摘要
目的探讨复发性腹股沟疝手术策略的选择。方法采用描述性病例系列研究方法，回顾性分析2010年4月至2017年4月间长沙中南大学湘雅医院胰胆外科收治的82例复发性腹股沟疝病例手术及随访资料，手术方式包括腹腔镜下经腹腹膜前疝修补术（TAPP）、Lichtenstein术和杂交手术。具体术式选择根据欧洲疝学会指南，并结合患者的病史、术前检查结果及术中情况决定：（1）前次手术为前入路手术（Lichtenstein术、Bassini法或Shouldice手术），复发疝则首选TAPP；（2）前次手术采取后入路[TAPP或完全腹膜外疝修补术（TEP）]，首选Lichtenstein术，当患者身体条件不能耐受全身麻醉时，选择局部麻醉或神经阻滞下行Lichtenstein术。（3）对于前次手术采取前入路手术方式，腹腔镜探查术中发现腹膜前广泛粘连，尤其是在多次手术后复发或原先注射过硬化剂的患者，则采取杂交手术。随访收集患者腹股沟疼痛情况。结果82例患者均顺利完成手术治疗，其中TAPP术74例，Lichtenstein术4例，杂交手术4例。TAPP手术、Lichtenstein手术、杂交手术中位时间分别为70（40-130）min、60（40-90）min、120（70-150）min。术后第一天中位疼痛评分为2（0-6）分，术后2例（2.4%）发生疼痛。有4例患者（4.9%）术后出现血清肿，1例经穿刺抽液治愈，3例经保守治疗观察自行吸收。术后尿潴留发生率为1.2%（1/82），术后中位住院时间为2（1-6）d。72例（87.8%）患者获得术后随访，中位随访时间为27（11-87）月。术后1个月腹股沟疼痛中位评分（IPQ）为2（0-8）分。1例（1.2%）患者术后1年复发。术后无切口及补片感染、腹股沟区慢性疼痛病例。结论对于开放式前入路术后复发患者，可依据术者的熟练度选择TAPP或腹腔镜全腹膜外疝修补术（TEP）；行TAPP或TEP术后复发患者，可行Lichtenstein术；腹横筋膜前和腹膜前均有粘连者，可根据术中粘连情况，选择杂交手术。
Objective To explore the appropriate operative strategy in recurrent groin hernia repair. Methods Clinical and follow-up data of 82 patients with recurrent groin hernia undergoing operation at Department of Pancreatobiliary Surgery, Xiangya Hospital of Central South University from April 2010 to April 2017 were analyzed retrospectively. The operative approaches included laparoscopic transabdominal preperitoneal （TAPP） hernia repair, Lichtenstein repair and hybrid repair. Surgical method selection was based on the basis of European Hernia Society guidelines, combined with hernia histories, preoperative examination results and intra-operative results： （1） When an anterior approach （Lichtenstein, Bassini or Shouldice surgery） was adopted in the previous operation, TAPP was preferred for the recurrent groin hernia. （2） When the previous operation was an posterior approach [TAPP or total extraperitoneal hernioplasty （TEP）], Lichtenstein method was preferred. Moreover,Lichtenstein surgery with local anesthesia or nerve block was also selected when the patient could not tolerate general anesthesia. （3） When extensive preperitoneal adhesions were found in patients with previous anterior approach repair during laparoscopic exploration, especially in patients who had relapsed after multiple operations or had previous biochemical glues injection, hybrid surgery was preferred. Results All 82 patients completed operations smoothly. TAPP, Lichtenstein and hybrid operation were applied in 74, 4 and 4 patients, respectively, with median operative time of 70 minutes （40-130 minutes） in TAPP, 60 minutes （40-90 minutes） in Lichtenstein and 120 minutes （70-150 minutes） in hybrid operation, respectively. The median numerical rating scales （NRS） score was 2 （0-6） on postoperative day 1. The incidences of postoperative seroma, pain and urinary retention were 4.9% （4/82）, 2.4% （2/82） and 1.2% （1/82） respectively. The median postoperative hospital stay was 2 days （1-6 days）. Seventy-two patients were followed-up from 11 to 87 months. The median follow-up period was 27 months. The median inguinal pain questionnaire （IPQ） score was 2 （0-8） month after operation. One recurrent case was reported 1 year after operation. No incision or mesh infection and long-term inguinal chronic pain were observed. Conclusions For recurrent patients with previous open anterior approach, TEP and TAPP repair are equivalent surgical techniques, and the choice should be tailored to the surgeon＇s expertise. For those with previous TAPP or TEP repair, Lichtenstein technique is recommended. For those with adhesions both in anterior transverse fascia and pre-peritoneum, hybrid operation may be the preferable choice according to adhesion conditions.
作者
王曦滔
黄耿文
申鼎成
林嘉晏
宁彩虹
曹昕彤
纪连栋
陆晔斌
魏伟
Wang Xitao;Huang Gengwen;Shen Dingcheng;Lin Jiayan;Ning Caihong;Cao Xintong;Ji Liandong;Lu Yebin;Wei Wei(Department of Pancreatobiliary Surgery, Xiangya Hospital, Central South University, Changsha 410008, China)
出处
《中华胃肠外科杂志》
CAS
CSCD
北大核心
2018年第7期761-765,共5页
Chinese Journal of Gastrointestinal Surgery
关键词
腹股沟疝
复发
手术策略
Groin hernia
Recurrence
Surgical strategy
