[LASER TECHNOLOGIES IN LAPAROSCOPIC HERNIOLOGY].

Objective - to analyze the expediency of using a universal laser coagulator "Lika-surgeon" with a wavelength of 1470 nm as an alternative to an electrocoagulation while performing dissection for TAPP. The work is based on the analysis of 88 TAPP patients, using a universal laser "Lika-surgeon" with a wavelength of 1470 nm at a radiation power of 10-12.5 W and 102 patients operated according to the trivial standard TAPP procedure, where an electrocoagulation hook with a coagulation and cutting power of 35 W is used as a dissection instrument. Evaluation considered the criteria of operating time, duration of hospital stay, severity of pain syndrome, morphological assessment of the prevalence of laser and electrical effects on the tissues in the affected area.. All surgical interventions were performed in the Department of General and Vascular Surgery of the PNCO "Kyiv City Hospital №1, Shalimov's National Institute Of Surgery And Transplantation National Academy Of Medical Sciences Of Ukraine and Republican Clinical Hospital Of Batumi in 2020. The cutting mode in an electrosurgical apparatus is accompanied by tissue wrinkling and smoke in the operating field. The laser device is devoid of these disadvantages. At the same time, laser coagulation requires practical skills of the operator to select the optimal distance between the optical fiber and the object. The operating time and the duration of hospital stay in patients of the first group are significantly shorter. The severity of pain in the early postoperative period was comparable in both groups. In the late postoperative period, the pain syndrome was more severe in the second group - it accompanied 6.1% of patients in the first group and 15.2% in the second group. Analysis of the morphological material showed significantly less tissue trauma in the affected zone in the first group - the coagulation zone is 372.91 µm versus 835.88 µm in the second group. A laser coagulator with a wavelength of 1470 nm has a number of significant advantages over an electrosurgical coagulator: more efficient cutting and coagulation modes; optical clarity of the operating field; minimal thermal damage of the underlying tissues (the depth of tissue damage in the first case is 166.36 microns, in the second 835.88 microns); significant reduction of operating tine and the duration of hospital stay; significant reduction of pain in the postoperative period. This opens up new perspectives for its use in laparoscopic surgery of inguinal hernia.

[PECULIARITIES OF CARBOPNEUMPEROPERITONEUM AT LAPAROSCOPIC OPERATION UNDER CONDITIONS OF RHYTHM DISORDERS AND CONDUCTIVITY OF CARDIAC ACTIVITY].

The aim of the research - to study the effect of carbopneumoperitoneum on the possibility of laparoscopic surgery in patients with cardiac rhythm disorders and conduction disturbances. We conducted analysis of 940 patients who underwent laparoscopic surgery. The patients were divided into two groups. The first group included 630 patients (67,0%) with cardiac arrhythmias; the second group included 310 (33,0%) patients with heart rhythm disturbance that arose during carbopneumoperitoneum. In all patients of the first group in the preoperative period, heart rhythm disturbance was observed: sinus tachycardia - 30 (4,8%); sinus bradycardia - 50 (7,9%); paroxysmal tachycardia with a narrow QRS complex - 5 (0,8%); complete blockage of the right leg of the bunch Gis - 12 (1,9%); complete blockage of the left leg of the bunch Gis - 21 (3,3%), AV- blockade of the I degree - 23 (3,7%), the AV- blockade of the II degree Mobitz I - 12 (1,9%), AV- II degree blockade Mobits II - 8 (1,3%), complete AV- blockade - 5 (0,8%), supraventricular extrasystole - 216 (34,3%), persistent atrial fibrillation - 103 (16,3%), paroxysms of atrial fibrillation - 41 (6,5%), a constant form of atrial flutter - 12 (1,9%), paroxysms of atrial flutter - 4 (0,6%), ventricular extrasystole - 70 (11,1%), episodes of unstable ventricular tachycardia - 10 (1,6%), episodes of sustained ventricular tachycardia - 8 (1,3%). All patients also observed an increase in the dispersion of the QT interval - 61,4±1,9 ms. In the second group, during carbopneumoperitoneum, cardiac arrhythmias appeared during surgical interventions with various risks of its development: with a low risk of development (laparoscopic appendectomy) occurred in the form of episodes of sinus bradycardia (27,8%), ventricular extrasystole (27,8%), supraventricular extrasystole (16,7%), the variance of the interval was - QT 61,2±1,0 ms; with an mediunrisk of developing heart rhythm disturbances (laparoscopic cholecystectomy, transabdominal prepperitonealenlovideogernioplasty) - ventricular extrasystole (37,5%), episodes of sinus bradycardia (29,5%), supraventricular extrasystole (14,3%), QT dispersion 64,9±1,0 ms; with a high risk of developing heart rhythm disturbances (laproscopichernioplasty of hernias of the diaphragm, laparoscopic operation on the colon, simultaneous laparoscopic surgery) - ventricular extrasystole (23,6%), episodes of sinus bradycardia (20,1%), supraventricular extrasystole (15,8%), dispersion QT interval - 72,3±1,3 ms. When performing laparoscopic surgery with a high risk of heart rhythm disturbance, arrhythmias that are potentially malignant (supraventricular extrasystole, including early supraventricular extrasystole (type "R on T"), unstable VT, more often than in patients with low and medium risk AF), and malignant (persistent VT, including polymorphic and pirouette tachycardia), which can cause critical hemodynamic disorders and can transform into FS or asystole. Also, in such patients, episodes of AV blockade of I degree, episodes of AV blockade of II degree Mobitz I, episodes of AV blockade of II degree Mobitz II, episodes of complete AV block are more often recorded. Patients possibly holding laparoscopic surgery after a course of antiarrhythmic treatment and taking into account the risk of cardiac arrhythmias, where intraoperative intra-abdominal pressure plays a major role. Carbopneumoperitoneum increases the risk of sinus bradycardia (up to 26,5% of cases), all episodes during CO2 insufflation. The incidence of ventricular extrasystole was 2 times higher than that of supraventricular extrasystole (31,0% and 15,2% respectively). Including early ventricular extrasystoles (type "R on T") - in 3,8% of cases. Increases the likelihood of occurrence of both unstable (4,5%) and stable (2,6%) ventricular tachycardia, including "pirouette" -tachycardia (2,9%). There is also an increased risk of episodes of second degree AV-blockade Mobitz II (1,6%) and episodes of complete AV-blockade (1,0%).

