高频超声在腹直肌肌皮瓣转移修复胸壁放射性溃疡中的应用价值

目的探讨术前运用高分辨率彩色多普勒血流成像技术（CDFI）检测腹壁上、下血管对腹直肌肌皮瓣覆盖胸壁放射性溃疡的价值。方法16例乳癌放疗术后胸壁放射性溃疡患者行胸部溃疡切除、腹直肌肌皮瓣转移术。术前用以CDFI探查双侧腹壁上、下动脉位置、走行，以二维超声检测双侧腹壁上、下动脉的管腔内径，同时以脉冲多普勒分段测血管收缩最大血流速度。结果16例32根腹壁上、下动脉均成功检测，腹壁上动脉均存在不同程度的损伤，血管出现走行变异、管腔变窄等表现，并为手术证实。结论术前使用彩色超声血管检查仪对腹壁上、下动脉主干及其肌皮穿支检测，有利于筛选手术适应证和选择肌皮瓣的血供类型，同时可指导肌皮瓣设计和确定术中腹直肌前鞘切开游离部位。     

Free rectus abdominis muscle flap: advantages in lower extremity reconstruction

Major soft tissue losses of the distal portion of the leg usually require free tissue transfer for reconstruction. We have recently treated seven patients with free rectus abdominis muscle flaps. The rectus abdominis has several advantages over other muscles; these advantages simplify such reconstructions. Elevation of this muscle can be done simultaneously with recipient vessel dissection without the need for patient repositioning. The deep inferior epigastric vessels provide a reliable pedicle of one large artery and two veins of sufficient length to accomplish microvascular anastomosis outside the zone of injury without the use of vein grafts. The size and shape of the muscle conforms well to the defects of many wounds in the leg. There is no functional deficiency from the use of one muscle, and the donor site scar is relatively inconspicuous since the rectus abdominis is harvested through a midline abdominal incision. There have been two complications in this series, one intraoperative flap failure, and one case of recurrent osteomyelitis. There has been no donor site morbidity. We recommend the free rectus abdominis muscle flap for the reconstruction of many complex wounds of the distal portion of the leg.     

腹直肌-腹膜瓣移植修复舌缺损的围手术期护理

目的总结腹直肌-腹膜瓣移植修复舌缺损的护理。方法2003年9月至2004年6月共5例患者接受了舌癌联合根治术,同期腹直肌-腹膜瓣转移修复术,手术前后实施了有针对性的护理,并对并发症进行严密的观察与护理。结果患者术后无血管危象,无腹壁切口疝及呼吸道感染并发症,无院内感染,供受区切口均一期愈合,组织瓣成活,康复出院。结论根据腹直肌-腹膜瓣的特点和舌再造术的要求做好相应的术前准备,术后对并发症的进行积极的观察与护理是围手术期护理的重点。     

1例乳腺肌纤维母细胞瘤术后行I期带蒂腹直肌皮瓣移植的围术期护理

乳腺肌纤维母细胞瘤是一种比较罕见的软组织肿瘤,目前病理学家普遍认为其介于良恶性之间,少数可转移,说明其中一部分有复发的可能,属于低度恶性肿瘤[1],治疗主要以手术切除为主,切除范围由肿瘤大小决定,可以适当扩大切除范围,甚至     

腹直肌横形皮瓣乳房再造术患者的围手术期护理

乳房的完整是女性体态完美的重要因素.乳房缺失会给女性患者造成严重的身心伤害.腹直肌横形皮瓣(transverse rectus abdominis myocutaneous flap,TRAM)乳房再造是目前最常用的自体组织乳房再造的方法.其优势是组织量大,再造乳房丰满,并有一定的下垂度,手术的同时又进行了腹壁整形,不仅为患者提供了一个自然、持久、美学效果良好的乳房,而且为患者解决了身心两方面的痛苦,从而提高了乳房缺失患者的生活质量.     

