Shouldice法加平片修补术治疗腹股沟疝

目的　总结Shouldice法加平片修补术治疗腹股沟疝的临床价值。方法　对 15 0例腹股沟疝采用腹横筋膜重叠缝合加用聚丙烯网片修补的手术方法进行治疗。结果　手术时间 40～ 90min ,平均 5 5min ;术后 6～ 12h可下地活动 ;病人切口疼痛及牵拉感明显轻于Bassini法。均临床治愈。随访 2个月～ 5年 ,无一例复发。结论　两种修补方法联合应用 ,针对疝发生的根本原因 ,把修补的重点放在腹股沟管后壁的腹横筋膜层 ,达到了低张力或无张力修补的手术效果 ,同时也明显地比充填式疝修补术降低了治疗费用。     

腹股沟疝修补方法的改进

198 8年 1月～ 1989年 8月 ,我们应用改进的腹股沟疝修补方法行疝修补术185例 ,其中Ｆｅｒｇｕｓｏｎ法 116例 ,Ｂａｓｓｉｎｉ法 6 2例 ,Ｍｃｖａｙ法 7例 ,术后随访 10～11.3年 (平均 10 .8年 ) ,无 1例疝复发及副损伤。手术方法的改进 :传统的腹股沟疝修补术即先进疝囊高位结扎后再进行相应修补术。改进的方法是先不结扎疝囊颈荷包缝线 ,术者用食指伸入腹腔作引导 ,边触摸边缝置腹内斜肌 ,联合腱下缘的修补缝线及腹横筋膜缝线 ,再结扎疝囊颈及腹横筋膜 ,然后缝合腹股沟韧带或耻骨梳韧带 ,一并打结加强腹股沟管前壁或后壁 ,其余同传统术式…     

选用最佳术式推动我国疝外科向前发展

当今我国腹股沟疝和其他医外疝临床外科中最突出问题是手术术式陈旧和落后，几十年不变，复发率较高。主要由于手术修补方式不符合疝的病理生理。腹外疝的手术历经有张力的不合理修补到低张力的合理修补术式。早已明确，任何腹外疝总是以腹横筋膜缺损为基础，因此修补加强此筋膜是手术方式是否合理的准则。以腹股沟疝为例，合理的术式是针对腹股沟管的后壁腹横筋膜缺损修补和加强，决不能将腹横肌、腹内斜肌弓状下缘美其名日“联合肌腱”（只有＜5％人群该处有肌腱膜组织），强力拉下与腹股沟韧带缝合。红色肌肉缝至白色光亮韧带上，并未有…     

自体组织无张力腹股沟疝修补的长期疗效观察

目的探讨自体组织无张力修补腹股沟疝的临床应用。方法回顾性分析118例自1998年2月至2001年12月本院施行的自体组织无张力修补腹股沟疝手术的临床资料,手术方式均采用腹直肌前鞘鞘膜片翻转加强腹股沟管后壁同时加强腹横筋膜的方式,观察此种手术方式治疗腹股沟疝的治疗效果。结果手术平均时间为27min,所有患者的手术切口均甲级愈合,随访2~12年复发1例,无慢性疼痛。结论采用腹直肌前鞘片修补腹股沟疝,可达到无张力修补的效果,此种手术方式简单、经济,复发率低,无异物反应,是一种值得选择的疝修补方法 。     

Shouldice和Lichtenstein疝修补的前瞻性随机比较

Shouldice手术被称为无张力迹修补术,Lichten－stein手术则用聚丙烯网片（2．5X10cm）以加强腹股沟区后壁,也属无张力性疝修补术。前者是腹股沟疝Bassini4层修复方法的改良,后者是用网片覆益腹横筋膜,下缘缝合在腹股沟韧带上,人工制成一内环,并缝合在耻骨结节和腹内斜肌表面上。作者前瞻性分析这两种手术的效果,在672例腹股沟疝病例中,45例为双侧,一侧采用Shouldice手术修补,另一间则用Lichtenstein手术修补,每一例何侧采用什么方法均由抛币随机法决定。在672例病人共行修补术717次。337次Shouldice手术发生7例早期疝复发（2…     

腹股沟疝无张力修补的治疗进展

腹股沟疝治疗的历史回顾腹股沟疝是普外科的常见病和多发病，腹股沟疝修补术是外科最古老和最常见的手术，自从Bassini首创经典的Bassini疝修补术以来，腹股沟疝修补术历经百年，由有张力到低张力，最后为无张力疝修补术的历史演变。由于有张力疝修补手术所致的高复发率和给病人带来的诸多不便，现正在逐步被弃用。在这一百多年中，对疝外科发展起重要作用和值得一提的是低张力腹股沟疝修补术即Shouldice手术。1945年加拿大的外科医师Shouldice建立了用腹横筋膜来加强腹股沟管后壁的术式，将腹股沟疝修补术带入了低张力时代。在Shouldice…     

