疝环充填式无张力修补术治疗腹股沟疝体会

目的 探讨疝环充填式无张力修补术治疗腹股沟疝的特点。方法 采用美国Bard公司生产的Bard mesh，Perfix p1ug治疗89例腹股疝癌，观察手术时间、切口疼痛、活动能力恢复、并发症和复发率。结果 手术平均时间为29min切口无明显疼痛，无紧绷感；术后6—8h下床活动，2周恢复日常工作；术后切口血肿l例，腹股沟区局部肿胀l例，尿潴留l例；无切口感染；随访2—34个月，无一例复发。结论 疝环充填式无张力修补手术操作方便，损伤少，恢复快，复发率低，适用范围广，是理想有效的疝修补术。     

Re-operation due to severe late-onset persisting groin pain following anterior inguinal hernia repair with mesh

Objectives  Mild pain lasting for a few days is common following mesh inguinal hernia repair. In some patients however, severe groin pain may appear months or even years postoperatively. The aim of this study was to report our experience of late-onset persisting severe postoperative groin pain occurring years after mesh hernioplasty. Methods  In a 9-year period, 1,633 patients (1,073 men), median age 63 years (range 19–88), underwent mesh groin hernia repair. Between 1.5 and 4 years postoperatively, six patients (0.35%) presented with severe chronic groin pain unrelieved by conservative measures and surgical exploration was essential. The patients’ records were retrospectively reviewed for the purpose of this study. Results  Ilioinguinal nerve entrapment was detected in four patients. The meshes appeared to be indistinguishable from the nerve and were removed along with the stuck nerve. New meshes were properly inserted. Mesh fixation on the periostium of the pubic tubercle by a staple was found in the other two patients. The staples were removed from the periostium in both patients. Neither hernia recurrence nor chronic groin pain was persisting in all six patients during a follow-up of 6–44 months postoperatively. Conclusion  From the results of this study, it appears that ilioinguinal nerve entrapment and/or mesh fixation on the periostium of the pubic tubercle are the causes of late-onset severe chronic pain after inguinal mesh hernioplasty. Mesh removal, along with the stuck ilioinguinal nerve and staple detachment from the periostium, are the gold-standard techniques if conservative measures fail to reduce pain.     

疝环充填式无张力疝修补术治疗腹股沟疝

目的探讨聚丙稀网塞及补片在腹股沟疝修补术(疝环充填式无张力疝修补术)中的优点,并总结经验教训.方法采用美国巴德公司的聚丙稀锥形充填物及成型补片对108例腹股沟疝病人施行疝环充填式无张力疝修补术.观察手术时间、伤口疼痛、术后自主能力的恢复、并发症及复发率.结果手术时间平均48.5min;术后4～6h病人能下床活动;伤口疼痛时间2～3d.术后排尿困难2例,伤口积液3例,切口感染2例,1例阴囊积液,1例睾丸炎.术后获随访3月～33月98例,仅2例复发.结论锥形充填物及成型补片组织兼容性好,无排异反应,具有一定的抗感染能力,是理想的疝修补材料.疝环充填式无张力疝修补术手术操作简便,损伤轻,恢复快,并发症少和复发率低,并可放宽手术指征,是较先进的疝修补术式.     

轻量型网片和普通聚丙烯补片在腹股沟疝修补术中的对比研究

目的探讨轻量型网片（强生UPP）在腹股沟疝无张力修补中的作用。方法回顾分析90例次腹股沟疝无张力修补患者的临床资料,其中47例次行普通聚丙烯材料修补,43例次行强生UPP修补。结果强生UPP修补组与普通聚丙烯材料修补组比较,早期并发症发生率（切口疼痛、切口积液、伤口感染、肺部感染、尿道损伤以及尿潴留等）和住院时间差异无统计学意义。在6个月时强生UPP修补组其局部切口疼痛、异物感的患者明显少于普通聚丙烯材料修补组,腹壁顺应性明显好于普通聚丙烯材料修补组,在6个月时两组均没有复发。结论轻量型网片在腹股沟疝无张力修补中,其后期并发症明显减少,有望成为腹股沟疝无张力修补的首选材料。     

Single surgeon experience with bilayer polypropylene mesh repair of inguinal hernia

