique of abdominal wall repair for postoperative ventral hernia without disadvantages which are intrinsic for open and laparoscopic surgery. MATERIAL AND METHODS: Combined open and laparoscopic hernia repair was used in 18 patients with postoperative ventral hernia. Open stage provided safe dissection of abdominal adhesions and defect closure by autoplasty, laparoscopic procedure consisted of prosthesis deployment without separation of abdominal wall layers. Two types of composite endoprostheses with anti-adhesive coating were used for abdominal wall repair. RESULTS: There were no cases of recurrence or infectious complications in long-term period (from 3 to 106 months). CONCLUSION: Hybrid repair of postoperative ventral hernia is safe and effective procedure. Further studies are necessary to assess cost-effectiveness ratio of this method in view of expensive composite endoprostheses and laparoscopic supplies.

[Morphological and functional aspects of recurrent postoperative ventral hernias]. / Morfofunktsional'nye aspekty retsidiva posleoperatsionnykh ventral'nykh gryzh.

AIM: To define the optimal treatment of postoperative ventral hernias. MATERIAL AND METHODS: It was performed microscopic examination of intraoperative specimens which were obtained from 40 patients with medium, large and giant hernia. The aim was to reveal ultrastructural changes and morphological features which are associated with abdominal wall weakness in case of postoperative ventral hernia. There were 28 (70%) cases of primary postoperative hernia and 12 (30%) cases of recurrent and multiple-recurrent hernia. In 4 patients polypropylene mesh implants were implanted prior to recurrence. Tissue specimens were obtained from the top of herniation, hernial ring and in 6 cm from the hernial ring. RESULTS AND DISCUSSION: Electron microscopy showed that postoperative ventral hernias are accompanied by ultrastructural destructive changes in cells of the skin, aponeurosis and muscles that indicates on morphofunctional failure of abdominal wall tissues. Swelling and degradation of collagen, fibroblasts vacuolization, capillary sludge of erythrocytes, development of vacuum zones with the fragments of altered collagen fibrils, red blood cells and mast cells are morphological signs of micronecrosis followed by abdominal wall weakness and postoperative ventral hernias. CONCLUSION: Postoperative ventral hernias are associated with morphological and functional failure of abdominal wall due to tissue destructive changes. Therefore, this obviously defective tissue can not be used per se and especially with tension. Mesh implants should be applied.