RUDN UNIVERSITY

INSTITUTE OF MEDICINE Department of Hospital

Surgery with the course of pediatric surgery

Kurbanov Fazil Samedovich.

Chinikov Maxim Alekseevich.
Faibushevich Alexandr Georgivich.
Bachoo Mohamed Rafik Hussein.
Panteleeva Ilona Sergeevna.
Maksim Lynnyk.

ABDOMINAL SURGERY IN QUESTIONS AND ANSWERS

EDUCATIONAL-METHODICAL HANDBOOK

Moscow
RUDN University
2017

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 The educational-methodical manual contains answers to typical questions on the section of "Abdominal
Surgery" included in the program of the State Exam on Surgery of the Medical Faculty of the Peoples’
Friendship University of Russia. The questions are compiled on the basis of the current State Educational
Standard.
The manual is intended for students of the 6th year of the medical faculty of the PFUR, interns, and residents.

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 CONTENT

Acute appendicitis. Clinic, diagnosis, treatment, 6

complications. Chronic appendicitis. Clinical manifestations,
differential diagnosis, indications for surgery. Appendicular
infiltration. Clinical manifestations, diagnosis, indications for
surgery.
The general concept of a hernia. Types of hernias. Inguinal 11
hernia: anatomy, Clinical manifestations, types, differential
diagnosis and treatment. Femoral hernia: anatomy, clinic,
differential diagnosis, treatment. Umbilical and hernia of the
white abdominal line: clinic, diagnosis, surgical treatment.
Congenital inguinal hernia: types, clinical manifestations,
diagnostics, operational techniques.
Gallstone disease and its complications. Acute cholecystitis: 22
clinic, diagnosis, treatment. Complications of cholecystitis.
Chronic cholecystitis: Clinical manifestations, diagnosis,
treatment, types of operations.
Acute pancreatitis: Classification, clinical manifestations, 25
diagnosis, complications. Chronic pancreatitis: classification,
clinical manifestations, methods of diagnosis and surgical
treatment.
Obturation jaundice: cause, differential diagnosis, treatment. 29
Postcholecystectomy syndrome: Clinical manifestations, 35
diagnosis, treatment.
Intestinal obstruction. Classification, pathogenesis, clinical 36
manifestations, differential diagnosis, treatment, complications.
Crohn's disease: Clinical manifestations, diagnosis, 42
treatment.
Nonspecific ulcerative colitis: Clinical manifestations, 44
diagnosis, treatment, complications.
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 Diverticulitis and diverticulosis of the large intestine. 45
Complications, diagnosis, treatment.

Stomach and duodenal ulcer. Clinical manifestations, 48

diagnosis, treatment. Indications for surgical treatment. Types of
surgical interventions.
Perforated ulcers of the stomach and duodenum: Clinical 50
manifestations, diagnosis, treatment.
Acute gastroduodenal hemorrhages: differential diagnosis, 52
tactics of the surgeon.
Diseases of the operated stomach: classification, clinical 56
manifestations, diagnostics, treatment.
Rectal prolapse. Anal fissure. Hemorrhoids. Clinical 64
manifestations, diagnosis, treatment. Anomalies in the
development of the rectum: diagnosis, treatment.
Syndrome of portal hypertension: classification, clinical 69
manifestations, complications, principles of surgical treatment.
Parasitic diseases of the liver (echinococcosis, 71
alveococcosis). Clinical manifestations, diagnosis, treatment.
Purulent complications in abdominal surgery. Peritonitis: 73
classification, etiology, pathogenesis. Clinical picture at various
stages of peritonitis, treatment. Subdiaphragmatic, pelvic,
intestinal abscesses: etiology, Clinical manifestations, diagnosis,
treatment.

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 INTRODUCTION

The educational-methodical manual is compiled on the questions

included in the tickets of the State Exam on Surgery for students of
medical universities. Compiled according to the current State
Educational Standard for Surgical Diseases.
In this manual, questions and answers on abdominal surgery are
reviewed. The manual focuses students on the correct methodology for
responding to a given question, namely, the definition of a disease,
etiology, pathogenesis, clinical manifestations, treatment, and helps
professionally how to answer.
This manual does not replace textbooks and fundamental scientific
publications and literatures.

RECOMMENDED LITERATURE

1. Хирургические болезни (под ред. М.И. Кузина). М.,

Медицина, 2002.
2. Хирургические болезни (под ред. Ю.В. Таричко). М., МИА,
2007.
3. Клиническая хирургия:национальное руководство: в 3т. /
под ред. В.С. Савельева, А.И. Кириенко. - М.:ГЕОТАР-Медиа,
2009. - Т.II. - 832 с.
4. Клиническая оперативная колопроктология: Руководство
для врачей / Под ред. Федорова В.Д., Воробъева Г.И., Ривкина В.Л.
- М.: ГНЦ проктологии, 1994. - 432 с.
5. Черноусов А.Ф., Богопольский П.М., Курбанов Ф.С..
Хирургия язвенной болезни желудка и двенадцатиперстной кишки:
Руководство для врачей. - М., Медицина, 1996. - 256 с.

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 Question: Acute appendicitis. Clinical manifestations, diagnosis,
treatment, complications. Chronic appendicitis. Clinical
manifestations, differential diagnosis, indications for surgery.
Appendicular infiltration. Clinical manifestations, diagnosis,
indications for surgery.
Answer:
Acute appendicitis - an acute inflammation of the appendix.
Clinical manifastations and symptoms:
 Pain that appear in the epigastrium that migrates towards the right
iliac region and it is constant (Kocher's symptom). The localization
of pain varies depending on the location of the appendix: with the
pelvic location - in the lower abdomen; with retrocaecal - in the
lumbar region; with subhepatic - in the right mesogastrium and
hypochondrium. With gangrenous appendicitis, the pain syndrome
may not be present.
 Nausea, single vomiting.
 Soreness and positive Shchetkin-Blumberg symptom in the right
iliac region (weakly expressed in retrocaecal position of the
appendix).
 Voskresensky’s Symptom (a "rubshka or shirt" symptom) in the
right iliac region: the zone of hypersthesia when stroking through
the shirt.
 Protective muscle tension in the right iliac region (“abdominal
guarding”).
 Rovsing’s Symptom: the appearance of pain in the right iliac region
with a sharp one-handed pressure on the area of the descending
colon and pressing the sigmoid colon with the other hand.
 Sitkovsky’s Symptom: the appearance of pain in the right iliac
region when the patient is on the left side.
 Bartomier-Michelson's sign: increased pain in the right iliac region
at palpation of the abdomen on the left side.
 Obraztsov's symptom: palpation of the right ileal region in the
patient's position on the back is sharply painful with the right leg
raised.
More than 150 symptoms of acute appendicitis are described.
Diagnosis:
Characteristically acute onset and duration of pain syndrome from

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several hours to 2-3 days.
At palpation of the abdomen, local tenderness in the right iliac region
with positive symptoms of Sitkovsky, Bartomier-Michelson, Rovzing
and Shchetkin-Blumberg is revealed, and the protective guarding of the
muscles of the abdominal wall is determined there.
The other methods are of practical importance and are more used for
differential diagnostics and diagnosis of pelvic, subhepatic and retro-
cecal positions of the appendage.
In the general blood test, leukocytosis increases in dynamics.
During the ultrasound of the abdominal cavity a hyperechoic thickened
appendix with an effusion in the right iliac fossa is sometimes
visualized. In destructive forms in the cross section of the appendage,
the symptom of the "target" or "cockade" is revealed.
In doubtful cases at diagnostic laparoscopy, a fibrinous or purulent
effusion in the right ileal fossa is found; a thickened hyperemic rigid
vermiform appendage with fibrin deposits is visualized.
Treatment:
Emergency surgery - appendectomy.
The operation is performed under general, spinal or local anesthesia.
Access: oblique variable according to Volkovich-Dyakonov in right
iliac region or lower-medial laparotomy (with peritonitis symptoms).
Currently, most appendectomies are performed through laparoscopic
access.
If the inflammatory process spreads to the dome of the cecum (tiflitis)
and it is impossible to immerse the stump of the appendage into the
purse string suture, atypical suturing of the stump of the process with
separate nodal sutures is performed and the abdominal cavity
necessarily drained.
Complications of an acute appendicitis
The most typical complications of acute appendicitis are appendicular
infiltration, appendicular abscess, abscesses in the abdominal cavity
(interintestinal, pelvic, sub-diaphragmatic), peritonitis, retroperitoneal
phlegmon (with retroperitoneal location of the appendage) and
pylephlebitis.

Appendicular infiltration
Morphological substrate: an inflammatory adhesive conglomerate

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around the appendix, consisting of the caecum, small intestine loops,
strands of the large omentum, parietal peritoneum. Sometimes the
infiltrate is soldered with a sigmoid loop (in case of dolichosigma) or
with a transverse gut (in case of transversoptosis).
The formation of an appendicular infiltrate is aimed at delimiting the
focus of inflammation from a free abdominal cavity.
Clinical symptoms:
Weak permanent or spasmodic pains in the right of the iliac region, the
presence of the tumor-like formation and an episode of pain in the right
iliac region 3-5-7 days ago, very similar to an episode of acute
appendicitis. The temperature is subfebrile or normal.
Diagnosis:
Physically: in the right iliac region a round, weakly painless or painless,
displaced or non-displaceable formation without clear boundaries is
palpable.
According to the ultrasound of the abdominal cavity in the right iliac
region, a hyperechoic rounded formation with indistinct contours is
defined, in the center of which a vermiform appendage is identified.
Treatment:
Conservative: antibiotics, antispasmodics, infusion - crystalloids.
In case of regression of the infiltrate - planned operation
(appendectomy) in 2-3 months; in case of abscessing - see treatment of
an appendicular abscess.
Indications to operation:
• abscessing of infiltrate;
• appearance of peritonitis symptoms.
If an appendicular infiltrate is found during an operation for acute
appendicitis, then in case of a loose infiltrate the adhesions are
separated and appendectomy is performed, with a dense infiltrate and
the impossibility of its separation, the operation is completed by
draining the abdominal cavity without appendectomy.

Appendicular abscess.
Clinical symptoms:
Same as the appendicular infiltrate + hectic character of fever and
symptoms of intoxication.
Diagnosis:
In a general blood test, leukocytosis with a shift of the leukocyte

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formula to the left.
Ultrasound of the abdominal cavity: the picture of an appendicular
infiltrate, in the center of the infiltrate is a rounded hypoechoic
formation with a capsule and heterogeneous contents.
Treatment:
Only surgical: opening and draining the abscess cavity (puncture and
drainage under ultrasound control is possible). If the appendix is free
and its removal is possible without technical difficulties, the operation
is supplemented with appendectomy. In other situations, appendectomy
is not performed. Access - preferably extraperitoneal according to
Pirogov (prevention of infection of the free abdominal cavity along the
drainage).

Pylephlebitis
Thrombophlebitis of the portal vein and its branches is a rare but the
most severe complication of acute appendicitis, which usually occurs
with gangrenous appendicitis, when the necrotic process passes to the
mesentery and then extends to the portal vein. The patients develop
severe intoxication - the temperature rises, while jaundice appears on
the hepatic veins, the liver increases, liver and kidney failure develops,
and patients can die within 7-10 days from the onset of the disease.
Treatment: broad-spectrum antibiotics, symptomatic treatment.

Abscesses of abdominal cavity, peritonitis

See the same question.

Retroperitoneal phlegmone
This complication develops with retroperitoneal location of the
appendix. Characteristic is the appearance of a painful infiltrate in the
right lumbar region with hyperemia of the skin above it and fluctuations
in the center. There are symptoms of severe intoxication, the condition
of patients progressively worsens, hectic fever is noted.
Treatment: opening and draining the right retroperitoneal space by
extraperitoneal access. The appendix is removed only if it is free in the
wound and is technically capable of immersing its stump. Mortality
with this complication reaches 50%.

Chronic appendicitis

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Clinical symptoms
 Chronic constant or spastic pains in the right iliac region, which
increase with coughing, physical activity, walking. Irradiation is
possible to lumbar, inguinal area, bladder, and right thigh.
 Dyspeptic symptoms (nausea, vomiting, constipation, less often
diarrhea).
Diagnosis
When palpating the abdomen the positive symptoms of Sitkovsky and
Rovsing are present, without tension of muscles of the abdominal wall
and the symptom of Shchetkin-Blumberg.
Irrigoscopy produces an uneven contrasting of the appendix with its
hook-shaped deformation.
In clinical analyses of blood and urine, there are no changes.
The diagnosis is established with the exclusion of other diseases
accompanied by pain syndrome of the indicated localization:
 Crohn's disease (at the colonoscopy in the terminal ileum, a
"cobblestone pavement" type of mucosa, at biopsy - granulomatous
inflammation with giant light-nuclear Pirogov-Langhans type cells);
 Cancer of the cecum (colonoscopy reveals a tumor, a biopsy study
allows to verify the diagnosis);
 Yersiniosis (acute onset, fever, abdominal pain, diarrhea up to 10-12
times/day, myalgia, arthralgia, positive ELISA, feces culture reveals
pathogens);
 Intestinal tuberculosis (positive Mantoux test and PCR);
 Irritable bowel syndrome (soreness in the projection of other parts of
the colon);
 Osteochondrosis of the spine with radicular syndrome (soreness in
the paravertebral points and characteristic changes in the x-ray of
the lumbar spine);
 Chronic right-sided salpingo-oophoritis (at laparoscopy the ovary is
enlarged, peritubar adhesions and hydrosalpinx are visualized).
Thus, the more carefully the patients with chronic appendicitis are
examined, the less often this diagnosis is established.
Treatment:
Planned appendectomy.

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 Question: The general concept of a hernia. Types of hernias.
Inguinal hernia: anatomy, Clinical manifestations, types,
differential diagnosis and treatment. Femoral hernia: anatomy,
clinic, differential diagnosis, treatment. Umbilical and hernia of the
white abdominal line: clinic, diagnosis, surgical treatment.
Congenital inguinal hernia: types, clinic, diagnostics, operational
techniques.
Answer:
Abdominal hernia - is the protrusion of internal organs from the
abdominal cavity through natural or artificial openings in the abdominal
wall under the skin or from the abdominal cavity to the thoracic cavity
through natural or artificial openings in the diaphragm.
Hernias are divided into external and internal.
External hernias – are protrusions of the parietal peritoneum through
the defects of the muscular aponeurotic wall of the abdomen or pelvis
with (or without) the exit of the internal organs with the integrity of the
outer covers.
Internal hernias are formations in the area of natural folds or after
surgery, trauma and inflammation of the peritoneal sac, into which the
abdominal organs move. These are diaphragmatic hernia, duodeno-
jejunal, areas of the cecal pocket, inter-sigmoidal, etc.

External abdominal hernias

The hernia formation is promoted by general and local factors.
General factors: hypotrophy of muscles of the abdominal wall,
reduction of muscle tone, features of the constitution, weight loss.
Local factors: vulnerability of typical sites of hernia formation;
long-term increase in intra-abdominal pressure (heavy physical labor,
difficult births, constipation, cough, etc.); local loss of strength (trauma,
suppuration, denervation of the anterior abdominal wall after previous
operations).
Weak sites of abdominal wall:
 Inguinal canal zone;
 An oval fossa (saphenous opening) on the thigh;
 Supra-umbilical section of the aponeurosis of the white
abdominal line;
 Peri-umbilical section of the aponeurosis of the white
abdominal line;

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  Zone of the Spigelian line;
 The area of the Petit triangle;
 The area of the Grünfeld-Lesgaft quadrangle;
 Zone of the obturator foramen.

