腹腔镜治疗陈旧性创伤性膈疝的初步探讨

目的探讨腹腔镜手术治疗陈旧性创伤性膈疝的安全性和有效性。方法回顾分析2011年3月~2014年2月我院收治陈旧性创伤性膈疝5例资料,男3例,女2例,年龄20~47岁,中位年龄36岁。车祸伤4例,高空坠落伤1例。术前均经CT确诊。采用腹腔镜手术,还纳疝入的腹腔器官,采用不可吸收线间断缝合修补膈肌缺损,4例缺损无法缝合修补,采用补片修补。结果 5例手术均成功实施,手术时间74~210 min,平均135 min;手术出血量10~70 ml,平均24 ml;术后住院时间4~8 d,平均6 d。随访3~36个月,平均19.5月,未发现膈疝复发。结论腹腔镜治疗陈旧性创伤性膈疝具有创伤小、术后恢复快、术后并发症少等优点,是治疗创伤性膈疝的有效手术方式。     

创伤性膈疝的临床诊断及手术治疗的疗效分析

目的研究讨论创伤性膈疝的诊断要点及手术修补后的临床效果评估。方法回顾性分析本院2011年1月至2014年2月36例创伤性膈疝患者资料。结果 36例患者中,35例完全治愈出院;1例出现胸部积脓,经再次对症处理后治愈;2例因术前失血性休克,术中发现疝入的腹腔脏器伴有绞榨性坏死或穿孔,胸部发生感染导致肠粘连,经多次手术治疗后基本痊愈。1例因术前创伤性膈疝伴有多发性脏器损伤,术后器官功能衰竭导致死亡。无再次出血、腹膜炎或缝合口裂开、伤口不愈合或延迟愈合、感染、膈疝复发等并发症发生。临床效果评估,显效33例,有效2例,无效1例。有效率97.22%。结论创伤性膈疝诊断比较困难,对入院患者需严格监测临床症状,并采用X线、CT等影像学检查,提高早期诊断率,一经确诊需行急诊手术治疗,修复破裂膈肌,均可达到较好的治疗效果。     

创伤性膈疝的外科治疗分析

目的探讨创伤性膈疝的诊断及治疗效果。方法对32例创伤性膈疝患者实施膈肌修补手术并对胸腹受损腔脏器进行治疗。回顾性分析患者的临床资料。结果 29例均痊愈,术后死亡3例。结论根据临床征象并经胸腹部X线平片、C T、钡餐等检查,创伤性膈疝可及时诊断。早期进行手术治疗,可有效减少病死率,改善预后。     

23例创伤性膈疝的急诊手术分析

目的总结创伤性膈疝的诊治经验。方法对我院所收治的21例创伤性膈疝进行回顾性分析。结果术前确诊16例,术中探查确诊5例;经腹径路手术17例,经胸径路手术2例,胸腹联合径路手术2例;21例全部治愈。结论创伤性膈疝一经确诊应尽早手术治疗。开胸探查术是绝大多数创伤性膈疝首选的手术方法,尽早手术修补膈肌裂口,及时正确地处理合并脏器伤是提高治愈率,降低病死率的关键。     

创伤性膈疝25例临床诊治体会

目的总结创伤性膈疝的临床诊断和早期治疗的经验,为减少误诊、漏诊及提高治愈率提供参考。方法对25例创伤性膈疝患者的临床资料与治疗经验进行总结分析,21例于伤后24 h内就诊,3例于伤后48h就诊;1例CT检查发现空腔脏器疝入胸腔,追问病史,2年前有外伤史。术前均完善胸片、胸腹部CT和胸腹部B超检查,术前均获确诊,确诊率100%。采用经胸手术14例,经腹手术8例,胸腹联合切口3例。疝内容物为肝3例,脾6例,胃7例,大网膜4例,结肠2例,其他3例。同时行肝修补术3例,行脾切除术6例,行胃肠破裂修补术13例。结果术中发现左侧膈疝23例,右侧膈疝2例。膈肌呈线性破裂20例,呈不规则破裂5例。膈肌破裂长度平均为7.6(4～16)cm。治愈23例,死亡2例,病死率8%。23例均获随访,平均随访时间28.5(6～40)个月,未见膈疝复发。结论创伤性膈疝多发生于严重胸腹部损伤,缺乏特异性临床表现,一经确诊应尽早手术治疗。修补膈肌裂口,及时正确地处理合并脏器伤是提高治愈率,降低死亡率的关键。     

