术后腹内疝致急性肠梗阻20例诊治分析

目的 探讨术后腹内疝所致急性肠梗阻的病因、临床特点、诊断及治疗.方法 对2000年1月至2013年3月诊治的20例经手术证实为腹内疝患者的临床资料进行回顾性分析.结果 20例术后腹内疝中,粘连束带嵌顿性内疝5例,肠系膜裂孔疝7例,吻合口后间隙疝6例,造瘘口旁内疝2例.均行手术治疗,15例出现肠坏死行肠切除肠吻合术,1例因中毒性休克而死亡.结论 术后腹内疝发生的病因基础是腹内粘连物粘连后局部有裂隙形成或术后遗留未修复的裂隙,此病病情进展快,易发生肠绞窄及肠坏死,提高认识、早期诊断、早期手术是本病治愈的关键.     

腹部术后内疝的诊断治疗

目的探讨术后腹内疝发生的病因,提高对该病的认识、诊断及治疗水平。方法对经手术证实的17例腹内疝临床资料进行回顾分析。结果剖腹探查手术证实为胃大部切除毕Ⅱ式胃空肠吻合口后疝3例,食管空肠Roux-Y吻合口后疝2例,胆道空肠Roux-Y吻合口后疝2例,经腹腔粘连间隙疝5例,肠系膜裂隙疝3例,造瘘口旁内疝1例,盆底裂隙疝1例。均手术治疗,无死亡病例。结论腹内疝临床较少见,术前诊断困难,均以肠梗阻收入,对有手术史及腹部外伤史,考虑腹内疝者,应及时手术,以防发生肠绞窄、肠坏死。     

逆行性疝7例报告及文献复习

逆行性疝(Maydl’疝)甚为罕见,其疝囊中有两个肠袢,而两肠袢之间的闭袢则仍留在腹内。这种W形疝的特点是在疝囊内肠袢尚具有活力时,腹内闭袢可能已坏死。文献表明其发病率为绞窄性疝的0.6%～1.92%。作者曾在2年中为7例逆行性疝施行手术。7例全系男性,右侧占5例,各例疝块均很大。手术发现肠坏死仅见于腹内闭袢者1例,同时见于腹内闭袢及疝囊内肠袢者1例;前者切除大段回肠后一期吻合,后者切除部分空肠及大部回肠后一期吻合。本组有1例无肠坏死者疝囊内两肠袢分别为盆结肠和横结肠。除1例未坏死者因复位困难而行二期手术外,本组其     

腹部术后腹内疝致急性肠梗阻的诊治体会（附26例报道）

目的　探讨腹内疝致急性肠梗阻的术前诊断和处理对策。方法　回顾性总结 1985～2 0 0 0年收治的 2 6例腹内疝患者的诊断和处理 ,并比较早期和延迟手术其肠坏死的发生率及术后并发症。结果　 17例施行了坏死肠段切除肠吻合术 ,另 9例分别采用束带松解和系膜裂孔缝补术。比较有无肠坏死与手术时间早晚的结果有显著性差异 (P <0 .0 1)。 2 5例治愈出院 ,1例术后死于MSOF。结论　腹内疝致急性肠梗阻术前诊断困难 ,早期诊断和手术是避免发生肠坏死和术后并发症的关键     

剖宫产术后腹内疝性肠梗阻11例分析

腹内疝性肠梗阻是因先天或后天因素形成腹腔内异常间隙,肠管经此间隙疝人而导致梗阻的一类病变.腹腔手术是导致腹内疝形成的最常见后天因素,因手术造成腹腔内异常的孔隙、术后组织器官间的粘连、术后形成的异常索带,都可以构成腹内疝的疝环,肠管疝人其中,持续遭受疝环卡压发生肠坏死,如不及时诊断处理,病死率高达50％.     

胃大部切除胃空肠吻合术后吻合后疝

胃大部切除、胃空肠吻合术后内疝较少发生,但发生后很少引起注意,故死亡率常高达40%。吻合后疝可发生于输入段,亦可发生于输出段,无论那种术式,无论空肠段那种走向均可发生。作者报导了此种病例10例,并介绍了吻合后疝之发生,类型,诊断,预防及处理。吻合后间隙胃空肠吻合后形成了一定的空隙,这些间隙的弹力性和松弛性限度很小,并形成了一种疝环。在结肠前胃空肠吻合后形成一大间隙,间隙前方为空肠段,胃肠吻合部,上方为残胃腹膜反折,后方为部分后腹膜、横结肠、结肠系膜及大纲膜,下方为Treitz 靭带。     