Classification
By the time of the appearance of a hernia: congenital and acquired.
By localization: inguinal, femoral, umbilical, white abdominal line,
post-operative, post traumatic, rare hernias (spigelian, area of the
xiphoid process, lumbar, sciatic, obturator, perineal), artificial.
By ability to be moved back: reducible and irreducible.
By the contents of the hernial sac: sliding (contain organs that do
not have a mesentery or are partially covered with the peritoneum) and
conventional.
By presence of complications: complicated and non-complicated.
Complications of hernias:
 Hernial strangulation with the development of necrosis of the
contents of the hernial sac, phlegmon of the hernial sac and/or
peritonitis.
 Acute intestinal obstruction in the hernial sac (by faecal
blockage type).
External abdominal hernias consist of hernial neck, a hernial sac,
hernial contents and external hernial membranes.
Hernial neck – is a section in the abdominal wall or diaphragm,
through which the parietal peritoneum protrudes and internal organs
can move into.
Hernial sac - it is a sheet of the parietal peritoneum that emerges
through the hernial neck through the thickness of the abdominal wall or
diaphragm. Over time, accretions (multicameral hernia) can form in the
lumen of the sac. In the hernial sac, the isthmus, neck, body and fundus
are distinguished. The isthmus is a borderline part with the abdominal
cavity, where the peritoneum is collected in longitudinal folds and is
eventually replaced by scar tissue. The neck is the narrow part of the
sac located in the hernial neck. The body of the hernial sac is the largest
part, the distal part of it is called the fundus of the hernial sac.
Clinical symptoms
Hernial protrusion in the projection of weak points of the abdominal

1
wall, which disappears in a horizontal position, pain in the area of
protrusion during exercise, dyspeptic symptoms are possible.
Diagnosis
Physically: in the vertical position of the patient, the location, the
size of the hernial sac are defined; in the horizontal position of the
patient is determined whether hernia is reducible or not, the size of the
hernial neck are assessed, the symptom of a cough push determined
(negative for a strangulated hernia). In addition, the character of the
skin over the hernial protrusion is evaluated: in the case of the
phlegmon of the hernial sac, the skin above the protrusion is hyperemic
with the area of fluctuation. When the peritonitis appears, the muscle
tension of the anterior abdominal wall is determined, the positive
symptom of Shchetkin-Blumberg, and in the later stages - signs of
intoxication and intestinal paresis.
The purpose of CT of the organs of the abdominal cavity and
anterior abdominal wall: the determination of the sizes of the hernial
gates and of the hernial sac (with gigantic multi-chamber postoperative
hernias).
The purpose of ultrasound of the hernial sac: clarification of the
contents of the hernial sac, its topographic and anatomical interposition
of the sac and surrounding structures.
Radiography with contrasting of the stomach, intestine, colon,
cystoscopy are performed to clarify the nature of the contents of the
hernial sac.
Spirography allows predicting the risk of postoperative pulmonary
complications at giant hernias.
Treatment
In uncomplicated hernias, hernia repair is indicated in the planned
order.
The stages of the operation: dissection of the tissues over the hernial
sac (1), dissection of the hernial neck (2), excision of the hernial sac
(3), opening it (4), directing the hernial contents into the abdominal
cavity (5), ligation and cutting of the hernial sac at the cervix (6), plasty
of the muscles and the aponeurosis of the abdominal wall (7).
With a small size of the hernial sac and the absence of
complications, the hernial sac is not excised, but is invaginated into the
abdominal cavity without opening the lumen.
The operation is performed under local, conductive (spinal,

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epidural) anesthesia or under general anesthesia. The advantage of local
anesthesia during hernia repair: in case of difficulty during the search
and isolation of the hernial sac (especially with small hernias), the
patient strains, the intra-abdominal organs fill the hernial sac, which is
easily differentiated from surrounding tissues.
With the development of complications of the hernia, an urgent
operation is indicated.
Inguinal hernia
Anatomy
The inguinal space is a zone bounded from below and laterally by a
Poupart’s ligament, from above - by the lower edge of the internal
oblique muscle, medially – by external margin of the vagina of the
rectus abdominis muscle. The higher the inguinal space, the greater is
the risk of hernia formation.
The inguinal canal is the space bounded from the front by the
aponeurosis of the external oblique abdominal muscle, from the rear by
the transverse muscle, and in the medial corner by the vagina of the
rectus abdominis, at the bottom by the Poupart’s ligament, at the top by
the free edge of the aponeurosis of the inner oblique abdominal muscle.
The fibers of the aponeurosis of the external oblique abdominal muscle
run parallel to the Poupart’s ligament and run apart around the pubic
tubercle, forming two legs - medial and lateral. The medial leg is
attached to the pubic tubercle, the lateral to the pubic symphysis. The
hole between the medial and lateral legs forms the outer opening of the
inguinal canal.
In the lower half of the posterior surface of the abdominal wall, the
peritoneum forms five folds and four fossae. The median fold (plica
mediana) is the remainder of the obliterated urinary duct (urachus).
Lateral from the median are two folds (plicae intermediae), formed by
obliterated umbilical arteries and veins. Even more outside are lateral
folds (plicae laterales), formed by internal inferior epigastric vessels.
Between the folds described are formed grooves, called inguinal
depressions or fossae. The medial inguinal cavity (fossa medialis) is
located between an empty umbilical artery and internal inferior
epigastric vessels. This fossa serves as a place for the exit of the direct
inguinal hernia (an external opening of the inguinal canal is projected
into this cavity). The lateral inguinal cavity (fossa lateralis) is located
outside of the lateral fold of the peritoneum. Here lies the internal

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opening of the inguinal canal - the exit point of the oblique inguinal
hernia. In the inguinal canal passes the spermatic cord in men and the
round ligament of the uterus in women.
Classification
By localization of the hernial sac:
 Indirect (leaves through the internal opening of the inguinal
canal, parallel to the spermatic cord, descends into the scrotum).
 Direct (coming out in the projection of the external opening of
the inguinal canal, located medially from the spermatic cord, does not
descend into the scrotum).
 Sliding (contains organs that do not have a mesentery or are
partially covered by the peritoneum).
 Intra-abdominal wall (hernial sac is located intramuscularly in
the thickness of the abdominal wall).
 Double-horned (hernia has one isthmus and 2 hernial sacs).
 Peri-inguinal (the hernia exits not through the outer inguinal
ring).
 Combined (several separate hernial sacs).
 Postoperative.
The following types of oblique hernia are distinguished by stages of
development:
 Primary (palpable with the tip of the finger in the projection of
the inner inguinal ring).
 Ductal (located in the inguinal canal).
 Inguinal-scrotal (descends into the scrotum).
In congenital inguinal hernias, the hernial sac (dilated vaginal
appendage of the peritoneum) contains the fallen organ and testicle,
with acquired ones, it has no communication with the testicular
membranes.

Differential diagnosis
In femoral hernia, the hernial protrusion is located below the
inguinal fold, in the projection of the oval window, is more common in
women.
In inguinal lymphadenitis in the subcutaneous tissue is palpated
conglomeration of dense rounded formations, with ultrasound in the
inguinal area, the hernial sac and hernial gates are not visualized.

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 In the cyst of the spermatic cord, the symptom of a cough push is
negative, according to ultrasound in the elements of the spermatic cord,
a rounded hypoechoic formation with a capsule and homogeneous
contents is revealed.
In the case of a preperitoneal lipoma or a lipoma of the circular
ligament, the symptom of a cough push is negative, with ultrasound in
the inguinal canal, a rounded lobular structure and normal echogenicity
are revealed.
When the testicle is hydropic there is no connection between the
formation and the aponeurosis of the abdominal wall, there is no
separately palpable testis, with ultrasound in the scrotum, a rounded
hypoechoic formation around the testicle is located.
In the case of cryptorchidism, palpation does not determine the
testicle in the scrotum, ultrasound of the inguinal canal reveals a
rounded structure of normal echogenicity with appendages (testicle).
Treatment
Treatment is surgical. A hernia repair with plasty of the inguinal
canal by local tissues or a synthetic reticular implant is performed. It is
possible to use traditional open or laparoscopic approaches. It should be
noted that nowadays the hernioplasty is most often performed by
porous implants and, with plasty of aponeurosis by local tissues, it is
necessary to use only the methods of plasty of the posterior wall of the
inguinal canal. All variants of the plasty of the anterior wall of the
inguinal canal are considered inadequate and are not currently used.
Used variants of plastics of the inguinal canal:
 Bassini method (plastics of the posterior wall of the inguinal
canal: joint aponeuroses of the transverse and internal oblique muscles
are hemmed with separate nodular sutures to the inguinal ligament).
 The method of Shouldice (plastic of the posterior wall of the
inguinal canal: a transverse fascia, transverse and internal oblique
muscles are separately sutured to the inguinal ligament with a
continuous suture).
 Liechtenstein method (plastics of the posterior wall of the
inguinal canal with a synthetic porous mesh implant).
 The method of Postemsky (elimination of the inguinal canal,
moving the spermatic cord under the skin: the adjoining of the external
and internal oblique ligaments and the transverse muscles are sutured to
the inguinal ligament, the lower part of the aponeurosis of the external

1
oblique muscle is fixed from above with the formation of the
duplication).
 The Corbitt method (laparoscopic version of hernioplasty: the
parietal peritoneum in the projection of the inguinal space is dissected
and separated; the elements of the spermatic cord, the pubic tubercle,
the inguinal and Poupart’s ligaments, the aponeurosis of the internal
oblique muscle are mobilized; the plasty is performed with a synthetic
porous implant, which is fixed with a stapler and covered with a
parietal peritoneum). If access is through the abdominal cavity - this
hernioplasty is called transabdominal preperitoneal (TAPP), if without
opening the parietal peritoneum /in the preperitoneal tissue/ - extra-
abdominal is called totally extraperitoneal plasty (TEP).

Femoral hernia
Anatomy
The Poupart’s ligament is stretched between the superior anterior
iliac spine and the pubic symphysis. Between the Poupart’s ligament
and the bones of the pelvis (pubis and ilium) there is a space that is
divided by the iliopectineal (lacunar) ligament, going from the
Poupart’s ligament to the eminence of lacunar on the branch of the
pubic bone into two lacunae - muscular and vascular. In the muscular
lacuna, which is about 2/3 of the subpoupart’s space, there is the
iliopsoas muscle and the femoral nerve. In the vascular lacuna there are
femoral artery and femoral vein. The vascular lacuna is covered from
above with a large layer of adipose tissue, in which there are lymph
nodes through which the lymphatic vessels pass from the lower limb.
The femoral vessels do not completely fill the vascular lacuna.
Medially to the vessels is a space filled with fatty tissue and lymph
nodes (Pirogov-Rosenmuller node) with a width of 1.2-1.8 cm. In this
space, when a femoral hernia occurs, a femoral canal is formed.
The external orifice of the femoral canal is an oval fossa (saphenous
opening). The inner opening is bounded from the top by the inguinal
ligament, externally - by the femoral vein, medially - by the lacunar
ligament, from below - by the iliopubic ligament, which is tightly fused
to the periosteum of the pubic bone.
Clinical symptoms
Hernial protrusion below the inguinal fold, pain in projection
protrusion during walking and exercise, protrusion changes its shape

1
when the position of the body changes.
Differential diagnosis
In inguinal hernia, the hernial sac is located above the inguinal
ligament.
In inguinal lymphadenitis in the subcutaneous tissue a
conglomeration of dense rounded formations is palpated, by ultrasound
in the inguinal area there is no hernial sac and hernial gates.
In the case of an aneurysm of the femoral artery, pulsation is
determined during palpation, by auscultation systolic noises over the
formation, by ultrasound of the inguinal region, a circular formation
associated with the femoral artery is detected, blood flow is recorded
inside the formation.
In congestive abscess, an infiltrate is found in the projection of the
oval fossa with fluctuations, and with radiography of the spine - signs
of spondylitis.
In the case of benign tumors, the size of the formation does not
change at different positions of the body, there is no symptom of cough
push. At metastases of malignant tumors it is necessary to reveal the
primary tumor.
Treatment
The operation is performed under local anesthesia.
Access to the femoral hernia: femoral and inguinal.
Types of operations:
 Lockwood method (The cut of the skin is made vertically along
the hernial protrusion. Plasty of the inner opening of the femoral canal
is made by suturing the inguinal ligament to the periosteum of the pubic
bone with 2-3 nodal sutures).
 Bassini method (It is a modification of Lockwood's method and
differs in that after suturing the inguinal ligament to the pubic bone, a
second row of sutures is applied to the semilunar edge of the oval fossa
of the thigh and the pectineal fascia).
 Ruggi-Parlavecchio method (The transverse fascia is dissected
from the side of the inguinal canal and the neck of the hernial sac is
dully isolated from the inner opening of the femoral canal. The hernial
sac dislocates into the wound from the inguinal ligament, is ligated at
the neck and is removed. The hernial gates are closed by suturing the
inguinal ligament to the iliopubic ligament by 3-4 sutures. Then the
dissected transverse fascia and aponeurosis of the external oblique

1
abdominal muscle are sutured).
 The method of Reeves (In the preperitoneal space a synthetic
porous implant is sutured behind the transverse fascia).

Umbilical hernia
Clinical symptoms
Hernia protrusion in the navel, pain in the area of protrusion.
These hernias tend to strangulate.
Diagnostics
Physical examination, ultrasound of the abdominal cavity organs
(clarification of the localization of hernias and their contents).
Treatment
 Sapezhko method (formation of duplication of aponeurosis
vertically).
 The Mayo method (formation of duplication of aponeurosis
horizontally).
 Plasty of aponeurosis with a synthetic mesh implant (with large
or recurrent hernias) with open or laparoscopic access.

Hernias of the white line of the abdomen

Classification
By localization: epigastric, paraumbilical and hypogastric.
Clinical symptoms
Herniated protrusion in the projection of the white line of the
abdomen, pain in the area of protrusion. These hernias tend to
strangulate.
Diagnosis
Physical examination, ultrasound of the abdominal cavity organs
(clarification of the localization of hernias and their contents).
Treatment
 hernia repair with plasty of aponeurosis using a synthetic mesh
implant (fixed to the aponeurosis in the pre-peritoneal adipose tissue /
sublay / or to the posterior sheet of the vagina of the rectus abdominal
muscles /inlay retromuscular/ in open operations; for laparoscopic
operations, the implant is fixed to the parietal peritoneum around the
hernial gates /IPOM/).

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 Strangulated hernia
Complication, which involves the infringement of the contents of
the hernial sac in the hernial neck.
Types of strangulations:
1. in the hernial sac;
2. Retrograde (W-shaped): the intestinal loop subjected to
infringement is in the free abdominal cavity, a sign of such
infringement is the presence of two intestinal loops in the hernial sac.
The portion of the intestine between these loops, located in the
abdominal cavity, is necrotic.
3. Partial enterocele (Richter’s): more often in the inner opening of
the inguinal canal at oblique inguinal hernias, the part of the intestinal
wall by the edge opposing to the mesentery is strangulated.
Clinical symptoms
An acute onset, persistent intense pain in the projection of the
hernial sac, the hernial sac is strained, sharply painful at palpation, the
symptom of a coughing push is negative. Diagnosis is established based
on the examination data.
Treatment
After the diagnosis of the strangulated hernia is established, an
urgent operation is indicated because of the risk of developing gangrene
of the gut region.
With the strangulated hernia, the stages of the operation change:
after isolation of the hernial sac, it is opened, hernial water is
evacuated, while retaining the contents of the hernia the strangulation
ring is dissected. Then, the viability of the strangulated organ is
assessed. If the loop of the intestine is viable (loop of the gut of normal
color, peristalsis is present, there is a pulsation of the marginal vessels
of the mesentery), further steps are analogous to surgery of
uncomplicated hernia. If the intestinal loop is unviable, a resection of
the necrotic area of the intestine is performed, taking 30-40 cm in the
proximal and 15-20 cm in the distal directions. With doubtful viability
of the bowel, diagnostic laparoscopy is indicated after 12-24 hours. In
the case of detection of gangrene of the gut region, resection of the
necrotic intestinal loop is performed.
If during the introductory anesthesia the affected organs are
repositioned and after the dissection of the hernial sac, the contents

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were not found in it, a median laparotomy with a revision of the
intestinal loops and an assessment of the viability of the strangulated
intestinal loop are indicated.
If there is a laparoscopic stance and the surgeon is able to perform
laparoscopic interventions, laparoscopic hernioplasty can be performed.
When the symptoms of peritonitis appear, the operation should
begin with a median laparotomy.
If, after opening the hernial sac, the phlegmon of the hernial sac is
diagnosed, the median laparotomy is performed. From the side of the
abdominal cavity the strangulated afferent and efferent loops of the
intestine are determined, they are cut immediately above the entrance to
the strangulation ring, the parietal peritoneum is mobilized at the site of
the hernial gates and is sutured over the muffled sites of the constricted
gut (peritonization), entero-enteroanastomosis is formed, the
laparotomic wound is sutured. Then the purulent exudate and a necrotic
bowel loop are removed from the hernial sac, the cavity is washed with
antiseptics, loosely tamponized with ointment napkins and treated like a
purulent wound. Plasty of the hernial gates is not performed.

