单孔Port技术在腹壁疝全腹膜外Sublay修补术中的应用

目的评价单孔Port技术应用于腹壁疝全腹膜外Sublay（TES）修补的可行性并总结手术经验。 方法回顾性分析2019年5至7月，上海交通大学附属第一人民医院5例结合单孔Port的腹壁疝TES修补术患者的临床资料。所有患者经专家门诊随访，对术中和术后情况的数据进行搜集、整理和统计分析，并评价本组腹壁疝患者手术时间、观察术后引流量和并发症发生情况。 结果所有腹壁疝患者均顺利完成手术，手术时间120～300（184.00±73.92）min，引流量少，无近期并发症，术后第1天疼痛视觉模拟评分（VAS）（1.00±0.63）分，第14天VAS（1.20±1.17）分。 结论利用Port减孔和单孔手术可以进行腹壁疝TES修补术。单孔Port技术与TES结合，可以给腹壁疝患者更多微创选择。     

内镜下全腹膜外Sublay修补在腹壁疝中的应用

目的评价腹壁疝内镜下全腹膜外Sublay(TES)手术的效果并总结经验。方法回顾性总结国内10所医院自2016年3月至2019年7月115例腹壁疝内镜下TES手术的患者资料。分析患者情况、疝的特点、手术经过和结果。结果115例计划实施TES的患者中,因严重腹膜破损中转为IPOM修补患者1例,其余均成功手术。可以缝合缺损患者108例(94.74%),需要永久补片固定患者15例(13.16%)。放置引流患者76例(66.67%),中位手术时间为144 min,术中无严重并发症发生。随访时间3~45个月,总并发症发生率为20例(17.54%),其中出现血清肿患者5例(4.38%)。绝大多数患者术后仅出现轻微疼痛,未出现慢性疼痛。结论在腹壁疝的治疗中,对熟悉腹壁解剖的外科医师而言,TES是一种有效、安全的修复手段。在熟悉手术的基础上适应症可逐步拓展。     

内镜下经腹Sublay修补术在腹壁疝治疗中的应用

目的初步评估经腹Sublay修补(transabdominal sublay, TAS)修复腹壁疝的可行性、安全性和有效性,并从初步临床实践中总结其手术要点和适应证。 方法回顾研究2016年5月至2019年5月同济大学附属东方医院等四家医院实施的21例中小型原发性腹壁疝和切口疝患者的资料,分析病例资料、疝的情况、手术细节和手术结果。 结果21例计划实施TAS修补的患者中,19例成功完成,另2例中转完成修补。手术中位时间120 min,术后48 h绝大部分患者仅存在轻度疼痛。无术中、术后严重并发症;血清肿是最常见并发症(15.8%),都在6个月内吸收;1例复发。 结论初步结果表明,TAS修补对于治疗中小型原发性腹壁疝和切口疝是可行、安全、有效的;但手术耗时较长,实施手术的外科医师需要更多的耐心和技巧,但成功实施TAS可避免将补片放置入腹腔,患者术后恢复也更快。     

腹腔镜完全腹膜外Sublay修补术治疗脐疝的回顾性临床研究

目的:探讨腹腔镜完全腹膜外Sublay修补术(TES)与腹腔内补片修补术(IPOM)治疗脐疝的临床效果。方法:回顾分析2016年3月至2020年11月行腹腔镜手术治疗的49例脐疝患者的临床资料,根据手术方式将患者分为TES组(n=21)与IPOM组(n=28),对比两组手术情况,评估临床效果,并随访掌握并发症发生率与复发率。结果:两组患者临床资料差异无统计学意义(P>0.05)。与IPOM组相比,TES组术中出血量多,手术时间、术后住院时间、肠蠕动恢复时间长,但医疗费用低,差异均有统计学意义(P<0.05)。TES组总有效率为95.24%,IPOM组为96.43%,两组差异无统计学意义(P>0.05)。TES组术后并发症发生率为23.81%,IPOM组为10.71%,差异无统计学意义(P>0.05)。两组复发率差异亦无统计学意义(P>0.05)。结论:腹腔镜TES与IPOM治疗脐疝均具有良好的临床效果,TES的医疗费用较低,但手术时间较长,术后恢复较慢。     

腹腔镜腹膜前疝修补新方法

目的:探讨腹腔镜腹膜前疝修补新方法的临床应用价值。方法:采用自行设计的腹腔镜腹膜前疝修补术治疗5例腹股沟疝患者,经腹腔在腹腔镜下旷置疝囊,在疝环口内外侧纵行切开并潜行游离腹膜,于腹膜前放置补片,覆盖疝环口,再用脐外侧韧带覆盖补片。结果:手术均获成功,无并发症发生,随访1年未见复发。结论:腹腔镜腹膜前疝修补新方法安全,可靠,方便易行,术后患者康复快、疼痛轻、效果好。     

腹腔镜完全腹膜外补片修补术治疗脐疝、脐旁疝的疗效分析

目的:对比分析腹腔镜完全腹膜外补片修补术(TES)与腹腔镜腹腔内补片修补术(IPOM)治疗脐疝、脐旁疝的临床疗效,探讨TES的安全性与局限性.方法:选取2018年6月至2020年6月行腹腔镜修补术的48例脐疝、脐旁疝患者进行前瞻性研究,随机分为两组,对照组25例,接受IPOM;研究组23例,接受TES.术后随访6个月....     

