[Safe thyroidectomy for thyroid and parathyroid diseases]. / Puti osvoeniya bezopasnoi tekhniki tireoidektomii pri zabolevaniyakh shchitovidnoi i okoloshchitovidnykh zhelez.

OBJECTIVE: To offer the ways for safe thyroidectomy aimed at prevention of damage of recurrent laryngeal nerve in patients with thyroid and parathyroid diseases. MATERIAL AND METHODS: We analyzed postoperative outcomes after thyroidectomy in 342 patients aged 20-80 years. Topography of recurrent laryngeal nerves was studied on 20 laryngeal-tracheal complexes of deceased patients. Technique of visualization of various segments of recurrent laryngeal nerve was worked out. RESULTS AND DISCUSSION: Thyroidectomy was performed in 342 patients with thyroid and parathyroid diseases. Thyroidectomy was performed in accordance with recommendations described by F.W. Lahey, W.B. Hoover (1938) and H. Malcolm, M.D. Wheeler (1998). Location of recurrent laryngeal nerve varied in patients with nodular, retrosternal goiter and parathyroid gland adenoma. Comparison of intraoperative and morphological data on recurrent laryngeal nerve visualization showed possible risks of its damage during manipulations on thyroid gland, esophagus and trachea. Our study confirmed the need for visualization and mobilization of recurrent laryngeal nerve in all procedures on thyroid and parathyroid glands. Introduction of the described technique of thyroidectomy and training sessions for recurrent laryngeal nerve mobilization on laryngeal-tracheal complexes reduced postoperative incidence of phonation disorders from 21.6% to 0.98%. CONCLUSION: Thyroidectomy may be a safe procedure if surgeons are familiar with the details of surgical technique and prevent damage to adjacent structures.

[Features and choice of surgical strategy in patients with gastrointestinal fistulas]. / Osobennosti taktiki i vybora sposoba khirurgicheskogo lecheniya patsientov so svishchami zheludochno-kishechnogo trakta.

OBJECTIVE: To evaluate the features and choice of surgical strategy in patients with gastrointestinal fistula based on classification of their types. MATERIAL AND METHODS: There were 398 patients with gastrointestinal fistula. Fistula type 1 was found in 126 (31.7%) cases, type 2 - 38 (9.6%) cases, type 3 - 73 (18.3%) cases, type 4 - 26 (6.5%) patients, type 5 - 135 (33.9%) cases. One-stage and two-stage treatment was applied in patients with fistula type 1, two-stage treatment only - for fistula type 2. In patients with fistula type 3, treatment strategy depended on timing of fistula formation, its level and amount of intestinal chymus loss. In case of fistula type 4, radical treatment is difficult. However, surgery is safer when adhesions between intestinal loops are not yet dense enough. Indeed, dissection is associated with less risk of their damage. Reconstructive procedures were applied for fistula type 5 depending on its localization. RESULTS: The causes of gastrointestinal fistula were complications after surgery for acute ileus in 73 patients (17 ones died), blunt abdominal trauma in 81 (8), open abdominal trauma with cold weapons in 39 (6) and firearms in 11 cases (2), mesenteric thrombosis in 33 patients (8), pancreatic necrosis in 25 cases (9), abdominal hernia in 15 cases (4), acute appendicitis in 40 patients (3), colonic diverticulosis in 24 patients (1), urological diseases in 5 cases, colon perforation by a foreign body in 3 cases, colonoscopy in 5 patients, Hirschsprung's disease in 2 patients, Crohn's disease in 11 cases (3), colon polyps in 4 patients, intestinal tuberculosis in 1 case (1), small bowel resection for obesity in 1 patient and gynecological diseases in 25 patients (2). Fistulas type 1 and 4 were followed by the highest postoperative mortality since these interventions are associated with the most severe changes in abdominal cavity. Low mortality was observed in patients with fistula type 5, no abdominal inflammation and normalized intestinal passage. The overall mortality in patients with gastrointestinal fistulas was 16.1%. CONCLUSION: Treatment strategy in patients with gastrointestinal fistula primarily depends on the type of fistula that requires emergency, urgent, delayed or reconstructive surgery. Staged approach in patients with gastrointestinal fistulas can improve treatment outcomes.

[Thoracoabdominal hernia after treatment of chronic sterno-mediastinitis]. / Torakoabdominal'nye gryzhi posle lecheniia bol'nykh khronicheskim sternomediastinitom.

AIM: To analyze clinical course and develop surgical technique for thoracoabdominal hernia in patients after previous sterno-mediastinitis. MATERIAL AND METHODS: There were 7 (20%) patients aged 53-69 years with thoracoabdominal hernia after previous cardiac surgery followed by postoperative sterno-mediastinitis. Thoracoomentoplasty was used for treatment of this complication. There were 2 males and 5 females. RESULTS: All patients underwent surgery aimed at translocation of the organs from mediastinum to abdominal cavity, restoring normal anatomical location of stomach, transverse colon and large omentum, stabilizing the thorax and closing the defects in the diaphragm and anterior abdominal wall. CONCLUSION: Surgical indications are justified by stomach and transverse colon dysfunction due to their displacement to the mediastinum with threat of strangulation, cardiac compression by hernial sac, as well as chest instability. Combined approach allows to achieve recovery in all patients.