Congenital inguinal hernia

Clinical symptoms
Corresponds to uncomplicated inguinal hernia.
Diagnosis
At palpation, the hernial sac (the dilated vaginal appendage of the
peritoneum) contains the fallen organ and testicle, which is confirmed
by ultrasound of the hernial sac.
Treatment
The peculiarity of the operation is the cutting off of the vaginal
process of the peritoneum from the testicle. Further stages of the
operation are the same as for inguinal hernias.
Plasty of aponeurosis — see inguinal hernia.

Question: Gallstone disease and its complications. Acute

cholecystitis: clinic, diagnosis, treatment. Complications of
cholecystitis. Chronic cholecystitis: clinic, diagnosis, treatment,
types of operations.
Answer:

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 Gallstone disease — is a disease in which there is a formation of
concrements in the bile duct and gall bladder.
Complications of GD: acute cholecystitis, mechanical jaundice,
cholangitis, choledocholithiasis, strictures of the bile ducts, external or
internal biliary fistula, acute biliary pancreatitis.

Acute cholecystitis
According to the presence of concrements in the gallbladder,
calculous and acalculous acute cholecystitis are distinguished. By the
character of the morphological changes of the walls of the organ
catarrhal, phlegmonous and gangrenous cholecystitis are distinguished
(the last two forms are called destructive). When the neck of the
gallbladder is obstructed with a concrement, an occlusive acute
cholecystitis develops.
Clinical symptoms
Complaints of nausea, vomiting, pain in the right upper quadrant,
associated with the reception of fatty and spicy food. In the anamnesis,
similar attacks related to food intake, previously detected concrements
in the gallbladder on the ultrasound.
Diagnostics: 1. Typical clinical symptoms
2. Physically: pain during palpation in the right hypochondrium,
positive symptoms of Ortner (sharp pain in the projection of the
gallbladder at light pattering on right costal arc by the edge of palm ), Kehr
(increased inspiratory pain at deep palpation of the right
hypochondrium region), Georgievsky-Mussy (painfulness when
pressed between right sternocleidomastoid muscle (above a collar-bone).
3. Ultrasound of the abdominal cavity allows to reveal signs of acute
calculous cholecystitis:
- In the lumen of the gallbladder a hyperechoic rounded formation
with distinct contours unconnected with the wall of the bladder is
located, giving a clear acoustic shadow (sign of a concrement);
- The gallbladder is enlarged in size;
- There is a thickening of the wall of the gallbladder (> 0.4 cm);
- Cleavage of the wall of the gallbladder and/or discontinuity of the
wall contour (which indicates destructive forms of cholecystitis);
- Signs of perivesical complications (peri-gallbladder exudate,
infiltration, abscess).
Treatment:

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 1. Conservative (antispasmodics, antibiotics, crystalloid infusion,
symptomatic).
2. Surgical:
a) A radical operation - cholecystectomy.
The purpose of the operation is to remove the inflamed gallbladder
with concrements.
b) Palliative surgery - cholecystostomy or microcholecystostomy.
The purpose of the operation is to reduce intravesical hypertension
(decompression) without completely removing the stones from the
gallbladder.
In the treatment of acute cholecystitis one adheres to the following
tactics. After the diagnosis is established, all patients begin conservative
treatment (with the exception of peritonitis, in this situation, an urgent
operation is indicated).
Then, on the background of ongoing conservative treatment by
clinical (complaints and physical examination data), laboratory
(leukocytosis, neutrophil left shift) and instrumental (ultrasound) data,
the dynamics of the disease is assessed. In the case of positive
dynamics, conservative treatment is continued until complete relief of
the attack and operated within a period of up to 2 weeks from the onset
of the attack or routinely after 4-6 months. In the case of negative
dynamics, an urgent operation is indicated. If there is no dynamics
against the background of ongoing conservative treatment, surgery is
indicated in an urgent or delayed manner. In the absence of any
dynamics, the observation of the patient takes no more than a day.
After determining the indications for surgery, the degree of surgical
intervention is determined. Patients of young and middle age without
severe concomitant diseases are indicated to perform cholecystectomy.
In patients over the age of 60 with decompensated concomitant
diseases and high operational anesthesia risk, microcholecystostomy is
indicated under ultrasound guidance or cholecystostomy.
If a decision is made to perform a cholecystectomy, the option of
surgical access is determined.
By access options, cholecystectomy is distinguished to be traditional
(open), laparoscopic, from minilaparotomic access.
Each of the accesses has positive and negative sides.

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 Access Positive aspects Negative aspects

Lapara- Good visualization, the Traumatism, high risk of wound

tomy possibility of a full revision suppuration and postoperative
and timely elimination of hernias, long rehabilitation
intraoperative complications period, poor cosmetic effect
Laparo- Good visualization, low Impossibility of tactile revision,
scopy traumatism, short when intraoperative
rehabilitation period, good complications arise, access
cosmetic effect conversion to laparotomy,
complications of
pneumoperitoneum (risk of PE,
decompensation of
cardiovascular diseases), need
for special instruments
Mini- Elimination of Limited visualization, the need
laparo- intraoperative complications for special instruments
tomy without access conversion,
low traumatism, short
rehabilitation period, good
cosmetic effect
Complications of cholecystitis
Perivesical infiltrate, perforation of the gallbladder with the
development of perivesical abscess or peritonitis, mechanical jaundice,
cholangitis, gallbladder edema, external or internal bile fistula, acute
biliary pancreatitis.
Perivesical infiltrate, abscess and diffuse peritonitis are indications
for traditional cholecystectomy.

Chronic cholecystitis
Clinical symptoms
Complaints of nausea, spasmodic pains or discomfort in the right
upper quadrant associated with taking fatty and spicy food. In the
anamnesis, similar attacks related to food intake, previously revealed
concrements in the gallbladder during ultrasound.
Diagnostics
The main method of diagnosis is the ultrasound of the abdominal
cavity in order to identify signs of concrements in the gallbladder (see
acute cholecystitis).

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 Treatment
Cholecystectomy from laparotomic or minilaparotomy access,
laparoscopic cholecystectomy. Currently, the preference is given to the
last two options for operations. In recent years NOTES-technologies
have been used to perform cholecystectomy (laparoscopic access
through the puncture of the walls of the internal organs: the posterior
wall of the vagina, the anterior wall of the stomach, the wall of the
transverse colon).

Question: Acute pancreatitis: classification, clinic, diagnosis,

complications. Chronic pancreatitis: classification, clinic, methods
of diagnosis and surgical treatment.
Answer:
According to the variants of the clinical course, acute and chronic
pancreatitis is distinguished.
Acute pancreatitis
Acute pancreatitis — inflammation of the pancreatic tissue,
accompanied by pronounced disturbances of homeostasis and the
development of polyorganic insufficiency.
Classification:
By etiological factor: biliary, alcoholic, idiopathic.
The prevalence of lesions: focal, subtotal and total.
On macroscopic changes: edematous, hemorrhagic and fatty.
Stages of clinical course: 1. enzymemia (3-5 days) 2. parapancreatic
infiltrate formation (7-14 days) 3. parapancreatic infiltrate outcome and
purulent complications (2-4th weeks).
Simplified pathogenesis of acute pancreatitis can be represented in
the following way: a violation of the outflow of pancreatic juice →
intraductal hypertension → early activation of pancreatic enzymes →
damage to the acinar cells. Further, there is a systemic effect
(enzymemia) and a local damaging effect of enzymatic exudate.
1. Systemic effect: penetration of enzymes into the bloodstream
from the inflammatory focus → damage to the vascular wall and blood
cells (hemolysis and coagulopathy with the development of the DIC
syndrome) + damage of all organs and tissues by the enzymes with the
development of a cascade of inflammatory responses (systemic
inflammatory response) and the subsequent development of a multi-
organ insufficiency.

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 2. Local effect: damage to surrounding tissues with the development
of aseptic necrosis of parapancreatic, paranephric, presarral, pararectal,
paracolonic, pre-peritoneal adipose tissue, as well as cellulose of
mesocolon, root of the mesentery of small intestine and posterior
mediastinum with development of omentobursitis, enzymatic peritonitis
and/or left-sided pleurisy.
Clinical symptoms
Nausea, repeated vomiting, not bringing relief, epigastric pain,
hypotension or collapse, symptoms of intoxication, oliguria (symptoms
associated with the intake of spicy or fried foods, alcohol).
Diagnostics
On ultrasound of the abdominal cavity, the pancreas is enlarged in
size, its contours are not clear, the gland tissue has uneven echogenicity
(alternation of hypo- and hyperechogenous zones), an effusion in the
omental bursa and abdominal cavity and/or parapancreatic infiltrate is
determined.
CT of the abdominal cavity (more sensitive and specific method)
allows to identify similar ultrasound changes in the pancreas and
visualize the signs of complications.
With the help of a calcitonin test, a diagnosis of infected pancreatic
necrosis (in which surgical treatment is often indicated) is set,
diagnostically significant is an increase in the level of procalcitonin by
>2 ng/ml.
An increase in the serum level of phospholipase A2 (a rise in the
level occurs earlier than amylases and high levels of the enzyme persist
longer).
Amylasemia is not a marker of pancreonecrosis, because its level
depends on the stage of the disease.
Complications:
In the 1st stage - pancreatogenic shock, enzymatic peritonitis.
In the 2nd stage - acute fluid accumulation, parapancreatic
infiltration.
In the 3rd stage - early: pseudocyst, abscess and/or phlegmon of the
above mentioned cellular spaces, arrosive bleeding; late: true cyst,
pancreatic fistula.
Treatment:
Conservative treatment of pancreatic necrosis includes:
1. Antisecretory drugs - Sandostatin and analogues.

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 2. Antiprotease drugs (only act in the vascular channel) - Gordoks,
Contrikal.
3. Infusion of crystalloids (correction of ABS and normalization of
CBV).
4. Infusion of colloids (correction of CBV).
5. Antibiotics of a wide spectrum of action (prevention of purulent
complications).
6. Symptomatic treatment.

Surgical treatment is indicated only with the development of

complications of the disease.
At enzymatic peritonitis a laparoscopic sanation of the abdominal
cavity is performed, preferably without drainage (installation of
drainage catheters significantly increases the risk of early infection).
In acute fluid accumulation, fine needle puncture under the guidance
of ultrasound or CT with aspiration of the contents (without drainage) is
advisable. It is possible to conduct a puncture needle through the
stomach.
With abscesses and phlegmon of different localizations are needed
puncture and drainage under the supervision of ultrasound or opening
and draining of purulent foci preferably by extraperitoneal access.
With the development of an arrosive bleeding, ligation of the
bleeding vessel is indicated.
In the presence of sequestrants a necrsequestrectomy is performed.
Pseudocysts are punctured under the control of ultrasound
sometimes in combination with the introduction of sclerosants into the
pseudocyst cavity.
With true cysts (there is a connection between the cyst and the ducts
of the gland) are performed: cystectomy, resection of the pancreas (at
localization in the region of the tail of the gland), or cystoenterostomy
by Roux.
Treatment of external fistulas – is conservative: prolonged forms of
analogues of endogenous somatostatin; in the absence of the effect, a
pancreatofistulojejunoanastomosis by Roux is formed.

Chronic pancreatitis
Classification
By the nature of morphological changes:

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  Calculous pancreatitis (virsungolithiasis, calcifying pancreatitis).
 Fibrous-sclerotic (indurative).
 Hyperplastic (pseudotumorous).
 Cystic.
By clinical manifestations: painful, hypo-secretory. astheno-neurotic
(hypochondriacal), latent, combined.
By the nature of the clinical course: rarely recurrent, often recurrent
and persistent.
On the etiology: biliary, alcoholic, dismetabolic (diabetes mellitus,
hyperparathyroidism, hypercholesterolemia, hemochromatosis),
infectious, medicinal, idiopathic.
Clinical symptoms
Recurrent pain in epigastrium, loss of body weight, signs of
exocrine (steatorrhea) and endocrine (diabetes mellitus) pancreatic
insufficiency.
Diagnostics
On ultrasound of the abdominal cavity, the pancreas is thickened, its
contours are uneven, there are an alternation of areas of high and low
echogenicity, intraductal and parenchymal calcifications, a dilatation of
the Wirsung duct (> 2 mm) and its lateral branches, fluid formations
with hypoechogenic uniform contents (pseudocysts) and hyperechoic
capsule (true cysts).
According to CT scan of the abdominal cavity, changes similar to
those obtained by ultrasound are revealed.
The results of the elastase test allow us to judge the degree of
exocrine gland insufficiency. The concentration of pancreatic elastase
in the feces of <200 mcg/g of feces corresponds to the mild and
moderate severity of exocrine pancreatic insufficiency; <100 mcg/g - to
the severe degree.
When the breath test with 13C-triglycerides (based on the
determination of the total concentration of 13CO2 in the exhaled air
within 6 hours after oral intake of 300 mg of 13C-octanoylglycerol), a
concentration of <27.3% indicates exocrine pancreatic insufficiency.
Glucose tolerance test - after 2 hours after oral intake of 75 g of
anhydrous glucose, hyperglycemia is recorded (which indicates a
violation of the endocrine function of the pancreas).

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 Surgical treatment
Indications: persistent pain syndrome not subdued by conservative
means, pseudocysts with a diameter of >6 cm, mechanical jaundice,
stenosis of the duodenum, regional portal hypertension with recurrent
gastric bleeding, pancreatic fistula, pancreatic abscess, Wirsung duct
stones with its dilatation, suspicion for cancer of pancreas.
Operation types:
 Isolated subtotal resection of the head of the pancreas (Beger's
operation) with termolatero-lateral (with dilatation of the Wirsung duct)
or termino-terminal (with the normal diameter of the Wirsung duct)
pancreato-jejunoanastomosis on a loop that is disconnected by Roux.
With dilatation of the common bile duct and mechanical jaundice, a
choledocho-jejuno- or hepatico-jejunoanastomosis distal to pancreato-
jejunoanastomosis is formed.
 Partial resection of the head of the pancreas (Frey's operation)
with longitudinal pancreato-jejunoanastomosis on the loop that is
disconnected by Roux. With the same effectiveness, in comparison with
the operation by Beger, this operation is technically simpler, there are
less intraoperative complications with its implementation.
 Pancreato-duodenal resection.
Stenosis of the duodenum is usually eliminated after resection of the
head of the pancreas. At regional portal hypertension splenectomy is
performed.
Treatment of pseudocysts, abscesses and fistulas - see acute
pancreatitis.

Question: Obstructive jaundice: cause, differential diagnosis,

treatment.
Answer:
Obstructive (mechanical) jaundice is a syndrome developing when
the outflow of bile along the bile ducts is violated.
For mechanical jaundice are characteristic: icteric skin and mucous
membranes, dark urine, acholic stool, hyperbilirubinemia (>35-40
μmol/L) predominantly due to direct bilirubin, an increase in the level
of gamma glutamyltranspeptidase (GGTP) and alkaline phosphatase
(AP), dilation of choledochus (> 1.0 cm) and/or other bile ducts
according to ultrasound.
Causes of mechanical jaundice:

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 Choledocholithiasis, pancreatic head cancer, cancer of major papilla
of the duodenum (MDP), stricture of the ducts, adenoma of MDP,
cholangitis, primary sclerosing cholangitis, common bile duct cancer,
compression of extrahepatic bile ducts with metastatically altered
lymph nodes in the liver gates, para-Vater (parapapillary) diverticulum
and others.

Choledocholithiasis
Diagnostics:
The main method: cholangiography.
By the way the contrast medium is administered, there are 3 types of
cholangiography:
1. Endoscopic retrograde pancreatocholangiography (ERPCG) - a
contrast agent is introduced retrogradely after endoscopic cannulation
of major duodenal papilla (MDP);
2. Percutaneous transhepatic cholangiography (PTC) - contrast
material is administered antegradely after puncture of the segmental
intrahepatic bile duct under the control of ultrasound;
3. Fistulography - contrast material is introduced through the
drainage previously installed into the ducts.
Objectives of cholangiography: the detection of the level and cause
of the violation of outflow of bile, the determination of the patency of
the bile duct at the site of the obstruction (and the discharge of contrast
medium into the duodenum).
X-ray semiotics: in the lumen of the duct are determined rounded
single or multiple defects of filling not associated with the walls of the
ducts, the common bile duct is enlarged.
Additional diagnostic methods:
Ultrasound of the abdominal cavity - to detect the expansion of
extra- and/or intrahepatic bile ducts, sometimes in the lumen of the
ducts, hyperechoic rounded formations with a clear acoustic shade
(concrements) are located.
Duodenoscopy - when examining the MDP, it is possible to identify
the infiltration of the calculus in the MDP, and also to see the leakage of
bile into the duodenum (which indicates an incomplete block of the
common bile duct with a concrement).
MRI of the hepatobiliary zone with contrasting (MR-
cholangiography) - to identify the expansion of the bile ducts and

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concrements in them.
Treatment
When performing ERPCG and confirming the diagnosis of
choledocholithiasis, diagnostic manipulation becomes therapeutic -
endoscopic papillosphincterotomy (EPST) is performed followed by the
extraction of concrements by the aid of Dormia basket or Fogarty’s
vascular catheter.
At large sizes of the calculi after EPST, contact lithotripsy is
performed and the fragments are recovered in the manner described.
In rare cases, at the impossibility of performing EPST and extracting
concrements, a choledochotomy is performed with extraction of
concrements and installation of external drainage into the lumen of the
bile duct (T-shaped Ker drainage or Holstad-Pikovsky drainage).
Currently, this intervention is performed from a standard laparotomy
access, through a laparotomy from a mini-access or by a laparoscopic
method. However, in most cases, lithoextraction can be performed
endoscopically.

