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MODERN PROBLEMS AND PERSPECTIVE OF TREATMENT
OF PATIENTS WITH VENTRAL HERNIA
WITH SIMULTANEOUS PATHOLOGIES
1 2 Mardonov B.A. , Shamsiev J.Z.
'Mardonov Bobosher Amirovich - Assistant;
2Shamsiev Jasur Zafarovich - Student, MEDICAL FACULTY, SAMARKAND STATE MEDICAL INSTITUTE, SAMARKAND, REPUBLIC OF UZBEKISTAN
Abstract: the presented work provides an overview of domestic and foreign literature on the problems of performing simultaneous operations in herniology, assessing traumatism and clinical and economic efficiency, an integrated systemic approach to the elimination of simultaneous pathologies, the peculiarities of performing combined operations in the combination of hernias with other surgical pathologies.
Keywords: postoperative hernia, pathogenesis, hereditary connective tissue disorders, simultaneous operations.
The hernia frequency exceeds 50 people per 10,000 people. According to statistical data, in the surgical departments, a hernia is determined up to 25% of patients [1, 25]. The abdominal hernia is caused by functional insufficiency of the muscular protective mechanisms of the abdominal wall [3, 10], its anatomical and functional weakness, obesity and abdominal operations [2, 6]. After laparotomy, a hernia is formed in 0.5-20% of patients [1], and in 72-97% of them within the first 5 years after surgery [13, 15]. Hernia can be the result of the following factors [13]: wound suppuration, morphological changes in muscles and aponeurosis [10, 12, 24]. Predisposes to the formation of postoperative ventral hernia structure of the patient, type of incision, technique of suturing the abdominal cavity, and also suture material [2, 15]. Hernias formed in late terms (2 years after surgery) have some differences. They are associated with morphofunctional changes in the tissues of the abdominal wall and the rumen area due to heavy physical labor, concomitant diseases, smoking, age and sexual predisposition [20]. In women, the development of hernias is facilitated by repeated pregnancies and childbirth. With aging, the fibers of muscles and collagen are thinning, they lose elasticity, and inclusions of adipose tissue appear between them [4, 10]. A hernia can be a consequence of a violation of the innervation of the abdominal wall [13, 25], increasing intra-abdominal pressure [2, 5, 15].
J.R. Salameh (2008) [8] shows that the disordered arrangement of collagen fibers can be an important cause of hernia. A number of authors have noted the influence on the formation of collagen exchange of scars [4]. It was found that in patients with postoperative ventral hernia the ratio of collagen types I and III was reduced [10]. Already today, the practical significance of these studies is that a prosthetic abdominal wall is observed with a significantly increased expression of the type III collagen gene in patients with postoperative ventral hernia [4, 10].
Consideration of the causes of the formation of hernias leads to an understanding that eventually they are formed through the mechanism of multifunctional changes in the abdominal wall. Taking into account the concept of the pathogenesis of the ventral hernia, it becomes clear to revise the approaches to the methods of its surgical treatment: it is necessary to close the defect in the abdominal wall without stretching the tissues. Are there such opportunities when using only local tissues? There is an unambiguous answer - no! Attempts to use methods of closing hernial defects by local tissues for a long historical period have shown that the incidence of relapse of the disease in patients reaches 30-54% [3, 11, 24, 28]. In addition, stretch methods of plastics increase the risk of sudden death in patients, pulmonary embolism, acute respiratory and heart failure, etc. [1, 11, 21, 22]. Further study and analysis of
the hernia pathogenesis will help improve the procedure of operations and improve the results of treatment. To date, there are many classifications of ventral hernias [12, 13, 19, 24]. In Moscow on October 18-19, 2006 at the conference "Actual questions of herniology" the SWR classification developed by JP Chevrel and AM Rath was adopted and approved at the XXI International Congress of Herniologists in 1999 [22].
