卷 24, 编号 4 (2020)

Introduction. This study describes authors’ experience in performing laparoscopic pyeloplasty in infants whose age does not exceed 3 months of life, and compares pre- and postoperative results of these surgeries in order to answer the question - does the laparoscopic technology for the treatment of hydronephrosis in newborns and infants provide acceptable results based on improving kidney morphology and function? Material and methods. 105 children, aged 3 months, were enrolled into this retrospective study who for 8 years, since 2012, have been laparoscopically operated on for congenital hydronephrosis. Because of bilateral renal damage, a total of 110 surgeries were performed, including simultaneous pyeloplasty in 5 patients. All patients had dismembered pyeloplasty with the Anderson-Hynes technique via transparietal laparoscopic access. Indications for surgery were: decreased renal function with obstruction signs of urine outflow from the pelvis confirmed by radioisotope renography; a combination of reduction of parenchyma thickness and increase of pelvis diameter at serial ultrasound studies; or a combination of these pathologies with urinary tract infection. During the trial, the following parameters were recorded: demographic data, findings of perioperative diagnostic examinations, surgical details, recovery process after surgery and long-term consequences. Results. The average age of patients was 50.24 days. Of 105 patients, 60 (57.14%) were less than 1 month old, and the remaining 45 (42.86%) were 1-3 months old. Gender distribution in groups was as follows: m / f = 73:32. Unilateral operations on the left kidney were in 61.82% patients, on the right kidney - in 33.64% patients. 4.54% patients had bilateral pyeloplasty. Average duration of surgery was 73.07 minutes (40-120 minutes). The average length of hospital stay was 4.19 days (2-9 days). At the early postoperative period, 4 (3.6%) patients developed postoperative complications - urinoma formation. A comparison of pre- and postoperative renal morphometry findings by ultrasound and Doppler ultrasound examination showed a significant decrease of renal pelvis dimensions and improved renal blood flow. The pelvis size decreased in average from 23.5 to 5.5 mm (p = 0.001), and RI from 0.72 to 0.64 (p = 0.001). Functioning of the operated kidney, as showed by the radioisotope renography, improved from 34 to 45.27 (p = 0.001). Long-term follow-up observation revealed one relapse of the disease (0.9%) - stenosis of pyeloureteral anastomosis which required a repeated laparoscopic pyeloplasty. One patient (0.9%)/ who was under follow-up observation for 36 months, had deterioration and loss of kidney function without signs of renal obstruction at the level of pyeloureteral segment which required laparoscopic nephrectomy. Thus, taking into account one relapse and loss of kidney function in one patient, we can state that the effectiveness of laparoscopic pyeloplasty in our study was 98.2%. Conclusion. Summarizing results of the applied laparoscopic pyeloplasty in the youngest group of patients whose age does not exceed 3 months of life, it can be stated that the minimally invasive approach contributes to normalizing morphological and functional parameters of kidney.

A surgical management of extensive diaphragmatic defects is an actual problem in pediatric thoracic surgery. Despite of a large number of existing diaphragmatic prostheses, the search for an ideal plastic material is still going on. Material and methods. The authors analyze the effectiveness of xenopericardium in 15 children, aged 2 days - 17 years, with extensive diaphragmatic defects. Congenital hernia was in 8 (53.3%) patients, recurrence of congenital hernia - in 4 (26.7%) children, acquired hernia - in 3 (20.0%) children. The thoracoscopic approach was applied in 10 (66.7%) patients, thoracotomy - in 2 (13.3%) patients, laparotomy - in 3 (20.0%). Results. Diaphragmatic integrity was restored in all operated children. There were no any relapse of diaphragmatic hernia at the late postoperative period. There were no any xenopericardium rejection either. The article describes two clinical observations. In the first case, a 15-years-old girl with an extensive defect in her left dome of the diaphragm after the resection of lower lobe in the left lung and the diaphragmatic dome because of alveolar rhabdomyosarcoma had retoracotomy on the left and prosthetics of the diaphragm with a xenopericardium plate. In the second case, a thoracoscopic plastic surgery on the diaphragmatic dome with a xenopericardium plate was made in a newborn baby with aplasia of the right diaphragm on the 3rd day of his life. A long-lasting effect was obtained in both cases. Conclusions. Diaphragmatic plasty with xenopericardium can be successfully applied in children with extensive congenital and acquired diaphragmatic defects. The surgical technique with xenopericardium is possible both in open surgeries and in thoracoscopic interventions.

Introduction. Lymphangiomas (lymphatic malformations) are benign vascular formations that develop from the lymphatic vessels and locate at the intermediate position between tumor and malformation [1,2,3]. The lack of unified algorithm in the treatment of lymphangiomas and a variety of operative and conservative techniques used with a high percentage of relapses leave the problem of treating lymphangiomas open. Material and methods. This article demonstrates outcomes of surgical treatment of lymphangiomas in soft tissues in newborns after they were treated with a technique developed and patented by the authors (Patent No 2711257 dated 15.01.2020*). The technique for treating lymphangiomas with video endoscopic component allows to simultaneously and radically remove tumors in children (including newborns) with minimally invasive approach. 10 surgical interventions were performed with the discussed technique. Results. In all cases the result was a complete radical simultaneous removal of soft tissue lymphangiomas under video control. The proposed curative technique is considered to be the most reasonable one due to its radical nature and good cosmetic effect when removing superficially located lymphangiomas. Discussion. A persistent high risk of recurrences dictates a search for the improvement of existing techniques and for the optimal combination of various tactics in treating lymphangiomas. In these group of patients, an important strategy is to have a personalized approach in each case. In our experience, a surgical intervention is the only technique for treating lymphangiomas of superficial location. This technique leads to simultaneous and radical removal of pathological formations within healthy tissues. Conclusions. Mostly important advantages of the discussed technique for treating lymphangiomas are: 1) A proper visualization of the formation and its complete removal what reduces the risk of relapses and lymphorrhea in the postoperative period. 2) Minimal tissue damage which leads to more rapid rehabilitation, less intensity of postoperative pain as well to less anesthesia support and less recovery period after surgery. 3) Better cosmetic effects.