Duct strictures
Choledochus strictures are iatrogenic (if the ducts are damaged
during open or laparoscopic operations with a clip or an electric
coagulation/burn – which often appear in the common hepatic duct and
proximally) or are a complication of choledocholithiasis (they form in
the terminal section of the common bile duct).
By length, short (<1.5 cm) and long (> 1.5 cm) strictures are
distinguished; by the degree of narrowing of the lumen - complete and
incomplete.
Diagnostics
Principal method
At any kind of cholangiography, a narrowing of the duct with
smooth contours and suprastenotic dilatation of the duct are detected
proximal to the stricture level. The level and extent of stricture, the
degree of expansion of the ducts are determined. The ducts are not
dilated distal to the level of stricture. At complete strictures beyond the
stricture site, the bile ducts are not filled with a contrast agent (at
ERPCG, the proximal sections are not contrasted, while at PTC - the
distal ones). In this situation, a combination of ERPCG and PTC is used
to determine the extent of the stricture.

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 Additional methods
At ultrasound and MRI of the abdominal cavity, indirect signs are
revealed - the expansion of intra- and extrahepatic bile ducts.
Treatment
With short incomplete strictures of the terminal site of choledochus -
EPST + treatment of choledocholithiasis.
With short incomplete strictures of other localizations - endoscopic
balloon dilatation and stenting (sometimes repeated interventions are
required).
With short complete strictures or extensive incomplete strictures -
stenting with the replacement of a plastic stent after 3-5 months for a
new one. With the impossibility of stenting - an open surgery
(hepaticojejunoanastomosis by Roux).
With extensive complete strictures, an open surgery
(hepaticojejunoanastomosis by Roux) is also indicated.

Cancer of the head of the pancreas

Jaundice develops as a result of mechanical compression or a tumor
ingrowth of the intrapancreatic part of the common bile duct.
Diagnostics
On ultrasound of the abdominal cavity, a voluminous formation of
the head of the pancreas with fuzzy contours, expansion of the common
bile duct (in the late stages of the disease) are revealed.
According to the CT of the abdominal cavity organs (necessarily
with three-phase contrast), the contrast accumulating voluminous
formation of the gland head with uneven contours, the regional lymph
nodes enlargement, and the common bile duct dilatation are visualized.
Differential diagnosis
of the cancer of the head of the pancreas is performed with a
pseudotumorous pancreatitis (at this disease there are no signs of
metastasis in regional lymph nodes, by fine needle biopsy, no malignant
cells are detected); a cyst, an abscess of the pancreas (CT scan reveals
fluid formations with a capsule, the presence of non-uniform contents
testifies in favor of an abscess).
Treatment
With a resectable tumor - (any tumor size without invasion into the
inferior mesenteric artery or abdominal aorta, absence of distant
metastases) pancreatoduodenal resection.

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 With an unresectable tumor, stenting of choledochus with
continuous nitinol stents.

Cancer of MDP, adenoma of MDP

Diagnostics
At duodenoscopy – on MDP is revealed a voluminous formation
(the biopsy study verifies the diagnosis).
According to the ultrasound of the abdominal cavity, the expansion
of the common bile duct can be visualized (which is an indirect sign of
the tumor of the MDP).
Treatment
Cancer of MDP - pancreatoduodenal resection.
Adenoma of MDP - adenomectomy (including endoscopic in
combination with EPST).

Cholangitis
Infection of bile occurs on the background of choledocholithiasis
and biliary hypertension or reflux of the contents of the duodenum into
choledochus.
Clinical symptoms
The triad of Charcot: jaundice, fever and pain in the right upper
quadrant. The disease is accompanied by hyperthermia of up to 39 0-
400С with symptoms of severe intoxication.
Complications: cholangiogenic abscesses of the liver, sepsis.
Diagnostics
It is based on a characteristic clinical symptomatology and revealing
the causes of mechanical jaundice (often choledocholithiasis).
Treatment
See treatment of choledocholithiasis + (nasobiliary drainage of
choledochus at endoscopic treatment or installation of T-shaped Ker
drainage at open operations).

Primary sclerosing cholangitis

Etiology
Autoimmune as a mechanism of disease development.
Clinical symptoms (see cholangitis).

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 Diagnostics
At cholangiography, hepaticocholedochus is narrowed, has a
characteristic (rosary) convoluted course, intrahepatic ducts are not
dilated.
Treatment: orthotopic liver transplantation.

Periampullary (juxtapapillary) diverticulum

Diagnostics
At EGDS - in the periampullary zone is detected an isthmus of the
diverticulum, sometimes it is possible to examine the walls of the
diverticulum.
According to the X-ray of the duodenum with the barium
suspension, near the ampulla of Vater is contrasted the saccular bulging
of the intestinal wall retaining the contrast for a long time.
Treatment
For the treatment of mechanical jaundice, endoscopic
papillosphincterotomy (EPST) is performed.

Cancer of the common bile duct

Diagnostics
On ultrasound of the abdominal cavity, the enlargement of the
intrahepatic bile ducts is determined.
On cholangiography, a filling defect with indistinct contours is
detected along one wall or circular.
During the cholangioscopy, the tumor tissue is detected in the lumen
of the choledochus (in the study of the tumor biopsy the diagnosis is
verified).
On CT of the hepato-biliary zone, the size and local spread of the
tumor are determined, and the enlarged intrahepatic bile ducts are
identified.
Treatment
In the case of resectable tumor – a pancreatoduodenal resection
(with cancer of the distal part of the choledochus) or resection of the
common hepatic and bile ducts with the gall bladder and
bihepaticojejuno anastomosis by Roux (at cancer of the proximal part
of the common bile duct). For a cancer of the common hepatic duct, a
resection of the hepatic duct with a confluence, or with right-sided or
left-sided hemihepatectomy.

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 At an unresectable tumor — a palliative endoscopic stenting of the
duct.

Question: Postcholecystectomy syndrome: clinic, diagnosis,

treatment
Answer:
Postcholecystectomy syndrome is a group of diseases of the
hepatopancreatobiliary system that occur or progress after
cholecystectomy.
Some diseases appear after technical errors of cholecystectomy,
others – are unrecognized before cholecystectomy and persistent under
the guise of acute and chronic cholecystitis. There is a true and false
postcholecystectomy syndrome.
A true postcholecystectomy syndrome occurs as a result of a
violation of the outflow of bile in connection with functional or organic
causes.
Functional causes: biliary dyskinesia, chronic hepatitis, gastritis,
pancreatitis; pericholedochal lymphadenitis.
Organic causes: a long stump of the gallbladder duct or a stone in it;
"forgotten" stones in the bile ducts; stricture of the terminal section of
the common bile duct; cicatricial strictures of hepaticocholedochus
(iatrogenic); the leftover part of the gallbladder; residual stones
(developed on suture threads).
False postcholecystectomy syndrome.
Causes - diseases of other organs of the digestive tract: peptic ulcer
of stomach and duodenum, hernia of esophageal hiatus of diaphragm,
duodenostasis, chronic colitis.
Clinical symptoms
Include the preservation of the same complaints as before the
operation, or the appearance of qualitatively different ones. The most
common symptom is pain in the right hypochondrium of various
character and intensity. Symptoms of dyspepsia may appear - nausea,
vomiting, diarrhea, bloating, obstipation.
Diagnostics
On ultrasound of the abdominal cavity organs, a dilated
choledochus, rounded hyperechoic formations with a clear contour not

3
connected to the duct wall, giving a clear acoustic shadow (signs of
choledocholithiasis) are revealed.
During EGDS, a gastric or duodenal ulcer, a hernia of the
esophageal opening of the diaphragm is detected.
Colonoscopy can detect signs of colitis.
During ERPCG, choledocholithiasis, ductal strictures (see
mechanical jaundice, diagnosis of choledocholithiasis), a long stump of
the cystic duct are revealed.
On contrast radiography of the stomach and duodenum, a hernia of
esophageal hiatus of the diaphragm or signs of duodenostasis
(enlargement of the duodenum by >4 cm) are revealed.
Treatment
depends on the causes. With a long stump of the cystic duct or the
leftover part of the gallbladder, they are removed. In the case of
choledocholithiasis and stenosis of the large papilla of the duodenum,
the same operations are performed as in the case of choledocholithiasis
(see treatment of choledocholithiasis). Extensive posttraumatic
strictures of extrahepatic bile ducts require stenting or formation of
choledochoenteroanastomosis in the disconnected Roux loop of the
small intestine (see treatment of strictures of the bile ducts). At a hernia
of the esophageal opening of the diaphragm, lowering the stomach,
fundoplication and cruroraphy are performed. Functional causes, ulcer
disease and colitis are treated conservatively.

QUESTION: Intestinal obstruction. Classification, pathogenesis,

clinic, differential diagnosis, treatment, complications.
ANSWER:
Intestinal obstruction - is a disease that occurs as a result of partial
or complete disturbance of the passage of food through the intestines.
The cause of intestinal obstruction can be:
 malignant and benign tumors (of intestines or surrounding
organs);
 adhesions;
 bezoars;
 torsion, nodulation, intussusception;
 gallstones, foreign bodies, ascaris balls;
 cicatricial narrowing of the intestine.

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 Classification
On the localization of the obstacle: small intestinal and large
intestinal. The small intestinal is often adhesive; the colonic is more
often tumorous.
By the degree of intestinal lumen narrowing: complete and partial.
By involving the mesentery vessels in the process: obturation,
strangulation and mixed.
Pathogenesis
Closure or narrowing of the lumen of the gut → accumulation of
intestinal contents proximal to the obstruction + growth of the bacterial
flora → overstretch of the intestinal wall → disruption of the trophic of
the mucosa → reduction of the barrier properties of the mucosa →
vascular leakage of fluid from the extracellular space and vascular bed
into the lumen of the gut → decrease of the CBV → transposition of
bacteria into the portal blood flow and abdominal cavity → organ
dysfunction + intoxication → multiple organ dysfunction syndrome.
Clinical symptoms
The main symptoms of the disease are: stool and gas retention,
abdominal distention, abdominal pains, nausea, vomiting. Vomiting at
the beginning of the disease is often due to intoxication, at later stages -
mechanical (due to gastrostasis).
Permanent high-intensity pain syndrome not stoppable by taking
antispasmodics is a manifestation of strangulation obstruction.
There are also extreme forms of obstruction, when not all clinical
symptoms are present, which makes diagnosis difficult, leads to loss of
time and the development of complications. These forms include high
and low intestinal obstruction.
High intestinal obstruction
Localization of the obstruction: the distal parts of the duodenum -
the initial parts of the small.
At this form of obstruction, the first and sometimes the only
symptom can be only vomiting of bile. Accordingly, there will be no
bloating, and given the level of obstruction, there will also be no stool
and gas retention. Characteristic is a rapid dehydration of the patient.
Low intestinal obstruction
The first symptoms of this type of obstruction are stool and gas
retention, abdominal bloating develops later, and nausea and vomiting

3
may not be present.
Pathognomonic for this form of the disease are the symptoms of the
Obukhov hospital (gaping of the anus with empty ampoule of the
rectum) and Tsege-Manteifel (small capacity of the distal intestine
when performing the siphon enema).
Complications
 Diastatic gut ruptures (due to overstretch of the wall) with the
formation of abscesses of the abdominal cavity or the development of
peritonitis.
 Gangrene of the gut region (in case of strangulation obstruction).
 Intoxication, dehydration, multiple organ failure.
Diagnostics
Upon examination, the abdomen is swollen, asymmetric, the
swollen bowel loop (Val's symptom) is palpated, "splash noise" is
determined.
On the survey radiograph of the abdominal cavity organs, the
intestinal loops are overstretched by gas with fluid levels in the lower
regions (a symptom of intestinal arches) or contain liquid levels with
the accumulation of a small amount of gas above them (Kloiber's cups).
When assessing the passage of barium through the intestine (used
for intestinal obstruction), a delay of the barium suspension in the loops
of the small intestine is noted for more than 6 hours, which makes it
possible to diagnose total obstruction. The appearance of contrast in the
caecum indicates the absence of small intestinal obstruction, in this
situation the study is discontinued.
During the irrigoscopy, the level of the block at colonic obstruction
is determined. At the colonic or ileocaecal invaginate - the symptom of
a "trident" or "claw" is identified.
On ultrasound of the abdominal cavity, stretched loops of the
intestine with a high content of fluid and waves of antiperistalsis, free
effusion in the abdominal cavity (indirect signs of intestinal
obstruction) are revealed. At tumor obstruction, a voluminous
formation with clear contours associated with the intestine is found.
Diagnosis of high intestinal obstruction
On the survey radiograph of the abdominal cavity organs there will
be no intestinal levels, because the liquid intestinal contents will be
diverted back into the stomach and evacuated from it with vomiting.
Diagnosis is based only on the study of the passage of barium

3
suspension in the intestine: after the introduction of barium into the
nasogastric tube, barium contrasts only the initial parts of the jejunum
and is retained there for a long time; there is no passage of contrast in
the small intestine.
Diagnosis of low intestinal obstruction
This type of disease is characterized by a symptom of the Tsege-
Manteifel (small capacity of the distal intestine when performing a
siphon enema).
With urgent colonoscopy or irrigoscopy, the level of obstruction and
the cause are revealed, and with a tumor obstruction during a
colonoscopy, a biopsy is performed.
Differential diagnosis
At pancreatic necrosis during ultrasound of the abdominal cavity are
revealed unclear contours and an increase in the size of the gland, the
appearance of effusion in parapancreatic cellulose; hyperamylasemia is
possible.
At perforated gastroduodenal ulcer, a free gas is detected under the
dome of the diaphragm on the overview radiograph of the abdominal
organs.
In acute appendicitis, positive appendicitis symptoms, there are no
Kloiber’s cups on the overview radiograph of the abdominal organs, on
the ultrasound of the abdominal cavity organs in the right iliac region
there is no muff-like thickening of the gut (ileocaecal intussusception).
In acute cholecystitis, gallbladder edema, on ultrasound of the
abdominal cavity there are signs of acute cholecystitis (see the
diagnosis of acute cholecystitis) or an enlarged gallbladder with a thin
wall of normal echogenicity, and the contents of the gallbladder are
homogeneous, hypoechoic (edema of the gallbladder).
Crohn's disease is characterized by a prolonged chronic course,
when assessing the passage of barium through the intestine, segmental
stenoses of the small intestine are revealed; at a colonoscopy, in
terminal section of ileum, changes of mucosa in the form of
"cobblestone pavement" are found.
At dystopia kidney, during ultrasound of the abdominal cavity
organs, the parenchyma and the pelvicalyceal system of kidney are
found in the place of a palpable formation.
Treatment
Conservative:

