闭孔疝的临床特征与诊治分析：附10例报告

背景与目的 闭孔疝是临床较为罕见的腹外疝,老年女性由于盆底松弛等特点,易罹患此病。由于闭孔疝的疝环狭小缺乏弹性,患者多因嵌顿造成的急腹症就诊,一般在肠梗阻手术时发现。彻底缝闭半坚硬的疝环有一定困难,故疝易复发,再手术率高,使用修补材料可有效降低复发率。本文中笔者通过回顾收治的闭孔疝病例,分析总结闭孔疝的疾病特点及临床诊治方面经验体会,以期为该病的临床诊治提供参考。方法 回顾性总结2019年6月—2021年6月复旦大学附属华东医院和郑州大学附属郑州中心医院胃肠、疝和腹壁外科收治的10例闭孔疝患者的相关临床资料。结果 10例患者均为女性,年龄48 ~86岁,中位年龄（70.7±11.8）岁。所有患者术前接受腹盆腔CT扫描检查,发现2例左侧闭孔疝,8例右侧闭孔疝。术中证实嵌顿疝内容物中肠管8例,大网膜1例,腹膜外脂肪1例。全组病例中未有无张力修补的绝对禁忌患者,结合腹腔污染情况,2例使用生物补片,其余8例患者使用聚丙烯补片。6例完全在腔镜下完成,1例在腔镜下疝修补完成后观察肠管活力恢复欠佳中转开腹行肠切除,1例腔镜探查后中转开腹行肠切除及疝修补,2例患者腔镜不耐受直接行开腹探查并无张力修补术。手术时间50~120 min,平均75.5 min。术后1例患者死于围术期内科疾病合并症,其余患者顺利出院,住院时间3~28 d。术后6、12、18个月随访,均无复发及补片相关感染。结论 闭孔疝发病率低,起病隐匿容易发生嵌顿。腹盆腔CT扫描对此病诊断有较高价值。使用补片修补并恰当地固定有助于降低复发率。腹腔污染的情况下使用合成补片一期修补具有可行性,污染较重时生物补片更具优势。修补区域严重感染,应放弃使用补片修补。     

闭孔疝9例临床诊治分析

目的总结闭孔疝的发病原因、临床特点及诊治策略。方法回顾性分析2000年10月至2011年10月期间第三军医大学大坪医院野战外科研究所和解放军第三二四医院收治的9例闭孔疝患者的临床资料。结果 9例患者的临床表现均为急性机械性肠梗阻。术前均行腹盆腔CT检查,诊断为闭孔疝4例,嵌顿性腹股沟疝3例,嵌顿性股疝1例,原因不明的小肠机械性梗阻1例。急诊行剖腹探查术4例,行择期手术5例。所有患者均于术中确诊,闭孔疝位于左侧4例,右侧5例,嵌顿疝内容物均为回肠。均行闭孔疝修补术,其中8例行闭孔管口直接缝合,1例经腹行腹膜外间隙补片无张力修补。手术时间75~150 min,平均116 min。术后所有患者均治愈出院,住院时间7~26 d,平均13.8 d。术后均获访,随访时间为0.5~2.0年,中位数为1.6年。随访期间所有患者均无闭孔疝复发。结论消瘦老年女性出现病因不明的急性机械性肠梗阻时应考虑闭孔疝可能,腹盆腔CT检查有助于闭孔疝的术前诊断。早期手术是有效的治疗措施,术中应注意探查有无合并疝或对侧隐匿性闭孔疝,同时应避免损伤闭孔血管神经。     

闭孔疝早期诊断和外科治疗

目的探讨闭孔疝的早期诊断,以及开放式全腹膜外疝修补术在闭孔疝治疗中的应用。方法回顾性分析2000年1月至2013年6月,浙江大学医学院附属第二医院收治的4例闭孔疝患者的临床资料,分析、讨论其病例特点。结果4例闭孔疝患者,术前皆行CT检查,明确闭孔疝诊断。其中3例因肠梗阻急诊人院,并急诊行剖腹探查术,术中发现肠管坏死而行肠切除,单纯修补闭孔缺损;另1例患者,因左下肢痛入院,择期行开放式全腹膜外疝修补术,术后恢复良好。结论对于能早期诊断的闭孔疝患者,开放式全腹膜外疝修补术是一种安全、有效的手术方法。     

