Peer-reviewed journal "Moscow Surgical Journal"
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A modern view on the treatment of gallstone disease: a retrospective analysis of the results of the surgical technique of single-access cholecystectomy
Introduction. A standard laparoscopic cholecystectomy is performed using four surgical incisions and is the "gold standard" in global surgical practice. The widespread epidemiology of gallstone disease necessitates the ongoing search for ways to minimize postoperative pain, speed up the recovery period, and improve patient satisfaction. Currently, the single incision laparascopic cholecystectomy technique is the most minimally invasive treatment for gallstone disease. The purpose of this study is to improve the results of surgical treatment of patients with cholelithiasis and substantiate the clinical effectiveness of operations from a single access. Materials and methods. A group of authors conducted a retrospective analysis of the treatment results of patients operated on in the period 2023–2024 at the study sites: City Clinical Hospital named after M.E. Zhadkevich and City Clinical Hospital no 24 of the Moscow Health Department. Research results and discussion. 87 patients underwent single-port cholecystectomy. There were no adverse events related to medical intervention. The median of intraoperative blood loss was 20 ml. The average duration of surgery was 55 minutes. There were no intraoperative complications that caused the conversion. No deaths related to surgical intervention have been recorded. An analysis of the immediate and long-term outcomes of surgical treatment was conducted. Long-term outcomes were assessed using the Gallstone Impact Checklist (GIC) questionnaire and demonstrated satisfactory results. Conclusion. The results of this study and data from the world literature demonstrate the clinical effectiveness, functionality and reproducibility of SILS operations.
Choosing the surgical approach for repeat abdominal surgery: a decision-making algorithm
Introduction. MPostoperative intra-abdominal complications (POIACs) remain one of the most challenging problems in modern abdominal surgery, associated with high morbidity, significant mortality, and substantial socio-economic burden. To date, there are no systematized, clinically validated algorithms in the global literature for selecting the surgical approach in the management of POIACs. Existing recommendations are primarily descriptive, based on expert opinion, and do not provide quantitative decision-making criteria. The purpose of this study To develop a clinical algorithm for selecting the surgical approach (laparoscopic or open) in reoperations for patients with postoperative intra-abdominal complications (POIACs). Materials and methods. The study included 253 patients with POIACs requiring reintervention. Infectious complications (peritonitis) were diagnosed in 141 (55,7 %) patients, and non-infectious complications in 112 (44,3 %). An assessment was performed of demographic parameters, physical status (ASA), prognostic scores (SAPS II, SOFA, APACHE II), specialized peritonitis indices (Mannheim Peritonitis Index – MPI, Peritonitis Strategy Scale – PSS, WSES SSS scale), and laboratory markers (procalcitonin – PCT, C-reactive protein, lactate). Independent predictors for selecting an open approach and their threshold values were determined using logistic regression and ROC analysis. Research results and discussion. Independent predictors for choosing laparotomy were age ≥60 years, ASA ≥IV, SAPS II ≥28 (AUC 0,820), SOFA ≥4 (AUC 0,781), APACHE II ≥17 (AUC 0,776). In patients with peritonitis, additional significant criteria were MPI ≥21 (AUC 0,813), PSS ≥4 (AUC 0.841), and WSES SSS ≥6 (AUC 0.833). The combined criterion "PCT ≥7 ng/mL and lactate ≥2 mmol/L" had 85 % specificity for predicting an open approach. In patients with non-infectious complications, a body mass index ≥30,6 kg/m² (AUC 0,747) was a significant predictor. Based on the obtained data, a three-level risk stratification algorithm ("green", "yellow", and "red" zones) was developed to guide intervention strategy. The use of a laparoscopic approach in accordance with the algorithm reduced 90-day mortality in infectious complications from 15,1 % to 1,1 % (p<0.001), shortened hospitalization duration by 17–29 %, and reduced ICU length of stay by 2–5 times. In 48.7% of cases with infectious complications and 63,5 % with non-infectious complications, laparoscopic management was successfully performed after primary laparotomy (a "minimally invasive step"). Conclusion. The proposed algorithm, based on the integration of objective prognostic criteria, allows for standardization of surgical approach selection in reoperations, minimization of subjectivity, and significant improvement in treatment outcomes for patients with POIACs.
Evaluation of analgesic therapy in the postoperative period in patients with surgical pathology of the stomach performed, according to the ERAS protocol
Introduction. Surgical treatment with mandatory pre- and postoperative chemotherapy remains the main method of treating stomach cancer. Despite the existence of various chemotherapeutic treatment regimens, there are few surgical treatment options: gastric resection and gastrectomy with dissection of regional lymph collectors. The main reason for the long postoperative recovery of patients is the severe pain syndrome. The use of multimodal analgesic therapy as a component of the ERAS protocol can accelerate the patient's recovery after surgery without reducing the quality of rehabilitation and reduce the patient's hospital stay. Goal. To evaluate the effectiveness of multimodal analgesic therapy under the ERAS protocol in the postoperative period in patients with gastric pathology requiring radical surgical treatment. Materials and methods. We analyzed the results of postoperative recovery and the features of analgesic therapy in the framework of the ERAS protocol in 84 patients undergoing surgical treatment at the Federal State Budgetary Scientific and Scientific Center of the FMBA of Russia in Krasnoyarsk from 2018 to 2025. To do this, we assessed the severity of pain syndrome in the postoperative period and compared the dynamics of postoperative pain reduction in different groups of patients, which was evaluated on a visual-analog scale. Results. A total of 84 patients with gastric pathology requiring routine surgical treatment were examined. Each of the patients was ranked into one of four groups. A statistically significant relationship was found between the traumatic nature of surgery and postoperative pain syndrome on the second, third, fourth and fifth days of the postoperative period. All patients of the studied groups achieved a statistically significant (p<0.05) reduction in postoperative pain. There was a direct statistically significant relationship between body mass index and postoperative pain. Discussion. The use of multimodal analgesic therapy within the framework of the ERAS protocol has shown its high effectiveness in relieving postoperative pain syndrome in patients with surgical pathology of the stomach, early expansion of patients' motor activity and reducing the use of narcotic analgesics. Conclusion. The presented data confirm the expediency of using multimodal analgesia based on prolonged epidural blockade and paracetamol as part of the ERAS protocol for surgical patients. Further prospective randomized trials involving a larger number of patients and health care facilities are needed to obtain more convincing evidence.
