腹腔镜腹壁切口疝修补术并发症演变及防治

腹腔镜腹壁切口疝修补手术随着术式的演变,在不同阶段有不同的并发症。经过近30年的发展,腹腔内修补技术相关并发症大多已得到解决,而补片相关并发症则越来越受到关注。规范化操作可以减少此类并发症的发生,目前研究的焦点是补片材料。腹膜外修补技术进展迅速,一直处于探索和发展阶段,有可能产生新的腹壁并发症。腹腔内和腹膜外修补术的原理、技术、并发症类型不同,适应人群也不相同。现代疝外科理念强调微创腹壁功能重建,腹腔内补片研发和腹膜外技术探索是减少并发症的关键,也是未来进展方向。机器人技术在减少腹腔和腹壁并发症方面逐渐体现出技术优势。可以预见,随着技术和材料的进展,基于微创技术的腹壁切口疝手术会拥有更佳的解决策略。     

腹壁切口疝的治疗进展

腹壁切口疝是开腹手术最常见的远期并发症之一，是腹内组织或器官经由手术切口的潜在问隙或薄弱区域突出于体表所形成的腹壁包块。欧洲疝学会将腹壁切口疝定义为：在临床体检或影像检查中可看到或可触及的原切口下的腹壁缺损，可伴或不伴腹壁包块。60％的切口疝病人可以没有任何症状，部分病人是由于发生了肠管嵌顿甚至绞窄才发现为切口疝并急诊手术。自1989年美国医师Lichtenstein提出“无张力疝修补手术”的理念后，由于使用补片材料的修补手术具有术后恢复快、疼痛轻、复发率低以及易于操作等优点，此技术在国际上得以迅速开展。     

腹壁切口疝的外科治疗

腹壁切口疝是腹部手术的常见并发症之一,发生率约2%~11%,需外科手术治疗,本文就腹壁切口疝的发生病因、疝的病理类型、手术时机和手术方法的选择以及围手术期处理进行了综述。     

腹壁切口疝修补术后腹壁膨出相关因素研究

目的探讨腹壁切口疝术后腹壁膨出（bulging）及复发的发生率及其相关危险因素。 方法回顾性分析2008年1月至2017年12月,复旦大学附属华东医院行腹壁切口疝修补术治疗的774例患者临床资料,观察腹壁膨出及疝复发的发生率与临床病例因素的关系。 结果术后平均住院时间（8.15±2.60）d,随访时间3～78个月。术后腹壁膨出58例（7.49%）,患者体质量指数（BMI）、是否急诊手术、是否使用补片、补片放置层次、手术入路、是否关闭腹壁缺损等与腹壁切口疝修补术后腹壁膨出有关。 结论影响腹壁切口疝术后腹壁膨出发生的独立危险因素为BMI、是否急诊手术、是否使用补片、补片放置的层次、手术入路、是否关闭腹壁缺损。临床应加强术前病例的筛选,减少急诊手术的同时,严格控制患者体重,选择合适的手术方式和植入修补、确实关闭腹壁缺损,并加强术后切口管理,以预防和减少腹壁切口疝术后腹壁膨出的发生。     

巨大腹壁切口疝的现代外科治疗

腹壁巨大切口疝的修补是很困难的手术 ,在一些特殊的病例中 ,由于患者的全身情况严重恶化使得切口疝无法修补 ,如年老、病态性肥胖及呼吸功能严重紊乱的患者。近年来 ,随着生物材料在疝和腹壁外科的广泛应用 ,对巨大腹壁切口疝的治疗已取得了明显进展。1　定义巨大切口疝的定义通常是根据疝环直径的大小来确定。目前国内外对巨大切口疝的定义不完全一致 ,中华外科学会疝和腹壁外科学组的切口疝分类法 (2 0 0 1年草案 )中将疝环直径>5ｃｍ的疝定为巨大切口疝[1 ] ,Ｆｌａｍｅｎｔ等[2 ] 将疝环直径 >1 0ｃｍ的疝定为巨大切口疝 ,Ｓｃｈｕｍｐ…     

腹壁巨大切口疝术前评估及准备

腹壁切口疝是腹部手术后的远期并发症之一,其发生率约为2%～11%,若切口感染疝的发生率可增加至23%[1]。目前,美国1年的切口疝修补手术为20万例左右[2],年龄>65岁的老年病人尤为突出,约占39%[3]。近年来,随着人工合     

腹壁切口疝防治体会(附64例临床分析)

