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22страдающих зависимостью от ПАВ, совершались, как правило, в состоянии алкогольной абстиненции, протекающей с тоскливо-раздражительным аффектом, идеями самообвинения, на фоне переживания психотравмирующих ситуаций, связанных с конфликтом в сфере значимых потребностей. Выводы
1. Среди пациентов с сочетанной травмой, обусловленной суицидальным поведением преобладают лица молодого возраста, страдающие психическими и поведенческими расстройствами в результате употребления алкоголя.
2. С учетом преобладания в структуре пострадавших с сочетанной травмой лиц с аддиктивной патологией, необходимо проведение превентивной работы с лицами молодого возраста с психическими и поведенческими расстройствами в результате употребления алкоголя.
Список литературы
1. Шамрей В.К. Психотерапия. Учебное пособие. СПб.: Спецлит, 2012. 495 с.
2. Костюк Г.П., Синенченко А.Г., Дягтяренко В.И. Особенности пограничных психогенных расстройств у военнослужащих проходящих военную службу по призыву в экстремальных условиях учебно-боевой обстановки // Медико-биологические и социально-психологические проблемы безопасности в чрезвычайных ситуациях, 2010. № 3. С. 19-22.
3. Синенченко А.Г. Опыт оказания психиатрической помощи в многопрофильном стационаре пациентам с алкогольной патологией // Вестник науки и образования, 2018. № 13 (49). С. 95-97.
4. Парфенов В.Е. Психические нарушения при тяжелой сочетанной травме. Учебное пособие. СПб., 2019. 28 с.
OPTIMIZATION OF TREATMENT OF PATIENTS WITH VENTRAL HERNIA Mardonov B.A.1, Isakov A.M.2, Sayinaev F.K.3, Yuldashov P.A.4
1Mardonov Bobosher Amirovich - Assistant, DEPARTMENT OF SURGICAL DISEASES № 1;
2Isakov Abdurauf Mamadiyarovich - PhD, Associate Professor, DEPARTMENT OF PEDIATRIC SURGERY; 3Sayinaev Farrukh Karamatovich - Assistant;
4Yuldashov Parda Arzikulovich - Assistant, DEPARTMENT OF SURGICAL DISEASES № 1, SAMARKAND STATE MEDICAL INSTITUTE, SAMARKAND, REPUBLIC OF UZBEKISTAN
Abstract: abdominal wall hernias are one of the most common surgical diseases. The increase in life expectancy of the population and the annual increase in the number of operations on the abdominal organs led to an absolute and relative increase in the number of patients with this pathology. To ensure optimal results of surgical treatment and prophylaxis of postoperative complications in patients with aesthetic deformities of the abdomen, it is necessary to take into account not only the general condition, but also the anatomical and functional features of anterior abdominal wall tissues in the area of the proposed intervention. Ultrasound of the abdominal wall showed that with an increase in BMI in patients, an increase in the thickness of subcutaneous fat is noted. In these patients, fascial layers in adipose tissue were located less orderly. In patients of group I, the superficial fascia and its individual elements, together with the aponeurosis of the external
oblique muscle, were well expressed and represented by continuous plates. In patients with overweight and obesity, the connective tissue plates in the fat layer were loose, the thin and intermittent superficial fascia was not always determined, and the aponeurosis was thinned throughout. Thus, the use of hernia repair with alloplasty supplemented with dermatolipectomy makes it possible to reduce the number of general and local complications, relapses and satisfies the aesthetic needs of patients.
Keywords: abdominal wall hernias, anterior abdominal wall, treatment, hernia repair, alloplasty, dermatolipectomy, postoperative complications.
