[Innovated Judet Ribs Plates - Preclinical Study, First Clinical Experience]. / Inovované zeberní dlahy Judetova typu ­ preklinická studie, první klinické zkusenosti.

PURPOSE OF THE STUDY Based on the experience with using the Judet plates in stabilization of rib fractures an innovated Judet plate was constructed in cooperation with the Development Department of Medin company. During the preclinical part of the project, following the construction of the new Judet plate, a surgical technique was elaborated. Subsequently, the clinical application of rib osteosynthesis with innovated plates was commenced. MATERIAL AND METHODS In the course of the last three years the innovated Judet rib plate including the instruments were constructed by the Development Department of Medin company in cooperation with the Trauma Centre and the Department of Surgery of the University Hospital Královské Vinohrady. The goal of the innovation was the changes in technical parameters of rib plates which are compared with the new plates of other companies: 1. Adequate plate stability along the rib axis. 2. Creation of fixation clips for a stable, but not traumatized fixation of the plate around the rib. 3. Decreased robustness of the plate with sufficient stiffness. 4. Working out of a new technique of plate fixation with the use of new instruments. 5. Ensuring plate fixation with cortical locking screws. In the preclinical part of the project osteosynthesis of the broken rib was performed with a plate on a chest model for the basic types of rib fractures. Subsequently, the plate was used for rib osteosynthesis in a cadaver. The goal of the new instruments was besides temporarily maintaining the rib fracture reduction also the subsequent temporary application of plates with the assistance of fixation tongs before the final fixation of plates. In 2017, the clinical part of the project on the stabilisation of flail chest with the innovative Judet plates was launched. This type of innovative Judet plates has so far been used in 3 patients. RESULTS As to the surgical technique of ribs osteosynthesis: The profile of the plate has been adapted to the rib profile and can be further adjusted to rib curvature, also the fixation shoulders of the plates have been reshaped. The innovated plate has been complemented with a new configuration of fixation clips and the possibility to fix the plate with locking screws. The used cortical locking screws enable appropriate stabilisation of plates. They were tested on a laboratory model of ribs and on a cadaver using the new set of instruments. The plates can be easily shaped with tongs. The anchorage of fixation clips is adequately provided for also by means of tongs. The plates can be fixed to the rib without any significant compression of intercostal nerves. The essential change of the innovated Judet plate is its weight, which meets the contemporary trends in construction of rib plates designed for anatomical fixation. The first experience with the innovated plates in flail chest injury confirmed the safety of the procedure for stable osteosynthesis of rib fractures. Adequate stability of the chest wall facilitated an early withdrawal of ventilatory support. Osteosynthesis of rib fractures with innovated plates performed in the first three patient was without complications, including in the postoperative period. DISCUSSION A series of prospective studies prove the correctness of the indications of early rib osteosynthesis in flail chest. Further indications for rib osteosynthesis are postinjury chest deformity, dislocation of rib fracture fragments with a lung injury, and malunion of rib fracture. According to these studies the surgical stabilisation of the chest is a safe and efficient method resulting in pain reduction, decrease of ventilatory support time, and also in reduced morbidity. For rib osteosynthesis anatomical plates, Judet plates and intramedullary plates are used. Our innovation of the Judet plate aimed to improve the technical parameters of the plate. The innovative Judet plate means a significant improvement in technical parameters and stands comparison with the plates of others companies, which are used in the Czech Republic. This is also evidenced by preliminary clinical results. CONCLUSIONS Surgical stabilisation of the flail chest segment is considered to be he method of choice in treating selected patients, leading to the improvement of respiratory function and shortening of the ventilatory support time. The new technical parameters of the plate, including its weight, new fixation clips, locking screws and instruments are the priorities of the innovated Judet plates. The innovation of Judet plates represents an important step towards the extension of indications for surgical stabilisation of the chest. Key words:innovative Judet plates, preclinical study, osteosynthesis of rib fractures.

