内镜组织结构分离技术治疗腹壁缺损

如何有效进行复杂腹壁缺损的修复与重建一直是困扰腹壁外科医师的一个难题,传统的组织结构分离技术虽然能够通过自体组织推进实现腹壁缺损的功能性修复,但其广泛皮瓣分离所导致的切口并发症是其重要不足。而内镜组织结构分离技术由于可保护腹壁穿支血管,因此具有并发症少、恢复快、术后住院时间短的优点。作为一种自体组织修复的重要手段,内镜组织结构分离技术必将在腹壁缺损修复重建中发挥越来越重要的作用。     

The external oblique muscle flap technique for the reconstruction of abdominal wall defects

PurposeSeveral modifications to the anterior component separation technique (ACST) have been reported to facilitate the closure of abdominal wall defects. In this study, the external oblique (EO) muscle flap for modified ACST during major abdominal wall defect reconstructions has been described.MethodsA retrospective review of consecutive patients undergoing modified ACST was conducted. The clinical data were collected and retrospectively analyzed.ResultsAmong the 36 patients admitted to our hospital from December 2014 to December 2020, 9 cases had rectus abdominis tumors, 1 case had rectus abdominis trauma, and 26 cases had incisional hernias. The average age was 61.17 ± 13.76 years, and the mean BMI was 24.25 ± 3.18 kg/m². The average width of the defect was 14.33 ± 2.90 cm. Unilateral EO muscle flap technique was used to reconstruct the abdominal wall. 3 cases of surgical site infection (8.3%), 4 cases of grade III or IV seroma (11.1%) and 2 cases of intestinal obstruction (5.5%)were reported postoperatively. Ischemic necrosis of the abdominal EO muscle flap, incision dehiscence, intestinal fistula, or other complications were not observed. 1 case of incisional hernia recurrence (2.8%) was reported. Recurrence of tumors or abdominal wall bulging were not noted during the follow-up period of 32.53 ± 14.21 months.ConclutionsThe EO muscle flap technique is associated with low postoperative morbidity and recurrence rate, which approves it a reliable technique for selected groups of patients. Further research are needed to confirm the effectiveness of this technique.     

Congenital anterior abdominal wall defects

Anterior abdominal wall defects are a common cause of morbidity and even mortality. These include gastroschisis, usually an isolated defect, and exomphalos, a more fundamental failure of abdominal wall formation often seen in association with chromosomal and other systemic anomalies. The worldwide incidence of gastroschisis has risen inexorably over the past 30 years while the incidence of exomphalos, at least at the time of birth, has been relatively static. This article provides an overview of the key aspects of antenatal, perinatal and postnatal management, highlighting areas of controversy where further study is required.     

Congenital anterior abdominal wall defects

Anterior abdominal wall defects are a common cause of morbidity and even mortality. These include gastroschisis, usually an isolated defect, and exomphalos, a more fundamental failure of abdominal wall formation often seen in association with chromosomal and other systemic anomalies. The worldwide incidence of gastroschisis has risen inexorably over the past 30 years while the incidence of exomphalos, at least at the time of birth, has been relatively static. This article provides an overview of the key aspects of antenatal, perinatal and postnatal management, highlighting areas of controversy where further study is required.     

Challenging abdominal wall defects.

BACKGROUND: We propose a simple algorithm for management of patients with challenging abdominal fascial defects. METHODS: The medical records of 64 patients with complicated abdominal wall defects representing a consecutive series by a single surgeon over a 4-year period were reviewed. Group I patients presented with massive fascial defects and closed wounds. They were reconstructed with autogenous tissue using either the separation of parts (SOP) procedure or free tensor fascia lata (TFL) grafts. Group 2 patients had fascial defects with open wounds. Wound closure was first accomplished with either STSG or primary skin closure over viscera. These patients, now "converted" into patients with closed wounds, were reconstructed months later as in group 1. RESULTS: Average defect size was 320 cm2. Wound closure was achieved in one procedure in all patients with open wounds. Time to discharge after this procedure averaged 9 days. The only morbidity of wound closure was skin graft donor site pain. Average time from temporary staged closure with skin grafts to definitive closure with autogenous tissue was 5 months. Repair of closed fascial defects with autogenous tissue was performed in 51 patients. Average time to discharge after autogenous tissue repair was 6.6 days. Recurrence of hernia was noted in 2 (3.9%) patients with an average follow-up of 24 months. CONCLUSIONS: Treatment of challenging abdominal wall defects can be accomplished simply and safely utilizing the above surgical algorithm. Open wounds are converted into closed wounds and fascial defects are repaired with autogenous tissue. This treatment plan has proved to be effective in a wide variety of situations.     

