Alexey Kolygin

Background: Spleen-preserving (SP) distal pancreatectomy (DP) with splenic vessels resection (SVR) (Warsaw procedure, WP) is an option for the treatment of tumors with low malignant potential. The reverse blood flow through the short gastric arteries (SGA) explains the preservation of the spleen after SVR, but leaves the source of the blood supply to the SGAs hidden. The types of blood supply to the spleen after WP and their incidence have not been previously described, nor has the significance of these types for locally advanced pancreatic head cancer (LAPHC) surgery been determined. Aim: To determine the main types of spleen blood supply after WP, and to assess the feasibility and safety of splenic artery (SA) rotation for the organ-preserving surgery of LAPHC. Methods: Retrospective analyses of demographic and perioperative data, including CT scans, overall (OS) and progression-free (PFS) survival after 71 SP DP SVR and 41 SP SVR pancreaticoduodenectomies (PD) and total pancreatectomies (TP) for LAPHC (2007–2025). Results: In 134 SP procedures, SA was resected in 115 cases (71DP, 9 TP, 3 central, and 32 PD). Indications for surgery were MCN (41), IPMN (14), CSA (3), NEN (25), SPPN (8), PHDAC (40), sarcoma (1), autoimmune (1), and calculous chronic pancreatitis (1). There were no deaths or ischemia-related splenectomies. Morbidity—31% (n23); Dindo–Clavien (D-C) > 3b-2.8%; POPF-grade B-n7 (10.6%); splenic infarctions on CT after SVR-n18 (23%), one symptomatic. CT revealed three types of arterial blood supply to the spleen after SPDP SVR: left gastric artery (LGA) type (n50, 70, 5%), gastro-epyploic arcade (GEA) type (n9, 12, 5%), and an intermediate type (n12, 17%). Spleen- and pancreas tail-preserving SVR pancreatectomies for LAPHC (n41) were accompanied by rotation of the SA to substitute resected SMA (n19) and CHA (n15) for 26 Whipples and 8TPs. There were no ischemic complications. D-C > 3–19.5%. Median OS and PFS for PDAC were 35 and 21 months for 29.5 months median follow-up. Conclusions: Despite the preservation of blood flow through all potential sources of splenic blood supply following resection of the splenic artery, the main collaterals supplying the spleen after WP are LGA branches (~90%). This knowledge, with strict adherence to the developed criteria, allows for the safe preservation of the spleen, pancreatic tail, and stomach during pancreatectomies with SA resection, including its rotation for the substitution of the SMA and CHA in LAPHC.

Background. Spleen-preserving (SP) distal pancreatectomy (DP) with splenic vessels resection (SVR) (Warsaw procedure, WP) is an option for treatment of tumors with low-malignant potential. The reverse blood flow through the short gastric arteries (SGA) explains the preservation of the spleen after SVR, but leaves the source of blood supply to the SGAs hidden. The types of blood supply to the spleen after WP and their incidence have not been previously described, nor has the significance of these types for locally advanced pancreatic head cancers (LAPHC) surgery. Aim. To determine the main types of the spleen blood supply after WP, and to assess feasibility and safety of splenic artery (SA) rotation for the organ-preserving surgery of LAPHC. Methods. Retrospective analysis of demographic and perioperative data, including CT scans analysis, overall (OS) and progression-free (PFS) survival after 71 SP DP SVR and 41 SP SVR pancreaticoduodenectomies (PD) and total pancreatectomies (TP) for LAPHC (2007-2025). Results: In 134 SP procedures, SA was resected in 115 cases (71DP, 9 TP, 3 central, 32 PD). Indications for surgery were MCN (41), IPMN (14), CSA(3), NEN(25), SPPN(8), PHDAC(40), sarcoma(1), autoimmune(1), and calculous chronic pancreatitis(1). There were no deaths and ischemia-related splenectomies. Morbidity-31%(n23), Dindo-Clavien (D-C)> 3b-2,8%, POPF grade B-n7(10.6%), splenic infarctions on CT after SVR-n18(23%), with one symptomatic. CT revealed three types of arterial blood supply to the spleen after SPDPSVR: left gastric artery(LGA) type (n50,70,5%), gastro-epyploic arcade (GEA) type(n9,12,5%), and an intermediate type(n12,17%). Spleen- and pancreas tail-preserving SVR pancreatectomies for LAPHC (n41) were accompanied by rotation of the SA to substitute resected SMA(n19) and CHA(n15) for 26 Whipples and 8TPs. There were no ischemic complications. D-C >3-19.5%. Median OS and PFS for PDAC was 35 and 21 months for 29.5 months median follow-up. Conclusion. The main collaterals supplying the spleen after WP are LGA branches (~ 90%). This knowledge with strict adherence to the developed criteria safely preserves the spleen, pancreatic tail and stomach during pancreatectomies with SA resection, including its rotation for substitution of the SMA and CHA in LAPHC.