Hernia is a pathology that occurs in all age groups. Among patients with hernia, persons of working age from 30 to 60 years make up about 37%, older than 65 years - 21% [3, 27]. In patients with hernias, the heart, lungs, kidneys, diabetes and obesity are most often found [1, 11, 21]. Treatment of elderly patients with huge hernias and associated pathologies is a very complex problem [18, 20, 22]. Often this combination serves as an argument in favor of the patient's refusal to perform the operation. But then a vicious circle is created: a hernia aggravates the course of concomitant pathology, and concomitant pathology is a contraindication to the operation. Practice shows that 30% of patients older than 60 years have concomitant conditions requiring surgical treatment. In patients with hernias, the frequency of concomitant diseases varies from 13 to 100% [2, 22], which depends on the choice made by the authors [6, 18, 21], of which surgical diseases occur - from 11.8 to 16.3% [7, 22, 25]. And part of the surgical pathology is revealed only during surgical interventions. Analysis of concomitant pathology in the abdominal organs indicates that only 59.3% of patients with hernias had only one disease [1, 15]. Often they were diagnosed with two (13,3-25,5%) [17, 19, 24], three (13,5-51,6%), four (1,7-35,1%) and more diseases [17, 21]. It is established that the larger the hernia size, the more concomitant diseases are determined in her [7, 11, 19]. The tactics of treating patients with hernias and concomitant surgical pathology continues to be discussed to this day [1, 21].
There are two approaches to the treatment of concomitant diseases, and they vary considerably. According to the first, the combined pathology should be eliminated -simultaneously by simultaneous intervention [7, 21, 22]. According to another, concomitant diseases are eliminated step by step. The choice of one of the solutions depends, first of all, on the type of pathology. To do this, it is necessary to identify surgical diseases requiring simultaneous correction [12, 22]. This is facilitated by the algorithm for studying patients with hernias [24]. Among the diagnostic methods, ultrasound is the most accessible and informative [14]. Practically all patients with ventral hernia in need of surgical treatment, including with a small hernia and asymptomatic course. The extent of hernia intervention depends on the size of the defect [3, 13, 19]. Currently, it is recommended to close the defect in the abdominal wall with local tissues with a hernial portal up to 5 cm [3], and with umbilical up to 2 cm [28]. With hernia of defects more than 5 cm and with recurrent hernias only prosthetic ventroplasty is shown [25], and its success depends on the correct choice of the operation method and technical characteristics [16]. Patients with uncomplicated ventral hernia in need of routine treatment, with the development of complications - emergency surgery. If in case of planned treatment of patients with hernias with the use of modern technologies, the lethality is not more than 0.4-2.9% [9], then in complications it reaches 4268%, and without treatment - 100% [8, 23]. These indicators determine the tactics of treating patients with hernias, in which the operation is aimed at preventing complications that can occur at any moment of life, causing serious consequences. For more than a century of herniology history, approaches to the treatment of hernias have been significantly supplemented and revised, and the terminology used [1, 19] has changed. Today, it requires clarification and a clear definition, since the quality of the principle depends on the clarity of the formation of patient groups, the treatment and results shown to them.
At first, surrounding local tissues were used to close defects in the abdominal wall [2, 11]. The results obtained [8, 13] had a significant drawback, since in 70.4% of patients with large and giant hernias, operations led to severe respiratory failure [8, 17, 25] and a high relapse rate [5, 8, 29]. Dissatisfaction with the results of plastics by local tissues promoted the development of new variants of interventions [4, 13, 30], based on the modification of seams, on the movement of tissues on the nutrient muscle and vascular pedicle [1, 5, 8, 12, 23].
Already at the beginning of the 20th century, articles appeared in which the authors described the results of closure of hernial defects using transplants from various materials. In 1967, an international classification was adopted at the transplantation conference in Vienna, according to which explants are divided into autologous, allogeneic, xenogenic and their combinations. Allotransplantation, according to old terminology, homotransplantation, is a transplantation of tissues of the same species to genetically different people (from person to person, etc.). Xenotransplantation is transplantation of tissues taken from individuals of a different species (from animals to humans, etc.). Studies in this direction in the second half of the XX century were practically stopped due to the reaction of rejection of the transplanted material to [3]. However, at the end of the 20th and beginning of the 21st century, this trend was renewed in connection with the progress in genetic engineering. Explantation is the use of artificial limbs. Autotransplantation - transplantation of one's own tissue from one site to another in the same person. Combined plastic is the use of prostheses created from different types of tissues. All these directions in herniology have developed to varying degrees. This allowed to accumulate both positive and negative experience of their use, which led to a complete abandonment of their use or became the basis for further development and research [1, 26].
