目的 总结复发性腹股沟疝的临床特点,探讨其腹腔镜手术方式选择.方法 回顾性分析2001年1月至2014年12月上海交通大学医学院附属瑞金医院收治的330例(352侧)行腹腔镜腹股沟疝修补术复发性腹股沟疝患者的临床资料.手术由同组医师完成,手术方式由术者选择行经腹腹膜前修补术(TAPP)、全腹膜外修补术(TEP)或腹腔内补片平铺术(IPOM).观察指标包括前次手术的复发部位,此次手术的修补方法、手术方式选择和临床疗效.采用电话或门诊方式进行随访,随访内容为疝复发情况和术后并发症发生情况.随访时间截至2015年6月.正态分布的计量资料以x±s表示,偏态分布的计量资料以M(范围)表示;计数资料比较采用x2检验.结果 (1)复发部位:352侧复发疝中,直疝区域186侧,斜疝区域111侧,股疝区域6侧,复合疝区域49侧.125侧缝合修补术后复发疝中,直疝区域44侧,斜疝区域48侧,股疝区域2侧,复合疝区域31侧;110侧网塞平片修补术后复发疝中,直疝区域85侧,斜疝区域16侧,复合疝区域9侧;61侧平片修补术后复发疝中,直疝区域37侧,斜疝区域16侧,股疝区域3侧,复合疝区域5侧;36侧腹膜前修补术后复发疝中,直疝区域19侧,斜疝区域12侧,股疝区域1侧,复合疝区域4侧;14侧疝囊高位结扎术后复发疝中,直疝区域1侧,斜疝区域13侧;6侧硬化剂注射后复发疝均为斜疝.复发疝中直疝的比例为52.84％(186/352),高于初发疝的23.70％(998/4211),两者比较,差异有统计学意义(x2=171.397,P＜0.05);植入补片的复发疝中直疝的比例为68.12％(141/207),高于未植入补片复发疝的31.03％(45/145),两者比较,差异有统计学意义(x2=47.052,P＜0.05).(2)修补方法:未植入补片的复发疝和平片修补术后复发疝,均采用修补肌耻骨孔的方法完成手术,补片固定与不固定的比例为82:124;网塞平片和腹膜前修补术后复发疝,采用修补肌耻骨孔或修补疝缺损完成手术,补片固定与不固定比例为133:13.两种修补方法补片固定比例比较,差异有统计学意义(x2=94.552,P＜0.05).(3)手术方式选择:352侧复发疝中,行TAPP治疗288侧,行TEP治疗50侧,行IPOM治疗14侧.缝合修补术后复发疝:行TAPP治疗91侧,行TEP治疗34侧;网塞平片修补术后复发疝:行TAPP治疗108侧,行IPOM治疗2侧;平片修补术后复发疝:行TAPP治疗46侧,行TEP治疗15侧;腹膜前修补术后复发疝:行TAPP治疗24侧,行IPOM治疗12侧;疝囊高位结扎术后复发疝:行TAPP治疗13侧,行TEP治疗1侧;硬化剂注射后复发疝:行TAPP治疗6侧.(4)临床疗效:330例患者成功行腹腔镜手术,无中转开腹,术后未应用镇痛剂.330例患者的手术时间为(40±13) min(15～100 min).术后第1天疼痛分数为(2.4±1.1)分(0.6～7.3分),2周内恢复非限制性活动人数比例为99.70％(329/330).330例患者中发生并发症35例,其中1例平片修补术后复发疝患者,行TEP治疗时术中损伤肠管,再次手术行肠管修补并取出补片;其余34例并发症依次为血清肿22例,尿潴留8例,暂时性神经感觉异常3例,麻痹性肠梗阻1例,经对症支持治疗后痊愈.术后住院时间为(1.7±1.4)d(1.0～9.0 d).330例患者获得随访,中位随访时间为58个月(6～174个月).结论 复发性腹股沟疝中直疝区域复发较为常见,植入补片的复发疝中直疝比例更高.腹腔镜治疗复发性腹股沟疝时可根据术中情况采用修补肌耻骨孔或修补疝缺损方法进行修补.TAPP和TEP的选择取决于前次手术的入路、补片植入的间隙以及术者自身的经验.IPOM可做为TAPP的备选手术方式.