[Prospects of combined anterior prosthetic hernia repair in treatment of large and giant ventral hernias]. / Peredniaia proteziruiushchaia gernioplastika kombinirovannym sposobom pri bol'shikh i gigantskikh ventral'nykh gryzhakh.

AIM: To evaluate clinical efficacy of combined anterior prosthetic hernia repair in treatment of large and giant ventral hernias. MATERIAL AND METHODS: Patients with large and giant hernias have been analyzed. In the main group (n=675) combined methods of hernia gates repair were applied, in control group (n=257) - stretching repair including prosthesis deployment. Surgeons (n=22) were interviewed for learning curve, safety, limitations and reliability of combined methods. RESULTS: Combined method of hernia repair in patients with large and giant hernias reduces overall postoperative morbidity (p<0.001), wound complications (p<0.05) and incidence of recurrent hernia (p<0.001). Questionnaire data showed the possibility of learning for the method by the most of surgeons to treat these patients. As a result, some practical recommendations are presented for successful procedures and satisfactory results of treatment.

[Clinical and morphologic aspects of surgery choice by postoperative anterolateral and lateral ventral hernias].

Clinical picture, diagnostic features and operative techniques in patients with postoperative anterolateral and lateral ventral hernias have been analyzed. Synthetic endoprosthesis were comparatively tested on human dermal fibroplast cell cultures. Taking into account and practical use of the obtained results allowed the recurrence rate decrease from 63 to 6%.

[Treatment of medial ventral hernias with the use of synthetic endoprosthesis].

350 patients with medial ventral hernias were operated on. 307 of them had various concurrent diseases; 177 required simultaneous surgery on that account. Endoprosthesis (synthetic mesh) was fixed using an "inlay-sub-lay" technique. Local complications were detected in 19.4% of patients, 5.4% developed common complications. 1.1% of patients had died. Long-term hernia recurrence was registered in 1.1%.

[Modern principles of treatment of patient with lateral and anteriolateral hernias of the abdomen].

Among 88 patients with ventral hernias of the lateral and anteriolateral localization in 32 patients tension methods were used, in 56 patients non-tension combined methods of plasty with the lay-sub lay-on lay position of the implant. In the first group local and general complications were diagnosed in 2 (6.3%), in the second in 6 (10.7%) patients. Recurrent hernias in the long-term periods developed in the 1st group in 20 (62.5%) patients, in the 2nd--in 3 (5.4%). There were no lethal outcomes. The non-tension combined methods of plasty of the abdominal wall are thought to be preferable.

[Peculiarities of creating permanent vascular access in diabetic patients on programmed haemodialysis].

Over the period from 2004 to 2009, we performed a total of 18 procedures aimed at forming a permanent vascular access in diabetic patients on programmed haemodialysis. Of these, an arteriovenous fistula (AVF) was created in eight patients and a polytetrafluoroethylene (PTFE) graft was implanted in ten subjects. We than carried out a comparative assessment of the permanent vascular accesses (PVA) prepared based on AVF versus those based on PTFE graft. The assessment criteria were as follows: time interval between the operative intervention and the commencement of the haemodialysis procedure via the PVA, the duration of the functioning and adequate amount of blood flow the PVA provides during the haemodialysis procedure, the presence of antebrachial ischaemia symptoms, as well as infectious complication rates.

[Complex treatment of the patients with postoperative ventral hernia].

Overall 605 patients with postoperative ventral hernia underwent plasty of anterior abdominal wall by combined methods and on-lay or in-lay disposition of synthetic implant. Concomitant diseases were diagnosed 432 (71.4%) patients that required 495 simultaneous operations at 283 (43.8%) patients. Wound complications after surgery were seen at 21 (3.47%) patients. Long-term results were followed-up to 11 years: recurrences of hernia were diagnosed at 12 (1.9%) patients, 3 (0.5%) patients died due to pulmonary embolism. It is concluded that the treatment of patients with postoperative ventral hernia requires complex approach and leads to good short- and long-term results.

[Features of clinical finding, tactics and surgical treatment of patients with injuries of left subdiaphragmatic space organs].

Results of treatment of 208 patients with injuries of left subdiaphragmatic space organs are analyzed. At 130 (52.5%) patients injuries of spleen, stomach, left curve of colon, pancreas were isolated, at 78 (37.5%)--combined. Features of clinical finding depending on combination of organs injuries were revealed. In clinical finding of abdominal trauma the pancreatogenic syndrome is emphasized which does not prove itself just after trauma. At isolated trauma 2 (0.96%) patients died, at combined trauma--12 (5.77%).

[Variants of surgical treatment of lateral postoperative abdominal hernia by a combined method]. / Varianty khirurgicheskogo lecheniia bokovykh posleoperatsionnykh gryzh zhivota kombinirovannym sposobom.

