腹腔镜在食管裂孔疝修补术中的临床应用

目的探讨腹腔镜在食道裂孔疝修补术中应用的疗效及安全性。方法运用腹腔镜对21例食道裂孔疝患者行食道裂孔疝修补术,其中13例食道裂孔缺损≥4 cm者使用巴德Cru-raSoft补片进行修补,8例缺损4 cm者用2-0普理灵缝线连续缝合将两膈肌脚关闭。同时将胃底固定于食道左侧膈肌下,以恢复锐性His角。结果 21例均顺利完成疝修补术,无中转开腹,未出现并发症。平均手术时间117 min;平均出血量约36.7 ml;平均住院日3.7 d。术后3个月行胃镜复查,显示患者的食道炎均已明显好转,未见消化性溃疡或糜烂性胃炎;术后随访3～30个月,单纯缝合修补者有2例复发。结论对于老年人要适当控制气腹的压力。腹腔镜手术的高清晰度、宽广视野是直视手术所无法比拟的,用以治疗食道裂孔疝有手术损伤小、出血少、患者恢复快、住院时间短等优点,其并发症的发生率和死亡率都比开腹直视手术要低。腹腔镜下行食道裂孔疝修补的治疗是安全可行的,值得临床推广应用。     

腹腔镜食管裂孔疝修补胃底折叠术

食管裂孔疝多见于40岁以上的病人。其症状主要表现为胸痛、吞咽困难和咽下疼痛，并常伴有反流性食管炎引起的胸骨后及背部烧灼感。食管裂孔疝常伴有食管韧带松弛和食管下段括约肌功能减弱，易发生胃液反流，导致胃食管反流病（GERD）。胃食管反流病的发生机制与食管裂孔疝、食管下端括约肌缺陷等有关，常须长期服用质子泵抑制剂和胃肠动力药物治疗。     

腹腔镜食管裂孔疝修补术联合改良DOR胃底折叠术治疗食管裂孔疝合并胃食管反流病的临床疗效

目的探讨腹腔镜食管裂孔疝修补术联合改良DOR胃底折叠术治疗食管裂孔疝（HH）合并胃食管反流病患者的临床疗效。 方法选择2016年1月至2019年1月河北北方学院附属第二医院收治的108例食管裂孔疝合并胃食管反流病患者开展回顾性研究,按照不同手术方式将患者分为2组,每组患者54例。对照组行常规开腹手术,联合组行腹腔镜食管裂孔疝修补术联合改良DOR胃底折叠术,比较2组患者术前及术后6个月反流时间、反流次数、DeMeester评分、食管下括约肌压力及Gerd Q量表评分。 结果2组术前反流时间、反流次数、DeMeester评分、食管下括约肌压力及Gerd Q量表评分比较,差异无统计学意义（P>0.05）;2组患者术后6个月反流症状与术前比较,均得到明显改善,差异有统计学意义（P<0.05）;2组术后反流时间、反流次数、DeMeester评分、食管下括约肌压力及Gerd Q量表评分比较,差异有统计学意义（P<0.05）。联合组患者的手术时间、术中出血量及术后住院时长均明显优于对照组,差异有统计学意义（P<0.05）。 结论腹腔镜食管裂孔疝修补术联合改良DOR胃底折叠术对HH合并胃食管反流病患者效果显著,有利于患者身体快速恢复,微创、安全且近期疗效满意。     

腹腔镜Toupet胃底折叠术治疗食管裂孔疝合并胃食管反流病的临床疗效

目的探讨腹腔镜Toupet胃底折叠术治疗食管裂孔疝合并胃食管反流病的临床疗效。 方法选取2012年1月至2018年6月,吉林大学第二医院就诊的80例食管裂孔疝合并胃食管反流病患者为研究对象。依据患者具体状况行不同类型的疝修补术,所有患者均行腹腔镜Toupet胃底折叠术。于术后统计患者手术效果及反流情况,观察手术前后食管压变化。 结果与术前相比,术后6个月患者反流时间显著缩短、反流次数与长反流次数显著减少、酸反流时间百分比显著下降,差异均有统计学意义（P<0.05）。与术前相比,术后6个月患者DeMeester及GERDQ评分均显著下降,差异均有统计学意义（P<0.05）。与术前比较,术后6个月患者LES压力、残余压均显著升高,松弛率显著下降,差异均有统计学意义（P<0.05）。 结论腹腔镜Toupet胃底折叠术治疗食管裂孔疝合并胃食管反流病可有效增加食管压力,抑制患者反流症状,疗效良好,值得推广应用。     

