Vol 21, No 1 (2019)

The work highlights the role of S.P. Fedorov and his students in the formation and development of Perm surgery and urology. Graduate of the Military Medical Academy, Life-surgeon of the royal family VN Derevenko created and organized the work of the clinic of Perm University and the first in the province department of surgery and urology, leading it from 1919 to 1924. From 1925 to 1931 the department and the clinic was headed by an employee of the Military Medical Academy, Professor D.P. Kuznetsky. For the first time, the literature covers the inspection trip of S. P. Fedorov in 1926 to Perm. In 1928, A.V. Lunacharsky called the Perm clinic "the pearl of the Urals."

Goal. Develop a model of purulent liver abscess (GAP), which corresponds to all the classic signs of a delimited abscess. Material and methods. Simulation of GAP was carried out in an experiment on 60 laboratory animals. Under ultrasound control (UC), a double-lumen Fogerty catheter was inserted into the established portion of the liver, a cystic cavity was formed in 3 days, which was infected and after 3 days GAP was obtained. In the modeling of GAP, clinical, planimetric, microbiological, morphological and instrumental methods of investigation were used. Results. On the third day of the experiment, a round cystic cavity of the liver with a diameter of 1,8 cm3 was formed. Three days after infection, a classic purulent abscess develops, surrounded by a dense wall formed from the liver parenchyma. As a result of the experiment, a clinical, microbiological, morphological and instrumental justification for modeling GAP with all its classic features was obtained. The conclusion. The proposed method for modeling purulent liver abscess is economically and technically profitable, minimally traumatic, provides guaranteed formation of classical GAP in the shortest possible time.

In 2003, Russian developers proposed a new method of crushing stones by electric impulses of nanosecond duration, which has several advantages over contact electrohydraulic lithotripsy. The aim of the study was to evaluate the possibilities of transfistular nanoelectroimpulse lithotripsy (NEIL) in the treatment of choledocholithiasis. A nanoelectroimpulse lithotriptor "Urolit", manufactured by Medline Ltd. (Tomsk, Russia), was used to break down the gallstones. 66 patients with large and/or unmovable bile duct stones and bile ducts drains were performed transfistular NEIL. It was successful in 63 patients (95.5%). NEIL made it possible to perform removal of large and/or unmovable gallstones without destroying the sphincters of the major duodenal papilla in 89% cases. Transfistular NEIL is a new highly effective and safe method of crushing gallstones.

Complicated gallstone disease causes operative difficulties despite surgeon’s experience and patient’s examination. We have an experience of surgical management in patients with Mirizzi’s syndrome (MS) that made3,2% from a total number of operated patients with cholelithiasis (women 74%, men 26%). Patient’s age was from 28 to93years old.We want to stress that the final form of MS is defined only during surgery. We distinguish only 2 forms of MS without sharing according to involvement of common bile duct into destructive-and-inflammatory process.In 45% of patients I form of MS was registered, in 55% - II form. In MS-I the preferable surgery is cholecystectomy with outer bile ducts draining. Plasty of hepatocholedochus in MS-I is indicated for proved duct stricture. MS-II is the indication for performing different restorative or reconstructive surgery dependent on intraoperative data (application of primary suture on common bile duct, plasty of hepatocholedochus with the gallbladder wall, choleedochoduodenostomy, hepaticocholedochostomy, hepaticojejunostomy).

Theproblemofcholangitisandbiliarysepsisbecomemoreandmoreactual.Developingdiagnosticcriteriaforpatientswithinflammationofbiliarytractisoneofunsolvedquestionsofbiliarysurgery. Accordingtonewclassificationofgeneralizedformofinfections (Sepsis 3) it’sadvisabletoclassifiedpatients with biliary obstruction to three groups: mechanical jaundice, acute cholangitis and biliary sepsis with defying appropriate diagnostic criteria for each of them.Theaimofourworkistoimprovetreatmentresultsforpatientswithhyperbilirubinemia, biliary hypertension and system inflammation response syndrome (SIRS) by dividing them on groups and determining diagnostic criteria for each of them. Intheperiodfrom 2014 to 2018 wehavetreated 208 patientswithbiliaryobstruction. Accordingtodevelopeddiagnosticcriteriaallpatients was divided on three groups: mechanical jaundice, acute cholangitis and biliary sepsis.Afterthetreatmentthenextvalueswereanalyzed: timefromadmissiontohospitaltooperation, thetimeofoperation, thefrequencyofpostoperativecomplications, mortality, the duration of hospital stay, economic efficiency.Toassesstheeffectivesofdevelopedcriteriacomparativeanalysiswithretrospectivegroup, whichcontained 182 patients with hyperbilirubinemia, biliary hypertension and SIRS treated in a period from 2010 to 2014, was performed. Accordingtoobtainedresultswecanconcludethatdividingpatientswithhyperbilirubinemia, biliary hypertension and SIRS on groups and developeddiagnosticcriteria, routing and manage tactics let us to improve treatment results in this category of patients, about what we can judge by such figures as timefromadmissiontohospitaltooperation, thefrequencyofpostoperativecomplications, mortality, the duration of hospital stay, economic efficiency.

