[The variants and potentials of reconstructive surgery of the penile skin]. / Varianty i vozmozhnosti rekonstruktivnoi khirurgii kozhi polovogo chlena.

The authors have operated 24 patients to repair total and subtotal defects of penile integuments due to oleogranuloma. They have performed a total of 13 transplantations of axial island cellolocutaneous inguinal flaps basing on the external pudendal, superficial epigastric or superficial circumflex iliac arteries; 3 transplantations of free axial inguinal grafts; 2 transplantations of free axial grafts from the forearm on the radial artery. Microvascular anastomoses with the recipient zone vessels were formed. 8 two-stage Reich operations were conducted. Postoperative dynamic monitoring (skin thermometry, oxygen polarography, Doppler ultrasound scanning of the vessels) of the graft has found more favourable vascular reactions in the axial flaps vs. scrotal ones. Effective contralateral grafting was performed in a patient with the transplant necrosis on the superficial epigastric artery.

[Hand reconstruction and prosthesis]. / Rekonstruktsiia i protezirovanie kisti.

An experience of the work has shown that of 36 patients with severe defects of the hand after amputations who had been completely informed and free to decide, plastic operations were made on the majority (25) of the patients, microsurgical transplantations of toes (15) included. However 11 patients were satisfied with the prostheses alone. A complex method of rehabilitation was worked out including surgical plasty of one of the two clutch branches and the prosthezing of the other (11 patients).

[Microsurgery of the appendix testis (experimental research)]. / Mikrokhirurgiia pridatka iaichka (éksperimental'noe issledovanie).

Based on their own experience with 83 reconstructive microsurgeries performed for epididymis obstruction the authors concluded that a simple incorporation of microsurgical techniques into the surgery of excretory infertility failed to substantially improve the results of the treatment. Supposing a well-managed clinical study to be the main tool to provide better results and the data of animal studies to be inapplicable for the diseases of the human reproductive system, the authors suggested that the aforementioned study in the clinical settings should conform to the two major requirements: an uniform pattern of the techniques employed and an exacting control over anastomosis application. As a method of choice, end-to-side vasoepididymostomy was offered. A training model for gaining the mastery of epididymis microsurgery techniques was developed as well. The reliability of the method was proved by experiments on 20 rabbits. 17 animals gave offsprings. The system of epididymal ducts studied in health opened the possibility of a well-founded division of epididymis into zones of surgical importance.

[The elimination of extended defects of the ductus deferens]. / Ustranenie protiazhennykh defektov semiavynosiashchego protoka.

Based on their own experience gained in 12 reconstructive surgeries performed for iatrogenic lesions of the deferent duct in 8 patients the authors came to the conclusion that in the majority of patients an immediate vasovasostomy would be a failure or incompetence because of a significant tension of the tissues. To solve the faced problem, the authors proposed a technique of extra-anatomical (supra- and subpubic) anastomosis which enabled one to reduce the length of the duct by 9-19 cm. Transplantation of the duct's segments in the rat failed to demonstrate any benefit in case of homotransplantation of the duct's segments whereas autotransplants survived in 70 per cent of the cases and provided a 40 per cent recovery of the duct's patency. No signs of endoprosthetic effect on the transplantation outcomes were evident.

[Microsurgical reconstruction of the forearm tendons]. / Mikrokhirurgicheskoe vosstanovlenie sukhozhilii na predplech'e.

The authors analyse their clinical experience of treating 5 patients with immobilization of the hand and propose to use complex and composite vascularized grafts for the plasty of extensive defects of tendons and skin of the forearm. They consider microvascular grafting of skin flaps from the back of the foot with tendons from the extensors of the toes with their own paratenon to be an excellent material for the reconstruction of the tendons of the flexors. They advise to use the vascularized broad fascia of the hip incorporated into the lateral flap from the hip for the plasty of extensive defects of the tendons of the extensors. The authors point out that the indications for using a combined graft from the back of the foot carrying vascularized tendons require further elaboration.

Microsurgery of epididymis: laboratory background for further clinical trial.

Based on the experience of 75 microsurgical reconstructions of the obstructed epididymis, the authors conclude that a simple introduction of microsurgery does not improve the results significantly. This experience, however, has provided a better understanding of the most important problems of epididymal surgery and has shown the ways to solve them. The principal means, they believe, is a well organized clinical study. Experimental data are hardly applicable to human sperm viae pathology. This clinical study should satisfy two requirements: a uniform operative technique and special account for an anastomosis level. End-to-side vasoepididymostomy is suggested to be the method of choice. A training model for epididymal microsurgery is elaborated and used for working out the above-mentioned technique. The reliability of the technique is shown in 20 rabbits, with litters from 17 couples. A special investigation of the microsurgically significant details of epididymal anatomy substantiates several separate zones marking out.

