局麻下股疝的术式选择及手术技巧

目的 探讨局麻下股疝无张力修补的术式选择及改良腹膜前修补手术技巧.方法 2002年12月至2009年12月收治109例非绞窄性股疝,按时间段分为3组,其中2002年12月至2008年12月85例,45例为腹膜前修补组(preperitoneal组),40例为网塞修补组(plug组);2009年1月至2009年12月24例为改良腹膜前修补组.分别对3组患者手术时间、住院天数、术后疼痛评分(VAS)、局部异物感、术后复发率及切口血清肿等指标进行分析比较.结果 109例患者均在局麻下完成无张力疝修补术,围手术期无死亡病例.preperitoneal组在术后切口血清肿、局部异物感及复发率等方面均明显优于plug组(P＜0.05);改良腹膜前修补组在手术时间、住院天数及术后VAS等方面又明显优于preperitoneal组(P＜0.05).结论 非绞窄性股疝应选择局麻下改良腹膜前修补术.改良腹膜前修补术创伤更小、手术时间更短、术后恢复更快.     

50例股疝疗效分析

目的评估股疝术后患者发病率和死亡率的影响因素。方法对2005年6月到2008年6月50例股疝修补术后患者进行回顾性分析。手术方法为McVay疝修补术和Lichtenstein无张力疝修补术。研究性别,年龄,修补技术,嵌顿／绞窄的情况,嵌顿／绞窄的器官,术后并发症,住院时间,复发率,影响发病率和死亡率的因素。结果50例股疝患者中,年龄范围23岁至77岁（平均年龄48．74岁）,其中女性患者占72％。20例（40％）患者因嵌顿／绞窄行急诊手术,其中16例疝内容物为大网膜,4例发生小肠绞窄行肠切除。30例（60％）患者行择期手术。所有患者中44例行Lichtenstein无张力疝修补术,6例行McVay疝修补术,1例急诊手术术后伤口感染,无死亡病例,无复发病例。结论股疝容易发生嵌顿／绞窄,对老年患者而言,急诊手术增加手术风险和死亡率,因此股疝患者应尽早手术治疗。     

复合补片修补腹壁切口疝十例的临床分析

目的评价应用复合补片腹膜内置入修补腹壁切口疝的效果。方法2003年11月至2005年6月应用复合补片修补腹膜难以对合的腹壁切口疝10例，均采用腹膜内置入修补法。结果所有患者均顺利恢复，手术后早期未发生切口感染、皮下血肿和血清肿等并发症。10例患者术后均得到随访，随访6～24个月，平均18个月。随访期内未发现肠梗阻、窦道形成和肠瘘等远期并发症和切口疝复发，10例患者均局部感觉良好。结论应用复合补片腹膜内置入修补切口疝是一种安全、有效的方法。     

改良腹腔镜经腹腔腹膜前腹股沟疝修补术

目的探讨改良后的腹腔镜经腹腔腹膜前腹股沟在成人疝修补中的应用价值。方法2006年5月至2008年4月，对腹股沟疝403例、股疝22例行改良TAPP术。剪开脐外侧韧带，斜疝患者以缝合小儿疝的方法关闭内环口，直疝疝囊、股环疝囊予以剥离、置补片，游离的脐外侧韧带腹膜全部覆盖网片，钉合及可吸收线以针织的方法固定。结果手术无中转，每侧手术时间20～30min，出血量约4～5ml，随访时间2～22个月，无复发，无腹部牵拉不适，也无腹痛、腹胀、恶心等肠梗阻及尿频、尿痛等膀胱刺激症状。结论改良经腹腹膜前（TAPP）腹腔镜腹股沟疝修补术方法简单、效果确切、创伤小、并发症少、费用低，值得临床推广应用。     

成人腹股沟疝开放无张力修补治疗87例体会

目的探讨成人腹股沟疝开放无张力修补方法的选择。方法根据Gilbert疝分级对成人腹股沟疝进行分型。对Gilbert疝分级Ⅰ型、Ⅱ型成人腹股沟疝共41例采用平片修补法进行修补,对Gilbert分级Ⅲ～Ⅶ型的成人腹股沟疝共46例采用腹膜前铺网进行修补。结果采用平片修补法41例平均手术时间（63．7±9．5）min,平均住院时间（5．6±2．9）d,术后尿潴留2例,切口血肿2例,术后疼痛2例。采用腹膜前铺网法46例,平均手术时间（52．4±8．3）min,平均住院时间（5．3±2．7）d,术后尿潴留4例,腹壁血肿1例。无疝复发病例。结论根据不同类型疝采用不同的无张力疝修补方法,可以降低疝复发及减少并发症。     

