腹腔镜食管裂孔疝补片修补联合胃底折叠术的手术并发症原因及防治：单中心432例分析

Causes and prevention strategies of surgical complications in laparoscopic hiatal hernia repair with mesh and fundoplication: a single-center analysis of 432 cases

摘要:

背景与目的 腹腔镜下食管裂孔疝修补联合胃底折叠术是治疗中重度食管裂孔疝的主流手术方式，但术中及术后并发症的发生仍不容忽视。本研究通过单中心病例资料的回顾性分析，探讨常见并发症的发生原因及其防治策略，以优化围手术期管理并提升手术安全性。方法 回顾分析2018年1月—2023年12月在中山大学附属第六医院接受腹腔镜食管裂孔疝补片修补联合胃底折叠术的432例患者临床资料。所有手术均由同一团队按食管裂孔疝的腔镜修补规范化操作七步法完成，术后采用加速康复外科流程管理。统计术中及术后并发症发生率，并对影响术后主要并发症的相关危险因素进行单因素分析。结果 432例患者的总并发症发生率为15.3%。术中并发症以出血最常见（6.9%），主要包括隔下血管（3.2%）、胃短血管（1.6%）及实质脏器损伤出血（1.9%）。术后并发症以吞咽困难最常见（12.0%），其他并发症包括气胸（3.2%）、疝复发（1.9%）、补片感染或侵蚀（0.7%）、气顶综合征（6.3%）及胃瘫（0.9%）。多数并发症通过保守治疗、内镜扩张或介入手段缓解，2例吞咽困难患者最终接受二次手术拆除折叠瓣。中位随访时间为34个月，失访率为6.0%，无围手术期死亡病例。单因素分析结果显示，年龄≥50岁以及行Nissen术式的患者术后吞咽困难的发生率明显升高（均P<0.05）。结论 腹腔镜下食管裂孔疝补片修补联合胃底折叠术总体安全性良好，但术中血管损伤与术后吞咽困难仍需重点关注。建议术中注重层次辨识与精准操作，术式选择应结合患者年龄和食管动力状态，适当采用Toupet或Dor部分折叠方式。规范补片放置与固定、加强术后康复管理，可有效降低并发症发生率并提升远期疗效。

Abstract:

Background and Aims Laparoscopic hiatal hernia repair with mesh reinforcement combined with fundoplication has become the standard surgical approach for treating moderate to severe cases. However, intraoperative and postoperative complications remain a significant concern. This study was conducted to explore the causes of common complications and their prevention and management strategies through retrospectively analyzing clinical data from a single center to optimize perioperative care and improve surgical safety.Methods The clinical data of 432 patients who underwent laparoscopic hiatal hernia repair with mesh and fundoplication at the Sixth Affiliated Hospital of Sun Yat-sen University from January 2018 to December 2023 were retrospectively analyzed. All procedures were performed by the same surgical team using the standardized seven-step protocol for laparoscopic repair. Postoperative care followed the enhanced recovery after surgery pathway. The incidences of intraoperative and postoperative complications were recorded, and univariate analysis was used to identify risk factors for major postoperative complications.Results The overall complication rate was 15.3% among 432 patients. The most common intraoperative complication was bleeding (6.9%), primarily from the inferior phrenic vessels (3.2%), short gastric vessels (1.6%), and parenchymal organ injuries (1.9%). The most frequent postoperative complication was dysphagia (12.0%), followed by pneumothorax (3.2%), hernia recurrence (1.9%), mesh infection or erosion (0.7%), gas-bloat syndrome (6.3%), and gastroparesis (0.9%). Most complications were relieved through conservative treatment, endoscopic dilation, or interventional procedures. Two patients with persistent dysphagia underwent reoperation to remove the fundoplication wrap. The median follow-up period was 34 months, with a 6.0% loss to follow-up rate and no perioperative mortality. Univariate analysis showed that patients aged ≥50 years and those who underwent Nissen fundoplication had significantly higher rates of postoperative dysphagia (both P<0.05).Conclusion Laparoscopic hiatal hernia repair with mesh and fundoplication is generally safe and effective. However, intraoperative vascular injuries and postoperative dysphagia require special attention. Accurate dissection and identification of anatomical layers are critical during surgery. Surgical strategy should be tailored based on patient age and esophageal motility, with partial fundoplication (Toupet or Dor) preferred when appropriate. Combined with enhanced postoperative recovery protocols, standardized mesh placement and fixation can reduce complication rates and improve long-term outcomes.