[Surgical Stabilisation of Flail Chest Injury: Indications, Technique and Results]. / Chirurgická stabilizace u blokové zlomeniny zeber: indikace, technika a výsledky.

PURPOSE OF THE STUDY: Multiple rib fractures with segmental chest wall instability are caused by high-energy chest trauma and are associated with significant morbidity and mortality. Flail chest injuries are mostly combined with lung injury (contusion, rupture, laceration) and subsequent pneumothorax or haemothorax. Early mechanical ventilation with internal pneumatic splinting is a conservative treatment for flail chest in patients with respiratory insufficiency. The surgical stabilisation of a flail chest is an effective method of treatment and is beneficial for selected patients. It shortens the duration of mechanical ventilation and thus reduces morbidity associated with prolonged ventilatory support. In addition, it decreases long-term pain and the inability of a flail chest to heal due to malunion, non-union or progressive collapse of the flail segment. Surgical stabilisation of a flail chest is indicated when the clinical examination shows progressive respiratory dysfunction confirmed by the results of multiple detector computer tomography (MDCT) of the thorax. MATERIAL AND METHODS: Thirty-three consecutive patients who underwent surgical stabilisation of a flail chest at the Trauma Centre between 2010 and 2014 were retrospectively evaluated. This included patient demographics, chest injury extent, results of pre-operative chest imaging (MDCT), surgical stabilisation technique and post-operative outcome. In addition to providing a radiographic finding of respiratory failure, the result of MDCT chest examination was considered an important criterion for surgical intervention. Surgical stabilisation of the chest wall was performed at an interval ranging from 2 hours to 11 days after injury. Intra-thoracic procedures were indicated in patients with lung injury (pulmonary laceration). The surgical procedure was completed by chest tube placement. RESULTS: Surgical stabilisation was carried out using 3 to 8 plates for flail segment fixation involving 3 to 4 ribs. The duration of post- operative mechanical ventilation was 5 days on the average. It was longer in patients with associated injuries such as craniocerebral trauma or severe pulmonary contusion. Tracheostomy was performed in seven patients requiring prolonged mechanical ventilation. Two patients had superficial surgical site infection. No death was recorded in the follow-up period. CONCLUSIONS: Surgical stabilisation of the flail chest segment is considered an effective procedure in selected patients, leading to improvement of respiratory function. By allowing for a shorter period of time on mechanical ventilation, it reduces the occurrence of complications due to ventilatory support. The result of MDCT chest examination in patients with fail chest is an important indication criterion for surgical fixation.

[The spectrum of diaphragmatic injuries managed in a Prague traumatology centre]. / Spektrum poranení bránice osetrené v traumatologickém centru.

INTRODUCTION: Diaphragmatic injuries may result from blunt or penetrating injuries. The symptomatology is usually overlaid by symptoms of associated abdominal or thoracic injuries or by symptoms of other systems injuries in polytraumas. Multidetector computer tomography (MDTC) facilitates the improvement of preoperative diagnostics in blunt injuries. The retrospective study included analysis of a study group of subjects with blunt and penetrating diaphragmatic injuries. PATIENTS, METHODS AND RESULTS: From 1996 to 2009, a total of 44 injured patients with diaphragmatic injuries were operated in the FNKV (Faculty Hospital Kralovske Vinohrady) Traumatology Centre. The group included 17 blunt injuries and 27 penetrating injuries. There were 39 male and 5 female subjects, aged from 17 to 76 years. 32 subjects suffered from left-sided diaphragmatic injuries and 13 subjects from right-sided injuries. The commonest type of penetrating injuries were stab injuries in 21 subjects. 40 patients suffered from associated injuries. The commonest associated injuries included liver and splenic injuries. Simultaneous thoracotomy and laparotomy for associated injuries affecting the both cavities was performed in 21 patients. Left-sided diaphragmatic injury with associated abdominal injury was managed using laparotomy. Thoracoscopy or laparoscopy was used in 3 subjects with penetrating injuries. CONCLUSION: Penetrating injuries are the commonest cause of diaphragmatic injuries, with prevailing left-sided location of the injury. MDCT is an asset in the diagnostics of blunt diaphragmatic injuries. Surgical approach was selected based on the injury location and on the presence or absence of associated injuries. The miniinvasive approach contributes to the daignostics of penetrating diaphragmatic injuries in patients with stable hemodynamic conditions.