目的 總結複髮性腹股溝疝的臨床特點,探討其腹腔鏡手術方式選擇.方法 迴顧性分析2001年1月至2014年12月上海交通大學醫學院附屬瑞金醫院收治的330例(352側)行腹腔鏡腹股溝疝脩補術複髮性腹股溝疝患者的臨床資料.手術由同組醫師完成,手術方式由術者選擇行經腹腹膜前脩補術(TAPP)、全腹膜外脩補術(TEP)或腹腔內補片平鋪術(IPOM).觀察指標包括前次手術的複髮部位,此次手術的脩補方法、手術方式選擇和臨床療效.採用電話或門診方式進行隨訪,隨訪內容為疝複髮情況和術後併髮癥髮生情況.隨訪時間截至2015年6月.正態分佈的計量資料以x±s錶示,偏態分佈的計量資料以M(範圍)錶示;計數資料比較採用x2檢驗.結果 (1)複髮部位:352側複髮疝中,直疝區域186側,斜疝區域111側,股疝區域6側,複閤疝區域49側.125側縫閤脩補術後複髮疝中,直疝區域44側,斜疝區域48側,股疝區域2側,複閤疝區域31側;110側網塞平片脩補術後複髮疝中,直疝區域85側,斜疝區域16側,複閤疝區域9側;61側平片脩補術後複髮疝中,直疝區域37側,斜疝區域16側,股疝區域3側,複閤疝區域5側;36側腹膜前脩補術後複髮疝中,直疝區域19側,斜疝區域12側,股疝區域1側,複閤疝區域4側;14側疝囊高位結扎術後複髮疝中,直疝區域1側,斜疝區域13側;6側硬化劑註射後複髮疝均為斜疝.複髮疝中直疝的比例為52.84％(186/352),高于初髮疝的23.70％(998/4211),兩者比較,差異有統計學意義(x2=171.397,P＜0.05);植入補片的複髮疝中直疝的比例為68.12％(141/207),高于未植入補片複髮疝的31.03％(45/145),兩者比較,差異有統計學意義(x2=47.052,P＜0.05).(2)脩補方法:未植入補片的複髮疝和平片脩補術後複髮疝,均採用脩補肌恥骨孔的方法完成手術,補片固定與不固定的比例為82:124;網塞平片和腹膜前脩補術後複髮疝,採用脩補肌恥骨孔或脩補疝缺損完成手術,補片固定與不固定比例為133:13.兩種脩補方法補片固定比例比較,差異有統計學意義(x2=94.552,P＜0.05).(3)手術方式選擇:352側複髮疝中,行TAPP治療288側,行TEP治療50側,行IPOM治療14側.縫閤脩補術後複髮疝:行TAPP治療91側,行TEP治療34側;網塞平片脩補術後複髮疝:行TAPP治療108側,行IPOM治療2側;平片脩補術後複髮疝:行TAPP治療46側,行TEP治療15側;腹膜前脩補術後複髮疝:行TAPP治療24側,行IPOM治療12側;疝囊高位結扎術後複髮疝:行TAPP治療13側,行TEP治療1側;硬化劑註射後複髮疝:行TAPP治療6側.(4)臨床療效:330例患者成功行腹腔鏡手術,無中轉開腹,術後未應用鎮痛劑.330例患者的手術時間為(40±13) min(15～100 min).術後第1天疼痛分數為(2.4±1.1)分(0.6～7.3分),2週內恢複非限製性活動人數比例為99.70％(329/330).330例患者中髮生併髮癥35例,其中1例平片脩補術後複髮疝患者,行TEP治療時術中損傷腸管,再次手術行腸管脩補併取齣補片;其餘34例併髮癥依次為血清腫22例,尿潴留8例,暫時性神經感覺異常3例,痳痺性腸梗阻1例,經對癥支持治療後痊愈.術後住院時間為(1.7±1.4)d(1.0～9.0 d).330例患者穫得隨訪,中位隨訪時間為58箇月(6～174箇月).結論 複髮性腹股溝疝中直疝區域複髮較為常見,植入補片的複髮疝中直疝比例更高.腹腔鏡治療複髮性腹股溝疝時可根據術中情況採用脩補肌恥骨孔或脩補疝缺損方法進行脩補.TAPP和TEP的選擇取決于前次手術的入路、補片植入的間隙以及術者自身的經驗.IPOM可做為TAPP的備選手術方式.
