СПОСОБЫ ЛЕЧЕНИЯ ПАЦИЕНТОВ С ПОСЛЕОПЕРАЦИОННЫМИ ВЕНТРАЛЬНЫМИ ГРЫЖАМИ И СФОРМИРОВАННЫМИ СВИЩАМИ КИШЕЧНИКА

The aim of the work: based on the use of the program of multiparametric neural network clustering to analyze the results of examination and surgical treatment of patients with primary and postoperative ventral hernia in morbid obesity to identify a group of patients with high risk of complications in the postoperative period.
 Materials and Methods. A comprehensive clinical-instrumental and laboratory examination of 237 patients with primary ventral and postoperative ventral hernia with concomitant morbid obesity with subsequent assessment of the nature of complications in the early and late postoperative periods was conducted. Patients were examined according to standards with this nosology, including general clinical, detailed study of all organs and systems of the body and local status (location, size, length of hernial protrusion) according to the EHS classification (2009). In the postoperative period, early (prolonged lymphorrhea, seroma, hematoma, infiltrate, marginal necrosis of the skin, suppuration) and late (mesh migration, meshomas, intestinal and ligature fistulas, mesh rejection, chronic pain, hernia recurrence) local and general (abdominal compartment syndrome, pulmonary embolism, pneumonia, myocardial infarction) complications. Clustering of subjects by groups using the add-on NeuroXL Classifier for Microsoft Excel was conducted for more in-depth analysis and in order to predict the complications in the postoperative period
 Results and Discussion. Analysis of cluster pictures during neural clustering based on clinical and anamnestic data and types of surgical interventions revealed that in predicting the risk of complications in the postoperative period based on combined changes, the combination of sex, obesity II-III and respiratory failure when own tissue hernioplasty and Onlay in patients were the most important. It should also be noted that the identified pattern primarily relates to the development of complications such as acute cerebrovascular accident, seroma and marginal necrosis of the postoperative wound. The lowest complication rate was observed in obese patients during laparoscopic hernioplasty and eMILOS (mini/less open sublay).

Abstract. In the period from 2001 to 2017, 1419 patients with ventral and postoperative ventral hernia were operated on. The unsatisfactory results of the surgical treatment of this pathology were due to a number of disadvantages: the choice of an inadequate method of hernioplasty in a specific clinical situation, an incomplete revision of the muscle-aponeurotic layer of the anterior abdominal wall, especially in patients with postoperative veterinary hernias, concomitant syndrome of undifferentiated connective tissue dysplasia and obesity, and weak points, the wrong choice of the type of mesh implant (“light” or “heavy” polypropylene mesh) and its size, the choice of an inappropriate type of suture material, as well as the high invasiveness of surgical intervention. Based on the given causes of complications in the operated patients with a high risk of their development, we have made a technical improvement of the existing methods of hernioplasty and development of new ones, which significantly reduced the number of postoperative complications and increased the safety of performing surgical interventions in patients with ventral and postoperative ventral hernia.
 Purpose. Based on the results of the analysis of surgical treatment of patients with comorbid conditions for primary and incisional ventral hernias to develop technical prerequisites for improving the safety of surgical interventions in this category of patients.
 Methods. Іn the period from 2001 to 2017, an in-depth comprehensive clinical-instrumental and laboratory examination of 1419 patients with primary ventral hernia (PVH) and postoperative ventral hernia (PVH) was conducted. The patients were divided into groups according to the periods of surgical treatment of patients. For this purpose, two periods were formed: from 2001 to 2009 and from 2010 to 2017. At the first period, 597 (42.07%) patients were examined and operated on. These patients formed a comparison group. The main group corresponding to patients who were treated in the period from 2010 to 2017 was 822 (57.93%) people.
 Results. Developed techniques for performing retromuscular allogernioplasty, which were based on controlled visualization of suturing when fixing polypropylene mesh to the posterior leaf of the vagina of the rectus muscle, allowed us to reliably and safely place and secure the implant in the retromuscular space, significantly reduce the trauma and duration of surgery.
 Kind of treatment using the mesh allograft with a liposomal complex with included antibacterial and immunosuppressive agents during the operation on the "onlay" method significantly reduced the number of local infectious complications. The location of the PRF membrane over the polypropylene mesh during retromuscular allogernioplasty improved neoangiogenesis at the mesh implantation site, increased fibroblast activity and the formation of collagen fibers around the mesh material, which provided maximum integration of the "light" abdominal wall with polypropylene tissue.
 Conclusion. These features of the dynamics of the used methods of surgical interventions and types of polypropylene nets with an individualized approach to each patient were reflected in a significant reduction in the number of both early local and general late postoperative complications, which improved the effectiveness of surgical treatment of patients with primary postoperative ventral hernias.

