Кафедра хірургії № 4
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Item Non-operative treatment of gunshot wounds of soft tissues(2024) Khoroshun, Eduard; Makarov, Vitaly; Nehoduiko, Volodymyr; Shypilov, Sergiy; Tertyshnyi, S.; Veryovkin, I.; Vastyanov, R.The purpose of the study was to analyze own experience of soft tissues gunshot wounds non-operative treatment. Clinical observations were performed on 829 wounded which were admitted to the Military Medical Clinical Centre of the Northern Region of the Command of the Medical Forces of the Armed Forces of Ukraine. All of the wounded were men. The wounded were randomized on 3 groups according to the needs for primary surgical treatment of the wound. All wounded received the same treatment. Foreign bodies (metal fragments) were partially removed with the help of a modern surgical magnetic tool. A third of all soft tissue gunshot wounds were proved do not require primary surgical treatment. The criteria for primary surgical treatment not performing are soft tissues gunshot wounds of small sizes, of different localization and number without signs of inflammation. Non-operative treatment of soft tissues gunshot wounds includes antibiotic prophylaxis, anti-tetanus toxoid administration, anesthesia, treatment of wounds with antiseptic solutions, aseptic wound dressings. Non-operative treatment of wounded with soft tissue gunshot wounds using the magnetic detection turned out to be highly effective in modern conditions for a significant number of people due to the acceleration of diagnostic process, treatment and recovery and due to entirely medical accompanying advantages.Item Mortality analysis in blunt combined trauma and polytrauma(2024) Panasenko, S.; Nehoduiko, Volodymyr; Nizar KerbazhIntroduction. Modern traumatism from the standpoint of clinical epidemiology meets the classification criteria of a global pandemic. Important factors triggering the global clinical and epidemiological picture are the unsatisfactory state of prevention of all types of injuries in developing countries, traffic injuries in industrialized countries and the progressively increasing number of armed conflicts. The aim of the study. To conduct a comparative clinical and epidemiological analysis of mortality in blunt combined trauma and polytrauma. Materials and methods. A retrospective single- center cohort 10-year clinical and epidemiological study of 933 fatal clinical cases of blunt combined trauma on the basis of polytrauma department of the Kyiv City Clinical Emergency Hospital has been conducted. Clinical diagnoses and forensic medical conclusions were transformed into Hannover Polytrauma Score scale codes. The clinical and epidemiological experiment was based on the clustering of the research array according to the severity of the injury. Results. As a result of the clinical and epidemiological experiment, 5 stable clusters which can be characterized as separate randomized clinical- epidemiological groups were obtained. Clinical profile was determined by the dominant injury: cluster-1 (patients with an extremely severe thoracic profile), cluster-2 (patients with a severe thoracic profile), cluster-3 (patients with an extremely severe abdominal profile), cluster-4 (patients with a severe neurosurgical profile), cluster-5 (patients with an extremely severe neurosurgical profile). Conclusions. Lethal blunt combined injury has a clear hierarchical structure based on the severity of the injury and the presence of dominant damage to the corresponding anatomical and functional area. The results obtained during the current study indicate the need to find new technological approaches to the treatment of extremely severe injuries, as well as treatment and prevention of the development of complications of severe injuries in order to reduce mortality in polytrauma.Item A rare case of blast injury of the chest and spine on the background of a congenital malformation in the form of a complete mirror image arrangement of internal organs(2024) Khoroshun, Eduard; Makarov, Vitaliy; Nehoduiko, Volodymyr; Shypilov, Serhii; Tertyshnyi, S.; Slesarenko, K.The aim is to demonstrate a clinical case of blast injury of the chest and spine against the background of a complete mirror image arrangement of internal organs. Clinical case. The injured S., 37 years old, received a blast injury during mortar shelling. Upon admission, the injured person complained of aching pain in the area of the X rib on the left and in the lumbar region. The pain worsened during movement. He has known about the malformations of internal organs since childhood, but only about the right-sided location of the heart. The final established diagnosis is combined blast injury of the chest and spine. Closed chest injury on the left, closed fracture of the X rib on the left. Closed fracture of the lumbar processes L3–4 on the right. Congenital malformation. A complete