腹腔镜下造口旁疝补片修补术应用体会

目的探讨腹腔镜下造口旁疝修补术的临床效果。方法回顾性分析2007年9月至2010年4月期间8例行腹腔镜下造瘘口旁疝补片修补术患者的临床资料,分析手术情况、术后并发症及复发情况。结果 8例造口旁疝患者均在腹腔镜下修补成功。手术时间50～180min,平均135min。疝环大小4.5～6.5cm,平均5.0cm。术后1例出现肠梗阻及复发,后行腹腔镜探查及再次修补术。2例术后早期出现腹胀,1周后腹胀缓解。1例术后出现术区疼痛不适,对症治疗后缓解。本组未发生术区感染。住院时间5～14d,平均7.6d。术后随访1年,除1例复发后行再次手术外,均未见复发。结论腹腔镜下造口旁疝修补术如果注意操作要点,可以替代传统修补术。     

Evolution and advances in laparoscopic ventral and incisional hernia repair

Primary ventral hernias and ventral incisional hernias have been a challenge for surgeons throughout the ages. In the current era, incisional hernias have increased in prevalence due to the very high number of laparotomies performed in the 20 th century. Even though minimally invasive surgery and hernia repair have evolved rapidly, general surgeons have yet to develop the ideal, standardized method that adequately decreases common postoperative complications, such as wound failure, hernia recurrence and pain. The evolution of laparoscopy and ventral hernia repair will be reviewed, from the rectoscopy of the 4th century to the advent of laparoscopy, from suture repair to the evolution of mesh reinforcement. The nuances of minimally invasive ventral and incisional hernia repair will be summarized, from preoperative considerations to variations in intraoperative practice. New techniques have become increasingly popular, such as primary defect closure, retrorectus mesh placement, and concomitant component separation. The advent of robotics has made some of these repairs more feasible, but only time and well-designed clinical studies will tell if this will be a durable modality for ventral and incisional hernia repair.     

腹腔镜腹壁切口疝修补术的围手术期整体护理干预

【摘要】 目的 探讨腹腔镜治疗腹壁切口疝围手术期的护理方法。方法〓对我院2010年1月至2014年12月间接受腹腔镜腹壁切口疝修补术的46例患者进行围手术期针对性护理干预,对治疗效果和护理要点进行分析。结果〓手术时间64~184 min,平均(102±26) min。无围手术期死亡病例。术后出现轻度腹胀4例,血清肿3例,腹壁修补区疼痛6例。无切口或补片感染。术后住院4~11 d,平均6.7±1.2 d。随访6~31个月,平均21.4个月,无切口疝复发。结论〓对接受腹腔镜腹壁切口疝修补术的患者实施全程、优质的心理辅导、个体化专科护理及健康教育等整体护理干预,可有效预防或减少术后并发症,促进早日康复。     

造口旁疝的腹腔镜手术

手术是治愈腹壁疝的唯一方法,但外科医生对造口旁疝的手术治疗却较为棘手。近年来,腹腔镜技术及补片被广泛应用于造口旁疝的治疗中．取得了一些进步．但依然存在复发及造口功能和外观不佳等问题．因此．对造口旁疝的手术不仅要运用无张力疝修补手术的方式来修补缺损,而且还要需要对造口进行重建。     

Performance of simulated laparoscopic incisional hernia repair correlates with operating room performance

Background

The role of simulation for training in procedures such as laparoscopic incisional hernia repair (LIHR) is unknown. The purpose of this study was to determine whether performance in simulated LIHR correlates with operating room (OR) performance.

Methods

Subjects performed LIHR in the University of Maryland Surgical Abdominal Wall (SAW) simulator and the OR. Trained observers used a LIHR-specific global rating scale (Global Operative Assessment of Laparoscopic Skills–Incisional Hernia) to assess performance. Global Operative Assessment of Laparoscopic Skills–Incisional Hernia includes 7 domains (trocar placement, adhesiolysis, mesh sizing, mesh positioning, mesh fixation, knowledge and autonomy in instrument use, and overall competence). The correlation between simulator and OR performance was assessed using the Pearson coefficient.