Complex enterocutaneous fistula: closure with rectus abdominis muscle flap

Most enterocutaneous fistulas are caused by complications of abdominal surgery that may result from anastomotic failure, poor blood supply, or iatrogenic bowel injuries. Mortality rates are high when associated sepsis and malnutrition are uncontrolled. Fistulas that occur late and those that recur spontaneously present more difficulty and may close spontaneously in less than 30% of cases. Mortality rates in patients with complex enterocutaneous fistulas may reach 60% to 80%. When traditional conservative surgeries of fistulous tract excision, bowel mobilization, and resection with primary end-to-end anastomosis fail, a more aggressive approach is required. The rectus abdominis muscle flap has been extensively studied and used in a wide variety of abdominal, vaginal, and perineal repairs. We report successful closure of complex enterocutaneous fistulas with a rectus abdominis muscle flap in a complicated case.     

胸壁肿瘤术后缺损的修复重建

目的:探讨胸壁肿瘤术后胸壁复杂缺损的修复方法。方法:2007年3月至2014年12月共完成胸壁肿瘤缺损修复46例,平均51.7岁。其中,皮肤鳞状细胞癌16例,软组织肉瘤8例,乳腺癌复发22例。单纯肋骨缺损15例,采用单纯网片修复;单纯软组织缺损14例,采用带蒂皮瓣修复;胸壁全层缺损合并胸骨、心前区、大范围的肋骨缺损17例,采用"网片+骨水泥+网片"三明治的方法坚强内固定,软组织修复采用带蒂或游离皮瓣修复。结果:1例腹直肌带蒂皮瓣术后边缘部分坏死,再采用局部推进皮瓣修复;1例游离腹壁下动脉穿支皮瓣修复患者术后第2天出现静脉危象,急诊手术探查清除血块后皮瓣顺利成活;其余患者伤口均一期愈合,皮瓣完全成活。随访12~68个月,平均(29.4±0.7)个月,无患者复发,皮瓣外观、功能恢复满意。结论:不同形式的带蒂皮瓣和游离皮瓣是修复肿瘤切除术后复杂缺损的有效方法。     

Preexpanded vertical trapezius musculocutaneous flap for reconstruction of a severe neck contracture after burn injury.

Preexpanded flaps are a method to replace a larger postburn contracture area. We describe the use of a preexpanded vertical trapezius musculocutaneous flap for reconstruction of a severe mentosternal contracture in a 10-year-old male patient with second- to third-degree burn wounds. A 500 cm(3) rectangular-shaped tissue expander was inserted under the trapezius muscle via a lateral incision in first stage. Two months later, after serial expansion of the expander, the neck scar was excised. The preexpanded flap (size = 27 x 9 cm) was harvested and rotated into the defect. The donor site could be closed primarily. The flap totally survived. The hospital stay was 7 days. After 6 months follow-up, a significant improved range of motion with good esthetic outcome was achieved. The use of a preexpanded trapezius flap can provide thin, large, and pliable tissue for reconstruction of a severe mentosternal scar contracture with excellent functional outcomes.     

剖宫产术后腹直肌肿物的CT分析

目的分析剖宫产术后腹直肌切口肿物的CT影像表现,探讨诊断思路及CT影像特征。方法对25例经病理证实的剖宫产术后腹直肌肿物CT表现进行回顾性分析。所有患者临床资料完整,均行多排螺旋CT平扫加增强检查。结合其临床资料(包括剖宫产术式、术后出现腹直肌肿物的时间、肿物触诊情况等)和CT影像特征进行归纳总结。结果 25例均为腹直肌单发肿物,病灶位于切口处腹直肌内。(1)子宫内膜异位症8例。出现症状时间为剖宫产术后9~48个月,CT表现为腹直肌内实性或囊实性结节,增强囊壁及实性部分明显强化。(2)韧带样瘤6例。出现症状时间为剖宫产术后12~36个月,触诊为质硬无痛性包块;6例密度均等于或稍低于肌肉,均呈渐进性强化;5例呈梭形与腹直肌长轴一致。(3)脓肿7例。出现症状为剖宫产术后2~4周,触诊边界不清,CT表现为不规则软组织肿块,内见气-液平面,增强呈环形强化。(4)血肿4例。出现症状为剖宫产术后2周内,肿物呈梭形局限于腹直肌内,边界清楚,增强后无强化,周围可见新生血管。结论剖宫产术后腹直肌肿物是一组与手术相关的疾病,结合发病时间和临床特征,根据CT影像表现,能作出较准确的诊断。     

