Regarding extremely large inguinal hernias with a contribution of two cases.

We report two men of ages 62 and 80 years, respectively, with giant inguinoscrotal hernias. They were operated with a single-stage repair by two approaches, extended preperitoneal of Nyhus and an inguinal method. After hernia content reduction, a policaproamide antimicrobial mesh Ampoxen (MEDICA SA, Sandanski, Bulgaria) with dimensions 20 x 30 cm was inserted by using Stoppa's technique. An additional inguinal reinforcement with other mesh patch was done on the external aponeurosis hernial defect. Synchronous orchiectomy and transscrotal drainage of both patients was performed. The first patient suffering from umbilical hernia was also operated at the same stage. He was prepared by preoperative pneumoperitoneum. The second patient, due to scrotal skin cellulitis with ulceration, was operated without pneumoperitoneum preparation. The latter created easier mobilization and reduction of the hernial content. The sizable mesh dimensions allowed, to some degree, an acceptable level of intra-abdominal pressure after the repair. These hernias demand interdisciplinary teamwork and their treatment has to be adapted to the individual condition of the patient using all therapeutic options.

[Application of colonic pouch in the operative treatment of rectum carcinoma].

For the last two decades a new techniques has been used for the rectum tumor treatment. While sphincter sparing of it upper third localization is with favorable functional results, the same in mid and lower third is questionable. The correct surgical approach could have a positive influence on the quality of life in these patients. Pouch interposition, for example, could help some unpleasant after-effects of the "low" operations to be avoided.

[Technics for laparoscopic cholecystectomy--their use and results]. / Tekhniki za laparoskopska kholetsistektomiia--prilozhenie i rezultati.

In mini-invasive surgery mainly two operative techniques for laparoscopic cholecystectomy are familiar and implemented in practice--"American" and "French" technique. Over the period May 1993 to September 1997, in the two surgical clinics of H. M. I.--Pleven a total of 311 laparoscopic cholecystectomies are performed. Of them 218 are done according to the "American" technique, 87--according to the "French" technique, and six patients are operated using the so-called "lifting" technique. In the appear submitted the advantages and shortcomings of the two techniques for laparoscopic cholecystectomy are comparatively studied. The timing of operative intervention CO2 quantity expenditure and intraoperative complications are analyzed. The choice of technique for laparoscopic cholecystectomy depends on the surgeon's personal judgement, but under given situations one of the two techniques or a combination thereof should be mandatorily used.

[Decontamination in colorectal surgery]. / Dekontaminatsiiata v kolorektalnata khirurgiia.

The results of perioperative decontamination in a series of 136 patients presenting diseases of the colon and rectum are evaluated. Of the total 74 are subjected to operation according to schedule, and 62 are operated on an emergency basis. Perioperatively, metronidazole plus a cephalosporin antibiotic (cephazolin, cephalothin or cephamandol) are administered. Primary anastomoses are done in 32 cases operated according to schedule, and in fourteen patients operated in the emergency room. Insufficiency of the anastomosis is recorded in 3.5 per cent in the former group, and in 15 per cent in the latter group (p > 0.05). Operative wound suppuration occurs in 5.4 per cent against 13 per cent (p > 0.05), with lethality amounting to 1.3 per cent and 19 per cent, respectively (p < 0.001). Postoperative pneumonia is registered in 4 per cent of those operated on schedule and in 9.6 per cent of those operated by urgency (p > 0.05). In either group there is not a single case of operative wound dehiscence. In colorectal operations antibacterial prophylaxis applied perioperatively proves effective in combating systemic and local inflammatory complications.

[The role of the surgeon in treating multiple organ failure]. / Roliata na khirurga pri tretiraneto na mnogoorgannata nedostatuchnost.

Over the period 1990 through 1995, thirty-five patients with multiorgan insufficiency (MOI) undergo treatment. Abdominal operations are performed in all of them, except for one male patient aged 31 years, dying of bilateral pneumonia and metabolic disorders resulting from duodenal stenosis. Overall mortality rate amounts to 77 per cent (20 cases). Programmed peritoneal lavage (PPL) is done in seventeen patients with lethality 77 per cent (13 cases). In two instances iatrogenic damage to the spleen contribute to fatal septic complications development. All PPL treated patients with fatal outcome have bilateral pneumonia. MOI prevention is still closely linked to prophylaxis against the complications producing it. Programmed peritoneal lavage in immunocompromised and malnourished patients is a risk factor equally serious as the septic noxa being attacked, and what is more it runs the risk of inflicting additional iatrogenic noxae. General endotracheal anesthesia in PPL is likewise a factor demanding further clarification.

[Emergency reoperations in surgery of the gastrointestinal tract]. / Neotlozhni reoperatsii v khirurgiiata na gastrointestinalniia trakt.

