腹横肌松解术在腹壁巨大切口疝修补中的临床应用

doi:10.3877/cma.j.issn.1674-392X.2018.03.009

目的

探讨腹横肌松解术（transversus abdominis muscle release，TAR）在治疗腹壁巨大切口疝中的临床效果。

方法

回顾性分析2016年1月至2017年8月，杭州市第一人民医院集团收治的25例腹壁巨大切口疝患者的临床资料。

结果

25例腹壁巨大切口疝患者中，其中男性16例，女性9例。平均年龄（65.0±11.4）岁，体质量指数（body mass index，BMI）为（31.15±5.83）kg/m²。平均腹壁缺损宽度（11.40±1.36）cm。22例为中线切口疝，3例为侧方切口疝。4例为复发性切口疝。所有患者均采用TAR＋后组织结构分离技术进行腹壁功能性重建，并采用肌后补片加强修补的手术方式。手术时间（152.0±31.6）min，术中出血量（116.8±44.1）cm³，住院时间（13.9±2.9） d。术后有2例出现浅表手术部位感染，4例Ⅲ型血清肿，1例不完全机械性肠梗阻，均经非手术治疗后治愈。无补片感染、肠瘘等并发症。随访期间未发现有复发、腹壁膨出病例。

结论

腹横肌松解术＋后组织结构分离术是腹壁巨大切口疝治疗一种有效、安全的手术修补方法。

关键词: 切口疝, 腹横肌松解术, 后组织结构分离技术, 腹壁重建

Objective

To investigate the clinical utility of the transversus abdominis muscle release (TAR) procedure in repair of large incisional hernia.

Methods

Retrospectively studied Twenty-five cases of large incisional hernia patients admitted to Hangzhou First People's Hospital from January 2016 to August 2017. Clinical materials were collected and analyzed.

Results

Among 25 cases of Large incisional hernia, there were 16 males (64.0%) and 9 females (36.0%). Mean age were (65.04±11.38) years, BMI were (31.15±5.83) kg/m². Mean width of abdominal defect were (11.40±1.36) cm. Twenty-two cases were midline incisional hernia, and three cases were lateral. Four cases were recurrent incisional hernia. All patients underwent retro-muscular mesh repair, and abdominal wall reconstruction using TAR procedure. The operation time was (152±31.6) minutes, and estimated blood loss was (116.8±44.1) cm³. Length of hospitalization were (13.9±2.9) days. We had 2 cases of superficial surgical site infection, 4 cases of type Ⅲ seroma, and 1 ileus. Postoperative complications were cured after non-surgical therapy. No mesh infection, fistula, recurrence, and postoperative bulging were found during the follow-up.

Conclusion

Posterior component separation via TAR is a reliable and effective technique for large incisional hernia repair.

Key words: Incisional hernia, Transversus abdominis muscle release, Posterior component separation, Abdominal wall reconstruction

表1 美国克利夫兰医学中心最新切口疝分级系统

分级	缺损宽度和污染程度	风险度
Ⅰ级	<10 cm清洁	低SSO,低复发
Ⅱ级	<10 cm,污染;10~20 cm	中等SSO,中等复发
Ⅲ级	≥10 cm,污染;任何≥20 cm	高SSO,高复发

表1 美国克利夫兰医学中心最新切口疝分级系统

分级	缺损宽度和污染程度	风险度
Ⅰ级	<10 cm清洁	低SSO,低复发
Ⅱ级	<10 cm,污染;10~20 cm	中等SSO,中等复发
Ⅲ级	≥10 cm,污染;任何≥20 cm	高SSO,高复发

表2 腹壁巨大切口疝患者临床资料

临床资料		统计值
性别[例(%)]		?
?	男	16(64.0)
?	女	9(36.0)
年龄(岁, ±s)		65.0±11.4
体质量指数(kg/m², ±s)		31.1±5.8
合并基础疾病[例(%)]		?
?	糖尿病	5(20.0)
?	慢性阻塞性肺疾病	4(16.0)
?	免疫抑制状态	2(8.0)
视觉模拟量表评分(分,±s)		2.72±1.10
切口疝分级[例(%)]		?
?	Ⅱ级	19(76.0)
?	Ⅲ级	6(24.0)
手术时间(min,±s)		152.8±31.6
术中出血(cm³,±s)		116.8±44.1
缺损大小(cm,±s)		11.4±1.4
补片大小(cm²,±s)		512.0±105.3
手术切口不良事件[例(%)]		6(24.0)
?	血肿[例(%)]	0
?	血清肿(Ⅲ、Ⅳ型)[例(%)]	4(16.0)
?	切口裂开[例(%)]	0
?	手术部位感染[例(%)]	2(8.0)
?	浅表感染[例(%)]	2(8.0)
?	深部感染[例(%)]	0
?	补片感染[例(%)]	0
其他术后并发症[例(%)]		?
?	肠梗阻	1(4.0)
?	肠瘘	0
?	住院时间(d,±s)	13.9±2.9
?	随访时间(个,±s)	12.20±5.57
?	复发[例(%)]	0
?	膨出[例(%)]	0

表2 腹壁巨大切口疝患者临床资料

临床资料		统计值
性别[例(%)]		?
?	男	16(64.0)
?	女	9(36.0)
年龄(岁, ±s)		65.0±11.4
体质量指数(kg/m², ±s)		31.1±5.8
合并基础疾病[例(%)]		?
?	糖尿病	5(20.0)
?	慢性阻塞性肺疾病	4(16.0)
?	免疫抑制状态	2(8.0)
视觉模拟量表评分(分,±s)		2.72±1.10
切口疝分级[例(%)]		?
?	Ⅱ级	19(76.0)
?	Ⅲ级	6(24.0)
手术时间(min,±s)		152.8±31.6
术中出血(cm³,±s)		116.8±44.1
缺损大小(cm,±s)		11.4±1.4
补片大小(cm²,±s)		512.0±105.3
手术切口不良事件[例(%)]		6(24.0)
?	血肿[例(%)]	0
?	血清肿(Ⅲ、Ⅳ型)[例(%)]	4(16.0)
?	切口裂开[例(%)]	0
?	手术部位感染[例(%)]	2(8.0)
?	浅表感染[例(%)]	2(8.0)
?	深部感染[例(%)]	0
?	补片感染[例(%)]	0
其他术后并发症[例(%)]		?
?	肠梗阻	1(4.0)
?	肠瘘	0
?	住院时间(d,±s)	13.9±2.9
?	随访时间(个,±s)	12.20±5.57
?	复发[例(%)]	0
?	膨出[例(%)]	0

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Repair of large incisional hernia using the transversus abdominis muscle release procedure in clinical practice

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Repair of large incisional hernia using the transversus abdominis muscle release procedure in clinical practice