普理灵疝装置在股疝无张力修补术中的应用

目的探讨应用普理灵疝装置(Polypropylene-Prolene Hernia System,PHS)行股疝无张力修补的疗效。方法分别应用美国强生公司生产的普理灵疝装置(PHS)和美国巴德公司生产的网塞(PerFix Plug,Plug)作为疝修补材料行股疝修补术,将36例股疝患者随机分为PHS组和Plug组,对2组的手术时间、住院天数、术后并发症和复发率等临床资料进行对比研究。结果随访6- 30个月,PHS组与Plug组手术时间分别为(42±7)min和(41±4)min;住院天数(4．1±1．0)d和(4．4±1．2)d;PHS组术后无复发,1例出现阴囊积液,Plug组复发2例,1例出现皮下血肿。Plug组术后5例有异物感,PHS组0例,差异有统计学意义(P<0．05)。结论普理灵疝装置在股疝无张力修补术中的应用是安全有效的。     

Surgical mesh for ventral incisional hernia repairs: Understanding mesh design

Surgical mesh has become an indispensable tool in hernia repair to improve outcomes and reduce costs; however, efforts are constantly being undertaken in mesh development to overcome postoperative complications. Common complications include infection, pain, adhesions, mesh extrusion and hernia recurrence. Reducing the complications of mesh implantation is of utmost importance given that hernias occur in hundreds of thousands of patients per year in the United States. In the present review, the authors present the different types of hernia meshes, discuss the key properties of mesh design, and demonstrate how each design element affects performance and complications. The present article will provide a basis for surgeons to understand which mesh to choose for patient care and why, and will explain the important technological aspects that will continue to evolve over the ensuing years.     

Dynamic self-regulating prosthesis (Protesi Autoregolantesi Dinamica-PAD): A new technique in the treatment of inguinal hernias

Summary Inguinal hernia has been successfully treated using prostheses. However, doubts still remain with regard to tension-free and sutureless techniques, about tension and torsion, wrinkling, prosthesis dislocation and complications in the post-operative phase. We are therefore proposing a new technique, involving the use of a polypropylene prosthesis (Prolene^®), known as P.A.D. (Protesi Autoregolantesi Dinamica) which is designed to eliminate these complications. P.A.D. consists of two superimposed layers of surgical mesh. The lower and upper layers of this dynamic prosthesis can move independently from each other, since each is fixed only to one side facing the side of the other layer, allowing for the movement of the aponeurotic and muscular structures. P.A.D. may be used to treat all forms of inguinal hernia in adult males. This study is based on 500 randomly selected male patients with primary inguinal hernias. Excellent results, improved post-operative comfort and recurrence-free follow-up have been observed in all patients treated using this method. There was a significant fall in the consumption of analgesics in the post-operative period, as a result of greater post-operative comfort. P.A.D application is a simple procedure, and is easily replicated.     

Anterior tension-free repair under local anesthesia of abdominal wall hernias in continuous ambulatory peritoneal dialysis patients

Background A 10-year experience of abdominal wall hernia repair performed with anterior tension-free mesh or plug technique under local anesthesia in end-stage renal failure patients submitted to continuous ambulatory peritoneal dialysis (CAPD) is described in order to assess the safety and effectiveness of this approach.Methods Between January 1993 and December 2002, 18 hernia repairs were performed under local anesthesia in 16 patients (14 males and two females) with a mean age of 70 years (48–78). One umbilical and three unilateral inguinal hernias were observed and repaired before starting peritoneal dialysis (PD), while two umbilical, eight unilateral, and two bilateral groin hernias developed and were then treated during PD. Repairs were performed electively in all but one case, which was an emergency operation for strangulation. An ipsilateral scrotal swelling was also present in two indirect unilateral inguinal hernias. In these cases, the hernia sac was ligated before entering, while in the others it was simply dissected and inverted.Results Patients were discharged the same day or the day after surgery. No local or general immediate or late complications occurred. CAPD in subjects operated on during PD treatment was resumed the same day of surgery. In no instance was hernia recurrence or leak of dialysis solution observed at follow-up examinations.Conclusions The absence of surgical and general complications and the nearly immediate resumption of PD indicate the anterior tension-free repair under local anesthesia as a safe and effective technique for CAPD patients even in an ambulatory or day-surgery setting.     