Reconstruction of large abdominal wall defects

Reconstruction of a large abdominal defect is a technically demanding procedure. A single flap is sometimes insufficient for cover. Compound procedures play an important role in solving this problem. The case of a 35-year-old man with a large abdominal hernia as a result of a traumatic defect on the right abdomen, previously covered by a skin graft, is presented. The reconstructive method was initially expansion of posterior and upper parts of the defect and also of the tensor fascia lata in situ and then deepithelization of the previous skin graft over the intestinal serosa. The defect was covered by Prolene mesh, the upper and dorsal expanded skin was approximated, and an expanded tensor fascia lata flap was transposed to complete the cover. During follow-up examinations, there were no complications such as infection or recurrence of the hernia. Received: 29 January 1999 / Accepted: 14 June 1999     

Congenital abdominal wall defects: gastroschisis and omphalocele

From this recent review of the literature and a personal experience with 125 cases of abdominal wall defects over the last nine years, the following conclusions have been reached regarding current concepts of treatment. Early management is keyed to the prevention of complications related to hypothermia, hypovolemia, aspiration and infection. Gastric decompression, transportation in a plastic bowel bag, vigorous fluid resuscitation and institution of broad spectrum antibiotics will usually reduce the risk related to these preoperative problems. Considering the fact that synthetic materials are associated with an increased incidence of infection, morbidity and mortality related to sepsis, we believe that primary abdominal wall repair is the procedure of choice when feasible. Manual stretching of abdominal wall facilitates this maneuver. In cases of visceral abdominal disproportion, however, attempting to accomplish “too tight” a closure is probably a poor decision. In these instances, one should reduce as much of the viscera as possible without compromising the patient and at this point, a Silastic or teflon prosthesis can be applied. Reduction can be completed in a few days so that the prosthetic material can be removed prior to an infection and a fascial repair accomplished. Gastrostomy tubes are not routinely needed in the uncomplicated patient with gastroschisis. However, gastrostomy has proven an extremely useful adjunct in cases of gastroschisis complicated by bowel atresia, perforation and enterocutaneous fistula. While total parenteral nutrition (TPN) offers complete nutrition for the patient, septic, metabolic and mechanical problems preclude its routine use in the uncomplicated case. For infants with primary repair or prompt silo reduction, peripheral parenteral nutrition with the addition of lipids for relatively short term nutrition support (e.g., 25–30 days) is advisable to avoid the potential complications of TPN. In complicated cases, (e.g., atresia, perforation, enterocutaneous fistula) where prolonged intestinal dysfunction is anticipated or in those instances where venous access becomes a significant problem, TPN should be instituted. In these latter cases, the caloric expenditure and demand are in excess of that in the usual uncomplicated situation and TPN is a better source of calories over a long-term course (>30 days). The elective routine use of ventilators to ensure a primary closure in every instance seems unwarranted. Short term ventilator support, however, has been a welcomed adjunct to postoperative care, and certainly has improved the outlook for these infants. Although the current survival rate for gastroschisis has improved dramatically to greater than 90%, even some of the deaths (of the 10%) are preventable. Most infants with gastroschisis should survive and have normal growth and development and life expectancy.In cases of omphalocele with an intact sac, the pediatric surgeon has a number of options available in the therapeutic armamentarium. Nonoperative therapy is appropriate in patients with severe cardiac anomalies and chromosomal syndromes (e.g. trisomy syndromes) who are not expected to survive. In addition, this method of treatment is useful in selected patients whose survival is anticipated but who have other serious complications that may be life threatening—such as the premature infant with respiratory distress syndrome or the patient with a small epigastric omphalocele in heart failure due to correctable intracardiac defects. For the vast majority of infants with small or moderate sized omphaloceles, resection of the sac, and primary abdominal wall closure is feasible and is the operative procedure of choice. Careful assessment of these patients for the presence of associated congenital anomalies is essential and a thorough system review is required in the early neonatal period (in some instances prior to surgical therapy). In patients with a large defect, partial reduction of the viscera and application of a prosthetic silo has been associated with reasonably good results, especially if the reduction of the viscera progresses promptly and the Silastic sheeting is removed relatively early. We have employed dacron reinforced Silastic as the prosthesis (as advocated by Allen and Wrenn)⁴ since this method is somewhat simpler than Schuster's technique¹⁰³ and has proven to be a successful method of management.^{40, 51, 52, 63, 74, 92} Close attention to detail in construction of the silo, use of nonabsorbable sutures in its application, and antibiotic ointment at the interface of the Silastic prosthesis and the skin, has reduced both the rate of sac separation and infection in these cases. In instances when infection occurs, the sac should be removed and topical therapy, biologic dressing (amnion) or Opsite should be applied. Most patients with omphalocele who have no other anomalies should survive. Survival in the remaining patients with multiple congenital anomalies, chromosomal defects and special syndromes is somewhat dependent upon the natural history of these other conditions. Long term follow-up of these patients is essential.In the 1980s, the pediatric surgeon has a variety of options in the management of infants and children with congenital abdominal wall defects. Proper surgical therapy is based on a careful selection of that type of treatment best suited for the patient.     

