微创腹壁切口疝的术式进展、争议和展望

正1993年,美国Le Blanc等~([1])首次将腹腔内补片修补术(intraperitoneal onlay mesh,IPOM)用于腹壁切口疝治疗,开启了腹腔镜腹壁切口疝修补(laparoscopic ventral and incisional hernia repair,LVIH)新模式,同时改变开放手术的修补层次,引入腹腔内修补的新思路。IPOM具有最佳力学原理、无需分离腹壁组织、手术操作简化、切口并发症明显下降等优势,在全世界迅速推广和普及。早期的一些技术难点,如粘连分离、缺损关闭、补片固定等逐一得到解决~([2])。手术指征、缺损分类、手术步骤、边     

A型肉毒素用于巨大切口疝修补的辅助治疗

正切口疝是腹部手术后常见的并发症,其发生率在20%左右。对于有高危因素的病人,手术后切口疝的发生率可高达35%~([1-2])。切口疝修补的关键是关闭腹壁缺损和重建腹壁功能。随着腹壁外科技术的发展,已有多种术中应用的技术降低腹壁肌肉张力,包括前组织结构分离~([3])、后组织结构分离加腹横肌松解术~([4])等。但对于巨大切口疝,这些技术仍不能     

腹部暂时关闭术

腹部暂时关闭术 (ｔｅｍｐｏｒａｒｙａｂｄｏｍｉｎａｌｃｌｏｓｕｒｅ ,ＴＡＣ)是从分期剖腹手术的基础上发展起来的。随着损害控制外科 (ｄａｍａｇｅｃｏｎｔｒｏｌｓｕｒｇｅｒｙ ,ＤＣＳ)概念的提出 ,ＴＡＣ已经成为危重患者剖腹手术后腹部切口临时关闭的专用名称 ,是ＤＣＳ的重要内容。传统的ＴＣＡ是一种不得已而为之的被迫性行为 ,现代ＴＣＡ则是为了预防损害而主动采用的有效手段 ,得到临床医生的广泛认同。本文简述ＴＣＡ的有关问题。一、临床指征任何妨碍腹部切口缝合和愈合的腹壁及腹腔因素 ,以及需要早期再次剖腹的情况都是Ｔ…     

组织结构分离技术进展及其相关并发症

正腹部再次手术的原因中,腹壁切口疝一直位居前列,近期Strik等~([1])分析一组择期腹部再手术病例中,18%为切口疝。剖腹手术后腹壁切口疝发生率各家报道差异很大,最新一篇荟萃分析显示腹壁中线切口疝2年发生率为12.8%[2]。目前,外科手术仍然是腹壁切口疝唯一、彻底、有效的治疗方法。腹壁疝修补术中的一个重要步骤是缝合关闭肌筋膜层缺损以恢复重建腹壁结构的完整。除了较小的腹壁切口疝,通常疝修补术中这个重建过程多少都会引     

腹腔镜腹壁切口疝修补术及并发症处理

正腹壁切口疝为腹部切口处筋膜或肌肉组织愈合不良,腹腔内容物经薄弱处突出到皮下而形成的疝。切口疝的发生率2%~11%,且近年发病率有升高趋势。腹壁切口疝修补后,仍会有超过40%的病人复发~([1])。切口疝常隐匿发生在术后几个月内,随着时间的延长,在术后2~5年内发病。切口疝不会自愈,手术是唯一的治疗方法。切口疝的手术方式分     

切口疝修补术常见局部并发症的预防与处理

正随着腹部外科手术量的增长,腹壁切口疝病人的数量也日益增加。2014年,Itatsu等~([1])报道,腹部手术后2年腹壁切口疝的发病率达10.3%。因此切口疝修补术是普通外科最常见的手术之一。肥胖、高龄、糖尿病、激素应用、肺部疾病以及手术部位并发症等因素均有可能促进腹部手术后切口疝的发生。切口疝补片修补术可根据补片在腹壁重建时     

暂时性腹腔关闭与常规关腹技术治疗严重腹腔感染的临床对比

目的观察暂时性腹腔关闭(temporary abdominal closure,TAC)与常规关腹技术在严重腹腔感染中的临床效果。方法回顾性分析2010年3月~2014年7月15例严重腹腔感染的临床资料,其中8例采用负压封闭引流关闭系统(vacuum sealing drainage,VSD)行暂时性关腹,7例常规关腹。比较2组术后腹内压变化、创面愈合时间、术后并发症等。结果常规关腹组术后72 h内腹内压逐渐升高,术后6~72 h各监测的时间点均高于暂时性关腹组(P0.01)。暂时性关腹组术后腹内压变化相对平稳(波动在7.7~18.1 mm Hg之间),创面愈合早[(11.3±1.8)d vs.(19.4±6.7)d,t=-3.142,P=0.005],切口感染少[12.5%(1/8)vs.100%(6/6),P=0.005]。结论暂时性腹腔关闭技术在治疗严重腹腔感染中能有效地预防腹内压升高,促进创面愈合,减少术后并发症,疗效确切。     

切口疝治疗的手术选择与核心策略

正腹部手术数量逐年增加,切口疝总数也相应增加。综合多项单中心大宗病例分析结果,腹壁切口疝的发生率为2%～11%。腹部手术切口复杂,导致切口疝发生部位不一。有传统意义上的切口疝,也包括trocar疝等新型疝~([1])。其中有报道巨大腹壁切口疝约占15%~([2])。切口疝分型方法不同导致很多研     

切口疝的发病率和复发率的问题

1 发病率有逐渐增加趋势 切口疝是腹部手术后常见的长期并发症之一,腹壁切口疝的发病率为2%～11%~[1].前瞻性研究表明经腹部中线手术后切口疝的发病率为11%～20%~([2-3])引,而切口感染的切口疝发病率为23%~[4],特别是70岁以上同时合并呼吸和心血管疾病的患者更高~[5].     