Shouldice手术的几点体会

我们自80年代起从事腹横筋膜在腹股沟疝修补中的应用的临床研究，集500余病例的基础上，近年来又应用Shouldice手术行腹股沟疝修补近百例。兹将初步体会总结如下。一、疝手术的历史启示腹股沟疝修补手术经历了漫长的历史演变，近百年来逐渐形成了两大学派：（1）主张增强腹股沟管前壁并缩窄外环口；（2）主张增强腹股沟管后壁缩小内环口。前者的代表人物是德国医生Czerny（1877）；后者是意大利人Bassini（1889）。原始的Bassini手术是将联合肌腱及腹横筋膜一并缝合到腹股沟韧带上，从而奠定了符合解剖学的现代如修补的基础。但由于译文的…     

无张力疝修补术的现代解剖生理学基础

腹股沟疝是外科最常见的疾病,而疝修补术则是外科最基本的手术。自1884年Bassini创建真正解剖疝修补术以来,虽有100多年历史,无论术式如何演变,其术后5年的复发率为10%～15%,复发性疝术后复发率高达20%～30%[1]。疝修补术后复发的原因可能与腹股沟区局部组织先天性缺损、对腹股沟区的解剖认识不足、修补方法的缺陷及腹股沟区局部组织的胶原纤维代谢异常等因素有关。腹股沟疝发生的解剖生理学因素众所周知，腹股沟直疝是获得性的,故常见于老年病人。其解剖结构Hesselbach三角是一薄弱区,仅有一层菲薄的无抗力的腹横筋膜覆盖,其浅面为腹外斜…     

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。     

利用疝囊修补腹股沟管后壁缺损(附18例报告)

目的：报告利用疝囊修补腹股沟管后壁缺损的方法和体会。方法：本组男17例,女性1例,年龄35～64岁。对18例易复性斜疝患者手术,将切下的疝囊重新整合成至少3层的“疝囊膜”,在精索后把疝囊膜与腹横筋膜、联合肌腱、腹股沟韧带及耻骨梳韧带缝合以加强腹股沟管后壁。结果：均治愈,随访0．5～4．5年无复发。结论：该术式取材方便,缝合修补无张力,具有可行性和临床价值。远期效果还有待于继续随访。     

Abdominal musculature and the transversalis fascia: an anatomical viewpoint

This anatomical study investigated the connection of the muscles of the abdominal wall to the transversalis fascia in the groin. In six unfixed male corpses we prepared the single levels of the inguinal abdominal wall and examined their interrelationships. Of special interest were the direction of the force vectors determined by the direction of the muscular fibers in relation to the transversalis fascia. We found no confirmation of a direct connection between the muscles of the abdominal wall and the transversalis fascia in the inguinal region. No force vector of the different muscular layers points away from the triangle of Hesselbach. By contraction each muscle thus relaxes the transversalis fascia of the Hesselbach triangle.     

Technique for repairing inguinal hernias with Marlex mesh

A technique using Marlex mesh for the repair of inguinal hernias is described. In this procedure the transversalis fascia is incised and a 1 inch strip of Marlex mesh is sutured as a cuff over the free edge of the conjoined tendon. The mesh-reinforced conjoined tendon is then sutured to Poupart's ligament. Continuous sutures of polypropylene monofilament are used both to affix the mesh cuff to the conjoined tendon and to suture the reinforced conjoined tendon to Poupart's ligament. Use of the mesh cuff results in a significant mechanical advantage and an exceptionally strong repair. This technique has been used in 72 patients since January 1979, with good results.     

Anatomic pecularities of the inguinal canal in West Indians. Influence on the management of inguinal hernia

Inguinal and umbilical hernias are much more frequent in the black and half-breed than in the white population. We have observed anatomical differences in the inguinal region between Whites and Blacks. The latter have a vertical, wide subcutaneous ring and a smaller conjoined tendon, and it is hardly possible to reconstruct the fascia of the obliquus externus abdominis anterior to the cord in them. For Black patients, we propose the suture of the conjoined tendon to the crural arch, like in the Bassini procedure, and the suture of the fascia of the obliquus externus to the arch, but in a retrofunicular position. This technique allows, so to speak, duplicating the caudal connection of the conjoined tendon to the arch by means of the extensive suture of 2 tissues of similar nature, ie. the fascia of the obliquus externus and the crural arch.     

The "Fletching": a new implant for the treatment of inguino-femoral hernias

Inguino-femoral hernias present a special problem. Destruction of vital structures such as the inguinal ligament, the femoral sheath, the transversalis fascia and the conjoined tendon, is usually extensive. Repairs have often relied upon the use of sheets of prosthetic materials but never on a three dimensional implant. This article will examine such an implant, the "Fletching". The latter is a three leaved prosthesis with a common reinforced backing, the aim of which is to replace the inguinal ligament and associated structures necessary for the successful repair of the much feared inguino-femoral hernia. This prosthesis has been implanted in 24 patients with excellent results. Follow-up has now been longer than 2-1/2 years and careful steps are taken to continue this follow-up.     

