腹壁疝修补术后疼痛预防及处理

疝修补术后疼痛是严重影响手术效果和病人生活质量的并发症。影响疼痛的因素有疝修补术中神经损伤、补片周围组织增生对神经的卡压、补片固定方法以及病人的体质差异等。预防疝修补术后发生疼痛须注意手术规范化操作,熟悉腹股沟区及腹壁神经解剖,合理选择补片,减少纤维结缔组织过度增生,并适当固定补片。疼痛发生后应及时进行干预,包括给予止痛药物、局部神经封闭、脊神经阻滞等非手术治疗方法。对于非手术治疗无效的顽固性疼痛,经过慎重评估后可再手术取出补片,并切除补片周围受损伤的神经,以缓解疼痛。     

下腹部普通外科手术造成的外周神经损伤

尽管普通外科手术疤痕很少产生疼痛症状,然而一旦出现疼痛,确是需要诊断和治疗的问题。腹股沟区的手术。诸如阑尾切除术、疝修补术和作横切口的妇科手术所产生的痛性疤痕是有一些原因的,在作鉴别诊断时,应包括1)切口疝、腹股沟疝和股疝,2)淋巴腺病变,3)术后髂腹股沟一髂腹下神经包埋综合症,4)腹肌劳损,5)耻骨结节骨膜炎,6)腹直     

腹腔镜下造口旁疝补片修补术可行性、安全性探讨

目的：就所开展的腹腔镜下造口旁疝补片修补术的临床资料，进行该手术可行性和安全性的探讨。方法：自2004年9月至2006年4月，我院为10例造口旁疝病人进行了腹腔镜下补片修补术。结果：10例造口旁疝病人中9例修补成功，1例因腹腔内广泛致密粘连而中转为开腹缝合修补；手术时间平均113（45～180）min：疝环大小平均5．6（4～6）cm；术后2例出现暂时性腹胀；7例修补区域腹壁疼痛，持续2周后均明显缓解：1例出现呼吸功能减退，经使用无创呼吸机辅助治疗后缓解；5例出现浆液肿，经2～4次穿刺抽液并加压包扎后治愈，无血肿发生．也未发生与手术相关的感染。术后住院时间平均5．7（3-9）d；术后随访平均9．1（2～19）个月，未见早期复发。结论：腹腔镜造口旁疝补片修补术从技术上讲是安全、可行的，从早期的临床结果来看．效果较理想。     

硬化剂治疗后局部顽固性疼痛的腹股沟疝处理

目的硬化剂治疗腹股沟疝造成局部顽固性疼痛,临床处理非常棘手,本研究将探究腹股沟疝局部硬化剂处理后局部顽固性疼痛的处理方法。方法鞍钢集团总医院于2006年5月至2015年5月共收治疗硬化剂注射治疗后局部顽固性疼痛的腹股沟疝患者6例,5例斜疝患者采用选择性髂腹股沟神经束离断术+Lichtenstein无张力疝修补术,1例直疝患者采用选择性髂腹股沟神经、生殖股神经生殖支离断术+充填式无张力修补术。结果术后随6例患者腹股沟疝无复发,术前顽固性疼痛均明显缓解。结论对于硬化剂治疗后腹股沟疝出现顽固性疼痛患者采用选择性神经束离断术治疗后是有效可行的。     

白线疝17例临床诊治体会

目的 探讨白线疝的临床表现及手术疗效。方法 回顾性分析2016年1月至2019年6月河北大学附属医院收治的17例白线疝病人的临床资料。结果 17例均经手术证实为白线疝,术后随访(11.2±4.5)个月(6～18个月)。(1)8例行开放手术,平均手术时间为125 min(95～175 min)。其中嵌顿性白线疝3例,均为小肠嵌顿,2例切除坏死小肠后,1例行疝环关闭,1例疝环关闭后使用生物补片进行腹直肌后置补片修补(Sublay法),3例中另1例还纳无坏死小肠后行腹直肌前置补片修补(Onlay法),均无并发症出现;余5例开放手术中有4例行疝环关闭+Sublay修补,术后1例出现慢性疼痛,另1例行Onlay修补,未行疝环关闭,术后8个月时疝复发。(2)9例行腔镜手术,平均手术时间为100 min(78～124 min);其中2例行腹腔镜腹腔内补片修补术(IPOM),1例术后1周即出现假性复发;余7例行缝合疝环关闭联合IPOM,随访期间无并发症发生。结论 术中还纳、切除嵌入的肝圆韧带或脐正中韧带以及关闭疝环行强化修补,是缓解腹壁牵涉痛和降低术后复发的有效手段。     