Laparoscopic ventral hernia repair: a systematic review

Background  Laparoscopic ventral hernia repair may be an alternative to open mesh repair as it avoids a large abdominal incision, and thus potentially reduces pain and hospital stay. This review aimed to assess the safety and efficacy of laparoscopic ventral hernia repair in comparison with open ventral hernia repair. Method  A systematic review was conducted, with comprehensive searches identifying six randomised controlled trials (RCTs) and eight nonrandomised comparative studies. Results  The laparoscopic approach may have a lower recurrence rate than the open approach and required a shorter hospital stay. Five RCTs (Barbaros et al., Hernia 11:51–56, 2007; Misra et al., Surg Endosc 20:1839–1845, 2006; Navarra et al., Surg Laparosc Endosc Percutan Tech 17:86–90, 2007; Moreno-Egea et al., Arch Surg 137:266–1268, 2002; Carbajo et al., Surg Endosc 13:250–252, 1999) reported no conversion (0%) to open surgery, and four nonrandomised studies reported conversions to open surgery ranging from 0% to 14%. Open approach complications generally were wound related, whereas the laparoscopic approach reported both wound- and procedure-related complications and these appeared to be less frequently reported. Conclusion  Based on current evidence, the relative safety and efficacy of the laparoscopic approach in comparison with the open approach remains uncertain. The laparoscopic approach may be more suitable for straightforward hernias, with open repair reserved for the more complex hernias. Laparoscopic ventral hernia repair appears to be an acceptable alternative that can be offered by surgeons proficient in advanced laparoscopic techniques.     

戈尔（Gore）平片在腹股沟疝无张力修补术中应用的临床体会

目的总结Gore平片在腹股沟疝无张力修补术中的临床应用。方法回顾性分析我院2004年5月至2008年5月413例使用Gore平片行腹股沟疝无张力疝修补手术的临床资料。结果本组随访3个月到2年，治愈410例，复发3例，复发率0．73％（3／413）。术后伤口感染2例，感染率0．48％（2／413）。术后疼痛2例，发生率0．48％（2／413）。术后异物感3例，发生率0．73％（3／413）。结论本方法具有适应证广，操作简便，复发率低，异物感轻，并发症少等优点，是安全有效的无张力疝修补法。     

Kugel^TM补片在腹壁疝修补中的应用

目的探讨Kugel补片在腹壁疝治疗中的效果。方法总结2004年1月至2007年1月应用Kugel补片治疗的97个病例的临床资料。结果手术时间缩短30％，住院天数少于10d，术后不良反应少，复发率为1．03％。结论使用Kugel补片的修补术是一种微创、高效的手术。可以使用肌后腹膜前修补的方法（stoppa技术）进行腹壁疝的修补。     

人工材料修补老年腹壁切口疝的手术方法探讨

目的总结采用人工材料无张力修补腹壁切口疝的临床经验和方法，探讨人工材料置于腹壁不同的层次是否影响疗效。方法回顾性分析67例老年腹壁切口疝的手术方法、围手术期处理、术后并发症、引流的放置、抗生素的使用及随访结果。根据人工材料放置位置不同分为两组：前鞘前、腹膜前，比较两组间一期愈合和复发情况。结果患者平均年龄68．52岁；全部采用人工材料修补；人工材料分别放置于前鞘前（皮下）42例、腹膜前（肌层后）25例；术后放置负压吸引49例（73．13％），全部使用抗生素预防感染；术后皮下积液6例（8．96％），切口延迟愈合5例（7．46％），肺部感染5例（7．46％）；随访2．4年（0．5～4年），两组患者均无复发，两组间一期愈合率无显著差别。结论采用人工材料行无张力疝修补是合适的治疗老年腹壁切口疝的方法，人工材料置于腹壁不同层次均可取得良好疗效，良好的围手术期处理是疗效的重要保证。     

Impact of the mesh fixation technique on operation time in laparoscopic repair of ventral hernias

Background

Fixation of the prosthesis is one of the critical components of laparoscopic repair of ventral and incisional hernia (LRVIH). The impact of the fixation technique used on operative time has never been analyzed. We compared the duration of the operation according to the fixation technique used in a series of 138 patients with primary umbilical hernia.

Methods

All patients underwent a straightforward repair by using completely standardized techniques. One hundred and seven patients had mesh fixation with a single crown of tackers (ProTack^®, TycoUSS, Norwalk, CT) and eight transabdominal sutures (TAS). Thirty-one patients had mesh fixation with a double crown of tackers (DC) without TAS.

