腹腔镜切口疝修补术中腹腔粘连的诊断、分型及分离技巧

Diagnosis, classification and dissection skills of abdominal adhesions in laparoscopic incisional hernia repair

摘要:

背景与目的 切口疝是腹部手术的常见并发症之一，而患者在经历了腹部手术后常有不同程度的腹腔内粘连，分离粘连是切口疝修补过程中不可回避且有相对难度的工作。术前人工渐进性气腹是腹腔镜切口疝修补术中的重要环节，笔者前期发现，通过对比气腹前后的影像学资料，可评估切口疝患者腹腔内状态，有利于手术预判，提高手术精准度，减少手术风险。本文旨在进一步探讨人工气腹结合腹部CT在伴腹腔粘连切口疝患者的腹腔镜修补术中的应用价值，并总结腹腔粘连的类型和分离粘连的手术技巧。方法 回顾性收集分析2019年4月—2020年5月在中山大学附属第六医院胃肠、疝和腹壁外科行腹腔镜切口疝修补术患者的临床资料和手术录像。通过术前人工气腹前、后腹部CT对比，判断是否存在腹腔粘连。研究者通过手术录像复盘，观察腹腔粘连的分型，总结粘连分离的技巧，记录术中粘连分离时间和并发症，统计观察孔穿刺时副损伤情况，术后并发症与恢复情况。结果 共收集72例行腹腔镜切口疝修补术病例，其中15例术前未建立人工气腹，7例建立人工气腹后术前未复查腹部CT，15例气腹前或气腹后未行疝囊三维CT重建，均予以排除。最终纳入35例患者，均为II型腹壁缺损；复发疝5例；男16例，女19例；年龄（63.26±11.11）岁；体质量指数25.04（23.03~27.34）kg/m²；既往手术术后有腹腔内感染伴切口感染者4例，切口感染者7例；最多手术次数5次。通过人工气腹前、后腹部CT对比，诊断存在腹腔内容物与腹壁粘连者33例（94.29%），无粘连者2例（5.71%）。其中主要粘连物为肠管20例（60.61%），主要粘连物为网膜组织13例（39.39%）。根据粘连的形态可分为：点状粘连，线状粘连，片状粘连及混合型粘连。根据粘连的质地可分为：膜性粘连，瘢痕性粘连及复合型粘连。粘连分离采取层面变峰面，面转化线和点，钝锐结合分离膜性粘连，锐性分离瘢痕性粘连的程序化方法。全组均成功松解分离粘连，分离时间32（4.50~46.50）min。其中5例发生小肠壁浆肌层损伤，予3-0可吸收缝线行浆肌层缝合。在行观察孔穿刺时，均未发生腹腔内脏器损伤。术后1例出现肺部感染，术后恢复排气时间3（2~4）d。结论 术前人工气腹结合腹部CT有助于判断是否存在腹腔粘连及粘连部位，有利于观察孔布局的选择。根据其形态和性质采取程序化的方法有利于简化腹腔粘连的分离。

Abstract:

Background and Aims Incisional hernia is one of the common postoperative complications of abdominal surgery. Patients undergoing abdominal surgery will usually develop intra-abdominal adhesions of varying degrees, and adhesion separation is an unavoidable and relatively difficult task during incisional hernia repair. Preoperative progressive pneumoperitoneum (PPP) is an important component of laparoscopic incisional hernia repair, and the authors previously found that comparison of the imaging data before and after PPP can assess the intra-abdominal status of patients with incisional hernia, thereby is helpful for surgical predetermination, improving surgical precision and reducing surgical risk. Therefore, this study was conducted to further evaluate the application value of PPP combined with abdominal wall CT imaging in laparoscopic repair for patients with incisional hernia and concomitant intra-abdominal adhesions, and summarize the types of intra-abdominal adhesions and surgical skills of adhesion separation.Methods The clinical data and surgical videos of patients meeting the inclusion criteria and undergoing laparoscopic incisional hernia repair in the Department of Gastrointestinal, Hernia and Abdominal Wall Surgery of the Sixth Affiliated Hospital of Sun Yat-sen University from April 2019 to May 2020 were retrospectively collected. The presence or absence of intra-abdominal adhesions was determined by comparison of the abdominal CT before and after PPP. Through the operation video review, the classification of intra-abdominal adhesions was observed, the techniques of adhesion separation were summarized, and the time and complications of intraoperative adhesion separation were recorded. The associated injuries during puncture, and postoperative complications and recovery were also documented.Results A total of 72 cases of laparoscopic incisional hernia repair were collected, of whom, 15 cases with no preoperative artificial pneumoperitoneum, 7 cases with no preoperative abdominal CT review after the establishment of artificial pneumoperitoneum, and 15 cases with no three-dimensional CT reconstruction of the hernia sac before or after pneumoperitoneum were excluded. A total of 35 patients were included finally. All of them were type II abdominal wall defect including recurrent hernia in 5 cases. Of the patients, 16 were males and 19 were females, with an age of (63.26±11.11) years; body mass index was 25.04 (23.03-27.34) kg/m²; 4 cases had intra-abdominal infection with incision infection and 7 cases had incision infection after previous operation; the maximum number of operations that a single patient experienced was 5. By comparing the abdominal CT before and after PPP, 33 patients (94.29%) were diagnosed with adhesions between the abdominal contents and the abdominal wall, and 2 patients (5.71%) had no adhesions. Among them, the dominant findings were intestinal adhesions in 20 cases (60.61%), and omental adhesions in 13 cases (39.39%). According to the morphological characteristics, the adhesions were classified as point-like adhesions, linear adhesions, sheet-like adhesions, and mixed adhesions. According to the texture of adhesions, the adhesions were categorized into membranous adhesions, cicatricial adhesions, and complex adhesions. The adhesion separation was performed by a procedural approach of changing the plane to the peak plane, transforming the plane to the line and point, blunt-sharp separation of the membranous adhesions, and sharp separation of the cicatricial adhesions. Adhesion separation was successfully completed in the whole group. The separation time was 32 (4.50-46.50) min. Small intestinal wall seromuscular injury occurred in 5 patients, which was repaired with a 3-0 absorbable suture. No intra-abdominal organ injury occurred during observation port puncture. One patient developed pulmonary infection after operation, and the time to anal gas passage was 3 (2-4) d.Conclusion PPP combined with abdominal CT imaging is helpful for determining the presence or absence of intra-abdominal adhesions as well as the location of the adhesions, and also helpful for the selection of the layout of the observation port. A procedural approach based on the morphology and nature of adhesion is beneficial for simplifying the dissection of intraperitoneal adhesions.