腹腔镜食管裂孔疝修补联合胃底折叠术治疗胃食管反流病合并食管裂孔疝

目的：探讨腹腔镜下行食管裂孔疝修补联合胃底折叠术治疗胃食管反流病合并食管裂孔疝的临床疗效和安全性。 方法：回顾性分析2012年1月—2014年2月在我院进行食管裂孔疝修补联合胃底折叠术的58例胃食管反流病合并食管裂孔疝患者临床资料,其中36例在腹腔镜下行食管裂孔疝修补联合胃底折叠术（观察组）,22例患者行开腹手术（对照组）。观察并比较两组患者手术时间、术中出血量、术后住院时间、术后胃肠道功能恢复时间及术后并发症发生情况,手术前及手术后4个月进行反流性疾病问卷（RDQ）调查结果。 结果：观察组手术时间、术后住院时间、术后胃肠道功能恢复时间均明显短于对照组（均P<0.05）;观察组术中出血量及术后并发症发生情况均明显优于对照组（P<0.05）;两组患者RDQ评分显示术后4个月症状均有不同程度的改善,观察组患者症状改善程度优于对照组患者（均P<0.05）。 结论：腹腔镜下行食管裂孔疝修补联合胃底折叠术治疗胃食管反流病合并食管裂孔疝,疗效显著,安全性好,可积极应用于临床上胃食管反流病合并食管裂孔疝的治疗。     

腹腔镜胃底180°前折叠术治疗食管裂孔疝疗效分析

目的探讨腹腔镜食管裂孔疝修补联合胃底180°前折叠术治疗食管裂孔疝疾病的可行性和安全性。方法回顾性分析了沧州市中西医结合医院与天津南开医院2008年9月至2013年6月采用腹腔镜技术治疗的180例食管裂孔疝患者资料,其中30例应用补片修补裂孔,剩余患者丝线缝合裂孔,均加做胃底180°前折叠（Dor手术）。结果手术顺利,无中转开腹者。术后随访3～60个月,手术效果满意率92.31％,术后3个月复查胃镜、上消化道造影等检查基本恢复正常。其中7例患者术后早期出现轻度反酸、烧心症状,均在4个月内通过保守治疗好转,无复发病例,无严重吞咽困难病例。结论腹腔镜食管裂孔疝修补和胃底180°前折叠术治疗食管裂孔疝疾病有微创手术创伤小、恢复快、安全可行、疗效可靠等特点,值得临床广泛应用。     

腹腔镜下胃底Nissen折叠术式治疗的食管裂孔疝临床应用

目的探讨使用腹腔镜行食管裂孔疝修补术的安全性和疗效评价。方法对38例食管裂孔疝患者使用腹腔镜行食管裂孔疝修补术,做胃底360°折叠术(Nissen术),9例应用补片修补疝缺口,29例采用7号丝线缝合。结果38例腹腔镜食管裂孔疝修补术全部获得成功。手术时间30～190min,平均手术时间110min,失血10～50ml;术后24～48h进流质饮食,无术后并发症;术后平均住院5.7d。结论腹腔镜下胃底Nissen折叠术式具有疗效好、安全和创伤小的优点。值得进一步推广应用。     

腹腔镜下食管裂孔疝修补和胃底折叠术的护理体会

食管裂孔疝（hiatushemia）是指食管腹段、食管胃连接部和部分胃组织通过食管裂孔凸人胸腔形成的一种疝。多见于40岁以上的患者,其症状主要表现为胸痛、咽下疼痛伴吞咽困难,可同时伴有反流和胸骨后及背部烧灼感。目前伴随着腹腔镜微创外科技术的不断发展,在腹腔镜下修补食管裂孔疝及同时行胃底折叠术治疗已在国内外普遍开展,     

腹腔镜食管裂孔疝修补、胃底折叠术的综合评价

临床上食管裂孔疝并不少见，胃食管反流性疾病更是多见。但是此类疾病在国内还没有得到应有的重视，施行外科治疗者还很少。胃食管反流病（GERD）的发生机制与食管下端括约肌缺陷、食管裂孔疝等有关，约25％～50％的GERD患者为慢性疾病过程，需要长期药物治疗。自20世纪50年代中期起，经过40多年的临床实践，以Nissen手术为代表的一系列抗反流手术对治疗严重的GERD取得了非常理想的疗效。     

