腹腔镜下疝囊高位结扎术治疗腹股沟嵌顿疝18例

目的探讨腹腔镜手术治疗腹股沟嵌顿疝的临床效果。方法 2009年1月～2010年12月对18例腹股沟嵌顿疝行腹腔镜下腹股沟嵌顿疝松解术及疝内环关闭术。建立CO2气腹后置入10 mm trocar,置入30°腹腔镜,腹腔内探查,寻找嵌顿的疝内容物,置入电凝钩或超声刀切开内环口狭窄环,回纳嵌顿肠管。6例嵌顿小肠已坏死,在相应部位腹壁做小切口（约4 cm）,拖出相应小肠行坏死小肠切除,端端吻合术。疝内环结扎术可采用2种方法：6例于疝内环腹壁投影处做0.3 cm切口,穿刺导线针行疝内环结扎术;12例镜下腹腔内置入针线行疝内环缝合打结。结果麻醉后2例嵌顿疝自动复位。嵌顿肠管无坏死;16例在腹腔镜下松解、复位。嵌顿内容物：小肠16例,大网膜2例;10例嵌顿肠管和2例嵌顿大网膜无坏死,6例嵌顿肠管坏死,拖出相应小肠行坏死小肠切除,端端吻合术。2例发现无症状的隐匿疝,给予疝内环结扎。2例术后出现皮下气肿,均于1 d自行吸收;4例出现腹股沟区原疝囊部位积液、水肿,即血清肿,经局部穿刺（1～4次,平均1.8次）痊愈;术后均无出血、感染。术后住院4～7 d,平均5 d。术后7～30 d（平均15.2 d）行二期无张力疝修补术,二次手术期间无疝复发。结论腹腔镜下腹腔探查、嵌顿疝松解术及疝囊高位结扎术更适合急诊腹股沟嵌顿疝的治疗,具有术式安全、暴露充分、操作简便、易掌握等优点,可同时发现及处理对侧隐匿性疝,符合微创治疗的原则。

Laparoscopic High Ligation for Incarcerated Inguinal Hernia: Report of 18 Cases

Objective To explore the efficacy of laparoscopic high ligation for incarcerated inguinal hernia. Methods Totally 18 patients with incarcerated inguinal hernia underwent laparoscopic hernia lysis and high ligation combined with hernia ring closure in our hospital between January 2009 and December 2010. After establishing CO2 pneumoperitoneum, a 10-mm trocar was inserted so that to place a laparoscope （30°） for abdominal exploration. Electrocoagulation or ultrasound scalpel were used to cut the inner ring stricture so that to return the hernia back into the abdominal cavity. In six of the patients, resection of necrotic intestinal segment and end-to-end anastomosis were made through a small abdominal incision （4 cm）. High ligation was then carried by laparoscopy （ 12 cases） or via a 0.3-cm incision at the cast shadow of the inner ring on the abdominal wall （6 cases）. Results Among the patients, the hernia was returned automatically after anesthesia in two patients, the other 16 patients were cured by laparoscopic lysis and high ligation. The incarcerated tissues included intestine （16 cases） and the greater omentum （2 cases）. Six of the patients developed intestine necrosis and thus received resection of the necrotic segment and then end-to-end anastomosis. Asymptomatic concealed hernia was detected in two patients, who then received ligation of the inner ring. After the procedure, 2 patients developed subcutaneous emphysema, which was cured spontaneously in one day; 4 patients showed seroma at the location of the hernia, and thus underwent a second operation for tension free herniorrhaphy puncture （ 1 to 4 times, with a mean of 1.8）. No patient had postoperative hemorrhage or infection. The mean postoperative hospital stay was 5 days （ranged from 4 to 7 days）. The tension free herniorrhaphy was carried out in 7 to 30 days （mean, 15.2 days） after the first operation. No recurrent hernia was reported during the second surgery. Conclusions Laparoscopic abdominal exploration, incarcerated hernia lysis and high ligation are optimal for incarcerated inguinal hernia in emergency room. The procedure is safe, simple, and minimally invasive while creating a well exposed surgical field, which is helpful for detecting concealed hernia.