十二指肠第三、四段切除术四例

例 1　女 ,30岁。因胃溃疡施行胃大部切除、经结肠后Billroth Ⅱ式胃肠重建术 ,1周后出现上腹疼痛、呕吐、腹胀、腹肌紧张。腹部X线透视 :左上腹有液平面。再次手术探查。术中发现腹腔内约有 80 0ml含胆汁暗黑色液体 ,部分空肠经胃空肠吻合口后间隙疝入 ,压迫空肠输入襻致梗阻 ,十二指肠扩张显著 ,第三段扩张尤甚 ,呈囊袋状 ,且已发黑坏死并穿孔 ,十二指肠第二段 (降段 )血运良好 ,腹膜后也有较多与腹腔内相同的液体。诊断 :内疝、输入襻梗阻、十二指肠部分坏死穿孔。清除腹腔内及腹膜后液体 ,切除空肠输入襻及十二指肠第三、四段 ,封闭靠…     

胃大部切除术后吻合口后疝14例分析

目的探讨胃大部切除术后发生吻合口后疝的原因以及诊断、治疗和预防措施。方法回顾性分析１９７５～１９９７年诊治的１４例胃大部切除术后吻合口后疝的资料。结果１４例皆并发于ＢｉｌｒｏｔｈⅡ式胃肠吻合术后，其中属结肠前吻合者１２例（输入袢长１６～２５ｃｍ）；结肠后吻合者２例（输入袢长１０～１４ｃｍ）；治愈１０例，死亡４例（２８％）。结论胃大部切除吻合口后疝术前诊断极困难，一旦确诊应尽早手术治疗。预防胃大部切除吻合口后疝的关键是消除吻合口后裂隙，正确选择输入袢长度。     

阑尾炎术后继发性腹内疝致急性肠梗阻的分析

粘连性肠梗阻是普通外科常见疾病,部分病例经非手术治疗无效,发生肠坏死而必须手术治疗.我们研究发现可导致肠梗阻的常见粘连类型如内疝、索带、成角、扭转、粘连成团等,腹内疝导致肠绞窄最多,而阑尾炎术后粘连性肠梗阻病例中腹内疝发生率甚高,其肠绞窄发生率亦较高. 资料与方法 1.一般资料:我院自2009年8月至2012年6月临床诊断粘连性肠梗阻并接受手术治疗的患者共109例,均为粘连直接导致的机械性肠梗阻,无肿瘤复发或其他可导致肠梗阻的腹腔内疾患,其中阑尾炎手术治疗后粘连性肠梗阻25例,距阑尾切除术时间最短2个月,最长达35年;肠梗阻手术时间最早为发病24h内,22例在3d内手术,最长35 d手术.     

腹内疝所致肠梗阻32例临床诊治体会

目的　提高对腹内疝所致肠梗阻的认识。方法　回顾性分析 32例腹内疝所致肠梗阻病人的临床资料。结果　 32例均为小肠疝入粘连形成的孔隙引起 ,术前诊断率为 5 6 .3% (1 8/32 ) ,术中证实并伴有肠坏死者为 71 .9% (2 3/32 ) ,死亡率为 9.4 % (3/32 )。结论　本病术前诊断困难 ,即使作出诊断也多已有肠坏死。对本病临床特点缺乏认识是延误诊断的主要原因     

Incarcerated incisional hernia of the sigmoid colon after appendectomy: A case report

IntroductionIncisional hernia after appendectomy is rare, affecting 0.4% to 0.9% of cases. The small bowel and omentum are commonly herniated through the abdominal wall defect, but incisional hernia of the sigmoid colon is extremely rare.Case presentationA 78-year-old man presented with a right lower quadrant abdominal wall mass on the previous McBurney incision site. He had a history of appendectomy for appendicitis 40 years ago. Computed tomography (CT) showed the sigmoid colon herniated thorough the abdominal wall defect. During the operation, a feces-impacted sigmoid colon was found protruding through the defect of the abdominal wall. Reduction of the sigmoid colon into the peritoneal cavity and herniorrhaphy with primary repair were performed.DiscussionThe ascending and descending colon are fixed into the retroperitoneum, whereas the transverse and sigmoid colon are not, which can allow these bowel segments to herniate through a weak abdominal wall just as small bowel loops do. However, incisional hernia of the colon is extremely rare. The diagnosis of incisional hernia can be easily made because a reducible abdominal wall mass can be detected by physical examination. In cases with rare type of hernia, CT can identify unusual types of abdominal hernias and differentiate hernias from neoplasms, inflammatory disease, and hematoma.ConclusionAlthough incisional hernia of the colon after appendectomy is extremely rare and preoperative diagnosis by physical examination is difficult, CT is a useful method to make the correct diagnosis, avoiding unnecessary invasive intervention, particularly in patients with an unusual abdominal wall mass.     