3
 Installation of the nasogastric tube, the introduction of crystalloid
infusion, the introduction of antispasmodics, the performance of
cleaning and siphon enemas.
Surgical:
At cicatricial strictures, bypass inter-intestinal anastomoses are
formed. At torsion, knotting is performed a detorsion of the loops with
an assessment of their viability (color of the intestinal wall, the
presence of peristalsis, pulsation of the marginal mesenteric vessels). If
a nonviable gut area is detected, the intestinal section is resected
(retreating 30-40 cm in the proximal direction and 15-20 cm in the
distal direction) with interintestinal anastomosis. At sigmoid volulus
and a viable gut is performed a mesosigmoplication by Hagen-Tornu or
a sigmopexy, in the case of gangrene of the sigmoid colon - the gut is
resected with the formation of a single-barrel colostomy. At
intussusception, disinvagination is performed, in case of detection of a
site of the nonviable gut, the tactic is similar to the treatment of torsion.
Small intestinal obstruction
Adhesive obstruction
Dissection is performed of only those adhesions, which are the
direct cause of obstruction (proximal to the site of the obstacle the
loops of the intestines are dilated, distally - collapsed).
Recurring adhesive obstruction
On one hand, the obstruction requires surgical treatment, on the
other hand, in most patients the volume of surgery is dissection of
adhesions. All patients with adhesive intestinal obstruction have an
increased tendency to adhesion formation. Each re-intervention
contributes to the adhesion formation and each repeated operation with
adhesive obstruction increases the risk of recurrence of adhesion
obstruction, and also does not guarantee a complete cure. Proceeding
from this, at present, the most conservative tactics of treatment of this
type of obstruction are adhered to.
With the exclusion of a complete adhesive obstruction, the treatment
is conservative with the use of aspiration of intestinal contents through
an endoscopically installed naso-intestinal probe.
An absolute indication for surgery with adhesive obstruction are
peritonitis, complete intestinal obstruction, and clinical
symptomatology of strangulation.
Obstruction due to a foreign body or a gallstone

4
 A longitudinal enterotomy is performed proximal to the site of
obturation, the cause of obstruction is removed and the intestinal wall
sutured in the transverse direction.
Obscuration due to a bezoar or a ball of ascaris
The cause of obstruction is fragmented without enterotomy and they
are directed distally to the place of obturation.
Large intestinal obstruction
Tumor bowel obstruction
When colon and rectum cancer are detected as reasons for the
obstruction, the tumor resectability is first evaluated.
If the tumor is resectable, variants of resection of the part of
intestine with the tumor are performed:
 Right-sided hemicolectomy (cancer of the caecum, ascending and
hepatic flexure of the colon);
 Resection of the transverse colon (cancer of the transverse colon);
 Left-sided hemicolectomy (cancer of the splenic flexure of the
colon and descending intestines);
 Rresection of sigma (sigma cancer);
 Anterior rectal resection (cancer of the rectosigmoid section).
Because the proximal parts of the intestine are inflated, their
intestinal wall is thinned, with the disturbed blood supply, after the
resection of the transverse colon at tumour obstruction, the anastomosis
is not imposed, but a proximal single-stem colostomy is formed (there
is a high risk of dehiscence of sutures of colocoloanastomosis!).
Sometimes, at short periods of obstruction and absence of pronounced
expansion of the colon loops, the operation is terminated with a primary
colocoloanastomosis (in some cases, for decompression of the
anastomosis zone the unloading proximal loop colostomy is formed).
The exception is right-sided hemicolectomy, which is completed by the
formation of ileotransversoanastomosis. This approach is due to the fact
that the formation of the terminal ileostomy leads to serious losses of
fluid and electrolytes in the postoperative period, which in most
patients can not be compensated. These patients have to perform a
second operation - the elimination of ileostomy with the formation or
ileotransversoanastomosis - in the cold period after the regression of the
phenomena of obstruction.
If the tumor is unresectable, the operation is terminated by

4
formation of the proximal double-barrel colostomy or bypass
anastomoses (ileotransversoanastomosis at cancer of the right half of
colon or transversosigmoanastomosis - with left-sided cancer).
In other types of large bowel obstruction, treatment is similar to that
described above, but after resection of the large intestine, the operation
should be terminated by formation of the proximal colostomy.
An important stage of the operation at small intestinal obstruction is
the nasointestinal intubation of the initial sections of the small intestine
with a 2-lumen probe with the evacuation of intestinal contents and the
conduct of intestinal lavage (washing of the intestine with 1.5-2 liters of
physiological solution followed by aspiration). This procedure allows to
work on the main link pathogenesis of obstruction, reduces
intoxication, promotes early recovery of intestinal wall trophism and
elimination of intestinal paresis.
When the diagnosis of "intestinal obstruction" is established, the
following treatment tactic is adopted.
In the presence of clinical symptoms of strangulation or peritonitis -
an urgent operation.
In all other cases, conservative treatment is started, which in the
case of mechanical obstruction, is a preoperative preparation.
The emergence of negative clinical and radiological dynamics
against the backdrop of conservative treatment (strengthening of the
pain syndrome, enlargement of abdomen in size, an increase in the
number of intestinal levels during repeated survey radiography of the
abdominal cavity organs) dictates the need for urgent intervention.
In the case of positive clinical and radiological dynamics and
regression of the phenomena of obstruction, the patient is not operated
and is examined for the purpose of identifying the causes of
obstruction.
In the absence of any dynamics on the background of conservative
treatment, the patient should be operated on with small intestinal
obstruction 2-3 hours after the diagnosis, at large intestinal - after 6
hours.

Question: Crohn's disease: clinic, diagnosis, treatment.

Answer:
Crohn's disease - is a chronic nonspecific bowel disease
characterized by a granulomatous type of inflammation. Crohn's

4
disease can affect any part of the gastrointestinal tract (from the oral
cavity to the rectum), but is most often localized in the terminal ileum
(terminal ileitis).
The etiology of the disease is not fully understood, the main
importance is given to the autoimmune nature of the disease, especially
the tumor necrosis factor α.

By the clinical course, acute and chronic forms of the disease are
isolated.
Typical complications of Crohn's disease are stenosis, perforation,
malignancy, bleeding, fistula formation.
Clinical symptoms
The disease is characterized by abdominal pains that occur after
food intake; bloating; transient diarrhea (up to 2-3 times a day);
subfebrility; weight loss; toxic-allergic lesions of the eyes and joints.
When rectum is involved in the process, there are anal fissures and
pararectal fistulas.
Diagnostics
Characterized by the chronic nature of abdominal pain with diarrhea
and weight loss.
The colonoscopy of the terminal section of the ileum reveals
changes in the mucosa in the form of a "cobblestone pavement".
At a histological examination of the biopsy specimen of the
intestinal mucosa, a granulomatous type of inflammation is detected,
giant light-nucleated cells of the Pirogov-Langhans type.
During the radiography of the intestine with barium, segmental
stenoses of the intestine are revealed, alternating with unchanged areas.
Treatment
Conservative:
 preparations of 5-aminosalicylic acid (sulfasalazine, mesalazine)
 topical steroids (budesonide)
 systemic glucocorticosteroids
 cytostatics (azathioprine, 6-mercaptopurine)
 monoclonal antibodies to the tumor necrosis factor α
(adalimumab (Humira®), infliximab (Remicade®)
Surgical (in the presence of complications):
In the perforation of the intestine with symptoms of peritonitis,

4
resection of the gut area, sanation and drainage of the abdominal cavity
are performed.
In the perforation of the intestine with the formation of an abscess,
the abscess cavity is opened and drained.
With intestinal stenosis, the part of intestine is resected with an
interintestinal anastomosis or a bypass interintestinal anastomosis is
formed.
In the case of intestinal bleeding, endoscopic hemostasis is
performed, at its ineffectiveness - resection of the intestine with
interintestinal anastomosis.
At malignancy, resection of the intestine with interintestinal
anastomosis is performed.
It must be remembered that Crohn's disease is an autoimmune
disease and surgical treatment is indicated in the presence of
complications. The frequency of relapse after surgical treatment reaches
50-80%.

Question: Nonspecific ulcerative colitis: clinic, diagnosis,

treatment, complications.
Answer:
Nonspecific ulcerative colitis (UC) is a nonspecific disease of the
colon, which is characterized by the formation of superficial ulcers of
the mucosa in the distal parts of the colon.
The etiology is not clear, the disease is considered autoimmune.
Forms of the disease: proctitis, proctosigmoiditis, left-sided colitis.
Complications: toxic megacolon, bleeding, malignization,
perforation.
Clinical symptoms
Patients present complaints about abdominal pain (more often in the
left half); diarrhea with an admixture of blood; temperature rise up to
390С. Characteristic are "false urges" and mandatory urges for
defecation, weight loss and arthralgia.
Toxic megacolon: continuous diarrhea, massive bleeding,
septicemia, abdomen is swollen, asymmetric, on palpation an abruptly
dilated loop of colon, "splash noise" on auscultation.
Diagnostics
At a colonoscopy extensive drainage superficial ulcers are revealed,

4
on the edges of which there are growths of the mucous (pseudopolyps).
With a histological examination of the biopsy specimen, only
mucosal and submucosal lesions are detected without granulomatous
inflammation.
During irrigoscopy there is no haustration of the intestine,
characteristic are thickening and unevenness of the intestinal wall,
narrowing of the lumen with enlargement in the proximal sections,
pseudopolyps, shortening of the intestine.
Treatment
Conservative:
 preparations of 5-aminosalicylic acid (sulfasalazine, mesalazine)
preorally and in microenemas;
 topical steroids (budesonide) in microenemas;
 systemic glucocorticosteroids (prednisolone, dexamethasone);
 fluoroquinolones and metronidazole;
 cytostatics (azathioprine, 6-mercaptopurine) with ineffectiveness
of glucocorticosteroids.
Treatment of toxic megacolon: prednisolone i/v 180-240 mg/day,
antibiotics, gas outlet tube. In the absence of effect in one day and the
increase in intoxication, resection of the dilated portion of the gut is
indicated urgently.
When treating intestinal bleeding, endoscopic hemostasis is
performed (irrigation with 96% alcohol or E-aminocaproic acid, fibrin
glue).
Indications for surgical treatment:
 toxic megacolon (with ineffectiveness of conservative treatment);
 bleeding (with ineffective endoscopic hemostasis);
 malignancy;
 progressive recurrent course.
In all cases, resection of the altered bowel part is performed.
It must be remembered that UC is an autoimmune disease and a total
colproctectomy is a radical operation. The frequency of relapse after
resection of the affected area of the gut reaches 50-80%.

Question: Diverticulitis and diverticulosis of the large intestine.

Complications, diagnosis, treatment.

4
 Answer:
Diverticular disease of the colon (the old name for diverticulosis) is
a disease characterized by the formation of saccular protrusions of the
intestinal wall to the outside.
Most diverticula are localized in the sigmoid and left parts of the
colon, but may occur throughout the digestive tube.
The disease is asymptomatic, clinical symptoms appear in the
development of complications.
Complications of diverticular disease: diverticulitis, intestinal
bleeding, diverticulum perforation with the development of paracolonic
infiltrate, abscess or peritonitis.

Diverticulitis.
Diagnostics
Patients complain of constant or spastic pains of varying intensity in
the left iliac region or the left side of the abdomen, which arose after a
lapse in the diet or against a background of constipation. In the
anamnesis are similar attacks of pain, an indication of the colon
diverticula revealed in colonoscopy. Physically: in the left iliac region
moderate pain is determined, there are no peritoneal symptoms, there
may be protective tension in the muscles of the anterior abdominal
wall, unstable stools.
Leukocytosis in a general blood test.
Colonoscopy reveals the diverticula of the colon with the
phenomena of diverticulitis (the study is performed on the 7-10th day
of treatment after regression of the pain syndrome, because in the initial
stage the risk of perforation of the diverticulum is high).
Treatment
conservative: antibiotics, antispasmodics, preparations of 5-
aminosalicylic acid (sulfasalazine, mesalazine), crystalloid infusion
(detoxification).

Intestinal bleeding.
Diagnostics
Common symptoms of hemorrhage (hypotension, tachycardia,
pallor, cold sticky sweat).
Isolation of blood from the rectum, with finger rectal examination
on the glove traces of blood.

4
 In the general analysis of blood, anemia can be detected.
With urgent colonoscopy, the isthmus of diverticulum of the large
intestine with ongoing or established bleeding is revealed; the
localization of the source of bleeding is specified.
Treatment
In case of established intestinal hemorrhage, conservative treatment
begins: transfusion of fresh frozen plasma and erythromass according to
clinical indications, hemostatics (etamzilate, vikasol), enemas with E-
aminocaproic acid, antibiotics, 5-aminosalicylic acid preparations
(sulfasalazine, mesalazine), crystalloid infusions.
If there is an ongoing bleeding, the diagnostic colonoscopy turns
into a treatment colonoscopy - endoscopic hemostasis is performed
(irrigation of the source of bleeding with 96% alcohol, E-aminocaproic
acid).
With the recurrence of intestinal bleeding, repeated endoscopic
hemostasis is indicated.
In the absence of the effect of endoscopic hemostasis, resection of
the intestine with primary interintestinal anastomosis is indicated.

Paracolonic infiltrate
Diagnostics
On the background of the symptoms of diverticulitis in the left iliac
region or in the projection of the colon, a moderately painful infiltrate
with uneven edges, displaced or unshifted, is palpated, a muscular
defense over the infiltrate is detected.
In a general blood test, leukocytosis with a stab left-shift.
On ultrasound of the abdominal cavity, the infiltrate associated with
the large intestine is revealed, its size and structure are determined, and
the reactive effusion in the abdominal cavity is detected.
More accurate and specific in the diagnosis of a paracolonic
infiltrate is CT of the abdominal cavity.
Colonoscopy is performed in the cold period after regression of pain
syndrome (risk of perforation) to clarify the genesis of the disease and
for differential diagnosis with colorectal cancer.
Treatment
Conservative, similar to the treatment of diverticulitis.

Paracolonic abscess

4
 It is one of the variants for the outcome of a paracolonic infiltrate.
Clinical symptoms, diagnosis are similar to appendicular abscess.
The difference is in localization. With ultrasound or CT, the destruction
of the walls of the diverticulum is detected with the formation of the
cecal cavity.
     With an abscess size of up to 3 cm, conservative treatment is
indicated. If the size of the abscess is ≥3 cm or the effect of
conservative treatment is absent, then puncture and drainage of the
abscess under the supervision of ultrasound or CT are indicated. In the
absence of the effect of minimally invasive treatment, resection of the
intestinal segment with proximal colostomy (Hartmann's operation) or
double-barrel colostomy (Mikulich's operation) is indicated.

Question: Stomach and duodenal ulcer. Clinic, diagnosis,

treatment. Indications for surgical treatment. Types of surgical
interventions.
Answer:
Stomach ulcer and duodenal ulcer – is a chronic relapsing disease,
accompanied by the formation of gastric and duodenal ulcers.
The disease is polyethiological, however, for different ulcer
localizations, there are fundamentally different basic pathogenetic
factors: in duodenal ulcer, increase in acid production in the stomach;
with gastric ulcer - a violation of the regenerative properties of the
gastric mucosa.
By localization, peptic and duodenal ulcers are isolated.
Complications of ulcer disease: bleeding, perforation, penetration,
cicatrico-ulcerative stenosis, malignancy.
Clinical symptoms
Patients complain of pain in epigastrium and right hypochondrium
associated with eating, heartburn, nausea, vomiting, diarrhea, or
obstipation. The disease is also characterized by periodicity, seasonality
of exacerbations (spring, autumn). The gastric ulcer is characterized by
early pain that occurs after eating, for duodenal - late (1.5-2 hours after
eating) and night pain.
Diagnostics
Relationships of pain with eating, seasonality of exacerbations are
typical. With palpation, moderate pain in epigastrium and right

4
hypochondrium is determined.
EGDS allows identifying ulcer, determining its location, size, and
diagnosing the complications.
Radiography of the stomach and duodenum with double contrasting
(niche symptom with periulcerous inflammatory shaft and convergence
of mucous folds, scar deformation) allows diagnosing, pinpointing the
localization and dimensions of the ulcer, and evaluating the motor-
evacuation function of the stomach.
It should be noted that EGDS is a screening study and, in some
cases, allows taking a biopsy. Radiography is the main method of
diagnosis. It is necessary to carry out both studies, because one of them
complements the other and helps to establish an accurate diagnosis.
Treatment
Conservative: diet, dietary regime, antisecretory drugs (H2-blockers
and proton pump inhibitors), antacids, antispasmodics.
Surgical:
Indications for surgical treatment:
Absolute: profuse ulcerous bleeding with the impossibility or
ineffectiveness of endoscopic hemostasis, perforation of the ulcer,
decompensated cicatricial-ulcerative stenosis of the pylorus,
malignancy.
Conditionally absolute: penetration of the ulcer, recurrence of
bleeding in the hospital or repeated ulcer bleeding in the anamnesis,
recurrence of the ulcer in the presence of a perforated ulcer in an
anamnesis, giant callous ulcers, stomach ulcers with no effect from
complex conservative treatment for 2-3 months.
Relative: no effect of complex conservative treatment for 2-3
months, combination of peptic ulcer with other gastrointestinal diseases
requiring surgical treatment.
Types of operations:
In uncomplicated gastric ulcer, a radical operation is a classic distal
resection of 2/3 of the stomach (the acid production zone / body of the
stomach / and the gastrin producing zone / antrum section are
removed). It is possible to perform antrumectomy in combination with
trunk vagotomy (localization of ulcers in the antrum and pyloric
sections) or subtotal distal resection of the stomach (when the ulcer is
located proximal to the line of classical resection of 2/3 of the
stomach).