Purpose of the study: optimize surgical tactics for bile duct obstruction in patients with various forms of chronic pancreatitis (CP). Materials and methods: The results of the examination and treatment of 503 patients with CP, 354 of whom were operated on, were analyzed. Mechanical jaundice was detected in 76 (21.5%) patients. The main type of relief of symptoms of biliary tract obstruction were transpapillary endoscopic and laparoscopic techniques or their combinations, which in 37 (47.4%) patients were the final treatment option, and in 35 (46.1%) - a preliminary stage before performing traditional surgical interventions. Traditional interventions were the only treatment method in 4 (6.4%) patients. Results: Based on the modified Marseille-Rome classification of CP (1988), a systematic approach was developed to assist this category of patients. It has been established that the use of endoscopic techniques in patients with obstructive CP allows not only to stop the symptoms of biliary hypertension, but also to influence the course of the underlying disease, by ensuring adequate drainage of both the bile and pancreatic ducts. The use of transduodenal and laparoscopic techniques for the relief of obstructive jaundice in patients with inflammatory CP, calcifying CP is best justified as a preliminary stage of treatment. The preferred option of surgical correction in patients with inflammatory and calcific CP with primary lesions of the pancreas head should be resection of the pancreas head according to Beger or Frey. Conclusion: The optimal combination of minimally invasive surgical treatment options and traditional surgical interventions, taking into account the shape and variation of CP, complicated by the development of obstructive jaundice, allows for maximum correction of the course of the disease in the near term and in the long term.

Improvement of endoscopic techniques and tools, minimal invasiveness of transpapillary endoscopic surgery (TES), accumulated experience, as well as the introduction of preventive measures, do not always avoid the development of life-threatening complications (6.8 - 10,2% of patients) and deaths (1,7 - 3%). The purpose of the study is to assess the practical significance of the proposed predictors of TES complications in the treatment of patients with impaired patency of the ductal systems of the liver and pancreas, to propose program measures for the prevention of complications. The results of TES in 3305 patients performed in the planned and emergency order with various diseases of the hepatopancreatobiliary region are analyzed. Based on multivariate analysis, statistically significant (p <0.05) predictors of major life-threatening complications of TES were distinguished: 1) post-operative pancreatitis (female (78.2%), difficult cannulation (54.6%), multiple cannulation, fast / tight contrasting pancreatic duct (49.4%)); 2) bleeding (current mode (52.1%), presence of cholangitis (43.5%), coagulopathy in the presence of jaundice (65.2%)); 3) duodenum perforation (elderly and senile age (68.2%), difficult cannulation (66.7%)); 4) acute cholangitis (inadequate drainage of the bile ducts (83.3%), unsuccessful attempt to drain the bile ducts (48.6%)). We are supplemented prophylactic measures for postoperative complications in case of TES. A personalized record of the main predictors of complications of the feasibility study and the use of a program of preventive measures will allow an adequate choice of tactical approaches and technical options for operations, which will lead to improved treatment outcomes, minimizing the frequency of complications and mortality.

