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复发性腹股沟疝微创治疗的术式选择

The surgical strategy for laparoscopic approach in recurrent inguinal hernia repair: 213 cases report

摘要:

目的 探讨复发性腹股沟疝微创治疗的术式选择.方法 回顾性分析2001年1月至2011年12月采用微创技术治疗的213例(225侧)复发性腹股沟疝患者的临床资料,男性202例,女性11例,平均年龄(67±14)岁,其中经腹腹膜前腹腔镜腹股沟疝修补术(TAPP) 174侧,腹腔镜全腹膜外疝修补术(TEP)41侧,腹腔镜腹腔内补片植入术(IPOM) 10侧.随访时间15 ~ 60个月(中位时间42个月),随访率100%.结果 74侧(32.9%)单纯缝合修补术后复发疝,采用TAPP治疗48侧,TEP治疗26侧;38侧(16.9%) Lichtenstein修补术后复发疝,采用TAPP治疗23侧,TEP治疗15侧;91侧(40.4%)网塞平片修补术后复发疝,采用TAPP治疗90侧,IPOM治疗1侧;22侧(9.8%)腹膜前修补术后复发疝,采用TAPP治疗13侧,IPOM治疗9侧.手术无中转,平均手术时间(39±14) min(15 ~90 min),无患者术后应用镇痛剂,术后第1天平均视觉模拟疼痛评分2.4±1.1(1.2~6.4),术后平均住院时间(1.7±1.5)d(1 ~9 d),2周内恢复非限制性活动人数为212例(99.6%).随访期内无复发,术后累计并发症25例(11.1%),其中1例(0.4%)严重并发症为腹腔感染,需再次手术干预;其他24例并发症依次为血清肿15例(6.7%),尿潴留5例(2.2%),暂时性神经感觉异常3例(1.3%)和麻痹性肠梗阻1例(0.4%).结论 单纯缝合与Lichtenstein修补术后复发疝,TAPP和TEP都是合理的术式,具体选择取决于术者的临床经验;网塞平片修补术后复发疝,绝大多数都可以通过TAPP治疗,不建议选择TEP.腹膜前修补术后复发疝,建议先选择TAPP治疗,如术中无法分离出足够的间隙和腹膜,可改为IPOM治疗.

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abstracts:

Objective To evaluate the surgical strategy for laparoscopic approach in recurrent inguinal hernia repair.Methods Between January 2001 and December 2011,the clinical data of 213patients with 225 recurrent inguinal hernias underwent laparoscopic repair were retrospectively analyzed.There were 202 male and 11 female patients and their average age were (67 ± 14) years old (range 22-97 years old).The surgical methods included laparoscopic transabdominal preperitoneal hernia repair (TAPP,n =174),total extraperitoneal herniorrhaphy (TEP,n =41) and intraperitoneal onlay mesh (IPOM,n =10).The follow-up period ranged from 15 to 60 months (median 42 months).No patient lost to follow-up during the investigation.Results The 48 TAPP and 26 TEP were applied to 77 (32.9%) recurrent hernias after conventional suture repair; 23 TAPP and 15 TEP were utilized to 38 (16.9%) recurrent hernias after Lichtenstein repair; 90 TAPP and 1 IPOM were employed for 91 (40.4%) recurrent hernias after Patch and Plug repair; and the other 22 (9.8%) recurrent hernias after preperitoneal repair were repaired by using 13 TAPP and 9 IPOM techniques.No conversion to open surgery was observed.The average operative time was (39 ± 14) minutes (range 15-90 minutes).No patients required analgesia postoperatively.The postoperative average VAS score was 2.4 ± 1.1 (range 1.2-6.4).The average hospital stay was (1.7 ± 1.5) days (range 1-9 days),and the patients returned to unrestricted activities in 2 weeks was 99.6% (212 cases).No recurrence was observed during the follow-up.The accumulative postoperative complications rates was 11.1% (25 cases),with 1 severe complication (surgical intervention was needed) as intraabdominal infection (0.4%),as well as other 24 complications including 15 cases of seroma (6.7%),5 cases of urinary retention (2.2%),3 cases with transient paresthesia (1.3%) and 1 case with paralytic ileus (0.4%).Conclusions TAPP and TEP are both feasible and efficacious techniques to treat recurrent hernias after suture repair and Lichtenstein repair,while the choice depends on surgeons' experience.Most recurrent hernias after Patch and Plug repair could be treated successfully by TAPP but TEP technique is not encouraged.For recurrences after preperitoneal repair,the TAPP repair should be recommended as first choice,while IPOM is a good technique to cope with the cases which TAPP failed.

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