腹腔镜下切口疝补片修补术的临床应用

目的 探讨腹腔镜下腹壁切口疝修补术的手术方法、安全性等问题。方法对2004年3月至2006年5月79例行腹腔镜下补片修补术治疗腹壁切口疝病人的临床资料进行分析。结果 78例（98．7％）手术成功，1例因腹腔内广泛粘连而中转开放修补。平均手术时间为88min，平均术后住院4．6d，18例（22．8％）病人术中发现有1个以上的隐匿性缺损。术后并发症：术后短期内修补区腹壁明显疼痛58例（73．4％）。腹壁缝合点较长时间疼痛6例（7．6％），浆液肿14例（17．7％），无手术死亡，1例术后出现肠瘘，经保守治疗好转，1例腰部切口疝的病人术后复发。结论 多数病人腹壁切口疝可以经腹腔镜行粘连松解及补片修补术，并可在术中发现其他隐性缺损，手术安全性较高。对腹腔内广泛粘连而影响操作器械进入及粘连分离者，应及时中转开腹手术。     

青少年腹股沟疝术后复发手术治疗9例临床分析

目的 分析青少年腹股沟疝术后复发的手术方式及效果。方法 回顾性分析佛山市第一人民医院2006年1月至2018年12月收治的9例青少年（13～18岁）腹股沟疝行手术治疗后复发病人的资料。主要收集病人前次手术方式、再次手术方式、疝环口大小、术后主要并发症及复发率。结果 170 例行腹股沟疝手术治疗的青少年病人中,有9例青少年复发性腹股沟斜疝（前次手术方式均为内环口高位结扎术）病例,其中2例行开放手术,7例行腹腔镜手术。9例病人中,3例为多次复发,6例为首次复发。术中见疝环口大小0.3～3.0 cm。手术方式,4例行腹腔镜内环口缝扎术,疝环口大小0.3～2.0 cm;5例行腹腔镜腹股沟疝补片修补术（3例为多次复发病人）,疝环口大小1.5～3.0 cm。随访6个月至10年,无伤口或补片感染,其中3例病人术后近期出现腹股沟区隐痛不适,行补片修补2例,行内环口高位结扎1例;1例出现血清肿,为补片修补;复发1例,为补片修补。结论 青少年复发性腹股沟疝再次手术方式应根据前次手术方式、复发次数及是否存在大的内环缺损或腹横筋膜缺损进行选择。初次复发、内环口缺损≤2 cm者,建议行腹腔镜内环口高位结扎。多次复发或内环口缺损大者,建议使用补片修补。     

腹股沟嵌顿疝153例一期修补临床经验

目的探讨腹股沟嵌顿疝的术式选择,放置补片的指征,术后并发症的影响因素及处理方法。方法回顾性分析2005年8月至2014年7月,杭州市第一人民医院153例接受手术治疗腹股沟嵌顿疝患者的临床资料,统计分析一般情况、疝类型、发病至就诊时间、手术方式、是否放置补片及补片类型、术后并发症。结果本组患者,71例行肠切除,82例行无肠切除。肠切除主要风险因素为性别、年龄、疝类型、痴呆等精神疾病、嵌顿时间等。本组患者放置补片76例,补片感染者2例,1例移除补片,无复发。结论肠切除不是补片修补的禁忌,对于相对清洁的创面可选择补片修补,对患者减少复发的获益大于增加的潜在感染风险。     

腹股沟疝修补术后慢性疼痛的诊治体会

目的 报告腹股沟疝修补术后慢性疼痛的诊治经验.方法 回顾性分析35例腹股沟疝修补术后慢性疼痛患者的临床资料,总结其诊断和治疗经验.结果 28例患者经物理治疗联合药物治疗疼痛缓解;4例经神经阻滞治疗后好转;3例手术治疗,1例神经瘤形成,切除瘤体后将断端植入肌肉后治愈,1例补片移位,1例补片内环口固定过紧,皆经手术清除补片和周围瘢痕组织而治愈.结论 疝修补术后慢性疼痛要早期积极治疗,应先行理疗、药物治疗或神经阻滞等保守治疗,疗效差者或疼痛程度严重者才考虑手术治疗.     

