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REKONSTRUKCIJA DOJKE by Prof Dr Milan Visnjic

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Tumori dojke su danas nažalost cesto oboljenje i incidenca ove bolesti je u permanentnom porastu. Do pre desetak godina, na našim prostorima, jedina hiruška terapija zloćudnih tumora dojke je bila amputacija dojke.

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Ovakva operacija sigurno je predstavljala jednu radikalnu intervenciju ali je zato praćena velikim brojem problema kao sto su emocionalni bol, psihološki problemi, gubitak seksualnog intereso- vanja, gubitak ženstvenosti, problemi sa odevanjem itd.

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Napredkom hirurgije, posebno rekonstruktivne hirurgije razvile su se nove hirurške tehnike koje pored onkoloskih principa sve vise vode računa o kvalitetu života. Tako se sada često rade tzv. postedne operacije dojke, kada se odstranjuje tumorsko tkivo i deo zdravog tkiva oko tumora a ne amputira ćela dojka. No ova operacija nije indikovana kod svih pacijntkinja i kod tih bolesnica se radi rekonstrukcija dojke nakon operacije - amputacije dojke.

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Rekonstrukcija dojke se može raditi odmah nakon amputacije - neposredna rekonstrukciju u istom operativnom aktu i odložena rekonstrukcija nakon završene onkološke terapije. Za rekonstrukciju dojke se danas koriste implantati - proteze različitog oblika i veličine, tkivo pacijentkinje i kombinacija proteze i tkiva pacijentkinje.

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Izuzetno važno je naglasiti da rekonstruisana dojka nikako ne utiče negativno na tok bolesti, čak se može reci obrnuto jer ta pacijentkinja sa rekonstruisanom dojkom stiče veću sigurnost i pouzdanje a time i stvara uslove za uspesnije lecenje.

Vreme kada treba raditi sekundarnu rekonstrukciju dojke nije limitirano i može se raditi i posle nekoliko godina nakon amputacije. Nekada je potrebno korigovati i drugu zdravu dojku da bi dojke bile simetrične.

Operacije, amputacije dojke i nepostredne rekonstrukcije, kao i rekonstrukcije dojki kod pacijentkinja kod kojih je već uradjena amputacija su rutinske tj svakodnevne u mom kliničkom radu.
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Takodje u toku rada sa pacijentkinjama, primetio sam veliko zadovoljstvo i sreću kod pacijentkinja, nakon rekonstrukcije dojki, posebno kod onih koje su živele po nekoliko godina sa amputiranom dojkom.

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PRVI OPIS – TANSINI 1897 g.
(REKONSTRUKCIJA DEFEKTA GR. KOŠA – MIŠIĆNI REŽANJ)
HUTCHINS 1936 g.
(PREVENCIJA I LEČENJE LIMFEDEMA POSLE MASTEKTOMIJE – MIŠIĆNI REŽANJ)
MC CRAW 1970 g.
(IDEJA MIOKUTANOG REŽNJA )
OLIVARI 1976 g.
MUHLBAUER i OLBRISCH 1977 g.
(REKONSTRUKCIJA DOJKE MIOKUTANIM LATISSIMUS REŽNJEM)

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tekst i fotografije by:
Prof Dr sci med Milan Visnjic, Specijalista opste i plasticne hirurgije, Profesor plasticne hirurgije ,Dekan Med. Fakulteta u Nisu. Jedan od prvih hirurga u Evropi koji je jos davne 1984 uradio primarnu rekonstrukciju dojke. Stalni konsultant i clan naseg tima.

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Editor: Dr med Bojan Ciric
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REKONSTRUKCIJA DOJKE

Cilj: Rekonstrukcija, odnosno nadoknađivanje nepostojećeg tkiva dojke nakon amputacije ili kod urođeno nerazvijene dojke.

Operativna tehnika: Amputirana dojka može se rekonstruisati na dva načina, uz pomoć silikonskog implantata ili sopstvenim tkivom.

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Primena implantata je lakši i jednostavniji način, ali pošto skoro uvek postoji nedostatak kože, ona se najpre mora proširiti ekspanzijom u prvom aktu, primenom takozvanog tkivnog ekspandera, ili se odmah ubacuje Becker-ova proteza-ekspander koja trajno ostaje.
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U narednih nekoliko nedelja pacijentkinja dolazi na 5-7 dana kada se kroz posebno mesto na koži ubacuju manje količine fiziološkog rastvora, tako da dolazi do postepenog punjenja implantata do željenog volumena.
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Primena sopstvenog tkiva sa trbuha ili leđa takođe je veoma zastupljena u rekonstrukciji dojke.
Savremeno lečenje maligne bolesti dojke danas podrazumeva i primarnu rekonstrukciju kada se bolesnici odmah nakon amputacije izvrši nadoknada izgubljene dojke.
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Nekoliko meseci nakon operacije može se izvršiti rekonstrukcija bradavice sa kožom vaginalnih usana, sa delom bradavice zdrave dojke ili tetovažom, kao i eventualna dodatna korekcija u smislu postizanja simetrije sa drugom dojkom (smanjivanje i podizanje druge dojke).
Trajanje procedure i anestezija: Obe operativne tehnike izvode se u opštoj anesteziji, prva traje oko 1-1.5 čas, a druga znatno duže.
Oporavak: Veoma kratak kod ubacivanja proteze-ekspandera, osim što treba dolaziti nekoliko puta zbog postepenog povećavanja volumena. Kod rekonstrukcije sopstvenim tkivom, odnosno kožno-mišićnim režnjevima, oporavak je znatno duži, jer se radi o velikom operativnom zahvatu.
Retke komplikacije: Otok, pojava seroma koji se produženo drenira, blaga asimetrija dojki, a kod rekonstrukcije tkivom sa stomaka retka pojava trbušne kile.
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Hipospadija

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Definicija
Hipospadija je urođeni poremećaj razvoja muškog polno-mokraćnog sistema kod koje se spoljni otvor mokraćne cijevi ne nalazi na vrhu penisa. Taj se otvor može nalaziti bilo gde od baze do površine penisa. Često je prisutna i zakrivljenost penisa te postoji povezanost s drugim anomalijama mokraćnog sistema i interseksualnošću.
Mokraćna cev
Mokraćna cev (urethra) deo je mokraćno-polnog sistema muškarca koja se normalno otvara na vrhu penisa, a služi za odvođenje mokraće i semena.
Latinski naziv: hypospadia
Engleski naziv: hypospadia
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Učestalost
Hipospadija je najčšća urodjena anomalija mokraćne cevi i javlja se kod 1:300 - 1: 500 muške novorođenčadi.
Uzrok
Hipospadija nastaje kad izostane spajanje dvaju mokraćnih nabora u embrionalnom životu. Bolest se recesivno nasljeđuje s preskakanjem nekih generacija.
Podela
Na prednjoj strani penisa često se nalazi vezivna chorda. Kod jako razvijene korde otvor mokraćne cevi može biti jako blizu glavića penisa, ali se nakon operativnog odstranjenja korde spušta nisko dole na penis. Opisano je 11 vrsta hipospadija (Cembel). Prema m