P-084 OPEN PARASTOMAL HERNIA REPAIR: STOMA RELOCATION WITH CST, MODIFIED RIVES SUBLAY MESH TECHNIQUE WITH CST OR MODIFIED SUGARBAKER INTRAPERITONEAL MESH TECHNIQUE WITH CST

Aim

To presents results of various open surgical techniques for parastomal hernia repair.

Material and Method

Between January 2014 and January 2020, 22 patients with parastomal hernias were treated by three various operative techniques: a) stoma relocation using component separation techniques (CST); b) modified Rives sublay mesh technique with CST; c) modified Sugarbaker intraperitoneal composite mesh repair with or withouth CST. Stoma relocation and CST was performed in two patients, modified Rives sublay technique and CST in 15 patients and modified Sugarbaker technique with or without CST in five patients.

Results

Hernia recurrence was developed in one of two patients treated by stoma relocation and CST and in two of 15 patients treated by modified Rives sublay mesh technique and CST. In five patients treated by modified Sugarbaker technique no complications occured. Mean follow up was 28 months.

Conclusion

Modified Rives sublay technique with CST and modified Sugarbaker technique with or withouth CST provide good results in treatment of patients with parastomal hernia.

OC-013 INDIVIDUAL STRATEGY FOR PATIENTS WITH ABDOMINAL WALL EVENTRATION – DIFFERENT COMPONENTS SEPARATION TECHNIQUE WITH MESH AUGMENTATION

Aim

To present individual approach for patients with abdominal wall eventration using various anterior component separation techniques (aCST) with mesh augmentation.

Materials and Methods

Between January 2008 and April 2022, 194 patients with abdominal wall eventration underwent surgery by single surgeon. Surgical treatment consists: a) enlargement of the abdominal cavity using different aCST (Ramirez CST, modified CST in the presence of enterostomies, “open book” modification CST, “method of wide myofascial release” or combination of these techniques); b) mesh augmentation (sublay or onlay hernioplasty); c) prolonged muscle relaxation and mechanical respiratory support in intensive care unit.

Results

Type of abdominal wall reconstruction: 143 Ramirez CST, 35 modification CST in the presence of enterostomies, 11“open book” CST modification, 5 “method of wide myofascial release”, 159 onlay mesh hernioplasty and 35 sublay mesh hernioplasty. Mean hernia defect size was 255 cm2 (100–750). During the mean follow-up of 31 months, 78 (40%) patients had one or more complications: intraabdominal hypertension 8 (4,1%), seroma 13 (6,7%), hematoma 10 (5,1%), wound/mesh infections 21 (10,8%), skin necrosis 40 (20,6%), pain 3 (1,6%), and recurrence 5 (2,6%). There were 10 (5,1%) postoperative deaths. The cause of dead was significant comorbidity in 8 patients and postoperative compartment syndrome in two.

Conclusion

Eventration disease is a complex surgical problem and its treatment is associated with significant complications. Individual strategy for each patient based on multidisciplinary approach using different component separation techniques with mesh augmentation may improve postoperative results.

OC-051 MANAGEMENT OF EPIGASTRIC, UMBILICAL, SPIGELIAN AND SMALL INCISIONAL HERNIA AS A DAY CASE PROCEDURE: RESULTS OF LONG–TERM FOLLOW–UP AFTER OPEN PREPERITONEAL FLAT MESH TECHNIQUE

Aim

To investigate short and long-term outcome after the open preperitoneal flat mesh technique (OPPFMT) for umbilical, epigastric, spigelian, small incisional and “port-site” hernia performed as a day case procedure.

Materials and Methods

We retrospectively analyzed records of patients who underwent OPFMT for umbilical, epigastric, Spigelian, small incisional and “port-site” hernia. All patients were operated under local anesthesia in ambulatory settings. The operative technique is as follows: polypropylene flat mesh exceeding the size of the hernia defect for 2–3 cm in all directions is placed into a pre-peritoneal position above the intrabdominaly repositioned hernia sac (mesh is placed into hernia sac) and fixed by at least 8 transfascial “U” sutures.