[The role of VATS in the treatment of thoracic empyema]. / Role VATS v lécení empyému hrudníku.

INTRODUCTION: Videothoracoscopy (VTS) and video-assisted thoracoscopic (VATS) decortication is commonly used in the treatment of early thoracic empyema. However, its conversion to thoracotomy is more frequent in chronic empyema cases. The authors evaluate the role of VTS/VATS in the pleural empyema therapy in the group of patients treated for thoracic empyema using VATS or thoracotomic decortication. PATIENTS, METHOD AND RESULTS: The retrospective study included 165 patients who underwent surgery for thoracic empyema. Pneumonia was the the commonest cause of pleural empyema (77%), while elective lung and esophageal surgery resulted in pleural empyema in 11% of the subjects, trauma in 9% and intraabdominal infection in 3% of the subjects. The subjects were diagnosed with thoracic empyema stage II or III either prior to the procedure on CT examination, or during the procedure. VTS/VATS was indicated in 52 subjects, and conversion to open decortication was required in 23 of them. Open thoracotomic decortication was performed in 113 subjects. VTS/VATS was successful in stage II disorders, in particular in the removal of pus and fibrin, with targeted chest drain insertion. VATS decortication was performed in 15 subjects with stage II or early stage III disorders. In open decortications, the procedure was extended to lung resection (8x lobectomy and 10x wedge non-anatomical resection) for residual abscess pneumonia or lung abscess. Conservatively managed postoperative complications included protracted chest drain air leak (11 patients) and fluidothorax relapses which were treated with redrainage (8 patients). Early postoperative rethoracotomy was indicated in 6 patients for hemothorax, resulting from hemocoagulation disorder in septic conditions. 4 patients were indicated for rethoracotomy for empyema relapses. During the postoperative period, 6 patients exited in the open decortication group. CONCLUSION: VTS is the method of choice in the treatment of stage II thoracic empyema, with a potential for the infectious focus removal, targeted drainage and lung reexpansion. VATS is an alternative thoracotomy method for decortication in the early stage III empyema. Decortication via thoracotomy is a standard treatment method for the management of chronic empyema.

[Penetrating thoracic and abdominal injuries: diagnostic and therapeutic approach]. / Penetrující poranení hrudníku a bricha: diagnostický a lécebný postup.

INTRODUCTION: Penetrating thoracic or abdominal or combined injuries are associated with high risk of life-threatening intraabdominal or intrathoracic organ injury. Most patients require acute surgery. When miniinvasive technique is available, thoracoscopic or laparoscopic intervention is indicated in hemodynamically stable patients to evaluate severity of the injury, as well as to treat the condition. AIM OF THE STUDY: Retrospective analysis of incidence, diagnostics and treatment of penetrating thoracic and abdominal injuries and combined thoracoabdominal injuries in a Trauma centre. PATIENTS, METHODS AND RESULTS: A total of 195 patients with penetrating thoracic, abdominal or combined injuries, who were hospitalized in the FNKV (Krilovské Vinohrady Faculty Hospital) Trauma centre in Prague from 1999 to 2010, were included in the study. The study group included 177 (91%) males. Out of the total, 102 patients (53%) suffered from penetrating abdominal injuries, 71 (36%) from thoracic injuries and 22 (11%) from combined, thoracoabdominal injuries. The majority of injuries were stab injuries (173, i.e. 89% of the patients). 22 subjects, the penetrating injury was caused by shot injuries. In stable patients, MDCT has been lately used to establish the diagnosis. In 171 subjects, acute thoracotomy or thoracotomy was indicated. Patients with combined injuries of the both cavities were indicated either for thoracotomy and laparotomy or thoracophrenolaparotomy. Videothoracoscopy or laparoskopy was conducted in 21 (11%) of the subjects. During the surgical revision, two subjects exited due to ireversible hemorrhagic shock, further 2 subjects died because of septic complications following shot abdominal injuries. CONCLUSION: Incidence of penetrating thoracic, abdominal or combined thoracoabdominal injuries is fairly rare in our country. Subjects with unstable hemodynamic conditions are indicated for acute thoracotomy or laparotomy. Miniinvasive procedures have diagnostic and therapeutic benefit in stable patients. Diagnostic thoracoscopy and laparocopy provides evidence of some injuries (diaphragm, alimentary tract). Therapeutically, miniinvasive methods may be used to manage the source of bleeding and for targeted drainage. Nonsurgical procedure is the method of choice in a selected group of hemodynamically stable patients with stab injuries, with monitoring of the patient's condition, including the use of x-ray imaging.

