疝钩针的改进及其在小儿单孔腹腔镜经皮腹膜外疝内环结扎术中的应用

发布时间：2018-09-12 07:48

【摘要】：目的：腹股沟斜疝（indirect inguinal hernia）是小儿外科最常见的疾病，鞘状突未闭是其发病主要原因。经典手术方法是经腹股沟解剖进行疝囊高位结扎术，会造成多层组织被切开、剥离疝囊，而对侧可能存在的隐性疝却无法探查，多数情况下只有待另一侧出现症状后才能发现。随着微创外科技术的快速发展，腹腔镜手术治疗小儿腹股沟斜疝也成为当前的研究热点之一。然而，由于传统腹腔镜的三孔内环缝扎技术复杂而且无论从美观还是手术效果较传统单纯疝囊高位结扎术并无明显优势。随着研究的深入，目前趋向于采用各种缝针或注射针辅助在腹膜外进行内环关闭，此举不但简化了操作，而且降低了术后复发的风险。本研究在使用硬膜外穿刺针进行疝内环结扎术的基础上，通过自制单钩疝针并进一步完善为双钩疝针在单孔腹腔镜监视下完成经皮腹膜外疝内环结扎术，评价疝钩针在小儿单孔腹腔镜经皮腹膜外内环结扎术的可行性及安全性，讨论其手术相关并发症及其相应处理措施，为避免术中意外、减少术后并发症提供对策及可行性建议。方法：经医院伦理委员会批准，参照文献自制疝钩针并在手术过程中发现弊端不断改进。首先采用硬膜外穿刺针，将针头勺状部分的外套和针芯制成钩针形状，再将前1/3段弯成弧形，便于沿内环腹膜外潜行；因钩槽在外壳退针过程中会钩挂组织，进而自制了单钩疝针，仅在针芯前端内弧侧打磨一个沟槽便于钩挂结扎线，后端鞘内装有弹簧，方便推出针芯前端钩挂结扎线后自动退回嵌入挂牢；因送线退针和再穿刺钩线两次操作可能结扎腹壁组织，将单钩疝针进一步改进为双钩疝针并将针芯前端内弧侧的一个沟槽改进在针芯外弧侧的两个凹槽，，前方浅凹槽开口向前用于钩挂折叠线送入腹腔便于拨线留置腹内，后方深沟槽开口向后便于钩挂腹内预留折叠线，从而完善为一次穿刺腹壁即可完成疝内环腹膜外结扎术。回顾2007～2012年在我科接受腹腔镜辅助腹股沟斜疝手术的466例男性患儿临床资料，术前诊断单侧疝412例和双侧疝54例，包括硬膜外针法97例、单钩疝针法103例和双钩疝针法266例三组，均在单孔腹腔镜监视下经皮腹膜外实施内环结扎术。手术仅在脐部放置一个5mm套管，腹腔镜探查后进行手术：①硬膜外针法先用无沟槽的硬膜外针经皮穿过肌层沿内环内侧腹膜外潜行剥离输精管越过后穿透腹膜入腹，经针芯送入结扎线退针，再用另一带钩硬膜外针沿内环外侧腹膜外潜行越过精索血管从同一腹膜穿孔处进入腹腔，调整钩针角度，用勺状针面侧方的沟槽挂住预置结扎线退针、一并将腹内预置结扎线端带出体外，收紧荷包缝线，体外打结埋置于皮下；②单钩疝针法类似前述操作，只是再次钩线时，推出带钩针芯，用针芯钩槽挂住预置结扎线回缩将其卡压在针芯与外鞘之间，将腹内预置结扎线带出体外，打结埋置于皮下；③双钩疝针法：先将一根2-0丝线对折、中间钩挂在疝针伸出针芯前端的浅凹槽上回缩卡住，钩挂对折双线与疝针在外并行，沿内环口内侧腹膜外分离潜行，穿透后腹膜入腹，用腹腔镜挑拨丝线、推出针芯使钩挂丝线与疝针分离，将折叠线暂留在腹内，将疝针缓慢退至内环前壁腹膜外，随即再将疝针沿内环口外侧腹膜外潜行，剥离精索血管紧贴腹膜越过，从后腹膜预置结扎线穿刺点进入腹腔，推出双钩针芯，用近端深钩槽挂住预置线环回缩卡牢，带出体外结扎，线结埋置于腹壁肌层下、内环口前壁腹膜外间隙。对各组手术时间、术后住院时间、围手术期并发症、复发率以及家长对手术效果的满意度进行回顾性比较。采用SPSS l3．0软件进行统计学分析。计量资料采用单因素方差分析；率的比较采用x2分割法检验，当P0.0167时认为差异有统计学意义。结果：全部患儿均在单孔腹腔镜监视下完成经皮腹膜外内环结扎术。412例术前诊断单侧腹股沟斜疝的患儿腹腔镜探查发现79例对侧隐性疝同时得以治疗。