Planned staging for posterior surgical correction of multi-planar spinal deformities, does it differ?

Введение. В современной Казахстанской и зарубежной литературе немалое число работ посвящено изучению послеоперационных вентральных грыж. Однако результаты их хирургического лечения не всегда устраивают как клиницистов, так и самих пациентов [5, 9, 47, 53, 55, 74]. Развитие инфекционных раневых осложнений в послеоперационном периоде - одна из причин увеличения длительности госпитализации, возникновения рецидива грыжи, роста расходов на лечение [34, 76, 78, 79]. Цель. Провести обзор литературных данных по вопросам хирургического лечения послеоперационных вентральных грыж и профилактики раневых осложнений после герниопластики. Стратегия поиска. Был проведен анализ полнотекстных научных публикаций в базах Google Scholar, E-library.ru, PubMed, Cyberleninka, а также анализ литературных источников «вручную». Глубина поиска составила 47 лет, с 1970 по 2017 года. Были изучены эпидемиология, патогенез, частота рецидивов, разновидность методов оперативного лечения послеоперационных вентральных грыж. Критерии включения: отчеты рандомизированных и когортных исследованиях, проведенных на больших популяциях, систематические обзоры, полные версии статей. С целью проведения литературного обзора изучалась литература на русском и английском языках. Критерии исключения: статьи, описывающие единичные случаи, резюме докладов, личные сообщения и газетные публикации, тезисы, личные сообщения. Всего было найдено источников 1435, из которых для последующего анализа отобраны 80. Результаты. Современные концепции лечения пациентов с послеоперационной вентральной грыжей заключаются в применении герниопластики с использованием сетчатых эндопротезов [62, 68]. Однако их применение сопровождается высокими показателями раневых осложнений, к которым относятся серомы, инфильтраты, разрыв и сморщивание эндопротеза [20]. Одним из путей устранения грыжевых ворот и предупреждения раневых осложнений является аутодермальная пластика [61], другие - причиной раневых осложнений после герниопластики считают место расположения трансплантатов, которые требуют уточнения. К тому же важным также является разработка простых эффективных способов профилактики осложнений послеоперационных ран с применением физических методов лечения под ультразвуковым контролем и показателями динамики цитокинов в течения раневого процесса. Выводы. Литературные данные свидетельствуют о необходимости поиска и разработки новых эффективных и простых способов в хирургическом лечении и ведении послеоперационных ран при герниопластике вентральных грыж для профилактики раневых осложнений. Introduction. In today’s Kazakhstani and foreign literature there are lots of works devoted to the study of postoperative ventral hernia. However, the results of their surgical treatments do not always suit both clinicians and the patients themselves [5, 9, 47, 53, 55, 74]. The development of infectious wound complications in the postoperative period is one of the reasons for the increase in hospitalization duration, the occurrence of hernia recurrence, and the increase in treatment costs [34, 76, 78, 79]. Purpose.To review the literature data on the surgical treatment of postoperative ventral hernias and the prevention of wound complications after hernioplasty. Search strategy. The analysis of full-text scientific publications in the databases of Google Scholar, E-library.ru, PubMed, Cyberleninka, as well as the “manual” analysis of literary sources was carried out. The period studied was 47 years, from 1970 to 2017. Epidemiology, pathogenesis, recurrence rate, a variety of surgical treatment methods for postoperative ventral hernias were studied. Criteria for inclusion: reports of randomized and cohort studies conducted on large populations, systematic reviews, full versions of articles. In order to conduct a literary