TAPP联合腹壁小切口技术在难复位腹股沟嵌顿疝急诊手术患者中的应用

2020-09-14 12:01:57 中国现代医生 2020年19期

何守敏 傅军 刘建郭 郑清盛 王梽 王守铭

[摘要] 目的 分析腹腔鏡经腹腹膜前疝修补术(Transabdominal preperitoneal,TAPP)联合腹壁小切口的杂交技术治疗急性难复位腹股沟嵌顿疝的临床疗效。 方法 回顾性分析福建中医药大学附属人民医院2017年8月~2019年8月应用TAPP联合腹壁小切口的杂交技术治疗的12例难复位腹股沟嵌顿疝急诊患者,均为单侧斜疝嵌顿,疝内容物在腔镜下用器械辅助无法完全返纳,遂取内环处腹股沟区小切口,返纳疝内容物,再完成TAPP术。观察患者术中出血量、手术时间、住院天数及术后并发症情况。 结果 嵌顿疝内容物10例为小肠,2例为大网膜。其中1例完成TAPP术后,发现小肠坏死,另取脐部小切口完成坏死小肠切除吻合。12例患者均顺利完成手术,术中出血量10~30 mL,平均(20.1±3.2) mL;手术时间80~125 min,平均(95.2±20.6) min。术后腹股沟区血清肿1例,阴囊积液2例,无腹股沟区顽固性疼痛、缺血性睾丸炎、腹腔感染、肠梗阻及切口感染病例。经过对症处理后,1周内阴囊积液及血清肿症状趋于消失。住院时间平均(4.0±1.2)d,随访3~24个月未见疝复发、腹股沟区慢性疼痛及补片感染病例。 结论 TAPP联合腹壁小切口的杂交技术治疗难复位腹股沟嵌顿疝具有康复快、创伤小等优点,如果严格掌握适应证,可在临床广泛应用。

[关键词] 疝;腹股沟;嵌顿;疝修补术;腹腔镜检查;急诊手术

[中图分类号] R726.5          [文献标识码] B          [文章编号] 1673-9701(2020)19-0047-03

The application of TAPP combined with abdominal wall small incision technology to emergency operation for the patients with difficult reduction inguinal incarcerated hernia

HE Shoumin   FU Jun   LIU Jian'guo   ZHENG Qingsheng   WANG Zhi   WANG Shouming

Department of General Surgery, The People's Hospital Affiliated to Fujian University of Traditional Chinese Medicine,  Fuzhou   350001, China

[Abstract] Objective To analyze the clinical efficacy of laparoscopic transabdominal preperitoneal(TAPP) hernia repair combined with abdominal wall small incision hybrid technology in the treatment of acute difficult reduction inguinal incarcerated hernia. Methods A retrospective analysis was made on 12 patients with difficult reduction inguinal incarcerated hernia who were treated through TAPP combined with abdominal wall small incision hybrid technology in The People's Hospital Affiliated to Fujian University of Traditional Chinese Medicine from August 2017 to August 2019. All the patients had unilateral indirect inguinal incarcerated hernia. The contents of hernia could not be completely returned with the aid of instruments under endoscopy. Therefore, a small incision in the inguinal region at the inner ring was made to return the contents of hernia before TAPP was completed. The intraoperative blood loss, operation time, hospitalization days and postoperative complications of the patients were observed. Results The contents of incarcerated hernia were small intestine in 10 cases and greater omentum in 2 cases. One of them had necrosis of small intestine detected after TAPP, and another small incision was made in umbilical region to complete resection and anastomosis of necrotic small intestine. All the 12 patients successfully completed the operation. The intraoperative blood loss was 10-30 ml, with an average of (20.1±3.2) mL. The operation time was 80-125 min, with an average of (95.2±20.6) min. After operation, inguinal seroma was found in 1 case, scrotal effusion in 2 cases, and there was no case of intractable pain in inguinal region, ischemic orchitis, abdominal infection, intestinal obstruction and incision infection. After targeted treatment, the symptoms of scrotal effusion and seroma tended to disappear within one week. The average hospitalization time was(4.0±1.2) d, and no case of recurrence of hernia, chronic pain in inguinal region and sticking patch infection was found during 3 to 24 months of follow-up. Conclusion TAPP combined with abdominal wall small incision hybrid technique has the advantages of fast recovery and fewer traumas in the treatment of difficult reduction inguinal incarcerated hernia. If the strict indications are mastered, it can be applied widely in clinical practice.