Alternative options for anti-reflux intervention in a personalized approach
Introduction. Hiatal hernia and gastroesophageal reflux disease are among the most common surgical pathologies, which entails the inclusion of fundoplication in the list of the most frequently performed elective surgeries in the "Surgery" profile. Due to the prevalence of the disease, a wealth of experience in scientific comprehension of the effectiveness of laparoscopic interventions by Nissen and Chernousov has been accumulated, while there is no orderly algorithm for choosing the type of antireflux surgical intervention. The purpose of this study is to justify of alternative fundoplication options according to Nissen and Chernousov, depending on the prevalence of hiatal hernia or gastroesophageal reflux disease. Materials and methods. The study is based on data obtained during treatment of 128 patients with hiatal hernias and gastroesophageal reflux disease at the I.V. Davydovsky City Clinical Hospital of the Moscow Health Department in the period from February 2020 to May 2025. The patients were divided into 2 clinical groups based on the prevalence of hiatal hernia (n=66) or gastroesophageal reflux disease (n=62). Both clinical groups were subsequently divided into two subgroups, depending on the type of fundoplication: Nissen or Chernousov. Research results and discussion. The following indicators were used to assess intraoperative, early, and delayed outcomes: the average duration of surgery, blood loss volume, the number of intraoperative and postoperative complications according to Clavien-Dindo, as well as data from postoperative instrumental examinations and questionnaires 1 year after surgery. Conclusion. In the prevalence of hiatal hernia symptoms, patients who underwent Nissen fundoplication showed the best postoperative results. At the same time, patients with Chernousov fundoplication showed more favorable results in the prevalence of GERD symptoms.
Cardiac rhythm variability in patients with inguinal hernias in the postoperative period using a grid and autotissue to close the inguinal canal
Introduction. The expediency of using autotissues in inguinal hernias is dictated by the risk of implant-associated complications. The method of assessing heart rate variability objectifies their advantages in light of the body's adaptive capabilities. The purpose of this study is to develop a hernioplasty method for patients with low stress tolerance and high risk of adaptive failure. Materials and methods. An open comparative study enrolled 87 men with inguinal hernia. Patients were randomly divided into two groups: the main group (n=43) underwent non-tension hernioplasty using autologous inguinal canal tissues (Russian Patent No. 2456928), while the control group (n=44) received standard Lichtenstein repair with a mesh implant. Heart rate variability (HRV) was recorded one hour before surgery and on the first postoperative day. Pain intensity was assessed using the Visual Analog Scale (VAS). Results. Preoperatively, no significant HRV differences existed between groups. Postoperatively, a significant difference emerged in HF % values (р=0,019). The median HF % in the main group increased from 25,0 % to 32,0 % (р=0,031), while it decreased in the control group from 23,6 % to 20,0 % (р=0,24). Conclusion. Autologous non-tension hernioplasty (Russian Patent no 2456928) represents a viable alternative to mesh prostheses, particularly for patients with low stress tolerance and high risk of adaptive failure.
Fundoplication and gastroplication in reconstructive surgery for cardiofundal, subtotal, and total hiatal hernias
Introduction. Surgical intervention is the only radical treatment for reflux esophagitis associated with hiatal hernia. The technique of creating a complete symmetric fundoplication or gastroplication cuff, developed by Professor A.F. Chernousov, has demonstrated its efficacy and is currently the method of choice in the surgical treatment of this pathology. Purpose of the study. To present the results of surgical treatment of patients with cardiofundal, subtotal, and total gastric hiatal hernias who underwent creation of a complete symmetric fundoplication or gastroplication cuff via conventional and laparoscopic approaches. Materials and Methods. Surgical treatment was performed in 48 patients with reflux esophagitis associated with cardiofundal, subtotal, or total hiatal hernia. The first group included 35 patients who underwent laparoscopic surgery (fundoplication – 8, gastroplication – 27, posterior cruroplasty – 26). The second group included 13 patients who underwent laparotomy (fundoplication – 6, gastroplication – 7, posterior cruroplasty – 11). Radiological control was performed on postoperative days 3 and 7. Results. Grade I–II complications according to the Clavien–Dindo classification were observed in 4 (8,3 %) patients and were managed conservatively. According to postoperative radiological examination with oral contrast in the early postoperative period, surgical treatment was effective in all patients regardless of the surgical approach. Conclusion. A complete symmetric antireflux cuff created by fundoplication or gastroplication demonstrates high clinical efficacy in the treatment of reflux esophagitis. The key success factors are its symmetry and complete esophageal wrap, whereas intra- or supradiaphragmatic localization and the type of surgical approach do not have a statistically significant impact on the long-term antireflux outcome. Excision of the hernia sac from the posterior mediastinum is also mandatory. Correction of the diaphragmatic esophageal hiatus diameter using posterior cruroplasty without mesh implants is effective in the treatment of subtotal and total hiatal hernias.
Port site hernias: risk factors and prevention methods
Introduction. The widespread use of laparoscopic surgery has led to an increase in the incidence of port site hernias (PSH). The incidence of PSH can reach 40%, according to various studies. PSH not only reduce patients' quality of life but also require planned and sometimes emergency surgical treatment. Aim of the study: To assess the incidence of PSH, identify the main risk factors, and determine the effectiveness of various trocar wound closure methods based on a literature review and our own clinical experience. Materials and methods. The study consisted of several stages: Stage 1 was a retrospective analysis of 34 patients with trocar hernias after laparoscopic cholecystectomy (LC) and a prospective randomized study of 100 patients with acute calculous cholecystitis who underwent closure of either the aponeurosis alone (n=50) or all layers using the EndoClose device (n=50). Stage 2 was a multicenter, non-randomized study that included a retrospective analysis of 131 patients with postoperative ventral hernias and a prospective follow-up of 134 patients after various laparoscopic procedures with wound closure through all layers. Results. The incidence of PSH in the retrospective group was 5,6 % (34 cases), while in the later cohort it was 15,27 % (20 of 131). Statistically significant risk factors included age over 60 years (p=0,011; r=0,82), obesity (BMI>30 kg/m², p=0,023; r=0,73), connective tissue dysplasia (p=0,037; r=0,56), and postoperative wound suppuration (p=0,042; r=0,64). In a prospective study, hernias developed in 5 patients (10 %) with laparoscopic-guided closure of only the aponeurosis, whereas no hernias were recorded in the group with laparoscopic-guided closure of all layers (p=0,028). With the EndoClose or Berci devices, the hernia incidence in the long-term period (3 years) did not exceed 1,49 % (2 of 134). Conclusion. PSH remains a significant complication of laparoscopic surgery. Their development is facilitated by both general factors (age, obesity, connective tissue dysplasia) and local factors (infection, suturing technique). Suturing trocar wounds through all layers with intra-abdominal visual control using specialized devices significantly reduces the risk of hernia formation and should be considered the standard of care.