Introduction. Abdominal wall hernias are one of the most common surgical diseases. The increase in life expectancy of the population and the annual increase in the number of operations on the abdominal organs led to an absolute and relative increase in the number of patients with this pathology [3, 5, 7]. Especially difficult in the technical solution of the problem are recurrent, recurrent hernias and hernias with extensive defects of the abdominal wall. An increase in the number of complex hernias among people of working age, frequent disability, limited ability to work, and a decrease in the quality of life of this group of patients are the most important socioeconomic problems of practical medicine [2, 8, 13, 15, 31]. The combination of hernias of the anterior abdominal wall (AAW) with a violation of the correct proportions of AAW and the trunk resulting from muscle overstrain and an increase in the thickness of the skin-fat fold of the abdomen negatively affects the results of hernioplasty [7, 11, 16, 30]. This is a so-called saggy stomach or fat apron. Therefore, it is urgent and even necessary to supplement hernioplasty with dermatolipectomy, which is aimed at restoring the morphological state of the abdominal wall, preceding the changes that occurred with it as a result of pregnancy, surgery, prolonged herniation, and obesity [1, 4, 6, 9, 12, 29].
The indication for hernioplasty with dermatolipectomy can be considered massive fatty deposits of AAW, deforming the figure, interfering with hygiene procedures that contribute to maceration of the skin in the folds. All this in general affects the development of the complex of psychoemotional, physical, as well as social inferiority, the solution of which patients see only in the restoration of the normal form of the abdomen. Therefore, the problem of plastic surgery of AAW is currently gaining not only medical, aesthetic, but also great social significance [10, 11, 13, 16]. An important stage of hernioplasty with dermatolipectomy is the reliable strengthening of the weakened muscular aponeurotic framework of AAW. The result of the entire operation, aimed not only at eliminating the existing changes, but also at preventing relapse, depends on the correct choice of surgical tactics at this stage [14, 17, 29].
These operations are reconstructive, because include not only the reconstruction of AAW, the elimination of hernias and excess skin-fat layer, but also the elimination of functional disorders of the gastrointestinal tract, cardiovascular system, respiratory organs, as well as the elimination of concomitant functional disorders of the abdominal organs [10, 18, 28].
However, it should be borne in mind that dermatolipectomy is not a treatment for obesity. Therefore, before resorting to it, it is necessary to find out the causes of obesity and in various ways to achieve weight loss. Under these conditions, new deposition of fat and stretching of the skin in the area of operation are possible only to a very small extent [19, 20, 27]. If the operation is performed at maximum weight, then its result will be negative, since excess skin and subcutaneous fat are re-formed [34].
Surgery for hernia should be as simple and least traumatic as possible. This principle, however, must be based on the belief that the intervention chosen will provide a radical cure. If with the bulk of uncomplicated inguinal, femoral and umbilical hernias, good results can be achieved using fairly simple autoplastic methods of surgery, then with complex hernias, including in the above cases, surgical treatment is often a difficult task [22, 23]. When closing the hernia gate, due to a lack of tissue, one has to look for ways to replace them, and even if it is difficult to connect the edges of the surgical wound, the suture is fragile. In such cases, relapse can be prevented only by transplanting the missing amount of tissue, for which purpose alloplastic methods of surgical treatment are used [21, 24, 33]. Moreover, it is necessary to
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restore the anatomical integrity of the abdominal wall as much as possible, since the muscular-aponeurotic complex forming the abdominal wall is a functionally uniform formation. It plays an important, active role in the act of breathing, in protecting internal organs, regulating intraabdominal pressure, as well as in the movements and fixation of the spinal column when running, walking, standing, sitting, and maintaining balance [5, 19, 25].
The purpose of this study is to improve the immediate and long-term results of surgical treatment of patients with complex forms of abdominal hernias with overweight and deformation of the abdominal wall by improving treatment tactics and introducing rational methods of surgical treatment.
Material and methods. To ensure optimal results of surgical treatment and prophylaxis of postoperative complications in patients with aesthetic deformities of the abdomen, it is necessary to take into account not only the general condition, but also the anatomical and functional features of AAW tissues in the area of the proposed intervention. In matters of a comprehensive assessment of changes in AAW tissue, there is a need for additional functional studies. We performed an ultrasound examination (ultrasound) of the state of the skin-fat and muscle-aponeurotic layer, a duplex study of the vascularization of AAW in patients with various constitutional types and body mass index (BMI).