目的:探讨腹壁切口疝的防治方法。方法：回顾性分析1991-1998年收治的腹部各类手术33 684例中术后发生腹壁切口疝的64例病例的临床特点及切口疝修补方法。结果：疝囊组织切除，腹壁分层丝线间断缝合37例；“强生“可吸收线连续缝合24例；腹壁缺损用聚丙烯丝网补片修补2例；Dacron修补腹壁缺损1例。本组64例均恢复良好，无明显并发症发生。51例获得6个月-1年的随访，2例复发，均为麦氏切口，复发率为3.9%。失访13例。结论：切口疝的发生与体质因素和局部因素，特别是感染有关，而与切口的大小、方向、部位等无关。必须改善围手术期病人营养状况，治疗伴发的疾病，改进操作技术以预防切口疝的发生。     

切口疝的腹壁缺损方式及处理

切口疝的手术方式众多,评价不尽相同。我们在临床工作中认识到正确认识不同类型切口疝的缺损方式、类型、程度及其与内脏的关系等,对修补方法有重要指导意义,可避免不必要的手术失败,以下结合我们的临床经验分析几种切口疝的腹壁缺损及处理。     

自体腹壁真皮片修补腹壁巨大切口疝

我院自 1980～ 2 0 0 1年采用自体腹壁真皮片修补腹壁巨大切口疝 (大于 10ｃｍ) 2 9例 ,效果满意。现报告如下。临床资料1.一般资料 :本组 2 9例 ,男 9例 ,女 2 0例。年龄 44～79岁 ,平均年龄 6 2 7岁。 1次腹部手术史 8例 ,2次腹部手术史 18例 ,3次腹部手术史 2例 ,4次腹部手术史 1例 ;疝环最大 2 2ｃｍ× 13ｃｍ ,最小 10ｃｍ× 7 5ｃｍ。2 手术方法 :有效麻醉使腹壁肌肉充分松弛 ,龙胆紫将疝环以虚线标出 ,捏起松弛皮肤估计皮肤切除范围 ,以修补缝合时无张力为准并以龙胆紫实线标出 ;依实线以缺损为中心做梭形切口至深筋膜。巨大切口疝…     

Classification of incisional hernias of the abdominal wall

Summary Incisional hernias of the abdominal wall assume many clinical forms in terms of their site and size, the quality of the tissues of the abdominal wall and the number of previous recurrences, among many other factors. Any serious prospective and possibly comparative scientific study dealing with the results of treatment must begin by defining the type of incisional hernia studied. Hence, it seemed necessary to employ a classification allowing a study or comparison of homogeneous groups. The aim of this work was to propose a simple classification of predictive value, based on a statistical study of the relations between four parameters, i.e. the site of the incisional hernia, the width of the hernial orifice, the number of previous recurrences, and the results of treatment. A retrospective study dealing with a series of 435 abdominal incisional hernias was done to this end.This work was presented at the XXI EHS International Congress, Madrid, Spain, 3–6 November 1999     

Classification of primary and incisional abdominal wall hernias

Purpose  A classification for primary and incisional abdominal wall hernias is needed to allow comparison of publications and future studies on these hernias. It is important to know whether the populations described in different studies are comparable. Methods  Several members of the EHS board and some invitees gathered for 2 days to discuss the development of an EHS classification for primary and incisional abdominal wall hernias. Results  To distinguish primary and incisional abdominal wall hernias, a separate classification based on localisation and size as the major risk factors was proposed. Further data are needed to define the optimal size variable for classification of incisional hernias in order to distinguish subgroups with differences in outcome. Conclusions  A classification for primary abdominal wall hernias and a division into subgroups for incisional abdominal wall hernias, concerning the localisation of the hernia, was formulated.

Respiratory mechanics in abdominal compartment syndrome and large incisional hernias of the abdominal wall

Summary The abdominal compartment syndrome (ACS) is a clinical condition characterized by an increase of abdominal pressure which needs prompt abdominal decompression. The surgery of large abdominal hernias can present similar problems with an increased abdominal pressure at peritoneal closure which needs a prosthetic tension-free abdominal closure to correct the increased respiratory work-load. We undertook a study in order to compare the respiratory mechanical work-load changes during the surgery of large abdominal incisional hernias and the ACS. We measured the static compliance of the entire respiratory system (Crs), and its components-lung (CL) and chest-wall (Ccw)-during the acute phase of increased abdominal pressure and after decompressive treatment. In ACS the baseline measurements of Crs, CL, Ccw were 0.034, 0.049 and 0.115 L/cmH₂0 respectively; after decompression treatment we observed a great increase of Ccw (0.167 L/cmH₂O) whereas Cl remained the same (0.O49L/cmH₂O); Crs varied from 0.034 to 0.038 L/cmH₂O. In the surgery of large laparoceles, the Crs changed from 0.048 to 0.046 and the Ccw from 0.150 to 0.180, with an unchanged Cl. We conclude that the abdominal compartment syndrome is characterized by a well-defined alteration of respiratory work-load (decrease of chest-wall compliance), and that from a mechanical point of view there is only a quantitative difference if compared to large ventral hernia repair. The decrease of chest-wall compliance in the latter is less severe and statistically different (p = 0.002).This work was presented as a poster at the AHS EHS Joint Meeting Hernia in the 21st Century, Toronto, Canada, 15 18 June 2000     