Results of coronary artery bypass grafting using the beating heart technique in patients with severe chronic obstructive pulmonary disease
Introduction. The combination of coronary artery disease (CAD) and chronic obstructive pulmonary disease (COPD) in patients referred for coronary artery bypass grafting (CABG) is associated with a high risk of postoperative respiratory complications. Objective. To determine the features of surgical treatment of patients with combined CAD and COPD, to evaluate the results of interventions in off pump and on pump CABG, and to identify the optimal management strategy for such patients. Materials and methods. The study included 100 patients who underwent CABG in 2020–2024. All patients had COPD. In group I (n=50), operations were performed off pump; in group II (n=50), operations were performed on pump with cardioplegia. Discussion. The data obtained indicate that the advantage of surgery on a working heart in patients with COPD is achieved primarily by reducing respiratory complications, especially in patients with severe disease, and is accompanied by a lower annual mortality rate. Results. Group I had fewer complications: prolonged mechanical ventilation, pneumonia, respiratory failure, mediastinitis. The incidence of respiratory complications (pneumonia, prolonged ventilation) was lower in group I compared to group II. Complications from other organs and systems were also higher in group II than in group I. Conclusion. Minimized surgical myocardial revascularization off pump in patients with COPD reduces the number of respiratory complications and improves early postoperative outcomes.
Reduction plasty for borderline dilatation of the ascending aorta in combination with aortic valve replacement: one-year results of a prospective randomized study
Introduction. Borderline dilatation of the ascending aorta (4,2–4,7 cm) is associated with an increased risk of fatal complications but does not always meet the criteria for replacement. Reduction plasty as a less radical alternative requires evaluation of efficacy and safety. Aim. To evaluate the efficacy and safety of reduction ascending aortoplasty performed simultaneously with aortic valve replacement in patients with borderline aortic dilatation. Materials and methods. A prospective randomized single-center study was conducted. 40 patients with indications for aortic valve replacement and ascending aorta diameter of 4,2–4,7 cm were randomized into two groups: isolated valve replacement (n=20) and combined intervention with reduction aortoplasty (n=20). Aortic diameter was assessed before surgery, intraoperatively, after surgery, and at 12 months using echocardiography/MSCT. Results. In the plasty group, a significant reduction in aortic diameter was achieved: from 4,45±0,12 cm to 3,64±0,17 cm after surgery (p<0,001) and 3,67±0,18 cm at 12 months (p<0,001). In the non-plasty group, the diameter remained stable. The annual diameter increase in the plasty group (0,03±0,02 cm) tended to be lower than in the non-plasty group (0,07±0,03 cm), p=0,063. No differences were noted in the duration of cardiopulmonary bypass, myocardial ischemia, operation time, ICU or hospital stay. No cases of aortic dissection, mortality, or reinterventions were recorded during the 12-month follow-up. Conclusion. Reduction ascending aortoplasty combined with aortic valve replacement is a safe and effective method that provides significant and stable reduction of aortic diameter over 12 months without increasing the risk of early postoperative complications.
Surgical correction of mitral valve defect of rheumatic etiology from right-sided mini-thoracotomy: experience of one center
Introduction. Rheumatic mitral valve disease remains a common cause of acquired mitral valve disease. Median sternotomy is traditionally considered the "gold standard" surgical approach; however, it is associated with high morbidity and a lengthy recovery period. The development of minimally invasive techniques, particularly right anterior mini-thoracotomy, offers new opportunities for improving treatment outcomes; however, the evidence base for the use of this approach in patients with rheumatic diseases remains insufficient. The purpose of the study. To compare the immediate results of surgical correction of rheumatic mitral valve defects using right anterior mini-thoracotomy and median sternotomy. Materials and methods of research. Between 2021 and 2024, 12 surgical interventions for acquired rheumatic mitral valve defects were performed in the Cardiac Surgery Department of Sechenov University Clinical Hospital no 1. Patients were divided into two groups based on surgical approach: Group 1 (n = 6) consisted of patients operated on through a right anterior mini-thoracotomy; Group 2 (n = 6) consisted of patients operated on through a median sternotomy. Intraoperative parameters (operative duration, cardiopulmonary bypass time, aortic cross-clamping time, and blood loss volume), postoperative parameters (duration of mechanical ventilation, intensive care unit stay, mobilization time, postoperative hospital stay, and pain severity), and complication rates were analyzed. Results. In the mini-thoracotomy group, there was a significantly lower volume of intraoperative blood loss (391,7 ml versus 590 ml; p = 0,004), shorter duration of mechanical ventilation (6 hours versus 12 hours; p < 0,05), shorter time of stay in the intensive care unit (20 hours versus 43 hours; p < 0,05), earlier time of mobilization (2 days versus 4 days; p < 0,05) and shorter duration of pain syndrome (2 days versus 5 days; p < 0,05). The postoperative hospital stay was also significantly shorter with the mini-access (18,0 versus 30,4 days; p = 0,008). The duration of the operation and the time of artificial circulation did not differ significantly between the groups (p > 0,05). There was a tendency towards an increase in the time of aortic cross-clamping with mini-thoracotomy (p = 0,067). The incidence of postoperative complications (mortality, resternotomy, hydrothorax, atrial fibrillation, infectious complications) was comparable in both groups (p > 0,05). The need for blood transfusions was significantly lower in the mini-access group (p < 0,05). Conclusion. Right anterior mini-thoracotomy for the correction of isolated rheumatic mitral valve defects demonstrates safety and efficacy comparable to median sternotomy. This method offers the advantages of minimally invasive surgery: less blood loss, shorter duration of mechanical ventilation and intensive care unit stay, earlier patient mobilization, and shorter postoperative hospital stay.