骨盆骨折合并创伤性膈疝的临床特点及漏诊原因分析

[目的]总结骨盆骨折合并创伤性膈疝的临床特点并分析漏诊原因。[方法]回顾性分析2001年12月~2012年3月收治的836例骨盆骨折患者,其中7例合并创伤性膈疝。全部为男性。年龄19~63岁,平均40.5岁。交通伤3例,高处坠落伤2例,挤压伤1例,砸伤1例。骨盆骨折按Tile分型:B1型1例,B2型6例。膈疝全部为左侧。合并创伤性休克3例,合并肋骨骨折6例,合并脾破裂6例,合并胃肠道破裂2例,合并尿道断裂1例,合并其他部位骨折3例。2例骨盆骨折行骨盆外固定架固定,其余5例保守治疗。膈疝均行手术治疗。[结果]7例患者均于治愈或好转后出院。患者均获得随访,随访时间9~36个月,平均16个月。7例患者中4例创伤性膈疝漏诊。漏诊原因1例为膈疝症状不典型,3例为严重创伤掩盖膈疝症状。骨盆骨折均愈合,愈合时间3~6个月,根据Majeed功能评分,优4例,良2例,可1例,优良率85.7%。随访过程中未发现与创伤性膈疝相关的呼吸、消化、循环系统并发症。[结论](1)骨盆骨折合并创伤性膈疝多见于男性,多为高能量损伤所致,多合并肋骨骨折及脾破裂,其中骨盆骨折多为Tile B2型,膈疝多见于左侧;(2)骨盆骨折患者中创伤性膈疝的发生率虽低,但漏诊率较高,漏诊原因多为膈疝症状不典型或严重创伤掩盖膈疝症状;(3)骨盆骨折合并创伤性膈疝如能及时确诊,给予相应治疗,预后是良好的。     

成人非创伤性膈疝诊治分析

目的总结成人非创伤性膈疝的诊治体会。方法回顾性分析10例成人非创伤性膈疝患者的临床资料。结果 10例均痊愈,治愈率达100%。结论成人非创伤性膈疝诊断明确后即应尽早施行手术治疗,疗效满意。     

创伤性膈疝的外科治疗（附16例报告）

目的 总结创伤性膈疝的诊治经验。方法 对16例创伤性膈疝临床资料进行回顾性分析。结果 术前确诊15例，治愈15例，死亡1例，病死率6．25％。结论 创伤性膈疝一经确诊应尽早手术治疗。开胸探查术是绝大多数创伤性膈疝首选的手术方法，尽早手术修补膈肌裂口，及时正确地处理合并脏器伤是提高治愈率，降低病死率的关键。     

电视胸腔镜手术治疗创伤性膈疝

目的探讨电视胸腔镜手术（video-assisted thoracoscopic surgery,VATS）在创伤性膈疝治疗中的应用价值。方法 2005年12月～2011年12月对27例创伤性膈疝行VATS膈疝回纳联合膈肌修补术。术中探查损伤情况,分离粘连并止血后,将膈疝回纳入腹腔,丝线8字缝合后prolene线加固缝合膈肌裂口。出血、裂伤脏器行修补或切除,损伤严重者中转开胸探查。结果 26例术后均恢复顺利,好转或痊愈出院,1例因病情严重术中死亡。5例中转开胸,其余21例均在VATS下完成手术,中转率18.5%（5/27）。手术时间45～190 min,平均135 min;术中出血量20～680 ml,平均278 ml。术后胸腔引流2～5 d,平均3.5 d;引流量30～280 ml,平均185 ml。术中、术后无并发症。术后住院时间2～10 d,平均6.5 d。26例随访1～24个月,平均12.5月,无并发症发生。结论 VATS治疗创伤性膈疝可行、安全。     