Laparoscopic repair of a paraesophageal hiatus hernia without fundoplication

We treated a case of paraesophageal hiatus hernia by laparoscopic repair. The procedure included a reduction of the gastric fundus and duodenal bulbus, closure of the diaphragmatic defect, mesh wrapping of the closure, gastropexy to the diaphragm, and a gastrostomy. Preoperative monitoring of the pH for 24h showed no reflux. Intraoperative intraluminal manometry of the esophagus after hernia reduction showed the pressure of the lower esophageal sphincter to be normal, and thus an antireflux procedure was not deemed to be necessary. The patient was put on a soft diet from postoperative day 2. A postoperative upper gastrointestinal series showed no gastroesophageal reflux. No complications or recurrence of the hiatus hernia have been observed in the 12 months since the operation. Laparoscopic repair of a paraesophageal hiatus hernia with normal pressure of the lower esophageal sphincter, so that fundoplication is not needed, is thus considered to be possible.     

Laparoscopic repair of paraesophageal hernia

Large paraesophageal hernias are generally repaired by reduction of the stomach into the abdomen, sac excision, crural closure, and gastropexy or fundoplication. After gaining experience performing laparoscopic repair of sliding hiatal hernias and Nissen fundoplication we combined laparoscopic access with traditional surgical technique in treating patients with complex paraesophageal hernias.Ten adults, six males and four females, with type III paraesophageal hernias underwent laparoscopic repair between February 1993 and April 1994. The average age of the patients was 60.4 years (range 38–81). Using five ports (three 10 mm and two 5 mm), the stomach was reduced into the abdomen, the hernia sac was resected, and the defect was closed with pledgeted horizontal mattress sutures. In addition, nine patients had a Nissen fundoplication performed and one patient had a diaphragmatic gastropexy.The procedure was completed laparoscopically in all ten cases and the median operating time was 282 min (range 165–430). Two complications occurred, an intraoperative gastric laceration, and a postoperative mediastinal seroma. All patients were discharged on the 2nd or 3rd postoperative day. Eight of nine patients were asymptomatic at last follow-up (mean 8.9 months postop). One patient has mild dysphagia and heartburn from partial migration of the fundoplication into the chest. One patient died 3 months postoperatively of unrelated causes. Paraesophageal hernia can be reduced and repaired safely with laparoscopic access using standard surgical techniques.Presented at the annual meeting of the Society of American Gastro-intestinal Endoscopic Surgeons (SAGES), Nashville, Tennessee, USA, 18–19 April 1994     

Controversies in paraesophageal hernia repair; a review of literature

Background The surgical repair of paraesophageal hiatal hernias (PHH) can be performed by endoscopic means, but the procedure is not standardized and results have not been evaluated systematically so far. The aim of this review article was to clarify controversial subjects on the surgical approach and technique, i.e., recurrence rate after conventional versus laparoscopic PHH treatment, results of mesh reinforcement of the cruroplasty, the necessity for additional antireflux surgery, and indications for an esophageal lengthening procedure. Methods An electronic Medline search was performed to identify all publications reporting on laparoscopic and conventional PHH surgery. The computer search was followed by additional hand searches in books, journals, and related articles. All types of publications were evaluated because of a lack of high-level evidence studies such as randomized controlled trials. Critical analysis followed for all articles describing a study population of >10 patients and those reporting postoperative outcome. Results A total of 32 publications were reviewed. Randomized controlled trials comparing laparoscopic and open techniques could not be identified. Nineteen of the publications described the results of retrospective series. Therefore, most of the studies retrieved were low in hierarchy of evidence (level II-c or lower). The overall median hospital time as published was 3 days for patients operated laparoscopically and 10 days in the conventional group. Postoperative complications, such as pneumonia, thrombosis, hemorrhage, and urinary and wound tract infections, appeared to be more frequent after conventional surgery. Follow-up was longer for conventional surgery (median 45 months versus 17.5 months after the laparoscopic technique). Recurrence rates reported were higher in patients operated conventionally (median 9.1% versus 7.0% for patients operated laparoscopically). Recurrences after PHH repair may decrease with usage of mesh in the hiatus, although uniform criteria for this procedure are lacking. No conclusions could be drawn regarding the necessity for an additional antireflux procedure. Furthermore, uniform specific indications for the need of an esophageal lengthening procedure or preoperative assessment methods for shortened esophagus could not be detected. Conclusion Treatment based on standardized protocols for preoperative assessment and postoperative follow-up is required to clarify the current controversies.     