Results

In the period from January 2004 to April 2022, 531 patients with ventral hernias (272 with umbilical, 155 with epigastric, 69 with small incisional, 17 with “port site” and 18 with Spigelian hernia) underwent surgery. During the median follow-up of 44 months, 8 (1,5%) hematomas, 2 (0,4%) seromas, 2 (0,4%), superfitial wound infections, 8 (1,5%) mesh infections and 24 (4,6%) recurrences occurred.

Conclusion

Management of epigastric, umbilical, spigelian and small incisional hernia with OPFMT under local anesthesia as a day case procedure is a safe and associated with favorable long-term outcome.

OC-025 STRATEGY FOR SURGICAL TREATMENT OF GIANT INGUINOSCROTAL HERNIA - SERIES OF 21 CONSECUTIVE PATIENTS DURING 15 YEARS

Aim

To present our strategy for surgical treatment of patients with giant inguinoscrotal hernia whose hernia defect is ≥10 cm or who have a loss of domain.

Material and methods

Between January 2006 - January 2022, 21 consecutive patients with giant inguinoscrotal hernia and high risk of postoperative intra-abdominal hypertension were managed. The hernia was repaired in the following manner: modified Rives technique performed through direct inguinal approach in 10 patients; additional procedures were needed to reduce the volume of organs returned to the abdomen in four patients; the primary abdominal cavity was enlarged by various components separation techniques with or without mesh hernioplasty in seven patients.

Results

The hernia defect size was in range 7–17 cm. In three patients the contents of the hernia sac accounted for more than 50% of the intestines: entire large bowel without the rectum, ileum, jejunum except proximal 15 cm and greater omentum). Postoperative complications occurred in eight patients were: scrotal hematoma, deep mesh infection, seroma and hydrocele. There were three postoperative deaths: 12 hours, 17 and 42 days after the surgery because ischemic enteritis, cerebrovascular stroke and heart failure, respectively.

Conclusion

Our strategy consisting of modified Rives technique performed through direct inguinal approach with or without additional procedures to reduce the volume of organs returned to the abdomen or to enlarge the primary abdominal cavity can be a good solution for giant inguinoscrotal hernias. Procedure is followed by the risk of deadly complications and requires trained team in intesive care unit.

P-073 THE MODIFIED SUBLAY TECHNIQUE FOR THE MANAGEMENT OF MAJOR SUBCOSTAL INCISIONAL HERNIA: LONG-TERM FOLLOW-UP RESULTS OF 41 CONSECUTIVE PATIENTS

Aim

To present the concept of original technique in the management of major incisional subcostal hernias bassed on sublay position of large haevy-weight polypropylene mesh between the two myofascial layers in the anterolateral abdominal wall.

Material and methods

Between January 2010 and May 2022, 41 consecutive patients underwent the modified sublay technique for major incisional subcostal hernia (minimal defect surface100 cm2 or minimal defect width or height 10 cm). The operative technique is: a) hernia sac dissetion and reposition into the abdominal cavity; b) rectus muscle and rectus muscle stump dissection from posterior rectus sheath, rectus muscle atachement dissection from thoracic wall and external oblique muscle dissection from internal oblique muscle around hernia defect at the side of the hernia defect; c) separate posterior and anterior rectus sheaths reconstruction at the midline; d) reconstruction of the posterior miofascial layer suturing internal oblique/transversal muscle and posterior rectus sheaths; e) large haevy-weight polypropilene mesh placement between posterior and anterior miofascial layer; e) reconstruction of the anterior miofascial layer by suturing external oblique muscle and anterior rectus sheaths.

Results

A median (range) hernia defect surface was 160 (100–500) cm2. A median operative time was 120 (90–330) minutes. The morbidity rate was 19.5%. A median (range) postoperative hospital stay was 7 (2–24) days. After the median follow-up of 50 (1–124) months, two patients (4,9%) developed recurrent hernia.

Conclusions

The modified sublay technique using large heavyweight polypropylene mesh provides good results in the management of major subcostal abdominal wall defects.