616 patients with postoperative abdominal hernias (AH) were treated, 124 (20%) of them had lateral hernias. By M. Yatsentyuk classification, there were 41 (33.1%) patients with small hernias, 37 (29.8%)--with middle-size, 35 (28.2%)--with big, 6 (4.3%)--with very large, 5 (4%)--with giant hernias. Two operative techniques for lateral AH based on an original method of combined plastic surgery were applied in 37 patients. Good immediate and long-term results were achieved in all the patients. There were no recurrences.

[Surgical treatment of postop abdominal wall hernia]. / Khirurgicheskoe lechenie posleoperatsionnoi gryzhi briushnoi stenki.

Two methods of combined plasty of postoperative abdominal wall hernia (PAWH), based on biochemical conception of pathogenesis of the disease, were proposed. Application of the methods had allowed to close the defect of any size of anterior abdominal wall. For the 1996-2001 period 221 patients with large, huge and giant PAWH were operated. Local and general complications in 29 (13.1%) patients had occurred, one patient died. Result of treatment in term up to 6 years was studied, recurrency of the disease was not revealed.

[The method of treatment choice for the abdominal wall hernia]. / Vybor metoda lecheniia gryzhi briushnoi stenki.

Experience of treatment of 975 patients with postoperative and recurrent abdominal wall hernia (AWH) and of 1473 patients with inguinal hernia was summarized. Intraoperative classification of Shevrel and Rets for AWH and of Gilbert and Rutkov for inguinal hernia were applied. The conventional methods of plasty, using local tissues, were performed up to 1998 in 648 patients with AWH and in 983--with inguinal hernia. Synthetic implants were used since 1999 in 327 patients with AWH and in 181--with inguinal hernia. In application of conventional methods recurrency had occurred after plasty for AWH in 26.6% and for inguinal hernia--in 5.8% of observations; hernial recurrency was not noted after usage of the modern plasty methods.

[Combined plastic surgery of the abdominal wall in ventral hernia]. / Plastika briushnoi stenki pri ventral'nykh gryzhakh kombinirovannym sposobom.

A combined mode of abdominal wall plasty in ventral middle-point hernia is presented. The principle of this method is to close the defect with hernial sac tunica, to dissect rectus sheath anterior layers and suture the medial margins of aponeurotic flaps. The defect formed between the lateral layers of aponeurosis are replaced either by an autodermal perforated flap treated by Yanov's procedure or by synthetic graft (polypropylene net). It is concluded that the combined mode of hernioplasty corresponds to the biomechanical conception of the pathogenesis of ventral hernia. This approach may expand indications for surgery in patients with serious concomitant diseases. The rate of early and late complications decreased.

[A biomechanical concept of the pathogenesis of postoperative ventral hernias]. / Biomekhanicheskaia kontseptsiia patogeneza posleoperatsionnykh ventral'nykh gryzh.

A biomechanical concept of pathogenesis of incisional ventral hernias is presented. The main point is that during the formation of a defect along the abdomen medium line, the lateral muscles of the abdominal wall loose the medial point of attachment. The function of the muscles is disturbed and there appears a myogenic contracture. Thus, the contraction ability is gradually slowing down. Special morphological, ultrasonographic and electromyographic researches were made. The authors consider that all types of surgery when the muscle-aponeurotic elements of the hernial hilus become closer under tension result in a less volume of the abdominal cavity and compression of the fascial muscles which gives rise to pathogenetic mechanisms for the development of early and late postoperative complications.

[Clinical variants and treatment of gastrointestinal fistulas]. / Klinicheskie varianty svishchei zheludochno-kishechnogo trakta i ikh lechenie.

The experience of 411 patients treatment, aged from 15 to 78 years with gastrointestinal tract fistulas are summarized. Depending on clinico-anatomical picture, fistulas are divided in 5 types. There were 110 (26.8%) patients with fistula type I, 36 (8.7%)--type II, 70 (17.03%)--type III, 29 (7.5%)--type IV, 66 (40.4%)--type V. Treatment policy was developed for each group. Necessity of urgent relaparotomy in patients with fistula type I, early relaparotomy in fistula type II, late relaparotomy and elective operations in fistula types III, IV and V were substantiated. At usage of this treatment 102 (24.8%) from 411 patients died.

[Treatment of fistula of abdominal part of the esophagus, stomach and duodenum]. / Lechenie svishcha briushnoi chasti pishchevoda, zheludka i dvenadtsatiperstnoi kishki.

The results of treatment of 142 patients with fistula of the abdominal esophagus, stomach and duodenum were analyzed. Tactic and principles of treatment of different types of the alimentary canal fistulas were elaborated. Mortality was 31.7%.

[Results of surgical treatment of postoperative abdominal hernia]. / Rezul'taty khirurgicheskogo lecheniia posleoperatsionnoi gryzhi zhivota.

There were examined 525 patients with postoperative abdominal hernia, in 47.3% of them big, vast and giant hernia was revealed. There were operated 436 patients using local tissues with duplicature formation--according to Mayo, Sapezhko, Napalkov and Yanov method.