Delayed recognition of inadvertent gut injury during laparoscopy

Bowel injuries, which may occur as a result of the insertion of an insufflation needle or trocar, are a rare complication of laparoscopy. They are generally recognized either immediately or a few days after the operation. We present a case of laparoscopic perforation of the small intestine in a patient who had undergone previous pelvic surgery for an ovarian carcinoma. On ultrasound (US), the patient had multiple hepatic lesions resembling hepatic metastases. To confirm the diagnosis, laparoscopy with guided liver biopsy was performed on the grounds that this procedure is regarded as more appropriate than CT- or US-guided hepatic biopsy. Veress needle and trocar insertion were performed at a proper distance from the abdominal scar. However, the abdominal cavity was not visible after the trocar's insertion due to the unexpected presence of adhesions. This precluded the continuation of the procedure. In the following days, the patient experienced only mild abdominal discomfort. However, 2 weeks after laparoscopy, the patient presented signs of peritoneal reaction and underwent laparotomy. Adhesion-fixing jejunal loops to the anterior abdominal wall were discovered at the site of the trocar puncture. Moreover, two hiatuses of these loops were observed and sutured. The follow-up was uneventful. As this case illustrates, laparoscopic bowel injuries remain an unpredictable event. Recognition of this complication may occur several days after the procedure, as the tamponating effect of adhesions on the jejunal hiatus delays the involvement of the peritoneum.     

Internal Hernia after Laparoscopic Roux-en-Y Gastric Bypass for Morbid Obesity: A Continuous Challenge in Bariatric Surgery

Background: Roux-en-Y gastric bypass (RYGBP) has long been associated with the possible development of internal hernias, with a reported incidence of 1-5%. Because it induces fewer adhesions than laparotomy, the laparoscopic approach to this operation appears to increase the rate of this complication, which can present dramatically. Methods: Data from all patients undergoing bariatric surgery are introduced prospectively in a data-base. Patients who were reoperated for symptoms or signs suggestive of an internal hernia were reviewed retrospectively, with special emphasis on clinical and radiological findings, and surgical management. Results: Of 607 patients who underwent laparoscopic primary or reoperative RYGBP in our two hospitals between June 1999 and January 2006, 25 developed symptoms suggestive of an internal hernia, 2 in the immediate postoperative period, and 23 later on, after a mean of 29 months and a mean loss of 14.5 BMI units. 9 of the latter presented with an acute bowel obstruction, of which 1 required small bowel resection for necrosis. Recurrent colicky abdominal pain was the leading symptom in the others. Reoperation confirmed the diagnosis of internal hernia in all but 1 patient. The most common location was the meso-jejunal mesenteric window (16 patients, 56%), followed by Petersen's window (8 patients, 27%), and the mesocolic window (5 patients, (17%). Patients in whom the mesenteric windows had been closed using running non-absorbable sutures had fewer hernias than patients treated with absorbable sutures at the primary procedure (1.3% versus 5.6%, P=0.03). Except in the acute setting, clinical and radiological findings were of little help in the diagnosis. Conclusions: Except in the setting of acute obstruction, clinical and radiological findings usually do not help in the diagnosis of internal hernia. A high index of suspicion, based mainly on the clinical history of recurrent colicky abdominal pain, is the only means to reduce the number of acute complications leading to bowel resection by offering the patient an elective laparoscopic exploration with repair of all the defects. Prevention by carefully closing all potential mesenteric defects with running non-absorbable sutures during laparoscopic RYGBP, which we consider mandatory, seems appropriate in reducing the incidence of this complication.     