Background: Open mesh repair of inguinal hernia has been shown to be an effective and safe method of hernia repair. In search of the ‘ideal’ method of open mesh hernia repair, many different methods of mesh placement have been developed. Laparoscopic hernia repair is reported to be superior to open repair in terms of postoperative pain and rehabilitation. These improved functional outcomes could be the result of placement of mesh in the preperitoneal space (underlay), rather than the laparoscopic method per se. A bilayer polypropylene mesh implant has been developed that provides onlay and underlay (preperitoneal) mesh layers. The present study reports the singular experience of a general surgeon with this bilayer polypropylene mesh implant. Methods: A retrospective audit of the first 169 consecutive inguinal hernia repairs was conducted by mailed questionnaire and telephone interview. Data was collected on patient demographics, postoperative pain scores and complications. Patients with potential recurrences at the time of follow up were invited for clinical review. Results: One hundred and three patients (71%) participated in the audit. Thirteen per cent of cases were for recurrent hernia. Median age was 60 years (range 21?99). Median length of follow up was 19 months (range 8?27). No recurrences were detected in the patients who underwent primary repair of inguinal hernia. Conclusion: Inguinal hernia repair with bilayer polypropylene mesh is safe and has low complication and recurrence rates.     

轻量型和普通聚丙烯补片在腹股沟疝修补术中的对照研究

目的：比较使用普通聚丙烯补片f普理灵）和轻量型聚丙烯补片（薇普Ⅱ）进行腹股沟疝修补术后的疗效。方法：2006年10月至2008年3月间,我院对609例腹股沟疝病人,行Lichtenstein修补术,病人分成2组,一组使用普理灵补片,另一组使用薇普Ⅱ补片。比较两组平均手术时间、术后炎症反应程度、并发症及恢复工作的时间,并根据SF-36对病人术前和术后6个月内的生活质量进行评估。使用疼痛的数字评分法（NRS）对术后第2天和6个月的疼痛情况进行评分．以此判断术后6个月腹股沟区是否仍有异物感。结果：与普理灵补片相比,使用薇普Ⅱ补片可减轻术后导致的腹壁活动受限,炎性反应和纤维组织的生成也减低;术后6个月运动时疼痛的比例也降低（P〈0．05）;腹股沟区有异物感的病人较少。结论：腹股沟疝行Lichtenstein修补术中更适宜使用轻量型聚丙烯补片。     

Self-gripping mesh versus sutured mesh in open inguinal hernia repair: system review and meta-analysis

Background

The objective of this article was to compare the outcomes of self-gripping mesh (GM) with sutured mesh (SM) in open inguinal hernia repair.

Methods

A systematic review and meta-analysis were taken to compare the outcomes of GM and SM in open inguinal hernia repair.

Results

A total of 1,353 patients in 6 randomized controlled trials and 2 observational studies were reviewed (666 patients in GM group; 687 patients in SM group). The 2 groups did not significantly differ in chronic groin pain (P = .23) or recurrence (P = .59). The operating time was significantly shorter in GM group (P < .00001). There was no significant difference in infection (P = .18), seromas (P = .35), hematomas (P = .87), or discomfort (P = .58) between the 2 groups.

Conclusions

The data showed that GM was equivalent to SM in open inguinal hernia repair. However, this new mesh still needs to be confirmed in large, multi-center, well-designed randomized controlled trials.     

应用聚丙烯网片组合补片治疗老年腹股沟疝138例

目的探讨聚丙烯网片（赫美T4）组合补片在老年腹股沟疝无张力修补术的治疗效果。方法回顾性分析我科在2007年1月～2010年12月应用聚丙烯网片（赫美T4）组合补片治疗老年腹股沟疝138例的临床资料。结果本组术后并发症13例,其中尿潴留6例,阴囊水肿7例。其中97例随访2～40个月,无自觉不适或异物感,近期随访无复发。结论应用聚丙烯网片（赫美T4）组合补片行无张力疝修补术治疗老年腹股沟疝,具有操作简单,安全有效,恢复快,无复发,并发症少等优点。     

