Comparative analysis of surgical methods of intervention for varicocele in adolescents of the Voronezh region


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Abstract

Relevance. Varicocele is a varicose vein of the pampiniform plexus of the spermatic cord, the surgical treatment of which is widespread in pediatric surgery. In addition to the pathology of the reproductive function, the disease causes a violation of the physical and psycho-emotional well-being of the patient.
Progress in the surgical treatment of this disease does not stand still. Discussions and disputes continue in the scientific world about the feasibility and advantages of choosing one method or another, and there is no consensus in the leadership of a particular method.
Target. To compare the statistical data of surgical treatment of varicocele in adolescents using the Palomo technique and laparoscopic varicocelectomy. To study the data of relapses and complications of the disease after surgery, to identify the most effective technique of surgical treatment of varicocele in adolescents from the compared surgical techniques.
Materials and methods. Using the statistical data of the Voronezh region (on the basis of ODKB No. 2, 2016-2021) of surgical treatment of varicocele using the Palomo method and laparoscopic varicocelectomy, a qualitative and quantitative analysis of the effectiveness of surgical interventions performed on adolescents from 12 to 17 years old was carried out.
Results. The study included an assessment of the course and duration of operations, complications and relapses. Both operations have completely different techniques, and laparoscopic varicocelectomy requires the use of special equipment. The execution time varies and is often in direct correlation with the experience and skills of the surgeon, on average the Palomo technique takes 7-10 minutes, laparoscopic varicocelectomy - 10-15 minutes. Varicocele recurrence was observed only in 15% of adolescents operated on using the Palomo technique. Laparoscopy revealed a complete absence of complications and relapses, which emphasizes the preferential choice of this technique. In addition, patients who underwent laparoscopic varicocelectomy rehabilitated much faster than the other group.
Conclusion. Based on the studies, it was found that in the practice of pediatric surgery, the most effective and successful surgical treatment of varicocele is laparoscopic varicocelectomy.