腹腔镜切口疝修补术中腹腔粘连的诊断、分型及分离技巧

背景与目的 切口疝是腹部手术的常见并发症之一，而患者在经历了腹部手术后常有不同程度的腹腔内粘连，分离粘连是切口疝修补过程中不可回避且有相对难度的工作。术前人工渐进性气腹是腹腔镜切口疝修补术中的重要环节，笔者前期发现，通过对比气腹前后的影像学资料，可评估切口疝患者腹腔内状态，有利于手术预判，提高手术精准度，减少手术风险。本文旨在进一步探讨人工气腹结合腹部CT在伴腹腔粘连切口疝患者的腹腔镜修补术中的应用价值，并总结腹腔粘连的类型和分离粘连的手术技巧。方法 回顾性收集分析2019年4月—2020年5月在中山大学附属第六医院胃肠、疝和腹壁外科行腹腔镜切口疝修补术患者的临床资料和手术录像。通过术前人工气腹前、后腹部CT对比，判断是否存在腹腔粘连。研究者通过手术录像复盘，观察腹腔粘连的分型，总结粘连分离的技巧，记录术中粘连分离时间和并发症，统计观察孔穿刺时副损伤情况，术后并发症与恢复情况。结果 共收集72例行腹腔镜切口疝修补术病例，其中15例术前未建立人工气腹，7例建立人工气腹后术前未复查腹部CT，15例气腹前或气腹后未行疝囊三维CT重建，均予以排除。最终纳入35例患者，均为II型腹壁缺损；复发疝5例；男16例，女19例；年龄（63.26±11.11）岁；体质量指数25.04（23.03~27.34）kg/m²；既往手术术后有腹腔内感染伴切口感染者4例，切口感染者7例；最多手术次数5次。通过人工气腹前、后腹部CT对比，诊断存在腹腔内容物与腹壁粘连者33例（94.29%），无粘连者2例（5.71%）。其中主要粘连物为肠管20例（60.61%），主要粘连物为网膜组织13例（39.39%）。根据粘连的形态可分为：点状粘连，线状粘连，片状粘连及混合型粘连。根据粘连的质地可分为：膜性粘连，瘢痕性粘连及复合型粘连。粘连分离采取层面变峰面，面转化线和点，钝锐结合分离膜性粘连，锐性分离瘢痕性粘连的程序化方法。全组均成功松解分离粘连，分离时间32（4.50~46.50）min。其中5例发生小肠壁浆肌层损伤，予3-0可吸收缝线行浆肌层缝合。在行观察孔穿刺时，均未发生腹腔内脏器损伤。术后1例出现肺部感染，术后恢复排气时间3（2~4）d。结论 术前人工气腹结合腹部CT有助于判断是否存在腹腔粘连及粘连部位，有利于观察孔布局的选择。根据其形态和性质采取程序化的方法有利于简化腹腔粘连的分离。     

三维双层补片治疗腹股沟疝

目的　探讨采用新型无张力三维双层补片修补术治疗腹股沟疝 ,及其减少腹股沟疝的术后并发症和复发率的效果。方法　分析行三维双层补片疝修补术 47例患者的临床资料。 47例均为男性。中位年龄 65岁。斜疝 3 6例 ,直疝 11例。该组患者的五六评分总得分均大于或等于 6分。术中广泛解剖腹股沟区 ,将疝囊完全剥离至疝囊颈后 ,通过内环口将腹横筋膜与腹膜分离。在将疝囊经内环送入腹腔的同时 ,将三维补片的下层片经内环置入腹横筋膜与腹膜之间的间隙 ,上层补片缝合在腹股沟韧带和弓状下缘上 ,形成一个对腹股沟区前后修补的三维结构。结果　术后患者无不良反应 ,术后第 1天即可下床活动 ,第 3天出院。全部患者随访 1～ 2年 ,均无不适感 ,手术部位未出现硬结 ,无复发。结论　该术式适用于“五六评分法”总分 >6分且腹股沟管后壁需要修补的患者。该手术方式符合人体解剖特点 ,手术后并发症和复发率少 ,值得临床推广。但手术方法较复杂 ,对手术者的手术技巧要求较高。     

Non-closure of Defects during Laparoscopic Roux-en-Y Gastric Bypass

Background The concern about internal hernias has prompted recommendations for routine closure of defects during laparoscopic Roux-en-Y gastric bypass (LRYGBP). Our belief is that not all techniques require closure of defects. We hypothesize that nonclosure of defects with our particular technique would not cause a significant clinically evident internal hernia rate. Methods All patients who were operated on between December 2002 and June 2005 were included in this study. The technique that was utilized included an antecolic antegastric gastrojejunostomy (GJ), division of the greater omentum, a long jejunojejunostomy (JJ) performed with three staple-lines, a short (<4 cm) division of the small bowel mesentery, and placement of the JJ above the colon in the left upper quadrant. Clinical records were reviewed for reoperations. Results here was a total of 300 patients, and no incidence of internal hernia. In the first 100 patients, there was 97% follow-up for 1 year or more. Four patients underwent reoperations for unexplained abdominal pain. Intraoperative findings included an adhesive band from the JJ to the colon (1), an adhesive band from the JJ to the anterior abdominal wall (1), an adhesive band 3 cm from the GJ to the anterior abdominal wall (1), and adhesions of the jejunum to the anterior abdominal wall (1). No patient had an internal hernia. Conclusions Internal hernias are not common after this particular method of LRYGBP. Before adopting routine closure of potential spaces, surgeons should consider their technique, follow-up, and incidence of internal hernias. Routine closure of these defects is not always necessary.     