Reports of immediately and urgent interventions on the thyroid gland are rare. The aim of the study was to develop and put into practice the optimal tactics of treating patients with nodular tumors of the thyroid gland, which caused compression of the organs of the neck and mediastinum. From 1974 to 2015, 97 patients with thyroid disease were operated in the Endocrine Surgery Center, they was 0.57% of 29325 patients. All patients had symptoms of compression syndrome. All patients were divided into 2 groups. I group consist of 52 (31.1%) patient who underwent immediately surgical interventions. The second group included 115 (68.9%) patients operated for urgent indications. The mean age of patients operated for immediately reasons was 73.0 ± 1.39 year.The mean age of patients operated for urgent indications was 63.8 ± 1.51 year. Among the reasons that caused the compression syndrome, the differentiated cancer of the thyroid gland was observed in 79 (47.3%) cases. Benign thyroid diseases caused urgent surgical interventions in 88 (52.7%) patients. In our work, we first used the definition of the degree of tracheal constriction with spirography in 135 (80.84%) patients to identify the timing of surgery. In the course of emergency surgical interventions, radical operations were performed on 8 (22.9%) patients with differentiatedcancer of the thyroid gland, in cases of urgent interventions, this figure is 2 times more - 23 (52.3%) patients. The performance of urgent operations increases the possibility of radical surgical interventions, reducing the frequency of postoperative complications.

Diabetic foot syndrome (SDS) is one of the most severe complications of diabetes mellitus (DM), and the treatment of such patients is one of the difficult tasks. Purpose: to present the epidemiological characteristics of SDS on the basis of the state register of SDS of the Perm region and to analyze the results of treatment of this category of patients in different departments of surgical profile. Evaluation of results of treatment was given on the basis of expert analysis of 150 case histories of the patients Patients were performed General clinical examination, microbiological examination of the wound content, rheovasography, angiography, duplex scanning, x-ray examination of the feet, the survey for the assessment of the risk of developing VTS. According to the register, SDS was registered in patients older than 18 years with type 2 diabetes in 4.4 % of cases. The prevalence of SDS and amputations correlated with the duration of type 2 diabetes. The average age of SDS development was 64.3±0.5 years. Inpatients belonged to the older age group, had long-term disease poorly compensated diabetes in combination with associated diseases. The average duration of the purulent-necrotic process was 1 month. Patients had an average risk of SDS according to the survey. In the specialized Department of vascular surgery, the effectiveness of treatment was higher, due to the level of diagnosis and the use of innovative surgical technologies. All of the above is a significant argument in favor of the development of specialized care for patients with diabetic foot syndrome.

Background: pancreaticneuroendocrine tumors occur in almost all patients with multiple endocrine neoplasia type 1 (MEN1) and are a major cause of death. Surgical resection is the only potentially curative therapy for pNETs, otherwise various endocrine syndromesdevelop threatening the patient's life. Aim: to evaluate the short-term results of surgical management of patients with pancreatic neuroendocrine tumors with MEN1. Materials and methods: by last 20 years, 40 patients with pancreatic neuroendocrine tumors within MEN1 were operated. Results: in the early postoperative period,according to the classification of Clavien-Dindo, complications occurred in 12 (26%) patients. The following types of complications were diagnosed: IIIa in 6 patients; IIIb - in 2; type V in 4 patients. Complications of types I, II and IV were not identified. Conclusion: less percentage of postoperative complications is achieved by performing organ-preserving operations, after precise imaging diagnose, due to minimal intraoperative pancreatic injury.

Background: insulinoma is a neuroendocrine tumor characterized by hyperproduction of insulin and hypoglycemia that decrease patient's quality of life. The only curative method of treatment is surgery. Aim: studying the quality of life of patients after various options for surgical treatment of insulin-producing pancreatic tumors. Materials and methods: 48 patients operated in the First Moscow State Medical University were included in the quality of life study. Patients were divided into two groups: those who underwent tumor enucleation (n 28), and patients who underwent resection of the pancreas (n 20). The study was performed using the questionnaire SF-36, not earlier than 3 months after surgery. Results: in the study of quality of life, a significant difference was only in a scale of role-physical functioning, which was higher in patients that underwent tumor enucleation, as opposed to patients after resection procedures. Conclusion: the quality of life in both groups remained at a high level; the differences were noted only in the scale of role-physical functioning, which was higher in patients after tumor enucleation.