[Hemorrhagic complications of warfarin therapy]. / Hemoragické komplikace lécby warfarinem.

INTRODUCTION: Introduction of warfarin use in prevention and treatment of thromboembolic diseases resulted in lower rates of thromboembolic complications, however, on the other hand, it has been associated with increased incidence of hemorrhagic complications,which often require surgical management. AIM, MATERIAL, METHODS: The aim of the study was a retrospective analysis of hemorrhagic complications in 184 patients, hospitalized in the FNKV (Královské Vinohrady Faculty Hospital) Surgical Clinic during 2000-2008, following warfarin overdose. The following diagnostic or treatment methods were used: endoscopy of the upper or lower GIT in GIT hemorrhages and spiral CT when peritoneal bleeding was suspected. RESULTS: GIT bleeding, such as hematemesis, melena, enterorrhagy, was the commonest complication observed in 147 patients, ie. 79.9%. Upper GIT was identified as the source of bleeding in 76 subjects, i.e. 51.7%, lower GIT was the identified source in 26 subjects, ie. 17.7%, and the source remained unidentified in 45 patients, ie. in 30.6%. 10 patients suffered from soft tissue bleeding, m. rectus abdominis hematoma was detected in 7 subjects, hemoperitoneum and/or retrohemoperitoneum was identified in 8 subjects. Intestinal wall or its intestinal peritoneum was affected in 3 subjects and 3 patients suffered from liver or splenic intraparenchymal hematoma. Out of the total of 184 patients, 165 subjects were treated conservatively (89.7%), 19 subjects underwent surgery (10.3%), including 14 laparotomies for acute abdomen symptoms and 5 incisions with removal of hematomas. Overall lethality rate was 7/184, ie. 3.8%, 5 subjects undergoing conservative treatment and 2 subjects undergoing surgery exited. CONCLUSION: Uncontrolled warfarin administration may cause serious, even life- threatening complications. Therefore, patients undergoing warfarin therapy should be adequately informed about potential complications and regular INR monitoring is required.

[Contemporary approach to treatment of the posttraumatic empyema of the thorax]. / Soucasné moznosti lécení poúrazového empyému hrudníku.