腹膜前间隙无张力修补马鞍疝的体会

目的 探讨腹膜前间隙无张力疝修补术在马鞍疝中的应用.方法 用美国强生公司生产的普理灵疝装置作为疝修补材料,在局麻下行151例马鞍疝腹膜前间隙无张力疝修补术,回顾性分析手术时间、术后切口疼痛、住院时间、并发症及复发率.结果 平均手术时间为(29.8±9.6) min,术后腹股沟区疼痛1例、阴囊水肿4例,无切口感染,无围手术期死亡.患者均于术后3～5 d痊愈出院,平均住院时间为(3.0±0.8) d,其中145例术后随访1～5年,平均(2.2±0.8)年,无术后复发.结论 腹膜前间隙无张力疝修补术治疗马鞍疝是安全可靠的.     

有高复发风险因素的腹股沟疝的治疗(附25例报告)

目的探讨加强固定的前入路腹膜前补片修补术治疗高复发风险的腹股沟疝的应用价值。方法 2011年2月～2019年2月,有高复发风险的腹股沟疝病人25例,均采用加固的前入路腹膜前补片修补术治疗,通过腹壁小切口置入补片于腹膜外间隙并缝合固定,同时附加Bassini法,以达到最大强度的修补。结果手术均顺利完成,包括3例疝囊直径超过30 cm的巨大腹股沟疝和1例双侧大腹股沟疝并耻骨上疝,手术切口中位数5.0 cm(最小切口3.5 cm),手术时间平均85分钟,术后30天内并发症发生率20.0%,无严重并发症,随访平均42个月,无术后复发。结论对于有高复发风险因素的腹股沟疝病人(包括巨大腹股沟疝病人),加固的前入路腹膜前补片修补术效果良好;对于瘦弱的直疝病人,还可以采用小切口进行手术。     

腹膜前无张力疝修补治疗复发疝的体会

目的讨论腹膜前无张力疝修补术治疗复发疝的应用方法对我院收治的42例复发疝患者采用北京天助畅运公司的善释腹膜前修补装置进行腹膜前无张力疝修补,观察手术时间、术后并发症、平均住院日及近期随访情况。结果手术时间45-90min,术后尿潴留6例,阴囊肿胀1例,皮下积液1例,异物感1例,平均住院日5．8d。结论腹膜前无张力疝修补是治疗复发疝的有效方法。     

腹腔镜全腹膜外疝修补术效果观察

目的观察腹腔镜全腹膜外疝修补术的效果。方法随机将96例腹股沟疝患者分为2组,每组48例。观察组采用腹腔镜全腹膜外疝修补术,对照组采用开放式全腹膜外疝修补术,比较2组治疗效果。结果观察组手术时间长于对照组,差异有统计学意义(P0.05)。观察组术中出血量、下床活动时间、住院时间、并发症发生率均少于对照组,差异有统计学意义(P0.05)。结论腔镜全腹膜外疝修补术治疗腹股沟疝创伤小、并发症少、术后恢复快。     

头侧入路的内镜下全腹膜外疝修补术治疗原发性腹壁疝的临床研究

目的探讨治疗原发性腹壁疝的微创新方法——头侧入路的内镜下全腹膜外疝修补术（TEA）的临床效果。 方法回顾性分析2019年11月至2020年1月,南方医科大学附属何贤纪念医院患者2例,河南中医药大学第一附属医院患者1例,河南省商丘市睢县中医院患者2例,郑州市第七人民医院患者1例,共6例接受头侧入路的TEA手术的原发性脐疝患者的临床资料。阐述手术操作流程及技术细节,分析其可行性和有效性。 结果6例患者术中均成功分离中上腹腹膜外空间并置入大张网片加强修复脐疝缺损,手术均获得成功,无中转开放手术。平均手术时间164 min（120～240 min）。术后伤口疼痛较轻,且术后第1天平均疼痛视觉模拟评分2.2分（2～3分）。术后平均住院时间2.2 d（2～3 d）。术后1例出现脐部少量血清肿,观察后自愈,未影响手术效果。术后随访时间6～15周,未发现复发患者。 结论头侧入路的TEA术式是安全可行的,可作为治疗中线原发性腹壁疝的一个选择,同时也是对TEA术式的一个补充。此术式扩大了TEA技术的适应证,避免了腹腔内置片修补术的弊端,值得向经验丰富的腔镜疝外科医师有限度推广。     