Introduction. Restoration of trunk balance is the basic task in surgical correction of spinal deformities and in hip joint instability of various etiology. Purpose. To analyze and to define the relevance of roentgen-anatomical parameters of spine-pelvis relationships for surgical correction of deformities in the thoracolumbar spine and of hip joint instability of dysplastic and neurogenic etiology. Material and methods. An X-ray analysis of parameters of the frontal and sagittal spine-pelvis balance was performed in 220 patients with dysplastic and neurogenic deformities of the thoracic and lumbar spine (n = 98) and with instability of hip joints (n = 122) but who were able to walk. They were operated in the neuro-orthopedic department with orthopedics in National Medical Research Center for Children’s Health. The reference group included 60 relatively healthy children without any scoliotic deformities of the spine and with stable hip joints. Dynamics of changes in X-ray parameters was analyzed using findings of orthostatic spondylograms from the indicated groups of children. The obtained data were compared with reference values. Results. The trial performed has revealed typical changes in spine-pelvis relationship parameters in patients with hip joint instability and spine deformities and in the reference group . The researchers also found out relations between various parameters of the trunk balance before and after surgical correction. Conclusion. While planning a surgical correction of trunk balance in spinal deformities, one should take into account parameters of spine-pelvis relationships, such as PI, SS, PT, SVA deviation and the mid-sacral line; and in case of hip joint instability - local roentgen-angulometric parameters of the femoral and acetabular components of instability. This is due to the fact that the lower the level of reconstructive surgical manipulation is located, the greater effect it has at the frontal and sagittal balance of the trunk.

Introduction. Cerebral palsy (CP) is the main cause of childhood neurological disability in the world. Due to the fact that the prevalence of knee contractures in children with cerebral palsy occupies the 3rd place in the structure of orthopedic pathology of the lower extremities, this topic is least covered in the scientific periodicals. Material and methods. Findings from 40 patients of the main group, aged 7-12 and having cerebral palsy (CP), were studied retrospectively. They had knee flexion contractures with patella alta. Findings of goniometry and of Gillette FAQ were analyzed before and after surgery. The Spearman coefficient was used for the correlation analysis of goniometry parameters and surgical intervention effectiveness before surgery. 35 patients having no bilateral CP damage and other diseases leading to lower limb deformities were included into the reference group. X-ray examination and goniometry assessment of a healthy limb were made in patient’s lying position on his back with passive extension; plus goniometry in a standing position with shin active extension. Results. The median of deformation angles before and after surgery was 20° and 5°, respectively (p <0.05). Correction volume was 80%. The median of scores by the Gillette increased from 2 to 3 (p <0.05) after surgery. Assessment of the correlation between preoperative goniometry values and treatment efficacy values showed a significant moderate feedback (p <0.05). Conclusion. The stronger the deformity before surgery, the less chance for developing the standing-up function. The best result can be achieved when deformity is 10-25°. Normal values of passive extension by goniometry in a healthy knee for children aged 7-12 in a lying position are 6 ° hyper-extension (genu recurvatum) (± 2 °) and 12 ° hyper-extension (±3°) of a knee joint by lateral X-ray. Normal active extension in children aged 7-12 in a standing position is 3° hyper-extension (±2°). Smaller values of the tibiofemoral angle by goniometry in a standing position and maximun values for passive extension by X-ray and goniometry assessment may serve as clinical and radiological criteria of knee flexion contracture.

This article describes two clinical cases of surgical treatment of children with an unobliterated bile duct. The first boy, aged 21 day, was admitted to the hospital with complaints of constant “wetness” in the umbilicus area and a lack of effect of conservative treatment. The fistulography showed communication with the iliac lumen what confirmed involution violation of the omphalomesenteric duct and the formation of complete umbilicus fistula. An unobliterated bile duct was incised and umbilical ring plasty with a surgical stapler was made under general anesthesia. The second child, aged 10 days, was transferred from a cardiosurgical hospital after the staged correction of a congenital heart defect. He had the intussusception of small intestine loops through the umbilical ring, with signs of ischemia. In anamnesis few days before, a yellow-green discharge from the umbilical wound was noted. The additional examination revealed that it was a complication of unobliterated complete omphalomesenteric fistula. Transumbilical incision and resection of intestinal necrotic area with further anastomosis were made; revision and sanitation of abdominal organs and layer-by-layer suturing of the wound were performed too. The postoperative course was uneventful. The described clinical cases demonstrate that primary care specialists (especially of non-surgical profile) have to be cautious about pathological processes in the umbilical region in newborns. If the conservative treatment is ineffective and in order to verify the diagnosis, consultation with a pediatric surgeon is recommended. If the X-ray contrast fistulography is indicated, it should be performed at a specialized hospital.