發(fā)布時(shí)間：2018-09-18 07:47

【摘要】： 研究背景 腹股溝疝是人類特有的疾病,這和人類進(jìn)化過程中由四肢爬行到直立行走,腹股溝區(qū)所承受的壓力改變有關(guān)。腹股溝疝也是臨床上的常見病和多發(fā)病,隨著人們生活水平提高和壽命的延長(zhǎng),其發(fā)病率也有增長(zhǎng)的趨勢(shì),最保守的估計(jì),我國(guó)腹股溝疝發(fā)病每年超過200萬人,因此疝的治療不僅是繁重的醫(yī)療任務(wù),而且是一巨大的社會(huì)問題。人類對(duì)疝的認(rèn)識(shí)最早可以追溯至遙遠(yuǎn)的上古時(shí)代,公元前1500年,在古埃及制成的紙上就有腹股溝疝的記載。疝的發(fā)展凝結(jié)了整個(gè)外科發(fā)展各個(gè)時(shí)期重要事件的精義,諸如外科解剖、無菌術(shù)、麻醉止痛、止血、生物材料和微創(chuàng)技術(shù)等。成人腹股溝疝不可自愈,手術(shù)是惟一有效的治療方法。雖然現(xiàn)代的腹股溝疝修補(bǔ)術(shù)經(jīng)歷了一百多年的歷史及改進(jìn),但仍然沒有一種術(shù)式達(dá)到完美的效果,均存在一定的并發(fā)癥及復(fù)發(fā)率�，F(xiàn)代疝外科的先驅(qū)者Astely、Paston、Cooper曾敘述道:“在屬于外科醫(yī)師職責(zé)范疇的人類機(jī)體的疾病中,在治療上沒有其他疾病比不同種類的疝更需要綜合準(zhǔn)確的解剖知識(shí)和外科技巧�！睂�(duì)解剖學(xué)的熟悉程度決定了一個(gè)外科醫(yī)生的工作能力和水平,只有很好的掌握解剖才能使外科醫(yī)生在手術(shù)過程中得心應(yīng)手,避免不必要的損傷,減少并發(fā)癥,使手術(shù)獲得最好的效果。特別是腹腔鏡下腹股溝疝修補(bǔ)術(shù)的出現(xiàn)及發(fā)展,改變了常規(guī)的手術(shù)入路及操作方法,出現(xiàn)了新的解剖視野。國(guó)內(nèi)外許多解剖學(xué)專家及外科學(xué)專家均進(jìn)行了相關(guān)的研究,取得很大的成績(jī),但發(fā)表的論文中缺乏腹腔鏡視野下腹股溝疝修補(bǔ)術(shù)解剖學(xué)的精細(xì)測(cè)量。因此,對(duì)腹股溝區(qū)的解剖學(xué)特點(diǎn)有必要更進(jìn)一步深入研究。本研究旨在通過對(duì)腹股溝區(qū)的深入解剖研究,重新認(rèn)識(shí)腹股溝區(qū)腹膜前解剖學(xué)的特點(diǎn),對(duì)臨床中腹腔鏡下全腹膜外腹股溝疝修補(bǔ)術(shù)(TEP)操作給予基礎(chǔ)性的指導(dǎo),并結(jié)合臨床中具體手術(shù)病例探討TEP術(shù)的技術(shù)要點(diǎn)。 目的 觀察和確認(rèn)腹股溝區(qū)腹膜前應(yīng)用解剖學(xué)特點(diǎn),進(jìn)一步探討TEP術(shù)的技術(shù)要點(diǎn),為臨床手術(shù)提供更精細(xì)的解剖學(xué)依據(jù)。總結(jié)我中心TEP成功手術(shù)經(jīng)驗(yàn)技巧,為該手術(shù)的推廣普及提供借鑒。 方法 在1具新鮮女尸標(biāo)本和7具(14側(cè))教學(xué)用男性成人尸體標(biāo)本上進(jìn)行TEP術(shù)的應(yīng)用解剖學(xué)研究。對(duì)腹股溝區(qū)腹膜前間隙內(nèi)的主要韌帶、血管、神經(jīng)等組織解剖分離,并進(jìn)行相關(guān)的觀察、拍照及測(cè)量工作;對(duì)行TEP的手術(shù)入路、手術(shù)空間的分離、固定補(bǔ)片等技術(shù)操作的解剖學(xué)特點(diǎn)進(jìn)行觀察、拍照及測(cè)量。使用SPSS 13.0軟件分析數(shù)據(jù)。回顧分析我中心2005年7月至2008年11月行TEP術(shù)的31例病人,男29人,女2人,均為單側(cè)疝,包括直疝10例,斜疝21例,其中復(fù)發(fā)疝2例。進(jìn)行術(shù)中的解剖學(xué)觀察,回顧分析手術(shù)錄像,詳細(xì)闡述分析TEP手術(shù)方法、步驟、難點(diǎn)技巧。 結(jié)果 腹股溝區(qū)腹橫筋膜分為兩層,兩層之間是疏松結(jié)締組織,外層與腹橫筋膜相融合,內(nèi)層與腹膜難以分開;半環(huán)線距臍中心距離為60.01±4.77(mm),經(jīng)腹直肌后鞘前入路,過半環(huán)線后即可進(jìn)入腹膜前間隙;從恥骨結(jié)節(jié)外側(cè)緣沿髂恥束向外分離約55.61±3.86(mm)可遇腹壁下血管;在恥骨梳韌帶上釘合補(bǔ)片有損傷死亡冠的可能,死亡冠存在率為87.5%;在恥骨結(jié)節(jié)、腹直肌、髂腰肌三處釘合固定補(bǔ)片較合適,不會(huì)損傷重要血管及神經(jīng)。我中心腹腔鏡下全腹膜外腹股溝疝修補(bǔ)術(shù)手術(shù)時(shí)間90.2±9.5分鐘,術(shù)后并發(fā)癥發(fā)生率9.5%,復(fù)發(fā)1例,術(shù)后平均住院時(shí)間2.9±0.9天。 結(jié)論 TEP手術(shù)的操作空間是兩層腹橫筋膜之間,在肌恥骨孔后方用足夠大的補(bǔ)片覆蓋修補(bǔ)符合壓力學(xué)原理,理論上復(fù)發(fā)率較其他術(shù)式最低;TEP具有合理性和微創(chuàng)性,掌握TEP的一些手術(shù)要領(lǐng)和技巧,可以縮短學(xué)習(xí)曲線,手術(shù)并不困難,應(yīng)成為腹腔鏡治療腹股溝疝的主要術(shù)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.
【學(xué)位授予單位】：廣州醫(yī)學(xué)院
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2009
【分類號(hào)】：R656.2;R322

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