INTRODUCTION: Empyema of the thorax is a serious morbidity and mortality causative factor in the postoperative period in severe blunt and penetrating thoracic injuries. The posttraumatic empyema of the thorax results, primarily, from secondary infections of the haemothorax. Current therapeutic management of the posttraumatic empyema of the thorax depends on the disease stage. AIM: A retrospektive analysis of the treatment procedures in patients with posttraumatic empyemas of the thorax. MATERIAL, METHODS, RESULTS: A study group included 118 patients with empyemas of the thorax, who were operated during the period from 1996 - June 2005. The commonest type of the empyema was a parapneumonic empyema, present in 86 (73%) subjects. 15 (13%) patients were operated for posttraumatic empyemas of the thorax. In 13 (11%) patients the empyema followed elective intrathoracic procedures (lung or oesophagus resection). In 4 (3%) cases the empyema resulted from intraabdominal inflammatory disorders. The cause of the posttraumatic empyema of the thorax was a secondary infection following repetitive drainages for the pneumothorax in three patients, infection of the retinated haemothorax in two patients and infection of the pleural exudate from a subphrenic absces following a stab injury of the abdomen in one patient. Another patient developed empyema as a complication of the oesophagus perforation by a foreign body. 8 injured patients with ventilation pneumonias developed parapneumonic empyemas. The patients were indicated for surgeries. Videothoracoscopic procedures (VTS, VATS) proved successful in 4 injured patients with empyemas, stage II. Thoracotomy with decortication was conducted in the remaining 11 injured patients (in 3 of them as a VTS conversion). The postoperative course following the decortication in the injured group with the posttraumatic empyema was complicated by a protracted air leak with a partial pneumothorax in two subjects and by a relaps of the pleural exudate in one operated subject. CONCLUSION: 1. Open thoracotomy with empyemectomy and decortication is a standard treatment method in the thoracic empyema, grade III. 2. The videothoracoscopic procedures (VTS, VATS) are indicated in early forms of the grade II of the disorder. 3. The quality and the result of the therapy depend on the following: the management of the focus of the infection, as well as a sufficient lung expansion while the residual pleural cavity is being minimized and also the management of the air leak from the lung.

[Surgeries for blunt and penetrating thoracic injuries]. / Operace u tupého a pronikajícího poranení hrudníku.

INTRODUCTION: Up to 50% deaths due to fatal injuries result from thoracic injuries. Approximately 10-15 % of the injuries require thoracotomy. AIM OF THE STUDY: Indications and outcome of the surgery were assessed, based on the restrospective analysis data from subjects operated for blunt and penetrating thoracic injuries. SUBJECTS, METHODOLOGY AND RESULTS: 85 patients were operated for blunt or penetrating thoracic injuries during the period from 2000 to May, 2006. Urgent procedures for blunt thoracic injuries were performed in 13 subjects, and for penetrating injuries in 52 subjects. Immediate thoracotomy was indicated in 4 subjects suffering from stab injuries of the heart. 16 subjects were operated consequently for posttraumatic intrathoracic complications in blunt thoracic injuries. 4 subjects exited early postoperatively (4.7 %). CONCLUSION: The aim of urgent surgical interventions is to manage the major bleeding source (heart or large vascular injury), lungs, air leakage (tracheal or bronchial injuries) and diaphragmatic injuries. Irreversible hypovolemic shock in penetrating thoracic injuries and serious related injuries in blunt traumas resulted in peroperative and postoperative mortality.

[Traumatic rupture of the diaphragm in blunt injuries]. / Traumatická ruptura bránice u tupého poranení.

The authors present a group of 12 casualties operated on account of a traumatic rupture of the diaphragm. The rupture of the diaphragm was part of an associated thoracoabdominal injury or multiple injury. The casualties were examined within the framework of the diagnostic algorithm, in 11 of them rupture of the diaphragm was proved by spiral computed tomography. The diaphragm was injured in 7 subjects on the left and in 5 on the right. In 8 casualties during injury of the diaphragm also a serious intrathoracic injury was treated (in 5 laceration of the lungs) and of intraabdominal organs (in 4 laceration of the liver and in 2 laceration of the spleen). On the left side injuries of the diaphragm were always treated from laparotomy, on the right in 4 patients from thoracotomy. In 4 patients with concurrent injury of the intrathoracic and intraabdominal organs a thoracoabdominal approach was selected. During the postoperative period one female patient with multiple injuries died. The cause of death was contusion of the brain. According to the authors' experience it is useful to apply for early diagnosis of diaphragmatic injuries modern non-invasive imaging methods (spiral post-contrast computed tomography). The surgical approach depends on the presence of associated intrathoracic and intraabdominal injuries. The therapeutic results are limited by the presence of serious associated injuries.

