周志剛，楊兵

(1.陸軍軍醫(yī)大學(xué)西南醫(yī)院門診部，重慶 400038；2.重慶市長(zhǎng)壽區(qū)中醫(yī)院外科，重慶 401220)

腹腔鏡完全腹膜外疝無張力修補(bǔ)術(shù)對(duì)成人腹股溝疝的治療效果研究

周志剛1，楊兵2

(1.陸軍軍醫(yī)大學(xué)西南醫(yī)院門診部，重慶 400038；2.重慶市長(zhǎng)壽區(qū)中醫(yī)院外科，重慶 401220)

目的分析腹腔鏡完全腹膜外疝無張力修補(bǔ)術(shù)對(duì)成人腹股溝疝的臨床療效。方法125例手術(shù)治療的腹股溝疝患者分為觀察組(TEP，n=65)及對(duì)照組(開放疝無張力疝修補(bǔ)術(shù),n=60)。比較兩組手術(shù)時(shí)間、術(shù)后住院日、術(shù)后疼痛及術(shù)后1年復(fù)發(fā)率，并對(duì)比兩組患者手術(shù)前后外周血炎癥因子水平(CRP、IL-6及IL-10)變化情況。結(jié)果術(shù)后24 h，兩組患者外周血CRP及IL-6水平均高于術(shù)前水平(P<0.05)，但觀察組低于對(duì)照組(P<0.05)；觀察組患者術(shù)后住院時(shí)間及術(shù)后24 h的VAS評(píng)分均低于對(duì)照組患者(P<0.05)；兩組患者手術(shù)時(shí)間比較差異無統(tǒng)計(jì)學(xué)意義(P>0.05)；兩組患者術(shù)后1年疝累積復(fù)發(fā)率比較差異無統(tǒng)計(jì)學(xué)意義(3.08%vs. 5.00%;Log-rankχ2=0.282,P=0.595)。結(jié)論TEP對(duì)成人腹股溝疝的治療效果理想。

腹股溝疝；腹腔鏡完全腹膜外疝無張力修補(bǔ)術(shù)；炎癥；術(shù)后復(fù)發(fā)

腹股溝疝是普通外科最為常見的良性疾病之一，腹股溝疝無張力修補(bǔ)術(shù)是目前腹股溝疝的最常用手術(shù)治療方式[1]。疝的臨床治療得益于補(bǔ)片材料的長(zhǎng)足進(jìn)步，這使得傳統(tǒng)的高位疝囊結(jié)扎手術(shù)基本廢棄。隨著微創(chuàng)外科的發(fā)展以及腹腔鏡技術(shù)的不斷普及，在腹股溝疝治療領(lǐng)域不斷涌現(xiàn)出新的手術(shù)方式和技巧[2]。腹腔鏡全腹膜外無張力疝修補(bǔ)術(shù)(totally extraperitoneal prosthetics，TEP)是近年來不斷發(fā)展和應(yīng)用于臨床的新術(shù)式[3]。與傳統(tǒng)的開放式疝無張力修補(bǔ)術(shù)相比，TEP具有創(chuàng)傷更小、術(shù)后恢復(fù)更快等優(yōu)勢(shì)[4]。本研究嘗試分析TEP對(duì)成人腹股溝疝的治療效果，并與傳統(tǒng)的開放手術(shù)進(jìn)行對(duì)比，以期為此類疾病的診療提供參考。

1 資料與方法

1.1 研究對(duì)象

分析2014年1月至2017年1月在重慶西南醫(yī)院接受手術(shù)治療的125例腹股溝疝患者的臨床資料。依據(jù)患者采用的手術(shù)方式不同分為觀察組(TEP，n=65)及對(duì)照組(開放疝無張力疝修補(bǔ)術(shù),n=60)。兩組患者一般資料比較差異無統(tǒng)計(jì)學(xué)意義(P>0.05)，見表1。所有患者均經(jīng)臨床及影像學(xué)檢查明確診斷為腹股溝疝，并排除以下情況的患者：合并疝內(nèi)容物嵌頓、絞窄等血運(yùn)障礙；合并嚴(yán)重凝血功能障礙；合并活動(dòng)性感染；合并嚴(yán)重肝腎功能障礙；合并自身免疫性疾病。