闭孔疝的诊断和治疗体会

目的对闭孔疝的病因、诊断、治疗和预后进行总结和讨论。 方法回顾性分析2013年1月至2018年1月,复旦大学附属华东医院普外科疝和腹壁外科治疗与培训中心收治的9例闭孔疝患者的相关临床资料。 结果8例患者术前行腹盆腔CT,7例提示闭孔疝形成伴小肠嵌顿,1例未提示闭孔疝。所有患者均行手术治疗,8例行急诊手术治疗,1例非手术治疗3 d后予手术治疗。其中5例行传统剖腹探查手术,余4例行经腹股沟切口腹膜外入路手术,并行腹腔探查。所有患者均在术中明确闭孔疝,病变位于左侧4例,右侧4例,双侧1例。回纳疝内容物后,行小肠修补3例,1例因嵌顿小肠缺血坏死予以切除。修补方式中,1例行直接缝合,8例行补片修补,其中4例植入生物补片,4例植入合成补片。手术时间40～120 min,平均77.8 min。术后8例患者治愈出院,1例因感染性休克死亡。住院时间4～19 d,平均10.7 d。出院患者术后均随访,随访时间3个月至3年,中位数1.5年,随访期间患者均无闭孔疝复发。 结论对有体型消瘦、多次生育史的老年女性患者,如出现不明原因的小肠梗阻症状,应考虑闭孔疝可能,进行积极的诊治,行腹盆腔多层螺旋CT检查可作为诊断的标准方法。一旦明确诊断,应尽早行积极的手术治疗,术中应注意有无合并疝和对侧隐匿疝的探查。为防止复发,若无禁忌证,使用补片修补较为恰当。     

闭孔疝5例临床分析

目的总结闭孔疝的临床诊断、治疗及手术经验。方法回顾性分析笔者所在医院2010年7月至2012年7月期间收治的5例闭孑L疝患者的临床资料。结果5例患者查体时4例具有明确的Howship—Romberg征,均未发现Hannington—Kiff征。4例术前行腹部立卧位X线平片提示肠梗阻,1例提示不全性肠梗阻。5例均行腹部及盆腔CT平扫,仅1例怀疑病变侧可疑疝囊影像。术前均未确诊,均行剖腹探查,术中证实患者均为单侧闭孔疝嵌顿,嵌顿物为小肠,且所嵌顿小肠均已坏死,遂行坏死肠段切除、闭孔内口处缝扎疝囊颈。术后并发肺部感染3例,肠瘘1例;痊愈4例,死亡1例,死亡原因为肺部感染及肠瘘。5例患者的平均住院时间为10．5d（5～14d）。存活的4例患者均随访12个月,无复发。结论闭孔疝的临床表现不典型,对于年老、体弱的患者,出现不明原因肠梗阻,且伴有明确的Howship—Romberg征时应该高度怀疑该病的可能。早期诊断和早期手术是提高闭孔疝患者生存率的有效手段。     

术前获得明确诊断的闭孔疝一例

患者女 ,77岁 ,因腹胀腹痛伴肛门停止排气排便 5d于2 0 0 4年 4月 9日入院 ,查体 :腹部稍膨隆 ,未见肠型、蠕动波 ,上腹压痛 ,反跳痛不明显 ,肠鸣音减弱 ,未闻及气过水音。腹平片示可疑肠梗阻 ;右中腹致密影 ,泌尿系结石可能 ?血常规 :WBC 1 8 3× 1 0 9 L ,中性 :77 6 %;入院诊断 :急性肠梗阻。急查腹部CT显示右侧闭孔区见疝出的小段肠管 (图 1 ) ;腹腔内小肠积气积液扩张 ,内见液平 ;腹腔积液。诊断右侧闭孔疝嵌顿。急诊行剖腹探查闭孔疝还纳、修补术 ,术中见回肠部分肠壁疝入右侧闭孔 ,呈不完全阻断 ,松解后血运恢复 ,右侧疝囊颈大小…     

闭孔疝8例临床分析

目的探讨闭孔疝的病因、临床表现、诊断和治疗.方法对1987～2001年8例闭孔疝的病史、临床表现、影像学检查及术中所见进行总结分析并复习相关文献.结果经剖腹手术证实为右侧闭孔疝的全部8例中仅3例术前明确诊断为闭孔疝,误诊为粘连性肠梗阻2例,阑尾周围的脓肿1例,盆腔脓肿1例,盆腔肿块1例.术中死亡1例,术后发生盆腔脓肿1例,其余7例术后无一发生肠瘘,追踪观察1～6年,7例均无复发.结论闭孔疝多发生于老年、体型瘦弱、有多胎生育史的女性.此病在临床上较为隐匿,疝块突出时不易在体表发现;临床上常表现为不明原因的肠梗阻,而Howship-Rowberg Sign(H-R征)为较有诊断意义的临床表现,盆腔CT扫描检查有助于术前确诊.对已确诊或疑为闭孔疝者应尽早剖腹手术,手术方法为松解嵌顿的肠管和修补闭孔管.     