[Indications for emergency surgery in thoraco-abdominal injuries]. / Soucasné indikace k neodkladným operacím u torakoabdominálních poranení.

PURPOSE OF THE STUDY: Under the conditions of an increasing number of car accidents and criminal injuries the thoracis and abdominal trauma is a source of a significant morbidity and mortality in blunt and penetrating mechanism of injury. On the basis of a group of patients operated on for blunt and penetrating injury of the chest and abdomen evaluation was made of the current indication and results of lifesaving surgery in case of these injuries. PATIENTS: The group included 68 patients requiring a lifesaving surgery for a blunt and penetrating injury of the chest and abdomen hospitalized between the beginning of 1966 and the end of April 2001. Forty-five patients sustained a blunt injury and 23 a penetrating injury. METHODS: In case of blunt injuries the indication for surgery was determined on the basis of clinical examination supplemented with a radiograph examination of the chest and spiral computer tomography. In case of penetrating stab wounds the surgery was indicated on the basis of clinical examination, in gunshot wounds by means of x-ray examination and spiral computer tomography performed in order to assess the scope of the injury of intraabdominal organs and the location of the projectile. Indicated on the basis of the examination in the blunt injury was thoracotomy in 6 cases, laporatomy in 34 cases and the combination of thoracotomy and laparotomy in 5 patients. In case of the penetrating injury thoracotomy was performed in 8 cases, laparotomy in 11 cases and the combination of thoracotomy and laparotomy in 4 patients. RESULTS: In the post-operative period 6 patients (9%) died: 3 patients with a polytrauma died from an irreversible damage caused by a protracted hemorrghagic shock, one female patient from the contusion of brain, one patient after splenectomy for an isolated injury died from cardiorespiratory failure and pneumonia, one patient with a stab wound of the left ventricle of the heart died from the heart failure by hypoxy. DISCUSSION: Indication for a lifesaving thoracotomy and laparotomy in our group of patients operated on corresponds to the overviews of surgeries in thoracoabdominal injuries presented in literature. The procedure in preoperative examination is identically limited by the stability of hemodynamics in the patient after the injury using mainly ultrasound and computer tomography of the stabilized patient. In contrast to a number of authors in our conditions we have not performed some of the intervention examinations such as diagnostic peritoneal lavage or thoracoscopy and laparoscopy. The improvement of results in patients operated on for thoracoabdominal injury is in our conditions given both by the timeliness of the operation in the availability of examination methods (US, spiral CT) and by adequate stabilization of the patient in the peroperative period at the emergency department. CONCLUSION: Priority indication for a lifesaving surgery in thoracoabdominal injuries is significant intraabdominal bleeding diagnosed on the basis of the result of the clinical examination in hemodynamically unstable patients. In a stabilized patient the lifesaving surgery is performed on the basis of the result of visualization methods (spiral computer tomography, ultrasound, angiography, endoscopy) revealing apart from significant bleeding also severe injuries of intrathoracic and intraabdominal organs. Protracted hypovolemic shock with the development of multi-organ failure or the occurrence of simultaneous severe associated injuries in polytrauma are the most frequent causes of mortality in patients operated on for thoracoabdominal injury.

[Empyema of the thorax]. / Empyém hrudníku.

The authors evaluated the therapeutic procedure and results in patients with empyema of the chest. From December 1996 till June 1998 at the Surgical Clinic of the Third Medical Faculty, Charles University Prague 21 patients with empyema of the chest were hospitalized. The most frequent cause of empyema of the chest was pneumonia in 13 patients (62%). In 16 patients (in 76%) the empyema was classified as the third stage of the disease. Decortication, the most frequent procedure, was performed in 16 patients, incl. three where it was done using videothoracoscopy. Surgical treatment was supplemented by antimicrobial treatment, either monotherapy or a combination of antimicrobial preparations. From the total number one patient died 25 days after thoracotomy and partial decortication with a mesiotheloma of the pleura. The other patients have no signs of relapse of empyema. According to the authors experience the selection of the surgical procedure depends on the stage of the disease. In the authors group decortication by the thoracotomic route was used most frequently.

