任雁 劉娟 嚴鳳 彭敏

（成都醫(yī)學院第一附屬醫(yī)院胃腸外科，成都 610500）

內(nèi)鏡下組織結(jié)構(gòu)分離技術(shù)在腹壁切口疝治療中的應(yīng)用

任雁 劉娟 嚴鳳 彭敏

（成都醫(yī)學院第一附屬醫(yī)院胃腸外科，成都 610500）

目的：探討腹腔鏡下組織結(jié)構(gòu)分離術(shù)與傳統(tǒng)開放疝修補術(shù)的臨床療效差異。方法：擇期在全麻下行腹壁切口疝手術(shù)治療患者96例，隨機分為A、B組，每組各48例，A組采用傳統(tǒng)開放疝修補術(shù)，B組采用腹腔鏡下組織結(jié)構(gòu)分離術(shù)。比較兩組患者錄患者手術(shù)時間、術(shù)中出血量、術(shù)后進食時間、住院時間、住院費用、術(shù)后復(fù)發(fā)率及并發(fā)癥發(fā)生情況。結(jié)果：兩組患者手術(shù)時間及住院費用差異沒有統(tǒng)計學意義（P＞0.05），B組患者術(shù)中出血量、術(shù)后進食時間及住院時間較A組顯著減少，差異有統(tǒng)計學意義（P＜0.05），B組患者術(shù)后腹壁切口疝復(fù)發(fā)率及術(shù)后并發(fā)癥較A組均顯著降低，差異有統(tǒng)計學意義（P＜0.05）。結(jié)論：腹腔鏡下組織結(jié)構(gòu)分離術(shù)與傳統(tǒng)開放疝修補術(shù)相比，不增加手術(shù)時間和手術(shù)費用，同時可以有效地減少術(shù)中出血量，縮短術(shù)后進食時間，降低術(shù)后住院時間、術(shù)后復(fù)發(fā)率及并發(fā)癥發(fā)生率。

腹腔鏡；組織結(jié)構(gòu)分離；腹壁切口疝

腹壁切口疝是由于腹部手術(shù)后，腹壁肌腱膜層愈合不良使得腹壁薄弱、抗張力下降而引起的一種術(shù)后并發(fā)癥，發(fā)生率為2.0%～11.0%[1-2]。該疾病可導致胃腸道狹窄、黏連，甚至腸道梗阻壞死等嚴重并發(fā)癥，無法自行愈合，需要手術(shù)治療。然而傳統(tǒng)開放式疝修補手術(shù)具有較高的復(fù)發(fā)率[3-4]。近年來隨著腹腔鏡技術(shù)的不斷革新及相對應(yīng)手術(shù)技巧的完善，腹腔鏡下組織結(jié)構(gòu)分離術(shù)在腹壁切口疝手術(shù)中的運用越來越廣泛[5-6]。本研究通過比較腹腔鏡下組織結(jié)構(gòu)分離術(shù)與傳統(tǒng)開放疝修補術(shù)的臨床療效差異，探討腹腔鏡在腹壁切口疝治療中的安全性及有效性。

1 資料與方法

1.1 一般資料

選擇2015年8月至2016年8月于我院在全麻下行腹壁切口疝手術(shù)治療的成年患者96例，隨機分為兩組，分別采用傳統(tǒng)開放疝修補術(shù)（A組）及腹腔鏡組織結(jié)構(gòu)分離手術(shù)組（B組）。排除有嚴重心、肺疾病、嚴重肝腎功能不全、糖尿病患者或嚴重低蛋白血癥患者。本研究經(jīng)我院倫理委員會批準，且所有患者均簽署知情同意書。