表1 兩組患者一般資料比較

1.2 治療及評(píng)估

兩組患者均接受同一組醫(yī)師所施行的手術(shù)治療，觀察組患者采用TEP[5]：全麻后取平臥位，常規(guī)消毒鋪巾，選著臍孔作一10 mm切口置入腹腔鏡，臍平面下病變對(duì)側(cè)作2個(gè)5 mm腹直肌外側(cè)緣腹膜外操作孔；剝離疝囊直至腹膜盆壁化，分離腹膜前間隙，暴露生殖血管，將聚丙烯補(bǔ)片裁剪至合適大小后覆蓋在恥骨結(jié)節(jié)、聯(lián)合肌腱、Cooper’s韌帶及腹直肌背側(cè)上。開放式疝無張力修補(bǔ)術(shù)在腰麻下完成[6]。分別于術(shù)前及術(shù)后24 h抽取患者外周血5 mL，檢測(cè)如下指標(biāo)：C-反應(yīng)蛋白(C-reactive protein，CRP)、白介素-6(Interleukin-6，IL-6)及IL-10。記錄手術(shù)時(shí)間、術(shù)后住院時(shí)間，并于術(shù)后24 h采用視覺模擬評(píng)分法(visnal analogue scale，VAS)評(píng)估兩組患者疼痛情況。對(duì)每位患者進(jìn)行為期1年的隨訪，記錄術(shù)后1年累積復(fù)發(fā)率。

1.3 觀察指標(biāo)

比較兩組患者手術(shù)前后外周血炎癥指標(biāo)的改變；比較兩組患者手術(shù)時(shí)間、術(shù)后住院時(shí)間及術(shù)后疼痛情況；對(duì)比兩組患者術(shù)后1年疝復(fù)發(fā)率。

1.4 統(tǒng)計(jì)學(xué)分析

2 結(jié)果

2.1 兩組患者手術(shù)前后外周血炎癥指標(biāo)的改變比較

兩組患者術(shù)前各項(xiàng)指標(biāo)比較均差異無統(tǒng)計(jì)學(xué)意義(P>0.05)。術(shù)后24 h，兩組患者外周血CRP及IL-6水平均高于術(shù)前水平，且觀察組低于對(duì)照組，差異有統(tǒng)計(jì)學(xué)意義(P<0.05)。兩組患者手術(shù)前后外周血IL-10水平未見顯著差異(P>0.05)。見表2。

表2 兩組患者手術(shù)前后外周血炎癥指標(biāo)的改變比較

*P<0.05，與組內(nèi)術(shù)前比較；#P<0.05，與對(duì)照組比較。

2.2 組患者手術(shù)時(shí)間、術(shù)后住院時(shí)間及術(shù)后疼痛情況比較

觀察組患者術(shù)后住院時(shí)間及術(shù)后24 h的VAS評(píng)分均低于對(duì)照組患者(P<0.01)。兩組患者手術(shù)時(shí)間比較差異無統(tǒng)計(jì)學(xué)意義(P>0.05)。見表3。

觀察項(xiàng)目觀察組對(duì)照組t/χ2值P值手術(shù)時(shí)間(min)41．6±11．639．6±10．61．0040．318術(shù)后住院時(shí)間(d)2．1±0．63．6±0．811．920<0．01術(shù)后VAS評(píng)分3．6±1．24．9±1．65．164<0．01

2.3 兩組患者術(shù)后1年疝復(fù)發(fā)率比較

觀察組患者術(shù)后有2例出現(xiàn)復(fù)發(fā)，對(duì)照組患者有3例。兩組患者術(shù)后1年疝累積復(fù)發(fā)率比較差異無統(tǒng)計(jì)學(xué)意義(3.08%vs. 5.00%;Log-rankχ2=0.282,P=0.595)。見圖1。

3 討論

腹股溝疝是臨床常見病、多發(fā)病，此病約占腹外疝的90%以上。醫(yī)學(xué)界對(duì)腹股溝疝的治療經(jīng)歷過漫長(zhǎng)的發(fā)展，最早的有張力腹股溝疝修補(bǔ)手術(shù)曾經(jīng)使用了約100年。但這種治療方法存在復(fù)發(fā)率高、術(shù)后恢復(fù)時(shí)間長(zhǎng)等缺點(diǎn)。近年來，腔鏡技術(shù)在世界范圍內(nèi)迅速崛起，尤其是在中國的發(fā)展和普及的速度十分迅速。隨著腔鏡技術(shù)和設(shè)備的不斷普及，越來越多的醫(yī)院具備了腔鏡手術(shù)的條件。而腹腔鏡下疝無張力修補(bǔ)術(shù)開始逐步應(yīng)用于臨床，從最早的經(jīng)腹膜修補(bǔ)逐步發(fā)展至TEP[7-8]。本研究以成人腹股溝疝患者為研究對(duì)象，以開放疝無張力修補(bǔ)術(shù)為對(duì)照，從術(shù)后恢復(fù)、術(shù)后炎癥反應(yīng)及術(shù)后復(fù)發(fā)等多個(gè)角度評(píng)估TEP的臨床療效。