疝环充填及平片置入无张力修补治疗老年人复发性腹股沟疝

目的探讨疝环充填及平片置入无张力修补老年复发性腹股沟疝的临床疗效。方法回顾性分析我院1997年5月至2004年5月收治的32例老年腹股沟复发疝患者的临床资料,其中斜疝22例,直疝8例,膀胱滑疝2例。全部病例均同时行疝环充填、平片置入无张力修补术。结果全部病例无感染,1例术后发生尿潴留。3例伤口轻微疼痛。伤口一期愈合,术后5~10 d出院。随访5个月至5年,1例术后2年复发,再次行无张力疝修补术治愈。结论同时行疝环充填及平片置入,加强腹股沟管后壁的无张力修补方法,手术创伤小,术后恢复快,并发症少,治疗老年复发性腹股沟疝,疗效满意。     

The open mesh repair of Spigelian hernia

BACKGROUND: Spigelian hernias are rare defects of the abdominal wall usually appearing between the abdominal muscles, lateral to the rectus abdominis and through a debilitated Spigelian aponeurosis. Recently, mesh repair has been introduced for the treatment of these types of hernias and different approaches have been proposed. METHODS: Nine patients with Spigelian hernia were prospectively treated by placing a mesh prosthesis between the external oblique and the internal oblique muscles, based on principles of mesh repair established by the Lichtenstein group. RESULTS: Five women and 4 men, mean age 75.7 years, were operated on. In 1 patient the Spigelian hernia was an incidental finding during an inguinal hernia repair. Two patients were operated on an emergency basis. Elective operations were undertaken in ambulatory facilities in 3. Two patients had postoperative ecchymosis with no associated morbidity. No recurrences have been observed during follow-up. CONCLUSIONS: Open mesh repair of Spigelian hernias placing the mesh between the external and internal oblique muscles is a simple and safe approach that can prevent morbidity related to other techniques.     

固载去甲万古霉素缓释微球补片对切口疝金黄色葡萄球菌感染的预防作用

目的补片修补切口疝术后可能发生感染,采用载药补片预防感染是解决方法之一。通过制备大鼠切口疝金黄色葡萄球菌感染模型,观察固载去甲万古霉素缓释微球聚丙烯补片修补切口疝术后对感染的预防作用。方法采用复乳溶剂挥发法制备去甲万古霉素缓释微球,并将其固载至聚丙烯补片(50 mg/片)。扫描电镜观察去甲万古霉素缓释微球形态,采用高效液相色谱法检测微球中去甲万古霉素含量以及补片中去甲万古霉素释放率。取健康10～11周龄雄性SD大鼠40只,体重200～250 g;制备切口疝金黄色葡萄球菌感染模型,分别植入固载去甲万古霉素缓释微球聚丙烯补片(实验组,n=20)和聚丙烯补片(对照组,n=20)。术后观察两组大鼠切口愈合情况,3周时处死大鼠取补片及周围组织进行组织学观察,并进行炎症程度分级。结果扫描电镜观察示去甲万古霉素缓释微球形态完整,表面平滑;微球粒径较均一,64%微球粒径位于60～100μm;去甲万古霉素载药量为19.79%。固载去甲万古霉素缓释微球聚丙烯补片表面均匀,载药量为(7.90±0.85)mg/cm2,去甲万古霉素体外释放达28 d以上,累计释放率达72.6%。两组大鼠术后均存活至实验完成。22只大鼠切口发生感染,其中实验组2只(10%),对照组20只(100%);两组感染率比较,差异有统计学意义(χ2=32.727 3,P=0.000 0)。实验组镜下见局部炎性反应不明显,炎症程度分级Ⅰ级16只,Ⅱ级4只;对照组补片有大量炎性细胞浸润,炎症程度分级Ⅱ级3只,Ⅲ级17只。两组炎症程度分级比较,差异有统计学意义(Z=32.314,P=0.000)。结论固载去甲万古霉素缓释微球聚丙烯补片对大鼠切口疝金黄色葡萄球菌污染具有抗感染作用。     

Laparoscopic mesh repair of incisional hernia: an alternative to the conventional open repair?