The Shouldice Hospital technique

The Shouldice repair is used for all types of inguinal hernia whether indirect, direct, sliding, multiple, recurrent, male or female. Local anesthesia is given in more than 95% of cases. The repair is a modified Bassini. Essential preliminaries are accurate dissection at the internal ring with adequate treatment of any indirect hernia. The cremaster is excised. Accurate recognition and definition of the transversalis plane is routine and fundamental. Essentially the repair is an overlap of the divided transversalis plane utilising 4 lines of continuous monofilament stainless steel wire 34 gauge. Patients, ambulant immediately, stay in hospital 2-3 days postoperatively. A large personal series of more than 20,000 inguinal repairs performed almost exclusively in this hospital during a 30 year period from 1954 to 1984 is tabulated. Recurrence rates of less than 1% for repair of primary inguinal hernia and re-recurrence rates of 2-4% for repair of recurrent inguinal hernia are reported. Surgeons in other countries now employing this technique achieve comparable results, often using other non-absorbable suture material.     

Laparoscopic treatment of congenital inguinal hernia in children

PURPOSE: The authors report their experience in the laparoscopic treatment of congenital inguinal hernia in children. METHODS: Between September 1994 and September 1995, 45 boys between 8 months and 13 years of age (mean, 4 years) were treated laparoscopically for hydroceles, spermatic cord cysts, or hernias. Twenty-six (57.8%) boys showed a right inguinal hernia, 17 (37.8%) a left hernia, and two cases (4.4%) presented the clinical data of a bilateral pathology. The approach used for small hernias was the placement of purse-string suture around the internal orifice of the inguinal canal (28 cases). As to hernias exceeding 4 to 5 mm in diameter, the external hemicircumference of the neck was opened to bring the conjoined tendon closer to the crural arch with a nonresorbable suture (17 cases). There was never need to use a prosthesis. RESULTS: Surgery lasted from 15 to 45 minutes with the duration decreasing with experience. There were no intra- or postsurgical complications. Two patients (4.4%) experienced a recurrent inguinal hernia, which was successfully operated on again with laparoscopy. CONCLUSION: The early results of these authors suggest that laparoscopic surgery is a feasible and safe technique for the treatment of patent peritoneal vaginal canal (PVC) and inguinal hernia in children.     

小儿复发性腹股沟疝的手术治疗

目的探讨小儿腹股沟疝术后复发原因及治疗。方法分析小儿腹股沟部的解剖特点,探讨复发性腹股沟疝的原因。应用疝囊高位结扎、内环缩小及腹横筋膜修补等术式治疗。结果 30例均于手术后7～10 d出院,经平均3年以上临床随访无复发,治疗效果满意。结论小儿腹股沟疝手术中,高位结扎、内环缩小、腹横筋膜修补是疗效可靠、防止复发的关键。     

Classical herniorrhaphies of Bassini,Halsted and Ferguson

Eduard Bassini's paper describing his new operation for inguinal hernia was dated July 30, 1889 but did not appear until 1890. He had operated, upon 251 patients over a four and one-half year period with six recurrences. The main features of his operation are: suture of the threefold layer to Poupart's ligament to form the posterior wall of the new inguinal canal; suture of the aponeurosis of the external oblique muscle over the cord, forming the anterior wall of the new inguinal canal.Wm. S. Halsted's new operation for inguinal hernia was described December, 1889. He presented five patients, representing work over a six-month period. The main features of this operation are: excision of most of the veins of the spermatic cord; transplantation of the vas deferens under the skin; closure of the structures of the abdominal wall (excluding the peritoneum and the skin) in one layer with interrupted mattress sutures.Alexander Hugh Ferguson's inguinal herniorrhaphy, having been performed by him sixty-four times, was described July 1, 1899. In his book in 1907, he still recommended the same operation. The main features of the Ferguson herniorrhaphy are: leaving the cord undisturbed; utilizing the cremaster muscle and the transversalis fascia in the repair, and suturing the internal oblique muscle and the conjoined tendon over the spermatic cord to Poupart's ligament, it being recommended that the spermatic cord not be lifted from its natural bed.Wm. S. Halsted published his new method of hernia repair August, 1903. The main features of this operation, as contrasted with the Halsted of 1893, are: transplantation of the neck of the sac, careful excision of any enlarged veins of the spermatic cord, utilization of the cremaster muscle and the transversalis fascia in the repair, and placing three rows of interrupted silk sutures and one of catgut in an overlapping type of repair of the layers of the region. Concerning this operation, Ferguson⁶ wrote in his book: “This modification, which is very similar to my operation, was not published until three years after I produced my method.”     

Non-developed external oblique aponeurosis in inguinal hernia repair: a case report and discussion of the literature

Open inguinal hernia repair is one of the most commonly performed operations in the world. It relies heavily on the presence of an inguinal canal formed by the external oblique aponeurosis and conjoint tendon. Variations of the anatomy of this region are rarely described. We describe a patient with bilateral inguinal hernias and missing external oblique aponeurosis. The patient underwent open repair secondary to previous abdominal surgery and the inability to obtain laparoscopic access. A medline search was performed and we provide a synopsis of the literature. At operation, no clear external oblique aponeurosis could be identified and large defects of the transversalis fascia were corrected. CT images of the anatomic variations are provided. To the best of our knowledge, combined abnormalities of the external oblique aponeurosis and transversalis fascia have not been described before.