腹外疝的微创治疗

1、腹外疝的微创治疗腹腔镜腹股沟疝修补术(LIHR)2腹股沟 疝的修补层次 腹横筋膜前：腹外斜肌腱膜和腹横筋膜之间 “腹股沟盒间隙Inguinal box，第一间隙 肌前修补 Premuscular repair 1腹横筋膜后：腹横筋膜和腹膜之间 腹膜前间隙Preperitoneal space，第二间隙 腹膜前修补Preperitoneal repair21 Lichtenstein I. L., Shulman A. G., Amid P. K., et al. The tension-free hernioplasty. Am J Surg, 1989, 157: 188-193. 2 St

2、oppa R., Petit J., Henry X. Unsutured Dacron prosthesis in groin hernias Int Surg, 1975, 60: 411-412. 3?成人腹股沟疝诊疗指南?中华医学会 2021版 3 加强腹股沟管后壁：平片修补术，网栓平片术 加强肌耻骨孔：腹膜前修补术?成人腹股沟疝治疗指南?欧洲疝学会2021版 4- 推荐首选术式：平片修补术，TEP3 中华医学会外科分会疝和腹壁外科学组. 成人腹股沟疝诊疗指南. 中国实用外科杂志, 2021, 32(10):833-8354 Simons MP, Aufenacker T, Bay-N

3、ielsen M, et al. European Hernias Society guidelines on the treatment of inguinal hernia in adult patients. Hernia. 2021, 13(4): 343-403腹股沟疝的修补原理 腹横筋膜前LichtensteinGilbertKugelStoppaLIHRMK后壁+ 疝环内脏囊腹膜前+ 肌前+ 肌前+连接体腹腔镜腹横筋膜后Plug Patch3中华医学会外科分会疝和腹壁外科学组. 成人腹股沟疝诊疗指南. 中国实用外科杂志, 2021, 32(10):833-835腹股沟管后壁肌 耻

4、骨孔5病因、解剖、力学、层次、空间原理腹横筋膜前、后修补术的区别腹横筋膜前（肌前修补）腹横筋膜后（腹膜前修补）病因加强腹股沟管后壁重建“腹横筋膜”解剖没有覆盖“肌耻骨孔”覆盖“肌耻骨孔” 5力学疝缺损的前方疝缺损的后方层次浅深空间小大5 Fruchaud H. Surgical treatment of inguinal hernias in adults. Bull Med. 1957, 71(10):293 passim.6什么是肌耻骨孔？(Myopectineal Orifice )由Fruchaud提出5： 内界：腹直肌的外缘 外界：髂腰肌 上界：腹横筋膜和腹内斜肌 下界：骨盆的骨性边

5、缘。5 Fruchaud H. Surgical treatment of inguinal hernias in adults. Bull Med. 1957, 71(10):293 passim.788腹横筋膜后修补术的入路开放入路前入路：MK, PHS 6 , UHS，Kugel后入路：Stoppa，Kugel，开放式TEP腹腔镜入路TAPP 7 ,TEP 8后入路：6 Combined Anterior and Posterior Inguinal Hernia Repair: Intermediate recurrence rates with three groups of sur

6、geons Gilbert, AI et al. Hernia, 2004:8: 203-2077 Dion YM, Morin J. Laparoscopic inguinal herniorrhaphy. Can J Surg, 1992, 35(2):209-212.8 McKernan JB, Laws HL. Laparoscopic repair of inguinal hernias using a totally extraperitoneal prosthetic approach. Surg Endosc, 1993, 7(1):26-28.9经腹腔修补术 (TAPP) 7

7、全腹膜外修补术 (TEP) 87: Dion YM, Morin J. Laparoscopic inguinal herniorrhaphy. Can J Surg, 1992; 35:209-212.8: McKernan JB, Laws HL. Laparoscopic preperitoneal prosthetic repair of inguinal hernias. Surg Rounds, 1992; 6:597-607.LIHR腹腔镜入路 10TAPPTEP入径腹腔内腹膜前间隙学习曲线短长观察疝内容物容易不易观察“隐匿疝”容易不易打开/关闭腹膜需要不需要TAPP和TEP的区