钛板人工肋骨重建兔胸壁缺损的实验研究

目的:探讨钛板人工肋骨用于兔胸壁缺损重建的修复作用。方法:采用表面喷砂、酸蚀处理制备钛板人工肋骨。建立20只3cm×3cm的胸壁骨性缺损家兔模型,实验组应用钛板人工肋骨修复缺损(n=10),对照组采用带骨膜的自体肋骨移植(n=10)。检测血清碱性磷酸酶、血钙及血磷,行胸部X线片、病理组织学检查。结果:所有实验兔均无手术及术后死亡,无感染、胸壁塌陷及反常呼吸发生。两组血清碱性磷酸酶和钙磷乘积变化无显著性差异(P>0.05)。实验组钛板与肋骨断端连接成一个整体,固定牢靠,界面大量新生骨组织,无纤维组织介入;对照组肋骨断端处骨增生明显,有连续性骨痂生成。结论:钛板人工肋骨具有良好的生物相容性,能够对胸壁提供有效的支撑作用,值得进一步研究以应用于临床。     

10例双蒂横行腹直肌皮瓣转移乳房再造术的护理

总结了10例双蒂横行腹直肌皮瓣(双蒂TRAM)转移乳房再造术的护理经验.术前加强有针对性的心理护理,保护供区部位皮肤;术后给予正确的体位护理及充分合理的营养支持,采用红外线照射等方法,保护转移肌皮瓣;密切观察引流液的颜色、性质和量,保持引流管的通畅,认真观察有无肌皮辩坏死和皮瓣感染的发生.本组发生肌皮瓣感染2例,皮下积液1例,经积极治疗和护理,皮瓣愈合良好.术后患者再造乳房塑形良好,按计划进行化疗.     

保留皮肤或保留乳头、乳晕的乳腺癌改良根治术后扩展型背阔肌肌皮瓣即时乳房再造

目的探讨行保留皮肤或乳头、乳晕的乳腺癌改良根治术后应用扩展型背阔肌肌皮瓣即时乳房再造的疗效。方法30例乳腺癌患者中16例行保留皮肤乳腺癌改良根治术，14例行保留乳头乳晕乳腺癌改良根治术，术后即时切取包括背阔肌及其表面的脂肪和岛状皮肤、髂嵴上方脂肪、背阔肌前沿侧胸部脂肪和肩胛区脂肪构成扩展型背阔肌肌皮瓣，转移至胸壁再造乳房。结果30例即时乳房再造全部获得成功。切除乳房的组织量180～350ml（平均245ml），移植再造乳房的扩展型背阔肌肌皮瓣组织量210～440ml（平均265ml）。28例术后辅助化疗，5例辅助放疗。随访6～34个月（平均22个月），均生存，其中1例术后8个月骨转移，1例术后19个月腋窝胸壁局部复发。美容效果：优14例，良11例，一般3例，差2例。结论乳腺癌患者行保留皮肤或乳头乳晕改良根治术后应用扩展型背阔肌肌皮瓣即时乳房再造可获得足够的组织量，再造乳房形态良好，不影响乳腺癌的术后辅助治疗和远期疗效。     

岛状背阔肌肌皮瓣乳房再造加腋前皱襞重建术的护理配合

Objective To study nursing cooperation of second-stage reconstruction of breast and anterior axillary fold with island latissimus dorsi musculocutaneous flap after Radical Mastectomy. Methods Thirteen patients with severe defect of thoracic wall underwent second-stage reconstruction of breast and anterior axillary fold with island latissimus dorsi musculocutaneous flap and breast implants 1 ～ 4 years after the Radical Mastectomy for breast cancer. The nursing cooperation including preoperative preparation of staffs, surgical instruments, and articles, and methods of intraoperative nursing cooperation were retrospectively analyzed.Results Procedure success was gained in all 13 cases, without operation beingg delayed because of surgicalinstruments or poor cooperation. Flaps survived intraoperatively and postoperatively. Primary healing of incision without any infection was observed for all patients. Satisfactory mammary contour was achieved for all patients uneventfully with absence of any complications. Conclusions Careful preoperative preparation of articles and psychological nursing to gain best cooperation of the patients, and skilled intraoperative nursing cooperation are essential for procedure success.     

