摘要
背景与目的:巨大切口疝修复通常是一项具有挑战性的手术,由于关闭巨大缺损可能会产生严重的病理生理后果,甚至发生腹腔室隔综合征(ACS)等危及生命的并发症。术前渐进性气腹(PPP)可以扩大患者腹腔,促进疝内容物重新回纳,而A型肉毒毒素(BTA)可以可逆性松弛腹壁肌肉,两者联合用于巨大切口疝修复术的术前准备可能起到互补作用。因此,本研究探讨PPP联合BTA在巨大切口疝修补术中的应用价值。方法:回顾性分析2018年6月—2021年12月中山大学附属第六医院采用PPP联合BTA行腹腔镜下腹腔内补片植入术(IPOM)术前准备,治疗的巨大切口疝患者7例临床资料。患者术前在超声引导下进行侧腹壁肌肉BTA注射以及腹腔置管建立PPP,利用CT软件测量患者PPP+BTA处理前后侧腹壁肌肉长度、厚度以及疝囊容积(VIH)和腹腔容积(VAC)变化,记录PPP+BTA处理后的不良反应,术中、术后并发症及随访情况。结果:患者7例中,男4例、女3例,中位年龄59(44~71)岁,中位体质量指数25.6(21.3~31.2)kg/m^(2);6例患者为初发疝、1例患者为复发疝;合并基础疾病2例。PPP+BTA处理后,患者平均每边侧腹壁肌肉长度增加3.5 cm;平均每边侧腹壁肌肉厚度减小0.3 cm;VIH平均增加量为829 mL、VAC平均增加量为2982 mL、VIH/VAC比值降低1.7%;患者的疝内容物均有不同程度自行回纳腹腔。在PPP+BTA准备过程中,2例患者出现腹胀腹痛,1例患者出现肩背部疼痛,1例患者出现皮下气肿,均自行缓解。患者均顺利完成IPOM治疗,平均手术时间为(186±114)min,术后住院时间为(6.4±1.1)d。术后患者VAS评分均低于3分,无需使用镇痛药物。术后1例患者出现低位小肠梗阻,予以对症处理后缓解,未出现ACS等严重并发症。平均随访时间(10.4±8.8)个月,未出现慢性疼痛、复发及补片感染等并发症。结论:PPP+BTA行术前准备能够明显增加巨大切口疝患者的腹腔容积、延长侧腹壁肌肉长度,有利于巨大缺损关闭和减少术后严重并发症发生,值得临床推广应用。
background and Aims:Large incisional hernia repair is always a matter of challenge,because the closure of large defects may likely lead to serious pathophysiological consequences or even lifethreatening complications such as abdominal compartment syndrome(ACS).The preoperative progressive pneumoperitoneum(PPP)can widen the abdominal cavity of the patients,and facilitate reduction of the hernia contents,and the botulinum toxin A(BTA)can cause revisable relaxation the abdominal wall muscles,so their combined use in preoperative preparation of large incisional hernia repair surgery is considered to produce a complementary effect.Therefore,this study was performed to evaluate the application value of PPP combined with BTA injections in large incisional hernia repair.Methods:The clinical data of 7 patients with large incisional hernia undergoing laparoscopic intraperitoneal onlay mesh repair(IPOM)using the combination of PPP and BTA injections for preoperative preparation in the Sixth Affiliated Hospital of Sun Yat-sen University from June 2018 to December 2021 were retrospectively analyzed.Before operation,the patients underwent BTA injections into the lateral abdominal wall muscles and abdominal catheter insertion for the PPP under ultrasound guidance.The changes in the volumes of the incisional hernia(VIH),the volumes of abdominal cavity(VAC)and the length and thickness of the lateral abdominal wall muscle before and after PPP plus BTA treatment were measured by CT software.The adverse reactions after PPP plus BTA treatment,the intraand postoperative complications and follow-up results were recorded.Results:Among the 7 patients,4 cases were males and 3 cases were females,with a median age of 59(44-71)years and a median body mass index of 25.6(21.3-31.2)kg/m^(2);6 cases had primary hernia and one case had recurrent hernia;2 cases complicated with underlying diseases.After PPP plus BTA treatment,the average increase in length of the lateral abdominal muscle on each side was 3.5 cm,the average decrease in thickness of the abdominal wall muscle on each side was 0.3 cm,the average increaseing value of VIH was 829 mL,the average increaseing value of VAC was 2982 mL,and the average decreasing value of VIH/VAC ratio was 1.7%,respectively;varying degrees of spontaneous reduction of the hernia contents into the abdominal cavity occurred in all patients.During PPP plus BTA preparation,abdominal distention and abdominal pain occurred in 2 patients,shoulder and back pain occurred in one patient,and subcutaneous emphysema occurred in one patient,but all resolved spontaneously without special treatment.The IPOM operation was uneventfully completed in all patients,the average operative time was(186±114)min and the length of postoperative hospital stay was(6.4±1.1)d.The postoperative VAS scores for all patients were lower than 3,and no analgesic supplement was needed.After surgery,low intestinal obstruction occurred in one patient,which was relieved after symptomatic treatment,and no serious complications such as ACS occurred.The average follow-up time was(10.4±8.8)months,and no chronic pain,recurrence and mesh infection complications were observed.Conclusion:PPP plus BTA treatment for preoperative preparation can significantly increase the abdominal volume of large incisional hernia and prolong the length of the lateral abdominal muscles of the patients,which is helpful for defect closure and reducing the occurrence of serous postoperative complications.So,it is recommended to be use in clinical paractice.
作者
汤福鑫
马宁
刘创雄
黄恩民
马涛
陈双
王辉
周太成
TANG Fuxin;MA Ning;LIU Chuangxiong;HUANG Enmin;MA Tao;CHEN Shuang;WANG Hui;ZHOU Taicheng(Department of Colorectal Surgery,the Sixth Affiliated Hospital of Sun Yat-sen University,Guangzhou 510655,China;Department of Gastroenterological Surgery and Hernia Center,the Sixth Affiliated Hospital of Sun Yat-sen University,Guangzhou 510655,China)
出处
《中国普通外科杂志》
CAS
CSCD
北大核心
2022年第4期441-448,共8页
China Journal of General Surgery
基金
广东省科技计划基金资助项目(2021A1515410004)。
关键词
切口疝
疝修补术
腹腔镜
气腹
人工
肉毒毒素类
Incisional Hernia
Herniorrhaphy
Laparoscopes
Pneumoperitoneum,Artificial
Botulinum Toxins