목적 총결복발성복고구산적림상특점,탐토기복강경수술방식선택.방법 회고성분석2001년1월지2014년12월상해교통대학의학원부속서금의원수치적330례(352측)행복강경복고구산수보술복발성복고구산환자적림상자료.수술유동조의사완성,수술방식유술자선택행경복복막전수보술(TAPP)、전복막외수보술(TEP)혹복강내보편평포술(IPOM).관찰지표포괄전차수술적복발부위,차차수술적수보방법、수술방식선택화림상료효.채용전화혹문진방식진행수방,수방내용위산복발정황화술후병발증발생정황.수방시간절지2015년6월.정태분포적계량자료이x±s표시,편태분포적계량자료이M(범위)표시;계수자료비교채용x2검험.결과 (1)복발부위:352측복발산중,직산구역186측,사산구역111측,고산구역6측,복합산구역49측.125측봉합수보술후복발산중,직산구역44측,사산구역48측,고산구역2측,복합산구역31측;110측망새평편수보술후복발산중,직산구역85측,사산구역16측,복합산구역9측;61측평편수보술후복발산중,직산구역37측,사산구역16측,고산구역3측,복합산구역5측;36측복막전수보술후복발산중,직산구역19측,사산구역12측,고산구역1측,복합산구역4측;14측산낭고위결찰술후복발산중,직산구역1측,사산구역13측;6측경화제주사후복발산균위사산.복발산중직산적비례위52.84％(186/352),고우초발산적23.70％(998/4211),량자비교,차이유통계학의의(x2=171.397,P＜0.05);식입보편적복발산중직산적비례위68.12％(141/207),고우미식입보편복발산적31.03％(45/145),량자비교,차이유통계학의의(x2=47.052,P＜0.05).(2)수보방법:미식입보편적복발산화평편수보술후복발산,균채용수보기치골공적방법완성수술,보편고정여불고정적비례위82:124;망새평편화복막전수보술후복발산,채용수보기치골공혹수보산결손완성수술,보편고정여불고정비례위133:13.량충수보방법보편고정비례비교,차이유통계학의의(x2=94.552,P＜0.05).(3)수술방식선택:352측복발산중,행TAPP치료288측,행TEP치료50측,행IPOM치료14측.봉합수보술후복발산:행TAPP치료91측,행TEP치료34측;망새평편수보술후복발산:행TAPP치료108측,행IPOM치료2측;평편수보술후복발산:행TAPP치료46측,행TEP치료15측;복막전수보술후복발산:행TAPP치료24측,행IPOM치료12측;산낭고위결찰술후복발산:행TAPP치료13측,행TEP치료1측;경화제주사후복발산:행TAPP치료6측.(4)림상료효:330례환자성공행복강경수술,무중전개복,술후미응용진통제.330례환자적수술시간위(40±13) min(15～100 min).술후제1천동통분수위(2.4±1.1)분(0.6～7.3분),2주내회복비한제성활동인수비례위99.70％(329/330).330례환자중발생병발증35례,기중1례평편수보술후복발산환자,행TEP치료시술중손상장관,재차수술행장관수보병취출보편;기여34례병발증의차위혈청종22례,뇨저류8례,잠시성신경감각이상3례,마비성장경조1례,경대증지지치료후전유.술후주원시간위(1.7±1.4)d(1.0～9.0 d).330례환자획득수방,중위수방시간위58개월(6～174개월).결론 복발성복고구산중직산구역복발교위상견,식입보편적복발산중직산비례경고.복강경치료복발성복고구산시가근거술중정황채용수보기치골공혹수보산결손방법진행수보.TAPP화TEP적선택취결우전차수술적입로、보편식입적간극이급술자자신적경험.IPOM가주위TAPP적비선수술방식.
