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中华疝和腹壁外科杂志(电子版) ›› 2019, Vol. 13 ›› Issue (02) : 105 -110. doi: 10.3877/cma.j.issn.1674-392X.2019.02.003

所属专题： 文献；

论著

术前渐进性气腹在老年腹壁巨大切口疝修补术中的应用价值
汤福鑫1, 李英儒1, 杨伟胜1, 江志鹏1, 周太成1, 甘文昌1, 侯泽辉1, 马宁1, 余卓敏1, 刘伟1, 于洪艳1, 陈双1,†()   
  1. 1. 510655　广州，中山大学附属第六医院胃肠、疝和腹壁外科，广东省结直肠盆底疾病研究重点实验室
  • 收稿日期:2018-11-06 出版日期:2019-04-18
  • 通信作者: 陈双
  • 基金资助:
    广东省科技计划项目(2017A020215036); 广州市科技计划项目(201806020036)

Application value of the preoperative progressive pneumoperitoneum in the elderly with large incisional hernia

Fuxin Tang1, Yingru Li1, Weisheng Yang1, Zhipeng Jiang1, Taicheng Zhou1, Wenchang Gan1, Zehui Hou1, Ning Ma1, Zhuomin Yu1, Wei Liu1, Hongyan Yu1, Shuang Chen1,†()   

  1. 1. Department of Gastrointestinal, Hernia and Abdominal Wall Surgery, the Sixth Affiliated Hospital of Sun Yat-sen University; Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, Guangzhou 510655, China
  • Received:2018-11-06 Published:2019-04-18
  • Corresponding author: Shuang Chen
  • About author:
    Corresponding author: Chen Shuang, Email:
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引用本文：

汤福鑫, 李英儒, 杨伟胜, 江志鹏, 周太成, 甘文昌, 侯泽辉, 马宁, 余卓敏, 刘伟, 于洪艳, 陈双. 术前渐进性气腹在老年腹壁巨大切口疝修补术中的应用价值[J]. 中华疝和腹壁外科杂志(电子版), 2019, 13(02): 105-110.

Fuxin Tang, Yingru Li, Weisheng Yang, Zhipeng Jiang, Taicheng Zhou, Wenchang Gan, Zehui Hou, Ning Ma, Zhuomin Yu, Wei Liu, Hongyan Yu, Shuang Chen. Application value of the preoperative progressive pneumoperitoneum in the elderly with large incisional hernia[J]. Chinese Journal of Hernia and Abdominal Wall Surgery(Electronic Edition), 2019, 13(02): 105-110.

目的

探讨术前渐进性气腹（preoperative progressive pneumoperitoneum，PPP）辅助治疗老年巨大切口疝的临床应用价值。

方法

回顾性分析2017年2月至2018年2月，中山大学附属第六医院采用术前渐进性气腹行术前准备治疗的19例巨大切口疝老年患者的临床资料。患者气腹前后行腹部CT扫描、肺功能、动脉血气分析检查。主要观察以下指标：（1）PPP情况：气腹天数、完成情况、注入空气量等；（2）气腹前后，疝囊容积、腹腔容积、肺功能指标及动脉血气（PaO2、PaCO2）变化；（3）手术、术后恢复及随访情况。

结果

（1）PPP情况：19例患者气腹时间11~18（15.1±1.6）d，18例患者顺利完成人工气腹准备，注入空气总量4 400~7 200（5 910.5±615.4）mL。（2）气腹前后，疝囊容积、腹腔容积、肺功能指标及动脉血气变化：气腹前后，疝囊容积分别为（1 086.7±438.9）mL、（1 275.8±521.4）mL，二者比较差异具有统计学意义（t=3.228，P<0.05），PPP后增加（189±255.3）mL；腹腔容积分别为（6 144.0±1 758.4）mL、（8 748.5±2 084.5）mL，二者比较差异具有统计学意义（t=8.856，P<0.05），PPP后增加（2 604.5±1 322.3）mL；疝囊容积/腹腔容积分别为10.9~28.5（17.8±5.5）%、7.3~24.9（14.7±5.6）%，二者比较差异具有统计学意义（t=3.327，P<0.05）；气腹后腹腔容积增加量远远大于气腹前疝囊容积。气腹后，FVC、FEV1/FVC%、PEF、MEF75、MEF50、MMEF75/25分别平均下降5.11%、2.45%、3.69%、1.73%、4.55%、6.8%，差异均无统计学意义（t=1.595、1.605、0.243、0.663、1.682、1.720，P>0.05）；FEV1下降6.52%，差异有统计学意义（t=2.137，P<0.05）；PaO2平均下降5.71%，差异无统计学意义（t=1.461，P>0.05）；PaCO2平均下降9.14%，差异有统计学意义（t=3.392，P<0.05）。（3）手术、术后恢复及随访情况：19例患者顺利完成手术，17例患者缺损完全关闭，手术时间137~265（173.9±34.7）min。术后无腹腔间隔室综合征、心肺衰竭等严重并发症发生。术后住院时间4~12（8.1±2.0）d。19例患者均获得随访，随访时间6~18（13.2±3.5）个月，无1例复发。

结论

PPP应用于老年腹壁巨大切口疝患者安全有效，值得临床推广和应用。

关键词: 巨大切口疝, 术前渐进性气腹, 老年, 疝修补术, 并发症
Objective

To investigate the clinical application value of the preoperative progressive pneumoperitoneum (PPP) in the treatment of large incisional hernias in the elderly.