Laparoscopically assisted components separation technique for ventral incisional hernia repair

Reconstruction of the abdominal wall to repair ventral hernias continues to pose a challenge to surgeons due to relatively high rates of recurrence and morbidity. In 1990, Ramirez pioneered a technique of components separation of the abdominal wall for ventral hernia repair. Although an effective hernia repair, the mobilization of skin and subcutaneous tissue endangers the blood supply and predisposes midline skin to necrosis. The goal of this study is to determine whether releasing incisions in the transversus abdominis fascia and posterior rectus sheath provide adequate mobilization of the abdominal wall necessary for ventral hernia repair, thus paving the way for a laparoscopic component separation technique. Ten fresh cadavers were used and one side of the abdomen underwent the conventional Ramirez components separation: midline incision, dissection of skin and subcutaneous tissue off the anterior abdominal wall, and incisions in the external oblique aponeurosis and posterior rectus sheath, while the other side received incisions in the transversus abdominis fascia and the posterior rectus sheath with no undermining of the skin. The amount of fascial translation was measured after each incision. Incising only the external oblique aponeurosis produced greater mobilization of the abdominal wall at the level of the umbilicus (P = 0.02) and anterior superior iliac spine (ASIS, P = 0.029) than releasing only transversus abdominis fascia. More importantly, there was no statistically significant difference in the amount of release produced by the complete internal-release components separation versus the conventional technique. In order to test the feasibility of performing the procedure laparoscopically, one additional cadaver underwent a laparoscopic transversus abdominis fascia release. The procedure was successful and resulted in comparable amounts of fascial release as the other 10 cadavers. From this study, it appears technically feasible to perform a laparoscopic components separation to repair a ventral hernia and the procedure produces the same amount of release as the conventional open component separation technique.     

Planned totally extraperitoneal laparoscopic Spigelian hernia repair

A Spigelian hernia is a congenital defect in the tranversus aponeurosis fascia. Traditionally, an open anterior hernioplasty was used to repair these defects. Recently, laparoscopic approaches have been described. This report describes the first application of the totally extraperitoneal laparoscopic approach to a planned repair of a Spigelian hernia. The patient was a 62-year-old white female with a reducible left lower quadrant anterior abdominal wall bulge consistent with a Spigelian hernia. At the time of surgery, we exposed the posterior rectus fascia and modified our extraperitoneal inguinal hernia technique by passing the balloon dissector in a more lateral orientation. This created a unilateral preperitoneal space with adequate room for dissection and mesh fixation. The Spigelian defect was easily identified. Its preperitoneal fat contents were reduced, and a 5-mm laparoscopic tacking device was used to secure a piece of prolene mesh. The patient was discharged home with no complications. Placement of the mesh in the preperitoneal space avoids direct interaction of the mesh prosthesis and the intraperitoneal viscera. In conclusion, we find that a laparoscopic totally extraperitoneal approach is technically feasible and advantageous when a Spigelian hernia is diagnosed preoperatively.     

Totally endoscopic sublay (TES) repair for midline ventral hernia: surgical technique and preliminary results

The Rives–Stoppa procedure is used for ventral hernia repair but requires a large midline incision. This report describes a new, totally endoscopic approach to the retromuscular plane, corresponding to a reversed totally extraperitoneal procedure, to perform sublay repair of primary and secondary ventral hernias. This totally endoscopic sublay (TES) repair is described in detail, and its safety and efficacy were evaluated. In this prospective study, we assessed 26 consecutive primary and secondary epigastric midline ventral hernias that were repaired between July 2017 and July 2018 using the TES procedure. A large mesh was placed in the retrorectus position using this minimally invasive approach. Indications for this procedure include umbilical, epigastric, incisional hernias, and rectus diastasis. All TES procedures were successfully performed without conversion to an open operation. The mean operative time was 106.6 ± 29.1 min (range 75–205), with average mesh area of 318.8 cm2 for an average defect area of 26.5 cm2. Postoperative pain was mild, and the mean visual analog scale (VAS) under physical stress (e.g., climbing stairs) was 2.4 at the third postoperative day. The average postoperative hospital stay was 2.8 ± 0.8 days (range 2–5). Two patients developed postoperative seroma, with no final adverse effect. No recurrence nor readmissions within 30 days was observed during a mean follow-up of 9.2 ± 4.4 months. Initial experiences with this technique show that the TES procedure is safe and reliable, requires no specific instruments, and is highly reproducible. There is no need for an expensive anti-adhesion mesh or fixation device, making it cost-effective.     

