阑尾切除术后发生右侧腹股沟疝113例临床分析

目的探讨阑尾切除术后发生右侧腹股沟疝的病因、诊治方法及其预防措施。方法回顾性分析我院1976年1月-2006年12月阑尾切除术后发生右侧腹股沟疝113例的临床资料。结果阑尾切除术后发生腹股沟疝右侧与左侧之比为6．57：1，同期未施行阑尾切除术者右侧与左侧之比为2．48：1。阑尾切除术后右侧腹股沟疝发生的概率与未施行阑尾切除术者相比明显增高（P〈0．01）；而左侧腹股沟疝的发生与阑尾切除术无关。结论阑尾切除术后易发生右侧腹股沟疝是多种因素所致，其根本原因是阑尾切除术中损伤了髂腹下神经和髂腹股沟神经及损伤了腹壁肌肉。预防阑尾切除术后发生右侧腹股沟疝的关键是避免神经和腹壁肌肉的损伤。     

经外环口小切口治疗小儿斜疝108例

小儿斜疝是儿科的常见病、多发病。手术方法一般采用平行于腹股沟韧带的斜切口。切口较长，约4cm左右，由于小儿腹外斜肌腱膜下的髂腹下神经和髂腹股沟神经、腹壁下动静脉未发育，所以腹外斜肌腱膜很薄，几乎与浅筋膜难以区分，术中解剖层次又不分明，再加上腹股沟前区的神经血管较细小，更加难以辨认，术中很容易损伤，导致术后疝气容易复发，并发症多。     

预防性切断髂腹下神经对Lichtenstein手术术后疼痛影响的分析

目的:研究预防性切断髂腹下神经对于腹股沟疝修补术后慢性疼痛的影响。方法:对100例原发单侧腹股沟疝病人采用单盲法进行此项研究,将病人随机分为两组,实施Lichtenstein平片式无张力疝修补术,一组预防性切断髂腹下神经,另一组保留髂腹下神经。在术后3、6、12个月进行随访,对比两组病人的疼痛及其他不适感。结果:两组病人术后3、6、12个月时慢性疼痛发生率无统计学差异,术后6个月切断神经组病人局部麻木的发生率较高。结论:为预防术后慢性疼痛,应当规范手术操作,术中注意辨认、保护腹股沟区神经。常规切断髂腹下神经不能降低术后慢性疼痛的发生率。     

区域神经阻滞对腹股沟疝手术患儿的术后镇痛效果

腹股沟疝是儿童的常见疾病，一般于1岁以后在静脉全麻下行门诊手术治疗。由于术中的镇痛效应到手术结束时已经消失，而且患儿的术后呕吐又限制了口服镇痛药的使用。髂腹股沟神经-髂腹下神经联合阻滞是一种简单易行的腹股沟区域神经阻滞方法，本文旨在评价此种方法用于小儿腹股沟疝手术后镇痛的效果。     

超声引导下以旋髂深动脉为标记的髂腹股沟-髂腹下神经阻滞在老年斜疝手术中的应用

目的探讨超声引导下以旋髂深动脉为标记的髂腹股沟-髂腹下神经阻滞在老年斜疝手术中的临床应用效果。方法选择择期行斜疝手术的老年患者40例,男33例,女7例,年龄65~90岁,ASAⅠ~Ⅲ级,随机分为两组,每组20例。T组采用传统髂腹股沟-髂腹下神经阻滞解剖定位方法;V组采用超声引导下以旋髂深动脉为标记的髂腹股沟-髂腹下神经阻滞。记录神经阻滞起效时间,术中、术后6h VAS评分,麻醉满意度以及尿潴留、误入血管等并发症的发生情况。结果 V组神经阻滞起效时间明显短于T组[(6.1±1.8)min vs(12.1±2.0)min,P0.05];T组术中VAS评分明显高于V组[(4.5±1.1)分vs(2.1±0.9)分,P0.05]。术后6h两组VAS评分差异无统计学意义;V组麻醉满意度明显高于T组(P0.05)。两组均未出现尿潴留,T组有1例误入血管。结论超声引导下以旋髂深动脉为标记的髂腹股沟-髂腹下神经阻滞能为老年斜疝手术患者提供安全、有效、可靠的麻醉。     

