【摘要】：目的：腹股溝斜疝（indirect inguinal hernia）是小兒外科最常見的疾病，鞘狀突未閉是其發(fā)病主要原因。經(jīng)典手術(shù)方法是經(jīng)腹股溝解剖進行疝囊高位結(jié)扎術(shù)，會造成多層組織被切開、剝離疝囊，而對側(cè)可能存在的隱性疝卻無法探查，多數(shù)情況下只有待另一側(cè)出現(xiàn)癥狀后才能發(fā)現(xiàn)。隨著微創(chuàng)外科技術(shù)的快速發(fā)展，腹腔鏡手術(shù)治療小兒腹股溝斜疝也成為當(dāng)前的研究熱點之一。然而，由于傳統(tǒng)腹腔鏡的三孔內(nèi)環(huán)縫扎技術(shù)復(fù)雜而且無論從美觀還是手術(shù)效果較傳統(tǒng)單純疝囊高位結(jié)扎術(shù)并無明顯優(yōu)勢。隨著研究的深入，目前趨向于采用各種縫針或注射針輔助在腹膜外進行內(nèi)環(huán)關(guān)閉，此舉不但簡化了操作，而且降低了術(shù)后復(fù)發(fā)的風(fēng)險。本研究在使用硬膜外穿刺針進行疝內(nèi)環(huán)結(jié)扎術(shù)的基礎(chǔ)上，通過自制單鉤疝針并進一步完善為雙鉤疝針在單孔腹腔鏡監(jiān)視下完成經(jīng)皮腹膜外疝內(nèi)環(huán)結(jié)扎術(shù)，評價疝鉤針在小兒單孔腹腔鏡經(jīng)皮腹膜外內(nèi)環(huán)結(jié)扎術(shù)的可行性及安全性，討論其手術(shù)相關(guān)并發(fā)癥及其相應(yīng)處理措施，為避免術(shù)中意外、減少術(shù)后并發(fā)癥提供對策及可行性建議。 方法：經(jīng)醫(yī)院倫理委員會批準(zhǔn)，參照文獻自制疝鉤針并在手術(shù)過程中發(fā)現(xiàn)弊端不斷改進。首先采用硬膜外穿刺針，將針頭勺狀部分的外套和針芯制成鉤針形狀，再將前1/3段彎成弧形，便于沿內(nèi)環(huán)腹膜外潛行；因鉤槽在外殼退針過程中會鉤掛組織，進而自制了單鉤疝針，僅在針芯前端內(nèi)弧側(cè)打磨一個溝槽便于鉤掛結(jié)扎線，后端鞘內(nèi)裝有彈簧，方便推出針芯前端鉤掛結(jié)扎線后自動退回嵌入掛牢；因送線退針和再穿刺鉤線兩次操作可能結(jié)扎腹壁組織，將單鉤疝針進一步改進為雙鉤疝針并將針芯前端內(nèi)弧側(cè)的一個溝槽改進在針芯外弧側(cè)的兩個凹槽，，前方淺凹槽開口向前用于鉤掛折疊線送入腹腔便于撥線留置腹內(nèi)，后方深溝槽開口向后便于鉤掛腹內(nèi)預(yù)留折疊線，從而完善為一次穿刺腹壁即可完成疝內(nèi)環(huán)腹膜外結(jié)扎術(shù)�；仡�2007～2012年在我科接受腹腔鏡輔助腹股溝斜疝手術(shù)的466例男性患兒臨床資料，術(shù)前診斷單側(cè)疝412例和雙側(cè)疝54例，包括硬膜外針法97例、單鉤疝針法103例和雙鉤疝針法266例三組，均在單孔腹腔鏡監(jiān)視下經(jīng)皮腹膜外實施內(nèi)環(huán)結(jié)扎術(shù)。手術(shù)僅在臍部放置一個5mm套管，腹腔鏡探查后進行手術(shù)：①硬膜外針法先用無溝槽的硬膜外針經(jīng)皮穿過肌層沿內(nèi)環(huán)內(nèi)側(cè)腹膜外潛行剝離輸精管越過后穿透腹膜入腹，經(jīng)針芯送入結(jié)扎線退針，再用另一帶鉤硬膜外針沿內(nèi)環(huán)外側(cè)腹膜外潛行越過精索血管從同一腹膜穿孔處進入腹腔，調(diào)整鉤針角度，用勺狀針面?zhèn)确降臏喜蹝熳☆A(yù)置結(jié)扎線退針、一并將腹內(nèi)預(yù)置結(jié)扎線端帶出體外，收緊荷包縫線，體外打結(jié)埋置于皮下；②單鉤疝針法類似前述操作，只是再次鉤線時，推出帶鉤針芯，用針芯鉤槽掛住預(yù)置結(jié)扎線回縮將其卡壓在針芯與外鞘之間，將腹內(nèi)預(yù)置結(jié)扎線帶出體外，打結(jié)埋置于皮下；③雙鉤疝針法：先將一根2-0絲線對折、中間鉤掛在疝針伸出針芯前端的淺凹槽上回縮卡