Till now, there is no universal clinical classification about variations of the external branch of the superior laryngeal nerve despite the multiple classifications that was proposed. The aim of this research is identification and systematization of topographic types of the external branch of the superior laryngeal nerve. The study is based on the autopsy material (21 complexes organs of the neck) and on identification of variations of 40 external branches of the superior laryngeal nerve. We identify two permanent landmark that are located at the minimum distance from nerve and on which we made metrical calculations: oblique line of thyroid cartilage, tendinous arch of the inferior pharyngeal constrictor muscle. The “entry” point of the nerve is always located on the inferior pharyngeal constrictor muscle,and not protruding beyond the oblique line of thyroid cartilage superiorly and tendinous arch of the inferior pharyngeal constrictor muscle anteriorly. The proposed topographic classification of the location of the external branch of the superior laryngeal nerve is based on localization of point of pierced of the nerve relating to the length of the oblique line of thyroid cartilage. In 64.2% of cases, the external branch of the superior laryngeal nerve was in close proximity to the upper pole of the thyroid gland, which could lead to its damage during surgery (type I and II). In type III and IV (35.8%) - the point of "entry" in the muscle was located as far as possible from the upper pole of the thyroid gland, and most of the nerve was covered by the fibers of the inferior pharyngeal constrictor muscle.

Scientists and specialists, who works in the field of treatment thyroid gland diseases, identify and eliminate the effects of surgical interventions with nodular, multinodular and recurrent goiter with symptoms of compression of the organs of the neck and upper mediastinum. In total, the study included 119 patients who underwent extirpation of the thyroid gland (43), resection of the thyroid gland (33) and hemithyroidectomy (43). Comparisons were made on the basis of the volume of the preoperative examination, the immediate surgical intervention and the features of the intraoperative technique. It was established that the severity of local pain, postoperative complications such as neck edema during hematoma and gray formation reliably depended on the size of the skin incision, dissection of the short neck muscles, mobilization of the nodding muscles and removal of the tissue from the lymph nodes. 6 months after the surgical treatment, the patients had no complaints. If hypocalcemia occurs (in 14 cases), patients undergo a comprehensive treatment according to the original scheme. As a result of the treatment in all cases, the action of hypocalcemia was stopped. The study shows that the effectiveness of surgical treatment, the postoperative period, complications, cosmetic results and quality of life, as well as rehabilitation studies aimed at reducing the effectiveness of preoperative examination, increasing the amount of operational benefits and late statement of complications.

Parathyroid cancer is an extremely rare cause of primary hyperparathyroidism, accounting less than 1% of cases. The neoplasm is detected in people 40-50 years old. Ratio of men and women is 1: 1, in contrast to hyperparathyroidism caused by adenoma of epithelial bodies, when there are 3-4 times more women than men among the patients. Due to the rarity of this disease, surgeons and morphologists may have difficulties in verification of the tumor. Distinctive features of the course of the disease include the extremely rapid progression of bone changes, the development of hypercalcemic crises with a high level of blood calcium and serum parathyroid hormone. Radical surgery involves the removal of malignant parathyroid tumor in a single block with the ipsilateral thyroid gland, as well as paratracheal lymph nodes. The aim of investigation is to show a rare observation of bone manifestations of parathyroid cancer. Material and methods. Parathyroid cancer was diagnosed in 2 (0.7%) of 283 patients with primary hyperparathyroidism, operated in the Center of Endocrine Surgery. Male 29 years old was operated on in January 2016. Disease duration was about 2 years. The clinical picture was characterized by multiple bone fractures, generalized cystic osteodistorofy, renal failure, severe electrolyte disorders, cachexia. The diagnosis was confirmed by high values of total calcium and blood parathyroid hormone. The patient underwent removal of the parathyroid tumor, during the histological and immunohistochemical study of which parathyroid cancer was verified. The patient was able to sit on his own after 3 months, get up with support after 6 months and walk with the help 10 months later after the operation. In May 2017 an increase of parathyroid hormone to 1900 pg / ml was detected with a normal value of blood calcium, which indicates recurrence of parathyroid cancer. Findings. The high grade of the disease is due to both the aggressive course of parathyroid cancer and the late diagnosis.

