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Moscow Surgical Journal

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No 4 (2021)
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ABDOMINAL SURGERY

9-14 401
Abstract

Introduction. Aim of study. Nowadays, the most modern method of treatment of gallstone disease complicated by choledocholithiasis is a two-step, simultaneous, "rendezvous" intervention. Despite the advantages of "rendezvous", this technique requires a high skill in laparoscopy and endoscopy. Considering the aforementioned, we have developed a method of combined one-stage treatment of gallstone disease complicated by choledocholithiasis.
Methods. A combined one-stage intervention for the treatment of gallstone disease complicated by choledocholithiasis was performed in Botkin Hospital. A total of 7 patients were operated on.
Results. The average duration of the endoscopic stage was 34+2, 1 minutes (from 20 to 65 minutes). The laparoscopic stage took 55+5, 7 minutes (30 to 70 minutes). The total operation time averaged 80 + 9, 4 minutes (from 60 to 110 minutes).
Conclusion. The combined one-stage method of treating gallstone disease complicated by choledocholithiasis shows an advantage over the two-stage approach. However, its use is limited and dictates the need for a selective approach in choosing patients.

15-22 364
Abstract

Introduction. The development of surgical technologies in recent years makes it possible to translate the experience of treating patients with malignant neoplasms of the liver to the treatment of patients with benign liver damage.
Methods. Since 2018, in the surgical clinic of the Botkin Hospital, with liver echinococcosis and the need to perform extensive liver resections, the portoembolization technique has been used to develop vicarious hypertrophy of the remaining lobe of the liver. The analysis of the results of treatment of 64 patients who underwent a resection method of treatment was carried out. The main group included 13 patients who underwent 8 portoembolization procedures. The second group was represented by 51 patients who were operated without preliminary embolization of the right branch of the portal vein. The study evaluated the following indicators: duration of surgery, volume of blood loss, postoperative bed-day, complications according to the Clavien-Dindo classification, specific complications according to ISGLS, relapses during the first year after surgery.
Results. The immediate results of surgical treatment (the number of general surgical complications in the postoperative period and its duration) in patients after preoperative embolization of the right branch of the portal vein were significantly better than in patients operated on without taking into account the need to prevent the development of acute post-resection hepatic failure. Long-term survival results did not reveal significant differences.
Conclusion. Thus, modern surgical technologies that allow to achieve an increase in the volume of the functioning liver parenchyma can reduce the number and severity of postoperative complications and improve treatment results.

CARDIOVASCULAR SURGERY

23-29 307
Abstract

Introduction. According to the literature, aortic valve defects occur in 15% of patients with dilation of the proximal ascending aorta. With borderline ectasia of the aorta up to 5 cm, there are still numerous discussions about the methods of surgical treatment.
The aim of the study was to improve the results of surgical treatment of patients with aortic valve defect in combination with poststenotic expansion of the ascending aorta less than 5 cm.
Material and methods. The article analyzes the long-term results of surgical treatment of 69 patients with aortic valve defects in combination with poststenotic dilation of the ascending aorta from 4 to 5 cm.
Results. In control examinations of patients with isolated aortic valve replacement after 5 years, 20 (58.8%) patients showed no significant change in the size of the ascending aorta, 7 (20.6%) – an increase in the size of the ascending aorta annually by 2 ± 0.4 mm, 4 (11.7%) - annually by 1 ± 0.3 mm.
Conclusion. Taking into account the high risks of aneurysm growth, its dissection and rupture, patients with aortic valve defect with borderline dimensions of the ascending aorta are recommended to perform simultaneous prosthetics of the aortic valve and the ascending aorta.

CLINICAL CASE

30-34 450
Abstract

Introduction. Cholecystocardial syndrome is a symptom complex characterized by a change in normal cardiac activity against the background of pathological processes associated with the hepatobiliary zone.
Aim of the study: demonstration of a clinical case of treatment of a patient with acute myocardial infarction and acute destructive cholecystitis.
Materials and methods. This paper presents the clinical experience of diagnostics and treatment of a 57-year-old patient with cholecystocardial syndrome. The main complaints were: acute pain in the right hypochondrium, epigastric region, compressive pain behind the breastbone radiating to the upper left extremity, nausea, shortness of breath. The patient was diagnosed acute myocardial infarction in the emergency room.
Results. The patient underwent stenting about floating thrombus of the left coronary artery trunk, after stabilization of his condition in 2 days due to continuing clinical picture of acute cholecystitis, laparoscopic cholecystectomy was performed. Postoperative period was without complications. After examination of the patient with the cardiologist in 1, 6 and 12 months after the operation, no complications from the cardiovascular system were found, according to ultrasound study of the abdominal organs, there were signs of diffuse changes in the liver.
Conclusion. This syndrome is a dangerous "mask", timely diagnosis, allowed to avoid severe complications.

