Improvement of the Technique of Liver Resection in Echinococcosis

The research is dedicated to improving the surgical treatment of liver echinococcosis, specifically the development of indications and the refinement of the technique of liver resection for this disease. The study analyzes modern approaches to the diagnosis and treatment of echinococcosis, examining methods for combating postoperative purulent-inflammatory complications.

Special attention is given to the application of innovative instruments and technologies, such as an aspirator-dissector, hydrobombeks vacuum suction, and pneumothermocoagulator, aimed at increasing the radicality of operations, reducing blood loss, and preventing the dissemination of the parasite.

Relevance of the topic. In the structure of focal liver lesions, echinococcosis occupies a leading place and represents a serious medical and socio-economic problem. With the introduction of such advanced diagnostic methods as ultrasound (US), intraoperative ultrasound (IOUS), and computed tomography (CT), it became possible not only to early detect this pathology but also to fully perform surgical intervention, as well as to dynamically monitor the operative wound area in the postoperative period [31, 44, 82, 102, 130, 153, 184].

According to literature, liver echinococcosis is accompanied by the development of various preoperative purulent-inflammatory complications in 18-52% of patients, which not only complicates the choice of surgical correction of echinococcosis but is also an unfavorable factor for the development of postoperative complications (up to 60%), recurrences, and fatal outcomes [19, 29, 50, 79, 94, 110, 139].

Surgical treatment of liver echinococcosis provides for several variants of echinococcectomies: closed, semi-closed, open, cystopericystectomy, and liver resection (LR). Echinococcotomy performed by traditional methods (closed, semi-closed, open) is associated with a high risk of purulent inflammation of the residual cavity, often maintained by a purulent-biliary fistula and a prolonged postoperative period [12, 69, 88].

Moreover, in the complicated variant of echinococcosis, when destruction of the cuticular shell and partially fibrotic capsule creates conditions for the migration of daughter cells beyond the hydatid into liver tissue, performing the aforementioned operations is fraught with a high risk of disease recurrence [39, 46, 54, 74].

In light of the above, only some authors [35, 54, 59, 74, 107, 118] justifiably point to the necessity of primary liver resection in echinococcosis, although there is no clear recommendation regarding the indications for the technique and features of LR, effective methods of combating purulent complications from the liver and the free abdominal cavity. Goal of the research. The goal of this research is to improve the results of liver resection in echinococcosis by improving the technique and applying effective methods of combating purulent-inflammatory complications.

Tasks of the research:

1. To determine the criteria for indications and contraindications for performing various variants of liver resection in echinococcosis.

2. To study the clinical capabilities of applying an aspirator-dissector, hydrobombeks vacuum suction, pneumothermocoagulator, and intraoperative ultrasound at the stages of liver resection in echinococcosis.

3. To develop measures for the prevention of postoperative purulent complications in liver echinococcosis.

4. To study the immediate and late results of liver resection in echinococcosis.

Scientific novelty. Specific indications for performing liver resection in echinococcosis have been determined, taking into account the volume and stage of disease development.

The technique of liver resection in echinococcosis has been improved by:

- excluding the resectable lobe and (or) segment from the bloodstream, which, along with reducing intraoperative blood loss, allowed avoiding intra- and extra-organ dissemination of the parasite;

- increasing the radicality of operations and preventing damage to large vascular-secretory structures of the resectable part of the liver using intraoperative ultrasound echolocation;

- bloodless separation of liver parenchyma and tubular structures by an aspirator-dissector;

- preventing intraoperative dissemination of echinococcosis using a hermetic hydrobombeks vacuum suction;

- ensuring final hemostasis and destroying elements of echinococcosis on the cut surface of the liver by a stream of hot air supplied from a pneumothermocoagulator "Harmbod".

Prevention of postoperative purulent-inflammatory complications of the liver has been achieved by intraportal transport of antibacterial drugs.

Practical significance. The author has developed indications and improved the technique of LR in echinococcosis.

At the stages of LR, a complex of technological measures has been proposed, aimed at improving temporary and final hemostasis, preventing intra- and extra-organ dissemination of echinococcosis, reducing the trauma of surgical interventions themselves, and the frequency of postoperative purulent-inflammatory complications (tourniquet, aspirator-dissector, vacuum suction, pneumothermocoagulator), which allowed improving the immediate results of surgical treatment of liver echinococcosis.

Thorough monitoring of the operative wound area through dynamic US, selective transport of pharmacocytes through catheterization of the umbilical vein made it possible to early detect and remove fluid collections of postoperative specific complications long before their clinical manifestations.

Main provisions of the dissertation for defense.

1. The presence of a massive, rigid, multichambered fibrotic capsule of the echinococcal cyst with perforating biliary fistulas, occupying a lobe and (or) segment, whose liquidation by closed and open methods is associated with a high risk of developing purulent-inflammatory complications of the residual cavity and a purulent-biliary fistula, is an indication for liver resection.

2. Liver resection in echinococcosis is necessarily performed with observance of measures aimed at improving temporary and final hemostasis, preventing intra- and extra-organ dissemination of echinococcosis, reducing the trauma of surgical interventions themselves, and the frequency of postoperative purulent-inflammatory complications, which is ensured by the use of a tourniquet, aspirator-dissector, hydrobombeks vacuum suction, and pneumothermocoagulator.

3. Intraportal transport of antibacterial drugs, early diagnosis, and removal of fluid collections from the peritoneal space under the control of US, MRI reduce the frequency of developing purulent-inflammatory complications in the peritoneal space. Implementation of the results of the work. The results of the research have been introduced into the work of surgical departments of the City Clinical Hospital of Emergency Medical Care in Dushanbe.

Defense of the work. The main provisions of the dissertation were reported at: the IV Congress of Surgeons of Tajikistan (Dushanbe, 2005), VII, X, and XI annual scientific-practical conferences of TIGITMK, XII International Congress of Hepatic Surgeons (Tashkent, 2005), a meeting of the expert problem commission of TGMU on surgical disciplines (Dushanbe, 2007). Publications. Based on the materials of the dissertation, 15 scientific works have been published. 2 certificates of rationalization proposals and one certificate for patenting have been obtained.

Structure and volume of the work. The dissertation is presented on 122 pages of computer text, contains 17 tables, 39 figures, and consists of an introduction, 4 chapters, conclusion, conclusions, practical recommendations, and a bibliography containing 202 sources, of which 131 are in Russian and 71 are in a foreign language.