OC-012 THE COMBINATION OF THE THREE MODIFICATIONS OF THE COMPONENT SEPARATION TECHNIQUE IN THE MANAGEMENT OF COMPLEX SUBCOSTAL WALL DEFECT

Aim

To present a concept combining three modifications of the component separation technique (CST) in one procedure as an original solution for the management of complex subcostal abdominal wall defect.

Material and Methods

Between January 2010 and January 2022, seven patients with complex subcostal hernia defects compromised by infection, radiation, or chemotherapy underwent surgery in which three modifications of CST were combined into one procedure. Major complex subcostal hernia was defined by either width or length of the defect being greater than 10 cm. The following were the stages of the operative technique: (a) the “method of wide myofascial release” at the side of the hernia defect; (b) “openbook variation” of the component separation technique at the opposite side of the hernia defect; (c) a modified component separation technique for closure of midline abdominal wall hernias in the presence of enterostomies; (d) suturing of the myofascial flaps to each other to cover the defect; and (e) repair augmentation with an absorbable mesh in the onlay position.

Results

The median (range) length and width of the complex subcostal hernias were 15 cm (10–19) and 15 cm (8–24), respectively. The overall morbidity rate was 57.1% (wound infection, seroma and skin necrosis). There was no hernia recurrence during the median follow-up time of 19 (range 3–84) months.

Conclusion

The operative technique integrating three modifications of CST in one procedure with onlay absorbable mesh reinforcement is a feasible solution for the management of complex subcostal abdominal wall defect.

P-088 HOW TO REPAIR A LATERAL INCISIONAL ABDOMINAL WALL HERNIA?

Aim

To present our original method for surgical treatment of patients with lateral incisional hernia (LIH)

Material and Method

Patients with LIH and simultaneous presence of a middle incisional hernia (MIH) were treated by our original technique based on the principles of anterior component separation technique and sublay technique: a) skin and subcutaneous tissue incision along the midline and MIH dissection; b) subcutaneous tissue dissection in the lateral direction to the Spiegel line or the LIH lateral edge on the side of the LIH; c) vertical incision of the external oblique muscle (EOM) lateral to the Spiegel line or the LIH; d) the rectus muscle (RM) dissection from its posterior sheath on the opposite side of the LIH; e) suturing the posterior rectus sheath on the opposite side of the LIH with RM on the side of the LIH; f) suturing of the internal oblique muscle with the lateral edge of the RM on the side of the LIH; g) onlay polypropylene mesh hernioplasty.

Results

Between January 2013 and May 2022, 44 consecutive patients with LIH+MIH underwent surgery. A median (range) LIH defect surface was 90 (20–270) cm2. During mean follow up of 14 months postoperative complications occured in seven (15,9%) patients: seroma in three, hematoma in two, mesh infection and hernia recurrence in one.

Conclusion

Our original method can be one of the good solutions for simultaneous treatment of LIH and MIH.

The combination of the three modifications of the component separation technique in the management of complex subcostal abdominal wall hernia

PURPOSE

The purpose of this study is to present a concept combining three modifications of the component separation technique (CST) in one procedure as an original solution for the management of complex subcostal abdominal wall hernia.

METHODS

Between January 2010 and January 2020, seven patients presenting at the high-volume academic center with complex subcostal hernia underwent surgery in which three modifications of CST were combined into one procedure. Major complex subcostal hernia was defined by either width or length of the defect being greater than 10 cm. The following were the stages of the operative technique: (a) the "method of wide myofascial release" at the side of the hernia defect; (b) "open-book variation" of the component separation technique at the opposite side of the hernia defect; (c) a modified component separation technique for closure of midline abdominal wall hernias in the presence of enterostomies; (d) suturing of the myofascial flaps to each other to cover the defect; and (e) repair augmentation with an absorbable mesh in the onlay position.

RESULTS

The median length and width of the complex subcostal hernias were 15 cm (10-19) and 15 cm (8-24), respectively. The overall morbidity rate was 57.1% (wound infection occurred in three patients, seroma in two patients, and skin necrosis in one patient). There was no hernia recurrence during the median follow-up period of 19 months.