腹股沟疝修补术及其合并症

腹股沟疝修补术虽然是普通外科的最基本的常用手术之一,但是如果处理不当可以引起不少合并症,有些还很严重,故应予重视,加以防范, 腹股沟疝修补的方法比较多。这些方法各有不同的适应症和优缺点。然而,它们都包括几个基本步骤即显露和切除疝囊、高位结扎、疝修补或疝成形。现将实施的过程中可能出现的合并症加以讨论。 神经损伤 腹股沟疝修补中可引起髂腹下、髂腹股沟和生殖股神经的损伤。髂腹下神经位于腹股沟管上缘腹外斜肌腱膜下,切开腹外斜肌腱膜时可切断     

髂腹下神经切除术对腹股沟疝术后慢性疼痛患者的影响

目的探讨髂腹下神经切除术对腹股沟疝修补术后慢性疼痛患者的影响。 方法收集2014年7月至2016年7月,广东省人民医院640例腹股沟疝患者的临床资料,运用腹股沟前入路行Lichtenstein无张力疝修补术,以手术日期确定是否切除髂腹下神经并将入组患者均分为试验组和对照组。试验组患者在术中接受髂腹下神经切除术,而对照组未行神经切除,2组术后治疗及护疼痛水平。 结果本组患者均顺利完成手术。术中试验组切除髂腹下神经患者348例,对照组未切除髂腹下神经患者292例。试验组的患者平均手术时间为（50±12.5）min,平均住院时间为（1.8±0.6）d;理方法相同。随访6个月后应用疼痛数字评价量表（numerical rating scale,NRS）,比较2组患者的对照组平均手术时间为（49±14.3）min,平均住院时间为（1.9±0.8）d,2组在住院平均手术时间和住院时间比较,差异无统计学意义（P>0.05）。2组术后随访6个月,试验组NRS评分0分214例,1分53例,2分54例,3分25例,4分2例,5分及5分以上0例。对照组NRS评分0分93例,1分86例,2分32例,3分68例,4分9例,5分及5分以上4例。以3分为界试验组≤3分346例,>3分2例;对照组≤3分279例,>3分13例,2组以3分为界NRS评分比较,差异有统计学意义（P<0.05）。 结论髂腹下神经切除能够在不增加手术时间及住院时间的情况下,显著减少术后慢性疼痛的发生。     

阑尾切除术后右侧腹股沟疝诊治体会

阑尾切除术后右侧腹股沟疝发生率较正常人约高5倍.其主要原因是阑尾手术时损伤了腹股沟神经,致使腹内斜肌、腹横肌收缩无力,因而减弱了腹股沟管的括约肌和掩闭作用.此类疝常规修补方法复发率高,手术要点为切实修复内环、加强后壁.本文时腹内斜肌、腹横肌肌电图呈外周神经损伤的3例,采用改良式McVay 修补法后,随访4～7年未见复发.     

全身麻醉复合髂腹股沟-髂腹下神经阻滞在老年腹腔镜疝修补术中的效果

目的对比全身麻醉复合髂腹股沟-髂腹下神经阻滞和全身麻醉在老年腹腔镜疝修补术中的应用效果。 方法选择2020年1月至2021年8月于阜阳市人民医院收治的70例老年腹股沟疝患者参与研究,随机分为2组,每组患者35例。观察组采用全身麻醉复合髂腹股沟-髂腹下神经阻滞麻醉,对照组采用全身麻醉。记录2组患者不同时段的平均动脉压（MAP）和心率（HR）水平,分别在术后即刻、术后6、12 h评估2组患者的Ramsay、疼痛视觉模拟评分（VAS）,分析2组患者的麻醉复苏质量和麻醉效果。 结果T1、T2、T3时,2组患者的MAP、HR水平较T0均显著降低,而观察组显著高于对照组（P<0.05）。术后6、12 h,2组患者的Ramsay评分较术后即刻显著降低,且观察组显著低于对照组;2组患者的VAS评分较术后即刻显著升高,而观察组显著低于对照组（P<0.05）。术后,观察组患者的拔管时间、清醒时间、离开手术室时间均显著低于对照组（P<0.05）;观察组患者的麻醉优良率为97.14%,稍高于对照组的88.57%,差异无统计学意义（P>0.05）。 结论全身麻醉复合髂腹股沟-髂腹下神经阻滞全身麻醉在老年腹腔镜疝修补术中的麻醉可有效维持血流动力学稳定,具有良好的镇静、镇痛、麻醉复苏质量,可作为老年腹股沟疝患者腹腔镜疝修补术的优先选择。     