The assessment of overweight and determining the degree of obesity was carried out in accordance with WHO recommendations based on the determination of BMI. 92 patients are divided into 4 groups according to BMI values. I - with normal weight, II - overweight, III -obesity and IV - morbid obesity. Ultrasound of the skin-fat and muscle-aponeurotic layer of AAW was carried out in a patient position lying on his back in 9 topographic and anatomical areas: right and left hypochondrium, epigastric, right and left lateral, umbilical, right and left inguinal and pubic. In accordance with the thickness of the subcutaneous fatty tissue of AAW, patients were divided into 3 groups. The first group with a subcutaneous fat layer thickness of up to 3 cm, the second - from 3 to 6 cm and the third - more than 6 cm.
Discussion. Ultrasound of the abdominal wall showed that with an increase in BMI in patients, an increase in the thickness of subcutaneous fat is noted. In these patients, fascial layers in adipose tissue were located less orderly. In patients of group I, the superficial fascia and its individual elements, together with the aponeurosis of the external oblique muscle, were well expressed and represented by continuous plates. In patients with overweight and obesity, the connective tissue plates in the fat layer were loose, the thin and intermittent superficial fascia was not always determined, and the aponeurosis was thinned throughout. When studying the vascularization of AAW on the echograms of the fascial interlayers in the womb and the subcutaneous tissue of the AAW in the womb and in the subcutaneous tissue of AAW in the study groups I and II, the direction of the horizontal and vertical connective tissue jumpers coincides with the 6th direction of the vessels. In patients with obesity and morbid obesity, a similar relationship is noted only in the gum.
A study of hemodynamics showed that with an increase in BMI of 2 to 3 times, the total number of subcutaneous blood vessels of AAW increases with a slight change in their diameter, the blood flow increases at a minimum in patients of groups III and IV of the study. Such a change in indicators indicates regional hemodynamic disturbances in blood supply to the skin-fat layer of AAW. The results obtained by us in the course of the study revealed that AAW dermatolipectomy can reduce the force required to compare the edges of the defect of the hernial portal with a thickness of subcutaneous fat more than 3 cm. This decrease is the maximum in the range of areas of formed defects in AAW from 30 to 150 cm2 and when the thickness of the subcutaneous fat layer of the anterior abdominal wall exceeds 3 cm.
This fact is explained by the fact that the skin-fat apron, together with the muscular-aponeurotic layer of AAW, form a single anatomical and functional complex, which due to its mass, due to the vessels and nerves that pass through it, as well as the connective tissue located in it -woven frame prevents the convergence of the edges of the defect. Excision of the skin-fat apron leads to a decrease in tissue tension. It follows that dermatolipectomy, performed according to indications and supplementing herniation, is an additional factor that reduces the
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tension of AAW tissues and, as a consequence, a method that reduces the likelihood of relapse of ventral hernias. Treatment of complex forms of abdominal hernias in combination with dermatolipectomy consists of the following stages: preoperative examination, preoperative preparation, surgery, postoperative period, postoperative rehabilitation.
Ventral hernia repair in combination with dermatolipectomy can be divided into the following stages, each of which has its own characteristics. The marking of the surgical field was carried out taking into account the type of incision. With a bordering incision, the navel is left on the connective tissue vascular pedicle, which must be mobilized with minimal trauma all the way to aponeurosis. For free, without tension suturing of the postoperative wound, the possibility of moving the navel to a new, planned location or creating a future navel, as well as to give the abdominal wall a more aesthetically correct shape, it is necessary to mobilize the upper flap. The next stage is the removal of the skin-fat flap of AAW and the allocation of a hernial sac. Wide mobilization allows revealing hernial defects that were not recognized before surgery, and existing areas of "weakness" of the abdominal wall.
46 operations were performed out of 184 (25%) after herniolaparotomy. 16 patients underwent cholecystectomy for calculous cholecystitis, 14 - appendectomy, 2 - operation for liver echinococcus, 2 - operation for Meckel's diverticula. Gynecological operations were performed in 12 patients. In 6 cases, the intra-abdominal stage of the operation was completed by resection of the small intestine with anastomosis.