住，鉤掛對折雙線與疝針在外并行，沿內(nèi)環(huán)口內(nèi)側(cè)腹膜外分離潛行，穿透后腹膜入腹，用腹腔鏡挑撥絲線、推出針芯使鉤掛絲線與疝針分離，將折疊線暫留在腹內(nèi)，將疝針緩慢退至內(nèi)環(huán)前壁腹膜外，隨即再將疝針沿內(nèi)環(huán)口外側(cè)腹膜外潛行，剝離精索血管緊貼腹膜越過，從后腹膜預(yù)置結(jié)扎線穿刺點進入腹腔，推出雙鉤針芯，用近端深鉤槽掛住預(yù)置線環(huán)回縮卡牢，帶出體外結(jié)扎，線結(jié)埋置于腹壁肌層下、內(nèi)環(huán)口前壁腹膜外間隙。對各組手術(shù)時間、術(shù)后住院時間、圍手術(shù)期并發(fā)癥、復(fù)發(fā)率以及家長對手術(shù)效果的滿意度進行回顧性比較。采用SPSS l3．0軟件進行統(tǒng)計學(xué)分析。計量資料采用單因素方差分析；率的比較采用x2分割法檢驗，當(dāng)P0.0167時認(rèn)為差異有統(tǒng)計學(xué)意義。 結(jié)果：全部患兒均在單孔腹腔鏡監(jiān)視下完成經(jīng)皮腹膜外內(nèi)環(huán)結(jié)扎術(shù)。412例術(shù)前診斷單側(cè)腹股溝斜疝的患兒腹腔鏡探查發(fā)現(xiàn)79例對側(cè)隱性疝同時得以治療。以硬膜外針組、單鉤疝針組和雙鉤疝針組排序，單側(cè)手術(shù)平均耗時21.2±4.9min、17.9±4.7min和13.3±3.5min，P＜0.01；雙側(cè)手術(shù)時間分別為35.7±12.9min、27.9±7.9min和17.4±4.7min，P＜0.01；術(shù)后住院時間分別為2.9±0.5天、2.8±0.6天、2.1±0.4天，P=0.295；圍手術(shù)期并發(fā)癥分別為10.31%、5.83%和0.75%，P＜0.01；硬膜外針組出現(xiàn)術(shù)中腹膜外血腫5例、結(jié)扎腹壁組織術(shù)后疼痛不適3例和皮下線結(jié)反應(yīng)2例；單鉤疝針組術(shù)中血管損傷血腫1例、術(shù)后腹壁疼痛不適4例和皮下線結(jié)反應(yīng)1例；雙鉤疝針組1例合并血友病出現(xiàn)血腫和1例出現(xiàn)線結(jié)反應(yīng)。術(shù)后復(fù)發(fā)率分別為3.09%、1.94%、0.38%，P=0.246。術(shù)后隨訪家長對手術(shù)效果滿意率分別為92.78%、94.17%、99.25%。P＜0.01。隨訪所有患兒均未出現(xiàn)睪丸萎縮。 結(jié)論： 1腹腔鏡技術(shù)診治腹股溝疝有利于術(shù)中觀察對側(cè)隱性疝，并可以一次手術(shù)完成治療。 2硬膜外針雖可在單孔腹腔鏡監(jiān)視下完成經(jīng)皮腹膜外內(nèi)環(huán)結(jié)扎術(shù)，具有無可見瘢痕、恢復(fù)快、美容效果好的優(yōu)點；但因鉤槽在外殼，鉤線退針時會鉤掛精索血管或其它組織血管發(fā)生血腫影響操作、費時費力，且送線和鉤線兩次穿刺會結(jié)扎腹壁組織，線結(jié)埋于皮下引起異物反應(yīng)甚至感染。 3單鉤疝針雖消除鉤掛組織使操作更順暢，但仍需要送線和鉤線兩次穿刺會結(jié)扎腹壁組織，引起腹壁不適。 4雙鉤疝針經(jīng)皮腹膜外結(jié)扎術(shù)，經(jīng)腹壁穿刺導(dǎo)入和牽出結(jié)扎線可保持在同一路徑，不會結(jié)扎腹壁皮下組織，能夠確保腹膜外間隙無張力緊密結(jié)扎疝缺損。明顯縮短手術(shù)時間，省時省力。
[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.
【學(xué)位授予單位】：河北醫(yī)科大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2013
【分類號】：R726.5

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