Analysis of the results of the use of endovascular technologies in the treatment of patients with type 2 diabetes mellitus complicated by diabetic foot syndrome
Introduction. Revascularization for the neuroischemic form of diabetic foot syndrome is associated with difficulties in vascular reconstruction and a difficult postoperative course, due to the severe comorbidities in this patient population. Therefore, endovascular treatment of diabetic foot syndrome is rapidly becoming the treatment of choice for these patients, as lower extremity ischemia is a significant determinant of their mortality. The purpose of the study. To analyze the results of revascularization interventions in the neuro-ischemic form of diabetic foot syndrome and identify ways to improve these results. Materials and methods. The prospective study included 93 patients with ulcerative necrotic lesions of the feet and lower leg on the background of critical ischemia in the neuro-ischemic form of diabetic foot syndrome. The duration of diabetes mellitus in patients ranged from 1 month (diagnosed during examination for ulcerative necrotic lesions of the feet) to 41 years, the median was 12 years (the 25th percentile is 8 years, the 75th percentile is 20 years). Research results and discussion. Successful treatment of patients with ulcerative necrotic foot lesions in the neuro-ischemic form of diabetic foot syndrome is possible in centers where conditions are available for angiographic examination, endovascular interventions, and vascular angioreconstructions. A multidisciplinary team with a wide range of possibilities for limb revascularization and wound treatment is the main factor in the successful treatment of patients with the neuro-ischemic form of diabetic foot syndrome. Conclusion. The development of early diagnosis methods (before ulcerative necrotic foot lesions) and timely revascularization are promising areas for improving care for patients with the neuro-ischemic form of diabetic foot syndrome.
Possibilities of hybrid technologies in arterial surgery of the infrainguinal segment in critical limb ischemia: practical examples
Introduction. Critical lower limb ischemia is an ischemia that threatens the loss of a limb and most often develops with multiple atherosclerotic lesions of the arteries of the lower extremities, as well as with thrombosis of previously performed vascular reconstructive interventions. Hybrid arterial reconstructions combining both open and endovascular technologies with the possibility of restoring several arterial segments of the affected limb at once seem to be a promising area of surgery for critical lower limb ischemia, however, there are many contradictions in this approach. To date, there is no clear standardization and indications for hybrid operations on the arteries of the lower extremities, and there are no criteria for the stages of such interventions. In addition, performing hybrid operations requires a trained vascular, endovascular team and a hybrid operating room. The assessment of the long-term results of hybrid operations remains a matter of debate. The article provides practical examples highlighting the possibilities of hybrid technologies in arterial surgery of the infrainguinal segment in critical ischemia, including thrombosis of previously performed vascular reconstructions. Materials and methods. Three clinical examples are given demonstrating the effectiveness of hybrid reconstructions in patients with critical lower limb ischemia. Results. In the above clinical examples, hybrid reconstructions made it possible to restore blood flow in the infrainguinal segment and to stop the phenomena of critical ischemia of the affected limb in patients with a pronounced comorbid background, without resorting to longer and more traumatic bypass and resuscitation operations. Conclusion. In the above clinical examples, hybrid reconstructions made it possible to restore blood flow in the infrainguinal segment and to stop the phenomena of critical ischemia of the affected limb in patients with a pronounced comorbid background, without resorting to longer and more traumatic bypass and resuscitation operations.
Reconstructive surgery of the aortic root: algotithm for selecting surgery of the aortic root aneurysm depending on the anatomical and functional characteristics of the aortic valve
Introduction. Valve-sparing technologies still account for the smallest proportion of all surgeries performed for aortic root (AR) pathology. Despite the large number of modern surgical solutions, new technologies and procedures are still being developed and implemented in cardiac surgery. The Russian conduit (RC) procedure is a combination of the Bentall and Ozaki procedures, a method for replacing all structures of the AR. Objective. To develop a surgical protocol for the treatment of AR aneutysm, based on the anatomical features of the aortic valve (AV) and the classification of aortic insufficiency (AI) types. Materials and methods. The study included 198 patients with aneurysms of the root and/or ascending aorta with ≥ grade 2 AR who underwent the David, Yacoub, and RC procedures. Exclusion criteria: combined AV disease, acute aortic syndrome, minimally invasive procedures, and patients following the David procedure with cusps repair. 62 patients were divided into 3 groups: David – 36, Yacoub – 14, RK – 12. Results. Patients with AI types Ia, Ib, and Ic accounted for more than 80 % of each group. The longest operative time and aortic occlusion (AO) time were observed in the David group (317,5 [270–375] and 101,5 [92–135–5]), compared with the Yacoub (255 [240–290] and 98,5 [85–118]) and RK (285 [220–345] and 76 [68,5–109]) groups (p = 0,006 and 0,027, respectively). After excluding combined surgeries, the difference was not statistically significant (p = 0,077, p = 0,378). All techniques effectively reduced the fibrous annulus of the AV. In-hospital mortality and the proportion of patients with chronic heart failure ≥ 2 NYHA class were not statistically different between the groups. A higher proportion of patients with AI intermediate-grade were observed in the Yacoub group (21,4 %) compared to the David group (0 %) and the RC group (8,3 %) (p = 0,016). Conclusion. The David procedure is the procedure of choice for the surgery of AR aneurysm in patients with AI types Ia, Ib, and Ic, and an intact, symmetrical AV. RC is the procedure of choice for asymmetrical AV and AI types Id, II, and III.