创伤性膈疝12例临床诊治体会

目的总结创伤性膈疝的诊治经验。方法对12例创伤性膈疝临床资料进行回顾性分析。结果术前确诊10例，治愈11例，死亡1例，病死率8．33％。结论创伤性膈疝一经确诊应尽早手术治疗。剖腹术是绝大多数创伤性膈疝患者首选的手术方法，尽早手术修补膈肌裂口，及时正确地处理合并脏器伤是提高治愈率，降低死亡率的关键。     

创伤性膈疝的诊断和治疗

目的 总结创伤性膈疝的诊治经验。方法 回顾性分析自１９７２年１月至１９９８年８月４家医院收治的８５例创伤性膈疝,其发生原因为穿透性损伤４３例,闭合性损伤４２例,９５．３％的病人合并其它脏器损伤。手术治疗采用剖胸术１１例,剖腹术７２例,剖腹后剖胸术２例。结果 术前确诊５８例,全组治愈７８例,死亡７例,病死率８．２％。     

12例儿童创伤性膈疝的诊断与外科治疗

目的探讨儿章创伤性膈疝的临床特点、诊断与治疗方法。方法回顾性分析儿童创伤性膈疝12例，其中闭合性损伤10例，穿透性损伤2例。急性期膈疝10例，慢性期膈疝2例。结果本组手术治愈11例，1例死于合并的颅脑损伤（未做膈疝手术），术前误诊2例（16．7％）。结论儿童创伤性膈疝易被误诊，提高诊断意识并根据临床特征结合应用X线等影像检查方法，可提高早期确诊率；一旦确诊应时期手术治疗。     

创伤性膈疝26例诊治分析

目的 总结创伤性膈疝的诊治经验。方法 回顾性分析26例创伤性膈疝临床资料,其中开放性损伤7例,闭合性损伤19例。92.3％(24/26)的病人合并其它脏器损伤。手术采用剖腹术16例,剖胸术6例,胸腹联合切口4例。结果 术前确诊19例(73.1％),治愈24例,死亡2例。结论 创伤性膈疝一经确诊应尽早手术治疗。胸部X线检查最具诊断价值。早期诊断、尽早手术修补膈肌裂口,及时、正确地处理合并脏器伤是提高治愈率的关键。     

创伤性膈疝28例临床分析

目的总结创伤性膈疝的诊治经验。方法回顾分析1990年1月～2004年8月28例创伤性膈疝临床资料。其中开放性损伤7例,闭合性损伤21例。结果术前确诊19例（67．9％）,治愈25例。死亡3例（10．7％）,2例死于出血性休克,1例死于多器官功能障碍综合征（MODS）。结论胸部X线和CT检查是诊断创伤性膈疝的重要方法。早期诊断、及时手术,正确处理合并脏器伤是提高治愈率的关键。     

Traumatic diaphragmatic hernia. Report of 50 cases

The writers report a clinical series of 50 patients with traumatic diaphragmatic hernia. There were 36 hernias on the left side and 14 on the right. Stab or bullet wound was the cause of the hernia in 27 cases. The other 23 cases were due to traffic accidents or other blunt injuries. Immediate operative repair was done in 30 cases; in 20 cases the operation was carried out after a time interval of 11.5 years post trauma on an average. Plain chest X-ray, barium meal or enema and pneumoperitoneum were the most valuable diagnostic tools. Visceral injuries were discovered in 53% of cases caused by traffic accidents. The omentum, stomach, colon and spleen were the organs most frequently herniated. In two cases perforation of the stomach occurred before the operation. There were three cases of pericardial rupture associated with the diaphragmatic hernia in the series. The repair was done via thoracotomy in 28 cases, via laparotomy in 4 cases; and both thoracotomy and laparotomy were carried out in 18 cases. The hospital mortality was 2%. One of the patients died of peritonitis and renal failure following perforation of the stomach and intestines on the 9th postoperative day. Recurrence of the hernia occurred twice in one case. Re-examination revealed striction of the diaphragmatic movement in 11 cases. The clinical features, diagnosis and operative treatment are discussed.     