Results

Fourteen surgeons from 2 surgical departments participated. Experienced surgeons (n = 9) were defined as attending surgeons and minimally invasive surgury (MIS) fellows, and novice surgeons (n = 5) were general surgery residents (postgraduate years 3–5). The correlation between performance in the OR and the simulator for the entire group was .87 (95% confidence interval, .63–.96; P < .001).

Conclusions

There was an excellent correlation between LIHR performance in the simulator and clinical LIHR. This suggests that performance in the SAW simulator may predict performance in the operating room.     

Simplified technique for incisional hernia repair with mesh prosthesis

This paper describes a simplified technique for the repair of incisional hernias. The previous scar is resected, and the peritoneal sac is carefully dissected until it is completely exposed. The sac is opened to liberate structures adherent to the sac or to the area immediately surrounding the defect. The peritoneum is closed and invaginated to form a sac bed underlying the entire extent of the defect, and the mesh is laid on this sac bed. The mesh is then fixed with "U" stitches, reinforcing these by inserting a second line from the edge of the defect to the mesh. Suture material used is polypropylene 1/0 or 2/0. This procedure has been carried out on 15 patients, and after 1 year of follow-up, there has been no recurrence of the hernia. Operating time was reduced, and the surgical technique was found to be easier. Placing a mesh prosthesis inside the hernia sac and fixing it to the abdominal wall with two lines of suturing simplifies the repair procedure, reduces operating time, and is effective in the repair of all incisional hernias. A study is required to compare this outcome with the different mesh repair techniques.     

腹腔镜下CK Parastomal补片修补造口旁疝疗效分析

目的总结腹腔镜下应用CK Parastomal补片修补造口旁疝的手术方法及临床疗效。方法回顾分析2006年6月-2010年3月24例于腹腔镜下应用CK Parastomal补片修补造口旁疝患者的临床资料。男15例,女9例;年龄47～80岁,中位年龄55岁。左下腹结肠造口旁疝19例,右下腹回肠造口旁疝5例。发生造口旁疝时间1～4年,平均2.4年。疝环最大径3～7 cm,平均5.2 cm。均无疝修补史。结果 18例成功完成腹腔镜下修补,6例因腹腔内广泛致密粘连转为开放手术。手术时间78～178 min,平均121 min。术后切口均Ⅰ期愈合。术后3～7 d 8例发生浆液肿,均经穿刺抽吸后消失。术后1个月内11例出现修补区域腹壁疼痛,均自行消失。24例患者术后均获随访,随访时间6～39个月,平均27个月。术后3个月1例复发,其余患者随访期间均无复发。结论 腹腔镜下应用CK Parastomal补片修补造口旁疝是一种安全、可行的方法,可获得较好的近期疗效,但远期效果尚需进一步观察。     

Open randomized clinical trial of laparoscopic versus open incisional hernia repair

Background  Incisional hernia is a common complication following abdominal surgery. Although the use of prosthetics has decreased recurrence rates, the standard open approach is still unsatisfactory. Laparoscopic techniques are an attempt to provide similar outcomes with the advantages of minimally invasive surgery. Methods  Open randomized controlled clinical trial with follow-up at 1, 2, 3, 7, and 15 days, and 1, 3, and 12 months from hernia repair. The study was carried out in the surgery departments of three general hospitals of the Valencia Health Agency. Objectives  To compare laparoscopic with anterior open repair using health-related quality of life outcomes as main endpoints. Results  Eighty-four patients with incisional hernia were randomly allocated to an open group (OG) (n = 39) or to a laparoscopic group (LG) (n = 45). Seventy-four patients completed 1-year follow up. Mean length of stay and time to oral intake were similar between groups. Operative time was 32 min longer in the LG (p < 0.001). Conversion rate was 11%. The local complication rate was superior in the LG (33.3% versus 5.2%) (p < 0.001). Recurrence rate at 1 year (7.9% versus 9.7%) was similar in the two groups. There were no significant differences in the pain scores or the EQ5D tariffs between the two groups during follow-up. Conclusions  Laparoscopic incisional hernia repair does not seem to be a better procedure than the open anterior technique in terms of operative time, hospitalization, complications, pain or quality of life.     

