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中华疝和腹壁外科杂志(电子版)

中华疝和腹壁外科杂志(电子版) ›› 2021, Vol. 15 ›› Issue (01) : 12 -18. doi: 10.3877/cma.j.issn.1674-392X.2021.01.004

所属专题： 文献；

临床论著

内镜下全腹膜外Sublay修补在腹壁疝中的应用
吴卫东1, 蒋会勇2, 孟相真3, 刘国忠4, 蔡小燕5, 王涛6, 刘剑文7, 崔夕军8, 司仙科9, 魏云1, 汤睿10,†()   
  1. 1. 200080　上海交通大学附属第一人民医院普外中心
    2. 110015　沈阳，中一东北国际医院普外二科
    3. 110004　沈阳，中国医科大学附属盛京医院结直肠疝微创外科
    4. 350005　福州，福建医科大学附属第一医院肝胆胰疝外科
    5. 310016　杭州，浙江大学医学院附属邵逸夫医院普外科疝和腹壁外科中心
    6. 255036　山东省淄博市中心医院普外科
    7. 518000　广东省，香港大学深圳医院胃肠外科
    8. 264400　山东省威海市中心医院肝胆外科、疝与腹壁外科
    9. 200062　上海中医药大学附属普陀医院微创外科
    10. 200120　上海，同济大学附属东方医院疝与腹壁外科
  • 收稿日期:2020-05-09 出版日期:2021-02-18
  • 通信作者: 汤睿

Endoscopic totally extraperitoneal sublay repair for the treatment of ventral hernia

Weidong Wu1, Huiyong Jiang2, Xiangzhen Meng3, Guozhong Liu4, Xiaoyan Cai5, Tao Wang6, Jianwen Liu7, Xijun Cui8, Xianke Si9, Yun Wei1, Rui Tang10,†()   

  1. 1. General Surgery Center, Shanghai Jiaotong University First People’s Hospital, Shanghai 200080, China
    2. Second Department of General Surgery, Zhongyi Northeast International Hospital (co-first author), Shenyang 110015, China
    3. Department of Colorectal and Hernia Minimally Invasive Surgery, Shengjing Hospital Affiliated to China Medical University, Shenyang 110004, China
    4. Department of Hepatobiliary-Pancreatic and Hernia Surgery, First Affiliated Hospital of Fujian Medical University, Fuzhou 350005, China
    5. Department of General Surgery, Hernia and Abdominal Surgery Center, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, China
    6. Department of General Surgery, Zibo Central Hospital, Zibo 255036, China
    7. Department of Gastrointestinal Surgery, Shenzhen Hospital, University of Hong Kong, Shenzhen 518000, China
    8. Department of Hepatobiliary Surgery, Hernia and Abdominal Surgery, Weihai Central Hospital, Weihai 264400, China
    9. Department of Minimally Invasive Surgery, Putuo Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai 200062, China
    10. Department of Hernia and Abdominal Surgery, Tongji University Dongfang Hospital, Shanghai 200120, China
  • Received:2020-05-09 Published:2021-02-18
  • Corresponding author: Rui Tang
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引用本文：

吴卫东, 蒋会勇, 孟相真, 刘国忠, 蔡小燕, 王涛, 刘剑文, 崔夕军, 司仙科, 魏云, 汤睿. 内镜下全腹膜外Sublay修补在腹壁疝中的应用[J]. 中华疝和腹壁外科杂志(电子版), 2021, 15(01): 12-18.

Weidong Wu, Huiyong Jiang, Xiangzhen Meng, Guozhong Liu, Xiaoyan Cai, Tao Wang, Jianwen Liu, Xijun Cui, Xianke Si, Yun Wei, Rui Tang. Endoscopic totally extraperitoneal sublay repair for the treatment of ventral hernia[J]. Chinese Journal of Hernia and Abdominal Wall Surgery(Electronic Edition), 2021, 15(01): 12-18.

