Socio-economic aspects of healthcare development policy in Russia

The research is dedicated to the improvement of the intraoperative diagnosis of non-tumorous diseases of the extrahepatic bile ducts causing bile passage impairment. The study comprehensively employs methods of transabdominal and laparoscopic ultrasonography, as well as intraoperative cholangiography. The objective is to enhance diagnostic accuracy and determine surgical strategy. The comparative echosemiotics of the pathology, the informativeness of various research methods, and the features of ultrasonic semiotics of lesions of the hepatobiliary zone organs are investigated. It is proven that laparoscopic ultrasonography possesses superior informativeness compared to intraoperative cholangiography in the diagnosis of choledocholithiasis, which allows for the assessment of surrounding organs and the removal of concrements without radiation exposure and traumatization.

The practical significance of the work lies in the development of an improved diagnostic algorithm that includes transabdominal and intraoperative ultrasonographic examination. The application of this algorithm makes it possible to improve the diagnosis of non-tumorous obstructive diseases of the extrahepatic bile ducts and determine the strategy of operative treatment depending on the obtained results. Laparoscopic ultrasonography serves as the method of choice for diagnosing diseases of the biliary system and pancreas during endoscopic interventions, providing objective verification of pathology with minimal traumatization.

In surgical practice, in the diagnosis of various diseases, great importance is attached to establishing the precise localization of the pathological focus, the nature of the spread of the process, which is necessary to determine the strategy of the operation. The use of such highly informative methods as transabdominal ultrasonography (US), computed tomography (CT), magnetic resonance imaging (MRI), angiography, and various types of endoscopic technique, as a rule, determines the feasibility of performing a certain type of operation at the stage of preoperative examination of the patient.

However, in some situations, the final choice of the volume and strategy of surgical intervention has to be made directly during the operation. This led to the creation of equipment for intraoperative ultrasonography (IOUS), the main feature of which is the presence of miniaturizable sterilizable sensors [16, 28, 149, 174, 233].

The number of operations on the biliary tract is steadily increasing from year to year, which is associated with the rise in morbidity from cholelithiasis and pancreatitis [8, 34, 62, 80, 90]. It is believed that over 10% of the population suffers from cholelithiasis [87]. One of the most important manifestations of cholelithiasis is choledocholithiasis, which occurs in 5-20% of cases. Moreover, its probability increases proportionally to the duration of the disease and the age of the patients [91, 124, 129].

At the same time, the diagnosis of primary choledocholithiasis and, in particular, its anicteric form, in many cases causes considerable difficulties both before and during surgical interventions.

Laparoscopic ultrasonography (LUS) is the 'hand' of the surgeon during laparoscopic cholecystectomy, therefore the need for laparoscopic ultrasonography during endoscopic surgical interventions is significantly greater than during traditional 'open' operations.

During operations on the biliary tract, when it is necessary to examine the state of the intra- and extrahepatic bile ducts, laparoscopic ultrasonography is the method of choice in cases of contraindications to radiological examination or the impossibility of its performance. Moreover, in some situations, it is also necessary to assess the state of the surrounding organs and structures of the hepatopancreatoduodenal area; in these cases, laparoscopic ultrasonography is the only instrumental method providing the necessary information [83, 203]. Despite the achieved successes, many issues of laparoscopic ultrasonography in surgical diseases of the hepatopancreatobiliary system remain controversial and insufficiently developed. Thus, there is no single opinion on intraoperative ultrasonography in the complex of methods of intraoperative diagnosis of diseases; the features of ultrasonic semiotics of lesions of organs of the hepatobiliary zone are insufficiently studied; clear indications for the examination are not determined; the technique of ultrasonic control during operations on organs of the hepatobiliary zone requires further study and improvement.

Research objective.

Improving the intraoperative diagnosis of non-tumorous diseases of the extrahepatic bile ducts causing bile passage impairment, through the comprehensive use of ultrasonography.

Research tasks

1. To study the comparative echosemiotics of the pathology of extrahepatic bile ducts in laparoscopic and transabdominal ultrasonographic examination.

2. To carry out a comparative analysis of the results of comprehensive ultrasonographic examination and intraoperative cholangiography in terms of informativeness.

3. To evaluate the diagnostic informativeness in laparoscopic and transabdominal ultrasonography in a comparative aspect.

Research novelty.

Based on the comparative analysis of transabdominal and laparoscopic ultrasonographic data, informative, specific ultrasonographic signs of surgical diseases of the extrahepatic bile ducts have been established that improve their differential diagnosis.

It is proven:

-that the informativeness of laparoscopic ultrasonography is higher than the informativeness of intraoperative cholangiography in the diagnosis of choledocholithiasis;

-that laparoscopic ultrasonography provides the possibility of assessing the surrounding organs and removing concrements from the common bile duct under continuous visual control without radiation exposure and without traumatizing the examined organs.

A reduction in the duration of intraoperative diagnostic measures using laparoscopic ultrasonography by 20-30 minutes has been achieved, and accordingly, the total duration of laparoscopic cholecystectomy is reduced by the same amount of time.

An improved diagnostic algorithm using comprehensive transabdominal and intraoperative ultrasonographic examination allows improving the intraoperative diagnosis of obstructive diseases of the extrahepatic bile ducts.

Practical significance

An improved diagnostic algorithm for diseases of the extrahepatic bile ducts using laparoscopic ultrasonography has made it possible to improve the diagnosis of non-tumorous obstructive diseases of the extrahepatic bile ducts and determine the surgical strategy depending on the results of the examination.

The use of laparoscopic ultrasonography helps in diagnosis in cases of an unclear topographic picture, in cases of various anatomical variants of the structure and location of the bile ducts and major vessels.

Laparoscopic ultrasonography has made it possible to most objectively and least traumatically verify the pathology of the examined organ of the hepatobiliopancreatoduodenal zone.

Statements submitted for defense

1. In the diagnosis of choledocholithiasis, the informativeness of laparoscopic ultrasonography is higher than the informativeness of intraoperative cholangiography; laparoscopic ultrasonography has significant advantages compared to intraoperative cholangiography, as it is not associated with radiation exposure and allows examining not only the bile ducts but also the surrounding organs and structures.

2. The diagnostic algorithm for detecting pathology of the extrahepatic bile ducts, which includes transabdominal ultrasonography and laparoscopic ultrasonography, is an effective method of intraoperative diagnosis of obstructive diseases of the extrahepatic bile ducts.

3. Laparoscopic ultrasonography is the method of choice for diagnosing diseases of the biliary system and pancreas during endoscopic surgical interventions.