4
 At uncomplicated duodenal ulcer - selective proximal vagotomy
(classical distal resection of 2/3 of the stomach is possible).

Question: Perforated ulcers of the stomach and duodenum:

clinic, diagnosis, treatment.
Answer:
Perforated ulcer is a complication of peptic ulcer, in which
perforation of the organ wall occurs.
The following variants of the disease are distinguished: 1. typical
perforated ulcer; 2. atypical perforation (perforation in the omental
bursa, large and small omentum or retroperitoneal tissue); 3. Covered
perforated ulcer (perforation in a short time is closed by a piece of food,
a strand of a large omentum, left lobe of the liver, gall bladder or loops
of intestines).
Clinical symptoms
A perforated ulcer is characterized by a sudden onset, the emergence
of sharp permanent high intensity pains in the epigastrium and the right
upper quadrant, nausea, vomiting, and heartburn are possible. In the
anamnesis there may be an indication of a peptic ulcer, confirmed by
the data of EGDS.
With an atypical perforative ulcer, there are no peritoneal symptoms,
a pain syndrome of medium intensity, in epigastrium a weakly painful
infiltrate can be defined.
For a covert perforated ulcer, a typical short-term beginning with
regress of pain syndrome and localization of pain in the right abdominal
area or right hypochondrium (Differential diagnosis with acute
appendicitis and acute cholecystitis) is typical. This feature of clinical
manifestations is associated with the volume of gastric contents poured
into the abdominal cavity, and its location (the subhepatic space or the
right iliac fossa).
Diagnostics
Typical clinical symptoms, peritoneal symptoms in epigastrium and
right abdominal areas.
At suspicion of a perforated ulcer, overview radiography of the
abdominal organs is performed: a strip of free gas (symptom of a
sickle) is revealed under the dome of the diaphragm.
In the absence of free gas in the abdominal cavity on an overview
radiograph and a short period of time from the onset of the disease, an

5
EGDS (for ulcer detection) is performed, and repeated overview
radiography of the abdominal cavity organs is performed on which free
gas is detected.
The covered perforation is detected in a similar manner.
In the severe condition of the patient and bed patients, overview
radiography of the abdominal organs is performed in lateroposition.
At atypical perforated ulcer there is no free gas under the domes of
the diaphragm. Detection of gas is possible in the projection of the
omental bursa. On ultrasound of the abdominal cavity, the effusion in
the omental bursa is sometimes determined. On EGDS a stomach or
duodenal ulcer is detected. The main method of diagnosing an atypical
perforative ulcer is the radiography of the stomach with a water-soluble
contrast medium, in which an extra-organic diffusion of contrast is
detected.
Treatment
When the diagnosis is set, an urgent operation is indicated through
laparotomy or laparoscopic access.
Detection of a perforated hole <0.5 cm in diameter, without
pronounced inflammatory infiltrate, concomitant complications of
peptic ulcer (stenosis, bleeding) and widespread peritonitis are
indications for performing laparoscopic suture of the perforated ulcer.
Types of operations:
Palliative - a tamponade of a perforating hole with a part of the large
omentum by Oppel-Polikarpov, suturing a perforating hole.
Conditionally radical - excision of the edges of the perforated hole
with suturing of the formed defect (in carrying out the above
interventions at duodenal ulcer, pyloroplasty according to Gainike-
Mikulich, Judd or Finney is mandatory for the prevention of pyloric
stenosis).
Radical interventions (aimed not only at closing the perforation, but
also at a complete cure of ulcer disease):
- At gastric ulcer – a classical distal resection of 2/3 of the stomach,
it is possible to perform antrumectomy in combination with stem
vagotomy (with ulceration in the antrum and pyloric areas) or subtotal
distal resection of the stomach (with ulceration proximal to the line of
classical resection of 2/3 of the stomach);
- At duodenal ulcer – conditional-radical interventions for a given
localization + selective proximal vagotomy or stem vagotomy.

5
 To determine the scope of the operation, it is necessary to focus on
the patient's age, the presence of severe co-morbidities, the duration of
the ulcerative anamnesis, the nature of the ulcerative defect (callous
ulcer), the size of the defect and the character of effusion in the
abdominal cavity.
Indications for palliative operation:
 acute stress-induced perforated ulcers in young patients;
 patients older than 60 years with high operational anesthesia risk;
 combination of perforative ulcers with diffuse purulent peritonitis;
 insufficient qualification of the surgeon.
Indications for radical surgery:
 prolonged ulcer history and identification of a callous ulcer;
 large ulcers (in the stomach >2 cm in diameter, in the duodenum
>1.5 cm).

Question: Acute gastroduodenal hemorrhages: differential

diagnosis, tactics of the surgeon.
Answer:
Acute gastroduodenal bleeding refers to latent bleeding from the
upper sections of the gastrointestinal tract. For this type of bleeding,
there are common symptoms of blood loss (pallor, cold sweat,
tachycardia, hypotension) and specific signs (melena, vomiting of
blood with clots or "coffee grounds").
Among the causes of gastroduodenal bleeding are: a stomach ulcer
or duodenal ulcer, Mallory-Weiss syndrome, bleeding from esophageal
varices, gastric cancer with bleeding, and Dieulafoy's ulcer.
In anamnesis, there are sometimes indications of a gastroduodenal
ulcer or other diseases of this zone (identified with EGDS), possibly an
indication of a complicated course of the disease (bleeding,
perforation).
Upon examination, one can find the remnants of vomit and/or
melena on the skin and clothing of the patient.
On the finger rectal examination, melena is detected.
After the installation of the gastric probe, the blood flow through the
probe is detected, or an admixture of blood, clots and hydrochloric acid
hematin in the washing waters (diagnostic procedure and simultaneous

5
preparation for EGDS) is noted.
EGDS answers 2 questions: 1) what is the source of bleeding and 2)
whether bleeding at the time of examination is established or ongoing
(the answer to the second question has a significant effect on the tactics
of treatment of the patient).
If chronic gastric and duodenum ulcers are identified, for
endoscopic assessment of the state of hemostasis and a prognosis of the
risk of bleeding recurrence, classification by Forrest is used:
Forrest I - ongoing bleeding
I a - arterial
I b – venous or capillary
Forrest II – established bleeding
II a - thrombosed vessel on the bottom of the ulcer
II b - the bottom of the ulcer is covered with a loose clot
II c - on the bottom of the ulcer are small thrombosed vessels or
hydrochloric acid hematin
Forrest III - source of bleeding is not revealed.
At bleeding Forrest I after endoscopic hemostasis and Forrest IIa,
the risk of recurrence of bleeding from a chronic gastroduodenal ulcer
is high.
Differential diagnosis
Most causes of bleeding are revealed by EGDS: stomach ulcer or
duodenal ulcer, rupture of mucosa in Mallory-Weiss syndrome,
varicose veins of the esophagus, bleeding cancer, Dieulafoy's ulcer.
Also differential diagnosis is carried out with other hidden
bleedings:
 Intestinal - at finger rectal examination traces of blood on the
glove are revealed, and at colonoscopy the source of bleeding specified;
 Gynecological (ectopic pregnancy, metrorrhagia, rupture of the
ovarian cyst) - discharge of blood from the vagina, ultrasound of the
pelvis reveals the above diseases + it is possible to determine free fluid
in the small pelvis and the abdominal cavity, with puncture of the
posterior vaginal fornix, blood is obtained;
 Urological (kidney, bladder cancer, macrohematuria at
urolithiasis) - discharge of blood from the urethra, macrohematuria, on
ultrasound of the pelvis and kidneys are determined signs of
urolithiasis, kidney or bladder tumors;
 Intra-abdominal (penetrating wounds of the abdominal and

5
thoracic walls, blunt abdominal injury) - an indication of an abdominal
injury or wounds of the abdominal wall is received, on ultrasound of
the abdominal cavity free fluid in the abdominal cavity is determined;
 Pulmonary - there is a discharge of foamy blood through the
mouth, on tracheobronchoscopy the source of bleeding is specified;
 Nasal (examination of the posterior pharyngeal wall allows to
establish a diagnosis).
Tactics of the surgeon
Like other hemorrhages, treatment of gastroduodenal bleeding is
primarily based on stopping it by any available means.
If during the EGDS there is found an ongoing bleeding, the
diagnostic manipulation becomes therapeutic - endoscopic hemorrhage
control is performed (endoscopic hemostasis).
Types of endoscopic hemostasis:
 Coagulation (electrocoagulation);
 Thermal (thermal probe and cryodestruction);
 Radio wave (Surgitron);
 Laser (laser of different wavelengths);
 Infiltrational (injections of 5% glucose solution with adrenaline);
 Chemical (injections of ethanol or sclerosants);
 Mechanical (clipping);
 Biological (fibrin glue).
If bleeding cannot be stopped or it recurs, surgical intervention is
indicated.
Stomach ulcer and duodenal ulcer
All operations for gastroduodenal hemorrhages are divided into
palliative, conditionally radical and radical.
Palliative interventions (aimed only at stopping bleeding):
 Suturing of the bleeding vessel in the bottom of the ulcerative
defect;
 Suturing of ulcerative defect;
 Excision of the edges of the ulcer to the muscular layer with
suturing the formed defect.
At duodenal ulcer, the intervention is supplemented with
pyloroplasty according to Gainike-Mikulich, Finney or Judd (for
prevention of pyloric stenosis).
Conditionally radical interventions (variants of economical

5
resections, in which the goal of complete cure for peptic ulcer is not
pursued):
 Sphenoid resection of the stomach;
 Economical resection of the stomach.
Radical interventions (aimed not only at stopping bleeding, but also
for complete cure of ulcer disease):
 Gastric ulcer - classical distal resection of 2/3 of the stomach, it is
possible to perform an antrumectomy in combination with stem
vagotomy (for ulcer localization in the antral or pyloric areas) or
subtotal distal gastrectomy (when the ulcer is proximal to the line of
classical resection of 2/3 of the stomach);
 Duodenal ulcer - all palliative interventions for a given
localization + selective proximal vagotomy or stem vagotomy.
Treatment tactics
When an ongoing gastric ulcer gastroduodenal bleeding is detected,
endoscopic hemostasis is performed.
With ineffectiveness of endoscopic hemostasis or relapse of ulcerous
bleeding, an urgent operation is indicated.
In patients older than 60 years with severe concomitant diseases and
high operational anesthesia risk, in this situation, persistent attempts of
endoscopic hemostasis are justified.
After making a decision about surgical treatment, the scope of the
operation is determined: to patients with a severe degree of blood loss
and/or with a post-hemorrhagic shock a palliative operation is
performed. In the absence of severe blood loss, prolonged ulcer history
and/or large callous ulcers, a radical operation is indicated.

Mallory-Weiss Syndrome
This is a syndrome, in which after repeated vomiting (with
pancreatitis, toxicosis of pregnant women and other diseases), there is a
rupture of the mucosa of cardia with spread to the fundus of the
stomach and abdominal part of esophagus.
The depth of the defect varies from the rupture of only the mucosa
to the complete rupture of the organ wall. The rupture is localized on
the left or posterior wall of the esophageal-gastric junction, several
linear defects are possible.
Treatment tactics
Persistent attempts at endoscopic hemostasis are effective in most

5
patients. In the absence of the effect of endoscopic hemostasis,
gastrotomy with suturing of the defect with nodal sutures is indicated.
With a complete rupture of the cardia wall - suturing the defect with
peritonization of the seam line with a part of the large omentum,
sanation and drainage of the abdominal cavity.

Bleeding from varicose veins of the esophagus

Syndrome of portal hypertension leads to an expansion of the veins
of the upper portocaval anastomosis, which can be a source of bleeding.
Treatment tactics
Intubation of the Blackmore-Sengstacken tube for 24-48 hours.
In the absence of the effect of the tube placement, endoscopic
hemostasis (ligation by latex rings or by paravasal injections of
sclerosants) or an open operation is indicated: gastrotomy, stitching of
the varicose veins of esophagus).

Dieulafoy's ulcer
At the base of the disease is the arteriovenous malformation of the
submucosal layer and the gastric mucosa. The disease can be detected
only with continued bleeding: the portion of the vessel from which
blood comes is more often localized along the back wall of the upper
third of the body or the fundus of the stomach, the mucosa around it is
unchanged.
Treatment tactics
Endoscopic hemostasis. If bleeding cannot be stopped by the
endoscopic method, gastrotomy is performed and the bleeding vessel is
ligated.

Gastric cancer
Treatment tactics
Endoscopic hemostasis (fibrin glue, irrigation of the tumor surface
with 96% alcohol). If endoscopic hemostasis is ineffective in the case
of a resectable tumor, a subtotal resection of the stomach with the
tumor is performed; with an unresectable tumor, endovascular
embolization of the left or right gastric arteries or their ligation after
laparotomy is justified.

5
 QUESTION: Diseases of the operated stomach: classification,
clinic, diagnostics, treatment.
ANSWER:
This group of diseases is united by the fact that in the anamnesis in
all patients there are indications about any intervention on the stomach.

Classification:
 peptic ulcer of gastroenteroanastomosis,
 dumping syndrome,
 hypoglycemic syndrome,
 syndrome of the stagnant loop,
 unhealed or recurrent ulcers after vagotomy,
 post-resection anemia,
 alkaline reflux-gastritis, reflux-esophagitis,
 post-resection asthenia.

Peptic ulcer of gastroenteroanastomosis.

As the name implies, this disease occurs after a stomach resection
according to Billroth-2.
Among the main causes of the disease are:
1. Economical resection with preservation of part of the body of the
stomach;
2. Economical resection with preservation of a part of the mucous of
antral part of the stomach;
3. Endocrine causes (Zollinger-Elisson syndrome,
hyperparathyroidism, hereditary polyadenopathies).
All these reasons contribute to the preservation of residual acid
production in the stomach stump (the pH level in the stomach stump is
less than 7, which is not the norm in patients who have suffered distal
gastrectomy).
The peptic ulcer of gastroenteroanastomosis is often formed along
the anastomosis line or the small intestine (in its mesenteric margin,
which explains the frequent occurrence of bleeding). On EGDS, a
gastroenteroanastomosis ulcer is detected, often complicated by
bleeding.
Clinical symptoms

5
 Characteristic is the appearance of symptoms of peptic ulcer in 6-12
months after resection of the stomach.

Economical resection with preservation of a part of the stomach

body
This volume of resection implied the removal of less than 2/3 of the
distal part of the stomach (usually distal ½ of the stomach), and, of
course, in this situation, a part of the body of the stomach was retained.
The mucosa of this department continues to produce hydrochloric acid,
which leads to the formation of gastroenteroanastomosis ulcers,
because the jejunum mucosa is not adapted to the action of
hydrochloric acid of the stomach.
Diagnostics
The radiography of the stomach reveals the so-called "large" stump
of the stomach, which consists of the fundus and part of the body of the
stomach.
At histological examination of biopsy specimens of gastric mucosa
taken at EGDS in the distal sections of the gastric stump above the
gastroenteroanastomosis zone, cells characteristic of the gastric body
mucosa are identified.
Treatment
Because for this cause of the disease an incomplete volume of
stomach resection is initially performed, a gastric stump resection is
made (with preservation of only the cardiac part and stomach fundus)
with gastroduodenoanastomosis by Billroth-1 type.

Economical resection of the stomach with preservation of the

mucous membrane of antral part of the stomach in the stump of the
duodenum.
With this incomplete version of the distal stomach resection, the
stomach was cut off from the duodenum right after pylorus or with the
preservation of the latter. In this case, in the stump of the duodenum, a
part of the mucosa of the antral part of the stomach is retained, which
sometimes prolates beyond the pylorus. In such a situation, the G cells
of the mucosa of the antral part of the stomach begin to uncontrollably
produce gastrin, because there is no inhibitory effect of hydrochloric
acid of the gastric stump on them after the Billroth-2 resection.
Hypergastrinemia leads to the activation of residual parietal cells in the

5
stomach fundus, the production of hydrochloric acid begins in the
stomach stump, which leads to the formation of
gastroenteroanastomosis ulcer.
Diagnostics
When radiographing the stump of the duodenum, after the
endoscopically installed probe with the cuff into the afferent loop, a
parachute-shaped form of the stump of the duodenum is revealed.
On EGDS with biopsy of the mucous stump of the duodenum, a
large number of G-cells are found, which is characteristic of the
mucosa of the antral part of the stomach.
Treatment
A reresection of the stump of the duodenum (in combination with
the preserved part of the body of the stomach, the operation is
supplemented with resection of the stomach stump with an anastomosis
according to Billroth-1).