[Key words] Hernia; Inguinal; Incarceration; Hernia repair; Laparoscopy; Emergency surgery

难复位腹股沟嵌顿疝是常见的普外科急腹症,在腹股沟疝中的发生率为0.3%~2.9%[1],排除有些发病时间短,可以手法复位的病例,均需急诊手术治疗。以往在难复位腹股沟嵌顿疝急诊手术时,多采用传统开放手术,患者术后存在切口疼痛、恢复慢、遗漏肠管坏死及远期疝复发需要再次手术等并发症,有诸多不便之处。随着腹腔镜检查治疗技术的广泛普及,本研究尝试在难复位腹股沟嵌顿疝急诊手术患者中应用TAPP联合腹壁小切口技术一期修补治疗,效果良好,本文分析2017年8月~2019年8月由于难复位腹股沟嵌顿疝入院行急诊手术的12例患者的临床资料,现报道如下。

1 资料与方法

1.1 临床资料

12例患者中,男11例,女1例,年龄24~75岁,平均(63.00±15.32)岁,体质量指数(BMI)(24.2±2.5) kg/m2;均无复发疝,既往无严重心、肺基础病,能耐受腹腔镜手术,无下腹部手术病史,全部病例均为难复位嵌顿斜疝;排除术前可以手法复位、术中麻醉后内环肌肉松弛自动复位及术中通过手术器械牵拉及切开内环口复位的病例。嵌顿时间6~22 h,平均(12.00±3.21)h,临床症状表现为腹股沟区难复位肿块,男性患者多坠入阴囊,均有腹股沟区疼痛,严重者甚至有腹痛、腹胀、肛门停止排气、排便等。嵌顿疝内容物10例为小肠,2例为大网膜。

1.2 术前准备

患者入院完善生化、血常规、凝血功能、常规心电图、胸部正位片、腹股沟区彩色多普勒超声或全腹部CT平扫等术前检查,初步判断嵌顿疝内容物活力及是否存在腹腔积液,术前常规留置尿管,行气管插管全身麻醉。术前、术后预防性应用抗生素24 h。

1.3手术方法

麻醉成功后,患者取仰卧位,头低脚高,患侧略高。常规消毒铺巾后,于脐上缘行横切口,长度约1 cm,穿刺置入10 mm Trocar,维持气腹压力在12~13 mmHg,腹腔镜直视下分别于两侧腹直肌外侧缘平脐处穿刺置入5 mm Trocar,腹腔镜腹腔内探查明确难复位嵌顿疝的类型及疝内容物的性质、卡压情况(封三图5),先尝试用手从外部辅助压迫内环口,结合纱布包裹无损伤钳协助,将嵌顿肠管往腹腔内牵拉,勿使用暴力牵拉(因肠管嵌顿易致肠管炎症水肿,肠壁变薄,暴力牵拉肠管易致肠壁撕裂出血,甚至肠瘘等并发症发生)。如果仍无法返纳,可以向内环口外侧嵌顿粘连处稍切开,注意勿损伤嵌顿处的肠管及附近的腹壁下血管。有些嵌顿疝嵌顿致密,疝囊巨大,甚至远侧延伸至外环近阴囊处,经过上述两种方法仍不能回纳,遂采取联合腹壁小切口的杂交技术辅助返纳难复位的嵌顿疝。腹壁小切口位于腹股沟区内环口处,取长度约3 cm平行腹股沟区小切口,逐层切开至腹外斜肌腱膜,切开松解内环口嵌顿致密处,复位嵌顿的疝内容物。如嵌顿疝内容物为肠管,注意其血供情况,如不能确定肠管坏死,可向腹腔内注入温盐水1000 mL浸泡可疑肠管,观察肠管蠕动情况及颜色变化。然后于疝环上方约2 cm处切开腹膜,注意避开水肿粘连处,内侧不超过脐内侧韧带,外侧至髂前上棘。考虑到难复位嵌顿疝疝囊多巨大,完全剥离疝囊易致术区水肿渗血,且耗时长、难度大,故本研究术中远端疝囊均予横断(封三图6),但要注意远端疝囊断端彻底止血,防止术后阴囊血肿。分离腹膜前间隙(封三图7),注意腹膜前重要结构如腹壁下血管、髂血管的识别,防止误损伤,使用巴德10 cm×15 cm 3DMAX补片覆盖整个耻骨肌孔区域(封三图8)。

TAPP完成后,在腹腔内继续观察疝内容物,其中本组2例嵌顿的疝内容物为大网膜,大网膜返纳后无坏死及出血发生;余10例嵌顿的疝内容物为小肠,返纳小肠后,其中9例肠管颜色及蠕动功能均恢复正常,只有1例颜色变紫黑色,肠壁失去张力,无蠕动,相应系膜终末动脉无搏动,于肠系膜根部处注射2%利多卡因后,观察20 min仍未见肠管颜色及功能恢复,判断肠管坏死,遂于脐部纵行延长切口约3 cm,完成坏死小肠的切除吻合。缝合关闭切口前注意吸净腹腔液体,常规留置盆腔引流管1根。术后常规腹股沟区沙袋压迫,术后第1天下床活动,术后1~2 d引流量少于20 mL后予以拔除引流管。

1.4观察指标

观察患者术中出血量、手术时间及住院天数,对患者的术后并发症情况进行分析。

2 结果

12例患者均顺利完成手术,手术时间80~125 min,平均(95.2±20.6) min;出血量10~30 mL,平均(20.1±3.2)mL;住院時间3~5 d,平均(4.0±1.2)d。术后发生阴囊积液2例,其中1例经穿刺处理后消失,1例抬高阴囊后吸收;发生腹股沟血清肿1例,经保守治疗自行吸收。术后无腹股沟区顽固性疼痛、缺血性睾丸炎、腹腔感染、腹腔出血、肠梗阻及切口感染发生。随访3~24个月未见疝复发、腹股沟区慢性疼痛及补片感染病例。