1.2 方法

A組采用傳統(tǒng)開放式疝修補術(shù)，患者平臥位，取原手術(shù)切口，切除部分癱痕后逐層分離表皮、皮下脂肪及肌肉組織，直至找到腹直肌后筋膜前間隙，依據(jù)張力大小，確定游離范圍，對術(shù)中易破的后鞘及腹膜均應(yīng)修補縫合，在腹直肌后鞘前放置輕量型補片，可吸收線固定，將腹直肌及前鞘對攏縫合，關(guān)閉皮下皮膚。B組采用腹腔鏡組織結(jié)構(gòu)分離手術(shù)，患者側(cè)臥位，在腋前線第11肋骨下緣與髂棘連線中點處做一切口，切開皮膚與皮下組織后顯露腹外斜肌或其腱膜，將其切開進入腹外斜肌與腹內(nèi)斜肌的間隙，置入10 mm Trocar，由此Trocar注入1.6 kPa CO2建立氣腹，直視下在臍水平腋中或腋后線置入5 mm Trocar，在下腹部經(jīng)已松解的腹外斜肌腱膜處再置入第3個Trocar，直視下由肛側(cè)至頭側(cè)分離腹外斜肌及腱膜，在半月線處切開，必要時可切開腹直肌后鞘，對于寬度＜6 cm 的缺損無須進行補片修補，對于寬帶≥10 cm 的缺損在腹直肌后鞘前放置輕量型補片。兩組患者均由同一組經(jīng)驗豐富的外科醫(yī)生施行手術(shù)，術(shù)中順利。術(shù)后患者至少避免負重4周，術(shù)后根據(jù)患者恢復(fù)情況進食流質(zhì)飲食，并逐漸過渡到普通飲食。兩組患者術(shù)后常規(guī)電話隨訪6個月。

1.3 觀察指標分析

由一位不參與手術(shù)的臨床醫(yī)師負責采集數(shù)據(jù)，記錄兩組患者的手術(shù)時間、術(shù)中出血量、術(shù)后進食時間、住院時間、住院總費用、術(shù)后切口疝復(fù)發(fā)率及術(shù)后并發(fā)癥（切口感染、切口周圍皮膚缺血壞死、切口局部血腫、切口脂肪液化及術(shù)后切口疼痛）發(fā)生情況。采用SPSS19.0統(tǒng)計學軟件進行統(tǒng)計學分析。

2 結(jié)果

2.1 兩組患者一般情況比較

兩組患者一般情況（年齡、性別、體重指數(shù)、切口疝位置、切口疝面積）差異無統(tǒng)計學意義，P＞0.05，見表1。

表1 三組患者一般情況比較

2.2 圍術(shù)期指標比較

B組患者的術(shù)中失血量與A組相比顯著下降，B組患者術(shù)后進食時間、住院時間及術(shù)后復(fù)發(fā)率與A組患者相比均顯著減少，差異均有統(tǒng)計學意義（P＜0.05），見表2。

表2 兩組患者指標比較(x±s)

2.3 兩組患者術(shù)后并發(fā)癥發(fā)生情況比較

B組術(shù)后切口感染1例、切口脂肪液化1例、術(shù)后切口疼痛2例，除切開感染等并發(fā)癥外A組切口周圍皮膚缺血壞死、切口局部血腫各3例，B組術(shù)后并發(fā)癥發(fā)生率6.25%，遠低于A組的26.56%，差異有統(tǒng)計學意義，P＜0.05。

3 討論

腹壁切口疝治療效果的優(yōu)劣主要取決于手術(shù)能否夠?qū)崿F(xiàn)真正意義上的腹壁功能重建，而如何有效地修復(fù)腹壁缺損以及重建腹壁功能一直是普外科醫(yī)師的研究熱點[7-8]。組織結(jié)構(gòu)分離技術(shù)（component separation technique，CST）自上世紀90年代首次使用之后得到越來越多外科醫(yī)生的青睞，隨著腹腔鏡技術(shù)的進步與革新，腹腔鏡下組織結(jié)構(gòu)分離術(shù)在腹壁切口疝手術(shù)中的運用越來越廣泛[9-11]。