Background Tension-free incisional hernia repair using alloplastic material increasingly replaces conventional repair techniques. This change resulted in a decreased recurrence rate (50% vs. 10%, respectively). Recently, laparoscopic approaches for the intraperitoneal tension-free mesh application have been introduced. The decreased trauma at the incision site and the reduction in wound infections appear to be the main advantages. The aim of the present study was to evaluate the early and long-term complications as well as patients’ contentment. Methods Laparoscopic hernia repair with intraperitoneal polytetrafluroethylene (PTFE) mesh implantation was performed on 62 patients at the Klinikum Grosshadern between 2000 and 2005 (29 males, 33 females age 60.7). Intra- and postoperative complications were registered prospectively and retrospectively analyzed. In addition, 57 patients were evaluated for recurrence, postoperative pain and patient contentment (median follow-up 409 days). Results A low complication rate was observed in our patient collective. One trocar bleeding occurred. Three patients presented with wound hematoma. The recurrence rate was 8% (2/25). Sixty-two percent of the patients were free of complaints postoperatively. Eighty-five percent would once again choose the laparoscopic approach for incisional hernia repair. Conclusion The laparoscopic technique was associated with a low recurrence rate, a small rate of wound infections and high patient comfort. Thus, the laparoscopic approach for mesh implantation appears to be a safe and effective method for the treatment of incisional hernias. The efficiency for laparoscopic intraperitoneal mesh implantation, however, should be further evaluated within a prospectively randomized multicenter trial. M. Stickel and M. Rentsch contributed equally.     

Multiple concurrent bilateral groin hernias in a single patient; a case report and a review of uncommon groin hernias: A possible source of persistent pain after successful repair

IntroductionThe wide use of laparoscopy for groin hernia repair has unveiled “hidden hernias” silently residing in this area. During the open repair of the presenting hernia, the surgeon was often unaware of these occult hernias. These patients postoperatively may present with unexplained chronic groin or pelvic pain.Presentation of caseRare groin hernias are defined according to their anatomical position. Challenges in the diagnosis and management of occult rare groin hernias are discussed. These problems are illustrated by a unique case report of multiple (six) coexisting groin hernias, whereof five were occult and two were rare.DiscussionRare groin hernias are uncommon because they are difficult to diagnose clinically and are not routinely looked for. They are often occult and may coexist with other inguinal hernias, thus posing a diagnostic and treatment challenge to the surgeon, especially if there is persistent groin pain after “successful” repair. MRI is the most accurate preoperative and postoperative diagnostic tool, if there is a clinical suspicion that the patient might have an occult hernia.ConclusionPreperitoneal endoscopic approach is the recommended method in confirming the diagnosis and management of occult groin hernias. A sound knowledge of groin anatomy and a thorough preperitoneal inspection of all possible sites for rare groin hernias are needed to diagnose and repair all defects. The preperitoneal mesh repair with adequate overlap of all hernia orifices is the recommended treatment of choice.     

复合补片和生物补片治疗食管裂孔疝的疗效对比研究

目的:对比应用复合补片和生物补片治疗反流性食管炎和食管裂孔疝的疗效。方法:21例应用Crurasoft誖复合补片组及20例应用BiodesignTM Surgisis誖生物补片组修补食管裂孔疝病人,对比分析术后复发率和补片相关并发症发生的差异。结果:两组病人一般情况、食管裂孔长径和手术时间等方面无统计学差异。应用复合补片和生物补片均能使术前反流性食管炎的症状显著缓解。复合补片组和生物补片组围手术期并发症发生率分别为9.5%和30.0%,两组间无统计学差异。术后6个月随访裂孔疝复发率均为0。复合补片组和生物补片组长期随访平均时间分别为(16.3±8.9)个月和(17.3±6.8)个月,解剖性复发率分别为4.8%和5.0%,无统计学差异。两组病人均未发生食管侵蚀的并发症。复合补片组病人术后吞咽困难发生率高于生物补片组(38.1%比20..0%),但无统计学差异。结论:应用新一代小肠黏膜下基质补片和复合补片修补食管裂孔疝后疗效满意,复发率低,补片相关的严重并发症发生率差异无统计学意义。     

腹腔镜下腹腔内网片植入法和开放式肌后筋膜前补片修补法治疗腹壁切口疝的疗效比较

【摘要】 目的〓比较腹腔镜下腹腔内网片植入法(IPOM)和开放式肌后筋膜前补片修补法(Sublay)治疗腹壁切口疝的疗效。方法〓回顾性分析30例腹腔镜应用IPOM法和28例开放式应用Sublay法治疗腹壁切口疝的病例,比较其手术疗效及术后患者生活质量。结果〓两组手术时间、平均住院时间、术中出血量及术后并发症比较,腹腔镜组均明显优于开放手术组,有统计学差异(P<0.05)。结论〓应用腹腔镜行IPOM治疗腹壁巨大切口疝安全可行,具有有创伤小,住院时间短,恢复快,术后并发症少的优点。     

