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Sherbekov Ulugbek Axrorovich, candidate of medical sciences, Head of the Department of General Surgery, Samarkand Medical Institute of the Republic of Uzbekistan
E-mail: uasherbekov@gmail.ru Murtazaev Zafar Israfulovich, candidate of medical sciences, associate professor of the Department of General Surgery, Samarkand Medical Institute of the Republic of Uzbekistan E-mail: zafar.murtazaev1959@mail.ru Rustamov Murodulla Isomiddinovich, candidate of medical sciences, assistant Department of General Surgery, Samarkand Medical Institute of the Republic of Uzbekistan
E-mail: rustamov.1967@bk.ru Saydullaev Zayniddin Yakhshiboevich, assistant Department of General Surgery, Samarkand Medical Institute of the Republic of Uzbekistan
E-mail: zizu_medic86@bk.ru
SURGICAL TACTICS IN LIVER ECHINOCOCCOSIS OF SUBPHRENIC LOCALIZATION
Abstract: In the clinic ofgeneral surgery SamMI performed 125 surgeries for echinococcosis ofthe liver subphrenic localizatipn. Thoraco-abdominal access wos used in 31, parallel to the costal arch in 23 and 64 patients with a wide ancient laparotomic access. In the 7 patients with localization of cysts in the segment of the liver, a minidostine developed in our clinic was producted along the lower edge of the xirib along the posterior axillary line. Mostly used 4 types of operations, cyst extirpation (pericystectomy), closed echinococcectomy, semi-closed, echinococctomy, Askerhanov.
In the postoperative period, all patients were prescribed albendazole at 12 ml kg of body weight for 28 days of the 35 the corse with an interval of 14 days.After surgical complications were observed in 8 (6.4%).
Keywords: echinococcosis, thoracic-abdominal access, cyst extrusion, pericystectomy, omentoplasty.
Introduction. Subphrenic liver echinococcosis is the most difficult for diagnosis and treatment. The cyst located on the convex surface of the liver is difficult to observe, which leads to difficulties during the operation [1; 3; 4; 6; 8; 9]. The only radical method of treatment of echinococcosis, including subphrenic liver echinococcosis, is the surgical method. The difficulty of surgical treatment of this localization of echinococcal cysts is due to complexity of the topographic and anatomical location, as well as more frequent complicated forms compared to other localization of parasitic liver cysts [2; 5; 7; 10].
Materials and methods. For the last years 125 operative interventions of subphrenic liver echinococcosis were performed in the department of general surgery of Samarkand Medical Institute Clinic № 1. The age of patients ranged from 16 to 70 years. The largest number ofpatients suffering from this pathology was at the age group from 18 to 54 years old. A combination of subphrenic liver echinococcosis with echinococco-
sis of the abdominal cavity was observed in 12 patients, which was 9.6%. Complicated forms of echinococcosis of this localization were noted in 29 patients, which accounted for 23.2%. The most frequent complications were calcification (10.4%) and suppuration (4.8%), as well as a combination of suppuration of the parasitic cyst with calcification of its wall (4%). The breakthrough of a suppurated cyst in the pleural cavity was diagnosed in 2 patients (1.6%), a breakthrough into the abdominal cavity followed by the development of peritonitis was observed in 1 patient (0.8%), a breakthrough of the echinococcal cyst into the bile ducts with obliteration of the latter and the development of mechanical jaundice in 2 patients (1.6%).
A comprehensive examination of patients with the use of ultrasound and computer tomography is important in the establishment of correct diagnosis. A comprehensive examination allows diagnosing the right localization of the echino-coccal cyst, which determines the choice of optimal access
SURGICAL TACTICS IN LIVER ECHINOCOCCOSIS OF SUBPHRENIC LOCALIZATION
and method of operation. In case of difficulty in establishing the diagnosis, diagnostic laparoscopy was used. The use of informative ultrasound echography of the liver makes it possible to establish an accurate diagnosis. The study was performed in all patients.
Computed tomography was performed for all patients with subphrenic echinococcosis. This study allows not only to reveal the localization and size of the parasitic cyst, but also the calcification of the fibrous capsule. An integrated method of examination of patients with subphrenic cyst allowed putting the correct diagnosis before surgery in 96.1% of cases.
Results. The choice of optimal surgical access ensures adequate operation and depends on the location of the echi-nococcal cyst, the nature of the complications, the patient's condition. Thoracic-abdominal access at the eighth-ninth intercostal space with the intersection of the costal arch and the diaphragm is the most appropriate in patients with right-sided subphrenic localization. Access is advisable to patients with multiple subphrenic cysts of the liver and those with a pronounced adhesion process. This access creates all the conditions for performing adequate intervention on the convex surface of the liver, as well as in patients with various complications from the lungs, the latter being used in 31 patients.
23 patients were operated by the incision on the right hy-pochondrium parallel to the costal arch. This access is not as convenient as thoracic phrenic laparotomy, but less traumatic because it does not open the pleural cavity and allows removing echinococcal cysts not only from the right and left lobes of the liver, but also from the abdominal cavity.
Echinococcectomy from the liver through a wide median laparotomy access was performed in 64 (51.2%) patients. In 12 cases out of 64 removal of cysts from the liver was combined with echinococcectomy from the abdominal cavity, removal of cysts from the liver with splenectomy in 1 case and removal of cysts from retroperitoneal cavity on the left in 1 case.