Aim: to determine the possibilities of modern multislice computed tomography in the preoperative planning of a rational variant of surgical access to the adrenal gland with a tumor. Materials and methods: the results of the examination and treatment of 1196 patients with surgical diseases of the adrenal glands (AG) were studied. The virtual-figurative design of a rational variant of surgical access to AG with a tumor was carried out in 362 patients after evaluating the features of their topographic-anatomical location according to CT-scan. The criterion for the inclusion of patients in the study was the ability to perform after 2013 multislice computed tomography (MSCT) with intravenous contrast on the modern installation Aquillion 64 (Toshiba, Japan) and subsequent post-processing of images with the construction of multiplane and 3D reconstructions. Results: studying the features of the topographic-anatomical location of AGs with a tumor using MSCT allowed us to form a virtual-figurative perception of their syntopy in 362 patients and to design options for access to perform adrenalectomy (AE): retroperitoneoscopic (n = 303), laparoscopic (n = 25), thoracophrenotomy ( n = 30), thoracophrenolaparotomic (n = 5). 363 surgical interventions were performed for 362 patients. A single-sided retroperitoneoscopic AE for pheochromocytoma was performed in 1 patient. Reliable CT criteria were determined that affect the duration and safety of the above-mentioned accesses performed by AEs. It has been established that when designing access to the right AG, it is necessary to consider: the diameter of the neoplasm; the location of the AG with a tumor relative to the inferior vena cava and the lower right hepatic vein; contact with vessels in the gate of the kidney, as well as the presence of additional central veins AG. The determining factors in planning access to the left AG are: neoplasm diameter, contact with vessels in the gate of the kidney and splenic vessels, location in the aorto-renal vascular triangle. It was established that retroperitoneoscopic AE, performed in 83.7% of patients with AG tumors with a diameter of ≤ 8 cm, is an operation of choice. Laparoscopic access remains relevant only when the right-sided localization of an AG tumor with a diameter of up to 8 cm and planning simultaneous surgical interventions on the abdominal organs in individuals of a brachymorphic physique (8.3%). Open approaches are shown in benign lesions of the AG more than 8 cm in diameter, generalized forms of adrenocortical cancer (ACC) (T3-4N0-2M0-1), malignant paragangliomas with signs of invasion or distant metastasis (n = 9.7%). Conclusions: multispiral computed tomography allows, before the operation, to carry out adequate planning of the safest surgical access for adrenalectomy, avoiding the development of intra- and postoperative complications, minimizing operative trauma, shortening the operating time, and speeding up the medical and social rehabilitation of patients.

Introduction. Inguinal hernia is one of the most common diseases and occurs mainly in men of working age. The development of surgery and endoscopic technology made it possible to look at this pathology from the other side and move on to pathogenetically substantiated minimally invasive methods of treatment. The aim of the study. To improve the results of the endohernioplasty in inguinal hernias by improving the techniques and determining the advantages and disadvantages of various options for positioning mesh. Materials and methods. The paper reflects the experience of 203 endovideosurgical allohernioplasty in 161 patients using transabdominal preperitoneal (TAPP) and extraperitoneal techniques (TEP, e-TEP). Results. Intraoperative damage to the sigmoid colon occurred twice with sliding inguinal hernias on the left at the beginning of TAPP, one injury required a laparotomy, the other was eliminated laparoscopically. When performing 55 extraperitoneal hernia repair, there were no complications. Long-term results were traced from 6 to 36 months; no relapses were identified. Conclusion. Due to its advantages, the endovideosurgical technique for the treatment of inguinal hernias is a priority, e-TEP access are easier to learn and can be used even in difficult cases, expanding the surgeon’s capabilities and is the first step to master extraperitoneal approaches to other abdominal hernias.

Surgical treatment of patients with ventral hernias remains an urgent problem in abdominal surgery. More than 20 million operations are performed annually in the world for hernias. The urgency and complexity of the problem is based on the fact that inadequately performed surgery leads to a recurrence of the disease in 14-54% of cases. The aim of the work is to study the results of surgical treatment of patients with ventral hernias using mesh endoprostheses. The results of a retrospective analysis of 437 hernioplasty performed with hernias of various localizations for the period from 2010 to 2014 were used. Patients were classified by hernia localization and divided into groups depending on the methods of alloplasty. The duration of observation of patients operated by using polypropylene mesh ranged from 6 month to 3 years. An analysis of the complications that developed after alloplasty of the inguinal, postoperative, umbilical hernias and hernias of the linea alba was carried out. Our clinical experience confirms that the operation of Liechtenstein is rightly considered to be the “gold standart” for the treatment of inguinal hernias. However, the use of polypropylene mesh in the treatment of inguinal hernias leads to the development of postsurgical wound complications. Placed next to the polypropylene mesh peritoneum flap plays the role of internal drainage, prevents the development of seromas in the wound. The use of a new inguinal alloplasty technique reduced the number of postoperative complications. Also, the best immediate and long-term results are obtained by alloplasty using a sublay method. In patients with postoperative hernias operated by sublay method, no recurrences were observed and they showed the best quality of life.