CONCLUSION

The operative technique integrating three modifications of CST in one procedure with onlay absorbable mesh reinforcement is a feasible solution for the management of complex subcostal abdominal wall hernia.

Central rupture and bulging of low-weight polypropylene mesh following recurrent incisional sublay hernioplasty

A recurrent incisional hernia resulting from the rupture of low-weight polypropylene mesh is rarely reported in the literature. Three patients with recurrent incisional hernia due to low-weight polypropylene mesh central rupture were operated 5, 7 and 13 months after initial sublay hernioplasty. The posterior myofascial layer was fully reconstructed in all patients during the hernioplasty, whereas the anterior myofascial layer was only partially reconstructed. The recurrent hernia was managed using heavy-weight polypropylene mesh; in two patients, a new sublay hernioplasty was performed and in one patient an "open preperitoneal flat mesh technique" was performed under local anaesthesia as a day case procedure. If closing of the anterior myofascial layer cannot be ensured during the incisional hernioplasty, the use of low-weight polypropylene meshes should be avoided; preference should be given to the heavy-weight polypropylene meshes.

The clinical value of scintigraphy of neuroendocrine tumors using (99m)Tc-HYNIC-TOC

PURPOSE

To assess the value of whole body scintigraphy using (99m)Tc-HYNIC-TOC (Tektrotyd) and with single photon emission computerized tomography (SPECT) in the detection of primary and metastatic neuroendocrine tumors (NETs).

METHODS

Thirty patients with different neuroendocrine tumors, mainly gastroenteropancreatic (GEP), were investigated. Whole body scintigraphy was performed 2 h (if necessary 10 min and 24h) after i.v. administration of 740 Mbq (99m)Tc-Tektrotyd, Polatom. In cases of unclear findings obtained by whole body scintigraphy, investigation was followed by SPECT.

RESULTS

From 12 patients with NETs of unknown origin, there were 10 true positive (TP), and 2 false negative (FN) findings. Diagnosis was made with SPECT in 6 patients. From 8 patients with gut carcinoids, there were 4 TP, 2 true negative (TN), one FN, and one false positive (FP) finding. Diagnosis was made with SPECT in 2 patients. From 7 patients with neuroendocrine pancreatic carcinomas there were 4 TP and 3 TN findings. Diagnosis was made with SPECT in 2 patients. From 3 patients with gastrinomas there were 2 TP findings and one TN findings. Diagnosis was made with SPECT findings in 2 patients. Sensitivity of (99m)Tc-HYNIC-TOC was 87%, specificity 86%, positive predictive value 95%, negative predictive value 67% and accuracy 87%.

CONCLUSION

We concluded that scintigraphy with (99m)Tc-Tektrotyd is an useful method for diagnosis, staging and follow up of the patients with NETs.

Scintigraphic detection of colon carcinomas with iodinated monoclonal antibodies

PURPOSE

The aim of this study was to evaluate the clinical reliability of the immunoscintigraphy with iodinated monoclonal antibodies for the detection of metastases and recurrences of colon carcinomas.

METHODS

A total of 45 patients with colon carcinoma was investigated with gamma camera, after intravenous application of iodinated monoclonal antibodies.

RESULTS

The sensitivity of the method was 90%, specificity 86%, positive predictive value 93%, negative predictive value 80% and accuracy 87%. There was statistically significant relationship between immunoscintigraphic and ultrasonographic (US) findings (p=0.005). Also, there was significant relationship between immunoscintigraphy and Dukes stage (p=0.019). Tumor marker levels were not significantly correlated with immunoscintigraphic findings (p<0.05). Significant difference was noted in patients with positive findings for malignancy on US and immunoscintigraphic findings (p=0.006), i.e. patients with positive findings for malignancy had more frequently immunoscintigraphic findings of malignancy. Correlation with other diagnostic procedures (rectoscopy, colonoscopy, CT) did not show significant correlations.

CONCLUSION

We conclude that immunoscintigraphy can be helpful in the detection of metastases and recurrences of colon carcinomas.