Results

There were no significant differences in age, sex, hospital stay, and morbidity between the two groups. Mean operating time for the technique with TAS was 50.6 min compared to 41.4 min for the DC technique. The mean difference in operating time was 9.2 min. This difference was significant (P = 0.002). During a mean follow-up of 26.4 months, there were no recurrences in the entire series.

Conclusions

The difference in operative times between the two operative techniques can be entirely accounted to the difference in the time needed for insertion of eight TAS as compared to the time needed for application of an inner crown of tackers. This strongly indicates that insertion of every single TAS prolongs LRVIH for approximately 1 min. As long as no significant differences between the two fixation techniques are demonstrated on issues of recurrence, complications, and postoperative pain, the time difference we have measured might be an argument in favor of the DC technique, especially when mesh fixation would require a large number of TAS.

     

腹股沟疝患者年龄分布及特点分析

目的探讨成年腹股沟疝患者的年龄分布特征,总结老年腹股沟疝的治疗经验。方法回顾性分析2005年6月至2009年4月共465例在我院行疝环充填式无张力疝修补术的患者的临床资料,将患者按年龄分为中青年组（60岁）及老年组（≥60岁）,比较患者合并症、住院情况以及术后并发症在各年龄组的差异。结果成年腹股沟疝大多发生于50～77岁的年龄段,尤其在64～70岁间,其中≥60岁的老年患者约占全组的63．2％。老年组中,合并内科疾病者占30％,中青年组则为10％。与中青年患者相比,老年患者平均住院时间明显延长（P〈0．05）,而术后并发症发生率也较高,老年组15．3％,中青年组5．8％。424例随访1～45个月,无1例复发。结论在施行无张力疝修补术时,正确认识老年疝的特点、有效处理术前并发症及术后并发症,对减少治疗风险,减轻患者痛苦,缩短住院时间是至关重要的。     

疝囊腹膜前间隙还原法治疗股疝疗效分析

目的探讨疝囊腹膜前间隙还原法治疗股疝的临床效果。方法回顾性分析2010年3月至2013年3月,西安电力中心医院采用疝囊腹膜前间隙还原法治疗股疝27例患者的临床资料。结果27例患者手术时间35～66min,平均46min。患者在术后24～48h均能够下床活动,切口仅有轻微疼痛,无发生切口感染、局部血肿等并发症,术后随访6～24个月,均无复发。结论疝囊腹膜前间隙还原法治疗股疝符合现代疝修补的理念,采用腹股沟入路的方式,易于掌握,效果良好,并发症少,值得推广。     

腹膜前间隙网片修补治疗嵌顿性股疝24例临床分析

目的探讨无张力疝修补术治疗嵌顿性股疝的效果。方法回顾分析我院2004年l月至2009年11月24例嵌顿性股疝患者应用腹膜前间隙平铺网片修补耻骨肌孔进行手术治疗的临床资料。结果全组病例术后均痊愈,无局部异物感,无感染,随诊无复发。结论腹膜前间隙网片修补耻骨肌孔是对腹股沟区的全面修补,是治疗股疝的一种合理而理想的手术方式。     

日间手术中心复合局部麻醉下腰骶部筋膜脂肪疝的治疗

目的：探讨分析日间手术中心（ambulatory surgery center,ASC）复合局部麻醉下腰骶部筋膜脂肪疝的手术治疗体会。方法回顾性分析2012年10月至2013年7月,佛山市第一人民医院ASC接收手术治疗腰骶部筋膜脂肪疝患者33例的临床资料。手术方式：疝囊口扩大＋内容物切除术。麻醉方式：复方利多卡因乳膏表面麻醉＋哌卡因局部浸润麻醉。结果本组患者均在复合局部麻醉下顺利完成手术治疗,术中、术后无手术相关并发症发生。术后随访6个月,手术疗效价：优良率为93．94％。结论 ACS复合局部麻醉下手术治疗腰骶部筋膜脂肪疝疗效确切、安全可靠,减少了患者在院时间,节省了医疗成本。     

196例腹股沟疝平片无张力疝修补术的治疗分析

目的探讨腹股沟疝平片无张力疝修补术的疗效和优点。方法采用人工补片对196例腹股沟疝行平片无张力疝修补术的手术要点及临床效果进行回顾性分析。结果平均手术时间49min（42～55min），术后并发症为3％（6／196），术后随访2年，复发2例，复发率1．02％。结论平片无张力疝修补术是一种简单、安全、痛苦小、恢复快、效果好的疝修补方法。