Features of surgical tactics for injuries of abdominal and retroperitoneal major veins (review of literature)

Injuries of abdominal and retroperitoneal major veins, especially in combination with pelvic fractures, are accompanied by high mortality and require further improvement of treatment tactics. The objective of the study was to analyze the data from Russian and foreign literature for improving the treatment of patients with injuries of the major abdominal veins, including pelvic bone fractures, by General surgeons. The article considers treatment options for patients with damage to major abdominal veins, describes the methods of temporary and final hemostasis, features of temporary prosthetics and vascular suture, and considers indications for endovascular interventions. CONCLUSION. Indications for endovascular methods of treatment of injuries of abdominal and retroperitoneal major veins are expanded. For general surgeons, knowledge of rational approaches and methods of temporary and final hemostasis is necessary to save the life of the sufferer.

PHENOMENON OF DEMIKHOV. In the Sklifosovsky Institute (1960–1986). Demijоv V.P. Transplante experimental de órganos vitales. Madrid: Editorial Atlante, 1967

For the first time, the article introduces into scientific circulation and analyzes the Preface by V.P. Demikhov to his book "Transplantation of vital organs in experiment", published in 1967 in Spanish under the title "Transplante experimental de órganos vitales". Judging by the facts mentioned in the text, V.P. Demikhov wrote it in 1966, reflecting his views on the current state and prospects of homoplastic tissue and organ transplantation. As in previous publications, in particular, in the Preface to the German edition of the book published in Berlin in 1963, V.P. Demikhov substantiated the concept that the main condition for a successful transplantation of homoplastic organs was to restore the blood circulation in them. In his opinion, the success of engraftment depends, first of all, on the ideally performed vascular suture and the immediate inclusion of the transplanted donor organ into the blood circulation of the host body, as well as on the sterility of the undertaken intervention. Having discussed the use of pharmacological immunosuppression as a method of overcoming the biological incompatibility of homologous organs during their transplantation, V.P. Demikhov pointed out the toxicity of the drugs used for this purpose he tested experimentally, as well as his experiments, indicating the possibility of overcoming incompatibility by means of other methods (the selection of the donor and recipient with regard to the blood group, mixing the blood of the donor and recipient by parabiosis, etc.). In this text V.P. Demikhov again mentioned the scheme he had developed for two-stage transplantation of an additional heart as a reserve organ to maintain the function of the patient's decompensated heart and named the main stages of the operation: implantation on the femoral vessels (stage 1) and transplantation into the chest (stage 2). As in the Preface to the German edition of the book, V.P. Demikhov spoke in detail about the model of a “living physiological system” he had developed in 1963 aimed at creating a bank of reanimated organs that would retain their viability until transplanted into another body. Projects for growing the organs in anencephalic newborns for the rejuvenation of the elderly were also outlined.

Basic Principles in Microvascular Anastomosis and Free Tissue Transfer

Free tissue transfer pursues the best functional and aesthetic results in reconstructive surgery. As these techniques completely maximise the donor tissues’ disposability, these treatments have become a first-line option in many situations. When the donor site is taken form the same patient, these surgeries are often referred to as autotransplants. Free tissue transfer sustains in microvascular anastomosis, which are defined by a vessel lumen diameter inferior to 3 mm. Particular attention to some details is important in these techniques, as, for example, to preclude any damage to the vessel walls or any leakage in the microvascular anastomosis. But the success of these techniques does not only depend on an adequate vascular suture, but also on a constellation of details that must be taken into account. These go from the availability of a trained team, to the ergonomics of the surgeon, through the scrupulous cleanliness of the surgical field.

A temporary bypass used in end-to-end anastomosis of major vessels without stopping blood flow in the segment under repair