腹腔暂时性关闭方法和时机

随着外科治疗技术的进展,使得许多严重创伤的患者获得了更高的治愈率和生存率。在理念和技术方面。新进展包括损伤控制外科（damage control surgery）的观念的提出，以止血和引流为目标的损伤控制的腹腔探查术（abbreviated laparotomy）的实施和对腹腔室间隔综合症（abdominal compartment syndrome,ACS）的认识及处理方法的选择等。作为损伤控制外科的一部分，对严重的腹部损伤或污染等情况。常常在术后采用开放腹壁切口即暂时性腹腔关闭（temporary abdominal closure，TAC）技术以预防和治疗腹腔室间隔综合症的发生。     

Temporary abdominal closure techniques

Open abdomen treatment (OAT) is increasingly used, most often to prevent intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) after emergency abdominal surgery. The goal of temporary abdominal closure (TAC) techniques no longer is abdominal coverage alone, but fluid control and facilitation of early fascial closure are now important aspects. Various methods are available, but negative pressure therapy seems to be best suited to achieve these goals. Fascial approximation techniques prevent lateral retraction of the abdominal muscles and can be combined with TAC techniques. Mesh-mediated vacuum-assisted wound closure is emerging as one of the most promising approaches for OAT. In the intensive care unit, continued attention to IAH/ACS and measures to prevent or treat these conditions is imperative.     

The stapled abdominal wall closure revisited

Feeding gastrostomy can be troublesome, inconvenient and painful to the patient, especially if the catheter is redundant, thereby causing deformity of the opening and leakage of gastric juice and food around the tube. A skin level permanent feeding gastrostomy was fashioned in four patients with neurologic disease. The mushroom catheter was introduced into the stomach, secured by a purse-string suture and fastened to the abdominal wall by a metal hub. The hub was fitted to a syringe by an adaptor for feeding purposes and was covered between meals. The device is simple to construct, safe, spill-proof and easily adopted by the patients.     

暂时性腹腔关闭技术在腹腔间隔室综合征中的应用

目的探讨暂时性腹腔关闭技术在腹腔间隔室综合征中的应用。方法总结我院2006年1月至2009年12月共13例腹腔间隔室综合征应用暂时性腹腔关闭技术患者的临床资料,分析其治疗方法和效果。结果本组13例患者中,死亡1例,其余12例行确定性关腹,暂时性腹腔关闭平均11．6（7～48）d;确定性腹腔关闭后,切口的愈合时间为（15．3±8．4）d。出现切口疝1例。结论暂时性腹腔关闭技术是治疗腹腔间隔室综合征有效、安全、经济的方法。     

Modified Chevrel technique for abdominal closure in critically ill patients with abdominal hypertension and limited options for closure

Hernia - Abdominal compartment syndrome is a potentially life-threatening condition seen in critically ill patients, and most often caused by acute pancreatitis, postoperative abdominal vascular...     

Vacuum-assisted closure for complicated neonatal abdominal wounds

Background

Neonatal experience in vacuum-assisted closure (VAC) for complex abdominal wounds remains scant.

Methods

A neonatal VAC protocol was instituted in 2004. The medical records of patients treated with this protocol for the ensuing 3 years were retrospectively reviewed. Continuous data are reported as mean ± SD (range).

Results

Ten VAC applications occurred in 8 neonates for a 3-year period. Gestational age and age at VAC application were 30 ± 6.9 (24-40) weeks and 84.5 ± 51 (21-165) days, respectively. Birth weight and weight at VAC application were 1495 ± 1118 (615-3415) g and 3515 ± 2118 (989-7965) g, respectively. All wound complications occurred after laparotomies (7 elective, 3 emergent). Three wounds included intestinal stomas, and 3 included enterocutaneous fistulae. Average wound area at VAC initiation was 13.6 ± 6.0 (8.5-25) cm². Duration of VAC use was 19.1 ± 15.3 (7-60) days. Vacuum-assisted closure resulted in complete wound closure in all cases and did not result in any local or systemic complications. Five patients (63%) survived to discharge.

Conclusions

Vacuum-assisted closure for complicated abdominal wounds is safe and successful in neonates of any gestational age and birth weight. It provides effective wound management, even in the presence of stomas or enterocutaneous fistulae.     

Polypropylene mesh closure of infected abdominal wounds

The management of extensive abdominal tissue loss in the presence of intraabdominal infection or wound dehiscence challenges the surgeon's ingenuity in wound care. Radical debridement and primary fascial closure may be impossible due to tissue loss or extensive bowel edema. The use of a synthetic mesh to bridge the fascial defect and maintain the integrity of the abdominal cavity may initially appear to be an attractive alternative to simply leaving the viscera exposed. However, this report and review of the literature document the frequent complications and high morbidity associated with this technique. An overall complication rate approaching 80% can be anticipated if polypropylene mesh is used in this emergency situation. Two modifications of wound care appear to markedly diminish the incidence of serious complications. Covering the mesh with full-thickness skin or muscle flaps in the early postoperative period, or removing the mesh at the earliest time conducive to fascial closure (within 2 weeks) reduced the overall complication rate from 55% to 15% in this review. However, it is often impossible to predict which patients will be amenable to early mesh removal, and full-thickness coverage of a persistently infected wound is usually doomed to failure. Despite the occasional usefulness of these modifications, this review suggests that polypropylene mesh in the emergency setting has an unacceptably high complication rate, and alternative methods of wound care in these complex situations should be considered.