3 讨论

难复位腹股沟嵌顿疝为普外科的常见急症,由于患者发病年龄较大、基础病较多,如果发生绞窄性肠坏死、肠穿孔、中毒性休克等严重并发症,死亡率可高达3.1%[2],因此难复位腹股沟嵌顿疝无论发生部位及肿块大小,均需急诊手术干预。嵌顿疝的治疗中,关键是疝内容物的处理,疝内容物如何返纳,是否需要行肠切除等,存在诸多不确定因素,手术方式及术中是否需要放置补片一直存有争议。

腹腔镜疝修补术通过腹膜前修复缺损,完全覆盖耻骨肌孔,且术后疼痛轻,恢复快,切口感染率低,近年得到快速普及。全腹膜外疝修补术(Totally extraperitoneal,TEP)及腹腔镜经腹腹膜前疝修补术(Transabdominal preperitoneal,TAPP)是目前最常用的腹腔镜疝修补术[3-4]。对于难复位腹股沟嵌顿疝,以往多采用开放手术治疗,Siow等[5]尝试对嵌顿疝行腹腔镜下腹股沟疝修补术,取得了较好的疗效。在难复位腹股沟嵌顿疝的治疗中,应选择TAPP还是TEP?TEP完全在腹膜外操作,不进入腹腔,嵌顿疝时腹膜前操作空间变小,且无法判断疝内容物的来源及性质,如果主动行腹膜切开探查疝内容物,后续还要缝合腹膜,操作难度及风险大。Trevisonno等[6]应用TEP治疗嵌顿疝取得成功,但本研究未采用。由于TAPP可以进入腹腔全面探查,明确疝的类型及疝内容物的来源,操作空间大,有助于疝内容物的返纳,可以对返纳的疝内容物进行进一步观察,避免漏诊及误诊的发生,与开放手术相比明显降低肠切除的比例[7]。因此本研究对难复位嵌顿疝采取TAPP,但是并非所有的难复位疝内容物在腹腔镜下均能复位,腹腔镜下行嵌顿疝复位仍存在风险,特别是难复位腹股沟嵌顿斜疝由于嵌顿时间较长,往往内环水肿紧致,此时嵌顿肠管张力较高,外部手法按压结合腹腔器械牵拉,或者内环口外侧切开松解及复位过程中极易引起肠壁撕裂、出血穿孔,甚至肠瘘等严重后果。杂交技术在切口疝中的应用上取得了良好的效果[8-9],故借鉴此经验,在难复位腹股沟嵌顿斜疝上运用TAPP联合腹壁小切口的杂交技术,快速返纳疝内容物及完成修补术,降低了腹腔镜下返纳疝内容物的难度,又避免了开放手术的大切口。在难复位腹股沟嵌顿斜疝疝内容物的返纳上,如果经过腹腔内操作确定返纳较困难,不可强行返纳,应果断采取联合腹壁小切口的杂交技术返纳疝内容物,可以减少手术时间,降低手术难度及风险,减少术后并发症发生。

对于难复位腹股沟嵌顿疝,特别是疝内容物为小肠,如果术中行小肠切除,是否能够放置补片,是否可以行一期修补,目前尚有一定争论[10]。既往考虑到嵌顿疝急诊手术时容易导致菌群移位,手术区域污染,补片修补是相对禁忌证,我国2014版的成人腹股沟疝诊疗指南中对嵌顿疝行急诊手术不推荐使用材料,对有污染可能的手术不推荐使用不吸收材料进行修补[11]。近年来研究表明,嵌顿疝急诊手术治疗中,即使在小肠切除的情况下,只要术区处于清洁或相对清洁状态,补片并不增加手术部位感染率[12],术后复发率较非补片修补明显降低[13-14],所以避免嵌顿疝术后复发是需要考虑的一个因素。本研究认为嵌顿疝放置补片术后总体益处大于非补片修补,但如果嵌顿疝术区有肠液外溢,肠管坏死范围大,腹腔污染严重,是放置补片的绝对禁忌证。本研究中12例嵌顿疝有10例疝内容物为小肠,术中发现1例小肠坏死,无发生肠液外溢,术区处于相对清洁状态,完成TAPP修补后,另取脐部小切口完成坏死小肠切除吻合,小肠操作区域远离补片修补位置,确保腹膜缝合牢固,保持腹膜的完整性。温盐水常规冲洗腹腔及切口,已经证实可以有效降低感染发生率[15],本研究术后常规冲洗腹腔及放置引流管,术后随访未发现补片及切口感染。

综上所述,TAPP联合腹壁小切口的杂交技术一期修补治疗难复位腹股沟嵌顿疝,疗效良好,具有康复快、创伤小等优点,手术安全可行,但必须在严格掌握适应证的前提下进行。本研究病例数少,远期疗效需要大样本长期随访,需要进一步的多中心前瞻性随机对照研究来证实。

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(收稿日期:2019-12-11)