review, literature in Russian and English languages was studied as well. Criteria for exclusion: articles describing isolated cases, summaries of reports, private messages and newspaper publications, abstracts, personal messages. A total of 1435 sources were found, 80 of which were selected for further analysis. Results. Modern concepts of treating patients with postoperative ventral hernia consist in the use of hernioplasty using mesh endoprostheses [62, 68]. However, their use is accompanied by high rates of wound complications, which include seromas, infiltrates, rupture and wrinkling of the endoprosthesis [20]. One of the ways to eliminate the hernia orifice and prevent wound complications is autodermal plastics [61], the others consider the location of grafts requiring clarification to be the cause of wound complications after hernioplasty. In addition, it is also important to develop simple, effective ways to prevent complications of postoperative wounds using physical methods of treatment under ultrasound guidance and indicators of the dynamics of cytokines in the course of the wound process. Conclusion. Literary data show the need to find and develop new effective and simple methods in the surgical treatment and management of postoperative wounds in the hernioplasty of ventral hernias for the prevention of wound complications. Кіріспе. Заманауи Қазақстандық және шетелдік әдебиеттерде операциядан кейінгі іш жарықтарын зерттеуге арналған ақпараттар аз емес. Дегенмен, олардың хирургиялық емінің нәтижелері дәрігерлерді де науқастарды да үнемі қанағаттандыра бермейді [5, 9, 47, 53, 55, 74]. Операциядан кейінгі кезеңде жаралардың инфекциялық асқынуының дамуы- науқастың ауруханада өткізетін күнінің ұзаруының, операциядан кейінгі іш жарығы рецидивінің және емдеу құнының өсуіне бірден бір себебі [34, 76, 78, 79]. Мақсаты. Операциядан кейінгі іш жарығының емі және герниопластикадан кейінгі жараның асқынуының алдын алу сұрақтары жайлы әдеби деректерге шолу жасау. Іздеу стратегиясы. Google Scholar, E-library.ru, PubMed, Cyberleninka дерекқорларында толық мәтінді ғылыми жарияланымдарды талдау, сондай-ақ әдебиет көздерін «қолмен» талдау жүргізілді. Іздеу тереңдігі 1970 жылдан 2017 жылға дейін 47 жылды құрды. Операциядан кейінгі іш жарықтарының эпидемиологиясы, патогенезі, қайталану жиілігі, оперативті әдіспен емдеудің әртүрлілігі зерттелді. Іріктеу критерилері: үлкен популяцияларда, жүйелі шолуларда, мақалалардың толық нұсқаларында жүргізілген рандомизацияланған және когорттық зерттеулерден алынған есептер. Әдеби шолу жүргізу үшін орыс және ағылшын тілдеріндегі әдебиеттер зерттелді. Ерекшелік критерийлері: оқшауланған жағдайларды сипаттайтын мақалалар, есептердің жиынтығы, жеке хабарламалар мен газеттер басылымдары, рефераттар, жеке хабарламалар. Барлығы 1435 ақпарат көзі табылды, соның ішінен 80-і қосымша талдау үшін іріктелді. Нәтижелері. Торлы эндопротезді пайдаланып герниопластиканы қолдану - операциядан кейінгі вентральді жарығы бар науқастарды емдеудің заманауи концепциясы болып табылады [62, 68]. Алайда оларды қолдану серома, инфильтрат, эндопротез жарылуы және жиырылуы сияқты жараның асқынуларының жоғарғы көрсеткішіне алып келеді. [20]. Жарықтың кірер көзі мен жаралардың асқынуының алдын алудың бір жолы аутодермальді пластика болып табылады [61], басқалар герниопластикадан кейінгі жараның асқынуы трансплантат орналасқан орнына байланысты деп санайды. Сонымен қатар, жаралық процесс ағымында физикалық әдістерді және цитокиндер көрсеткішін қолдану арқылы ультрадыбыстық бақылаумен емдеуді жүргізу сияқты операциядан кейінгі жаралардың асқынуының алдын алатын қарапайым әдістерді ойлап табу маңызды болып саналады. Қорытындылар. Әдеби деректер іш жарықтарының герниопластикасы кезіндегі операциядан кейінгі жараларды жүргізу және хирургиялық емдеуде заманауи әсері жоғары және қарапайым әдістерді іздеудің және ойлап табу қажет екенін көрсетеді.