Data concerning the therapeutic approach in a series of 28 patients, representing 1.3 per cent of the total number of abdominal operations performed in the Chair of Propedeutics of Surgical Diseases over the period 1990-1995, are retrospectively analyzed. In 19 of them primary operative interventions are done on an emergency basis. In further 19 cases the complications have inflammatory character. A total of 31 operations are done with lethality amounting to 36 per cent (10 patients). Multiorganic insufficiency develops in five of them (mean age 39 years). The remainder, dying of septic complications, are with mean age 76 years. The successful treatment of intraabdominal postoperative complications is largely dependent on the surgeon's experience and skills, material equipment and facilities available and on the algorithm of the therapeutic approach adopted.

[The treatment problems of soft-tissue infections]. / Problemi pri lechenieto na mekotukannite infektsii.

The treatment results is a series of twenty-six patients running a very serious course of soft-tissue infections are analyzed. Of the total number ten have diabetes mellitus. The sepsis severity score is 23 average according to the APACHE II rating system. Operative management is undertaken without any delay. It is preceded by comprehensive correction of the metabolic disorders present and antibiotic treatment, initially substantiated by presumable microbial causing agents. A total of 62 operations are done. In 36 per cent of cases being examined, the microbiological study contributes to a proper orientation of the antibiotic therapy performed. Bacteremia is documented in three instances. Total mortality rate amounts to 32 per cent (8 patients). Infections running a serious clinical course may be caused by one or more microorganisms, but in either case the lethality is noteworthy. Active surgical management may prove effective provided it is initiated in the most opportune time. It is only part of the complex therapeutic approach to sepsis.

Ultrasonographic characteristics of different methods of inguinal hernia repair.

A randomized blind sonography estimation analysis of seven different methods of inguinal hernia repair was performed using a commercially available linear scanner with a 5-MHz transducer frequency. A total of 58 male patients with a mean age of 56 years who had been free of recurrence since undergoing a hernia repair were examined 3-12 years after surgery. The analysis was accomplished by three static and four dynamic indices. A five-grade scale was used to assess the operated side while control pattern images of the unoperated operated side, and of a control group of five men who had not undergone surgery, were assessed with four points. The score from the static ultrasound assessment ranked the methods of Lotheissen-McVay and Shouldice first and the methods of Marcy and Postempsky-Halsted I second, while the score from dynamic indices ranked iliopublic tract repair and the methods of Marcy and Shouldice first and the method of Lotheissen-McVay and bilateral preperitoneal prosthetic repair second. The highest aggregate score was demonstrated by the Shouldice method and the lowest by Bassini's method. The results of this study provide additional information which may be clinically useful in the context of the current state of inguinal hernia surgery.

[Our experience with the surgical treatment of cholelithiasis]. / Nashiiat opit ot khirurgichnoto lechenie na zhluchnokamennata bolest.

The treatment results in 312 patients with cholelithiasis, covering the period 1989 to 1993, are retrospectively analyzed. Overall postoperative lethality amounts to 4.4 per cent. The obtained results are fully comparable in terms of both missed concrements left behind within the extrahepatic bile ducts, and in terms of postoperative complications, associated with the indications for choledochotomy. This is attributed to the therapeutic approach algorithm adopted with respect to the indications for intraoperative cholangiography and choledochotomy.

[The possibilities for organ-preserving operations on the spleen]. / Vuzmozhnosti za organosukhraniavashti operatsii na slezkata.

Experience had with application of spleen salvaging operations in adult patients is shared. They are used traumatic lesions of the spleen in eleven patients, employing the method of Delany, as modified with the Bulgarian polyamide meshwork Ampoxen. In two of them the hemostasis fails, and splenectomy is resorted to. Preservation of the spleen is accomplished in one patient with chronic pancreatitis where left pancreatectomy with spleen preservation according to the technique of Pradere et al is done. In another female patient, presenting echinococcus of the spleen, echinococcectomy with preservation of the organ is performed. Based on updated knowledge of the role played by the spleen in promoting protection against infection, the strive for its salvage whenever possible is fully justified.

A case of intraduodenal diverticulum imitating choledochocele.

An intraduodenal diverticulum in 54 year old woman which caused alcalculous cholecystitis and pancreatitis is described. The diverticulum was missed at the first operation, performed for acute cholecystitis. Before the second it was interpreted as a pancreatic cyst. At the second intervention, the cyst wall was excised through a duodenotomy. Histological examination of the wall of the diverticulum is crucial for correct diagnosis.

Possibilities of preperitoneal approach methods in the treatment of groin hernias. Preperitoneal approach methods.

A series of 93 patients operated on for groin hernias by applying the preperitoneal approach is reported (89 bilateral and four unilateral). The patients were divided into two groups. Group one included 24 patients without prosthetic repair. Group two included 65 patients who had undergone repair with Ampoxen mesh. Some untraditional methods are reported, such as interparietal repair, rotative transposition of external oblique muscle aponeurosis, etc. As far recurrences are concerned, no differences were recorded between the two groups (Pt greater than 0.05). Of all 193 groin hernias 81% were followed up and the total percentage of recurrences was 4.5%. Slight testicular and neuralgic postoperative complications were reported (three and two patients respectively). The advantages of biomaterials were confirmed by ultrasound examinations of ten patients from both groups. A conclusion is made that hernia repair strategy should be based on natural groin tissue resources.