Zollinger-Elisson syndrome.
The disease is characterized by the presence of a hormonally active
tumor (gastrinoma) that does not come into contact with the gut lumen
(gastrin production does not depend on food intake), aggressive course
of stomach and duodenal ulcer, refractory to conservative treatment,
frequent ulcer bleeding.
Constant hypergastrinemia activates residual parietal cells of the
fundus of the stomach, which leads to the appearance of acid
production in the stomach stump.
Diagnostics
In the blood serum, hypergastrinemia is detected (provocative tests
with secretin, calcium chloride cause a sharp increase in the serum
gastrin level).
With CT of the abdominal cavity organs, a small pancreatic tumor
with clear, even contours or signs of infiltrative growth is detected.
Treatment
At benign, according to CT scan, origin of the tumor, an enucleation
of gastrinoma is performed.
If there are signs of malignancy and the tumor is located in the head
of the gland - pancreatoduodenal resection, in the body - an expanded
subtotal resection of the pancreas, in the tail - resection of the tail of the
pancreas.

5
 In the absence of visualization of a gastrinoma on CT - extirpation
of the stump of the stomach.

Hyperparathyroidism
In this disease, a high level of parathyroid hormone leads to
hypercalcemia, which activates residual parietal cells of the stomach
fundus and promotes the appearance of residual acid production.

Diagnostics
Hypercalcemia in the biochemical analysis of blood.
Elevated levels of parathyroid hormone in the blood serum.
On ultrasound of the parathyroid glands, an adenoma is detected.
Treatment
Is determined by endocrinologist, in the case of indications for
surgical treatment, adenomectomy or removal of parathyroid glands is
performed.

Postvagotomy ulcers
To this group of diseases all organ-preserving operations for peptic
ulcer, which were accompanied by vagotomy are included.
By the time of the onset, unhealed and relapsing postvagotomy
ulcers are isolated.
Recurrent ulcers are early (duodenal), recurring within 1 year after
vagotomy, and late (gastric), recurring more than 1 year after surgery.
Unhealed and early recurrent ulcers are formed due to persistent
acid production due to incomplete denervation of the acid-producing
zone of the stomach.
Late recurrent ulcers occur due to a violation of the gastric wall
neurotrophy and evacuation disorders.
Diagnostics
On EGDS an ulcerative defect is detected.
At intragastric pH-metry, residual acid production is determined (at
gastric ulcers there may be hypochlorhydria or achlorhydria).
Treatment
At duodenal ulcer and the presence of residual acid production, a
stem vagotomy with a circular myotomy of the abdominal esophagus
under the control of intraoperative pH-metry is indicated.
With a gastric or duodenal ulcer on the background of achlorhydria,

6
a classical distal resection of 2/3 of the stomach is performed.

Dumping syndrome
Dumping syndrome is a disease that develops as a result of rapid
intake of hyperosmolar food masses into the small intestine. It develops
after distal resection of the stomach (more often by Billroth-2),
gastrectomy, pyloroplasty.
The influx of a large amount of hyperosmolar contents into the small
intestine leads to a hyperextension of its wall. There is a release of
vasoactive substances (bradykinin, cholecystokinin, vaso-intestinal
peptide, etc.) and a decrease in the permeability of the mucosa. Then
there is a redistribution of fluid from the vascular bed into the lumen of
the intestine with a decrease in CBV and acceleration of passage of
food masses along the intestine.
Classification
By severity: mild, moderate and severe.
Clinical symptoms
The pathogenesis of the disease determines the variability of clinical
manifestations of dumping syndrome.
There are 2 groups of symptoms:
1. Vasomotor (hypo- or hypertension, tachy- or bradycardia, pallor
or hot flashes, etc.);
2. Dyspeptic (abdominal pain, nausea, vomiting, diarrhea,
obstipation).
The onset of an attack is always associated with eating.
Diagnostics
Identification of the relationship of seizures with food intake. In the
anamnesis - operation on the stomach.
On EGDS determination of the type of surgery performed earlier,
the size of the anastomosis, biopsy is taken in the presence of
indications.
Stomach radiography with an estimation of speed of evacuation
defines a type of the operation performed earlier, the sizes of a stump of
a stomach and anastomosis zone, speed of evacuation is increased.
When examining the passage of barium in the small intestine (the
time of entry of barium into the cecum is determined), the passage
speed is higher than normal.
Determination of severity of dumping syndrome:

6
 Criteria mild moderate severe

attack duration up to 30 min 0,5-1,5 hours 1,5-3 hours

attack frequency 1-2 a month 1-2 a week after each food

intake
ability to work decreased temporarily lost persistently lost

treatment diet out-patient with stationary only

courses of
stationary
evacuation from >30 min. 15-30 min. <15 min.
stump of stomach
passage through the 2,5-4 hours 1,5-2,5 hours <1,5 hours
small intestine
Treatment
With a mild degree of dumping syndrome, conservative treatment is
indicated, and moderate to severe disease requires surgical treatment.
Conservative treatment:
 diet with restriction of sweet and carbohydrate-containing foods;
 drugs that normalize bowel motility;
 antispasmodics;
 infusion of crystalloids (correction of water-electrolyte
disturbances);
 parenteral nutrition;
 symptomatic treatment;
 physiotherapy.
Surgical treatment:
Inclusion of duodenum in the passage of food or reduodenization
(conversion of resection of the stomach by Billroth-2 into Billroth-1 or
different variants of gastrojejunoduodenoplasty).

Hypoglycemic syndrome
Causes and pathogenesis of the disease are the same as with
dumping syndrome.
In clinical symptoms, symptoms of hypoglycemia predominate (cold
sweats, pallor, hypotonia, hunger), which develop 1.5-3 hours after
food ingestion.

6
 Diagnosis and treatment are the same as with dumping syndrome.

Syndrome of an afferent loop

Occurs after a stomach resection by Billroth-2 on a long loop due to
an adhesive process in the field of operation or an extra-organic
compression of the afferent or efferent loops of the small intestine by a
cyst or tumor.
Clinical symptoms
Characteristic is a growing pain syndrome in the right upper
quadrant, a feeling of heaviness there, vomiting with a lot of bile or bile
with an admixture of food with a short-term improvement. The old
name for this disease is "bile vomiting syndrome".
Diagnostics
At afferent loop stenosis:
During EGDS, a large amount of bile in the afferent loop is detected
at fasting, constriction or deformation of the afferent loop.
On ultrasound of the abdominal cavity in the right hypochondrium,
an overstretched loop of the intestine with liquid contents is identified.
Roentgenography of the stomach with barium is not informative; the
evacuation of contrast medium will be carried out through an efferent
loop (which is the norm in people with a stomach resection according
to Billroth-2 in the anamnesis).
At efferent lood stenosis:
According to EGDS - deformation or narrowing of the efferent loop,
a large amount of food and bile in the afferent loop at fasting.
On X-ray examination, most of the barium from the stomach enters
the afferent loop and is deposited there for a long time, the afferent loop
is dilated.
Treatment
1. Formation of interintestinal enteroenteroanastomosis (between the
afferent and efferent loops).
2. Cutting off the afferent loop from the stomach with the formation
of an anastomosis by Roux (elimination of the afferent loop as such).

Postresectional anemia
With this disease, there are 2 types of anemia: iron deficiency and
B12 deficiency.
Iron deficiency anemia develops on the background of a decrease in

6
acid production (after resection of the stomach), disruption of oxidation
and absorption of exogenous iron, which leads to the development of
iron deficiency.
B12-deficiency anemia appears due to a decrease in the production
of the Castle internal factor and impaired absorption of exogenous
vitamin B12.
Clinical symptoms
There are characteristic signs of anemia: weakness, pallor,
adynamia, growth disturbance of the appendages of the skin (hair,
nails), with a deficiency of B12 - neuropathy, aphthous stomatitis.
Diagnostics
Diagnostic Iron deficiency B12-deficiency
measures anemia anemia
General blood hypochromia, aniso- hyperchromia,
analysis and poikilocytosis macrocytosis
Biochemical blood decreased serum iron decreased serum В12
analysis
Sternal puncture depletion of red megakaryocytosis
marrow
Treatment
Iron deficiency anemia
Iron preparations parenterally (i/m or i/v). Oral reception is
unacceptable, because on the basis of pathogenesis is the violation of
absorption of iron from the digestive tract.
B12-deficiency anemia
Vitamin B12 is started with i/m injections at 1000 mcg/day until the
appearance of a reticulocytic crisis (after 7-10 days, an increase in the
level of reticulocytes to 5-8 0/00 is noted), then the dose of the vitamin is
reduced to 500 mcg/day i/m gradually decreasing the multiplicity of
injections to up to 1 time per month. When the hemoglobin level is
normalized, 1000 μg of vitamin B12 IM is injected once a year for life.
Alkaline reflux-gastritis, reflux-esophagitis and post-resection
asthenia require a syndrome-related conservative treatment.

Question: Rectal prolapse. Anal fissure. Hemorrhoids. Clinic,

diagnosis, treatment. Anomalies in the development of the rectum:

6
diagnosis, treatment.
Answer:
Rectal prolapse.
Disease, in which the prolapse of the rectum walls outside the
sphincter is observed as a result of a decrease in the tone of the pelvic
floor muscles and an increase in intra-abdominal pressure.
Clinical symptoms
Rectal prolapse of various degrees, spotting, incontinence of gases
and feces. According to the clinical course, there are:
1. Stage - prolapse of the intestine during defecation with its
subsequent independent correction;
2. Stages - the bowl prolapses during physical exertion, does not
self-correct, the patients direct it with their hand;
3. Stage - prolapse of the intestine even in the vertical position of the
patient's body, after the intestine readjustment it quickly protrudes
again.
Diagnostics
When straining, the intestinal wall (anal funnel) or mucosa
prolapses. By the volume of a prolapse of tissues there are 4 stages of
the disease:
1. Prolapse of the mucosa of the anus;
2. Prolapse of all layers of the wall of the anal part of intestine;
3. Prolapse of the rectum without prolapse of the anus;
4. Prolapse of the anus and rectum.
Treatment
At 1-2 stages of the disease, rectopexy (Kummel-Zerenin's
operation) is performed: the ampullar department of the rectum is fixed
to the periosteum of the sacrum.
At 3-4 stages of the disease and prolapse of the sphincter,
sphincterolevatoroplasty is implemented (provides narrowing of the
anal canal) in combination with rectopexy.
If only the mucous membrane prolapses, it is resected.

Anal fissure
- is a mechanical mucosal tear in case of constipation, diarrhea,
postpartum and gynecological trauma, genitourinary infection
Clinical symptoms
Sharply painful defecation, severe pain syndrome.

6
 Diagnostics
Finger rectal examination is sharply painful (sometimes it is
impossible without anesthesia), a sphincter hypertonus is revealed, and
at 6 o'clock is a longitudinal crack with a control tubercle in the
proximal corner.
Anoscopy reveals similar changes.
Treatment
Conservative: laxatives (treatment of constipation), local anesthetic
in candles, analgesics, diet, dietary regime.
In the absence of the effect of conservative treatment, anus
devulstion is performed under anesthesia (manipulation leads to
recovery in 70% of patients).
Surgical:
Excision of a fissure with a dosed sphincterotomy by Ryzhih
(indicated when conservative methods are ineffective).

Hemorrhoids
Hemorrhoids - a disease in which a pathological increase in the
cavernous bodies of the submucosal layer of the distal rectum develops.
These changes occur as a result of the violation of venous outflow from
the cavernous corpuscles of the rectum and dystrophic processes in the
longitudinal muscle of the submucosal layer and the Parks’ ligament
located in the inter-sphincter space of the anal canal.
Provoking factors are: sedentary work, taking spicy food and
alcohol, constipation. Typical localization of hemorrhoids is at 3, 7 and
11 hours on the conditional dial with the position of the patient on the
back.
By localization, the inner (proximal to the scallop line) and the
external hemorrhoids are distinguished.
The disease is characterized by the development of the following
complications: thrombosis of the hemorrhoidal node, hemorrhoidal
bleeding, cellulitis of perianal subcutaneous tissue. Acute hemorrhoids
are more often complicated by thrombosis of hemorrhoids, chronic – by
bleeding.
The following stages of the disease development are distinguished:
Stage 1 - bleeding nodes without prolapse;
Stage 2 - prolapsed nodes with their independent correction (with or
without bleeding);

6
 Stage 3 - prolapse of nodes with the need to manually reposition
them;
Stage 4 - permanent prolapse of nodes that cannot be repositioned.
Clinical symptoms
According to the clinical course, acute and chronic hemorrhoids are
isolated.
Acute hemorrhoids: are often manifested by thrombosis of
hemorrhoids, in which patients complain of pain in the rectum,
intensifying during defecation. Inflammatory changes can spread to the
tissue of the perianal region.
Chronic hemorrhoids: intestinal bleeding (secretion of scarlet blood
after defecation, blood with feces is not mixed), prolapse of
hemorrhoids. Pain syndrome is not typical. There may be anal itching
and mucus secretion from the anus.
Diagnostics
At finger examination of the rectum, internal hemorrhoids are
identified, as well as their localization, the presence of complications.
With thrombosis of the nodes, the study is extremely painful.
During anoscopy or rectoscopy, a detailed examination of the
mucosa is performed, the localization of the nodes and the presence of
complications are clarified, and differential diagnostics is performed.
Treatment
Conservative: phlebotonics (detraleks), NSAIDs and non-narcotic
analgesics, local combined agents (proctosedil, proctogliolol, relief,
etc.), local anticoagulants (heparin gel, troxevasin gel) - with
thrombosis of nodes, suppositories with adrenaline and local hemostatic
drugs - with bleeding.
Surgical treatment.
Minimally invasive:
1. Sclerotherapy - the introduction of sclerosants into the
hemorrhoid nodes causes thrombosis of the nodes and their obliteration.
In one session, the sclerosant is injected into no more than 2 nodes,
because sclerotherapy of more than 2 knots causes a pronounced pain
syndrome. According to the indications, repeated sclerosis of
hemorrhoids is performed in 2 weeks.
2. Infrared photocoagulation is based on blood coagulation in the
hemorrhoidal node when it is irradiated with an infrared laser. The
nodes are thrombosed and obliterated.

6
 3. Use of latex ligatures. With the help of a special device, latex
rings are put on hemorrhoids, which lead to ischemia and necrosis of
the node. Self-amputation of necrotic hemorrhoids occurs on the 7-9th
day.
The traditional operation in the treatment of hemorrhoids is a
hemorrhoidectomy according to Milligran-Morgan, which is performed
both with suturing the mucosa after removal of the hemorrhoids, as
well as without suturing.
A plastic variant is Parker's hemorrhoidectomy, in which the mucous
membrane is cut off at the node, excision of the node is performed,
followed by restoring the integrity of the anal mucosa.
Of the minimally invasive methods of treatment in recent years,
desarterization of hemorrhoidal nodes under ultrasound with lifting and
mucopexy of the anal mucosa has been widely used (HAL-RAR /
Hemorrhoidal Artery Ligation and Recto Anal Repair /).
The initial stages of the disease or thrombosis of the nodes are
indications for conservative treatment.
3 and 4 stages of the disease or recurrent hemorrhoidal hemorrhages
are indications for surgical treatment.
Minimally invasive techniques are used in 1-2 stages of the disease.

Anomalies of rectum development

Develop as a result of embryogenesis disorders.
Among the anomalies of development of the rectum are:
 Simple atresia of the anus - no hole in the anus, blind end of the
rectum reaching the outer covers;
 Simple atresia of the rectum - opening of the anus is formed as
a short blind canal, separated by a septum from the rectum;
 Atresia of the anus or rectum, complicated by communication
with neighboring hollow organs - the vagina or bladder;
 Atresia of the anus or rectum, complicated by fistula of the
perineum, scrotum, penis or vagina.
Diagnostics
Examination of the perineum and rectum, as well as signs of
intestinal obstruction shortly after birth, an admixture of meconium in
the urine (when communicating with the bladder), fever (a symptom of
ascending pyelonephritis) usually allow to set the diagnosis.
Treatment

6
 Surgical only:
Simple atresia of the anus or rectum - lowering the colon to the
perineum.
Atresia of the anal canal with the fistula of the vagina - moving the
fistula to the perineum + levatoroplasty.
Atresia of the anal canal with the fistula of the perineum -
displacement of the anterior semicircle of the sphincter +
levatoroplasty.
At the atresias accompanied by underdevelopment of the closure
apparatus of the anus, surgery is required to create a sphincter from the
gluteal muscles (sphincterogluteoplasty), sphincteroplasty, or
sphincterolevatoroplasty.