Laparoscopic mesh hiatoplasty for paraesophageal hernias and fundoplications

Background Little grade A medical evidence exists to support the use of prosthetic material for hiatal closure. Therefore, the authors compiled and analyzed all the available literature to determine whether the use of prosthetic mesh in hiatoplasty for routine laparoscopic fundoplications (LF) or for the repair of large (>5 cm) paraesophageal hernias (PEH) would decrease recurrence. Methods A literature search was performed using an inclusive list of relevant search terms via Medline/PubMed to identify papers (n = 19) describing the use of prosthetic material to repair the crura of patients undergoing laparoscopic PEH reduction, LF, or both. Results Case series (n = 5), retrospective reviews (n = 6), and prospective randomized (n = 4) and nonrandomized (n = 4) trials were identified. Laparoscopic procedures (n = 1,368) were performed for PEH, gastroesophageal reflux disease (GERD), hiatal hernia, or a combination of the three. Group A (n = 729) had primary suture repair of the crura, and group B (n = 639) had repair with either interposition of mesh to close the hiatus or onlay of prosthetic material after hiatal or crural closure. The use of mesh was associated with fewer recurrences than primary suture repair in both the LF and PEH groups. The mean follow-up period did not differ between the groups (20.7 months for group A vs. 19.2 months for group B). None of the papers cited any instance of prosthetic erosion into the gastrointestinal tract. Conclusions The current data tend to support the use of prosthetic materials for hiatal repair in both routine LF and the repair of large PEHs. Longer and more stringent follow-up evaluation is necessary to delineate better the safety profile of mesh hiatoplasty. Future randomized trials are needed to confirm that mesh repair is superior to simple crural closure.     

Simultaneous laparoscopic paraesophageal hernia repair and sleeve gastrectomy in the morbidly obese

BackgroundMorbid obesity is associated with increased rates of hiatal and paraesophageal hernias. Although laparoscopic sleeve gastrectomy is gaining popularity as the procedure of choice for morbid obesity, there is little data regarding the management of paraesophageal hernias found intraoperatively. The aim of this study was to evaluate the feasibility and benefits of a combined sleeve gastrectomy and paraesophageal hernia repair in morbidly obese patients.MethodsFrom May 2011 to February 2013, 23 patients underwent laparoscopic sleeve gastrectomy combined with the repair of a paraesophageal hernia. Only 4 patients had a large hiatal hernia documented preoperatively on esophagogastroduodenoscopy (EGD). The body mass index (BMI), operative time, length of stay, and complications were evaluated.ResultsThe average operative time was 165 minutes (115–240 minutes) and length of stay was 2.83 days (2–6 days). All patients were female except for one, with an average age of 53.4 years and a BMI of 41.9 kg/m². There were no complications during the procedures. Mean follow-up was 6.16 months (1–19 months), and mean excess weight loss was 39%. The average cost of admission for a combined procedure ($10,056), was slightly higher than a laparoscopic sleeve gastrectomy ($8905) or laparoscopic paraesophageal hernia repair ($8954) done separately.ConclusionsLaparoscopic sleeve gastrectomy combined with a paraesophageal hernia repair is well-tolerated and feasible in morbidly obese patients. Surgeons should be aware that preoperative EGD is not effective at diagnosing large hiatal or paraesophageal hernias. Surgeons with the skill set to repair paraesophageal hernias should do a combined procedure because it is well-tolerated, feasible, and can reduce the cost of multiple hospital admissions.     

腹腔镜食管裂孔疝修补术143例临床分析

目的 探讨腹腔镜手术治疗食管裂孔疝的可行性和临床应用价值。 方法 对2001年6月至2010年2月天津市南开医院143例食管裂孔疝行腹腔镜食管裂孔疝修补术的资料进行分析。 结果 143例均完成腹腔镜手术,无中转开腹病例,手术时间55～210min,平均86 min;术中出血量40～150mL,平均76mL;术后住院时间3～21d,平均4.6d。术后临床症状均得到缓解,无严重并发症及死亡病例。134例得到随访,随访时间3个月至9年,平均3.8年,手术结果满意率91.67%。8例进固体食物时有轻度哽噎感,5例反酸症状复发,其中4例应用抑酸药物后可控制,1例行开腹手术治疗。结论 腹腔镜治疗食管裂孔疝,充分体现了手术创伤小、恢复快、安全可行、疗效可靠的特点。     