Of the 184 operated on in 72 patients, hernia gate surgery was performed using an explant (polypropylene mesh), and 82 using autodermal surgery. In 26 cases, hernia gate repair was performed by an alloplastic combined method.
The next step is moving the navel to a new place. The navel is an aesthetic factor. Its elimination or absence after previous operations leads to such changes and distortions of the overall cosmetic picture of the abdominal wall that the creation of an imitation of the navel, especially in young patients, is mandatory.
The navel is displaced from its original position along with the white line of the abdomen with hernias of midline localization and displacement of the center of gravity. With respect to this point, body parts are automatically positioned so that the body maintains balance. The human body continuously reacts to a change in the position of the center of gravity in such a way as to maintain a state of equilibrium. The projection line of the center of gravity of the body in various poses of a person and even when lifting heavy objects always passes through the navel (or navel area). During the removal of excess skin and subcutaneous tissue, the navel on the skin graft from AAW was maintained in 24 patients. It was separated from the underlying tissues. When the surgical wound was sutured, the navel on the nourishing skin was applied to the wound and sutured to the edges of the skin. Isolation of the umbilicus from the underlying tissues is associated with the intersection of the arterial branches that feed the umbilical region, which can lead to necrosis and infection of the surgical wound. Therefore, recently, the navel was removed along with excess skin and subcutaneous tissue (for the most part, the navel was changed and distorted in the presence of hernias). In these cases, and in cases where the navel was absent after previous operations, when the skin wound was sutured, its edges in the region of the excised navel were sewn with semiconductor seams of "Vicryl" on each side to the underlying aponeurosis. The rest of the skin was sutured as usual.
When postoperative hernias are formed, the rectus and lateral abdominal muscles lose the medial point of attachment. The necessary balance of these muscles is provided by the white line of the abdomen, which is why we consider the formation of an artificial white line of the abdomen as an obligatory step in alloplasty. The introduction into clinical practice of a non-tensile alloplastic method of hernia gate repair with the formation of an artificial white line of the abdomen provides the necessary balance of forces of the rectus and lateral muscles, preventing excessive divergence of the rectus abdominis muscles, which makes it possible to evenly and persistently withstand an increase in intra-abdominal pressure of any degree. The method allows to improve the immediate and long-term results of treatment of patients with complex hernias of the abdomen of midline localization and expands indications for operations, especially in patients
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with severe respiratory and cardiac concomitant diseases. Before suturing the skin wound in all cases through contrapertures, we drain it with drains with active aspiration.
In the process, we were convinced that the excision of the skin-fat flap leads to a significant reduction in the load on the sutures imposed on the hernial defect, increasing the mobility of the elements that make up the AAW. In addition, in our opinion, the undoubted advantages of this access for ventral herniasis include the possibility of a complete revision of the aponeurosis, elimination of relaxation around the hernia gate, and not only in the area of elimination of the defect, and, of course, restoration of AAW configurations, which is an element of aesthetic surgery. The outcome of surgical treatment of patients largely depends on the proper management of the postoperative period. In hernia surgery in combination with dermatolipectomy, its main tasks are: drug prevention of respiratory and hemodynamic disorders; prevention of disorders of the gastrointestinal tract; prevention of purulent-inflammatory wound complications.
The state of hemodynamics in patients in the postoperative period directly depends on the adequacy of the replenishment of blood loss during surgery. The volume of blood loss in abdominoplasty, determined by various methods, ranges from 600 to 1200 ml, which is 20 - 25% of the removed tissue volume. As a result, with an inadequate transfusion program, the severity of the patient's condition in the postoperative period can be aggravated by the development of hypovolemia.
In the postoperative period, no pronounced respiratory disorders were observed in our patients. Toward the end of the first day, the patient was wearing an elastic girdle bandage that creates additional support for the muscular-aponeurotic skeleton of the abdominal wall and promotes adaptation and faster adhesion of the skin-fat flap of the abdominal wall with its aponeurosis, which reduces the production of tissue detritus.