Treatment of vas deferens large defects.

Based on the experience of 12 vas deferens reconstructions in 8 patients with iatrogenic (post-herniotomy in infancy) vasa lesions the authors conclude that in the majority of such cases the length of vas defects renders direct vasovasoanastomosis either impossible or too risky, due to tension. To solve the problem the methods of extraanatomical (sub- and suprapubic) vas rerouting were elaborated that allow to shorten the vas length necessary for anastomosing by 9-14 cm. Combined with various crossover techniques, and vasoepididymostomy if necessary, the method proved valuable in most cases of extensive mono- and bilateral vasa deferentia lesions. The experimental data on vas segment transplantation obtained in rats show poor results in the homotransplantation group while autotransplants survive in 70% and provide vas patency restoration in 40%. No experimental proof in favour of endoprosthesing of vas grafts is obtained.

Lower leg replantation in children: railroad amputation.

Replantation in the lower leg, although technically feasible, still remains a complicated clinical issue in terms of the decision-making process. In children, a limb salvage or replant procedure would seem preferable; however, in crush amputations from railroad injury, a very severe trauma, difficulties in treatment should be thoroughly weighed against prosthetic possibilities: for example, only a fair or good functional outcome would justify an attempt to replant a severed shin. Unfortunately, the outcome in most cases is unpredictable at the time of initial evaluation, and even during the replantation procedure itself. To facilitate prognosis, the authors determine four typical variants of replantation course and outcome, based on local patient conditions, although they stress that no clear indications for replantation vs. prosthesis can be derived from the variants listed. Rather, general guidelines for the surgeon's decision at a very early stage of treatment are presented. Choice of procedure and tactics cannot be determined once and for all, because the prognosis for functional outcome can change during the course of treatment. Among a few well-defined situations are clean amputations (replantation is indicated) and traumas with very extensive crushing of the whole lower leg (replantation is contraindicated). In the majority of cases, replantation is a worthwhile attempt, but this does not imply that a replanted extremity must be preserved at any cost. The surgeon must consider the possibility of re-amputation, in case of an unfavorable variant in the postoperative course. A successful case of replantation, involving two lower leg railroad amputations in a child, is presented.

[Microsurgical autograft in children and adolescents]. / Mikrokhirurgicheskaia autotransplantatsiia tkanei u detei i podrostkov.

Children make up 18% of 238 patients subjected to autotransplantation of tissues with the help of microsurgical technique. The reestablishment of blood circulation was reached in all the operations by making microvascular anastomoses. The results obtained show that the microsurgical autotransplantation of tissues can be successfully used in children and juveniles and is a perspective method.

Functional reconstruction of both hands by free transfer of combined second and third toes from both feet.

The correction of severe trauma to both hands by two major microsurgical operations and additional minor interventions on the already functioning transplants is described. The excision of combined second and third toes as transplants inflicts an injury on the foot, but for our patient this iatrogenic trauma was justified. Careful investigation of the feet after transfer shows that their condition does not significantly impair the quality of the patient's life. The special importance of the patient's desire to regain his or her abilities and to collaborate with the medical staff is emphasized.

Microsurgical method of reuniting ductus epididymis.

Based upon the experience of microsurgical treatment of 24 patients (45 operations), we consider epididymitis to be the main cause of obstructive aspermia. Thirty-eight interventions have been performed on the occluded epididymides. A new method of seminal vias restoration evolved by us is a microsurgical epididymoneostomy. This method consists of creating an anastomosis between two parts of the ductus epididymis, bypassing its scarred focus, with or without resection of the latter. Twelve such operations were performed in six patients. Follow-up in four of the patients revealed sperm in all cases. Although fertilizing characteristics of the sperm thus obtained were low, they were better than those obtained by other methods, excluding vasovasostomy, the simplest operation providing very good results. In dealing with spermostasis of obscure genesis, we attach special importance to the "isthmic" tubule, i.e., the part of the ductus epididymis connecting its corpus and cauda. Shut-down of this tubule by shunting epididymo-epididymoanastomosis resulted in spermatozoa appearance in an ejaculate in two of three such patients. We recommend application of microsurgical technique in the treatment of obstructive aspermia.

[Reconstructive operations using the latissimus dorsi muscle for correcting the postmastectomy syndrome]. / Rekonstruktivnye operatsii s ispol'zovaniem shirochaishei myshtsy spiny v korrektsii postmastéktomicheskogo sindroma.

26 patients with postmastectomy syndrome were examined. Myocutaneous latissimus dorsi flaps on vascular or muscular pedicle were used in the reconstruction of large areas of soft tissue in axillary space and frontal chest wall. The flaps were completely assimilated in 10 cases and particularly necrotized in 2 cases due to the insufficient width of muscular pedicles which caused damage to the thoracodorsal artery.