Approaches to the treatment of patients with ventral hernias and concomitant diseases require simultaneous operations. Thus, the first mention of the simultaneous correction of two surgical diseases is attributed to 1735, when Claudius performed an appendectomy and gernioplasty for an eleven-year-old boy [21]. The advantages of simultaneous operations are beyond doubt. Simultaneous interventions save the patient from several diseases, avoid the risk of reoperative surgery and general anesthesia, exclude the possibility of exacerbation of the accompanying disease in the postoperative period and, in addition, there are clear economic advantages [3, 7, 22]. An undeniable advantage of simultaneous operations is the simultaneous elimination of two or more surgical diseases, the surgical treatment of which was postponed to a later date. This eliminates the risk of repeated anesthesia and its complications, eliminates the need for re-examination and preoperative preparation [7, 21]. Given that concomitant pathology should be eliminated simultaneously with the implementation of hernial plasty, the combination of traditional and minimally invasive technologies significantly expands the possibilities of surgical treatment. This is especially effective when the hernia is combined with pathology in organs located in different anatomical regions [9, 17, 25]. The technology of operations from small accesses allows performing combined intervention without increasing the size of the hernia defect [8, 15, 29]. In such situations, stepwise treatment is often resorted to [2, 30], especially if the use of endovideososcopic techniques is possible. At the same time, with such tactics, unresolved pathology in the abdominal cavity can complicate the course of the early postoperative period. Therefore, tactics aimed at expanding the indications for simultaneous interventions are more justified [7, 21]. Confirmation of the correctness of this approach is the positive experience of numerous observations of the treatment of patients with hernias against the background of concomitant diseases. Such interventions are described in operations on large vessels and the heart [1, 17, 25], with liver transplantation [3, 5, 15, 21], complications in patients with chronic renal failure who are on programmed hemodialysis [3, 10, 29], with cirrhosis [13].
The authors note that the use of polypropylene endoprostheses improves the results of treatment of patients [4, 5, 13]. In the treatment of patients with small hernias, preference is given to the use of local tissues. In most patients with ventral hernia, the need for simultaneous interventions is associated with adhesions and chronic adhesive gut obstruction, diseases of the gallbladder and extrahepatic bile ducts, pathology of the uterus with appendages, fistulas of the gastrointestinal tract [7, 12]. In such patients complications arise in the presence of combined surgical and therapeutic pathology, which is especially common in elderly and senile people [22, 23]. However, despite the risk, pathogenetically justified simultaneous interventions improve the results of treatment [8, 18]. In patients with postoperative ventral hernias, obesity is one of the most common concomitant diseases
[2, 6, 11], and conversely, in 48% of obese patients, hernias of different sites are formed [12, 18]. Relapses in hernia with hernioplasty with local tissues develop in 22-56,3% of cases [5, 8, 13]. Such a high percentage of relapses is due to the preservation of the skin-subcutaneous apron during surgery [2, 20, 29]. Abdominoplasty in obese patients [16, 18] reduces the burden on aponeurosis, improves postoperative period and reduces the incidence of complications [20]. Simultaneous interventions in patients with postoperative ventral hernia are performed in 2.1-39.9% of cases [7, 17], in the presence of giant hernias - in 53.3% [6, 14]. The most frequent simultaneous operations with herniotomy are resection of the large omentum (16.9%) [7, 21], dissection of adhesions (18.2-24%) [5, 15], removal of the subcutaneous subcutaneous fat apron (35-61.5 %) [ 16, 26], cholecystectomy (5.5-6.4%) [9, 21], gastric resection (2.2%), amputation of the uterus with appendages (3.6-4.4%), resection of the small and large intestine (2,5-5,2%), inguinal hernia (2.8%) [7, 21]. The most complex group is represented by patients with ventral hernia and adhesions, chronic adhesive obstruction and intestinal fistulas [2, 5, 10]. According to statistics, adhesive intestinal conglomerates cause acute intestinal obstruction in 11% of patients [1, 14]. Often, simultaneous interventions should be performed in patients with strangulated hernias. Which is 10-35.5% of all ventral hernias [8, 17, 25]. In Russia, the ratio of planned and urgent interventions for hernia repair is 6:1, in developed countries - 15:1 [9]. Factors that adversely affect the results of treatment of strangulated hernias include late periods of hospitalization, advanced age of patients, the presence of serious co-morbidities, diagnostic errors and errors in the operation. The proportion of elderly patients in this group is 62.3% of the total number of patients with strangulated hernias. At the same time, more than 80% of them suffer from concomitant chronic diseases, the aggravation of which largely determines the frequency of unsatisfactory results of surgical interventions. Lethality with an injured hernia multiplies many times. Thus, with herniotomy without intestinal resection, it is 2.5%, and with resection - 43.4%.