Transabdominal preperitoneal versus totally extraperitoneal repair of inguinal hernia: a meta-analysis of randomized studies

Background

The aim of the present study was to comparatively evaluate the outcomes of laparoscopic transabdominal preperitoneal inguinal hernia repair and totally extraperitoneal repair.

Methods

The electronic databases of Medline, EMBASE, and the Cochrane Central Register of Controlled Trials were searched, and a meta-analysis of randomized clinical trials was undertaken.

Results

Seven studies comprising 516 patients with 538 inguinal hernia defects were identified. A shorter recovery time (P = .02) was found for totally extraperitoneal repair in comparison with transabdominal preperitoneal inguinal hernia repair (weighted mean difference = −.29; 95% confidence interval [CI], −.71 to .07) although the length of hospitalization (P = .89) was similar in the 2 treatment arms (weighted mean difference = .01; 95% CI, −.13 to .15). Operative morbidity (P = .004) was higher for the preperitoneal approach (odds ratio = 2.15; 95% CI, 1.29 to 3.61). No differences were found with regard to the incidence of recurrence, long-term neuralgia, and operative time.

Conclusions

Current evidence suggests similar operative results for endoscopic and laparoscopic inguinal hernia repair, with a trend toward higher morbidity for the preperitoneal approach. Randomized trials with a longer-term follow-up are needed in order to assess the effect of each approach on the prevention of recurrence.     

Abdominal lipectomy and mesh repair of midline periumbilical hernia after bariatric surgery: How to spare the umbilicus

Background: Abdominal lipectomy is becoming an increasingly common surgical procedure in patients with esthetic deformities resulting from massive weight loss induced by bariatric surgery. Sometimes a midline incisional hernia coexists with the pendulus abdomen. Herein presented is a technique to perform a retromuscular mesh repair of the incisional hernia while sparing the umbilicus. Methods: The abdominal lipectomy with concomitant retro-muscular mesh repair of a midline incisional hernia is done sparing the vascular supply of the umbilicus on one side only. Results: 5 consecutive women with pendulus abdomen resulting from bariatric surgery-induced massive weight loss and concomitant midline incisional hernia underwent abdominal lipectomy and incisional hernia mesh repair. Mean BMI was 28.6 kg/m² (range 26–35), one patient was a smoker, and another had type 2 diabetes requiring oral hypoglycemic agents. Two patients had had a previous incisional hernia repair with intraperitoneal mesh. One patient had partial necrosis of the umbilicus and another experienced necrosis of only the epidermis that recovered fully. Conclusions: The umbilicus can be safely spared during abdominal lipectomy with concomitant midline incisional hernia mesh repair. Recurrent incisional hernia and common risk factors for wound healing such as diabetes and obesity increase the risk of umbilical necrosis.     

Pneumomediastinum as a complication of extraperitoneal laparoscopic inguinal hernia repair.

A 52-year-old man with left indirect groin hernia was admitted for elective inguinal repair using the totally extraperitoneal (TEP) approach. After an uneventful intubation, TEP repair of the hernia was performed with three midline trocars. Immediately after extubation, the patient noted severe chest pain. There was a decrease in PaO2 saturation, and neck subcutaneous emphysema was detected. There was no emphysema of the abdomen or of the back. A chest film and thoracic computed tomographic (CT) scan confirmed the presence of pneumomediastinum without pneumothorax. The patient was discharged without complications.     

The preperitoneal tissue dilemma in totally extraperitoneal (TEP) laparoscopic hernia repair: an anatomo-surgical study

Background: One of the a main reasons for the long learning curve associated with totally extraperitoneal (TEP) laparoscopic hernia repair is an insufficient understanding of the dissection of the proper preperitoneal space. In this study, we investigated the conditions required for the correct anatomical approach to the preperitoneal space. Methods: The anatomo-surgical conditions for dissection of the correct preperitoneal space were evaluated in 10 video studies of TEP repairs. In addition, we also investigated the preperitoneal tissue layers in 10 embalmed human bodies. Results: The proper preperitoneal space can only be approached after cleavage of the ventral component of a bilaminar preperitoneal fascia complex, also known as the posterior lamina of the transversalis fascia. The cleavage can be accomplished spontaneously by a fully expanded balloon correctly introduced into the plane between the rectus muscle and the posterior lamina of the transversalis fascia. Conclusions: The anatomy of the preperitoneal tissues in the inguinal region is complex. To gain expertise in laparoscopic totally extraperitoneal (TEP) hernia repair, the presence of a bilaminar fascia complex and the importance of the cleavage of the posterior lamina of transversalis fascia must be appreciated.