Reconstruction of extensive abdominal wall defect using an eccentric perforator‐based pedicled anterolateral thigh flap: A case report

Reconstruction of extensive abdominal wall defects is a challenge for reconstructive surgeons. In this report, a case of reconstruction of a large abdominal wall defect using an eccentric perforator‐based pedicled anterolateral thigh (ALT) flap is presented. A 30‐year‐old man presented with recurrent desmoid‐type fibromatosis in the abdominal wall. The recurrent tumor was radically excised, and the en bloc excision resulted in a full‐thickness, large abdominal wall defect (25 cm × 20 cm). An eccentric perforator‐based pedicled ALT flap, including wide fascial extension, was transferred to the abdominal defect; fascial portions were sutured to the remnant abdominal fascia. Plication of the fascia along the sutured portion was performed to relieve the skin tension between the flap and the marginal skin of the abdominal defect. Eight months after surgery, the reconstructed abdomen had an acceptable esthetic appearance without tumor recurrence or hernia. The use of an eccentric perforator‐based pedicled ALT flap may be an alternative method for the reconstruction of extensive abdominal wall defects. © 2013 Wiley Periodicals, Inc. Microsurgery 33:482–486, 2013.     

腹壁巨大缺损的外科治疗

腹壁外伤、肿瘤切除、感染以及腹部手术后切口裂开是引起腹壁巨大缺损的主要因素，腹壁缺损已是腹部外科的常见病，其中由于腹部手术切口愈合不良引发的腹壁巨大缺损所致切口疝者占10％～20％。虽然腹壁巨大缺损的治疗方法诸多，但选择一个适宜的治疗方式仍然是一个难题。不恰当的治疗将会引起严重后果，甚至会危及病人的生命。本文结合笔者的临床经验以及众多学者的研究对腹壁巨大缺损的外科治疗进行简单的阐述。     

Management of massive abdominal wall defects.

Patients with acute losses of large portions of the anterior abdominal wall are discussed. Management is divided into the acute or immediate phase in which initial wound control is paramount, and then a subacute period in which coverage with skin is accomplished. Many weeks later during the chronic phase, reconstructive procedures are done if needed. Methods of handling these defects are presented.     