Internal Hernias after Laparoscopic Roux-en-Y Gastric Bypass: Incidence,Treatment and Prevention

Background: Laparoscopic Roux-en-Y gastric bypass (RYGBP) has been shown to be a safe and effective alternative to traditional "open" RYGBP. Although lack of postoperative adhesions is one advantage of minimally invasive surgery, this is also responsible for a higher incidence of internal hernias. These patients often present with intermittent abdominal pain or small bowel obstruction with completely normal contrast radiographs. Methods: Data was obtained concurrently on 2,000 consecutive patients from February 1998 to October 2001 and analyzed retrospectively. Radiographs, when available, were interpreted by both the operative surgeon and radiologist before intervention. Results: 66 internal hernias occurred in 63 patients, an incidence of 3.1%. 1 patient presented with a traditional adhesive band and small bowel obstruction. 20% of patients had normal preoperative small bowel series and/or CT scans. The site of internal hernias varied: 44 - mesocolon; 14 - jejunal mesentery; 5 - Petersen's space. Although most patients were symptomatic, 5% were incidental findings at the time of another surgical procedure. 5 patients required open repair. 6 patients presented with perforation either at the time of diagnosis or as a result of manipulation of the bowel. There was 1 death associated with complications of the internal hernia. The negative exploration rate was 2%. Conclusion: Internal hernias are more common following laparoscopic RYGBP than "open" RYGBP. Contrast radiographs alone are unreliable in ruling out this diagnosis. Early intervention is crucial; most repairs can be performed laparoscopically. This diagnosis should be entertained in all patients with unexplained abdominal pain following laparoscopic RYGBP. Meticulous closure of all potential internal hernia sites is essential to limit this potentially lethal complication.     

Traumatic abdominal wall hernia: A case report and literature review

IntroductionTraumatic abdominal wall hernia is a rare but serious diagnosis resulting from blunt abdominal trauma. The clinical diagnosis is not usually straightforward and the hernia is often discovered at the time of the surgical exploration for intra-abdominal injuries or by imaging studies.Presentation of caseA 25-year-old obese, restraint, male patient was the victim of a high-speed road traffic accident. Among other injuries, he showed extensive skin maceration and bruising over the lower abdomen and flanks upon presentation, however he did not need any surgical intervention. Contrast-enhanced computed tomography scan of the abdomen and pelvis demonstrated extensive abdominal wall muscular disruption over both flanks with herniation of the right colon. Counselled to follow up in 4–6 weeks to have the hernia surgically repaired, he showed up after 8 months with a large muscular defect resulting in a large hernia containing small and large bowel loops.DiscussionThe timing and type of the surgical repair of traumatic abdominal wall hernia depends upon the size of the hernia defect and the presence of associated intra-abdominal injuries. Delayed repair; however, may result in a large defect making primary, non-prosthetic repair impossible and increases the risk of abdominal compartment syndrome after surgical correction.ConclusionTraumatic abdominal wall hernia presents a diagnostic as well as a therapeutic challenge. The therapeutic approach is governed by a multitude of factors emphasizing the need of a patient-tailored, case by case management plan.     

Elective surgical treatment of a giant scrotal hernia]

We report on a 69-year-old man presenting with a giant scrotal hernia, who failed to tolerate a pre-operative pneumoperitoneum applied with the intention to increase his intra-abdominal capacity. After enlarging the hernial orifice, the hernia contents - comprising the entire small bowel, the right colon and the greater omentum - were replaced into the abdominal cavity. Closure of the abdominal wound with mesh support was possible only after extensive resection of the small bowel, together with the voluminous mesentery and greater omentum. In a second operation performed later on revision of the scrotum and penis was undertaken. It is not always possible to achieve the required increase in intra-abdominal capacity through the use of a pneumoperitoneum. In such cases, extensive bowel resections and the use of biomaterials for tension-free abdominal wall repair must form an integral part of the treatment concept. Surgical management of such giant hernias has to be adapted to the individual situation of the patient using all therapeutic options.