创伤性膈疝的诊断与治疗

目的探讨创伤性膈疝的诊断与治疗方法。方法回顾性分析1995～2004年收治的26例创伤性膈疝患者,并对其诊治方法和手术后并发症进行总结评价。结果本组25例治愈出院,因张力性气胸未能及时纠正术中死亡1例。术后发生并发症6例（23．1％）,其中胸腔积液3例,肾功能不全1例,继发出血1例,真菌感染1例,经非手术治疗均痊愈。结论早期诊断和及时手术治疗是减少并发症的根本措施。     

Treatment of thoracoabdominal gunshot wounds in civilian practice. Experience with forty-four cases

Forty-four acute cases of thoracoabdominal injuries in civilian practice are presented. Injury to multiple abdominal organs occurred in 50 per cent. The mortality in those with multiple organ injuries was 33 per cent whereas among those with injury to a solitary organ it was 4.5 per cent. The liver was injured in 61 per cent of cases. Although intercostal tube drainage (50 per cent) usually suffices in the management of the chest injury, thoracotomy was indicated in a number of cases. We advocate preservation of the thoracoabdominal barrier, by making a separate thoracic and abdominal wound, to prevent thoracic contamination, diaphragmatic hernia, and to achieve a thorough abdominal exploration. The total complication rate is 25 per cent. There were nine deaths (20 per cent) in the entire series, eight of which were directly related to the thoracoabdominal injury, yielding a corrected mortality of 18 per cent. One patient died from a separate gunshot wound to the brain.     

Acute diaphragmatic injuries

A 5-year experience with 43 patients with acute diaphragmatic injuries is reviewed. Thirty-three of the patients had penetrating trauma, and 10 suffered blunt trauma. All but 1 of the patients had associated intraabdominal trauma. Fifteen had traumatic diaphragmatic hernia at the time of operation. The operative approach was uniformly through the abdomen. Mortality and morbidity were directly related to the number of associated organs injured.Chest roentgenograms in 26 of the 43 patients were interpreted as suspicious or diagnostic of diaphragmatic injury when presented as unknowns to fully trained radiologists, but only 7 of these were originally so interpreted.Delay in operation was a significant contributing factor to morbidity, particularly in patients with thoracic stab wounds. Guidelines suggested to prevent delay include: (1) increased awareness of the possibility of acute diaphragmatic injury, (2) careful evaluation of the plain chest roentgenogram and liberal use of appropriate contrast studies when indicated, (3) prompt repair of recognized diaphragmatic injuries, (4) laparotomy as the operative approach in the acute injury, and (5) appropriate contrast studies after recovery from massive thoracoabdominal trauma and prior to hospital discharge.     

Traumatic rupture of the right hemidiaphragm

Sixteen cases of traumatic disruption of the right hemidiaphragm are presented. Six tears were treated in the acute post-trauma phase and ten were detected from late manifestations. The causal trauma was penetrating in 11 cases and blunt in five. Rupture of the right hemidiaphragm not uncommonly occurs without serious associated injuries. Bowel often herniates through such tears, unhindered by the liver, though the liver is the most commonly herniating organ. No recurrence of hernia was found after standard repair techniques (mean follow-up 5.2 years). Three of the 16 patients died, one from associated injury, one from strangulation of herniated bowel and one from postoperative myocardial infarction. To demonstrate diaphragmatic tearing and subsequent organ herniation, serial chest radiographs and computed tomography are useful, and exploratory laporotomy should be done without delay after penetrating injury to the trunk. The treatment of diaphragmatic tear is surgical, with better results from early than from late repair.