The “vein definition” for locally advanced pancreatic ductal adenocarcinoma (LA PDAC) assumes portal-to-superior mesenteric vein (PV/SMV) unreconstructability due to tumor involvement or occlusion. Radical pancreatectomies with SMV resection without PV/SMV reconstruction are scarcely discussed in the literature. Retrospective analysis of 19 radical pancreatectomies for “low” LA PDAC with SMV and all its tributaries resection without PV/SMV reconstruction has shown zero mortality; overall morbidity—56%; Dindo–Clavien—3–10.5%; R0—rate—82%; mean operative procedure time—355 ± 154 min; mean blood loss—330 ± 170 mL; delayed gastric emptying—25%; and clinically relevant postoperative pancreatic fistula—8%. In three cases, surgery was associated with superior mesenteric (n2) and common hepatic artery (n1) resection. Surgery was completed without vein reconstruction (n13) and with inferior mesenteric-to-splenic anastomosis (n6). There were no cases of liver, gastric, or intestinal ischemia. A specific complication of the SMV resection without reconstruction was 2–3 days-long intestinal edema (48%). Median overall survival was 25 months, and median progression-free survival was 18 months. All the relapses, except two, were distant. The possibility of successful SMV resection without PV/SMV reconstruction can be predicted before surgery by CT-based reconstructions. The mandatory anatomical conditions for the procedure were as follows: (1) preserved SMV-SV confluence; (2) occluded SMV for any reason (tumor or thrombus); (3) well-developed inferior mesenteric vein collaterals with dilated intestinal veins; (4) no right-sided vein collaterals; and (5) no varices in the upper abdomen. Conclusion: “Low” LA PDACs involving SMV with all its tributaries can be radically and safely resected in highly and specifically selected cases without PV/SMV reconstruction with an acceptable survival rate.

Introduction. “Vein definition” for locally advanced pancreatic ductal adenocarcinoma (LA PDAC) assumes portal-to-superior mesenteric vein (PV/SMV) unreconstructability due to tumor involvement or occlusion. Radical pancreatectomies with SMV resection without PV/SMV reconstruction are scarcely discussed in the literature. Retrospective analysis of 19 radical pancreatectomies for “low” LA PDAC with SMV and all its tributaries resection without PV/SMV reconstruction has shown zero mortality, overall morbidity – 56%, Dindo-Clavien – 3-10,5%, R0- rate – 82%, mean operative procedure time – 355±154 min, mean blood loss – 330±170 ml, delayed gastric emptying– 25%, clinically relevant postoperative pancreatic fistula – 8%. In three cases surgery was associated with superior mesenteric (n2) and common hepatic artery (n1) resection. Surgery was completed without vein reconstruction (n13) and with inferior mesenteric-to-splenic anastomosis (n6). There were no cases of liver, gastric, or intestinal ischemia. A specific complication of the SMV resection without reconstruction was 2-3 days-long intestinal edema (48%). Median overall survival – 25 months, median progression-free survival – 18 months. All the relapses, except two, were distant. The possibility of successful SMV resection without PV/SMV reconstruction can be predicted before surgery by CT-based reconstructions. The mandatory anatomical conditions for the procedure were: 1) preserved SMV-SV confluence; 2) occluded SMV for any reason (tumor or thrombus); 3) well-developed inferior mesenteric vein collaterals with dilated intestinal veins; 4) no right-sided vein collaterals, and 5) no varices in the upper abdomen. Conclusion: “Low” LA PDACs involving SMV with all its tributaries can be radically and safely resected in highly and specifically selected cases without PV/SMV reconstruction with an acceptable survival rate.