Extraoral implants for orbit rehabilitation: a comparison between one-stage and two-stage surgeries

The problem of surgical treatment of post­operative ventral hernias remains relevant today. Currently, a large number of methods of surgical interventions for hernias of the anterior abdominal wall have been proposed, the variety of which requires systematization and analysis of the immediate and distant results of treatment. Goal: to analyze the effectiveness of laparoscopic hernia repair in patients with postoperative ventral hernia with a body mass index of 30 kg/m2. The results of treatment of 29 patients with postoperative ventral hernia were analyzed. Men – 8 (27.5%), women – 21 (72.5%). In 16 (55.2%) patients (main group) laparoscopic intraperitoneal onlay mesh – IPOM was performed, in 13 (44.8%) patients (comparison group) open hernia repair with fixation of the mesh graft in the Sublay position was performed. The analysis of the duration of the surgical intervention indicates that with open hernia repair, there is a significant increase in the duration of the surgical intervention, p˂0.0001. Comparison of the duration of operations in both groups depending on the body mass index also indicates the dependence of the duration of surgery on this indicator. Thus, in the comparison group, there was a tendency to an increase in the duration of the operation with an increase in the body weight of patients with a significant difference in the duration of the operation between the main group and the comparison. The duration of a patient's stay in the hospital and the occurrence of respiratory complications correlates with the level of postoperative pain and the duration of surgery. Postoperative complications in the form of fluid accumulations in the wound area of the abdominal wall depend on the method of surgery and the location of the mesh graft. The use of laparoscopic – IPOM in obese patients significantly improves the results of surgery by reducing the level of postoperative pain, shortening the duration of surgery, and the absence of complications in the early and late postoperative period. When choosing the method of surgical intervention in patients with postoperative ventral hernia, laparoscopic IPOM should be preferred.

The presence of large defects in the anterior abdominal wall in patients is an important problem for surgeons, due to the complexity of the hernioplasty implementation, the need to use large mesh, high frequency of postoperative complications. Nowadays, widely used laparoscopic hernioplasty include the use of mesh materials. In patients with large hernias, laparoscopic techniques are associated with a number of technical difficulties during operations and a high frequency of postoperative relapses (up to 30 %). The problem of choosing the treatment method for postoperative ventral hernias of large and gigantic still remains unsolved. Currently, the main trend is to restore the anterior abdominal wall anatomical integrity with the reduction of the anterior abdominal wall muscles to the white abdominal line and open component separation. Since the development of laparoscopic and endoscopic technologies, the technique of endoscopic separation of the anterior abdominal muscles has been improved to improve the quality of life of patients and to reduce the incidence of postoperative complications and recurrences. The use of endoscopic methods makes it possible to prevent a wide tissue dissection, reduce the risk of necrosis of the skin and aponeurotic flap through the preservation of perforant vessels in the anterior abdominal wall. The result comparison between the use of open and laparoscopic methods of component separation showed that the use of open separation methods leads to a significantly greater number of both intraoperative and postoperative complications associated with the development of 30 % of necrosis of the skin and aponeurotic flap, and relapses. The results of the studies indicate some advantages in reducing the frequency of postoperative wound complications with endoscopic component separation methods in patients with postoperative large size ventral hernias.

Laparoendoscopic Single-site Repair of Incisional Hernias After Urological Surgery