8、别 11TAPP 一、手术室布局125二、套管的位置TAPP 13三、术中探查TAPP 脐韧带(Umbilical folds) 脐中韧带Fold umbilical median：正中线，膀胱底部 到脐之间形成的皱襞，是脐尿管闭塞后的残留痕迹。 脐内侧韧带Fold umbilical medial：脐动脉外表的腹 膜皱折，位于脐正中韧带的两侧。 脐外侧韧带Fold umbilical lateral：腹壁下动脉表 面的腹膜皱折，位于脐内侧韧带的外侧。19 膀胱上窝：位于两条脐内侧韧带之间，是膀胱的位置，前方 有腹直肌保护。不能翻开此处的腹膜。 内侧陷窝：位于脐内侧韧带与脐外侧韧带之间，是腹股

9、沟 直疝突出的部位。 外侧陷窝：位于脐外侧韧带的外侧，是腹股沟斜疝突出的 部位。TAPP 陷窝(Fosse)20四、腹膜的切开脐内侧韧带 - 髂前上棘TAPP 21五、腹膜前间隙的解剖TAPP Retzius间隙：耻骨膀胱间隙。上至脐平面，下至盆底肌， 外至腹壁下动脉。为疏松的脂肪结缔组织、无血管区域。 Bogros间隙：腹壁下动脉外侧的间隙。腹横筋膜与腹膜之间的间隙，分为：22TAPP Retzius间隙和Brogos间隙髂耻束 Ilopubic tract 腹横筋膜增厚的局部 起于髂前上棘，止于耻骨上支 全程伴行于腹股沟韧带的深面 是直疝和股疝的分界限TAPP 24髂耻束 Ilopubic

10、 tractTAPP TAPP 危险三角区Triangle of Doom 1991年由Spaw提出， 又称Doom三角 输精管和精索血管之间 髂外动静、脉通过26TAPP 死亡冠Corona Mortis (Circle of death) 22 为异常的闭孔动脉 跨过耻骨梳韧带 与腹壁下动脉和闭孔动 脉相连22 Pungpapong SU, Yhum-umnauysuk of corona mortis; preperitoneal anatomy for laparoscopic hernia repair. J Med Assoc Thai. 2005, 88(4):51-53.27T

11、APP 死亡冠Corona Mortis (Circle of death)TAPP 疼痛三角Triangle of pain 位于精索血管的外侧、髂耻束的下方 有腰丛神经的分支生殖股神经的生殖支和股支、股神 经、股外侧皮神经穿过 比较容易损伤的是股外侧皮神经和生殖股神经的股支 不能在该区域内钉合补片。29TAPP 30TAPP 腹膜前环(preperitoneal loop) 2323 Mainik F, Quast G, Flade-Kuthe R, et al. The preperitoneal loop in inguinal hernia repair following the

12、totally extraperitoneal technique. Hernia. 2021;14(4):361-7.六、疝囊的处理TAPP 直疝疝囊- “假性疝囊 不能横断 暴露耻骨梳韧带24 Stoppa R, Warlaumont C, Chantriaux JF. Prosthetic surgical treatment of inguinal hernias. Parietalization of the spermatic cord. Presse Med. 1984, 27;13(38):2317-8 斜疝疝囊TAPP 精索成份“腹壁化Parietalization13 33

13、斜疝疝囊横断TAPP 34斜疝疝囊TAPP 股疝疝囊TAPP 内侧：覆盖耻骨结节和腹直肌并超过中线25外侧：髂前上棘上缘：覆盖联合肌腱至少3cm下缘外侧：精索“腹壁化26下缘内侧：插入耻骨膀胱间隙Retzius27补片必须覆盖整个肌耻骨孔，并有一定的重叠!25 Chowbey PK, Bandyopadhyay SK, Sharma A, et al. Recurrent hernia following endoscopic total extraperitoneal repair. J Laparoendosc Adv Surg Tech A, 2003, 13(1):21-5 26 St

14、oppa R, Warlaumont C, Chantriaux JF. Prosthetic surgical treatment of inguinal hernias. Parietalization of the spermatic cord. Presse Med. 1984, 27;13(38):2317-827 Mirilas P, Colborn GL, McClusky DA, et al. The history of anatomy and surgery of the preperitoneal space. Arch Surg. 2005, 140(1):90-4.