The accuracy of ultrasonography in classification of groin hernias according to the criteria of the unified classification system

BACKGROUND

The modern concept of type-related individualized groin hernia surgery imposes a demand for precise and accurate preoperative determination of the type of groin hernia. The aim of this prospective study was to evaluate the accuracy of ultrasonography in classification of groin hernias, according to the criteria of the unified classification system. Unified classification divides groin hernias into nine types (grades): type I (indirect, small), II (indirect, medium), III (indirect, large), IV (direct, small), V (direct, medium), VI (direct, large), VII (combined-pantaloon), VIII (femoral), and O (other).

PATIENTS AND METHODS

One hundred and twenty-five adult patients with clinically diagnosed or suspected groin hernias were examined. Ultrasonography of both groins was performed with a 5 to 10-MHz linear-array transducer. Preoperative ultrasonographic findings of type of groin hernia were compared with the intraoperative findings, which were considered the gold standard.

RESULTS

Total accuracy of ultrasonography in determination of type of groin hernia was 96% (119 of 124 correct predictions of type of groin hernia compared with surgical explorations). All hernias of types I, IV, V, VII, and VIII were correctly identified with ultrasonography (sensitivity and specificity 100%). In the remaining five cases of the 124 (4%), hernia was incorrectly classified with ultrasonography: type VI (direct, large) was misdiagnosed as type III (indirect, large) in three cases, type III as type VI in one case, and type III as type II (indirect, medium) in one case. The sensitivity and the specificity of ultrasonography in classifying type II were 100 and 99%, respectively, for type III, 85 and 97%, and for type VI, 90 and 99%.

CONCLUSION

Ultrasonography of the groin regions could be used with great accuracy for precise classification of groin hernias in adults. Each type of groin hernia, according to the unified classification system that we used for classification, has a characteristic ultrasonographic presentation, which is demonstrated in this study.

[Hemobilia]

The phenomenon now known as haemobilia was first recorded in XVII century by well known anatomist from Cambridge, Francis Glisson and his description was published in Anatomia Hepatis in 1654. Until today etiology, clinical presentation and management are clearly defined. Haemobilia is a rare clinical condition that has to be considered in differential diagnosis of upper gastrointestinal bleeding. In Western countries, the leading cause of haemobilia is hepatic trauma with bleeding from an intrahepatic branch of the hepatic artery into a biliary duct (mostly iatrogenic in origin, e.g. needle biopsy of the liver or percutaneous cholangiography). Less common causes include hepatic neoplasm; rupture of a hepatic artery aneurysm, hepatic abscess, choledocholithiasis and in the Orient, additional causes include ductal parasitism by Ascaris lumbricoides and Oriental cholangiohepatitis. Clinical presentation of heamobilia includes one symptom and two signs (Quinke triad): a. upper abdominal pain, b. upper gastrointestinal bleeding and c. jaundice. The complications of haemobilia are uncommon and include pancreatitis, cholecystitis and cholangitis. Investigation of haemobilia depends on clinical presentation. For patients with upper gastrointestinal bleeding oesophagogastroduodenoscopy is the first investigation choice. The presence of blood clot at the papilla of Vater clearly indicates the bleeding from biliary tree. Other investigations include CT and angiography. The management of haemobilia is directed at stopping bleeding and relieving biliary obstruction. Today, transarterial embolization is the golden standard in the management of heamobilia and if it fails further management is surgical.

Ambulatory surgery of umbilical, epigastric and small incisional hernias: open preperitoneal flat mesh technique in local anaesthesia

