腹腔镜下全腹膜外腹股沟疝修补术的应用解剖学研究

发布时间：2018-09-18 07:47

【摘要】： 研究背景腹股沟疝是人类特有的疾病,这和人类进化过程中由四肢爬行到直立行走,腹股沟区所承受的压力改变有关。腹股沟疝也是临床上的常见病和多发病,随着人们生活水平提高和寿命的延长,其发病率也有增长的趋势,最保守的估计,我国腹股沟疝发病每年超过200万人,因此疝的治疗不仅是繁重的医疗任务,而且是一巨大的社会问题。人类对疝的认识最早可以追溯至遥远的上古时代,公元前1500年,在古埃及制成的纸上就有腹股沟疝的记载。疝的发展凝结了整个外科发展各个时期重要事件的精义,诸如外科解剖、无菌术、麻醉止痛、止血、生物材料和微创技术等。成人腹股沟疝不可自愈,手术是惟一有效的治疗方法。虽然现代的腹股沟疝修补术经历了一百多年的历史及改进,但仍然没有一种术式达到完美的效果,均存在一定的并发症及复发率。现代疝外科的先驱者Astely、Paston、Cooper曾叙述道:“在属于外科医师职责范畴的人类机体的疾病中,在治疗上没有其他疾病比不同种类的疝更需要综合准确的解剖知识和外科技巧。”对解剖学的熟悉程度决定了一个外科医生的工作能力和水平,只有很好的掌握解剖才能使外科医生在手术过程中得心应手,避免不必要的损伤,减少并发症,使手术获得最好的效果。特别是腹腔镜下腹股沟疝修补术的出现及发展,改变了常规的手术入路及操作方法,出现了新的解剖视野。国内外许多解剖学专家及外科学专家均进行了相关的研究,取得很大的成绩,但发表的论文中缺乏腹腔镜视野下腹股沟疝修补术解剖学的精细测量。因此,对腹股沟区的解剖学特点有必要更进一步深入研究。本研究旨在通过对腹股沟区的深入解剖研究,重新认识腹股沟区腹膜前解剖学的特点,对临床中腹腔镜下全腹膜外腹股沟疝修补术(TEP)操作给予基础性的指导,并结合临床中具体手术病例探讨TEP术的技术要点。目的观察和确认腹股沟区腹膜前应用解剖学特点,进一步探讨TEP术的技术要点,为临床手术提供更精细的解剖学依据。总结我中心TEP成功手术经验技巧,为该手术的推广普及提供借鉴。方法在1具新鲜女尸标本和7具(14侧)教学用男性成人尸体标本上进行TEP术的应用解剖学研究。对腹股沟区腹膜前间隙内的主要韧带、血管、神经等组织解剖分离,并进行相关的观察、拍照及测量工作;对行TEP的手术入路、手术空间的分离、固定补片等技术操作的解剖学特点进行观察、拍照及测量。使用SPSS 13.0软件分析数据。回顾分析我中心2005年7月至2008年11月行TEP术的31例病人,男29人,女2人,均为单侧疝,包括直疝10例,斜疝21例,其中复发疝2例。进行术中的解剖学观察,回顾分析手术录像,详细阐述分析TEP手术方法、步骤、难点技巧。结果腹股沟区腹横筋膜分为两层,两层之间是疏松结缔组织,外层与腹横筋膜相融合,内层与腹膜难以分开;半环线距脐中心距离为60.01±4.77(mm),经腹直肌后鞘前入路,过半环线后即可进入腹膜前间隙;从耻骨结节外侧缘沿髂耻束向外分离约55.61±3.86(mm)可遇腹壁下血管;在耻骨梳韧带上钉合补片有损伤死亡冠的可能,死亡冠存在率为87.5%;在耻骨结节、腹直肌、髂腰肌三处钉合固定补片较合适,不会损伤重要血管及神经。我中心腹腔镜下全腹膜外腹股沟疝修补术手术时间90.2±9.5分钟,术后并发症发生率9.5%,复发1例,术后平均住院时间2.9±0.9天。结论 TEP手术的操作空间是两层腹横筋膜之间,在肌耻骨孔后方用足够大的补片覆盖修补符合压力学原理,理论上复发率较其他术式最低;TEP具有合理性和微创性,掌握TEP的一些手术要领和技巧,可以缩短学习曲线,手术并不困难,应成为腹腔镜治疗腹股沟疝的主要术式。
[Abstract]:Research background
Inguinal hernia is a unique human disease, which is related to the change of pressure on the inguinal region during the process of human evolution from crawling on limbs to walking upright. Inguinal hernia is also a common and frequently-occurring disease in clinic. With the improvement of people's living standards and the extension of life span, the incidence of inguinal hernia also has an increasing trend, the most conservative estimate, China. Inguinal hernia occurs more than 2 million people a year, so the treatment of hernia is not only a heavy medical task, but also a huge social problem. The earliest knowledge of hernia can be traced back to ancient times. In 1500 B.C., there are records of inguinal hernia on paper made in ancient Egypt. The development of hernia has coagulated the development of the whole surgery. The essence of important events at various times, such as surgical anatomy, asepsis, anesthesia, analgesia, hemostasis, biomaterials, and minimally invasive techniques. Adult inguinal hernia is not self-healing, and surgery is the only effective treatment. Although modern inguinal herniorrhaphy has undergone more than 100 years of history and improvement, there is still no perfect operation. The pioneers of modern hernia surgery, Astely, Paston, and Cooper, have described that "no other disease in the human body that falls within the scope of the surgeon's responsibility requires more comprehensive and accurate anatomical