mirror image arrangement of internal organs. The injured person was taken to a territorial hospital base for further treatment, where he received painkillers, anti-inflammatory therapy, and prescribed multivitamins. The total bed-day was 7 days. The injured was taken to the Military Medical Commission and discharged in satisfactory condition to implement the decision of the Military Medical Commission. Conclusions. A congenital malformation in the form of a complete mirror image arrangement of internal organs is a rare pathology. Diagnosing a complete mirror image arrangement of internal organs is not difficult and is an accidental finding during the examination for the injury in this case. Anamnestic data help in the diagnostic search. The research was carried out in accordance with the principles of the Declaration of Helsinki. The research protocol was approved by the Local Ethics Committee of a participating institution. The informed consent of the patient was obtained for conducting the studies. No conflict of interests was declared by the authors.Item Classification of gunshot foreign bodies migration(2024) Lurin, I.; Khoroshun, Eduard; Makarov, Vitaly; Nehoduiko, Volodymyr; Tertyshnyi, S.; Veryovkin, Igor; Vastyanov, R.The purpose of the study was to provide the classification features of the gunshot foreign bodies migration. We analyzed 90 cases of gunshot shrapnel blind wounds of different localization for a certain period, where there was a foreign body migration in different ways. The wounded which were admitted to the Military Medical Clinical Centre of the Northern Region of the Command of the Medical Forces of the Armed Forces of Ukraine, were examined by X-ray and, as indicated, using videoendoscopic methods. We distinguish the following classification features: the localization of the entrance hole; the place of migration initiation; the direction of migration; the number of foreign bodies; the structure of foreign bodies; the migration distance; the process of migration occurrence; the time of migration; the cause of migration; the frequency of migration; the foreign body fixation during migration; the volume of referral of migration surgical treatment. The identification of following three landmarks (the entrance hole, the place of migration starts and the place of detection), two stages (the wound channel and the migration corridor) and the direction of gunshot foreign bodies migration form a complete conception. The authors state that gunshot foreign bodies migration represents a separate type of a gunshot wound manifestation. The proposed original classification of gunshot foreign bodies migration allows to sort the data of clinical observations, which is of great importance for adequate and rapid diagnosis, determination of direct foreign body migration and its direction, and for effective treatment of gunshot wounds with phenomena of gunshot foreign body migrationItem Objectivization of surgical tactics in case of covering tissue gunshot defects restoration(2024) Lurin, I.; Khomenko, I.; Kashtalyan, M.; Nehoduiko, Volodymyr; Vastyanov, R.; Tertyshnyi, S.; Stepanov, G.; Solodyanikova, O.; Tanasichuk-Gazhieva, N.The article presents the results of the objectification of surgical tactics in the restoration of defects in the integumentary tissue due to gunshot wounds in 126 soldiers. For this purpose, all the wounded were divided into 2 groups: Group I included 68 wounded, in whom 75 reconstructive operations were performed under dynamic angiographic multimodal control. Group II consisted of 58 wounded patients who underwent 96 surgical operations using conventional tactics. Rapid restoration of damaged anatomical structures and their aesthetic appearance, reduction of scars showed good results of operations in group I of patients. The results of the work show that dynamic monitoring improves the quality of surgical reconstructive operations and can be recommended at all stages of medical care.Item Features of diagnosis and treatment of a polytrauma victim with predominant closed chest trauma with lung and diaphragm rupture. Clinical case(2024-07-23) Khoroshun, Eduard; Makarov, Vitalii; Negoduyko, Volodymyr; Shypilov, Sergiy; Borodai, O.; Petiunin, O.The article describes a clinical case and presents clinical signs of traumatic rupture of the diaphragm and lung on the background of a wave-like course of the postoperative period. Open diaphragmatic injuries are more common than closed ones. In this case, the closed chest and abdominal trauma was sustained as a result of a road traffic accident. The injury was combined and severe, with signs of traumatic shock. The location of the diaphragmatic injury was on the right side, which is less common. The severe condition of the patient with respiratory failure (respiratory rate over 30 per minute) was an indication for artificial lung ventilation, which made it impossible to take