目的

评价腹壁疝内镜下全腹膜外Sublay（TES）手术的效果并总结经验。

方法

回顾性总结国内10所医院自2016年3月至2019年7月115例腹壁疝内镜下TES手术的患者资料。分析患者情况、疝的特点、手术经过和结果。

结果

115例计划实施TES的患者中，因严重腹膜破损中转为IPOM修补患者1例，其余均成功手术。可以缝合缺损患者108例（94.74%），需要永久补片固定患者15例（13.16%）。放置引流患者76例（66.67%），中位手术时间为144 min，术中无严重并发症发生。随访时间3～45个月，总并发症发生率为20例（17.54%），其中出现血清肿患者5例（4.38%）。绝大多数患者术后仅出现轻微疼痛，未出现慢性疼痛。

结论

在腹壁疝的治疗中，对熟悉腹壁解剖的外科医师而言，TES是一种有效、安全的修复手段。在熟悉手术的基础上适应症可逐步拓展。

关键词: 腹壁疝, 内镜下Sublay修补, 全腹膜外Sublay修补, 内镜下腹横肌松解
Objective

This retrospective study was undertaken to evaluate the preliminary results of totally extraperitoneal sublay (TES) repair and summarize our experience.

Methods

115 patients with primary ventral hernia or incisional hernia underwent TES in 10 Chinese hospitals between March 2016 and July 2019 were included in this study. Patient demographics, hernia characteristics, operative variables, and surgical results were recorded and analyzed.

Results

Among 115 cases planned with TES, 114 were operated on successfully, and 1 patient was converted to IPOM repair due to severe peritoneal damage. Defect closure was achieved in 108 cases (94.74%), and permanent mesh fixation was performed in 15 cases (13.16%). Drainage was placed in 76 cases (66.67%), and the median operation time was 144 min. No severe intraoperative complications occurred. Seroma was observed in 5 cases (4.38%). After a follow-up during of 3-45 months, the overall complication rate was 17.54%. The vast majority of patients had only mild pain after surgery, without chronic pain.

Conclusion

TES is feasible, safe, and effective for the treatment of ventral hernia when surgeons have in-depth anatomic knowledge of the abdominal wall and relevant surgical skills, such as technique of "partition-breaking" and eTAR.

Key words: Hernia, ventral, Endoscopic sublay repair, Totally extraperitoneal sublay, Endoscopic transversus abdominis release
图1 Trocar布局
图2 腹壁间隙的分区及间隙间的隔断
图3 全腹膜外Sublay流程
表1 114例腹壁疝患者手术处理和术后恢复
手术及术后情况 数据
疝囊处理[例(%)]  
  回纳 63(55.26)
  横断 51(44.74)
缺损关闭[例(%)]  
  否 6(5.26)
  是 108(94.74)
  缝合关闭 61(53.51)
  钩线针关闭 47(41.23)
补片固定[例(%)]  
  无 51(44.74)
  临时固定 48(42.11)
  医用胶 27(23.68)
  自粘补片 21(18.42)
  永久固定 15(13.16)
  钉枪 12(10.53)
  穿筋膜 3(2.63)
手术时间(min) 144(120~183)
引流放置 76(66.67%)
引流拔除时间(d)1 3(3~4)
饮食恢复时间(d) VAS 48 h2 2(1~3)
轻度 101(88.60)
  1 34(29.82)
  2 36(31.58)
  3 31(27.19)
中度 13(11.40)
  4 6(5.26)
  5 5(4.39)
  6 2(1.75)
重度(7~10) 0
术后住院时间(d) 4(3~6)
表2 114例腹壁疝患者并发症情况
并发症 [例(%)]
术中  
大血管损伤 0
脏器损伤 1(0.88)
术后短期(术后1个月以内)  
伤口感染或愈合延迟 3(2.63)
血清肿 2(1.75)
血肿 2(1.75)
出血 2(1.75)
腹壁水肿 2(1.75)
肠梗阻 1(0.88)
尿道感染 2(1.75)
肺部感染 1(0.88)
心血管意外 0
深静脉血栓 0
术后长期(术后1个月以后)  
血清肿1 3(2.63)
复发 0
穿刺孔疝 0
伤口延迟感染 1(0.88)
补片感染 0
肠梗阻 0
延迟性肠瘘 0
慢性疼痛 0
合计 20(17.54)
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