以硬膜外针组、单钩疝针组和双钩疝针组排序，单侧手术平均耗时21.2±4.9min、17.9±4.7min和13.3±3.5min，P＜0.01；双侧手术时间分别为35.7±12.9min、27.9±7.9min和17.4±4.7min，P＜0.01；术后住院时间分别为2.9±0.5天、2.8±0.6天、2.1±0.4天，P=0.295；围手术期并发症分别为10.31%、5.83%和0.75%，P＜0.01；硬膜外针组出现术中腹膜外血肿5例、结扎腹壁组织术后疼痛不适3例和皮下线结反应2例；单钩疝针组术中血管损伤血肿1例、术后腹壁疼痛不适4例和皮下线结反应1例；双钩疝针组1例合并血友病出现血肿和1例出现线结反应。术后复发率分别为3.09%、1.94%、0.38%，P=0.246。术后随访家长对手术效果满意率分别为92.78%、94.17%、99.25%。P＜0.01。随访所有患儿均未出现睾丸萎缩。结论： 1腹腔镜技术诊治腹股沟疝有利于术中观察对侧隐性疝，并可以一次手术完成治疗。 2硬膜外针虽可在单孔腹腔镜监视下完成经皮腹膜外内环结扎术，具有无可见瘢痕、恢复快、美容效果好的优点；但因钩槽在外壳，钩线退针时会钩挂精索血管或其它组织血管发生血肿影响操作、费时费力，且送线和钩线两次穿刺会结扎腹壁组织，线结埋于皮下引起异物反应甚至感染。 3单钩疝针虽消除钩挂组织使操作更顺畅，但仍需要送线和钩线两次穿刺会结扎腹壁组织，引起腹壁不适。 4双钩疝针经皮腹膜外结扎术，经腹壁穿刺导入和牵出结扎线可保持在同一路径，不会结扎腹壁皮下组织，能够确保腹膜外间隙无张力紧密结扎疝缺损。明显缩短手术时间，省时省力。
[Abstract]:Objective: Indirect inguinal hernia is the most common disease in pediatric surgery, and patent sheath process is the main cause of the disease. With the rapid development of minimally invasive surgical techniques, laparoscopic surgery for indirect inguinal hernia in children has become one of the current research hotspots. With the development of research, there is a tendency to use various suture needles or injection needles to assist in the closure of the inner ring outside the peritoneum, which not only simplifies the operation, but also reduces the risk of recurrence. To evaluate the feasibility and safety of double-hook hernia needle in pediatric single-hole laparoscopic ligation of extraperitoneal hernia ring, discuss the complications related to the operation and the corresponding treatment measures, in order to avoid intraoperative accidents and reduce postoperative complications. Feasible suggestions.