Laparoscopic repair of ventral incisional hernia

Background : Laparoscopic repair of ventral incisional hernias was first reported in 1993. Since then, there have been sporadic case reports and small series published about this procedure, but it has not been widely adopted. Newer types of composite prosthetic mesh may reduce the potential problem of bowel adhesion. Methods : Thirty cases of laparoscopic ventral incisional hernia repairs (carried out by two surgeons or their senior registrars) have been retrospectively reviewed and reported in this article. The data were obtained from patient records and subsequent phone surveys. Results : Thirty patients between 29 and 82 years (mean: 58 years) underwent this procedure. There were 14 men and 16 women. The average weight of the patients was 81 kg. The hernias were up to 6 or 7 cm in diameter. Mesh was used in 28 cases (polypropylene in 25 cases, expanded polytetrafluoroethylene in two cases and composite mesh in one case). Most meshes were laid intraperitoneally and fixed into position with laparoscopic spiral tacks. Twenty‐nine cases were completed laparoscopically. One operation (3.3%) was converted to an open procedure because of severe bowel adherence to the hernia sac. The mean operating time was 52 min for laparoscopic ventral incisional hernia repairs only. All but two patients tolerated an oral diet within 24 h. The postoperative hospital stay ranged from 0 to 11 days, with 17 patients (57%) staying overnight and eight patients (27%) staying another day. Over 80% of the patients returned to house duties within a week. There was no mortality, and minor complications occurred in four patients (14%). One patient had a small bowel obstruction treated successfully by repeat laparoscopy with division of fibrinous adhesions to polypropylene mesh on day four. Follow up ranged from 1 to 69 months (mean: 12 months). One patient did not attend follow‐up appointments. There were three cases of hernia recurrence (10%). Conclusion : The results suggest that laparoscopic repair of ventral incisional hernias is a safe, effective and technically feasible operation for small‐ to medium‐sized hernias allowing shorter hospital stay, early recovery and resumption of normal activities. However, recurrence rates are comparable to open mesh hernioplasty especially for larger hernias.     

腹腔镜下巨大食管裂孔疝修补术13例分析

目的 探讨腹腔镜下巨大食管裂孔疝应用补片修补和部分胃底折叠术的安全性及有效性。 方法 2006年8月至2009年4月中国人民解放军总医院普通外科对13例巨大食管裂孔疝病人行腹腔镜下裂孔疝补片修补,并同期行部分胃底折叠术。 结果 12例手术成功,1例伴有短食管,手术过程中因分离食管时出现食管损伤中转开胸治疗。手术时间90~180min,平均110min。 术中出血30~120mL,平均50mL,均未输血。12例术后症状完全缓解。术后住院时间3~30d,平均6d。术后随访3~25个月,平均12个月,未发现复发病例。 结论 对于巨大食管裂孔疝,腹腔镜下补片修补是一种安全有效的方法,具有创伤少,恢复快、副反应小的特点。     

Laparoscopic paraesophageal hernia repair, a challenging operation: Medium-term outcome of 116 patients

Laparoscopic paraesophageal hernia repairs performed in 116 patients between 1992 and 2001 were pro-spectively analyzed. Perioperative outcomes were assessed and follow-up was performed under protocol. There were 85 female and 31 male patients who had a mean (± SD)ageof65 ± 13 years and an American Society of Anesthesiology score of 2.3 ± 0.6. All but two patients underwent an antireflux procedure. Gastropexy was performed in 48 patients, an esophageal lengthening procedure in six patients, and prosthetic closure of the hiatus in six patients. Major complications occurred in five patients (4.3%) with two postoperative deaths (1.7%). Mean follow-up was 30 ± 25 months; 96 patients (83%) have been followed for more than 6 months. Among these patients, 73 (76%) are asymptomatic, 11 (11%) have mild symptoms, and 12 (13%) take antacid medications. Protocol barium esophagograms were obtained in 69% of patients at 6 to 12 months’ follow-up. Recurrence of hiatal hernia was documented in 21 patients (22% overall and in 32% of those undergoing contrast studies). Reoperation has been performed in three patients (3 %). When only the patients with recurrent hiatal hernias are considered, 13 (62 %) are symptomatic but only six (28%) require medication for symptoms. Laparoscopic paraesophageal hernia repair is generally safe, even in this high-risk group. This study confirms a relatively high incidence of recurrent hiatal abnormalities after paraesophageal hernia repair; however, most recurrent hiatal hernias are small and only 3% have required reoperation. Protocol esophagograms detect recurrences that are minimally symptomatic. Improved techniques must be devised to improve the long-term outcomes of laparoscopic paraesophageal hernia repair. Presented at the Forty-Third Annual Meeting of The Society for Surgery of the Alimentary Tract, San Francisco, California, May 19–22, 2002 (oral presentation). Supported by the Washington University Institute for Minimally Invasive Surgery.