Introduction. The dilemma whether to use the mesh or non mesh technique in the management of umbilical, epigastric and small incisional hernia is slowly fading away. The open preperitoneal "flat mesh" technique performed as ambulatory surgery may be one of the solutions. The Aim. The aim of this retrospective study is to present the results of open preperitoneal "flat mesh" technique in the management of umbilical, epigastric and small incisional hernia within Material and methods. This study included 34 patients (11 of them with umbilical, 13 with epigastric and 8 of them with small incisional hernia) operated by one surgeon in the period January 2004 - January 2006. Results. The median operative time was 52 minutes for umbilical hernia?s, 43 minutes for epgastric and 54 minutes for incisional hernia?s. The ambulatory surgery was performed at 91% of patients. The median hospitalization was 4h for patients with umbilical hernia?s, 3,7h for patients with epigastric and, 7,7h for patients with small incisional hernia. The follow up is 10,5 months. Apart of one superficial infection other complications were absent. Conclusion. The open preperitoneal "flat mesh" technique performed in local anesthesia as an ambulatory surgery provides good results in the management of umbilical, epigastric and small incisional hernia.

[The role of endoscopic ultrasonography in diagnostic and estimation of common bile duct carcinoma invasion]

The main purpose of this survey is to present the importance of EUS in establishing a diagnosis of tumor of the choledochus. It is also important to emphasize that EUS is the most suitable diagnostic method for determination of tumor invasion to choledochus, i.e. to determine TN patient status and to predict if tumor could be successfully resected. The author would like to present his own experience in using of EUS as a contemporary method for establishing a diagnosis and effective treatment of patients with tumor of choledochus. All patients were examined by Olympus equipment for endoscopic ultrasound with radial probe working with the frequency of 7,5 and 12 MHz at the Department for Endoscopic Ultrasound of the Clinic for Gastroenterology and Hepatology, Clinical Center of Serbia. All examined patients were subjected to surgical exploration after that. Therefore it was possible to compare preoperative estimation of tumor invasion with a final result obtained by surgical exploration. Five patients were diagnosed with tumor of choledochus localized at the distal part of choledochus. TN status of examined patients was specified by standard criteria. Estimated TN status for two patients was defined as T2N1a and T2N0, which indicate the possibility of excessive surgical treatment, what was confirmed by surgical exploration as well. A small number of patients was not possible to use for statistical evaluation. Our conclusion is that EUS presents the most effective method to estimate a degree of tumor invasion to choledochus, since it provides an accurate definition of TN patient status and predicts if tumor could be successfully resected.

Infekcija u hirurgiji kila

Traditionally, the operation of hernia is considered as a clean operation due to expected, low incidence of infection, on the spot of surgical work (SSI). The incidence of SSI in hernia surgery is more frequent then it is assumed. The important risk factors for SSI are the following: type of hernia (inguinal, incisional), operative approach (open - laparoscopic), usage of the prosthetic material and drainage. Comparing to inguinal hernia repair, incisional hernia repair, is more frequently followed by the infection. The laparoscopic operations are followed with the lower incidence of SSI then in the case of open operation. The usage of the mesh does not increase the incidence of SSI, although the consequences of the mesh infection may be severe. A type I of the prosthesis is more resistant to the infection then prosthesis II and III. The mesh infection (type I) never involves its body but it is present around sutures and bended edges. The mesh infection Type II involves entire prosthesis while in the case of Type III it is present in its peripheral part. In the case of SSI, a prosthesis Type I is possible to be saved, while prosthesis Type II must be removed completely; and the same is for the Type III (the partial removal is rarely suggested). The defect that remained after excision of non-resorptive prosthesis is a long-term and very complicated surgical problem. In regard to the position of the mesh, SSI is more common if the mesh is placed subcutaneously then in the case of sub-aponeurotic peri-muscular, pre-aponeurotic retromuscular or pre-peritoneal mesh placemen. If the infection is present the non-tension techniques using non-resorptive prosthetic implants are not recommended. the presence of drainage and its duration increases the incidence of SSI. It is more common for incisional hernioplasty then for inguinal hernia repair. If there is an indication for drainage it should be as short as possible. The cause of SSI for elective operations are bacteria?s that arrives from the skin, while in the case of opening of various organs dominant bacteria?s originate from them. The superficial infection does not lead to the recurrence, while it is very possible in the case for deep infection. There are no prospective studies that justify the usage of antibiotic prophylaxes in hernia surgery. The antibiotic prophylaxis in hernia surgery. The antibiotic prophylaxis is indicated for the clean operations when placing the implants and when severe complication is expected. The appearance of SSI increases the price of treatment and may lead to the recurrence.