本研究中傳統(tǒng)開放式疝修補術(shù)與腹腔鏡組織結(jié)構(gòu)分離手術(shù)組的手術(shù)時間差異沒有統(tǒng)計學意義，腹腔鏡組織結(jié)構(gòu)分離手術(shù)組患者的術(shù)中失血量與A組相比顯著下降，且差異有統(tǒng)計學意義。Carter[12]等研究表明腹腔鏡腹腔鏡組織結(jié)構(gòu)分離手術(shù)用于腹部術(shù)后疝與傳統(tǒng)開放式疝修補相比會增加手術(shù)時間，與本研究結(jié)果不符，可能原因是Carter研究中納入患者種類更多，包括了術(shù)后切口疝、造瘺口旁疝、復(fù)發(fā)性斜疝、術(shù)后膈疝等，手術(shù)難度較大，會在一定程度上增加手術(shù)時間，而本研究所納入患者更為單一，均為術(shù)后切口疝，手術(shù)難度相對下降，與此同時近年來腹腔鏡技術(shù)不斷革新也在一定程度上縮短了此類手術(shù)的時間[12-14]。腹腔鏡組織結(jié)構(gòu)分離手術(shù)切口較小，在手術(shù)過程中不需要廣泛分離病環(huán)周圍組織，一定程度地減少了手術(shù)過程中局部切口的滲血。表明腹腔鏡組織結(jié)構(gòu)分離術(shù)在減小術(shù)中創(chuàng)傷及術(shù)中出血量方面與傳統(tǒng)開放疝修補術(shù)相比具有一定的優(yōu)越性?；颊咝g(shù)后進食時間與術(shù)后胃腸功能的恢復(fù)情況密切相關(guān)，是評價患者術(shù)后恢復(fù)情況的重要指標之一。有研究表明，腹腔鏡手術(shù)與傳統(tǒng)開放手術(shù)相比減少了暴力操作對胃腸道的影響，對胃腸道生理功能影響較小，一般術(shù)后第二天便可恢復(fù)胃腸蠕動，并且進食流質(zhì)[15]。本組腹腔鏡下組織結(jié)構(gòu)分離方法在腹外斜肌與腹內(nèi)斜肌的間隙內(nèi)進行操作[16]，避免了開放式疝修補手術(shù)所需要的廣泛組織分離，減少穿支血管的損傷，術(shù)中滲血少，內(nèi)鏡鏡下解剖結(jié)構(gòu)更清晰，同時能夠發(fā)現(xiàn)隱匿性疝并作積極的處理，這些在傳統(tǒng)手術(shù)中往往很難做到，腹腔鏡下操作降低對腹壁的二次損傷，避免腹壁原有解剖結(jié)構(gòu)的改變，因此，B組患者住院時間、術(shù)后復(fù)發(fā)率及并發(fā)癥發(fā)生率均得以降低。本研究指標包括住院費用比較，盡管腹腔鏡及配套器械的使用費用高于開放式手術(shù)，但腹腔鏡組患者的住院時間縮短、術(shù)后用藥減少使得兩組間費用差異沒有統(tǒng)計學意義。

綜上所述，腹腔鏡下組織結(jié)構(gòu)分離術(shù)與傳統(tǒng)開放疝修補術(shù)相比，不增加手術(shù)時間和手術(shù)費用，同時可以有效地減少術(shù)中出血量，縮短術(shù)后進食時間，降低術(shù)后住院時間、術(shù)后復(fù)發(fā)率及并發(fā)癥發(fā)生率。

[1] LEBLANC K. Proper mesh overlap is a key determinant in hernia recurrence following laparoscopic ventral and incisional hernia repair[J]. Hernia, 2016, 20(1): 85-99.

[2] BRADY R R W, VENTHAM N T, ANDREW C, et al. Laparoscopic partially extraperitoneal (PEP) mesh repair for laterally placed ventral and incisional hernias[J]. Surg Laparosc Endosc Percutan Tech, 2014, 24(3): 99-100.

[3] ROGMARK P, PETERSSON U, BRINGMAN S, et al. Quality of life and surgical outcome 1 Year after open and laparoscopic incisional hernia repair: PROLOVE: a randomized controlled trial[J]. Ann Surg, 2016, 263(2): 244-250.

[4] COMAJUNCOSAS J, HERMOSO J, GRIS P, et al. Risk factors for umbilical trocar site incisional hernia in laparoscopic cholecystectomy: a prospective 3-year follow-up study[J]. Am J Surg, 2014, 207(1): 441-446.

[5] ROGMARK P, PETERSSON U, BRINGMAN S, et al. Shortterm outcomes for open and laparoscopic midline incisional hernia repair: a randomized multicenter controlled trial: the ProLOVE (prospective randomized trial on open versus laparoscopic operation of ventral eventrations) trial[J]. Am J Surg, 2013, 258(1): 37-45.

[6] NGUYEN D H, NGUYEN M T, ASKENASY E P, et al. Primary fascial closure with laparoscopic ventral hernia repair: systematic review[J]. World J Surg, 2014, 38(12): 3097-3104.

