微小切口开放腹膜前手术在腹壁疝修补中的临床应用

doi:10.3877/cma.j.issn.1674-392X.2019.01.007

目的

探讨微小切口开放腹膜前（mini/less open sublay，MILOS）手术在腹壁疝修补中的临床应用和效果。

方法

回顾性分析2016年11月至2018年6月，浙江大学医学院附属杭州市第一人民医院连续收治并接受MILOS手术修补的49例腹壁疝患者。

结果

平均腹壁缺损宽度（5.27±2.95）cm，平均切口长度（4.89±2.13）cm。36例为切口疝，13例为脐疝（其中3例合并腹直肌分离症）。所有患者均采用MILOS手术完成修补，于肌后、腹膜前间隙放置补片，并放置密闭式负压引流管。平均手术时间（114.2±48.8）min，术中出血量（88.7±38.5）ml，住院时间（10.6±2.4） d。术后有2例（4.1%）浅表手术部位感染，1例（2.0%）Ⅲ型血清肿，均经非手术治疗后治愈。无肠梗阻、补片感染、肠瘘、慢性疼痛等并发症。随访期间未发现有复发、腹壁膨出病例。

结论

MILOS手术是一种适应症较广的腹壁疝微创腹膜前修补方式，具有较高的临床应用价值。

关键词: 腹壁疝, 微小切口开放腹膜前, 微创

Objective

To investigate the clinical utility and outcomes of mini/less open sublay (MILOS) approach in ventral hernia repair.

Methods

Retrospectively studied Forty-nine cases of ventral hernia patients admitted to Affiliated Hangzhou First People's Hospital of Zhejiang University School of Medicine from November 2016 to June 2018. Clinical materials were collected and analyzed.

Results

Mean width of abdominal defect were (5.27±2.95) cm. Mean length of incisions were (4.89±2.13) cm. Thirty-six cases were incisional hernia, and thirteen cases were umbilical hernias (with 3 cases combined with diastasis recti abdominis). All the patients underwent MILOS surgery with retro-muscular/preperitoneal mesh reinforcement. Closed suction drains were routinely placed above the mesh. The operation time was (114.2±48.8) minutes, and estimated blood loss was (88.7±38.5) cm³. Length of hospitalization were (10.6±2.4) days. We had 2 cases of superficial SSI and 1 case of grade Ⅲ seroma which were cured under non-surgical therapy. No complications like mesh infection, intestinal obstructions, fistula or chronic pain were reported. No recurrence, or postoperative bulging were reported during the follow-up.

Conclusion

MILOS approach is a minimal invasive sublay repair with wide indications for ventral hernia repair, which worth utilizing in clinical practicing.

Key words: Ventral hernia repair, Mini/less open sublay, Minimal invasive

表1 微小切口开放腹膜前手术患者临床资料

临床资料	(n=49)
性别	?
男[例(%)]	30(61.2)
女[例(%)]	19(38.8)
年龄(±s,岁)	56.42±13.16
体质量指数(±s,kg/m²)	26.73±4.37
美国麻醉医师协会评分(±s)	2.25±1.18
手术时间(±s,min)	114.2±48.8
术中出血(±s,cm³)	88.7±38.5
缺损宽度(±s,cm)	5.27±2.95
切口长度(±s,cm)	4.89±2.13
补片大小(±s,cm²)	362.00±127.47

表1 微小切口开放腹膜前手术患者临床资料

临床资料	(n=49)
性别	?
男[例(%)]	30(61.2)
女[例(%)]	19(38.8)
年龄(±s,岁)	56.42±13.16
体质量指数(±s,kg/m²)	26.73±4.37
美国麻醉医师协会评分(±s)	2.25±1.18
手术时间(±s,min)	114.2±48.8
术中出血(±s,cm³)	88.7±38.5
缺损宽度(±s,cm)	5.27±2.95
切口长度(±s,cm)	4.89±2.13
补片大小(±s,cm²)	362.00±127.47

图1 微小切口开放腹膜前手术皮肤切口、缺损及补片范围示意图

图2 微小切口开放腹膜前手术操作关键步骤（中线切口疝）

图3 腔镜视野下微小切口开放腹膜前+侧方腹横肌释放术

表2 微小切口开放腹膜前手术患者术后临床资料

临床资料	(n=49)
手术切口不良事件[例(%)]	3(6.1)
[例(%)]	0(0.0)
血清肿(Ⅲ、Ⅳ型)[例(%)]	1(2.0)
切口裂开[例(%)]	0(0.0)
手术部位感染[例(%)]	2(4.1)
浅表感染[例(%)]	2(4.1)
深部感染[例(%)]	0(0.0)
补片感染[例(%)]	0(0.0)
其他术后并发症[例(%)]	?
肠梗阻[例(%)]	0(0.0)
肠瘘[例(%)]	0(0.0)
住院时间(d,±s)	10.6±2.4
随访时间(个月,±s)	12.13±6.42
VASmax评分^a(分,±s)	2.34±1.21
复发[例(%)]	0(0.0)
膨出[例(%)]	0(0.0)

表2 微小切口开放腹膜前手术患者术后临床资料

临床资料	(n=49)
手术切口不良事件[例(%)]	3(6.1)
[例(%)]	0(0.0)
血清肿(Ⅲ、Ⅳ型)[例(%)]	1(2.0)
切口裂开[例(%)]	0(0.0)
手术部位感染[例(%)]	2(4.1)
浅表感染[例(%)]	2(4.1)
深部感染[例(%)]	0(0.0)
补片感染[例(%)]	0(0.0)
其他术后并发症[例(%)]	?
肠梗阻[例(%)]	0(0.0)
肠瘘[例(%)]	0(0.0)
住院时间(d,±s)	10.6±2.4
随访时间(个月,±s)	12.13±6.42
VASmax评分^a(分,±s)	2.34±1.21
复发[例(%)]	0(0.0)
膨出[例(%)]	0(0.0)

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Clinical application of mini/less open sublay approach in ventral hernia repair

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Clinical application of mini/less open sublay approach in ventral hernia repair