35-39 1883
Abstract

Introduction. The wandering spleen is a rare developmental anomaly characterized by congenital insufficiency of the ligamentous apparatus, a long vascular pedicle, dystopia, and abnormal mobility of this organ. To date, about 500 cases of the vagus spleen in children and adults have been described in the world literature. In most patients, spleen volvulus is asymptomatic until the first episode of torsion. Ultrasound diagnostics with the determination of blood flow in the vessels of the spleen, spiral computed tomography without and with contrast and magnetic resonance imaging, as well as the data of an objective examination, are of great importance in the diagnosis of pathology. It should be emphasized that due to the high risk of developing serious complications, surgical intervention is indicated even in children with asymptomatic course of this disease. Observations of spleen volvulus in adults requiring emergency surgery are rare, which is of particular clinical interest.
Materials and methods. A 36-year-old patient was admitted to the hospital for emergency indications. As a result of the examination, the diagnosis was established: spleen dystopia, spleen volvulus. An emergency surgery was performed for spleen volvulus - diagnostic laparoscopy, laparotomy, organ detorsion and splenopexy of the latter in the retroperitoneal space of the left lateral canal. The postoperative period was smooth, the wounds healed by primary intention.
Conclusion. Timely surgical intervention made it possible to perform organ-preserving surgery and prevent further relapses of spleen volvulus.

40-46 288
Abstract

Introduction. Simultaneous procedures in bariatric operations account for 3.4-28.1% of cases. The main advantages of the approach is to achieve the maximum positive impact on the quality of life of patients. Most often, bariatric procedures are combined with simultaneous cholecystectomy, hernioplasty, and elimination of hiatal hernia. There are single descriptions of simultaneous interventions in combining obesity with other nosologies. The implementation of simultaneous surgical correction of chronic hemorrhoids during bariatric intervention has not been previously described in the available literature.
Clinical case. Presented the first experience of laparoscopic sleeve gastrectomy and submucous laser hemorrhoidoplasty in a 45-year-old woman with alimentary-constitutional obesity and grade 3 chronic hemorrhoids. The total time to complete the procedures did not exceed the total time of individual interventions. The severity of pain syndrome during the early postoperative period was comparable to the standard after bariatric interventions.
Discussion. Based on the first experience, the simultaneous submucous laser destruction of hemorrhoids, according to indications, simultaneously with the bariatric procedure for chronic hemorrhoids in patients with morbid obesity is a justified and fairly safe combination.
Conclusion. The simultaneous elimination of two diseases at once has a positive effect on the further quality of life and reduces the risk of further proctological problems.

UROLOGY

47-57 416
Abstract

Introduction. Purpose: to advance the laparoscopic partial nephrectomy (LPN) through the use of mixed reality (MR) technology.
Materials and methods. 47 patients with LPN were enrolled in the prospective research from June 2020 to February 2021 after institutional review board approval. Patients were randomly assigned to two different groups: the control group, which included 24 patients, was operated with an intraoperative ultrasound (US) control, while the experimental group, which included 23 patients, was operated with smart glasses with the individual MR model of the organ with a tumor. Our team takes credit for the creation of an open-source software package, “HLOIA,” which was tested in the experimental group. Demographic, perioperative, and pathological data sets were collected separately for each individual patient. A 5-point Likert scale questionnaire was used to evaluate the utility of an MR model during LPN. It was completed by the surgeon immediately after LPN.
Results. Experimental group outperformed the control group in several criteria, such as the time for renal pedicle exposure and the time from the renal pedicle to the detection of tumor localization (p <0.001). The questionnaire, filled out by the surgeon, revealed high utility scores of the MR model.
Conclusions. HLOIA© software and smart glasses introduced mixed reality technology that reduced the time for renal pedicle exposure and for renal tumor identification in a safe manner.