complaints and anamnesis. The individual spatial topography of the diaphragm depends on the size and location of the abdominal organs, body structure, and depends on the line of examination. The movement of internal organs into the pleural cavity indicates a diaphragmatic rupture, but in this case, the extrahepatic location of the diaphragmatic defect was covered by the liver, the lower lobe of the right lung, and adhesions, which led to the cover up of the diaphragmatic defect. Increased abdominal size due to polytrauma and mechanical ventilation in case of closed chest and abdominal trauma; increased air discharge through pleural drainage during video laparoscopy or increased abdominal size during video thoracoscopy; clamping of the pleural drainage with a spiral computed tomography of the chest and abdominal organs allows detecting pneumoperitoneum and pneumothorax, which indicates the presence of a defect in the diaphragm and lung. The use of video thoracoscopy, video laparoscopy, and spiral computed tomography does not always provide complete information about the existing damage to the diaphragm, so dynamic observation with control radiological examinations is preferred.Item A rare case of endoscopic removal of the metal fragment from the segmental bronchus after gunshot injury to the chest in combat patient injured in the war in Ukraine(2024) Lurin, I.; Khoroshun, Eduard; Makarov, Vitalii; Nehoduiko, Volodymyr; Cherniavskyi, Ye.; Gorobeiko, M.; Marchenko, О.; Dinets, А.Introduction and importancе: Russo-Ukrainian war is associated with severe injuries to the chest. Isolated chest injuries are associated with high mortality or advanced invalidization due to the severity of the trauma. The aim of the study was to demonstrate the experience and the challenges in diagnosis and management of the combat patient with gunshot injury to the lungs with subsequent migration of the shrapnel projectile to the segmental bronchus and its bronchoscopic removal by using forceps. Case presentation: A male patient 44 years of age was injured at an artillery strike in East Ukraine. The patient was evacuated to the Forward Surgical Team (Role 1) facility within one hour after the injury. The bronchoscopy was performed and to our surprise, the metal fragment in the lumen of the right segmental S2 bronchi was visualized at bronchoscopy, indicating its migration from the first place. The decision was made to attempt to remove the metal fragment endoscopically. At bronchoscopy, the metal fragment was caught by the endoscopic forceps and therefore removed endoscopically. The time of endoscopic removal of the metal fragment was 8 min. Clinical discussion: Removal of a foreign body (metal fragment) of gunshot origin from the lumen of a segmental bronchus by using bronchoscopy with endoscopic forceps is a rare phenomenon. Conclusions: The use of minimally invasive technologies in the treatment of gunshot blind penetrating wounds of the chest contributes to the reduction of operative trauma and shortens the time of operative treatment.Item Place and role of soft tissue ultrasound examination in tourniquet syndrome(2024) Lurin, I.; Khoroshun, Eduard; Nehoduiko, Volodymyr; Makarov, Vitalii; Tertyshnyi, S.; Tiron, O; Vastyanov, R.The purpose of the study was to demonstrate and analyze the possibilities of ultrasound diagnosis of tourniquet syndrome. All wounded were admitted at the Military Medical Clinical Center of the Northern Region of the Command of the Medical Forces of the Armed Forces of Ukraine from advanced surgical groups at different times from the wound with an existing tourniquet on the limb at different times after the tourniquet was placed (from 5 to 72 hours, on average 8.2±0.6). There were 32 male wounded. The average age of the wounded was 39.4±2.6 years. According to the location of the tourniquet, the wounded are distributed as follows: shoulder – 5 (15.6 %), thigh – 24 (75 %), leg – 3 (9.4 %) patients. All the wounded underwent an ultrasound and elastographic examinations. We used an average result after 12 measurements of each muscle group. When studying the data of muscle elastography against the background of the existing tourniquet, a significant difference in the elastography indicators of healthy superficial and deep muscles being under the tourniquet due to compression is noted. Elastography indicators in deep muscles are always higher than in superficial muscles. Changes in muscle elastography are localized by the location of the tourniquet. The use of ultrasound examination of soft tissues in tourniquet syndrome has an additional character. According to the data of elastography of soft tissues in the case of tourniquet syndrome, it is possible to determine the extent of soft tissue damage, which is important for determining the size of surgical interventionItem Management of gunshot injury to the abdominal aorta and inferior vena cava: a case