An important step towards the development of reticular endorotesis was the introduction and use of modern super-elastic material based on nickel-titanium. The article is devoted to a new way to solve one of the urgent problems of surgery. The experiment proved the possibility of an intraperitoneal method of disposing of a nickel-mesh titanium implant based on titanium nickelide modified by auto-coupling tissue in artificially created defects of the anterior abdominal wall, and anti-adhesive properties of the combined mesh material are shown. In the experiment, performed a series of experiments on 33 rabbits of the Chinchilla breed. Animals were divided into 3 groups of 11 animals each. The experiment included 2 stages. In the first part, netting of nickelide titanium implant was performed in the posterior pelvic limb of the animal. The second stage was carried out by replacing the artificially created defect of the anterior abdominal wall with a mesh implant based on titanium nickelide modified with connective tissue. The experiment proved the possibility of an intraperitoneal method of disposing of a nickel-mesh titanium implant based on titanium nickelide modified by auto-coupling tissue in artificially created defects of the anterior abdominal wall, and anti-adhesive properties of the combined mesh material are shown. The use of super-elastic reticular nickel-titanium implants in combination with an auto-connecting tissue will, with a high degree of effectiveness, replace the lost structures of the anterior abdominal wall in patients with postoperative ventral hernias.

На базе урологических отделений ФГБУ «3 ЦВКГ им. А.А. Вишневского» Минобороны РФ была проведена клиническая часть работы по разработке и внедрению новой комбинированной терапии урологическим пациентам для профилактики гнойно-воспалительных послеоперационных осложнений. Комбинированная терапия включала в себя лимфотропную антибиотикопрофилактику и терапию монооксидом азота. Во время проведения исследования важным является зависимость удовлетворенности результатом у пациентов от разных характеристик. Диагностика личностных особенностей пациентов в медицинской практике усложняется дефицитом времени и отсутствием специальной подготовки у врача. Исходя из этого, возможность определения психоэмоционального состояния пациента и качества его жизни во время лечения крайне ограничена. Таким образом, целью моего исследования явилось определение изменения психоэмоционального статуса пациентов под влиянием комбинированной NO-терапии. В данной работе комплексному обследованию были подвергнуты 130 больных, 67 из которых получали традиционное лечение, и 63 - комбинированную терапию. Для оценки состояния пациентов использовали личностные опросники: Методика «Шкала реактивной и личностной тревожности» и тест дифференциальной самооценки функционального состояния. Полученные в ходе исследования результаты позволяют подтвердить наличие достоверных изменений параметров психологического статуса пациентов после проведения комплекса терапий. Данные параметры полностью подтверждают клинические показатели пациентов, что еще раз доказывает эффективность предложенной комбинированной терапии.

Relevance. Minimally invasive methods of removing the ureteral calculus in urological practice have steadily taken the leading position. According to the Russian clinical recommendations the indications for endoscopic correction of ureteral calculus are concrements with a low probable passage, constant pain symptomatic on the background of adequate analgesia, the varying degrees of obstruction severity and impaired renal function. The purpose of the work is to assess the efficacy of transurethral pneumatic contact lithotripsy of ureteral calculus in emergency urological practice. The research tasks included the refinement of the endoscopic lithotripsy results, depending on the localization level among men and women. Materials and methods. The results of endoscopic treatment of ureteral calculus among 360 patients of both sexes, hospitalized in a urological hospital with emergency indications of a renal colic diagnosis, are presented. Results. The efficiency of retrograde pneumatic contact ureterolithotripsy reached 91.8 %. The most optimal this method is with the localization of calculus in the lower third of the ureter, regardless of the concrement size and sex. The percentage of the calculus fragmentation of the middle third of the ureter among men and women was 91.6 and 93.4 respectively. The lithotripsy in the upper part of the ureter was 23.6 % more effective among women. Operational complications were registered in 7.5 % cases.