Analysis of the literature showed that the most important condition for a favorable outcome of treatment of patients with hernia is the inclusion of concomitant pathology, the frequency of which reaches 98.2% [6, 27]. The combination of diseases in their elimination requires an integrated systemic approach. This means that during the intervention it is necessary to plasticize the hernia, eliminate the existing surgical pathology in the organs of the abdominal cavity, and in the final stage the defect in the abdominal wall should be closed without increasing the intra-abdominal pressure [3, 28]. Compliance with these requirements can only be carried out taking into account the factors, each of which is isolated, perhaps, does not matter much, but in combination represents a threat for both the result of the operation and the life of the patient. Unfortunately, this kind of research is not done enough.
Thus, simultaneous operations are a promising direction of modern hernology. In this regard, the development of objective indications and contraindications to the implementation of simultaneous interventions in patients with hernias is extremely important and influences the approaches to choosing the method of anesthesia, the method of the proposed operation and the technique of its execution.
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СОВРЕМЕННОЕ СОСТОЯНИЕ ВОПРОСОВ ДИАГНОСТИКИ И ЛЕЧЕНИЯ МЕХАНИЧЕСКОЙ ЖЕЛТУХИ (ОБЗОР ЛИТЕРАТУРЫ) Эгамбердиев А.А.1, Шамсиев Ж.З.2
1Эгамбердиев Абдукаххор Абдукодирович - ассистент;
2Шамсиев Жасур Зафарович - студент, кафедра хирургических болезней № 1, Самаркандский государственный медицинский институт, г. Самарканд, Республика Узбекистан
Аннотация: в статье представлен научный обзор патогенеза, диагностики и лечения механической желтухи. Подробно описаны миниинвазивные декомпрессия желчных путей, экстракорпоральные методы детоксикации при механической желтухе.
Ключевые слова: механическая желтуха, диагностика, билиарная декомпрессия, детоксикация, плазмаферез.
Механическая желтуха - это симтомокомплекс клинических и морфологических проявлений, развивающихся при нарушении проходимости желчных путей и прекращении поступления желчи в кишечник, встречающийся примерно в 45-50% случаев всех видов желтух [4, 11]. Нарушение оттока желчи в кишечник вызывается как доброкачественными заболеваниями, так и опухолями гепатопанкреатодуоденальной зоны. Непроходимость желчевыводящих путей неопухолевой этиологии диагностируется у 45-55% больных. Причиной её возникновения является: желчнокаменная болезнь - 61,3(73,6%) больных, стеноз большого дуоденального соска - 15(30%), панкреатит - 5,4(20%), рубцовое сужение внепеченочных желчевыводящих протоков - 11,8(15%), паразитарные заболевания печени - 4(6%) больных [8]. Практически все хирурги, занимающиеся проблемой диагностики и лечения заболеваний гепатобилиопанкреатодуоденальной зоны считают диагностическим скрининг методом ультразвуковую эхолокацию, позволяющую достаточно полно оценить состояние желчного пузыря, печени и поджелудочной железы, а также получить определенную информацию о состоянии внутри- и внепеченочных желчных протоков. Метод отличается практически полным отсутствием противопоказаний, возможностью выполнения в любое время суток. Исследование безболезненно, сравнительно кратковременно (3-5 мин.), не требует специальной подготовки больного [19]. Информативность УЗИ при механической желтухе в зависимости от поставленных задач колеблется от 39 до 74,3% [3, 9]. Наиболее достоверную информацию о состоянии желчных протоков дают прямые методы их контрастирования [10]: ретроградная панкреатохолангиография и