超声引导下髂腹股沟/髂腹下神经阻滞联合生殖股神经生殖支阻滞在老年腹股沟疝修补术中的应用效果

目的观察超声引导下髂腹股沟/髂腹下神经(ilioinguinal/iliohypogastric nerve,IIIHN)阻滞联合生殖股神经生殖支阻滞应用于老年腹股沟疝修补术的效果。方法择期行单侧无张力疝修补术的腹股沟斜疝老年患者53例,男52例,女1例,年龄65~96岁,体重55~82 kg,ASAⅠ-Ⅲ级,采用随机数字表法将患者随机分为两组:IIIHN阻滞联合生殖股神经生殖支阻滞组(G组,n=27例)和IIIHN阻滞组(I组,n=26例)。两组均行超声引导下IIIHN阻滞,注入0.5%罗哌卡因0.25 ml/kg。G组联合生殖股神经生殖支阻滞,注入0.5%罗哌卡因10 ml。阻滞完成30 min后测试皮区感觉神经阻滞效果,记录切皮时、牵拉精索/圆韧带时、行疝囊高位结扎时的VAS疼痛评分,记录术中舒芬太尼、布托啡诺使用情况和术后曲马多补救镇痛情况,记录区域阻滞效果评级以及穿刺部位血肿、腹内脏器损伤、股神经被阻滞表现、阻滞后感觉异常、局麻药中毒、术后恶心呕吐、尿潴留等并发症的发生情况。结果两组皮区感觉神经阻滞效果差异无统计学意义。切皮时和行疝囊高位结扎时两组VAS疼痛评分差异无统计学意义。牵拉精索/圆韧带时G组VAS疼痛评分明显低于I组[(2.0±1.0)分vs(4.7±1.4)分,P<0.05]。G组术中舒芬太尼、布托啡诺使用率明显低于I组(P<0.05)。两组术后曲马多补救镇痛率差异无统计学意义。G组区域阻滞效果评优者比例明显高于I组[25例(92%)vs 8例(31%),P<0.05],区域阻滞效果评良者比例明显低于I组[2例(7%)vs 18例(69%),P<0.05]。两组各有1例发生术后尿潴留,两组均无其他并发症发生。结论髂腹股沟/髂腹下神经阻滞联合生殖股神经生殖支阻滞应用于老年腹股沟斜疝修补术,效果优于髂腹股沟/髂腹下神经阻滞。     

Incidence of contralateral patent processus vaginalis in children with inguinal hernia

PURPOSE: The aim of this study was to investigate the incidence of contralateral patent processus vaginalis (PPV) in children with inguinal hernia using direct laparoscopic inspection. METHODS: This study evaluates the incidence and size of contralateral PPVs in 143 children (96 boys, 47 girls) with clinically unilateral indirect inguinal hernia who underwent laparoscopic hernia repair. During repair, the contralateral internal inguinal ring was evaluated for PPV. RESULTS: Boys with hernias on the right side had wide-open contralateral PPVs in 26% of cases compared with 11% in girls. Boys with hernias on the left side had wide-open contralateral PPVs in 30% of cases compared with 38% in girls. In all 4 groups, there were small contralateral openings in 15% to 20% of cases. CONCLUSION: Contralateral PPV seems to occur less commonly than previously assumed.     

Laparoscopic herniorrhaphy in children

Background: We report our clinical experience with 403 inguinal hernias in 279 children. They were treated via a purely laparoscopic approach using 2-mm instruments, obviating the need for a groin incision. Methods: Laparoscopic herniorrhaphy was performed in children ages 4 days to 15 years. A 5-mm laparoscope was inserted through the umbilicus, and two 2-mm needle holders were inserted through the inferolateral abdominal wall. The open inner inguinal rings were closed by placing Z-sutures of monofilamentous nonabsorbable material. Results: The mean operating time was 14 min for unilateral hernias and 21 min for bilateral hernias. We found 3.9% direct hernias. Hydroceles occurred in 1.7% of patients, testicular atrophy was noted in one patient, and no hernia was found in 2.3%. In girls with inguinal hernias, a contralateral asymptomatic patent processus vaginalis (PPV) was found in 45.2%, regardless of whether the hernia was on the right or the left side. In boys with inguinal hernias, contralateral PPVs were found on the right side in 21.9% and on the left in 8%. There were no major complications. One conversion to an open procedure was necessary because of a dilated bowel. The mean follow-up period was 23 months. There were 2.7% hernia recurrences; this rate was slightly higher than that seen with the open technique. The incidence of direct inguinal hernias was higher than has been previously reported. Conclusions: Laparoscopic herniorrhaphy allows the surgeon to identify the type of defect and proceed with immediate treatment. This technique is safe, reproducible, and technically easy for experienced laparoscopists. Bilaterality is of no concern. The cosmetic results are excellent; and in patients with recurrence of a hernia, this procedure is preferable to the open technique.     