改良Kugel补片治疗再发股疝的价值探讨

目的探讨改良Kugel补片在无张力斜疝修补术后再发股疝中的应用价值。方法对21例无张力斜疝修补术后再发股疝患者采用改良Kugel补片修补,观察手术时间、术后并发症及复发情况。结果本组患者均治愈,平均手术时间69（60—120）min。术后疼痛轻,2例出现阴囊积液,经多次穿刺抽吸后缓解。术后无切口感染,平均随访18．6（2～24）个月,无疝复发。结论改良Kugel补片腹膜前修补术治疗无张力斜疝修补术后再发股疝是一种安全、有效的手术方式,值得推广。     

Laparoscopically guided ilioinguinal nerve block for groin hernia repair

BACKGROUND: Percutaneous ilioinguinal nerve block may reduce postoperative pain after open groin hernia repair but may be complicated by transient femoral nerve palsy in some patients. The technique of laparoscopically guided ilioinguinal nerve block is reported, and its benefits assessed in patients undergoing laparoscopic total extraperitoneal groin hernia repair. MATERIALS AND METHODS: In this prospective study, patients who had laparoscopically guided ilioinguinal nerve block during groin hernia repair were assessed in the post-anaesthetic recovery room and the day surgery ward. Need for opiate analgesia in the recovery room and the day surgery ward was recorded. Verbal pain scores (on a scale of 0 to 3) on rest and leg movement were noted. RESULTS: Thirty-two consecutive men and one woman, mean age 49 years (range, 29-76 years), had laparoscopic total extraperitoneal repair of groin hernia with ilioinguinal nerve block. Postoperatively, 18% of the patients required opiate analgesia in the recovery room and none in the day surgery ward. Median verbal pain scores at rest and movement were 0 (range, 0-2) and 1 (range, 0-3), respectively. No patient developed transient femoral nerve block. CONCLUSION: Laparoscopically guided ilioinguinal nerve block may be applied safely and with improved postoperative comfort after groin hernia repair.     

Combined open and laparoscopic approach to chronic pain following open inguinal hernia repair

Introduction: Chronic groin pain is the most common long-term complication after open inguinal hernia repair. Traditional surgical management of the associated neuralgia consists of injection therapy followed by groin exploration, mesh removal, and nerve transection. The resultant hernia defect may be difficult to repair from an anterior approach. We evaluate the outcomes of a combined laparoscopic and open approach for the treatment of chronic groin pain following open inguinal herniorrhaphy. Methods: All patients who underwent groin exploration for chronic neuralgia after a prior open inguinal hernia repair were prospectively analyzed. Patient demographics, type of prior hernia repair, and prior nonoperative therapies were recorded. The operation consisted of a standard three trocar laparoscopic transabdominal preperitoneal hernia repair, followed by groin exploration, mesh removal, and nerve transection. Outcome measures included recurrent groin pain, numbness, hernia recurrence, and complications. Results: Twelve patients (11 male and 1 female) with a mean age of 41 years (range 29–51) underwent combined laparoscopic and open treatment for chronic groin pain. Ten patients complained of unilateral neuralgia, one patient had bilateral complaints, and one patient complained of orchalgia. All patients failed at least two attempted percutaneous nerve blocks. Prior repairs included Lichtenstein (n=9), McVay (n=1), plug and patch (n=1), and Shouldice (n=1). There were no intraoperative complications or wound infections. With a minimum of 6 weeks follow up, all patients were significantly improved. One patient complained of intermittent minor discomfort that required no further therapy. Two patients had persistent numbness in the ilioinguinal nerve distribution but remained satisfied with the procedure. Conclusions: A combined laparoscopic and open approach for postherniorrhaphy groin pain results in good to excellent patient satisfaction with no perioperative morbidity. It may be the preferred technique for the definitive management of chronic neuralgia after prior open hernia repair.     

针刀治疗腹股沟疝修补术后顽固性疼痛23例

目的探讨用针刀治疗疝修补术后切口顽固性疼痛。方法对23例疝手术后切口疼痛的病人应用针刀进行切口区域松解治疗。结果治疗后症状消失。结论可以考虑应用针刀治疗疝修补术后切口疼痛。     

Prophylactic ilioinguinal neurectomy in open inguinal hernia repair: a double-blind randomized controlled trial