Comparative morphological characteristics of thermal tissue damage caused by the use of various types of surgical energy in the treatment of hemorrhoidal disease
Introduction. The invasiveness of surgical intervention in the treatment of hemorrhoidal disease (HD) remains one of the key challenges in coloproctology. The intensity of postoperative pain, healing rate, and risk of complications are directly dependent on the depth and nature of thermal tissue damage caused by different types of surgical energy. Objective. To conduct a comparative analysis of the depth, morphological, and histochemical characteristics of thermal damage to hemorrhoidal tissue using a monopolar coagulator, diode (1,5 μm), 2-μm, and CO₂ lasers, as well as to evaluate the protective role of infiltration anesthesia. Materials and Methods. The study included 90 hemorrhoidal specimens removed intraoperatively using different types of surgical energy. The material was divided into three groups: Group 1 (n=40) – CO₂ laser; Group 2 (n=22) – monopolar coagulator; Group 3 (n=28) – diode and 2-μm lasers. Histological examination was performed to assess general morphological characteristics, vascular status, stromal changes, inflammatory infiltration, and to measure the depth of coagulation necrosis. Additionally, a literature review was conducted on the physical principles of energy-tissue interaction and the molecular mechanisms of repair. Results. Histological examination revealed signs of dermal edema (moderate – 87 %, severe – 13 %), vascular changes (venous thrombosis – 31 %, erythrocyte stasis – 40 %), foci of fibroblast proliferation (18 %), and lymphocytic infiltration (87 %) in all groups. Analysis of coagulation zones showed significant intergroup differences. In Group 2 (monopolar coagulator), the depth of damage ranged from 0,27 to 0,82 mm, reaching 1,50–2,20 mm in 14 % of cases, with the formation of total necrosis and foci of carbonization. In Group 3 (diode and 2-μm lasers), the depth of impact ranged from 0,11 to 0,75 mm (abnormal values of 1,30–1,68 mm in 7 %), with partial fiber homogenization and preservation of some vascular structures. The best results were observed in Group 1 (CO₂ laser): the depth of thermal effect ranged from 0,07 to 0,38 mm, reaching 0,40–0,48 mm in only 5 % of cases; histologically, it was characterized by the smallest damage zone and a complete absence of carbonization. The role of tumescent infiltration anesthesia as an additional tissue protective factor (photohydropreparation) was demonstrated. Conclusion. A direct correlation was established between the type of surgical energy and the extent of thermal necrosis. Monopolar electrocoagulation causes the most extensive and deep damage with tissue carbonization. Diode and 2-μm lasers provide an intermediate coagulation depth, sufficient for reliable hemostasis while preserving regenerative potential. The CO₂ laser in pulsed mode demonstrates a minimal necrosis zone (up to 0,38 mm) without carbonization, creating optimal conditions for rapid repair. A differentiated approach to the choice of energy source and the use of photohydropreparation can minimize surgical trauma, reduce the risk of anal stenosis, and improve patients' quality of life.
The advantage of free transplantation of the blood-supplied iliac crest into the position of a bone defect over non-vascularizable plastic surgery
Introduction. Autotransplantation is necessary to replace large bone defects. Traditional reconstruction methods, such as autotransplantation of unvascularized bone, have limitations in the form of slow consolidation and a high risk of graft lysis. Free transplantation of the vascularized iliac crest bone graft (VICBG) is an advanced microsurgical technique that provides rapid graft engraftment and the ability to take soft tissues over a bone composite by preserving blood supply. Objective: to compare the results of free non-vascular autoplasty and vascular pedicle autoplasty using the example of two clinical cases. Materials and methods. The article presents clinical cases of the use of free nonvascularized plastic surgery and VICBG. In the first case, the use of a non-vascularized graft was used to replace the resected segment of the right radius. In the second case, autotransplantation on the vascular pedicle was performed to replace a bone defect that occurred after a gunshot wound received in the conditions of the SVR. Results. In the first clinical case, it was not possible to achieve complete consolidation of the fracture of the radius. The main reason was lysis of the transplanted iliac bone fragments. In the second clinical case, the graft took root completely, and there were no infections. Upon control after 3 months, the X-ray picture of bone consolidation at all levels showed no signs of osteolysis. Discussion. The advantage of non-vascular autosteoplasty is the significantly shorter duration of surgery and the lack of proficiency in vascular suture techniques. The main disadvantage of the method is the high percentage of osteolysis and, as a result, the lack of bone consolidation. VICBG demonstrates advantages over non-vascular grafts: rapid consolidation (average time 3 months), low risk of osteolysis due to the preservation of blood supply inside the graft. Advantages: abundant bone supply, adaptive shape. Limitations: short vascular pedicle (6-8 cm), donor morbidity. Disadvantages: the long duration of the operation, the need for a surgeon with vascular suture skills to participate in the operation. Conclusion. Free transplantation of the vascularized iliac crest is an effective method for complex bone defects after injury with the development of bone deficiency.
Method for assessing the viability boundaries of a DIEP flap using near-infrared spectroscopy in breast reconstruction
Introduction. Breast reconstruction using a DIEP flap is associated with a risk of ischemic complications, requiring objective intraoperative perfusion control. Existing monitoring methods are either subjective or aimed at the postoperative period. The purpose of this study. To develop and evaluate the effectiveness of a method for intraoperative determination of the viability boundaries of a DIEP flap using near-infrared spectroscopy (INVOS). Materials and methods. A prospective study included 28 patients who underwent breast reconstruction with a DIEP flap. Intraoperatively, using the INVOS 5100C system, regional oxygen saturation (rSO₂) was measured in four zones of the flap before pedicle division (target values), as well as after reperfusion. A viability criterion was an rSO₂ value of ≥60 %. Areas with values below 60 % were resected. Research results and discussion. The mean rSO₂ values in zones I and II after reperfusion were 78,5±6,2 % and 72,1±8,4 %, respectively, which did not significantly differ from the target values. In zones III and IV, a decrease in rSO₂ below 60 % was observed in 11 (39,3 %) patients, requiring economical resection of the distal flap parts. The incidence of marginal necrosis in the postoperative period was 3,6 % (1 case). Conclusion. The use of INVOS spectroscopy with a threshold rSO₂ value of 60 % allows for an objective and non-invasive determination of the viable part of a DIEP flap intraoperatively, minimizing the risk of ischemic complications.
Three-stage hydropressive debridement purulent wounds: experimental substantiation technology efficiency
Introduction. Infections of the skin and soft tissues remain the most common reason for seeking surgical care. The development of resistance of the pathogenic microflora to antibiotics, changes in the spectrum of pathogens dictate the need for effective local treatment methods, the most promising of which are physical factors of influence. Goal. To develop a technology of three-stage hydropressive debridement, to study the effectiveness of its use in the surgical treatment of purulent soft tissue wounds in an experiment. Materials and methods. The study was performed on the basis of the Burdenko VSMU Research Institute of Experimental Biology and Medicine on 72 sexually mature male Wistar rats, which had purulent wounds modeled. The amount of treatment depended on the study group: in the 1st control group, daily dressings were performed with 0,9 % sodium chloride solution, in the 2nd control group, dressings were supplemented with a hydropressive treatment (GO); in the experimental group, a three-stage hydropressive debridement (THD). The animals were removed from the experiment on the 1st, 3rd, 7th and 10th days after the start of treatment. Objective, planimetric, laboratory, and statistical methods were used to assess the course of the wound process. Research results and discussion. The use of THD technology led to an acceleration in the timing of edema reduction by 25,06 % and hyperemia by 24,53 %, compared with the use of GO; it contributed to the fastest wound cleansing, a decrease in inflammation syndrome, the development of full-fledged granulation tissue, and the earliest closure of the wound defect – up to 94,13% on the 10th day from the beginning of treatment. Conclusion. The closest correlation was noted between leukocytes and bacterial contamination, which confirms the key role of the inflammatory response in controlling microbial load. The negative correlations between follow-up time, wound area, pH, leukocytes, and bacterial contamination reflect the regular healing dynamics most pronounced with the use of THD. The level of malondialdehyde correlated only with the level of white blood cells, which confirms the role of oxidative stress mediated by the inflammatory response and demonstrates the effectiveness of using THD in order to correct these parameters.