Laparoscopically assisted components separation technique for ventral incisional hernia repair

Reconstruction of the abdominal wall to repair ventral hernias continues to pose a challenge to surgeons due to relatively high rates of recurrence and morbidity. In 1990, Ramirez pioneered a technique of components separation of the abdominal wall for ventral hernia repair. Although an effective hernia repair, the mobilization of skin and subcutaneous tissue endangers the blood supply and predisposes midline skin to necrosis. The goal of this study is to determine whether releasing incisions in the transversus abdominis fascia and posterior rectus sheath provide adequate mobilization of the abdominal wall necessary for ventral hernia repair, thus paving the way for a laparoscopic component separation technique. Ten fresh cadavers were used and one side of the abdomen underwent the conventional Ramirez components separation: midline incision, dissection of skin and subcutaneous tissue off the anterior abdominal wall, and incisions in the external oblique aponeurosis and posterior rectus sheath, while the other side received incisions in the transversus abdominis fascia and the posterior rectus sheath with no undermining of the skin. The amount of fascial translation was measured after each incision. Incising only the external oblique aponeurosis produced greater mobilization of the abdominal wall at the level of the umbilicus (P = 0.02) and anterior superior iliac spine (ASIS, P = 0.029) than releasing only transversus abdominis fascia. More importantly, there was no statistically significant difference in the amount of release produced by the complete internal-release components separation versus the conventional technique. In order to test the feasibility of performing the procedure laparoscopically, one additional cadaver underwent a laparoscopic transversus abdominis fascia release. The procedure was successful and resulted in comparable amounts of fascial release as the other 10 cadavers. From this study, it appears technically feasible to perform a laparoscopic components separation to repair a ventral hernia and the procedure produces the same amount of release as the conventional open component separation technique.     

Laparoscopic ventral and incisional hernia repair: An 11-year experience

Incisional hernias develop in 2%–20% of laparotomy incisions, necessitating approximately 90,000 ventral hernia repairs per year. Although a common general surgical problem, a "best" method for repair has yet to be identified, as evidenced by documented recurrence rates of 25%–52% with primary open repair. The aim of this study was to evaluate the efficacy and safety of laparoscopic ventral and incisional herniorrhaphy. From February 1991 through November 2002, a total of 384 patients were treated by laparoscopic technique for primary and recurrent umbilical hernias, ventral incisional hernias, and spigelian hernias. The technique was essentially the same for each procedure and involved lysis of adhesions, reduction of hernia contents, closure of the defect, and 3–5 cm circumferential mesh coverage of all hernias. Of the 384 patients in our study group, there were 212 females and 172 males with a mean age of 58.3 years (range 27–100 years). Ninety-six percent of the hernia repairs were completed laparoscopically. Mean operating time was 68 min (range 14–405 min), and estimated average blood loss was 25 mL (range 10–200 mL). The mean postoperative hospital stay was 2.9 days and ranged from same-day discharge to 36 days. The overall postoperative complication rate was 10.1%. There have been 11 recurrences (2.9%) during a mean follow-up time of 47.1 months (range 1–141 months). Laparoscopic ventral and incisional hernia repair, based on the Rives-Stoppa technique, is a safe, feasible, and effective alternative to open techniques. More long-term follow-up is still required to further evaluate the true effectiveness of this operation.     

