摘要目的 探讨腹腔镜辅助下切取带血管蒂的腹膜瓣和腹壁下动脉穿支皮瓣构建嵌合瓣游离移植修复四肢大创面的可行性及临床应用价值. 方法 2012年9月至2014年9月我院对18例四肢皮肤软组织缺损伴肌腱、骨骼、血管和神经损伤外露的患者,急诊行清创加骨折复位内固定加肌腱、神经和血管修复加VSD,待创面清洁后,二期在腹腔镜辅助下切取带血管蒂的腹膜瓣和腹壁下动脉穿支皮瓣构建嵌合瓣,游离移植修复四肢创面. 结果 本组18例患者经VSD治疗后四肢遗留创面大小为12cm×8 cm～ 30cm×17cm,创面均伴有肌腱和骨外露.二期在腹腔镜辅助下切取以腹壁下血管束为蒂的腹膜瓣,大小为8 cm×6 cm～14cm× 10cm;同时切取腹壁下动脉穿支皮瓣,大小为13cm× 10cm～32cm× 18cm,形成以腹壁下动脉主干为血管蒂的嵌合瓣,游离移植修复四肢创面.术后14d患者腹壁伤口愈合良好,移植嵌合瓣基本存活.仅2例病人术后出现嵌合瓣表层组织坏死,通过植皮和换药受区创面获得愈合.术后随访6～ 18个月,患肢移植嵌合瓣色泽、质地良好,肢体屈伸功能部分恢复.18例患者供瓣区均无腹痛、腹胀、腹壁疝、腹膨隆和粘连性肠梗阻等并发症. 结论 在腹腔镜辅助下切取以腹壁下血管束为蒂的腹膜瓣和腹壁下动脉穿支皮瓣构建嵌合瓣游离移植修复四肢创面是确实可行的,可一次性修复大面积组织缺损,嵌合瓣供区仅留线状瘢痕,但其适应证及长期疗效仍需进一步临床探索与验证.

abstractsObjective To investigate the reliability and effect of using the chimeric flap retrieved by laparoscopic surgery to cover the large defect of the extremities.Methods The debridement and vacuum sealing drainage (VSD) were performed on 18 patients, who were admitted due to the defects of the extremities.The free chimeric peritoneal-deep inferior epigastric artery perforator (DIEP) flap assisted by laparoscopic surgery was transplanted to cover the defect with exposed tendons and/or skeleton.Results The remaining defects of the extremities were 12 cm × 8 cm-30 cm × 17 cm.The peritoneal component of the chimeric flaps measuring 8 cm × 6 cm -14 cm × 10 cm retrieved by laparoscopic surgery was used to cover the tendons, bones and joints.The deep inferior epigastric artery perforator (DIEP) flaps measuring 13 cm × 10 cm-32 cm × 18 cm allowed the cutaneous coverage of wounds.The chimeric flaps survived completely excepting two patients.The two patients experienced partial necrosis of the chimeric flaps and received skin grafting to achieve the wound closure.The function of the injured extremities recovered partially after 6-18 months of follow-up.No abdominal pain, distension, herniation,bulging and intestinal obstruction were recorded.Conclusion The chimeric flap assisted by laparoscopy is a helpful, safe and effective method for reconstruction of large wounds in extremities with exposed tendons and bones.