[Clinical and economic justification of icg-cholangiography in «difficult¼ laparoscopic cholecystectomy]. / Kliniko-ekonomicheskoe obosnovanie kholangiografii s indotsianinom zelenym pri «trudnoi¼ laparoskopicheskoi kholetsistektomii.

OBJECTIVE: To prove from a clinical and economic point of view the expediency of using ICG cholangiography in patients with «difficult¼ laparoscopic cholecystectomy for the prevention of damage to the bile ducts. MATERIAL AND METHODS: The results of treatment of 173 patients with cholelithiasis at various levels of health care providing were analyzed with regard to assessment of indicators of surgery complexity, developed complications and economic costs. RESULTS: The effectiveness of the original scale of «difficult¼ laparoscopic cholecystectomy has been proved. The financial and economic costs of treatment of patients with damage of biliary ducts and patients with cholelithiasis without development of complications have been analyzed and evaluated. A comparative description of financial costs for patients with «difficult¼ laparoscopic cholecystectomy with the use of ICG-cholangiography has been given. A program on care delivery for patients suffering from cholelithiasis in the conditions of region with regard to safety and economic effectiveness has been developed. CONCLUSION: The implementation of this program provides the minimization of postoperative complications and fatality at all levels of surgical care delivery. It has been established that a rational approach to reducing the number of biliary ducts damages is their prevention by prediction of «difficult¼ laparoscopic cholecystectomy and performance of such interventions in medical organizations of III level with the possibility of modern technologies use.

[Implementation of the «safe cholecystectomy¼ program in the Leningrad Region]. / Realizatsiya programmy «bezopasnaya kholetsistektomiya¼ v Leningradskoi oblasti.

OBJECTIVE: To present a treatment program for patients with cholelithiasis in the region in accordance with modern requirements for the quality of medical care in the realities of a three-level system of surgical care. MATERIAL AND METHODS: The results of treatment of patients with cholelithiasis at various levels of medical care were analyzed with an assessment of the indicators of operational activity of performing cholecystectomy by laparoscopic and open methods, the development of complications of surgery and inpatient mortality. RESULTS: A programmatic approach has been developed to assist patients with cholelithiasis in the conditions of regional healthcare at different levels of surgical care. CONCLUSION: The implementation of this program minimizes the number of postoperative complications and mortality at the second and third levels of surgical care. It is determined that a rational approach to reduce the number of bile duct injuries is their prevention by impeccable compliance with the technique of surgical intervention on the organs of the upper floor of the abdominal cavity, and to reduce the number of negative consequences - compliance with the proposed algorithm of diagnosis and treatment.

[SUBSTANTIATION OF SURGICAL APPROACH IN IATROGENIC INJURIES OF THE BILE-EXCRETING DUCTS].

The results of examination and treatment were analyzed in 51 patients with iatrogenic injuries of the bile-excreting ducts. Patients were divided into 5 groups according to international classification (EAES, 2013). It depended on the time of detection, the nature and scale of damage of the bile ducts, mechanism of injury, development of infectious and septic complications. Injuries of the main bile duct were detected intraoperatively (n = 14). The complete intersection was in 10 patients (the first group) and the edge intersection--in 4 cases (the second group). Iatrogenic injuries of the bile-excreting ducts were revealed in 37 patients in postoperative period. There were the complete intersections in 28 cases (the third group) and the edge intersections--in 7 cases (the fifth group). Injuries of additional bile ducts were determined in 2 patients (the fifth group). An analysis of the main qualifying features of iatrogenic injuries of the bile-excreting ducts allowed defining indications to reconstructive-restorative surgery in 60.8% patients, restorative operations--in 29.4%, an external drainage--in 5.8% and reclipping of additional bile ducts in relaparoscopy--in 3.9%. The rational surgical approach allowed obtaining perfect results in 65.8% and good, satisfactory results in immediate and long-term period with low postoperative lethality of 1.95%. The study of diagnostics results and treatment of the patients with iatrogenic injuries of the bile- excreting ducts indicated about reasonability of assessment of main factors, which are based on iatrogenic injuries according to the EAES classification. An individual program of examination and more rational variant of surgery could be chosen due to this approach, which provides minimization of negative results and good quality of life.