MODERN APPROACH TO THE USE OF MINIMALLY INVASIVE TECHNIQUES IN ADRENAL SURGERY

S.S. HAJIBABAYEV, P.S. VETSHEV, A.A. ZNAMENSKY

Russian National Medical and Surgical Center, Baku, AZERBAIJAN

The goal of our investigaton was the work up of optimal treatment modality of adrenal lesions depending on size, localization and morphological structure.

Materials and methods. Our investigation included 129 patients operated from the year 2006 to 2010. 65.5% of patients had hormone- producing tumors. The rest was non- active ones. Tumor size counted from 1 to 18 sm(mean 5.4 sm).We encountered malignancies in 8.5% of all cases. In 51.3% of cases tumor was on right, in 48.7% on the left. In 34.1% of cases we used endoscopic method (standard laparoscopy and Da Vinci system), in 1.7% adrenal cyst aspiration under US guidance, in 34 % mini ( 4 sm length) incision with the use of special wound retractors. In 30.2 % we performed traditional surgery. We benefited minimally invasive methodics in cases where tumor size was between 2 and 8 sm. Traditional incisions were used for tumors greater than 8 sm non-depending of side and suspicion of malignancy. The adrenalectomies were performed laparoscopically through a lateral decubitus or supine transperitoneal approach. Laparoscopy started at the beginning as diagnostic procedure to rule out local tumor invasion or metastatic spread. The lateral decubitus transperitoneal approach was used with three subcostal ports (5–12 mm) allowing the introduction of a 30° laparoscope and 2 working instruments. During right adrenalectomy, a fourth 5-mm port was placed in a subxyphoid position for liver retraction. For right adrenalectomies greater than 5 sm there was no need for the mobilization of the right hepatic lobe and incision of triangular ligament to the level of the diaphragm was enough.

Results. The conversion of standard laparoscopy into open surgery happened in 3.1% of cases mostly in tumors larger than 5 sm due to uncontrollable bleeding. The adrenal gland was dissected away from the retroperitoneum, using periadrenal fat as a “handle.” Laparoscopic management of tumors greater than 6 sm proved much easier and safer with the implication of Da Vinci robotic complex. Use of this system can solve the problem of management of left sided tumors which is still ambiguous. We did not face intraoperative complications in the course of robotic and open surgery. Patients were discharged on days 3-5 after minimally invasive surgery.

Outcome and analysis. Compared with those who underwent a traditional open surgery, patients who underwent a mini invasive adrenalectomy have demonstrated decreased preoperative morbidity, shorter hospital stay, significantly diminished intraoperative blood pressure changes and early recovery.

Conclusion. Minimally invasive adrenalectomy proves to be effective for management of controversial cases to gain better results of treatment.

VIDEO-ASSISTED THORACOSCOPY IN THE DIAGNOSIS AND SURGICAL TREATMENT OF PRIMARY SPONTANEOUS PNEUMOTHORAX

A.M. HAJIBAEV, R.O. RAHMANOV, B.I. SHUKUROV, F.B. SHOKIROV

Republican scientific center for emergency medical care, Tashkent, UZBEKISTAN

There were studied the results of surgical treatment of primary spontaneous pneumothorax (SP) in 274 patients. Left-sided pneumothorax was diagnosed in 107 (39.1%) patients, right - in 164 (59.9%) and bilateral - in 3 (1.1%). VATS as the primary method of intervention was performed of 274 patients. In 253 (92.3%) were identified multiple (170) and single bulls (82). Most commonly, in 154 (60.9%) cases bullous changes were located separately in the upper lobe, less frequently (68 patients - 26.9%) they affected all lobes, and only in 31 (12.3%) cases were observed isolated medium (5) or lower lobe (26) lesion. In another 21 (7.7%) patients the cause of pneumothorax has not been established by endoscopy. VATS curative interventions were performed in 144 (52.6%) cases: in 87 (31.8%) cases - electrothermal pleurodesis of parietal pleura; in 36 (13.1%) - electrocoagulation of single bulls not larger than 2 cm; in 20 ( 7.3%) - thoracoscopic resection of atypical bullous- changed site and in 1 (0.4%) case - thoracoscopic decortication of the lung were carried out. Video-assisted interventions were performed in 130 (47.4%) patients: in 88 (32.1%) patients were performed excision and suturing of multiple and large (more than 2 cm) bulls and blebs, in 40 (14.6%) - atypical lung resection and in 2 (0.7%) patients was carried out video-assisted pnevmolisis and pleurodesis on the adhesion process and rigid lung. After VATS intervertions (144) without minitoracotomy in 4 (2.8%) cases we had to resort to video-assisted intervention in connection with air leaks. Besides, in another 13 (8.2%) patients after thoracoscopy (7) and video-assisted intervention (6) we observed long-term (more than 4 days) flow of air over the pleural drainage, which resolved independently within the next day. Bleeding complications and empyema after thoracoscopy were not observed. Interventions with VATS usage proved to be effective in 270 (98.5%) cases.

Thus, the VATS technique allows performing the entire arsenal of traditional radical interventions during SP by means of minimally invasive access. The rational use of VATS in a daily practice reduces complications and improves outcomes.

Date: 2014-12-28; view: 943