Endoscopic totally extraperitoneal repair for occult bilateral obturator hernias and multiple groin hernias

INTRODUCTION: An obturator hernia is a rare hernia that is bilateral in about 6% of patients. Most patients present with chronic pelvic pain although a few patients may present with features of intestinal obstruction. Only about 10% of obturator hernias are diagnosed preoperatively. METHODS: A 65-year-old female patient with chronic obstructive pulmonary disease presented with bilateral groin swellings associated with local pain and heaviness. She also suffered from recurrent episodes of abdominal distension. She was diagnosed to have bilateral direct inguinal hernias and a left femoral hernia. At endoscopy under epidural anesthesia she was found to have a direct inguinal, an indirect inguinal, and a femoral hernia on the left side and an indirect inguinal hernia on the right side. Additionally, the endoscopic totally extraperitoneal approach to inguinal hernias identified hitherto undiagnosed bilateral obturator hernias. The hernias were reduced and polypropylene mesh was placed bilaterally covering the myopectineal orifice and pelvic floor bilaterally. RESULTS: The patient was discharged the next day and is symptom-free on followup at eight months. CONCLUSION: Endoscopic repair of groin hernias allows the surgeon not only to diagnose and treat unsuspected groin hernias but also allows identification, dissection, and repair of coincidental occult pelvic hernias like obturator hernias at the same time.     

Laparoscopic evaluation of the contralateral groin in pediatric inguinal hernia patients: a comparison of 70- and 120-degree endoscopes

BACKGROUND: Transinguinal laparoscopic groin evaluation using a 70-degree endoscope can obviate the need for a second incision when attempting to identify a contralateral patent processus vaginalis (PPV) during open repair of a symptomatic pediatric inguinal hernia. This technique can be technically unsatisfactory when a medial veil of peritoneum obscures adequate visualization of the internal inguinal ring. This study compared 70- degree and 120-degree endoscopes in identification of a contralateral PPV in the same patients. MATERIALS AND METHODS: From September 2000 to October 2003, 81 patients with known inguinal hernias underwent open hernia repair and transinguinal laparoscopic evaluation of the contralateral side. The patients were 62 male, 19 female; mean age 26 months (range, 1 month-10 years); mean weight 11.7 kg (range, 2-33 kg). There were 53 right side hernias and 28 left side. Mean operative time was 43 minutes. Fifty seven patients (70%) had one or more risk factors for developing a contralateral inguinal hernia (49 were younger than 1 year old and 19 were ex-premature). Nineteen patients underwent concurrent procedures (7 circumcisions, 10 hydrocelectomies, 1 orchidopexy, 1 appendectomy). RESULTS: Using the 70-degree endoscope, a medial veil of peritoneum made visualization of the internal inguinal ring impossible in 14 patients (17%) and difficult in an additional 5 patients (6%). Visualization with the 120-degree endoscope was deemed to be superior in 46 (57%), equal in 35 patients (43%), and inferior in none. Overall, contralateral PPVs were detected in 31 patients (38%) with the 120-degree endoscope and in only 23 patients (28%) with the 70-degree endoscope. Had we used only the 70-degree endoscope, 8 PPVs (10%) would have been missed. None of the negative 120-degree endoscope evaluations have developed symptomatic contralateral inguinal hernias. CONCLUSION: In this trial, transinguinal laparoscopic evaluation using the 120-degree endoscope provided superior visualization and identification of contralateral PPVs. This new technique obviates the need for a separate abdominal wall puncture, reduces missed contralateral PPVs, and should be considered for use during pediatric inguinal hernia repair.     

Side incidence of inguinal hernias

The reason for the right side predominance of inguinal hernias was studied. The case histories of 469 patients who had undergone inguinal hernia operations were analysed. 116 of the hernias were bilateral whereas 207 were right and 146 left sided, the difference being significant at the level p less than 0.05. More right than left hernias were found in every subgroup studied (children, women, men; direct, indirect, older people; with suspected increased intra-abdominal pressure). Neither of the two hypotheses envisaged for this side difference could be confirmed. These were a structural side difference in the inguinal canals, and a neuromusculature damaging abdominal incision. It is postulated that a physiological asymmetricity of the body musculature could be an explanation rather than any anatomical reason.     