OBJECTIVE: We conducted a double-blinded randomized controlled trial to investigate the short- to mid-term neurosensory effect of prophylactic ilioinguinal neurectomy during Lichtenstein repair of inguinal hernia. METHOD: One hundred male patients between the age of 18 and 80 years with unilateral inguinal hernia undergoing Lichtenstein hernia repair were randomized to receive either prophylactic ilioinguinal neurectomy (group A) or ilioinguinal nerve preservation (group B) during operation. All operations were performed by surgeons specialized in hernia repair under local anesthesia or general anesthesia. The primary outcome was the incidence of chronic groin pain at 6 months. Secondary outcomes included incidence of groin numbness, postoperative sensory loss or change at the groin region, and quality of life measurement assessed by SF-36 questionnaire at 6 months. All follow-up and outcome measures were carried out by a designated occupational therapist at 1 and 6 months following surgery in a double-blinded manner. RESULTS: The incidence of chronic groin pain at 6 months was significantly lower in group A than group B (8% vs. 28.6%; P = 0.008). No significant intergroup differences were found regarding the incidence of groin numbness, postoperative sensory loss or changes at the groin region, and quality of life measurement at 6 months after the operation. CONCLUSIONS: Prophylactic ilioinguinal neurectomy significantly decreases the incidence of chronic groin pain after Lichtenstein hernia repair without added morbidities. It should be considered as a routine surgical step during the operation.     

The effect of polypropylene mesh on ilioinguinal nerve in open mesh repair of groin hernia

OBJECTIVES: Repair of groin hernia is one of the most common operations performed by general surgeons, and mesh repair methods have gained wide acceptance. Chronic pain is the most serious long-term complication that can occur after repair of groin hernia. The development of chronic pain after herniorraphy has been attributed to several mechanisms, including damage to sensory nerves and mesh inguinodynia. MATERIAL AND METHODS: Twenty-four rabbits underwent bilateral inguinal dissection and synthetic polypropylene mesh laid on one side. Bilateral inguinal dissection was performed again after 3 months, and samples of nerve tissue were taken from both sides for histological examination. RESULTS: Light microscopic examination of the sections of control group peripheral nerves were in normal appearance, but the nerve fascicles in experimental group operated with mesh showed axonal dilation and mild-to-severe loss of myelinated axons. Examination of semi-thin and ultra-thin sections in control group peripheral nerve fascicles showed normal morphology. Ultrastructural nerve morphology in experimental group operated with mesh exhibited endoneurinal edema with thickening of both endoneurium and perineurium, causing separation of nerve fibers. Myelin sheaths of fibers showed an ondulation toward the axoplasm and the endoneurium. Separation of myelin layers from each other as a prominent feature of myelin degeneration in nerve fibers was also observed. Axoplasms exhibited edema and crystallization. CONCLUSIONS: The light microscopic and ultrastructural changes seen in peripheral nerves in experimental group operated with mesh suggested that mechanical compression of peripheral nerves is associated with myelin degeneration, endoneurinal and perineurial edema, fibrosis, axonal loss, and edema that may cause peripheral neuropathy. Chronic groin pain after hernia repair can be possibly caused by the entrapment of peripheral nerves in the scar tissue formed by the mesh.     

Bard网塞无张力疝修补术后并发症的防治

目的探讨Bard补片疝环充填式无张力疝修补术后并发症发生的原因及其防治措施。方法总结2005年6月至2007年12月采用无张力疝修补术的242例腹股沟疝患者的经验。结果全组均痊愈出院，平均手术时间66．2min，平均术后恢复时间7．3d，平均总住院时间9．7d。术后早期切口轻度疼痛，腹股沟区异物感2例（0．8％），切口感染1例（0．4％），尿潴留11例（4．5％），阴囊积液17例（7．4％），228例获随访时间4～22个月，1例有腹股沟区异物感，无1例复发。结论腹股沟区解剖结构的正确认识、手术规范操作和术前术后合理治疗可降低术后并发症的发生，进一步提高腹股沟疝的治疗效果。     

Lichtenstein无张力疝修补术中腹股沟区神经处理的体会

目的探讨Lichtenstein无张力疝修补术中正确处理腹股沟区神经对术后慢性疼痛的预防效果。方法对我院2007年2月至2010年3月期间收治的158例腹股沟疝患者行Lichtenstein无张力疝修补术,并在术中注意辨认及保护腹股沟区神经,保持神经床的完整性,若神经被损伤或干扰了网片的放置则予切除。结果术中髂腹下神经、髂腹股沟神经和生殖股神经生殖支辨认率分别为87.97%(139/158)、82.28%(130/158)和34.18%(54/158)。术后并发症发生率为5.06%(8/158),其中切口皮下积液5例,阴囊血肿2例,切口感染1例,均通过理疗、切口换药后治愈。随访12个月,无复发病例。术后1个月有轻度疼痛者63例(39.87%),中度疼痛者34例(21.52%),无重度疼痛者,平均疼痛评分为0.83分;术后6个月时慢性疼痛发生率为5.06%(8/158),其中轻度疼痛者7例(4.43%),中度疼痛者1例(0.63%);术后12个月时只有4例(2.53%)患者偶感轻微疼痛或不适,平均疼痛评分为0.03分。多分类logistic回归分析显示:神经切除对术后疼痛无明显影响(P>0.05);未辨清髂腹股沟神经会增加术后早期(1个月)中度疼痛的风险(疼痛风险比值=3.373,P=0.030)。结论只要严格遵照Lichtenstein手术操作规范,术中正确处理腹股沟区神经,就能降低患者术后慢性疼痛的发生,改善其生活质量。     