The article presents a rare clinical case both in the practice of a gynecologist and a surgeon. The cyst of the Nuck canal can be a cyst of a round ligament, localized in the inguinal canal. It is manifested by protrusion of the formation in the direction to the labia majora, clinically imitating an inguinal hernia.

OBJECTIVE To review the first robotic hernia repairs performed at the Ilyinsky Hospital, evolution of this technology, learning curve and early outcomes. MATERIAL AND METHODS There were 17 procedures at the Ilyinskaya Hospital between 2021 and 2023 (13 men and 4 women). Mean age was 60 years, body mass index 28 kg/m². ASA grade 1 was observed in 1 patient, grade 2 — 14 ones, grade 3 — 2 patients. Ventral, inguinal and umbilical hernias were diagnosed in 7, 8 and 2 cases, respectively. Ventral hernias required IPOM+ procedure in 3 cases, eTEP-RS procedure in 2 cases and eTEP-RS-TAR procedure in 2 cases. Patients with inguinal hernia underwent transabdominal preperitoneal hernia repair. In case of umbilical hernia, TARUP procedure was performed in 1 case and vTAPP procedure in 1 case. RESULTS Mean surgery time was 2 hours 38 min (min 1 hour 35 min, max 10 hours 11 min). There was one intraoperative complication (bleeding from epigastric artery). The follow-up period ranged from 3 months to 3 years. There were no recurrent hernias. Postoperative complications were noted in 2 cases. One patient was diagnosed with epididymitis after TAPP, 1 patient — with seroma after eTEP-RS procedure. All complications were relieved by conservative treatment. Bleeding from a. epigastrica inferior was diagnosed after removal of the trocar at the end of surgery. This event required suturing. CONCLUSION Robotic hernia repair appears to be technically feasible and safe. This approach provides favorable results regarding quality of life and recurrence rate.

Objective. To demonstrate safe introduction of a new technology (Da Vinci robotic system) into laparoscopic bariatric practice. Material and methods. We analyzed treatment outcomes in patients with morbid obesity who underwent robot-assisted sleeve gastrectomy between 2020 and 2023. The same team of surgeons performed all operations. Evolution of technique and preparation of the operating theatre were recorded. Demographic data of patients, surgery time (docking and total surgery time), simultaneity of intervention, intraoperative and postoperative complications, as well as weight loss after 6 months were retrospectively analyzed. Results. There were 15 robot-assisted sleeve gastrectomies between 2020 and 2023. Of these, 14 patients underwent surgery without complications. One patient was diagnosed with portal vein thrombosis that required anticoagulation. Median surgery time 194 [173.5; 241] min, period between incision and docking — 35 [30; 36] min. The length of hospital-stay was 3 days. The median weight loss after 6 months was 37.5% [29.5; 51.2]. Conclusion. This study demonstrates safe introduction of a new technology to prepare the bariatric team for more complex surgical interventions in the future.

Massive gastrointestinal bleeding (GIB) is a rare complication of Crohn’s disease (CD). For the recent decades a number of medical and surgical methods to control the GIB have been introduced. However, the unified algorithm and approach to this subset of patients is still lacking, mostly due to the absence of adequately powered and wellconducted RCTs. Determining the optimal treatment approach to inflammatory bowel disease (IBD) in patients who develop a GIB is still a valid research target.