Objective To summarize the clinical characteristics of recurrent inguinal hernia and investigate the choice of laparoscopic surgical procedures.Methods The clinical data of 330 patients with recurrent inguinal hernia (352 inguinal hernias) who underwent laparoscopic inguinal hernia repair (LIHR) at the Ruijin Hospital Affiliated to Shanghai Jiaotong University School of Medicine between January 2001 and December 2014 were retrospectively analyzed.The surgical procedures including transabdominal preperitoneal (TAPP) approach,total extraperitoneal (TEP) approach and intraperitoneal onlay mesh (IPOM) approach were selected and performed by doctors in the same team.Observed indicators included recurrent sites of previous surgery, repair methods, surgical procedures and clinical efficacies of this surgery.Patients were followed up by telephone interview and outpatient examination up to June 2015.The follow-up included the recurrence and postoperative complications.Measurement data with normal distribution were presented as x ± s, skew distribution data were described as M (range), and count data were analyzed using chi-square test.Results (1) Recurrent sites : of 352 recurrent inguinal hernias, 186 were detected in direct hernia region, 111 in indirect hernia region, 6 in femoral hernia region and 49 in compound hernia region.Among 125 recurrent inguinal hernias after suture repair,44 were detected in direct hernia region, 48 in indirect hernia region, 2 in femoral hernia region and 31 in compound hernia region.Among 110 recurrent inguinal hernias after mesh-plug repair, 85 were detected in direct hernia region, 16 in indirect hernia region and 9 in compound hernia region.Among 61 recurrent inguinal hernias after patch repair, 37 were detected in direct hernia region, 16 in indirect hernia region, 3 in femoral hernia region and 5 in compound hernia region.Among 36 recurrent inguinal hernias after preperitoneal repair, 19 were detected in direct hernia region, 12 in indirect hernia region, 1 in femoral hernia region and 4 in compound hernia region.Among 14 recurrent inguinal hernias after high ligation of hernial sac, 1 was detected in direct hernia region and 13 in indirect hernia region.Six recurrent inguinal hernias after sclerosing agent injection were detected in indirect hernia region.Incidence of direct hernia in recurrent inguinal hernias was 52.84％ (186/352) , which was significantly different from 23.70％ (998/4 211) in primary inguinal hernias (x2=171.397, P ＜0.05).Incidence of direct hernia in recurrent inguinal hernias with implanted patches was 68.12％ (141/207), which was significantly different from 31.03％ (45/145) in primary inguinal hernias without implanted patches (x2=47.052, P ＜ 0.05).(2) Repair methods : repairing myopectineal orifice was applied to recurrent inguinal hernias without implanted patches and after patch repair, with a ratio of fixed/unfixed patches of 82/124.Repairing myopectineal orifice or hernia defects was applied to recurrent inguinal hernias after mesh-plug repair and preperitoneal repair, with a ratio of fixed/unfixed patches of 133/13.There was significant difference in the ratio of fixed patch between the 2 repair methods (x2 =94.552, P ＜ 0.05).(3) Surgical procedures : of 352 recurrent inguinal hernias, 288 underwent TAPP approach, 50 underwent TEP approach and 14 underwent IPOM approach.TAPP approach and TEP approach were performed in 91 and 34 recurrent inguinal hernias after suture repair,TAPP approach and IPOM approach in 108 and 2 recurrent inguinal hernias after mesh-plug repair, TAPP approach and TEP approach in 46 and 15 recurrent inguinal hernias after patch repair, TAPP approach and IPOM approach in 24 and 12 after preperitoneal repair, TAPP approach and TEP approach in 13 and 1 recurrent inguinal hernias after high ligation of hernial sac and TAPP in 6 recurrent inguinal hernias after sclerosing agent injection.(4) Clinical efficacies : 330 patients underwent successfully laparoscopic surgery without conversion to open surgery and analgesics.The operation time, pain scores at postoperative day 1, the ratio of patients restoring unrestricted activities within 2 weeks and duration of postoperative hospital stay in 330 patients were (40 ± 13) minutes (range,15-100 minutes), 2.4 ± 1.1 (range, 0.6-7.3), 99.70％ (329/330) and (1.7 ± 1.4) days (range, 1.0-9.0 days) , respectively.Among 35 patients with complications, 1 patient with recurrent hernia after patch repair received reoperation of intestinal canal repair due to damnify of intestinal canal during TEP approach, other complications including 22 seroma, 8 urinary retention, 3 temporary nerve paresthesia and 1 paralytic ileus, and were cured by symptomatic treatment.All the patients were followed up for a median time of 58 months (range,6-174 months).Conclusions Recurrent inguinal hernias are found frequently in the direct hernia region, with a higher ratio of direct hernias with implanted patches.According to intraoperative conditions, repairing myopectineal orifice or hernia defects can be selected during LIHR, and a choice of TAPP approach and TEP approach depends on previous surgical approach, gap of implanted patches and doctors' experiences.IPOM approach can be served as an alternative for TAPP approach.