knowledge and surgical skills than the different types of hernia." The degree of understanding determines the ability and level of a surgeon. Only a good grasp of anatomy can make the surgeon handy during the operation, avoid unnecessary injuries, reduce complications, and achieve the best results. Especially the emergence and development of laparoscopic inguinal hernia repair have changed the conventional operation. Many anatomists and surgeons at home and abroad have made great achievements in this field. However, there is no precise measurement of the anatomy of inguinal hernia repair under laparoscopic vision in the published papers. The purpose of this study is to re-understand the characteristics of preperitoneal anatomy of the inguinal region through in-depth anatomical study of the inguinal region, to provide basic guidance for the clinical laparoscopic total extraperitoneal inguinal hernia repair (TEP) operation, and to explore the technical key points of TEP combined with specific clinical cases.
objective
To observe and confirm the characteristics of preperitoneal applied anatomy in the inguinal region, to further explore the technical points of TEP, and to provide more detailed anatomical basis for clinical operation.
Method
Applied anatomy of TEP was studied on one fresh female cadaver and seven (14 sides) male adult cadavers for teaching.The main ligaments, blood vessels and nerves in the anterior peritoneal space of the inguinal region were dissected and separated. From July 2005 to November 2008, 31 patients (29 males and 2 females) who underwent TEP were retrospectively analyzed. All of them were unilateral hernia, including 10 cases of direct hernia, 21 cases of indirect hernia, and 2 cases of recurrent hernia. Video recording, detailed analysis of TEP surgical procedures, steps, difficulties and skills.
Result
The transverse fascia of the inguinal region is divided into two layers, between which is loose connective tissue. The outer layer fuses with the transverse fascia, and the inner layer is difficult to separate from the peritoneum. 5.61 [3.86 mm] may encounter the Subperitoneal vessels; the possibility of injury of the dead corona may be found in the pubic comb ligament (87.5%); and it is more suitable to screw the fixed patch in the pubic tubercle, rectus abdominis and iliopsoas muscle three places without damaging the important vessels and nerves. In 9.5 minutes, the incidence of postoperative complications was 9.5%, 1 cases recurred, and the average postoperative hospital stay was 2.9 + 0.9 days.
conclusion
The operation space of TEP is between two layers of transverse fascia of abdomen. It is in accordance with the principle of pressure science to cover the pubic foramen with a large enough patch. The recurrence rate of TEP is the lowest in theory. TEP is reasonable and minimally invasive. The main operative method of inguinal hernia treated by mirror.
【学位授予单位】：广州医学院
【学位级别】：硕士
【学位授予年份】：2009
【分类号】：R656.2;R322

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