Reconstruction of the abdominal wall for incisional hernia repair

BACKGROUND: Abdominal wall reconstruction with mobilization of autologous tissue has evolved as a reliable option for patients with incisional hernias. METHODS: With the aim of evaluating morbidity and recurrence rates in patients who underwent abdominal wall reconstruction for incisional hernia repair, we retrospectively reviewed the charts of 188 patients treated between 1996 and 2003. RESULTS: Primary approximation of the fascial defect was achieved in 77% and was reinforced by either mesh placement or rectus muscle advancement. The remaining 23% were reconstructed either by mesh placement, components separation, or distant flap mobilization. Median follow-up was 15 months. Overall morbidity rate was 38%; recurrence rate was 13%. Dimensions of the hernia and intraoperative enterotomies were associated with postoperative complications. Lack of complete restoration of the myofascial abdominal wall continuity was associated with recurrence. CONCLUSIONS: In patients with incisional hernias, techniques involving autologous tissue mobilization are safe and associated with low recurrence rates.     

The ratio between anterior abdominal wall surface/wall defect surface: a new parameter to classify abdominal incisional hernias

Current classifications of incisional hernias are often not suitable. The aim of our study was to demonstrate that it is important to consider not only the wall defect surface (WDS) but also the total surface of the anterior abdominal wall (SAW) and the ratio between SAW/WDS). Twenty-three patients affected by >10 cm size incisional hernias were examined for anthropometric analyses. The SAW, the WDS and the ratio SAW/WDS were calculated. All of the 23 patients were operated on 13 patients were treated with the Rives technique using a polypropylene mesh while the remaning ten patients had an intraperitoneal Parietex Composite mesh (PC). The two groups were compared for post-operative pain (with VAS) and intra-abdominal pressure (IAP) 48 h after the operation: bladder pressure, length of the procedure, average hospital stay and return to work were calculated. In the Rives group, WDS being equal, the higher IAP values were, the lower was the ratio SAW/WDS; furthermore, SAW/WDS ratio being equal, IAP values were low in cases where intraperitoneal mesh was used. Post-operative pain, measured with VAS, was critical when there was a low SAW/WDS ratio and a high IAP. In our experience, it is possible to predict a strong abdominal wall tension if the SAW/WDA ratio is below 15 mmHg. In these cases it is advisable to use a technique requiring the use of an intraperitoneal mesh. Our experience with PC was so positive that it is used in our department for all cases where an intraperitoneal mesh is required. At present, our proposal is that the SAW/WDS ratio is to be considered as a new parameter in current classifications of incisional hernias.     

Sublay法无张力修补术在老年人腹壁切口疝中的应用

目的 探讨Sublay法无张力修补术在老年人腹壁切口疝手术治疗中的疗效。方法 回顾性分析江门市人民医院2004年1月至2010年2月采用Sublay法无张力修补术治疗的32例老年腹壁切口疝患者的临床资料。结果 32例患者手术均顺利完成,手术时间53～112min,平均72min。术后发生肺部感染2例,泌尿系感染2例,经保守治疗后均痊愈。术后未发生切口感染、积液、积血以及肠梗阻。所有患者均治愈出院。随访时间13～73个月,平均38.5个月,无一例复发。结论 Sublay法无张力修补术术后并发症少,复发率低,是治疗老年人腹壁切口疝的可靠方法。     

Some considerations on the use of heterologous prostheses in incisional hernias at risk of infection

Summary The authors report their experience in the use of heterologous prostheses in incisional hernias at risk of infection.45 out of 260 large incisional hernias (17.3%) were treated with nonabsorbable heterologous prostheses between January 1 1984 and January 1 1999. The literature shows a particular rigor in the treatment of incisional hernias, as in the French research by Chevrel and Flament [1990], where, in 1078 cases, the surgeons used autoplasty, relaxing techniques and, sometimes, absorbable prostheses, choosing to delay definitive treatment. The present authors deal with a series of cases treated with nonabsorbable prostheses. Even in incisional hernias at risk of infection, particularly with associated visceral surgery, the use of synthetic meshes has given encouraging results. The low incidence of suppurative complications, with neither removal of the patch nor recurrences in the short term, shows that this is a safe and definitive cure.     