Endoscopic retrograde cholangiopancreatography in patients undergoing gastric resection according to Billrot-II
Introduction. The relevance of using endoscopic retrograde cholangiopancreatography in patients after gastric resection according to Billroth II remains high, since up to 15–20 % of them face pathology of the biliary tract in the long term. According to research data, the actual success rate of ERCP in these conditions ranges from 61,7 % to 88,2 %, which is lower than in patients with unchanged anatomy (more than 95 %), due to the complexity of selective cannulation through a long adductor loop. Thus, the improvement of ERCP methods for the operated stomach remains critically important. The purpose of the study. To evaluate the effectiveness of endoscopic retrograde cholangiopancreatography in patients undergoing gastric resection according to Billroth II using a clinical case example. Materials and methods. A literature review was conducted using the electronic databases PubMed, Google Scholar, Scopus, and elibrary. The features of endoscopic retrograde cholangiopancreatography in patients who underwent gastric resection according to Billroth II are described using the example of a clinical case. Results. High-quality equipment and tools, teamwork of an experienced team of endoscopists, anesthesiologists, and surgeons are necessary for the successful completion of endoscopic interventions in the pancreato-biliary zone in patients after gastric resection according to Billrot II. As presented in the clinical case, the use of multi-stage minimally invasive interventions with various technical approaches and the individual choice of anesthetic aids can improve the outcome of treatment, which is critically important for patients with high operational risk. Conclusion. Thus, when choosing surgical tactics for performing ERCP in patients after gastric resection according to Billroth II, a personalized approach is needed to take into account not only previous operations and concomitant diseases, but also the anatomical features and compliance of the patient, which can greatly facilitate the implementation of the intervention.
Negative pressure wound therapy in a patient with an extensive soft tissue defect of the shoulder after a mine-blast injury
Introduction. Contemporary combat trauma surgery is characterized by a high incidence of extensive soft tissue defects resulting from gunshot and blast injuries, which underscores the relevance of developing and refining surgical treatment modalities for this patient population. The absence of standardized algorithms for managing patients with extensive soft tissue defects during the stages of treatment selection and defect reconstruction creates substantial challenges in clinical practice and underscores the necessity of an individualized approach. The authors present a clinical case of successful application of negative pressure wound therapy in the comprehensive surgical management of a patient with a severe combined shrapnel injury to the upper extremity and an extensive soft tissue defect of the shoulder. Description of the clinical case. This case report describes combat trauma secondary to a severe combined shrapnel injury to the upper extremity, characterized by a comminuted gunshot fracture of the proximal humerus (type C1), axillary vein injury, and an extensive, massive soft tissue defect of the anterior shoulder, further complicated by a protracted wound healing course and the onset of traumatic illness.
The role of venoactive drugs in the perioperative period of endovenous treatment for varicose veins
Introduction. Varicose veins of the lower extremities are the most common form of chronic venous insufficiency and remain a significant medical and social problem. Endovenous methods for eliminating pathological venous reflux (EVLA, RFA, MOCA, etc.) are currently considered the standard of surgical treatment. However, in the early postoperative period some patients continue to experience undesirable venous-specific symptoms, which are associated with thermal or mechanochemical endothelial injury and activation of inflammatory mechanisms. Despite the widespread use of venoactive drugs, their role in perioperative management during endovenous interventions and their impact on endothelial dysfunction remain a matter of discussion, which determines the relevance of the present analytical review. Aim of the study. Analysing current data on the use of phleboactive drugs in the perioperative period of endovenous treatment of varicose veins, with a focus on their effect on markers of endothelial dysfunction, inflammation, and the severity of clinical symptoms. Materials and methods. Available international and Russian literature analysed using the scientific databases PubMed, Google Scholar, and Scopus. Results. The analysis has demonstrated that the use of venoactive drugs in the perioperative period contributes to a faster regression of venous-specific symptoms, a reduction in the incidence of early adverse events, and an improvement in quality-of-life indicators. A positive effect on markers of endothelial dysfunction and microcirculation was also observed, which may be considered a pathogenetically justified effect. Conclusion. Current concepts regarding the mechanisms and clinical effectiveness of venotonic therapy in the context of endovenous interventions have been systematised. The summarised data provides a comprehensive understanding of the importance of perioperative pharmacological support.
Modern aspects of surgical treatment of coronary heart disease. Literature review
Introduction. CFor many decades, cardiovascular diseases have been in the first place worldwide and in the Russian Federation in terms of incidence and mortality (up to 40 %). Long-term scientific research in the field of therapeutic treatment has led to a significant improvement in the situation of reducing mortality from coronary heart disease. However, persistent disability forced the search for more radical methods of treating the disease. This was the surgical treatment aimed at revascularization of the myocardium. The purpose of the work: to highlight the current issues of myocardial revascularization in coronary heart disease according to literary sources. Materials and methods. In the course of the work, 116 scientific articles were analyzed. The search was conducted in scientific databases: eLibrary, CyberLeninka, Web of Science, Scopus, PubMed for 2010–2026. The main part. The paper highlights the main issues of surgical and endovascular treatment of coronary artery disease. The literature sources describing the use and results of CABG and MCG from mini-access on a working heart are considered. The expansion of indications for bypass surgery, the possibility and result of using MiECC, and the addition of coronary artery bypass grafting by extracardial revascularization methods have been determined. The issues of necessity and expediency of performing simultaneous operations and operations in acute myocardial infarction are also considered. Conclusion. Many years of experience in the use of surgical methods for the treatment of coronary heart disease leaves many unresolved questions regarding the optimization of long-term results. A personalized approach to the choice of surgery reduces the percentage of complications and deaths. This work allows us to conclude that further research on this issue is necessary.