Components separation: a solution to complex abdominal wall defects

Complex abdominal wall hernias can be challenging to treat. The purpose of this study was to retrospectively review the results of components separation. Seventeen patients underwent components separation between 2000 and 2007. Mean size of the hernia defect was 318 cm2. Mean number of prior abdominal operations/patient was 3.2. Nine patients (53%) had prior failed repair. At time of components separation, five patients (29%) had concurrent gastrointestinal operations and two (12%) had panniculectomy. Mean hospitalization stay was 3.8 days with a readmission rate of 41 per cent. The most common postoperative complications were wound related and occurred in 35 per cent of patients. During a mean follow-up of 21 months, only one patient had recurrent hernia (6%). Five patients (29%) required additional operations. Components separation is a viable option for patients with complex abdominal wall defects. Long-term recurrence is rare but wound related complications, operative reinterventions, and hospital readmission are common.     

单孔技术在腹外疝治疗中的应用

正1987年,以Mouret、Dubois、Perissat为代表的"法国链条"首先开展了腹腔镜胆囊切除术[1]。之后,腹腔镜技术迅速发展,腹腔镜手术得到了广泛应用,被称为外科技术的二次革命,目前已经涵盖了几乎所有的外科专业或领域。微创外科经历了"如火如荼发展"后,目前已进入"高位平台期"。突破空间有限,需新平台。郑民华教授提出微创外科需要"见微知著全新起航"。目前,腹腔镜手术在疝和腹壁外科领域也呈现普及趋势。     

Repair of abdominal wall defects with bovine pericardium

Background

Ventral hernia repair with prosthetic mesh has recurrence rates up to 54% and is contraindicated in the setting of infection. The aim of this study was to provide our experience with acellular bovine pericardium (Veritas collagen matrix; Synovis Life Technologies, Inc., St. Paul, MN) in complex abdominal wall reconstruction where prosthetic mesh had failed or was contraindicated. Between 2005 and 2008, a retrospective review of a single general surgeon's practice identified patients reconstructed with acellular bovine pericardium. Thirty primary or recurrent ventral hernias were treated in 26 patients. All patients presented with either contaminated wounds or failure of a prosthetic mesh material.

Results

Hernia size ranged from 20 cm² to 600 cm² (mean 111 cm²). Seven patients had previous hernia repair with prosthetic mesh, and 16 patients had ongoing infection or gross contamination at the time of repair. The mean follow-up was 22 months. The hernia recurrence rate in our series was 19% with no fistula development.

Conclusions

Acellular bovine pericardium's high strength, minimal infection rate, and low cost allow its use in the reconstruction of complex abdominal wall defects.     

Surgical treatment of large contaminated abdominal wall defects

BACKGROUND: Repair of a large, severely contaminated abdominal wall defect is a challenging problem. Most patients are currently treated with a multistaged procedure, which is time consuming, carries a high complication rate, and is often not finalized. STUDY DESIGN: In this study, our experience with a one-stage repair of contaminated abdominal wall defects using the Components Separation Method was evaluated with respect to morbidity and recurrence. Medical records of patients with contaminated abdominal wall defects, treated with the Components Separation Method from 1996 to 2000, were studied. Patients were invited to visit the outpatient clinic for a physical examination. RESULTS: Twenty-six patients with a median age of 49 years and a mean defect size of 267 cm2 were treated. Intraoperative contamination, graded according to the National Research Council (NRC), showed 22 National Research Council III patients and 4 National Research Council IV patients. Postoperatively, five superficial wound infections, three cases of pneumonia, three instances of recurrent enterocutaneous fistulation, and two cases of sepsis were observed. One of the patients with sepsis died after anastomotic disruption led to peritonitis and multiple organ failure. Two asymptomatic recurrences were diagnosed (8%) after a median followup of 27 months. CONCLUSIONS: Large contaminated abdominal wall hernias can be closed by the Components Separation Method, with a low recurrence rate but considerable morbidity.