15、七、补片的覆盖TAPP 37七、补片的覆盖TAPP 七、补片的覆盖TAPP 七、补片的覆盖TAPP 女性患者只有4个构造可以用来固定补片 陷窝韧带, 腹直肌外缘, 联合肌腱, 耻骨梳韧带补片是否需要固定？ 斜疝：小于4cm的疝缺损可以不固定补片 28 直疝：建议补片与陷窝韧带和腹直肌固定28 Moreno-Egea A. Randomized clinical trial of fixation vs nonfixation of mesh in total extraperitoneal inguinal hernioplasty. Arch Surg, 2004; 139(12): 137

16、6-137929 Descottes B, Bagot dArc M. Fibrin sealant in inguinal hernioplasty: an observational multicentre study in 1201 patients. Hernia. 2021 Jul 10. 固定的方法 疝固定器，缝合，纤维蛋白胶水29八、补片的固定TAPP 41八、补片的固定TAPP 九、腹膜的关闭TAPP 43TAPP 十、术后探查第一套管的位置 30 不能直接建立在脐孔上 不能翻开腹直肌后鞘一、套管的位置30 李健文. 腹腔镜腹股沟疝修补术的应用. 腹腔镜外科杂志. 2021,

17、07: 481-484 TEP 45第二、第三套管的置入TEP 第二、第三套管的置入TEP 第二、第三套管的置入TEP 腹横筋膜分前、后两层 31： 前层浅层：紧贴腹直肌和联合 肌腱深面，是真正意义上的腹横筋膜 后层深层：不规那么增厚的纤 维组织，又称为腹膜前筋膜，术中 要进展一定的别离 31 Memon MA, Quinn TH, Cahill DR. Transversalis fascia: historical aspects and its place in contemporary inguinal herniorrhaphy. J Laparoendosc Adv Surg Te

18、ch A. 1999, 9(3):267-72. 层次在腹横筋膜浅层和腹膜之间，而不是在腹横筋膜深、浅层之间！二、腹膜前间隙的建立TEP 49腹横筋膜TEP 球囊别离法 32 耻骨上穿刺法 33 手指别离法 34 镜推法 32 McKernan JB, Laws HL. Laparoscopic repair of inguinal hernias using a totally extraperitoneal prosthetic approach. Surg Endosc, 1993, 7(1):26-28 33 Tetik C, Arregui ME, Dulucq JL et al.

19、Complications and recurrences associated with laparoscopic repair of groin hernias. A muti-institutional analysis. Surg Endosc, 1994, 8(11): 1316-1322.34 Bringman Sven, Ek Asa, Haglind Eva, et al. Is a dessection Ballon beneficial in bilateral totally extraperitoneal endoscopic hernioplasty? A rando

20、mized prospective multicenter study. Surg Laparo Endosc, 2001, 11(5): 22-326.二、腹膜前间隙的建立TEP 51球囊别离器3232 McKernan JB, Laws HL. Laparoscopic repair of inguinal hernias using a totally extraperitoneal prosthetic approach. Surg Endosc, 1993, 7(1): 26-28TEP 52耻骨上穿刺法 3333 Tetik C, Arregui ME, Dulucq JL et

21、al. Complications and recurrences associated with laparoscopic repair of groin hernias. A muti-institutional analysis. Surg Endosc, 1994, 8(11): 1316-1322.TEP 53手指别离法 3434 Bringman Sven, Ek Asa, Haglind Eva, et al. Is a dessection Ballon beneficial in bilateral totally extraperitoneal endoscopic her