Хірургічне лікування пацієнтів із вентральною грижею є однією із важливих проблем хірургії органів черевної порожнини.Мета дослідження – на основі аналізу літературних даних визначити головні пріоритетні напрямки, що потребують подальшого вивчення і розробки при хірургічному лікуванні хворих на післяопераційну вентральну грижу за умов коморбідності.Матеріали і методи. Проведено огляд літературних джерел, присвячений вивченню питання хірургічного лікування хворих на післяопераційну вентральну грижу за умов коморбідності.Результати досліджень та їх обговорення. Від 3 % до 19 % усіх лапаротомій ускладнюються формуванням післяопераційної вентральної грижі (ПОВГ) із тенденцію до зростання. 60 % пацієнтів із ПОВГ є працездатного віку, що визначає проблему лікування таких хворих не тільки як медичну, але і як соціальну. Відсоток рецидивувань складає 4,3–46 %, а при великих і гігантських ПОВГ сягає 80 % з летальністю 12–21 % у хворих старшої вікової групи. У пацієнтів із морбідним ожирінням ризик виникнення ПОВГ як після лапаротомних, так і після лапароскопічних операційних втручань підвищується в 3–4 рази і складає 28–45 %. Досвід активного застосування сіток у хірургії ПОВГ продемонстрував значні переваги поліпропіленових монофіламентних матеріалів, порівняльна оцінка яких є досить стриманою. Аналіз літератури підкреслює, що результат хірургічного лікування післяопераційних вентральних гриж залежить як від місцевих чинників у зоні імплантації сітчастого ендопротеза, так і від загального стану організму.Висновки. Залишається невирішеною проблема підвищеної ексудації рідини в ділянці імплантації сітки, відсутня порівняльна оцінка тканинної реакції на сітки з різною питомою вагою вмісту пролену та діаметром пор. Відсутні критерії вибору імплантата та способу операційного втручання у хворих із недиференційованої дисплазії сполучної тканини (НДСТ). Недостатньо висвітлені можливості сонографічного моніторингу з метою оцінки стану тканин у зоні імплантації сітки в післяопераційному періоді. Все це підлягає подальшому науковому вивченню.

Timing, approach, and treatment strategies for infected pancreatic necrosis: a narrative review

Aim. To improve the results of surgical treatment for patients with postoperative ventral hernia by improving complex preoperative physical examination and better prevention of wound complications. Methods. Results of surgical treatment of 160 patients [mean age - 64 years, females - 120 (75%), males - 40 (25%)] with postoperative ventral hernia treated from 2003 to 2012 were analyzed. The surgeries were performed routinely. All patients were distributed to 2 groups depending on postoperative wound complications prevention. The main group included 60 patients who underwent a vacuum therapy (authors’ technology) during postoperative period for preventing wound complications. Perioperative management of patients with large and huge hernias in this group was performed according to recommendations of the European Society of Cardiologists and All-Russian Scientific Cardiologic Society for cardiovascular risk assessment at surgeries excluding heart surgery. Comparison group included 100 patients who underwent surgery for postoperative ventral hernias using a conventional vacuum drainage and common methods of patient examination according to recommended standards. Results. Using vacuum therapy in patients of the main group limited the number of Redon-drainage procedures, reduced the rate of local pyoinflammatory complications by 4.2 times (p 0.05). Cardiovascular risk identification and proper preoperative preparation allowed avoiding unfavorable outcomes associated with cardiovascular complications in patients with high cardiovascular risk. Conclusion. High efficiency of a complex approach in preventing postoperative complications after ventral hernias surgical treatment allows to recommend its use in clinical practice.

The original protocol for Brånemark System implants in the mandible was a two-stage procedure with 3 months healing time. With five or six implants and a cast framework of gold, the treatment is rather expensive, and simplified methods would be desirable. The goal of this controlled serial study was to investigate the outcome of a simplified procedure with one-stage surgery, four Brånemark implants, shortened healing time, and a new titanium-acrylic fixed full prosthesis. Eighty-two patients were treated in three different groups at two specialist centers. All patients were provided with four implants, loaded with a Procera All-in-One bridge (Nobel Biocare, Gothenburg, Sweden) after 12 weeks. In group A (n = 30), one-stage surgery was combined with two-piece implants. In group B (n = 30), the control group, two-stage surgery and two-piece implants were used. In group C (n = 22), one-stage surgery was combined with one-piece implants. Marginal bone level was rated from radiographs at implant insertion, at baseline, and after 1 year. The survival rate after 1 year for group A was 93.3%; group B, 97.5%; and group C, 93.2%. The differences were not statistically significant. Between fixture insertion and baseline, the average bone loss for group A was 1.2 mm; group B, 1.3 mm; and group C, 1.3 mm. No complications in the form of bridge loosening or acrylic fractures were recorded during the first year. The survival rates and the marginal bone changes did not differ significantly between the one-stage groups and the control group. The survival rate and the marginal bone changes were similar for one-piece and two-piece implants. Four implants were sufficient to support full fixed prostheses in the mandibles. The Procera All-in-One bridges proved to be of high quality, and no complications were experienced. key words: endosseous implants, nonsubmerged implants, one-piece implants, prospective clinical study, submerged implants