PERIOPERATIVE MULTIMODAL PROGRAM OF ENHANCED RECOVERY FOLLOWING PANCREATICODUODENECTOMY.

Mortality after pancreaticoduodenectomy (PD) decreased from 25% to 1-3% in the last decade. However, the number of early postoperative complications varies from 29.5% to 70%. Therefore, there is a need in new methods of perioperative management of patients after PD to improve the immediate results.  To analyze the effectiveness of perioperative treatment regimens, a prospective retrospective study of the results of 78 patients after PD with diseases of the head of the pancreas and the periampular zone for the period from 2003 to 2017 was conducted. For comparative analysis, the patients were divided into 2 groups: group I included 39 patients for the period from January 2015 to December 2017, the perioperative treatment of which was carried out in accordance with the enhanced recovery program, group II -39 patients from January 2003 to December 2014, which were conducted according to the traditional method. We studied the time of the restoration of oral nutrition, postoperative complications, the length of hospital stay (LoS).There were no mortality in groups. The overall incidence of Clavien-Dindo complications in I group was less than in II (10 (25.6%) vs. 18 (46.1%), p = 0.029). In I group, the incidence of delayed gastric emptying (DGE) was lower compared to II (15.4% (6 patients) versus 35.9% (14 patients), p=0.009). Pancreatic fistula (PF) in I and II groups did not differ significantly - 10.2% (4 patients) and 12.8% (5 patients), respectively (p=0.36). The incidence of surgical wound infections in I group was reduced in comparison with II (5.1% (2 patients) versus 17.9% (7 patients), (p=0.031).The LoS in I group was significantly less compared with II (14 days 95% CI: [13, 17] vs. 18 days 95% CI: [16, 18], p=0.012). The results of the ERAS program after PD shows the reducing number of postoperative complications and LoS, demonstrating the feasibility in clinical practice.

[Surgical treatment of particularly complicated forms of gall-bladder and anhepatic bile-duct diseases].

The authors offer analysis of surgical treatment methods of patients suffering from complicated forms of gall-bladder and anhepatic bile-excreting ducts' diseases. In elaborating tactics for treatment of the above-mentioned pathology the presently existing technical and tactical approaches are considered and the most acceptable for receiving favourable results are chosen. In implementing the operation the authors gave utmost attention to the choice of the method of bile-duct drainage depending on the severity of the disease, the age and the concomitant diseases. Taking into consideration application of the most approved and effective methods of treatment of complicated forms of gall-bladder and bile-duct diseases, 191 patients were operated within the period of 1990-2008 years. The operation cholecystectomy together with drainage of the choledochus was carried out in 64 cases, choledochoduodenostomy - in 54 cases, choledochojejunostomy - in 59 cases, reconstruction of the choledochus over a T-tube Kerr's drainage - in 8 cases. The portion of the gall-duct retained after the first operation was removed to 3 patients. There were 18 (9,4%) cases of complications in post-operation period, 8 patients died, lethality was 4,2%.