report of a combat patient wounded in the Russo-Ukrainian war(2024) Lurin, Igor; Khoroshun, Eduard; Makarov, Vitalii; Negoduyko, Volodymyr; Shypilov, Sergiy; Bunin, Yurii; Gorobeiko, Maksym; Dinets, AndriiBackground Russo-Ukrainian war is associated with severe traumas, including injuries to the major vessels. Penetrating aortic injury remains one of the most difficult injuries; the mortality rate is 90–100% in case of gunshot wounds, associated with frequent lethal outcomes due to uncontrolled bleeding. Of the three main abdominal veins, the inferior vena cava (IVC) is the most frequently damaged, which is required quick and appropriate surgical decisions to be made. Little is known about the management of gunshot injuries to such major vessels as the aorta and IVC. It is also worth mentioning about the importance to share our practical experience from the ongoing war for better understanding and future considerations by war surgeons of the vascular trauma management. The aim of the study was to demonstrate the specific features of the diagnosis and management of a gunshot shrapnel blind penetrating wound to the abdomen with injury to the aortic bifurcation level and the infrarenal section of the inferior vena cava. Case presentation A 44-year-old male soldier of the Armed Forces of Ukraine received a gunshot injury to the abdomen from a mortars’ explosive shelling. The patient was evacuated to the Forward Surgical Team (Role 1) and received primary surgical treatment within one hour after the injury according to the “golden hour” principle. Then, evacuated was performed to the Role 3 hospital in Kharkiv. At the Role 3 hospital, the patient underwent secondlook surgery as well as damage control surgery. At revision, no active bleeding was observed, and the surgical pads (packed previously by the Forward Surgical Team) were removed. Further revision showed a metal projectile within the aortic wall at the level of aortic bifurcation and wall defects were also detected for inferior vena cava. This metal projectile was removed by using the multifunctional surgical magnetic tool followed by suturing of the aortic wall defect as well as defects of the inferior vena cava. Conclusions Application of Damage Control Surgery is a useful approach in the management of severe vascular injury as well as useful to stop abdominal contamination by intestinal contents. The application of a surgical magnetic tool for the searching and removal of ferromagnetic foreign bodies reduces operative trauma and reduces the time for identification of foreign bodies.Item Management of thoracoabdominal gunshot injuries by using minimally invasive surgery at role 2 deployed field hospitals in Ukraine(2024) Lurin, I.; Vorovskiy, О.; Makarov, Vitalii; Khoroshun, Eduard; Negoduyko, Volodymyr; Ryzhenko, А.; Chobey, S.; Gorobeiko, M.; Dinets, А.The Russia-Ukraine war is associated with critical and severe thoracoabdominal injuries. A more specific approach to treating patients with thoracoabdominal injury should also include minimally invasive technologies. It remains unclear about the utility of using video-assisted thoracoscopic surgery (VATS) and laparoscopy in patients with thoracoabdominal injury. The aim of this study was to investigate and evaluate the utility of video-assisted thoracoscopic surgery, laparoscopy as well as magnetic tool applications for the management of severe thoracoabdominal injury in combat patients injured in the ongoing war in Ukraine and treated in the Role 2 deployed hospital. Patients and methods 36 male combat patients thoracoabdominal injury were identified for the study during the first 100 days from February, 24 2022. These individuals were diagnosed with thoracoabdominal GSW in the Role 2 hospital (i.e. deployed military hospital) of the Armed Forces of Ukraine. Video-assisted thoracoscopy surgery (VATS) and laparoscopy with application of surgical magnetic tools were applied with regards to the damage control resuscitation and damage control surgery. Results In 10 (28%) patients, VATS was applied to remove the metal foreign body fragments. Both thoracotomy and laparotomy were performed in 20 (56%) hemodynamically unstable patients. Of these 20 patients, the suturing of the liver was performed in 8 (22%) patients, whereas peri-hepatic gauze packing in 12 (33%) patients. Massive injury to the liver and PI 2.0–3.0 were diagnosed in 2 (6%) patients. Lethal outcome was in 1 (2.8%) patient. Conclusions Thoracoabdominal gunshot injuries might be managed at Role 2 hospitals by using video-assisted thoracoscopy (VATS) and laparoscopy accompanied by surgical magnetic tools. Damage control surgery and damage control resuscitation must be applied for patients in critical and severe conditions. Keywords Thoracoabdominal injury, Chest war injury, Abdomen war injury, Video-assisted thoracoscopy, Minimally invasive surgery, Russia-Ukraine war, Russo-ukrainian war