At present, we consider cases of multiple echinococcosis, relapse of the disease, laparotomies carried out in past, complicated course of the disease, localization of cysts in difficult-to-reach segments of the liver as an indication for echinococcectomy from a wide upper median laparotomic access. If necessary, we used Sigal's retractor to create an adequate exposure to the diaphragmatic surface and its posterior (VII, VIII) segments.
In 7 (5.6%) patients with localization of cysts in the VII segment of the liver, a mini-access, created in our clinic, was used along the lower edge of the XI rib along the posterior axillary line.
In 38 cases (30.4%) we performed repeated operative procedures on the background of expressed adhesions process. We encountered some technical and tactical difficulties in the cases of widespread echinococcosis, when there was a
combination of liver injury by the location of cysts under the diaphragm with a damage of the abdominal cavity. The choice of surgical intervention method was determined individually depending on the patient's condition, typical changes in the parasitic cyst, as well as pre sense of complications. We adhere to the tactics of sparing and organ-preserving methods of surgery. The most appropriate surgery is echinoccectomy, that is the removal of a cyst with all its elements or its membranes, followed by the elimination of the residual cavity in various ways. Removal of a parasitic cyst entirely in subphrenic location is always fraught with the occurrence of abundant bleeding, so we used this intervention only in exceptional cases.
Various types of echinococcectomy were performed to 125 patients. We mainly used 4 types of surgery: cyst extrusion (pericystectomy), closed echinococcectomy, half-closed echinococcectomy, Askerkhanov's omentoplasty. We used 2-3 methods of surgery simultaneously during the operation in 34(27.2%) patients with multiple cysts.
Closed echinococcectomy, or complete elimination of the residual cavity in the liver was performed in various versions. Indications for the implementation of closed echinococcectomy were cysts without signs of inflammation with the flexible walls of the fibrous capsule. This operation was performed to 61(51.2%) patients.
Closed echinococcectomy performed most often by suture plastics. Elimination of the fibrous cavity by capiton-age of Delbe is shown in cysts of small and medium size and performed in 26(21.8%) cases. In this method, closure of the residual cavity was achieved by successive application of the sutures on the wall of the fibrous capsule. Unfortunately, the method is not applicable in the rigid walls of the fibrous capsule, which cannot be pulled together because of the opening of the sutures in large cavities of the residual cavity.
Elimination of the residual cavity by invagination by screwing sutures according to Yu. S. Gilevich is indicated in the presence of a rigid fibrous capsule and the location of hydatid cysts near the great vessels and bile ducts and was performed in 22 patients (18.4%). And in 13 patients (11%) capitonnage was carried out according to our methodology (rat. suggestion No 1508).
A very effective and simple method of closing the residual cavity was filling with an omentum on a nourishing pedicle, which was performed in 35 (28%) patients. Considerable reparative properties of the omentum contributed to the rapid obliteration of the residual cavity.
In case of liver echinococcosis complicated by suppuration of cysts and cystobiliar fistulas, the semi-closed echinococcectomy was mostly performed. This type of surgery was performed in 25(20%) patients. The essence of the surgery was leaving of drainage in the sutured residual cavity of the liver.
The surgery of pericystectomy (extirpation of a cyst) -the removal of an echinococcal cyst together with a fibrous capsule, was performed at the marginal location of the cyst and its calcification. The surgery was performed by complete excision of the fibrous capsule in 5 (4%) patients.
In the postoperative period, Albendosol was prescribed to all patients at a dose of12 mg / kg for 28 days (3-5 courses with an interval of 14 days).
Postoperative complications were observed in 8 (6.4%) patients: suppuration of the residual cavity - 1, subphrenic abscess - 1, biliary fistula - 1, suppuration of the postoperative wound - 2. In 3 patients, a relapse of the liver echinococcosis was detected.
During the follow-up examination of these patients, performed from 6 months to 6 years, attention was paid to the results of the performed surgeries and the result of the invasion itself, such as postoperative hernias, scars deforming the abdominal wall, ligature fistulae and abdominal adhesive disease. Thus, the immediate results of the surgical treatment of patients with liver echinococcosis of the liver mainly depended on the course of the disease itself- the presence of certain complications.
We believe that when performing echinococcectomy, it is necessary to take into account such aspects of the surgery as its relation to the fibrous capsule: leaving it, partially or totally
removing it; as well as its relation to the residual cavity, when it is eliminated by one of the methods or adequately drained. An important part of the surgery for subphrenic echinococcosis of the liver is the plastic of the diaphragm, when its strong stretching by parasitic cyst leads to a significant thinning as well as manifestation of defects.
Thus, in most cases, we sought to perform echinococcectomy with the elimination of the residual cavity by one of the methods. Drainage of the residual cavity was performed in case when it was impossible to perform another surgery, most often to patients with suppuration of a parasitic cyst.
Conclusions. Optimal surgical access provides an adequate surgery on the posterior surface of the liver. Toracic -phrenic laparotomy creates the best conditions for surgical intervention in multiple sub phrenic liver cysts and pronounced adhesions. In the surgical treatment of patients with liver echinococcosis, we consider the priority of organ-sparing operations. In uncomplicated liver echinococcosis, we consider to perform closed echinococcectomy. In case of suppurative echinococcosis of the liver, a semi-closed echinococcectomy was mostly performed. Indications for pericistectomy were cases of the marginal location of echi-nococcal cysts and their calcification.
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