Ileocutaneous fistula formation following laparoscopic polypropylene mesh hernia repair

A rare case of enterocutaneous fistula caused by chronic erosion of polypropylene mesh after laparoscopic repair of a recurrent inguinal hernia is described. Successful treatment was achieved by fistulectomy, total resection of the implanted mesh, and small-bowel segmental resection. The patient recovered well postoperatively, and at follow-up 18 months later, the herniorrhaphy has remained intact. This complication needs to be added to the differential diagnosis in patients who present inflammation, abscess formation, or cutaneous fistula following laparoscopic hernia repair. Received: 7 October 1996/Accepted: 14 October 1996     

Randomized controlled trial of preservation or elective division of ilioinguinal nerve on open inguinal hernia repair with polypropylene mesh

HYPOTHESIS: Our study aimed to evaluate the effect of preservation or elective division of the ilioinguinal nerve on pain and postoperative symptoms after open inguinal hernia repair with mesh. DESIGN: Double-blind, randomized trial. SETTING: Four public, government-financed hospitals in Italy. PATIENTS: From January 1, 1997, to June 30, 2002, 813 patients with primary inguinal hernia were randomly allocated to undergo inguinal hernia repair either with ilioinguinal nerve preservation (408 patients, group A) or elective transection (405 patients, group B). INTERVENTION: Hernia repair with sutureless apposition of a polypropylene mesh. MAIN OUTCOME MEASURES: The primary outcome was the evaluation of chronic pain 1 year after operation. Secondary outcomes were postoperative symptoms assessment at 1 week and 1, 6, and 12 months after operation. Telephone interview was performed 35.5 months (range, 12-59 months) after operation to assess the presence of chronic pain. RESULTS: Of the 302 group A and 291 group B patients who made an office visit 1 year postoperatively, pain was absent in 231 (76.5%) and 213 (73%) (difference, 3.30%; 95% confidence interval, -3.68% to 10.28%), mild in 55 (18%) and 60 (21%), moderate in 11 (4%) and 9 (3%), and severe in 5 (2%) and 9 (3%), respectively (P =.55; Pearson chi2(3) test). At 1-month and 6-month follow-up visits, no difference was found between the 2 groups with respect to pain, but loss of pain or touch sensation were significantly greater when the ilioinguinal nerve was divided. One year after operation, the 2 groups were also comparable with respect to loss of pain sensation, but touch sensation remained decreased in group B. At telephone interview, the presence of chronic pain was similar in both groups. CONCLUSIONS: Pain after open hernia repair with polypropylene mesh is not affected by elective division of the ilioinguinal nerve; sensory disturbances in the area of distribution of the transected nerve are significantly increased.     

Tension-free open hernia repair using an innovative self-gripping semi-resorbable mesh

Background

Lichtenstein tension-free mesh repair is the most commonly used technique for the open treatment of inguinal hernia. Mesh fixation and the potential risk of associated pain are always a surgical concern. The aim of this study was to report the initial clinical experience using an innovative, partly resorbable mesh with self-gripping properties.

Methods

Fifty-two patients (70 hernias) underwent open Lichtenstein hernia repair with Parietene^® Progrip (Sofradim Production, Trévoux, France—Group Covidien). Patient pain as measured by a visual analogue scale (VAS) was the primary study endpoint. Clinical evaluation, with careful attention to the identification of hernia recurrence, was performed at 1 month and 1 year. The evaluation of fixation precision, quality of fixation and ease of use was assessed by the primary surgeon.

Results

The mean patient pain was 1.3 (±1.4) at discharge, 0.1 (±0.4) at 1 month and 0.0 (±0.1) (one patient with VAS 1/10) at 1 year, respectively. The mean operative time was 19 ± 4 min. There was one minor cutaneous infection and no documented recurrence. The quality of the gripping effect was rated very good in 51 (98.1%) of the cases performed.

Conclusion

The use of a novel low-density, macroporous mesh with semi-resorbable self-fixing properties during tension-free repair may be a satisfactory solution to the clinical problems of pain and recurrence following inguinal herniorrhaphy.