研究結(jié)果顯示，術(shù)后24 h，兩組患者外周血CRP及IL-6水平均高于術(shù)前水平，但觀察組低于對(duì)照組。CRP是一種非特異性急性期反應(yīng)蛋白，是臨床上用于評(píng)估應(yīng)激水平及炎癥反應(yīng)程度的常用指標(biāo)[9-10]。IL-6是一種促炎介質(zhì)，其在感染、組織損傷等過程中表達(dá)升高，主要由單核巨噬細(xì)胞系統(tǒng)所分泌，是評(píng)估炎癥及損傷的敏感指標(biāo)[11-12]。事實(shí)上，無論何種等級(jí)的手術(shù)對(duì)患者來說均是一種醫(yī)源性創(chuàng)傷，結(jié)果顯示腔鏡下的手術(shù)治療顯著降低了這種手術(shù)對(duì)患者造成的損傷，肯定了微創(chuàng)治療的優(yōu)勢(shì)[13-14]。同時(shí)，結(jié)果數(shù)據(jù)顯示觀察組患者術(shù)后住院時(shí)間及術(shù)后24 h的VAS評(píng)分均低于對(duì)照組患者。腔鏡下疝無張力修補(bǔ)術(shù)只需建立1個(gè)觀察通道及2個(gè)操作通道，僅需做10 mm皮膚切口1個(gè)、5 mm皮膚切口2個(gè)，這應(yīng)當(dāng)是患者術(shù)后24 h疼痛程度較對(duì)照組輕的主要原因之一[15-16]。此外，由于患者無腹壁長(zhǎng)切口，其術(shù)后恢復(fù)更為迅速。本研究未發(fā)現(xiàn)兩組患者手術(shù)時(shí)間及術(shù)后1年疝累積復(fù)發(fā)率有顯著差異，提示兩組患者的操作耗時(shí)及遠(yuǎn)期療效相當(dāng)。手術(shù)主刀應(yīng)當(dāng)選擇經(jīng)驗(yàn)豐富的外科醫(yī)師，主刀對(duì)局部解剖結(jié)構(gòu)及腔鏡的操作熟練程度直接影響手術(shù)時(shí)間和手術(shù)副損傷，而降低手術(shù)創(chuàng)傷是微創(chuàng)手術(shù)的主要目的。手術(shù)應(yīng)當(dāng)對(duì)適用患者做一定甄別，對(duì)于肥胖的患者來說，腔鏡下建立腹膜外氣腹較為困難；此外，對(duì)于合并有嵌頓及絞窄的患者也不應(yīng)選擇腔鏡手術(shù)。

綜上，TEP對(duì)成人腹股溝疝的治療效果可靠。

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Studyontheclinicaleffectoftotallyextraperitonealprostheticsinthetreatmentofinguinalhernia

ZHOU Zhi-gang1,YANG Bing2

(1.DepartmentofOvtpatient,SouthwestHospitalofChongqing,Chongqing400038;2.DepartmentofSurqery,ChangshouDistrictHosptialofTraditonalChineseMedicine,Chongqing412200,China)

Objective：To analyze the clinical effect of totally extraperitoneal prosthetics(TEP) in the treatment of inguinal hernia.Methods125 cases of patients with inguinal hernia were divided into the observation group (TEP,n=65) and the control group (open tension free hernia repair,n=60).The operation time,postoperative hospital stay,postoperative pain and recurrence rate after 1 year in the two groups were compared,and the changes of peripheral inflammatory cytokines (CRP,IL-6 and IL-10) in the patients of the two groups were compared.Results24 hours after surgery,the levels of CRP and IL-6 in the peripheral blood of the two groups were higher than those of the preoperative level (P<0.05),but the levels in the observation were lower than those in the control group (P<0.05).The postoperative hospitalization time and the VAS score of 24 h after operation in the observation group were lower than those in the control group (P<0.05).There was no significant difference in the operation time between the two groups (P>0.05).There was no significant difference in the cumulative recurrence rate between the two groups after 1 year of operation (3.08%vs. 5.00%，Log-rankχ2=0.282,P=0.595).ConclusionTEP show an ideal clinical effect in treatment of inguinal hernia.

Inguinal hernia；Totally extraperitoneal prosthetics(TEP)； Inflammation；Post-operation recurrence

10.3969/j.issn.1005-3697.2017.06.031

2017-06-29

周志剛(1979-)，男，主治醫(yī)生。E-mail：37931482@qq.com

時(shí)間： 2017-12-27 16∶44網(wǎng)絡(luò)出版地址http://kns.cnki.net/kcms/detail/51.1254.R.20171227.1643.062.html

1005-3697(2017)06-0915-03

R656.2

A

(學(xué)術(shù)編輯：全信保)