Methods

The clinical data of 19 elderly patients with large incisional hernia who underwent PPP prior to hernia repair in the Sixth Hospital Affiliated of Sun Yat-sen University from February 2017 to February2018 were analyzed retrospectively. Abdominal computed tomography (CT) scan, pulmonary function and arterial blood gas analysis were performed before and after PPP. The following indicators were mainly observed: (1) PPP situations: insufflation time (days), completion, the median insufflated volume of air; (2) Changes in the volumes of the incisional hernia (VIH), the volumes of the abdominal cavity (VAC), the pulmonary function and arterial blood gas (PaO2 and PaCO2) before and after PPP; (3) operation, postoperative recovery and follow-up situations.

Results

(1) PPP situations: the insufflation time in 19 patients ranged from 11-18 d, 18 patients successfully completed PPP, the median insufflated volume of air for PPP was 4 400-7 200 mL. (2) Changes in the volumes of the incisional hernia (VIH), the volumes of the abdominal cavity (VAC), the pulmonary function and arterial blood gas (PaO2 and PaCO2) before and after PPP: Before and after PPP, the mean VIH was (1 086.7±438.9) mL and (1 275.8±521.4) mL (t=3.228, P<0.05), the VIH increased by (189±255.3) mL; the mean VAC was (6 144.0±1 758.4) mL and (8 748.5±2 084.5) mL (t=8.856, P<0.05), theVAC increased by (2 604.5±1 322.3) mL; the mean (VIH/VAC)×100% was 10.9% to 28.5% and 7.3% to 24.9% (t=3.327, P<0.05); the VAC increased by 2 604.5 mL (P<0.01) and was greater than the mean VIH before PPP. After PPP, dynamic lung volumes fell by 5.11% for FVC, 2.45% for FEV1/FVC%, 3.69% for PEF, 1.73% for MEF75, 4.55% for MEF50, 6.8% for MMEF75/25 (t=1.595, 1.605, 0.243, 0.663, 1.682, 1.720, all P>0.05), FEV1 decreased by 6.52% (t=2.137, P<0.05); PaO2 decreased by 5.71% (t=1.461, P>0.05) and PaCO2 decreased by 9.14% (t=3.39). (3) Operation, postoperative recovery and follow-up situations: The operations was performed successfully in 19 patients, the mean operating time was 137 to 265 minutes, fascia closure was possible in 89.5% of cases (n=17). No severe complications such as ACS or cardiopulmonary failure occurred. The mean postoperative length of stay in hospital was 4 to 12 days. All patients were followed up for 6-18 months, and there was no hernia recurrence.

Conclustion

PPP is safe and effective in elderly patients with large incisional hernia repair, which is worthy of clinical promotion and application.

Key words: Large incisional hernia, Preoperative progressive pneumoperitoneum, Elderly, Hernia repair, Complication
图1 气腹前后，行腹部CT及疝囊腹腔容积三维重建
图3 气腹前后同一脊椎水平矢状位CT图像
表1 PPP前后肺功能参数变化（±s）
参数 气腹前 气腹后 t值 P值
FVC
(L) 2.11±0.63 2.00±0.57 1.311 0.200
(%) 78.33±20.12 73.22±20.21 1.595 0.128
FEV1
(L) 1.95±0.58 1.78±0.48 2.678 0.015
(%) 87.54±23.36 81.02±22.79 2.137 0.047
FEV1/FVC% 92.33±5.65 89.88±7.60 1.605 0.126
PEF
(L) 4.63±1.75 4.61±1.48 0.101 0.920
(%) 77.40±26.15 73.71±20.73 0.243 0.810
MEF75
(L) 4.42±1.53 4.33±1.27 0.628 0.538
(%) 79.13±27.38 77.40±23.09 0.663 0.516
MEF50
(L) 2.85±1.04 2.68±0.84 1.754 0.096
(%) 79.56±29.28 75.01±24.47 1.682 0.110
MMEF75/25
(L) 2.25±0.93 2.03±0.68 2.051 0.055
(%) 79.06±31.04 72.26±23.58 1.720 0.103
PaO2(mmHg) 82.3±8.6 77.6±10.0 1.461 0.161
PaCO2(mmHg) 39.4±4.5 35.8±4.0 3.392 0.003
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