Question: Portal Hypertension Syndrome: classification, clinical

manifestations, complications, principles of surgical treatment.
Answer: Syndrome of portal hypertension — a pathological
syndrome, which interferes with the outflow of blood from the vessels
of the portal vein pool with the increase in it pressure.
Classification
By the level of the block are isolated:
• Intrahepatic block (cirrhosis of the liver, 80-90% of all cases);
• Subhepatic block (congenital atresia or stenosis of the portal vein
or its compression from the outside);
• Suprahepatic block (Budd-Chiari syndrome, constrictive
pericarditis).
Clinical manifestations and symptoms
An increase in the abdomen in volume due to ascites, dilation of the
subcutaneous veins of the anterior abdominal wall, an increase of
spleen size.
At liver cirrhosis, pains occur in the epigastrium, a feeling of
heaviness in both hypochondria, constipation, flatulence, vascular
"stars" on the skin.
The syndrome of Budd-Chiari is characterized by sharp pains in
epigastrium and right hypochondrium, fever, progressively increasing
hepatomegaly and ascites.
Physically are determined free fluid in the abdomen, decrease in
liver size, liver with a bumpy surface (at cirrhosis) or an increase in

6
liver size and tenderness on palpation (Budd-Chiari syndrome).
On EGDS, varicose-dilated veins of the abdominal esophagus and
cardia are detected, and signs of bleeding are revealed. The following
degrees are distinguished by the diameter of varicose-dilated veins
(according to A.G. Scherzinger, 1986):
 I degree — veins up to 3 mm in diameter;
 II degree — from 3 to 5 mm;
 III degree — more than 5 mm.
Complications
Bleeding from esophageal varices (upper portocaval anastomosis)
and hemorrhoidal hemorrhages (lower portocaval anastomosis),
symptoms of encephalopathy (of hepatic genesis).
Principles of surgical treatment
Palliative methods
Options for portocaval shunting:
 Transjugular intrahepatic portosystemic shunting (TIPS);
 Selective portocaval shunting (distal splenorenal anastomosis
or Warren's operation);
 Partial portocaval shunting (splenorenal or mesentericocaval
"H"-type anastomosis by a synthetic prosthesis of small diameter of 8-
10 mm).
Dissociation of porto-caval connections in the zone of esophageal-
gastric transition:
 Endoscopic sclerotherapy or ligation of varicose veins of the
abdominal esophagus;
 Stitching and ligation of veins in this area;
 Endovascular embolization of the left gastric vein and short veins
of the stomach;
 Oesophageal and gastric devascularization;
 Transection of the esophagus;
 Resection of the esophagus and stomach.
Radical method (at decompensated cirrhosis): liver transplantation.
At bleeding and ineffective endoscopic hemostasis, a gastrotomy is
performed with the ligation of the esophageal varices.
At the initial stages of cirrhosis, surgical intervention is possible,
with decompensated cirrhosis the risk of surgery is extremely high, at
the occurrence of bleeding from varicose-dilated veins of the esophagus

7
and stomach, the advantage should be given to conservative or
"minimally invasive" methods of treatment.

Question: Parasitic diseases of the liver (echinococcosis,

alveococcosis). Clinical manifestations, diagnosis, treatment.
Answer:
Echinococcosis
The causative agent is the larval stage of Echinococcus granulosus.
The embryo germ - oncosphere - is introduced into the intestinal
mucosa, enters the veins or lymphatic vessels, through which it enters
the liver. Most oncospheres are retained in the liver, which is associated
with a high incidence of this organ - 50-80%. Less often the lungs, the
brain, the heart are affected.
Echinococcus, after penetrating the liver, transfers into the second
form of its development - the bubble stage or the stage of the hydatid.
Echinococcal cysts of the liver are more often solitary. The wall of the
cysts consists of two layers: the outer layer (the cuticular, or chitinous,
membrane) and the inner (germinative membrane). To the chitinous
membrane lies is a dense fibrous membrane, formed as a result of the
reaction of the liver tissue to the excretion of toxins by the parasite.
Clinical symptoms
During the course of echinococcosis, there are:
• Asymptomatic stage;
• Stage of progressive growth of the parasite (pain in the right
hypochondrium, symptoms of compression of neighboring organs);
• Stage of complications (calcification of the cyst, aseptic necrosis,
suppuration, bleeding and rupture of the cyst).
Diagnostics
 History of stay in an endemic area
 Hepatomegaly and palpation of a rounded liver formation
 A positive allergic reaction (Casoni reaction)
 Positive serological reactions (latex agglutination, passive
hemagglutination)

7
  CT of the abdominal cavity - rounded formation with a capsule and
heterogeneous contents, multiple daughter cysts.
Treatment
Conservative: mebendazole 400-600 mg/day for 21-30 days.
Surgical:
Radical operations:
 Anatomical or atypical resection of the liver with removal of
the cyst (at suppuration of the cyst, calcification of the cyst wall, at
multiple cysts in one anatomical lobe);
 Pericystectomy.
Palliative operations:
 Echinococcectomy,
 Echinococcystectomy.
At the rupture of the echinococcal cyst of the liver into the bile
ducts, a choledochotomy and external drainage of the common bile duct
is performed.
At the rupture of the echinococcal cyst of the liver into the bile ducts
and bronchi, is performed a simultaneous or staged removal of the
contents of the cyst (echinococcotomy), interference on the lung and
external drainage of the common bile duct.

Alveococcosis
The causative agent of the disease is the larval stage (oncosphere) of
the Alveococcus multilocularis tapeworm. The mechanism of
development of invasion is similar in many ways to the pathogenesis of
echinococcosis. Alveococcosis is characterized by invasive growth
(simulates malignant tumors) and germination in vessels, bile ducts and
adjacent organs. The brain and lungs are often affected.
Clinical symptoms
The disease is characterized by pain in the right hypochondrium,
hepatomegaly, and jaundice.
Diagnostics
It is similar to that in echinococcosis + serological reactions (latex
agglutination, reactions of enzyme-labeled antibodies with alveococcal
diagnosticum).
At CT of the liver, a rounded formation with infiltrative growth and
heterogeneous contents is revealed.

7
 Treatment
Radical operations: resection of the liver (atypical or anatomical,
taking into account the lobar or segmental structure of the liver).
Palliative operations: removal of the main bulk of the node and
leaving its fragments in the region of the liver portal, external or
internal drainage of the bile ducts with obstructive jaundice, drainage of
the decay cavity; introduction of antiparasitic drugs into the thickness
of the nodal tissue; cryodestruction of the remains of the unremoved
parasite by liquid nitrogen.

Question: Purulent complications in abdominal surgery.

Peritonitis: classification, etiology, pathogenesis. Clinical picture at
various stages of peritonitis, treatment. Subdiaphragmatic, pelvic,
intestinal abscesses: etiology, clinical manifestations, diagnosis,
treatment.
Answer:
Peritonitis – is an acute or chronic inflammation of the peritoneum,
accompanied by local and general symptoms of the disease, a violation
of the function of the most vital organs and systems.
Classification
By etiology: bacterial; aseptic or abacterial (bile, urinary,
enzymatic); special forms: carcinomatous (with inoperable cancer of
the internal organs) or fibroplastic (if foreign substances enter the
peritoneum).
By the nature of penetration of microflora into the abdominal cavity:
 Primary (microflora enters the abdominal cavity with
hematogenous, lymphogenous, through the fallopian tubes);
 Secondary (penetration of microflora from inflammatory
changes in the abdominal cavity), which is divided into perforative and
non-perforative.
By the character of the effusion: serous, fibrinous, fibrinous-
purulent, purulent, putrefactive, fecal.
By the prevalence of the inflammatory process:
 Local (localized near the source of the infection);
 Diffuse (occupies several anatomical areas of the abdomen).
By the clinical course: acute; subacute; chronic.
Pathogenesis

7
 Penetration of the inflammatory agent into the abdominal cavity →
intestinal paresis → accumulation of intestinal contents in the lumen of
the gut + growth of the bacterial flora → fluid effusion from the
extracellular space and vascular bed into the lumen of the gut +
exudation to the abdominal cavity → decrease in CBV + transposition
of bacteria to the portal blood flow → organ dysfunction + intoxication
→ multiple organ dysfunction syndrome (MODS).

Clinical manifestations and symptoms

Dry tongue, symptom of Schetkin-Blumberg, protective tension of
abdominal muscles, tachycardia.
In the development of the disease, staging is observed:
 Reactive stage (<24 h) - local symptoms are expressed:
protective tension of abdominal muscles, symptom of Schetkin-
Blumberg, peristalsis is weakened, tachycardia develops.
 Toxic stage (24-72 h) - in addition to local symptoms, intestinal
paresis develops, tachycardia develops, the tongue is dry,
hypotension, oliguria develop, symptoms of intoxication appear.
 Terminal stage (> 72 h) – is characterized by the development of
septic shock and multiple organ dysfunction syndrome without
pronounced local symptoms.
In perforated peritonitis, the duration of each stage is divided by 2.
Diagnostics
The diagnosis is established based on the examination.
On the review radiograph of the abdominal cavity organs, it is
possible to reveal signs of perforation of the hollow organ as the cause
of peritonitis (free gas in the abdominal cavity).
On ultrasound of the abdominal cavity organs, a free effusion and a
possible cause of peritonitis are revealed (at biliary, pancreatogenic and
other types of peritonitis).
In doubtful cases, diagnostic laparoscopy is used, which allows
detecting pathological effusions (pus, blood, fibrin, bile, feces, etc.) and
the cause of peritonitis.
Treatment
Emergency operation, which includes 2 main stages:
 Identification and elimination of the cause of peritonitis;
 Sanation and drainage of the abdominal cavity.

7
 In the case of an extremely severe condition of the patient and a
high operational and anesthetic risk, short-term preoperative
preparation for 2 hours is justified, which aims to stabilize
hemodynamics and normalize the urinary function of the kidneys.
The following approaches are used in the surgical treatment of
peritonitis:
Programmed relaparotomy - during the first operation it is not
possible to sanitize the abdominal cavity (widespread purulent or fecal
peritonitis) or completely eliminate the source of peritonitis
(pancreonecrosis, or perforation of the part of intestine if intestinal
resection is not possible due to adhesive process). In this situation, the
surgeon intraoperatively decides to re-sanate after 12-24 hours.
More often 2-4 relaparotomies are sufficient (more of them often
leads to the development of intestinal fistulas).
Relaparotomy on demand - when after the first surgery there are
symptoms of peritonitis, there is a need for a second laparotomy.
From the open laparostomy, at the present time have refused, since
its terrible complication is intestinal fistulas. The main measure of
prevention of intestinal fistulas is a precision technique of performing
operations, the absence of contact of the loops of the intestines with air
and dressings after the operation.
The method of peritonial lavage is also not used at the present time.
It does not allow adequately sanitizing and draining all parts of the
abdominal cavity.
One of the promising methods of treatment is vacuum-assisted
laparostomy. This method reduces the lethality and duration of
treatment promotes early regression of the inflammatory process.
Besides surgery, are performed a massive antibacterial (taking into
account genesis of peritonitis), infusion and detoxification treatment,
parenteral and enteral nutrition, correction of organ failure, combating
intestinal paresis (nasointestinal intubation with intestinal lavage,
stimulation of peristalsis), syndrome-related treatment.

Abscesses of the abdominal cavity

Abscess – is purulent tissue melting, limited to a capsule.
By localization are distinguished: interintestinal, subhepatic, sub-
diaphragmatic and pelvic abscesses.
By localization subdiaphragmatic abscesses are left-sided, right-

7
sided and central.
Etiology:
 Postoperative abscesses (as a complication after inadequate
sanation of the abdominal cavity during the previous intervention or in
case of failure of the anastomosis sutures);
 Abscesses, as complicated forms of acute diseases of the
abdominal cavity and pelvis (appendicular, paravesical, paracolonic,
tubovarial, etc.).
Clinical symptoms
Patients complain of hectic temperature, chills, moderate abdominal
pains (localization of which indicates localization of the abscess). With
pelvic abscess, dysuria, frequent loose stools, pain during defecation,
tenesmus are possible. With a subdiaphragmatic abscess, there may be
complaints of pain in the shoulder girdle, shoulder and thoracic cage
during breathing, dry cough (reactive pleurisy).
Diagnostics
Physically: it is possible to identify a slightly painful infiltrate in the
abdominal cavity with uneven contours, displaced or unshifted. In
pelvic abscess in the process of digital rectal and/or vaginal
examination, the overhanging of the walls of the organ from the side of
the abscess is determined, which is painful on palpation, fluctuation can
be determined by palpation. With a subdiaphragmatic abscess with
reactive pleurisy, a friction noise of the pleura is auscultated from the
side of the abscess.
In the general analysis of the blood: hyperleukocytosis with a stab
left-shift.
On ultrasound of the abdominal cavity (small pelvis) the presence of
infiltrate is confirmed, its size and localization specified, in the center
of the infiltrate a rounded hypoechoic formation with a capsule and
heterogeneous contents (signs of abscessing) is revealed.
On the survey radiograph of the abdominal cavity organs (at
subdiaphragmatic abscess) under the dome of the diaphragm, a rounded
formation with a liquid level, a high position of the dome of the
diaphragm are revealed.
At a small size of the abscess, especially in patients in the
postoperative period, if an abdominal abscess is suspected, CT scan of
the abdominal cavity organs is indicated, in which a liquid rounded
formation with a capsule and heterogeneous contents is revealed.

7
 Treatment
Only surgical: opening and draining the abscess cavity (or puncture
and drainage under the supervision of ultrasound).
Access is preferably extraperitoneal (to prevent infection of the free
abdominal cavity along the drainage).
With the subdiaphragmatic abscess the following approaches are
used:
Extrapleural access (according to Melnikov) - along the XI rib with
its resection, the posterior sheet of the periosteum is dissected, a
transitional fold of the pleura (sinus) is found, which is bluntly flaked
from the upper surface of the diaphragm to the top, the diaphragm is
dissected and the abscess is opened and drained.
Extraperitoneal (according to Clermont) - along the edge of the
costal arch through all the layers reach the transverse fascia, which,
together with the peritoneum, is exfoliated from the lower surface of
the diaphragm, after which the abscess is opened. Both of these
methods are dangerous for the possibility of infection of the pleura or
abdominal cavity due to the presence of infiltration and adhesions,
which complicate the isolation.
Transabdominal - accessing the abdominal cavity in the right or left
hypochondrium, delimiting it with napkins and then penetrating into the
cavity of the abscess along the outer edge of the liver or spleen.
Transthoracic - through the chest wall in the X-XI area of the
intercostal space or with resection of the X-XI rib a) single-stage, if
when the parietal pleura is reached it is opaque, the lung excursion is
not visible, the sinus is sealed; a puncture with a thick needle and
dissection of the abscess cavity along the needle is made; b) double-
staged - if the parietal pleura is transparent, the lung excursion is
visible, the sinus is not sealed, the pleura is treated with alcohol and
iodine (chemical irritation), then tightly tamponaded (mechanical
irritation) (1st stage). After 2-3 days, the tampon is removed and,
making sure that the sinus is sealed, puncture, opening and draining of
the abscess (stage 2) is performed. With an undamaged sinus, it is
possible to open the abscess cavity at a single stage. To do this, the
sinus is sutured to the diaphragm along a circle with a diameter of about
3 cm with a stalk suture with an atraumatic needle and in the center of
the sutured part the cavity of the abscess is opened.
Pelvic abscess is opened through the posterior fornix of the vagina

7
or through the front wall of the rectum after a preliminary puncture of
the abscess with a thick needle. Pus is evacuated, the abscess cavity is
washed with antiseptics, the drainage is fixed to the skin of the perianal
region or to the labia majora.
When treating interintestinal and hepatic abscesses transabdominal
access is used, before opening the abscess the free abdominal cavity is
delineated with gauze napkins.
Currently, preference is given to the minimally invasive procedure -
puncture and drainage of the abscess under ultrasound control.