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中华疝和腹壁外科杂志(电子版) ›› 2025, Vol. 19 ›› Issue (03) : 245 -252. doi: 10.3877/cma.j.issn.1674-392X.2025.03.001

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谈谈食管裂孔疝手术中食管裂孔缺损修补的方法
嵇振岭1,2,(), 刘宗航1   
  1. 1. 210044 南京江北医院普外科
    2. 210009 南京,东南大学附属中大医院普外科
  • 收稿日期:2025-04-15 出版日期:2025-06-18
  • 通信作者: 嵇振岭

How to repair the esophageal hiatus defect during hiatal hernia repair

Zhenling Ji1,2,(), Zonghang Liu1   

  1. 1. Department of General Surgery,Nanjing Jiangbei Hospital,Nanjing 210044,Jiangsu Province,China
    2. Department of General Surgery,Zhongda Hospital,Southeast University,Nanjing 210009,Jiangsu,China
  • Received:2025-04-15 Published:2025-06-18
  • Corresponding author: Zhenling Ji
引用本文:

嵇振岭, 刘宗航. 谈谈食管裂孔疝手术中食管裂孔缺损修补的方法[J/OL]. 中华疝和腹壁外科杂志(电子版), 2025, 19(03): 245-252.

Zhenling Ji, Zonghang Liu. How to repair the esophageal hiatus defect during hiatal hernia repair[J/OL]. Chinese Journal of Hernia and Abdominal Wall Surgery(Electronic Edition), 2025, 19(03): 245-252.

本文回顾了胃食管反流及食管裂孔疝治疗的历史。介绍了各种食管裂孔缺损的修补方法,强调了目前食管裂孔疝治疗的不确定性,对未来的发展方向提出了意向。

This article provides a comprehensive review of the historical development of treatments for gastroesophageal reflux and hiatal hernia, introduces various techniques used to repair hiatal defects, emphasizes the uncertainties in current management of hiatal hernia, and outlines potential directions for future research and advancements.

图1 食管裂孔表面积测量 注:Alpha 1为左、右膈肌脚夹角度数的1/2,Alpha 0 为左、右膈肌脚夹角度数,s 为食管裂孔最大横径,R 为左右膈肌脚的长度,b 指食管裂孔上方膈肌边缘的弧形长度,HSA 食管裂孔缺损表面积。
图2 食管造影DR测量食管裂孔缺损(图片引自[17] 注:上箭头指示食管胃交界,下箭头指示膈裂孔。
图3 多排螺旋CT测量食管裂孔缺损 注:3A 矢状面,白色实线代表斜轴位,并且与食管裂孔的前后边缘相交;3B 斜冠状面,白色实线代表斜轴位,并且与食管裂孔的左右边缘相交;3C 食管裂孔所在的双斜轴位平面;3D 食管裂孔的放大视图,即图中白色箭头所指图形(图片引自[19])。
图4 各种食管裂孔缺损的修补方法
图5 鞋带状缝合食管裂孔缺损操作图示(图片引自[25] 注:5A 缝合左右膈肌脚第一针,留3 cm尾线用于最后一针打结;5B 第二针从左侧膈肌脚前面由外向内进针,再从内向外穿过右侧膈肌脚;5C 下一针连续缝合,从右膈肌脚外侧向内穿过右侧膈肌脚,再从内侧穿到左膈肌脚的外侧,形成网状交叉;5D 轻拉缝线,靠拢左右膈肌脚。5E 反复连续交叉缝合,缝线呈鞋带状;5F 缝合至食管后壁时,保留适当的裂孔松紧度;再转向下方连续交叉缝合,最后一针缝合在第一针的打结的地方,收紧缝线,与第一针尾线打结。
图6 肝圆韧带修补(前修补)食管裂孔缺损操作图示(图片引自[28] 注:左图示肝圆韧带离断;中图示镰状韧带瓣静脉注射吲哚菁绿前(6A)和后(6B)韧带;6C 取下的皮瓣在左肝下方向肝裂孔方向旋转;6D 皮瓣转置到食管后方,在左侧和前部固定在胃壁上;右图示手术完成。
图7 肝圆韧带修补(后修补)食管裂孔缺损操作示意图(图片引自[29] 注:左图示肝圆韧带离断线;右图示肝圆韧带食管后方覆盖食管裂孔。
图8 肝脏镰状韧带修补食管裂孔缺损示意图(图片引自[30] 注:8A 后路裂孔成形术后存在前路残留缺损;8B 从肝缘超声解剖左三角韧带;8C 三角韧带延伸到食管的前方;8D 将三角韧带固定于左右膈肌脚纤维。
图9 图示Hill手术修补缝合食管裂孔缺损的方法(图片引自[32]
图10 图示胃底折叠瓣只需2针间断缝合加固(图片引自[32] 注:10A Hill及Nissen示意图;10B 缝合后的示意图,注意Nissen只用2针加垫片的间断缝合修补。
图11 胃前壁固定术操作示意图(图片引自[35]
图12 肝叶修补食管裂孔缺损法操作图示(图片引自[37] 注:12A 游离左侧肝脏三角韧带;12B 将左外叶尖端缝合至三角韧带残端;12C 采用肝左叶修补缺损;12D 手术完成后图片
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