Inguinal hernia in children

The authors report 611 cases of inguinal hernias of childhood operated between 1967 and 1985, which represent 28% of operations performed in all children in the same period. The mean age of patients was 33 +/- 4.1 months and the ratio M:F = 5.43:1. The right side was the most frequently affected (64.64%) with a bilaterality of 14.89%. The incarceration, observed at the rate of 13.23%, needed the surgical treatment in urgency in the 35.63% of the cases. A relapsing hernia appeared only two times (0.45%) and the incidence of contralateral metacronous hernias was 7.99%. They perform herniorrhaphy in the only symptomatic side without preoperative herniorrhaphy and operate on the silent contralateral side only when there a hernia will became symptomatic, as they think that herniorrhaphy and bilateral inguinal exploration cause a high number of unnecessary, sometimes harmful operations.     

经脐双孔法腹腔镜治疗婴幼儿腹股沟嵌顿性斜疝

目的探讨经脐双孔法腹腔镜治疗婴幼儿腹股沟嵌顿性斜疝的临床应用价值。方法2003年4月—2004年4月采用经脐双孔法腹腔镜治疗婴幼儿腹股沟嵌顿性斜疝48例,并与婴幼儿腹股沟嵌顿疝的传统手术在手术时间、肠功能恢复时间、住院天数、术后并发症等方面进行了比较。结果腹腔镜手术组手术过程顺利,未发现嵌顿物坏死,无附加嵌顿内容物切除手术,其平均手术时间为(30±5)min,肠鸣音恢复时间为(7.8±0.3)h,住院时间(4.4±0.3)d,均较传统手术组[平均手术时间(43±6)min,肠鸣音恢复时间(23.3±2.4)h,住院时间(6.7±0.4)d]缩短(P<0.05),术后随访3个月～1年未见疝复发和输精管损伤、膀胱损伤、睾丸萎缩等并发症。结论经脐双孔法腹腔镜治疗婴幼儿腹股沟嵌顿性斜疝是一种安全的微创手术,具有损伤小、恢复快、住院时间短等优点,值得推广应用。     

免气囊分离器完全腹膜外补片腹腔镜腹股沟疝修补术

目的探讨免气囊分离器完全腹膜外腹腔镜腹股沟疝修补术的优点、难点、术中常见的失误及解决办法. 方法 2003年11月～2004年7月,完成11例免气囊分离器完全腹膜外补片腹腔镜腹股沟疝修补术.腹股沟斜疝8例,7例为右侧,1例为左侧;直疝3例,左侧2例(其中1例为复发性直疝),右侧1例. 结果平均手术时间74.1 min,平均出血量13.6 ml,平均术后住院天数为2.2 d.术后平均5.3 d恢复日常活动.术中发生腹壁下动脉游离、误入解剖层次和腹膜撕裂各1例.随访1～7月,未见1例复发及神经性疼痛等并发症. 结论免气囊分离器完全腹膜外腹腔镜腹股沟疝修补术与常规气囊分离器完全腹膜外腹腔镜腹股沟疝修补术一样安全、可行,了解该术式的要点,有助于顺利完成手术.     

直疝前入路腹膜外修补术的手术技巧

目的总结单针三明治固定技术在腹股沟直疝前入路腹膜外修补术中的操作技巧与临床应用经验。 方法回顾性分析2012年3月至2014年3月泰安市第一人民医院同一手术组完成的68例直疝患者临床资料,其中102侧疝,双侧疝34例,右侧疝23例,左侧疝11例;复合疝3例,2例为斜疝Lichtenstein术后再发直疝,4例为直疝Lichtenstein术后复发。分析手术技巧、术中和术后并发症、5年以上的随访资料。 结果手术均成功,手术时间（22.35±14.26）min,术中无明显出血,1例腹壁下静脉主干牵拉损伤术中结扎,术中均未放置引流,术后无血清肿。术后近期无剧烈疼痛,远期无顽固性疼痛。随访期间无直疝复发病例,1例术后2年另发斜疝,再次手术治愈,1例高龄患者因其他疾病术后2年死亡。 结论单针三明治缝合固定技术在直疝前入路腹膜外修补术中具有操作简单、效果确切的优点,直疝分离腹膜外间隙要避免遗留隐匿斜疝。