Laparoscopic incisional hernia repair

Background Recent advances in laparoscopic surgery have made various abdominal surgeries possible. To avoid wound infection, mesh repair of abdominal incisional hernias is performed laparoscopically. Here we present a new procedure to fix mesh to the abdominal wall. Surgical technique Four anchoring sutures are made using a suture-grasping device; the additional transabdominal sutures are then made with a modified double-needle device. Additional circumferential fixation with tacks is not necessary. Conclusions This new mesh fixation method involves simple suturing techniques and is less time consuming than the conventional procedure.     

Laparoscopic incisional lumbar hernia repair

Purpose  Incisional lumbar hernia is an uncommon hernia type. Open surgical procedures have significant postoperative morbidity and patient dissatisfaction, therefore, for the repair of seven incisional lumbar hernias, we attempted using an intraperitoneal laparoscopic technique that was described to have good short-term results and decreased morbidity. Methods  We applied a laparoscopic technique using polypropylene meshes in five patients and composite meshes in two patients to cover the defect, then placed prolene sutures and hernia staples to secure the mesh intraperitoneally. Result  The technique was successful in all patients, and they tolerated the procedure well. All did well after surgery, ambulating and eating a regular diet on postoperative day 1. No postoperative complications developed. At a mean follow-up of 34.1 months (range 17–43 months) none of them had pain, mass, or evidence of recurrence, and furthermore, cosmesis was excellent. Conclusions  We believe that the laparoscopic approach is feasible, safe, and the least invasive choice for repairing difficult hernias such as incisional lumbar hernias.     

"对位对线"补片固定法在腹腔镜造口旁疝Sugarbaker修补术中的应用

目的腹腔镜下Sugarbaker修补手术是造口旁疝的主要手术方式，补片固定是手术的关键技术环节，本研究介绍一种新式补片固定方法，并探讨其在临床上的应用效果。 方法回顾性分析2017年6月至2019年6月在中山大学附属第六医院住院的66例造口旁疝患者临床资料，患者均行腹腔镜造口旁疝修补手术（Sugarbaker术式），根据补片固定方式的不同分为试验组（41例，采用"对位对线"补片固定法）和对照组（25例，采用传统疝钉双圈补片固定方法）。比较两组患者相关指标和治疗效果。 结果两组患者性别、年龄、体质指数、病程以及造口旁疝分型比较，差异均无统计学意义。试验组补片固定时间短于对照组[（32.6±9.0）min vs（38.7±11.0）min，P<0.05]，两组在疝钉固定数量、血清肿、补片感染、术后住院时间指标方面，差异无统计学意义。试验组和对照组的平均随访时间差异无统计学意义[（37.6±14.8）个月vs（38.8±15.2）个月，P=0.687]，试验组的造口旁疝复发率低于对照组（2.4% vs 20.0%，P<0.05），而两组术后慢性疼痛发生率差异无统计学意义（24.2% vs 24.0%，P=0.971）。 结论在腹腔镜造口旁疝Sugarbaker修补术中应用"对位对线"补片固定法，可以缩短补片固定时间并减少术后复发，值得临床上推广使用。     

生物补片在合并造口旁疝的肠造口还纳术中的应用

目的探讨生物补片在合并造口旁疝的肠造口还纳术中的应用价值。 方法回顾分析2017年5月10日至2019年9月30日中山大学附属第六医院,应用生物补片（SIS）在合并造口旁疝的肠造口还纳术中进行一期修补的22例患者的临床资料,观察造口部位切口疝（SSIH）的发生率及术后疼痛、血清肿、补片感染等并发症发生率。 结果所有手术均顺利完成,Onlay修补16例,Sublay修补6例。仅1例（4.5%）出现SSIH（Onlay修补）,术后疼痛以轻-中度为主,1周内基本回复正常,无血清肿、补片感染病例。Onlay与Sublay修补在SSIH发生率和其他并发症发生率方面差异无统计学意义。 结论应用生物补片在合并造口旁疝的肠造口还纳手术中加强筋膜缺损,在不明显增加手术并发症的情况下能显著降低SSIH的发生率,是一安全、有效的方法。     

Laparoscopic versus open repair of incisional/ventral hernia: a meta-analysis

Background

The aim of this article is to analyze laparoscopic versus open repair of incisional/ventral hernia (IVH).