[7] COBB W S, WARREN J A, EWING J A, et al. Open retromuscular mesh repair of complex incisional hernia: predictors of wound events and recurrence[J]. J Am Coll Surg, 2015, 220(4): 606-613.

[8] ZHANG Y, ZHOU H, CHAI Y, et al. Laparoscopic versus open incisional and ventral hernia repair: a systematic review and meta-analysis[J]. World J Surg, 2014, 38(9): 2233-2240.

[9] LEONARD J, HIEKEN T J, HUSSEIN M, et al. Delineation of factors associated with prolonged length of stay after laparoscopic ventral hernia repair leads to a clinical pathway and improves quality of care[J]. Surg Endosc, 2016, 30(4): 1614-1618.

[10] SILECCHIA G, CAMPANILE F C, SANCHEZ L, et al. Laparoscopic ventral/incisional hernia repair: updated Consensus Development Conference based guidelines [corrected][J]. Surg Endosc, 2015, 29(9): 2463-2484.

[11] ARMA?ANZAS L, RUIZ-TOVAR J, ARROYO A, et al. Prophylactic mesh vs suture in the closure of the umbilical trocar site after laparoscopic cholecystectomy in high-risk patients for incisional hernia. A randomized clinical trial[J]. J Am Coll Surg., 2014, 218(5): 960-968.

[12] CARTER S A, HICKS S C, BRAHMBHATT R, et al. Recurrence and pseudorecurrence after laparoscopic ventral hernia repair: predictors and patient-focused outcomes[J]. Am Surg, 2014, 80(2): 138-148.

[13] GOODENOUGH C J, KO T C, KAO L S, et al. Development and validation of a risk stratification score for ventral incisional hernia after abdominal surgery: hernia expectation rates in intra-abdominal surgery (the HERNIA Project)[J]. J Am Coll Surg, 2015, 220(4): 405-413.

[14] AL CHALABI H, LARKIN J, MEHIGAN B, et al. A systematic review of laparoscopic versus open abdominal incisional hernia repair, with meta-analysis of randomized controlled trials[J]. Int J Surg, 2015, 20: 65-74.

[15] DE SILVA G S, KRPATA D M, HICKS C W, et al. Comparative radiographic analysis of changes in the abdominal wall musculature morphology after open posterior component separation or bridging laparoscopic ventral hernia repair[J]. J Am Coll Surg, 2014, 218(3): 353-357.

[16] SILECCHIA G, CAMPANILE F C, SANCHEZ L, et al. Laparoscopic ventral/incisional hernia repair: updated guidelines from the EAES and EHS endorsed Consensus Development Conference[J]. Surg Endosc, 2015, 29(9): 2463-2484.

The application of organizational separation technology under endoscopic on the treatment of abdominal incisional hernia

REN Yan, LIU Juan, YAN Feng, PENG Min.
（Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chengdu Medical College,Chengdu 610500 China）

Objective: The objective of this study was to explore the difference of organizational separation technology under endoscopic and traditional open hernia repair on the treatment of abdominal incisional hernia. Methods: A total of 96 abdominal incisional hernia patients under general anesthesia were randomly divided into A and B group, with each group 48 cases. A group was given traditional treatment while B group was provided with organizational separation technology under endoscopic. The operative time, bleeding volume, postoperative feeding time, length of stay, hospitalizing fee, recurrence rate and complication incidence were compared between two groups. Results: The difference of operative time and hospitalizing fee of two groups was not statistically signif i cant(P＞0.05). the bleeding volume, postoperative feeding time, and length of stay of B group were less than that of A group and the difference was statistically signif i cant(P＜0.05). The recurrence rate and complication incidence of B group were signif i cantly lower than that of A group and the difference was statistically signif i cant(P＜0.05). Conclusions: Comparing to the traditional treatment, the treatment of organizational separation technology under endoscopic is capable of decreasing the bleeding volume, shortening the postoperative feeding time, cutting down the length of stay, recurrence rate and complication incidence without increasing the hospitalizing time and operation fee.

endoscopic; organizational separation; abdominal incisional hernia

R656.3

A

2095-5200(2017)04-113-03

10.11876/mimt201704046

任雁，本科，主治醫(yī)師，研究方向：胃腸外科臨床，Email：2477837621@qq.com。