闭孔疝九例诊治分析

目的探讨闭孔疝的临床特点,提高其诊断和治疗水平。方法对我院2004年1月至2008年12月收治的9例闭孔疝患者的临床资料、诊断和治疗作回顾性分析。结果术前确诊2例,确诊率22．22％,全部为单侧闭孔疝,疝内容物全部为小肠,4例发生肠坏死,行坏死肠管切除术,8例行补片修补闭孔,1例经腹外修补。8例治愈出院,1例术后死于吻合口瘘、感染性休克。8例随访至今无复发。结论闭孔疝发病率低,误诊率及病死率均高。多发于年老、消瘦、多孕多胎生育史的女性。Howship—Romberg征和CT检查有助于其诊断;对高度怀疑本病者果断剖腹探查,能降低本病病死率。     

嵌顿性闭孔疝8例临床诊治分析

我院1981年至2002年收治闭孔疝8例，仅3例术前得到确诊，手术死亡3例，值得引起临床重视，现报告如下。临床资料本组８例病人中男3例，女5例。除1例年龄为33岁外，其余7例为63～84岁，平均72岁。主要临床表现为腹痛、腹胀、呕吐，拟诊断为肠梗阻或不完全性肠梗阻入院。病史中述膝部疼痛３例，考虑为闭孔疝；2例既往有7～8年反复发作的、休息后可自行缓解的腹痛史；X线腹部平片均提示小肠梗阻或不全性肠梗阻，仅1例怀疑为闭孔疝所致；行CT检查1例提示闭孔疝。手术距发病时间1～14d，平均4.2d，术前均诊断为机械性肠梗阻，其中5例考虑为闭孔…     

闭孔疝临床诊治进展

闭孔疝占所有腹壁疝的0.05%~1.4%,常以急性肠梗阻为症状,因术前诊断困难,易延误治疗,导致术后死亡率高。根据发生的解剖途径或疝囊形成阶段闭孔疝分为3型,其临床表现以急性肠梗阻症状和闭孔神经受压为主。盆腔CT检查明显提高术前诊断率,可作为标准诊断方法。剖腹探查为闭孔疝的常规手术方式,尤其当病因未明时,经腹膜外入路手术和经腹腔镜入路手术在选择性患者中可采用。我们对闭孔疝解剖、临床表现、诊断和治疗4个方面进行综述,以提高临床对闭孔疝的认识和掌握正确诊治方法,减少发病率和死亡率。     

Obturator hernia: The plug technique

The obturator hernia is an uncommon condition, with clinical manifestations of pain and intestinal obstruction. The preoperative diagnosis is difficult. The treatment is always surgical. There are several repair techniques that have been described: sac ligation alone, direct suture repair, use of autologous tissue or prosthetic repair. We report a case of an obturator hernia that was treated by the use of a plug of Mersilene. Electronic Publication     

Totally extraperitoneal repair of obturator hernia

Background One distinct advantage of the 1aparoscopic inguinal hernia repair is the opportunity for clear visualization of the direct, indirect, femoral, and obturator spaces. The surgeon should routinely inspect all of them. Obturator hernia accounts for as few as 0.073% of all hernias, but the mortality rate when it is acutely incarcerated can be as high as 70%. There is only one previous report of a totally extraperitoneal repair for obturator hernia. Five such procedures are described.Methods A retrospective review was undertaken to evaluate one surgeons experience with the totally extraperitoneal repair of obturator hernia over a 4-year period. Four of five cases were completed, and the remaining case was converted to an open procedure.Results Three hernias were on the right side, and two on the left. One patient presented with an acutely incarcerated obturator hernia and underwent a small bowel resection for strangulated bowel within the obturator space. The other four hernias were found during totally extraperitoneal repair, and the patients were discharged home several hours later. There was one complication, a midline wound infection in the patient with strangulated bowel. It was treated with dressing changes. There were no other complications, and during a follow-up period of 3 to 48 months, there was no recurrence.Conclusions The laparoscopic totally extraperitoneal approach allows inspection and repair of direct, indirect, femoral, and obturator hernias. This study found this procedure to be feasible, safe, and highly effective for the diagnosis and repair of obturator hernias.     