Laparoscopic surgery aims at reducing wound complications and improving cosmetics, among other advantages. High rates of postoperative ventral hernia (POVH) are observed after laparoscopic-assisted colectomies. In a 2011 to 2016 retrospective study of all patients at Rabin Medical Center, we examined POVH prevalence after right hemicolectomy for neoplasia and correlation to specimen extraction site. We also compared laparoscopic-assisted colectomy to hand-assisted laparoscopic colectomy. Included were patients who had postoperative abdominal computed tomography or magnetic resonance imaging scan as part of their routine oncological follow-up to 6 months postsurgery. Patients were excluded for conversion to laparotomy, and prior abdominal surgeries after right colectomy and before follow-up computed tomography/magnetic resonance imaging scan. Demographic and surgical data were collected from patient electronic records, and scans reviewed for POVH by a designated radiologist. Of 370 patients, 138 (mean age 70.09 y, 58 males) were included: 54 (39.1%) were diagnosed with POVH, 42/72 (58.3%) at midline extraction site, and 12/66 (18.8%) at off-midline extraction sites (P<0.0001). Surgical site infections and patients positive for tumor metastasis were associated with higher POVH rates. Most (74%) POVHs were identified within 18 months postsurgery (P<0.0001). Body mass index, age, sex, diabetes mellitus, smoking, tumor size, lymph nodes positive for metastasis, and hand-assisted laparoscopic colectomy were not associated with POVH prevalence. High rates of radiologically diagnosed POVH were found after laparoscopic-assisted colectomy, with association to midline extraction site, surgical site infections, and positive tumor distant metastasis.

Interest in the use of one-stage surgery and immediate loading of oral implants has lately been increasing. The aim of this study was to compare the 3-year results of one-stage surgery versus two-stage surgery, early loading versus loading after a 3-month healing period, and the use of one-piece implants versus the use of two-piece implants. The study included 108 patients with edentulous mandibles. Each patient was treated with four Brånemark System implants (Nobel Biocare AB, Göteborg, Sweden) and with full fixed prostheses. Patients were consecutively treated and were distributed in four groups: group A (one-stage surgery), group B (control group with two-stage surgery), group C (one-piece implants), and group D (early loading). In groups A and B Brånemark Standard implants and standard abutments were used. In group C the conical one-piece Brånemark implant was used, and in group D the patients had Brånemark System Mk III implants together with multiunit abutments. All patients were observed for 3 years. Of the 432 inserted implants, 24 were lost. Survival rates in the three experimental groups ranged from 93.2 to 93.3% whereas the survival rate in group B (the control group with two-stage surgery) was 97.5%. The differences between the groups were not statistically significant. The changes in marginal bone level were measured from fixture insertion to the final follow-up at 3 years. The bone loss in group D (early loading) was significantly less than in group B (the control group) whereas there were no differences in marginal bone change between the other groups. Early loading seemed to give good results in the anterior part of the mandible. The survival rate of the early-loaded implants did not significantly differ from that of implants inserted with the conventional two-stage procedure, but the mean marginal bone loss around the surviving implants was less with early loading.

Effectiveness of the prevention of complications in wounds following reconstructive surgeries performed on the anterior abdominal wall in 84 patients with postoperative ventral hernias using the suggested comprehensive pharmacotherapy was analyzed. The method is based on the use of Mexidol, an antihypoxantantioxidant, to prevent postoperative wound complications in patients who underwent reconstructive surgeries of the anterior abdominal wall against the background of the use of bioflavonoid. The use of Mexidol was evidenced to decrease reliably the duration of serous exudation by 1.76 times, which contributes to the prevention of wound complications, and reduces the duration of inpatient treatment by almost 6 days. Such postoperative complications as hematomas, postoperative wound suppuration, ligature fistulas, rejection of reticular implant were not observed. All this made it possible to significantly improve surgical treatment in patients who undergo reconstructive surgery on the anterior abdominal wall.