Full Text

Relevance
Currently, in pediatric surgery, great attention is paid to the reproductive health of boys. A colossal number of pathological conditions and factors leading to them aggravates the possibility of further reproduction of offspring [1].
One of these pathologies is varicocele, which means varicose veins of the pampiniform plexus of the spermatic cord, which, in addition to impaired reproductive function, can affect the physical and psychological state of the patient [2].
Progress in the surgical treatment of this disease does not stand still. Discussions continue in the scientific world about the appropriateness of one method or another, and there is currently no consensus in the leadership of a specific method.
One of these methods of surgical treatment is the Palomo operation, discovered back in the middle of the 20th century, and laparoscopic varicocelectomy, which is a more modern method of treatment. However, the question of choosing a specific type of surgical intervention in children remains open, so the relevance of this work is beyond doubt.
Target
To compare the statistical data of surgical treatment of varicocele in adolescents using the Palomo technique and laparoscopic varicocelectomy. To study the data of relapses and complications of the disease after surgery, to identify the most effective technique of surgical treatment of varicocele in adolescents from the compared surgical techniques.
Materials and methods of research
The studies were carried out on the basis of the Regional Children's Clinical Hospital No. 2 of the city of Voronezh, with the direct participation of the Department of Pediatric Surgery of the Voronezh State Medical University named after I.I. N.N. Burdenko of the Ministry of Health of Russia.
We analyzed 100 boys, from January 2016 to November 2021, aged 12 to 17 years. All patients had left-sided varicocele. The diagnosis was confirmed by taking an anamnesis, clinical picture, manual examination, ultrasound of the scrotum with Doppler ultrasound [3]. Of these, 70 patients were operated on by the Palomo method, 30 - laparoscopic varicocelectomy. Operations were carried out as planned. The choice of the method of surgical treatment depended on the operating surgeon and the wishes of the parents. Before the operation, a conversation was held with the parents, during which the surgeon talked about a new technique - laparoscopic varicocelectomy, and also about the classic, long-established in the department of Palomo surgery techniques. As a result: 70 patients were operated on by Palomo, 30 by laparoscopic varicocelectomy [4].
The Palomo surgical treatment technique involves making an incision, about 4 cm in size, in a freer place - 3 cm above the projection of the internal opening of the inguinal canal, where the testicular vein, as a rule, already exits the plexus. An incision of the skin and subcutaneous adipose tissue is made parallel to the inguinal ligament, up to the aponeurosis of the external oblique muscle of the abdomen. Next, a dissection of the aponeurosis is performed, in accordance with the course of its fibers. By means of a palpation technique, the internal opening of the inguinal canal is determined. The fibers of the internal oblique and transverse muscles of the abdomen, located 2 cm above it, are stratified using a blunt method, and the peritoneum is shifted inwards. At the level of the inner ring of the inguinal canal, we find an enlarged testicular vein and testicular artery, which has a relatively small caliber, which are located on the parietal peritoneum. These vessels are tied up and intersected between two ligatures, in the area of ​​1-2 cm. Having controlled hemostasis, the wound is sutured tightly.
30 boys were operated on according to the method of laparoscopic varicocelectomy, using endoscopic equipment created by the research and production company "Krylo" in Voronezh.
Laparoscopic treatment of varicocele involves the injection of carbon dioxide into the abdominal cavity and the introduction of three trocars of appropriate sizes: the first - 10 mm - is installed in the umbilical ring, the second and third - 5 mm - on both sides of the umbilical ring. Video equipment is introduced into the lumen of the first trocar, providing visualization of the surgical field on the monitor. Subsequently, the varicose veins of the spermatic cord are isolated and ligated by means of clips. The next stages of the operation are suturing the sheath of the spermatic cord, removing the trocars and suturing the wounds.
The statistical data obtained during the study were processed using standard methods of variation statistics. Literature analysis was compared with clinical practice.
results
As a result of the research, it was found that in the practice of pediatric surgery, the most effective and successful surgical treatment of varicocele is laparoscopic varicocelectomy.
Discussion
1. The rehabilitation time for patients who underwent surgery according to the Palomo method was 7-8 days, and after laparoscopic surgery - 3-4 days.
2. After the operation, the pain syndrome was relieved with analgesics,this period was: after Palomo operation - 3-4 days, after laparoscopic varicocelectomy - 1-2 days.
3. Among the operated patients, recurrences of varicocele were observed only in 10 adolescents, whose surgical treatment was based on the Palomo technique, which is 15%. In the case of laparoscopic varicocelectomy, no relapses were observed.
4. On average, the operation time according to the Palomo method is 7-10 minutes, laparoscopic varicocelectomy - 10-15 minutes.
5. In 3 patients, as an accidental finding, an inguinal hernia was detected during laparoscopy, which was eliminated endoscopically (anamnestic, before the operation, there were no complaints from the patient).
Conclusion
Based on the studies, it was found that in the practice of pediatric surgery, the most effective and successful surgical treatment of varicocele is laparoscopic varicocelectomy.
Compared to the Palomo operation, this technique is superior to it:
1. the lowest number of complications, such as: dropsy of the testicle, elephantiasis of the scrotum, arising from damage to the lymphatic lines;
2. the absence of cosmetic defects, since the incisions are minimal and hidden in the natural folds of the skin;
3. fewer recurrences: during laparoscopy, we have the opportunity to ligate the vein directly at the exit from the internal inguinal ring (thus, the ligation is carried out before possible additional branches of small veins from the main trunk, which is not possible with Palomo surgery, since in this case dressing is done at a distance of 10-15 cm from the exit of the vein from the internal inguinal ring);
4. more favorable postoperative period (decrease in the timing of giving analgesics);
5. the shortest period of stay of the patient in the hospital.
6. The operation time depends on the acquired skill and can be reduced with increasing experience in the laparoscopic technique.

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About the authors

Nadezhda Bakaeva

FSBEI HE Voronezh State Medical University named after N.N. Burdenko

Author for correspondence.
Email: bakaeva.2000@bk.ru
ORCID iD: 0000-0001-9897-2649
SPIN-code: 7221-8025
Russian Federation, 394036, Russia, Voronezh, st. Student, 10

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