MILITARY FIELD SURGERY

58-64 327
Abstract

Introduction. The aim of the study is to compare the main characteristics of explosive pathology in peacetime and wartime.
Methods. The retrospective study is based on the analysis of the main characteristics of explosive trauma in victims of terrorist attacks in the metro of Minsk and St. Petersburg (250 people, first group) and in patients who were damaged by mine or explosives during a counter-terrorist operation in the North Caucasus in 1999–2002, (608 people, second group). The structure and the localization of injuries were studied. The objective severity of injuries was assessed using the MSD (Military Surgery-Damage) scale.
Results. Significant differences in the main characteristics of explosive trauma in peacetime and wartime were revealed (p<0.05). In the structure of trauma in the first group explosive injuries prevailed (52,3 %), in the second group fragmentation wounds prevailed (49,3 %). In the first group light injuries prevailed (68,0 %), in the second group severe injuries prevailed (56,2 %). An identical incidence of combined trauma was found in both groups (50,0 % and 56,9%, p> 0,05) and a greater number of affected anatomical areas in the first group (p=0,0006). In the first group head injuries were most often detected (73,2 %), in the second group limb injuries were the most frequent (77,1 %).
Conclusion. Differences in the main characteristics of explosive trauma in peacetime and wartime have been determined. They must be taken into account during organizing the reception of victims due to emergencies.

LITERARY REVIEWS

65-71 478
Abstract

Abdominal plastic is one of the most commonly performed cosmetic surgeries worldwide. Dermolipectomy has existed for more than a century and certainly in such a long time it has undergone significant changes. Modern endoscopic technologies, liposuctions, operations using mini-access, suturing of abdominal wall diastasis are widely used in abdominoplasty. However, there is no consensus on the choice of the method of operational intervention today. The review presents a modern classification of the omission of tissues of the anterior abdominal wall. From a historical point of view, the types and methods of strengthening the anterior abdominal wall, the materials used to strengthen it, with a description of negative and positive aspects are described. The formation of the "ideal" location of the navel and the postoperative scar are of enormous importance in the final cosmetic result of the entire operation, therefore, the review presents methods for the formation of the neo-navel.
The most common complications in the postoperative period of abdominoplasty are described in detail. When performing dermolipectomy, special attention is paid to aesthetics. Based on the study of the data of the medical literature on abdominoplasty, the authors identified the basic principles that must be observed when choosing a surgical approach to dermоlipectomy and measures for the prevention of postoperative complications.

72-79 243
Abstract

Introduction. Throughout the entire period of development of medicine, scars after surgical interventions were either not paid or very little attention was paid, and only in the last few decades have scientists been actively studying the processes involved in the formation of scars and scarless wound healing. This interest is due to the fact that scars have become a factor in a person's psycho-emotional maladjustment, reducing the quality of his life, and often they themselves are a disease that causes physical discomfort and leads to functional disorders.
The main part. Most superficial wounds do not leave significant scars, but with deep injuries, hypertrophic scars and keloids always appear, and scars that form as a result of burns require complex reconstructive multi-stage operations in order to facilitate the patient's life, but even in this case, we are not talking about aesthetics. According to the WHO, about 11 million burn patients require urgent medical attention every year.
Based on a review of domestic and foreign articles devoted to the problems of healing and scar formation, as well as points of influence on the wound process in order to minimize them, we have prepared this literature review, which summarizes, in our opinion, significant discoveries on the way to solving such a global medical social problem.

80-89 273
Abstract

Cushing's disease (CD) is a rare disease with a clinical picture of hypercortisolism, caused by the presence of pituitary tumor and characterized by hypersecretion of adrenocorticotropic hormone (ACTH) and an increase in cortisol production by the adrenal gland. Surgical treatment is the first line of therapy. Preoperative identification is required to achieve complete tumor resection and to achieve clinical remission. The volume and type of surgical intervention depends on the characteristics of the tumor.
The results of the operation are assessed by radicality, postoperative complications and biochemical parameters. But one third of patients does not achieve remission after surgery. The reason for the lack of effect after surgery may be anatomical and morphological features of the tumor, and the experience of the surgeon and the surgical technique used. Knowledge of the features of surgical tactics and the intraoperative picture makes it possible to assess the prognosis of the risk of recurrence. Assessment of radicality can be carried out both immediately after the operation and in the delayed period.
Calculation of the risk of recurrence of the СD at the preoperative and postoperative periods allows you to optimize and personalize the algorithm for monitoring and early diagnosis of CD recurrence and for the next stage of treatment.

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ISSN 2072-3180 (Print)