[Intraoperative and postoperative complications of splenectomy]

Spleen is being surgically removed because of trauma, in diagnostic and-or therapeutical purposes because of the benignant and malignant diseases. The percentage of morbidity during and after splenectomy is relatively low. During surgery might occur bleeding, trauma of the pancreatic tail, stomach, lineal flexure of the colon, left hemidiafragm, left suprarenal gland and upper pole of the left kidney, which must be correspondingly reclaimed during the same intervention. In the early postoperative period, postoperative bleeding, subfrenic abscess, pulmonal atelectasis, bronchopneumonia and left pleural extravasations might occur. Especially is important notification of these events in due time and adequate conservative and surgical treatment. After splenectomy, there is an increase of the number of trombocytes, which might lead to the tromboembolic complications. In the prevention of these complications in the postoperative period prolonged antiagregation therapy is suggested. Postsplenectomy sepsis is very late, general complication of splenectomy, which occurs because of the lower immunity in the child age. To prevent these complications, partial splenectomies, reimplantations of the spleen, prolonged application of the penicillin medicines after splenectomy and antipneumococcal vaccine are performed.

[Surgical treatment of hematologic disorders of the spleen]

Splenectomy--the surgical removal of spleen is being performed in cases of: traumatic spleen rupture, as part of other surgical procedures, number of hematological, infectious and metabolic disorders. During the years 1988.-2001., there were 396 splenectomies performed at the First surgical clinic, for the cause of: autoimmune disorders 187 (47.34%), lymphoproliferative diseases 89 (22.59%). Hodgkin disease 35(8.94%), myeloproliferative disease 39 (9.95%), as part a of "staging" laparotomy 37(9.34%), other hematological disorders 7(2.20%). The spleen of [table: see text] 244 patients weighted 500-1500 g(61.62%), in 56 patients (14.14%) weighted less than 500 g, and in 96 patients (24.24%) spleen weighted more than 1500 g. Patients with thrombocytes less than 40,000/l 16 (4.04%) were perioperativly treated with fresh thrombocytes. Postoperative morbidity and mortality were registered in 54 (13.64%), i.e. 8 (2.02%) patients. Delayed results depended on primary disorder, comorbidities and supportive therapy. In this article, the particularities of the operative procedure were discussed, as well as importance of cooperation of surgeon and hematologist in perioperative treatment.

[Elective resection of the spleen--overview of resection technics and description of a new technic based on radiofrequency coagulation and dessication]

The authors present a short overview of the development of elective splenic resections. Past and present indications are presented. Contemporary hemostatic technique for elective splenic resection are discussed. An original new technique for transsegmental partial splenic resection using RF generator Radionic Cool Tip(without any aditional hemostatic procedures is presented. This technique is inovative and when use properly it is a practically zero blood loos technique. A patient with transsegmental splenic resection using RF generator is presented. Further clinical application of the technique is necessary.

[The Rives technique (direct inguinal approach) in treatment of large inguino-scrotal and recurrent hernias]

In solving inguinal hernias, surgeons today have in front of them many variations of different operative procedures (both tensional and non-tensional techniques). They are performed through operative or endoscope approach. Classical tension techniques present the operation of choice for smaller indirect, direct or femoral hernias among younger patients while non/tensional techniques are the best solution for all types of inguinal hernia among older patients with big destruction of transversal fascia and the best solution for most of recurrent hernias. Positioning of mesh with non-tensional techniques can be completed on different levels, with big hernias where the biggest part of transversal fascia of miopectineal orifitium is destroyed it is anatomically the most useful to place the mesh in preperitoneal space. Rives technique is the base of that concept and it presents one of good solutions in that kind of situations. In the period January 2001 until december 2002 using different operative techniques the authors treated 99 inguinal hernias of which 78 were primary and 21 recurrent hernias. Rives technique was performed in 46 cases (46.5%) among which 26 cases were primary inguinoscrotal hernias (3 patients IIIA, 22 patients IIIB, 1 patient IIIC, according to Nyhus classification) and 20 cases were recurrent hernias (6 patients IVA, 11 IVB, 3 IVD). Complications after Rives technique were the following: 1 recurrence (2.17%), 1 ischemic orchitis (2.17%) and 1 scrotal hematoma (2.17%). Infections and chronic pain were not present. The follow up was from 30 days to 2 years. Authors have shown that Rives technique is reliable solution for primary indirect, direct and femoral hernias with big hernial defect (especially for big, so called "giant" inquinoscrotal hernias) and for all types of recurrent hernias. The advantage of the technique is an easy performance without some previous special training because of the fact that dissection and preparation is the same as for the tension techniques. With small amount of prosthetic material all weak points of miopectineal orifitium are closed. The real risks of this technique are ischemic orchitis and chronis neuralgia in treatment of recurrent hernias and the presence of polypropylene mesh in Bogras space.