22、nioplasty? A randomized prospective multicenter study. Surg Laparo Endosc, 2001, 11(5): 22-326.TEP 54镜推法3535 李健文. 腔镜疝修补术中应注意的问题. 中华疝和腹壁外科杂志, 2021, 3(3): 249-253TEP 55三、疝囊的处理直疝疝囊TEP 56三、疝囊的处理斜疝疝囊TEP TEP 斜疝疝囊结扎或横断TEP 三、疝囊的处理股疝疝囊TEP 四、补片的覆盖TEP 四、补片的覆盖TEP 四、补片的覆盖TEP TEP 五、术后探察64术中并发症 - 血管损伤(Vascular inj

23、ury)- 输精管损伤(Vas deferens injury)- 神经损伤(Nerve injury)- 内脏损伤(Visceral injury)- 膀胱损伤(Bladder injury)LIHR 65一、血管损伤- 腹壁下动脉损伤- 闭孔动脉损伤(死亡冠)- 髂外动静脉损伤(危险三角)- 精索血管损伤- 输精管滋养血管损伤- 耻骨后静脉丛损伤1. 腹壁下动脉损伤2. “死亡冠损伤 11 Pungpapong SU, Thum-umnauysuk S. Incidence of corona mortis; preperitoneal anatomy for laparoscopic h

24、ernia repair. J Med Assoc Thai. 2005, 88(4):51-53.3. 髂外血管损伤 2 2 Spaw AT, Ennis BW, Spaw LP. Laparoscopic hernia repair: the anatomic basis. J Laparoendosc Surg. 1991, 1(5):269-2774. 精索血管损伤 3 3 OMalley KJ, Monkhouse WS, Qureshi MA, et al. Anatomy of the peritoneal aspect of the deep inguinal ring: im

25、plications for laparoscopic inguinal herniorrhaphy. Clin Anat. 1997, 10(5):313-3174. 输精管滋养血管损伤5. 耻骨后静脉丛损伤二、输精管损伤二、输精管损伤二、输精管损伤AB三、神经损伤4 Ramshaw B, Shuler FW, Jones HB, et al. Laparoscopic inguinal hernia repair: lessons learned after 1224 consecutive cases. Surg Endsoc. 2001, 15(1):50-4. 四、肠管损伤 4五、膀

26、胱损伤 - 阴囊气肿(Emphysema)-血清肿(Seroma)- 暂时性神经感觉异常(Transient neuropraxia)- 尿稽留(Urinary retention)- 肠梗阻(Intraabdominal adhesion)- 感染(Infection)- 慢性疼痛(Chronic pain)术后并发症 79Incidence: 41.8%5 TEP TAPPAbsorbed 6-8 H5 李健文 郑民华 臧潞等. 腹腔镜腹股沟疝修补术复发与并发症分析. 理论与实践. 2002.一、阴囊气肿 80Incidence 5% in litterature 65.24% in ou

27、r studyNo require drainageConfused sometimes with recurrent hernia 6 Ljzermand J. Recurrent inguinal hernia treated by classical hernioplasty. Arch Surg, 1991, 126: 1097-2000二、血清肿 8182837 V. M. Reddy, C. D Sutton, G Garcea, et al. Laparoscopic repair of direct inguinal hernia: a new technique that r

28、educes the development of postoperative seroma. Hernia, 2007,11(5): 393-396.83Transient neuralgia - 1993年Eubanks报道 8 - More frequent than open surgery 9 - Disappeared 2 W2M postoperativelyPermanent neuropraxia - 3m - Lateral femoral cutaneous nerve - Genito-femoral nerve - Chronic pain8 Condon RE, Nyhus LM. Complications of groin hernia. In: Hernia, 4th ed. Philadelphia: JB Lippincott Co 1995: 269-282.9 Ljzermand J. Recurrent inguinal hernia treated by classical hernioplasty. Arch Surg, 1991, 126: 1097-2000三、神经痛 84四、尿潴留 - 耻骨膀胱间隙的别离或补片的刺激可能诱发尿潴留没有文献支持-