[Intrathoracic occurrence of post-transplantation lymphoproliferation]. / Nitrohrudní výskyt posttransplantacní lymfoproliferace.

In the submitted case-history the authors wished to draw attention to serious complications after transplantation. Posttransplantation lymphoproliferation (PTLP) is a rare complication of organ transplantation, its incidence amounts to some 2% of organ recipients, in combined heart-lung transplantations the incidence is as high as 10%. The prerequisite of lymphproliferations is infection with the Epstein-Barr virus. The virus causes transformation of B lymphocytes and subsequent lymphoproliferation. Immunosuppressive preparations, due to their effect on Tlymphocytes promote this transformation. The decisive imaging method in tumoriform occurrence is high resolution computed tomography. Based on CT examination surgical biopsy is performed with subsequent in situ hybridization which confirms unequivocally the diagnosis of posttransplantation lymphoproliferation. Only on the basis of results of in situ hybridization treatment may be started which involves restriction or discontinuation of immunosuppressive treatment and administration of antiviral preparations. Frequently this treatment fails and must be discontinued on account of a rejection reaction of the organism. The prognosis in untreated forms is adverse.

[Amputation of the lower extremities, contribution of collaboration with a vascular surgeon]. / Amputace dolních koncetin, prínos spolupráce s cévním chirurgem.

In 1990 due to collaboration with a vascular surgeon the care of patients with diseases of the peripheral vessels of the lower extremities improved. As compared with previous years, the rate of amputations of the thigh changed markedly as well as the rate of reoperations and the period of hospitalization was reduced.

[Tracheal replacement with a swine prosthesis]. / Substituce trachey protézou z vepre.

In 12 experimental operations the authors tested the biocompatibility of a xenologous trachea from a pig which was used to replace a 5 cm defect of the trachea in a dog. After special preparation eliminating the antigenicity of the pig trachea the thus prepared graft was sutured into the thoracic portion of the dog trachea. The experiment could not be evaluated in two instances because the dog died on the operating table. In the remaining ten cases it was found that all anastomoses healed perfectly. The fibrous tissues of the tunica propria of the graft was replaced by granulation tissue. Across the anastomoses newly formed capillaries penetrated into the trachea where they caused chondrolysis. This led to a breakdown of the central portion of the prosthesis and stenosis in the airways with terminal respiratory failure. The mucosa of the graft was at some sites covered by metaplastically altered epithelium. Even a reinforcing vascular prosthesis did not prevent the breakdown of the wall of the xenologous graft. An asset for future work is the finding of a well healed suture between the graft and the trachea and evidence that newly formed blood vessels penetrated into the prosthesis.

[Videothorascopic surgery--initial experience]. / Video torakoskopické operace--nase první zkusenosti.

Practical experience with the miniinvasive laparoscopic technique in abdominal surgery logically led to extension of this method to thoracic surgery. Video-assisted thoracoscopic operations hold their place in the treatment of spontaneous pneumothorax, pleural syndrome, benign tumours of the thoracic wall etc. A curative solution of malignant diseases by this route is so far controversial and is reserved only for specially defined cases. Experience from the authors' department is based on nine-month use of a thoracoscopic apparatus. The authors operated a total of 21 patients thoracoscopically, incl. pneumothorax 6x, fluidothorax 10x and tumourous disease of the lungs or mediastinum 5x. The use of thoracoscopy is controversial in metastases of the lungs and in thymectomy. With regard to the authors are against thoracoscopic indications in the latter conditions contemporary technical possibilities.