In the postoperative period, under the supervision of an instructor in exercise therapy, patients undergo mandatory breathing exercises. Adequately performed surgery, moderate tension in the suture area contributed to a decrease in pain intensity in our patients. This allowed in the postoperative period to abandon the use of narcotic analgesics.
For the prophylactic purpose of thrombosis, 0.3 - 0.6 ml of Fraxiparin was administered intraoperatively to patients. Injections of "Fraxiparin" of 0.3 ml twice a day for 2-3 days continued after surgery, focusing on the indicators of the coagulogram. In the postoperative period, we did not observe pronounced intestinal paresis, this is due to the fact that patients immediately after surgery received cerucal at a dose of 10 mg IM 3 times a day. The drug increases muscle tone of the stomach and intestines, accelerates the emptying of the stomach, reduces hyperacid stasis, prevents pyloric and esophageal reflux and stimulates intestinal motility. For the prevention of purulent-inflammatory wound complications, all patients received a short (4-5 days) course of antibiotic therapy.
The most serious complication of the early postoperative period in patients with ventral hernias is acute respiratory failure. It arises as a result of a postoperative decrease in the volume of the abdominal cavity, an increase in the tension of the tissues of the abdominal wall after hernioplasty, which leads to an increase in the level of the location of the diaphragm and limitation of lung excursion. 6 patients in the early postoperative period developed a pattern of severe respiratory failure, which required prolonged mechanical ventilation and intensive care lasting from 24 to 48 hours. General complications were 21 (22.8%). Local wound complications were manifested in the form of infiltrates, hematomas, seromas, ligature fistulas, suppuration of a postoperative wound, marginal skin necrosis.
The most common wound complication is seroma; it occurred in 16 (8.7%) patients. We believe that the main cause of this complication is inadequate drainage of surgical wounds. In all cases, seromas were eliminated by vacuum aspiration without repeated surgical intervention. Infiltrates were observed in 8 (4.3%) patients, hematomas - in 6 (3.3%). An analysis of the immediate complications showed that, despite the traumatic nature of the operation, its long duration in patients who underwent herniation supplemented with dermatolipectomy, the number
of general and local wound complications is small. A short period of inpatient postoperative stay was noted.
When assessing the long-term results of treatment of patients who underwent hernia repair supplemented with dermatolipectomy, we paid special attention to the following indicators: the number of relapses, the percentage of complete social rehabilitation, that is, patients retaining work in their previous specialty, aesthetic satisfaction with the treatment results.
We tracked long-term results in 160 (86.9%) patients. The number or frequency of relapses in the period remote after surgery is the main criterion for the effectiveness of any method of treating hernias. A hernia recurrence was detected in 2 cases (1.1%). When determining the causes of relapse, we found that the main causes of relapse were suppuration of the postoperative wound - in one and for a long time existing ligature fistulas in the second patient. Both patients suffered from obesity III-IV degree, diabetes mellitus, hypertension.
The indicator of social rehabilitation indicates that working patients (37) have begun to work in their specialty.
To assess the aesthetic results of surgical treatment, we conducted a survey and examination of patients. When satisfying the aesthetic needs of the patient himself, the absence of hernia recurrence, the absence of a saggy abdomen, keloid scars - the result was regarded as good.
A satisfactory result is the absence of hernia recurrence, the presence of a keloid scar or the appearance of a sagging abdomen, not complete satisfaction with the cosmetic effect. Unsatisfactory - the presence of relapse or the appearance of a gross keloid scar and a saggy abdomen, patient dissatisfaction with the results of treatment.
When analyzing the data obtained, a good result was found in 130 (81.3%), satisfactory in 20 (15%), unsatisfactory in 6 (3.8%) patients.
Conclusions. Thus, the use of hernia repair with alloplasty supplemented with dermatolipectomy makes it possible to reduce the number of general and local complications, relapses and satisfies the aesthetic needs of patients.
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