Preservation Versus Division of Ilioinguinal Nerve on Open Mesh Repair of Inguinal Hernia: A Meta-analysis of Randomized Controlled Trials

Background

Chronic groin pain after inguinal hernia repair, a serious problem, is caused by entrapment of the ilioinguinal nerve either by mesh or development of fibrosis. Division of the ilioinguinal nerve during hernioplasty has been found to reduce the incidence of chronic groin pain. However, the traditional approach favors preservation of the ilioinguinal nerve during open hernia repair.

Methods

We conducted a systematic review and meta-analysis of randomized controlled trials that compared the outcomes of preservation versus division of the ilioinguinal nerve during open mesh repair of inguinal hernia. The primary outcome was the incidence of groin pain; secondary outcomes were numbness and sensory loss.

Results

We reviewed six trials with 1,286 patients. We found no difference between the groups for the incidence of groin pain or numbness at 1, 6, and 12 months after open mesh inguinal repair. The incidence of sensory loss or change was significantly higher in the division group than in the preservation group at 6 months [risk ratio (RR) 1.25; 95?% confidence interval (CI) 1.02–1.53] and at 12 months (RR 1.55; 95?% CI 1.01–2.37) postoperatively. No significant differences between the groups were noted at any other points in time.

Conclusions

Preservation of the ilioinguinal nerve during open mesh repair of inguinal hernia is associated with a decreased incidence of sensory loss at 6 and 12 months postoperatively compared with that of the division technique. No significant differences were found between the groups for chronic groin pain or numbness.     

无张力疝修补术后慢性疼痛的临床研究

目的探讨无张力疝修补术后慢性疼痛的原因及防治方法。方法对2007-01—2011-06实施无张力疝修补术142例患者的临床资料进行回顾性地分析。结果均行无张力疝修补术,按补片类型分为2组:聚丙烯类组(n=70)和聚四氟乙烯组(n=72)。术后疼痛发生率,聚丙烯类组为10.0%(7/70),聚四氟乙烯组为4.2%(3/72),差异有统计学意义(P<0.05)。结论聚四氟乙烯平片无张力疝修补术可减少腹股沟疝修补术后慢性疼痛的发生,疝修补材料应采用更符合生理、柔软舒适、并发症少的材质。     

Chronic pain after laparoscopic and open mesh repair of groin hernia

BACKGROUND: The aim of this study was to compare the incidence of chronic pain or discomfort after laparoscopic totally extraperitoneal (TEP) repair and open mesh repair of groin hernia, and to assess the impact of such pain on patients' physical activity. METHODS: A postal questionnaire was sent to patients who had TEP or open mesh repair of groin hernia between January 1998 and December 1999. The patients were asked about any persistent pain or discomfort in relation to the groin hernia repair and whether this pain or discomfort restricted their ability to undertake physical or sporting activity. RESULTS: Of the 560 available patients 454 (81.1 per cent) replied. Laparoscopic TEP repair was performed in 240 patients (52.9 per cent) and open mesh repair in 214 (47.1 per cent). Of the 454 patients, 136 (30.0 per cent) reported chronic groin pain or discomfort, which was significantly more common after open repair than after laparoscopic repair (38.3 versus 22.5 per cent; P < 0.01). Chronic groin pain or discomfort restricted daily physical or sporting activity in 18.1 per cent of the patients. The patients who had open repair complained of significantly more restriction of daily physical activity than patients who underwent laparoscopic repair (walking, P < 0.05; lifting a bag of groceries, P < 0.01). CONCLUSION: Chronic pain or discomfort was reported by 30.0 per cent of patients after groin hernia repair and was significantly more common after open mesh repair than after laparoscopic TEP repair. It restricted physical or sporting activities in 18.1 per cent of the patients and significantly more so after open mesh repair.