[Modified Rives technic in the treatment of recurrent inguinal hernia]

After the introduction of prosthetic material in hernia surgery the fundamental changes in operative strategy occurred. This is because the coverage of myopectineal orifitium with non-absorbable prosthesis decreases the incidence of recurrences. Because of the appearance of lateral re-recurrences after the classical Rives procedure, we modified the operative technique. The modified Rives technique consists of the following: always polypropilen mesh 15x10 cm; creation of the new internal inguinal ring between Poupart's ligament and mesh; no lateral notching the mesh and anchoring mesh 2-3 cm from the medial, inferior, lateral and superior edge. During the period January 2001-December 2003, 34 cases of recurrent hernias were operated on 7th dept. of I Surgical Clinic of CCS. The recurrences were managed by classical (10/34) or modified Rives technique through direct inguinal approach (22/34), less frequently Lichtenstein procedure (1/34) and McVay (1/34) technique. Among 10 patients with recurrent inguinal hernias managed by classical Rives technique 2 re-recurrences appeared (indirect and interstitial) and 2 cases of infection (immediately after the operation or 7 months after the operation), and in the group of 22 cases with recurrent inguinal hernias managed by modified Rives technique the aim complications didn't appear. Using the modified Rives technique we managed the primary hernias in 56 cases without recurrences and infections. The modified Rives technique, because of the way of mesh fixation (all around), no lateral notching of mesh and remaining hem in all directions secures abdominal wall protection 2-3 cm from the line of fixation and prevents any movement of the mesh. This procedure enables management of all inguinal hernias regardless to their size and full protection of the medial, femoral and lateral inguinal triangle. The modified Rives technique is the technique of choice for big multiple defects (giant inguino-scrotal and re-recurrences), especially among patients with increased intra-abdominal pressure when other techniques may be insufficient because of mesh protrusion.

[Surgical treatment of liver metastases of colorectal carcinoma]

Colorectal carcinoma metastasizes into the liver, but liver-only metastases are infrequent. Liver-only metastases are seen mainly from colorectal carcinoma. This is the only metastatic disease where treatment aimed only or mainly at the liver metastases is employed with curative intent. If liver resection for colorectal metastases is done by an experienced team, adhering to predefined indications, five year survival ranges from 30-40%, operative mortality is 3-5% and the postoperative morbidity is acceptable. New diagnostic techniques have been introduced and indications for liver resection extended. This paper presents the current limitations and possibilities for the surgical management of colorectal metastases in the liver.

The role of membrane water permeability in characterization of pathologically altered human stomach tissues: NMR studies

Comparative NMR studies of normal and pathologically altered human stomach tissues were performed on the basis of proton T1 relaxation time measurements in the presence of high external concentrations of relaxation (contrast) agents manganese ethylenediaminetetraacetic acid (Mn-EDTA) and gadolinium diethylenetriaminepentaacetic acid (Gd-DTPA). Diffusion permeability of the cell membrane to water, Pd, was determined by measuring the longest proton T1 component sensitive to the exchange of water molecules through the cell membrane. Pathologically altered tissues showed substantially higher (2 to 10 times) average cell membrane permeabilities to water.