The authors developed an original set of tools and a method of carrying out end-to-end anastomosis on major vessels, without stopping blood circulation in the vascular segment being repaired. The proposed set of tools includes 10 tubes (temporary vascular grafts) made of medical silicone with external diameters from 8 to 26 mm. The length of each tube is not less than 10 cm, and the wall thickness is 1.2 mm. A spiral notch with a step of 1.2 mm is made on the outer surface of the tubes, to a depth of 1 mm. The set of tools also includes a set of metal hollow half cylinders with a through hole made in the middle, designed to extract the temporary shunt of the appropriate diameter. Before the formation of a vascular anastomosis, a silicone tube is selected, the outer diameter of which corresponds to the inner diameter of the damaged vessel. It is necessary to cut off a length of the tube, so that 23 cm of it could be introduced into the lumen of the proximal and distal segments of the damaged vessel. A stay-suture is laid in the center of the temporary bypass, on a site of its wall between two neighboring spiral notches. The ends of the temporary bypass, pre-filled with saline solution, are introduced into the distal and proximal ends of the divided vessel and are firmly fixed in the lumen of the vessel with two elastic bands. After placing the temporary bypass in the lumen of the damaged vessel, the blood flow is restored. Using the intraluminar temporary shunt as a scaffold, the edges of the vessel are approximated and stitched to its entire circumference, tying the first and last stitches of this seam. The last additional suture is placed in the area of the stay-suture overlying the wall of the temporary vascular shunt and is not tightened. A half-cylinder is placed above the untightened vascular suture and a stay-suture is placed at its opening. After that, tightly pressing the metal hollow half-cylinder to the vascular wall, and applying traction to the ends of the stay-suture the mechanical destruction of the silicone tube along the line of the spiral incision ensues. As a result, the tube is transformed into a double silicone rod, which is pulled through a through hole in the metal half-cylinder floor. After the extraction of the tube, the anastomosis is completed by tying a knot on the provisional suture. To simulate the proposed method, 10 operations were performed using a closed experimental circuit that completely simulates the real situation of restoring a damaged major vessel. The time of the operation, the technical features of the intervention, as well as the volume of blood loss, which was estimated by reducing the volume of blood circulating in the experimental circuit, were evaluated. Experimental testing with the use of a model simulating the situation of restoring a damaged major vessel, demonstrated the effectiveness of the developed method of applying a vascular end-to-end anastomosis with the use of a destructible temporary bypass; the average time of the operation was 10 minutes, and the volume of blood loss did not exceed 5 ml. The proposed set of tools and method can be effectively used in case of major vessels injury. The technique completely excludes the need for interrupting blood flow through the sutured vessel; it allows to reduce the volume of blood loss in vascular trauma, minimizes the time of ischemia in the area of blood supply to the damaged artery or venous stagnation of the drained segment (when suturing a vein), as well as to facilitate the imposition of a vascular suture to surgeons who do not have sufficient qualification in vascular surgery.

Through-and-Through Suture Technique to Stabilize a Sheath in Branched Endovascular Aortic Repair

Purpose: To describe a technique to catheterize antegrade branches of a branched thoracoabdominal endograft from a femoral access with the help of standard sheaths and a vascular suture. Technique: The technique is demonstrated in a patient who underwent successful complex thoracoabdominal branched endovascular aortic repair. After the deployment of an aortic endograft with two antegrade branches for the targeted renovisceral vessels, a standard braided sheath was preloaded with a 3/0 polypropylene suture and introduced inside an additional sheath from the groin to the thoracic aorta. Simultaneous gentle traction on the suture as the preloaded sheath was advanced achieved a very stable 180° curve of the proximal end of the sheath. It was possible to selectively catheterize the antegrade branches and respective target vessels sequentially, as well as deploy the planned bridging stents for each branch. Conclusion: The through-and-through suture technique is a helpful tool in branched endovascular aortic repair. It saves time, radiation, and materials; no snare is needed, and it can be preloaded into a sheath.

Superior mesenteric artery injury during laparoscopic radical nephrectomy

The authors present to your a en on a rare clinical case of complete intersec on of the superior mesenteric artery in laparoscopic radical nephrectomy. This complica on emerged in the process of learning the technique of laparoscopic radical nephrectomy, before reaching the “plateau” of the learning curve, in condi ons of poor vision and in the interposi on of tissues due to paratumorous infitiltra on. This type of injury has a high risk of total necrosis of the small intestine. However, due to the concerted ac ons of the surgical service and the readiness of surgeons to complete the vascular suture of the main vessels, a successful reimplanta on of the superior mesenteric artery into the aorta was performed. This is confi rmed by postopera ve observa on and examina on, which included CT angiography. It should be noted that descrip ons of cases of aor c reimplanta on of the superior mesenteric artery are extremely rare in the world and national literature, except for cases of mesenteric ischemia. This case contributes to the description of rare cases of aor c reimplanta on of the superior mesenteric artery and shows the correctness of the selected surgical tactics.

Analysis on the Curative Effect of Improved Radial Artery and Cephalic Vein Anastomosis in the Fistulation for the Hemodialysis in Patients

To investigate the application of improved radial arteryand cephalic vein anastomosis in the fistulation for the hemodialysis in patients, 80 cases of patients with chronic renal failure were randomly divided into two groups, a control group and an improved group. The procedure for the wrist radial arteryand cephalic vein anastomosis was improved, in which in a way of continuously everted full-thickness suture, the distal end of radial artery and the proximal end of cephalic vein were anastomosed. The patients were examined by the different methods before the surgery to evaluate the patients’conditions. Patients in the improved group underwent the anastomosis of the wrist radial artery and cephalic vein in a way of continuously everted full-thickness suture, and those in the control group underwent the anastomosis in the conventional way. The improved procedure showed some advantages, such as reduced anastomotic blood leakage, good alignment of the arteryand veinwalls, shortened vascular suture time, and less knot of sutures at the anastomotic junction. The improved procedure should be appropriated for the patients whose Allen's test is negative and cephalic vein is good in the blood flow and filling. However, the weak blood reflux of the distal end of radial artery should bethe contraindication for the improved procedure.