肌后间隙修补法治疗腹壁切口疝患者的疗效

目的探讨肌后间隙修补法（Sublay）在腹壁切口疝患者治疗中的手术效果。 方法回顾性分析2015年1月至2017年8月,首都医科大学附属北京朝阳医院疝和腹壁外科107例行Sublay手术的腹壁切口疝患者的临床资料,分析患者的一般资料、手术方法、并发症及术后转归情况,随访其有无切口疝复发及补片相关并发症发生情况。 结果本组患者均顺利完成手术,平均手术时间（60.3±7.8）min,平均住院时间（17.6±5.3）d,所有患者术后恢复良好,2例患者出现脂肪液化,经换药后伤口愈合;1例患者出现皮下血肿,1例患者出现血清肿,经局部加压保守治疗后治愈,无伤口感染及局部异物感,无死亡患者。随访时间6～38个月,平均随访时间（22.7±10.8）个月,无切口疝复发,无死亡患者,无补片感染、慢性疼痛及局部异物感等补片相关并发症发生。 结论肌后间隙修补手术（Sublay）治疗腹壁切口疝结果满意,手术疗效较好。     

Dynamic patchplasty—a tension-free reconstruction of incisional hernias

Background and aims An anatomical and physiological reconstruction of the abdominal wall after incisional hernia must include reconstruction of the linea alba to restore the physiological function of the vertebral column and respiration. Against this background, a special reconstruction method employing a mesh, which is performed in our department, is presented.Materials and methods In the period between 1 January 2000 and 1 June 2004, a total of 106 patients with incisional hernias after median laparotomy of the upper and lower abdomen were operated on in our department using this tension-free technique with one or two meshes. We have now evaluated the outcomes after a median follow-up of 25.8 months (6.5–53.3).Results In one patient (0.9%), the peritoneal sac was inadvertently opened, resulting in injury to the small bowel serosa. Surgical complications were observed in 14 patients (13.2%) after dynamic patchplasty. In seven cases (6.6%), wound healing disorders were seen. Overall, 6 out of 106 (5.5%) patients needed revision surgery. In the follow-up period, 92 patients (follow-up 86.8%) could be contacted and re-examined. Four patients (3.8%) had died. There were four recurrences (4.3%), which had already been repaired, and one chronic seroma, which caused no symptoms and which was detected in ultrasound and computed tomography.Conclusion In view of the possibility of achieving physiological reconstruction and in the light of a tolerable morbidity rate, dynamic patchplasty is a suitable method for incisional hernias. Long-term results hold out promise of an acceptable low recurrence rate.A commentary on this paper is available at .     

Laparoscopic treatment of ventral abdominal wall hernias: preliminary results in 100 patients.

OBJECTIVE: The laparoscopic treatment of eventrations and ventral hernias has been little used, although these hernias are well suited to a laparoscopic approach. The objective of this study was to investigate the usefulness of a laparoscopic approach in the surgical treatment of ventral hernias. METHODS: Between January 1994 and July 1998, a series of 100 patients suffering from major abdominal wall defects were operated on by means of laparoscopic techniques, with a mean postoperative follow-up of 30 months. The mean number of defects was 2.7 per patient, the wall defect was 93 cm2 on average. There were 10 minor hernias (<5 cm), 52 medium-size hernias (5-10 cm), and 38 large hernia (>10 cm). The origin of the wall defect was primary in 21 cases and postsurgical in 79. Three access ports were used, and the defects were covered with PTFE Dual Mesh measuring 19 x 15 cm in 54 cases, 10 x 15 cm in 36 cases, and 12 x 8 cm in 10 cases. An additional mesh had to be added in 21 cases. In the last 30 cases, PTFE Dual Mesh Plus with holes was employed. RESULTS: Average surgery time was 62 minutes. One procedure was converted to open surgery, and only one patient required a second operation in the early postoperative period. Minor complications included 2 patients with abdominal wall edema, 10 seromas, and 3 subcutaneous hematomas. There were no trocar site infections. Two patients developed hernia relapse (2%) in the first month after surgery and were reoperated with a similar laparoscopic technique. Oral intake and mobilization began a few hours after surgery. The mean stay in hospital was 28 hours. CONCLUSIONS: Laparoscopic technique makes it possible to avoid large incisions, the placement of drains, and produces a lower number of seromas, infections and relapses. Laparoscopic access considerably shortens the time spent in the hospital.