Methods: With the approval of the hospital ethics committee, the hernia hook needle was made by ourselves according to the literature and the malpractice was found to be improved during the operation. A single hook hernia needle was made by ourselves, and only a groove was grinded on the inner arc side of the front end of the needle core to facilitate the hooking and ligation of the wire. The spring was installed in the back sheath to facilitate the pushing out of the front end of the needle core to hook and ligate the wire and automatically return to the insertion and fastening. A groove on the inner arc side of the front end of the needle core is improved into two grooves on the outer arc side of the needle core. The shallow groove openings in the front are used to hook the folding line forward and send the folding line into the abdominal cavity for the convenience of dialing the line to stay in the abdomen. The clinical data of 466 male patients who underwent laparoscopic-assisted indirect inguinal hernia surgery in our department from 2007 to 2012 were reviewed. 412 cases of unilateral hernia and 54 cases of bilateral hernia were diagnosed preoperatively, including 97 cases of epidural hernia, 103 cases of single hook hernia needle and 266 cases of double hook hernia needle. Only a 5 mm cannula was placed in the umbilicus. After laparoscopic exploration, the operation was performed: (1) Extra-dural needle without groove was used to peel the vas deferens through the muscular layer through the medial peritoneum of the inner ring, then through the peritoneum to the abdomen, through the needle core into the ligation line, and then through another hooked epidural needle. The outer peritoneum slips through the spermatic cord blood vessel and enters the abdominal cavity from the same peritoneal perforation, adjusts the angle of the hook needle, hangs the preset ligation thread with the groove on the side of the spoon-shaped needle surface to withdraw the needle, and takes the end of the intra-abdominal preset ligation thread out of the body, tightens the purse suture, and places the external ligation under the skin; 2. When the second hook thread is put out, the hook core is pushed out, and the pre-set ligation thread is held back and pressed between the core and the outer sheath by the hook groove, and the pre-set ligation thread is taken out of the abdomen and buried under the skin by the knot; 3. Double hook hernia needle method: First fold a 2-0 wire thread, and the middle hook is hung on the shallow groove at the front end of the hernia needle core and retracted and clamped. Fold two lines and hernia needle outside parallel, along the inner ring peritoneum outside the separation of stealth, penetration of the peritoneum into the abdomen, with laparoscopic pick-up thread, push out the needle core hook thread and hernia needle separation, the folding line temporarily left in the abdomen, the hernia needle slowly retreated to the front wall of the inner ring outside the peritoneum, then the hernia needle along the outer peritoneum of the inner ring peritoneum stealth, stripping spermatic cord blood The catheter crossed the peritoneum and entered the abdominal cavity from the puncture point of the posterior peritoneal pre-ligation line. The double-hook needle core was pushed out. The pre-wired ring was retracted and fastened by the proximal deep-hook groove. The catheter was ligated out of the body. The catheter was placed under the muscular layer of the abdominal wall. The anterior wall of the inner ring was placed in the extraperitoneal space. Parents'satisfaction with the results of surgery was compared retrospectively. SPSS l3.0 software was used for statistical analysis. Measurement data were analyzed by one-way ANOVA. Rate comparison was tested by x2 partition method. When P 0.0167, the difference was statistically significant.
Results: All the cases were performed with single-hole laparoscopic surveillance. Laparoscopic exploration of 412 cases of unilateral indirect inguinal hernia revealed that 79 cases of contralateral recessive hernia were treated at the same time. 7 min and 13.3 (+ 3.5 min, P < 0.01); bilateral operation time were 35.7 (+ 12.9 min), 27.9 (+ 7.9 min) and 17.4 (+ 4.7 min) respectively, P < 0.01; postoperative hospitalization time were 2.9 (+ 0.5 days), 2.8 (+ 0.6 days), 2.1 (+ 0.4 days), P = 0.295; perioperative complications were 10.31%, 5.83% and 0.75% respectively, P There were 3 cases of pain and discomfort after ligation of abdominal wall tissue and 2 cases of subcutaneous nodal reaction; 1 case of vascular injury hematoma, 4 cases of abdominal pain and discomfort and 1 case of subcutaneous nodal reaction in the single hook hernia needle group; 1 case of hematoma and 1 case of linear nodal reaction in the double hook hernia needle group. The satisfaction rate of the parents to the operation was 92.78%, 94.17% and 99.25% respectively, P < 0.01. No testicular atrophy was found in all the children.
Conclusion:
Laparoscopic diagnosis and treatment of inguinal hernia is helpful to observe the contralateral recessive hernia during the operation and can be completed by one operation.
Although the epidural needle can be performed under the single-hole laparoscopic surveillance with no visible scar, quick recovery and good cosmetic effect, it is time-consuming and laborious to operate because the hook groove is in the outer shell and the blood vessels of the spermatic cord or other tissues will be hooked and hematoma will occur when the hook thread is withdrawn. The abdominal wall tissue is buried under the skin, causing foreign body reaction and even infection.
Although the single hook hernia needle can remove the hook tissue to make the operation more smoothly, it is still necessary to send and hook the abdominal wall tissue to ligate twice, causing abdominal wall discomfort.
4. Percutaneous extraperitoneal ligation with double hook hernia needle can keep abdominal puncture lead-in and pull-out ligation line in the same path without ligating the subcutaneous tissue of abdominal wall. It can ensure the tension-free tight ligation of hernia defect in the extraperitoneal space.
【学位授予单位】：河北医科大学
【学位级别】：硕士
【学位授予年份】：2013
【分类号】：R726.5

【参考文献】