Treatment of wounds in the neuropathic form of diabetic foot syndrome using platelet-rich autoplasma: problems and prospects
Introduction. The neuropathic form of diabetic foot syndrome develops as a result of hyperglycemia and neuropathy, which further leads to a violation of reparative processes. The standard amount of therapy, including surgical treatment of the wound, systemic antibacterial therapy, and limb unloading, is often insufficient to stimulate healing. Platelet–rich autoplasma (PRP) containing growth factors is a promising treatment method that accelerates tissue repair. This review examines the effectiveness of PRP in stimulating the healing of chronic wounds, including wounds with neuropathic form of diabetic foot syndrome. The purpose of this study is to review the available literature from domestic and foreign authors and to systematize the data on the mechanism of action, clinical efficacy, and optimal protocols for using platelet–rich autoplasma in the treatment of wounds in NFSDS. Materials and methods. Analysis of available literary data of foreign and domestic authors, scientific databases e–library, PubMed, PMC. Results. The analysis of literature data proved the role of PRP in accelerating wound healing in neuropathic form of diabetic foot syndrome by stimulating angiogenesis, collagen synthesis, and reducing the risk of amputations and infection recurrence. The technique does not replace the standard treatment, but increases its effectiveness. Conclusion. The use of platelet–rich autoplasma makes it possible to increase the effectiveness of treatment of chronic wounds, including wounds with neuropathic form of diabetic foot syndrome by activating reparative processes. This method can be considered as a component of personalized therapy.
The problem of treating complicated wounds. Methods of suturing in complex treatment. (A literature review)
Introduction. The problem of treating long-term non-healing, extensive, and complicated wounds remains one of the most challenging tasks in surgery. Traditional methods often prove insufficiently effective, leading to prolonged hospitalization, high risk of complications, and unsatisfactory functional and cosmetic results. This necessitates the continuous search for and implementation of innovative technologies capable of radically improving the process of tissue repair. Objective: To systematize and analyze the evolution of methods for treating complex wound defects over the period 2000–2024 to identify key trends, assess the effectiveness of various approaches, and determine the most promising directions for development. The main part. The analysis showed that the development of wound treatment methods has progressed from local medications to complex biotechnological and hardware systems. Major achievements include the creation of combined drug formulations, the improvement of surgical sutures and dermotension techniques, the application of laser and photodynamic technologies, the introduction of cell therapy and tissue engineering, and the use of biocompatible coatings. Modern approaches are aimed at creating a controlled environment for healing and reducing the invasiveness of interventions. Conclusion. Modern wound treatment is characterized by a shift towards complex and personalized therapy that combines mechanical, physical, and biological approaches. However, the search for optimal, cost-effective, and technically accessible methods for closing wounds of different origins and locations remains relevant. A promising direction is the creation of integrated systems capable of dynamically managing all stages of healing, which will significantly improve treatment outcomes and patients' quality of life.
Comparative analysis of surgical methods for the treatment of hemorrhoidal disease stages III–IV: a literature review
Hemorrhoidal disease (HD) is one of the most common anorectal pathologies, affecting 5–10 % of the population, predominantly in the 45–65 age group. Surgical treatment is indicated for stages III–IV of the disease; however, the choice of the optimal method remains a subject of debate. Results. Hemorrhoidopexy (Longo procedure) is characterized by low postoperative pain and rapid rehabilitation; however, at a mean follow-up of 15 years, recurrence of at least one hemorrhoidal symptom was recorded in 47,4 % of patients, and surgical re-intervention was required in 15,2 % of cases. Transanal Doppler-guided dearterialization (THD) is effective primarily in stages II–III, with a recurrence rate of 12–27 % and a low rate of postoperative complications. Conventional hemorrhoidectomy remains the gold standard for complicated forms and stage IV disease, with a recurrence rate of 2–8 %; however, it is associated with significant postoperative pain and prolonged rehabilitation. The use of modern modifications employing radiofrequency and ultrasonic energy (LigaSure, Harmonic Scalpel) reduces intraoperative blood loss and the intensity of postoperative pain. Conclusion. The choice of surgical strategy for HD stages III–IV should be determined by the degree and stage of the disease, the presence of complications, and the level of proficiency with the technique. Further studies are needed to develop a personalized approach, assess long-term outcomes and recurrence rates for various treatment methods, and clarify the indications for each of them.
Results of anastomotic leak after low Anterior resection with or without preventive stoma for rectal cancer in low-risk patients in nonemergency departments (RELOAD): final protocol of multicenter randomized controlled non-inferiority trial
Introduction. Anastomotic leakage (AL) following low anterior resection (LAR) for rectal cancer is a major complication. Preventive stoma formation reduces the risk of AL. However, it is associated with lower quality of life, reversal surgery, stoma-related complications and prolonged overall treatment. Routine stoma formation does not appear to confer clear benefits in low-risk patients. The aim of this study is to compare the safety outcomes of LAR with and without a preventive stoma in patients with a low initial risk of AL. Methods. This multicenter randomized non-inferiority trial will enroll patients classified as low-risk for AL (predicted risk ≤ 10 %) undergoing laparoscopic TME for rectal cancer. In the experimental group, preventive ileostomy or colostomy will not be performed. In the control group – standard practice. The primary endpoint will be the incidence of colorectal anastomotic leak. Discussion. The problem of preventive stoma is not solved in low predicted risk population. New evidence is needed to determine whether routine stoma formation can be safely omitted in these patients. Ongoing trials, including GRECCAR 17 and the SELSA trial, address related questions but have defined different primary endpoints. The present study focuses on the most clinically relevant and objective outcome – rate anastomotic leak. The results will help to support individualized surgical decision-making and improve the quality of life.