择期闭孔疝的临床特征分析及治疗方法探讨

目的分析择期闭孔疝的临床特征并探讨其治疗方法。 方法回顾性分析2013年8月至2018年8月,四川大学华西医院收治的11例择期行无张力闭孔疝修补患者的临床资料。分析其临床特征,探讨手术治疗方法,记录术后并发症发生及复发情况。 结果11例患者均为女性,确诊为闭孔疝,病程2个月至14年,平均体质量指数（17.62±2.16）kg/m²,平均年龄（76.63±9.15）岁,合并心肺疾病4例。均有反复下腹痛。术前诊断为双侧闭孔疝4例;术前诊断为单侧闭孔疝,术中探查后证实为双侧闭孔疝6例;1例术前及术中证实为单侧,仅行右侧闭孔疝无张力修补,半年后出现新发左侧闭孔疝。所有患者术后随访无闭孔疝复发,无再腹痛,无肠梗阻及腹股沟区慢性疼痛,无大腿及膝部放射性疼痛。所有患者术后切口均无感染。 结论择期闭孔疝常见于高龄消瘦女性,病程长,往往并发心肺基础疾病,临床表现反复下腹疼痛,通常不伴肠梗阻,腹部CT对诊断有重要价值。临床上误诊率高,通常是双侧并发,采用无张力修补复发率低,并发症少,可供借鉴。     

Obturator hernia: A case report and review of the literature

INTRODUCTIONAn obturator hernia is a rare condition but is associated with the highest mortality of all abdominal wall hernias. Early surgical intervention is often hindered by clinical and radiological diagnostic difficulty. The following case report highlights these diagnostic difficulties, and reviews the current literature on management of such cases.PRESENTATION OF CASEWe present the case of an 86-year-old lady who presented with intermittent small bowel obstruction, clear hernial orifices, and right medial thigh pain. Pre-operative CT imaging was suggestive of an obstructed right femoral hernia. However, intra-operatively the femoral canal was clear and an obstructed hernia was found passing through the obturator foramen lying between the pectineus and obturator muscles in the obturator canal.DISCUSSIONObturator hernias are notorious for diagnostic difficulty. Patients often present with intermittent bowel obstruction symptoms due to a high proportion exhibiting Richter's herniation of the bowel. Hernial sacs can irritate the obturator nerve within the canal, manifesting as medial thigh pain, and often no hernial masses can be detected on clinical examination. Increasing speed of diagnosis through early CT imaging has been shown to reduce the morbidity and mortality associated with obturator hernias. However, over-reliance on CT findings should be cautioned, as imaging and operative findings may not always correlate.CONCLUSIONA high suspicion for obturator hernia should be maintained when assessing a patient presenting with bowel obstruction particularly where intermittent symptoms or medial thigh pain are present. Rapid clinical and appropriate radiological assessment, followed by early surgery is critical to successful treatment.     

闭孔疝的临床诊断与治疗分析

目的 探讨闭孔疝的临床特征及诊治方法.方法 回顾性分析南京医科大学附属南京医院（南京市第一医院）2003年6月至2012年11月收治并经手术证实的7例闭孔疝患者的临床资料.结果 7例患者均行疝修补术,其中因肠管坏死行肠切除术5例,行嵌顿小肠松解复位2例.术后出现肺部感染3例,切口感染2例,痊愈出院5例,死亡2例.结论闭孔疝术前误诊、漏诊率极高,对老年体弱、有多胎生育史伴腹痛、呕吐等肠梗阻表现的患者,需高度警惕闭孔疝的可能,CT检查有利于闭孔疝的早期确诊,及时手术干预对减少该疾病的并发症及致死率是十分必要的.     

Obturator Hernia: Laparoscopic Diagnosis and Repair

Objective:

Review of international literature reveals eight reported cases of laparoscopic obturator hernia repair. Non-specific signs and symptoms make the diagnosis of an obturator hernia difficult. Laparoscopic intervention provides a minimally invasive method to simultaneously diagnose and repair these hernias.

Methods and Procedures:

A 35 year old woman presented with lower abdominal pain, vaginal bleeding, and dyspareunia. During gynecological diagnostic laparoscopy, a pelvic floor hernia was suspected, and a general surgical evaluation was sought. At a subsequent laparoscopy, the diagnosis of a left direct inguinal and a right obturator hernia was made. Both were repaired laparoscopically with polypropylene mesh.

Results:

At follow-up at one and six weeks postoperatively, the patient''s complaints of pain had completely resolved.

Conclusion:

The diagnosis of obturator hernia is problematic. The usual presenting signs and symptoms are non-specific. Without conclusive historical or physical findings, laparoscopy is an excellent method for diagnosing obturator hernia. This entity, once diagnosed laparoscopically, can be repaired simultaneously via laparoscopic mesh technique.     

闭孔疝的临床诊断与外科治疗

目的探讨闭孔疝的临床特点、诊断方法及外科治疗经验。 方法回顾性分析2014年1月至2017年8月,扬州大学附属医院收治的6例闭孔疝患者的临床资料,分析病例特点。 结果6例患者均痊愈出院。平均手术时间（77.5±29.2）min,术中平均出血量（42.5±30.9）ml,平均住院时间（11.5±2.4）d。1例术后切口脂肪液化,1例术后出现肺部感染,对症处理后均愈合。 结论闭孔疝是临床少见疾病,临床误诊、漏诊率极高,CT检查可早期明确诊断。