岛状背阔肌肌皮瓣乳房再造加腋前皱襞重建术的护理配合

目的探讨乳腺癌根治术后Ⅱ期应用岛状背阔肌肌皮瓣加乳房假体行乳房再造术及腋前皱襞重建手术的护理配合。方法回顾性总结13例乳腺癌根治术后1—4年胸壁严重缺损患者行Ⅱ期岛状背阔肌肌皮瓣加乳房假体行乳房再造术及腋前皱襞重建的手术配合,包括术前人员、器械、物品及病人的准备,术中护士的配合方法。结果13例手术均获得成功,未发生由于器械或配合不良耽误手术,术中、术后皮瓣成活,切口无感染、均Ⅰ期愈合,无并发症发生,乳房外形良好,患者满意。结论术前物品准备充分及做好心理护理,取得患者的最佳配合;术中熟练的手术配合技巧是手术顺利完成的重要保证。     

胸骨切除后钛网胸廓重建治疗胸骨肿瘤的临床研究

目的：探讨钛网用于胸骨切除后胸廓重建的方法和临床效果。方法：10例胸骨肿瘤患者行胸骨切除后采用钛网对缺损胸骨进行重建,随访观察以评价手术效果。结果：10例患者手术均成功,患者术后前胸壁外观良好,未发生排斥反应,无呼吸循环并发症,仅2例出现轻度呼吸反常。随访至撰稿日止无死亡病例。结论：钛网具有良好的生物相容性,对胸廓具有有效的支撑作用,值得在临床上推广应用。     

岛状背阔肌肌皮瓣乳房再造加腋前皱襞重建术的护理配合

Objective To study nursing cooperation of second-stage reconstruction of breast and anterior axillary fold with island latissimus dorsi musculocutaneous flap after Radical Mastectomy. Methods Thirteen patients with severe defect of thoracic wall underwent second-stage reconstruction of breast and anterior axillary fold with island latissimus dorsi musculocutaneous flap and breast implants 1 ～ 4 years after the Radical Mastectomy for breast cancer. The nursing cooperation including preoperative preparation of staffs, surgical instruments, and articles, and methods of intraoperative nursing cooperation were retrospectively analyzed.Results Procedure success was gained in all 13 cases, without operation beingg delayed because of surgicalinstruments or poor cooperation. Flaps survived intraoperatively and postoperatively. Primary healing of incision without any infection was observed for all patients. Satisfactory mammary contour was achieved for all patients uneventfully with absence of any complications. Conclusions Careful preoperative preparation of articles and psychological nursing to gain best cooperation of the patients, and skilled intraoperative nursing cooperation are essential for procedure success.     

猪源人工骨进行胸壁缺损修复重建的疗效观察

目的探讨用猪源生物材料骨进行骨性胸壁缺损修复重建的方法及疗效。方法对2008年12月至2011年9月我院胸外科收治的21例胸壁缺损患者用猪源生物材料骨进行重建。其中男16例,女5例,平均年龄45.8岁(10～72岁),17例为胸壁肿瘤或肺肿瘤侵犯胸壁手术切除后造成胸壁缺损,用猪源生物材料骨进行肋骨重建,外被自身软组织;4例为纵隔或胸骨肿瘤切除后造成胸骨或胸骨合并前胸壁缺损患者,用猪源生物材料骨替代胸骨与两侧前肋及锁骨固定。结果 21例患者均胸廓成形满意,术后无反常呼吸运动、浮动胸骨、血气胸、感染及材料相关并发症,术后X线及CT检查见生物材料骨与自体肋骨连接部有骨痂形成。随访6个月至3年3个月,全部病例胸廓成形满意,无材料松动、脱落、变形及折断。结论用猪源生物材料骨进行胸壁缺损修复重建疗效满意,术后见连接部有骨痂形成。     

皮瓣肌皮瓣修复感染性缺损创面的护理

目的总结应用皮瓣肌皮瓣修复感染性缺损创面患者的护理要点。方法选择2001年8月~2006年8月在本科室应用带血管蒂或吻合血管皮瓣肌皮瓣移植术修复组织缺损化脓性感染创面的53例患者,对这些患者进行针对性护理,包括心理护理、术前准备、控制感染、皮瓣观察等方面。结果创面Ⅰ期愈合44例,Ⅱ期愈合8例(部分坏死3例,经换药后痊愈,其余皮瓣肌皮瓣全部成活),皮瓣坏死1例。结论采用娴熟的多学科护理知识护理该类患者,可减少并发症,提高手术成功率。