Methods

A systematic review of the literature was undertaken to analyze clinical trials on IVH.

Results

Five randomized controlled trials involving a total of 366 patients were analyzed. There were 183 patients in each group. Open repair of IVH was associated with significantly higher complication rates and longer hospital stays than laparoscopic repair. There was also some evidence that surgical times may be longer for open repair of IVH. However, statistically there was no difference in wound pain or recurrence rates.

Conclusions

Laparoscopic repair of IVH is safe, with fewer complications and shorter hospital stays, and possibly a shorter surgical time. However, postoperative pain and recurrence rates are similar for both techniques. Hence, the laparoscopic approach may be considered for IVH repair if technically feasible, but more trials with longer follow-up evaluations are required to strengthen the evidence.     

腹腔镜下造口旁疝补片修补术

目的探讨腹腔镜下造口旁疝补片修补术的效果。方法2004年9月-2005年12月，对7例造口旁疝进行腹腔镜补片修补术。结果6例修补成功，1例因腹腔内广泛致密粘连而中转为剖腹缝合修补。手术时间45-180min，平均109min。疝环直径4-6cm，平均5．6cm。术后暂时性腹胀2例；5例修补区域腹壁疼痛，3周内明显缓解；4例血清肿，经2-4次穿刺抽液并加压包扎后治愈。无血肿发生，未发生与手术相关的感染。术后住院时间3-8d，平均5．1d；术后随访2-15个月，平均8．3月，未见复发。结论腹腔镜造口旁疝补片修补术技术上安全、可行，早期的临床疗效较理想。     

Laparoscopic repair for recurrent parastomal hernia of an end stoma using the sandwich technique while preserving an ileal conduit: A case report

IntroductionParastomal hernia is a common complication following stoma creation. The surgical approaches included local repair by suture, stoma relocation and mesh-based techniques; but none has been able to provide satisfactory results.Presentation of caseA 60-year-old asian female was referred complaining of abdominal pain and constipation caused by recurrent parastomal hernia of an end stoma. She had undergone total cystectomy with creation of an ileal conduit at the age of 53 years, and laparoscopic sigmoid colostomy at the age of 55 years. Parastomal hernia of an end stoma had developed postoperatively, and she had undergone recreation of colostomy at the same place with fasciorrhaphy at the age of 59 years, but parastomal hernia recurred 6 months later because of split fascia sutures. Laparoscopic repair for recurrent parastomal hernia was conducted using the sandwich technique while preserving an ileal conduit. The patient has been followed postoperatively for more than 3 years without any sign of recurrence.DiscussionAlthough further cases are required to get definitive conclusions, we suppose that the laparoscopic sandwich technique can be useful for parastomal hernia.ConclusionWe herein report a case of recurrent parastomal hernia treated laparoscopically while preserving an ileal conduit using the sandwich technique which combines the keyhole and Sugarbaker techniques. This is a quite rare case report of laparoscopic repair for recurrent parastomal hernia in a patient with an ileal conduit.     

Promising new technique in the repair of parastomal hernia

Parastomal hernia is a common complication after stoma formation. Although not all hernias require surgical repair, a variety of surgical techniques exist. Facial repair, relocation of the stoma, and the local use of a nonabsorbable mesh are the three major approaches. Despite this variety of techniques, recurrence rate and complications are high. We therefore invented a laparoscopic technique where we close the hernia and reinforce it with a hand-made funnel-shaped Gore-Tex dual mesh. This technique has all advantages of laparoscopy (less pain, short hospitalization) combined with the advantages of local mesh repair (no stoma replacement necessary, low recurrence rate). The risk of infection is also minimized. The shape of the Gore-Tex mesh reduces hernia recurrence even more, prevents prolaps, and allows easy colonoscopy and stoma irrigation.