Assessment of fibro-sclerotic changes in the thyroid gland from a surgical perspective. Part IV
Introduction. SMinimally invasive techniques for the treatment of thyroid disorders based on various physical energy modalities provide targeted local destruction of focal lesions with subsequent volume reduction. The resulting morphological changes depend on the type of exposure and structural characteristics of thyroid nodules and determine long-term treatment outcomes. Objective. To analyze published data on the effectiveness and technical aspects of minimally invasive treatment methods and to assess the patterns of fibro-sclerotic changes in thyroid tissue and nodular formations. Methods. A literature review was performed using the eLIBRARY, PubMed, Web of Science and Scopus databases with keywords related to fibrosis, sclerosis and various ablation techniques applied to thyroid pathology. Publications focusing on both immediate and long-term morphological outcomes were included in the analysis. Results. Despite differences in mechanisms of action, minimally invasive methods lead to the formation of coagulative necrosis followed by fibrosis, sclerosis and, in some cases, calcification. Over time, morphological changes become similar and are associated with partial or complete regression of nodules. The extent and rate of these processes may vary depending on the technique used and the initial structure of the treated lesion. Conclusion. Minimally invasive treatment modalities represent a promising direction in thyroid surgery; however, further studies are required to clarify the patterns of morphological changes and to evaluate long-term outcomes and clinical effectiveness
Preoperative thyroid artery embolization in thyroidectomy patients with big goiter (III-V degree) and diffuse toxic goiter (literary review)
Introduction. Thyroid surgery is a technically complex type of surgical intervention, which is associated with the close topographic relationship of the thyroid gland with the vital anatomical structures of the human neck. Objective: to analyze the results of published scientific studies on two-stage surgical treatment of thyroid gland in order to determine an effective, safe method for performing selective embolization of thyroid arteries (SETA) before thyroidectomy. Evaluate methods, clinical outcomes, and complications of SETA as a first stage of thyroidectomy in patients with large goiter (grades III–V) and diffuse toxic goiter (DTG). Improve surgical outcomes of thyroidectomy. Methods. A total of scientific publications were analyzed, including domestic and 3 foreign ones. Methods and results of hybrid interventions on the thyroid gland performed as preparation for thyroidectomy were analyzed. Results. Analysis of publications showed that thyroidectomy in this group of patients is associated with a high risk of bleeding, which increases the risk of injury to vital anatomical structures such as laryngeal nerves, esophagus, trachea, and parathyroid glands. SETA, as the first stage of surgical treatment for large goiters and DTG, has proven to be a promising, reproducible, safe, and effective way to prevent intraoperative hemorrhage. Additionally, performance of SETA carries risks of embolization of non-target vessels, including those of the brain. SETА reduces the blood supply to the thyroid gland, while venous outflow of blood remains unrestricted – this creates a potential risk of worsening thyrotoxicosis, which may be especially important in elderly people with coronary heart disease or severe arrhythmia. Conclusions. Surgical treatment of patients with large grade III-V goiters is technically complex due to the high risk of bleeding caused by intense vascularization of the thyroid gland, leading to increased risk of damage to adjacent structures. SETA, as the first stage of surgical intervention, has established itself as a promising, effective, and safe method for preparing for thyroidectomy. Despite its high efficacy, the technique is associated with risks of worsening symptoms of thyrotoxicosis and possible embolization of non-target vessels. Therefore, it is necessary to define a clear time interval between stages of hybrid intervention, identify embolic materials suitable for performing SETA that minimize adverse events, and ensure safe performance of thyroidectomy.
Rectal cancer: evolution of surgical and combined treatment methods over more than 100 years of history
Introduction. This review is dedicated to the evolution of rectal cancer treatment over more than a century. Objective. To trace the main stages of development: from the first palliative interventions at the end of the 19th century to modern high-tech approaches. Materials and methods. The article is based on an analysis of a wide range of domestic and foreign sources. Results and discussion. Key historical milestones are described, including the introduction of radical surgeries (Miles' operation, anterior rectal resection with primary anastomosis), the revolutionary significance of the total mesorectal excision technique, the establishment of combined treatment with neoadjuvant therapy, and the development of minimally invasive technologies (laparoscopy, robotic surgery, transanal total mesorectal excision). Special attention is paid to the paradigm shift from maximum oncological radicalism to the pursuit of preserving patient quality of life, including sphincter-preserving operations. The article also addresses current challenges, such as low anterior resection syndrome, and outlines prospects for treatment personalization. Conclusion. The article is useful for surgical oncologists and coloproctologists.
Tubular deformation of the mammary glands: modern concepts of etiology, diagnosis and surgical correction
Introduction. Tubular deformity of the mammary glands (TMJ, tubular breast, constricted breast) is a specific congenital malformation characterized by hypoplasia of the glandular tissue, mainly in the lower and/or medial quadrants. The main part. The review article systematizes current data on tubular breast deformity, a complex congenital malformation. The proposed etiological factors and key links of pathogenesis based on the concept of the presence of a fibrous ring at the base of the gland are considered in detail. The most relevant clinical classifications are given. Special attention is paid to the principles of choosing surgical tactics. Modern methods of surgical correction are described in detail, including variants of glandular plastic surgery techniques, the use of implants, biological mesh and lipofilling, as well as combined methods. Conclusion. Correction of the tubular deformity of the mammary glands is one of the most difficult tasks in aesthetic mammoplasty. The success of treatment is based on accurate diagnosis of the type of deformity, careful preoperative planning and the choice of an individualized surgical approach aimed at correcting all components of the defect. Modern combined techniques make it possible to achieve stable and aesthetic results, significantly improving the quality of life of patients.
The path we have traveled and what awaits us: a look at the prospects for the development of heart and aortic surgery
In 2013, the Journal of Cardiothoracic and Vascular Anesthesia published an article dedicated to the 60th anniversary of the first successful open heart surgery using an artificial circulatory system (AIC). It was a turning point in the history of surgery. Over the past 70+ years, cardiac surgery has achieved a level and results. The real technological breakthrough in heart surgery was the transcatheter implantation of an aortic prosthesis (TAVI). This minimally invasive intervention opened the way for an alternative treatment for severe aortic valve stenosis. Recently, transcatheter implantation of mitral and tricuspid prostheses has been actively developed and clinically successfully applied. Minimally invasive transcatheter surgery will eventually occupy an absolutely dominant position. In this regard, a reasonable question arises: which of the specialists will perform the most difficult repeated operations, especially in the case of infection of aortic and vascular stents, prostheses and catheter valves? The solution to all tasks and problems is the creation of interdisciplinary centers where angiologists and vascular surgeons, cardiologists and cardiac surgeons will work "under one roof ", and where all stages of diagnosis, treatment and follow-up are links in the same chain. Such an organization of specialized surgical care and a locally high concentration of patients will make it possible to qualitatively improve the training of the younger generation of surgeons, taking into account the requirements of technological progress, and timely identify and effectively treat both early and late postoperative complications.
May tenth... A victorious day has been lived...