疝修补术lichtenstein课件

Lichtenstein Hernia Repair By Dr. PK Amid President of American Hernia Society Dirctor Lichtenstein Hernia Institute 李金斯坦无张力疝修补 PK Amid 医生 美国疝协会主席 李金斯坦疝中心主任,翻译：同济医院普外科,Introduction 简介,In 1996,Liechtenstein attracted the attention of surgeons worldwide by justifying the use of a prosthetic mesh to create a tension-free hernia repair, thereby minimizing postoperative discomfort, one of the supplementary criteria for evaluating the efficacy of hernia repair. Lichtenstein有效地使用了修补网片进行无张力疝修补手术，并在1996年引起了全球外科医生的关注。这种手术方式极大地减轻了患者术后的不适，而这一点正是评价疝修补术疗效的重要标准之一。 Liechtensteins team popularized routine use of polypropylene mesh in 1984 and coined the term “tension-free hernioplasty”. 1984年起，Lichtenstein及其同伴即开始在手术中常规使用聚丙烯网片，并将这种手术方式命名为无张力疝成形术。 This technique has become the gold standard in open tension-free hernioplasty. 今天，这一技术已成为开放式无张力疝成形手术的金标准。,Anatomy 解剖,For proper performance of this procedure, an excellent understanding of the anatomy of the inguinal region is mandatory. The inguinal region may be divided into superficial and deep planes by defining the layers of the inguinal canal. 为了正确实施该项手术，充分理解腹股沟区的解剖结构是非常必要的。根据腹股沟管的解剖层次，可将腹股沟区分为浅层和深层两个层面。,Anatomy 解剖 - Superficial tissues 浅层组织,1. Anterior superior iliac spine 髂前上棘 2. External oblique muscle 腹外斜肌 3. Aponeurosis of the external oblique muscle (AEOM) 腹外斜肌腱膜（AEOM） 4. Femoral vessels 股血管 5. Spermatic cord 精索 6. External ring 外环,Anatomy 解剖 - Deep tissues 深层组织,1. Inguinal ligament 腹股沟韧带 2. Internal oblique muscle 腹内斜肌 3. Transversus muscle 腹横肌 4. Rectus sheath 腹直肌鞘 5. Cremasteric muscle 提睾肌 6. Deep epigastric vessels 腹壁深动静脉,Anatomy 解剖 - Inguinal canal 腹股沟管,1. Transversalis fascia 腹横筋膜 2. Internal ring (IR) 内环（IR） 3. Ducts deferens 输精管 4. Spermatic vessels 精索血管,凹间韧带,Inguinal triangle 腹股沟三角,Anatomy 解剖 - Rethophysiology 病理生理,The role of protease and protease-inhibitor imbalance in the pathogenesis of groin hernias has lead to a new understanding of the etiology of groin hernias and the causes of their surgical failure. 蛋白酶-抑制剂失衡在腹股沟疝的发病机制中有重要作用，这一发现使得对腹股沟疝的病因和外科治疗失败的原因有了新的认识。 The biochemical evidence that adult male inguinal hernias are associated with impaired hydroxylation of praline has lead to the theory that these changes lead to weakening of the fibro connective tissue of the groin and subsequent development of inguinal hernias. 已有证据证明成年男性腹股沟疝患者通常伴有脯氨酸羟基化作用减弱，这些改变导致了腹股沟纤维连接组织薄弱，并最终导致了腹股沟疝的发生。 The utilization of this already defective tissue, especially under tension, is a violation of basic principles of surgery. 利用这种已经有缺陷的组织进行手术，特别是在有张力的情况下，违背了外科基本原则。,Indications 适应症,This procedure is suitable for all adult patients regardless of their age, weight, general health or the size of the hernia. 这种手术适用于所有的成年病人，无论患者的年龄、体重、身体情况或者疝的大小。,Major principles 主要原则,In tension-free hernioplasty, the entire inguinal floor is reinforced by inserting a sheet of polypropylene mesh. The prosthesis is placed between the transversalis fascia (TF) and the external oblique aponeurosis (EOA). It should extend well beyond the inguinal triangle in order to provide sufficient mesh/tissue interface. Upon increased intra-abdominal pressure, the EOA applies counter-pressure upon mesh. This allows the increase in intra-abdominal pressure to act as an aide to the repair. 无张力疝成形术是在腹横筋膜(TF)和腹外斜肌腱膜(EOA)之间放置一张聚丙烯网片来加固腹股沟管的后壁。网片应延伸至腹股沟三角之外，以提供足够的网片/组织接触界面。在腹内压增加的情况下，腹外斜肌腱膜（EOA）可在网片上产生相应的对抗力。这种反方向的抗张力使得腹内压的增加有助于修补。 The mesh reinforcement has both therapeutic and prophylactic benefits. It prevents the entire groin region from herniation due to future mechanical stress factors and/or metabolic derangements. 网片对腹股沟区的加固具有治疗和预防双重作用。它可以防止整个腹股沟区因日后机械劳损和代谢异常所引发的疝复发。,Anesthesia 麻醉,Local anesthesia 局部麻醉 Local anesthesia is safe, simple, effective, economical, and without any side effects such as nausea, vomiting, and urinary retention. Furthermore, local anesthesia administered prior to making the incision produces a prolonged analgesic effect via inhibition of the build-up of local nociceptive molecules (Amid et al., 1994). 局部麻醉是一种安全、简单、有效、经济的麻醉方式，而且无恶心、呕吐、尿潴留等副作用。此外，在切开皮肤之前给予局麻药，可以抑制局部炎症介质的合成，从而延长镇痛效果。 Epidural anesthesia 硬脊膜外麻醉 Epidural anesthesia is preferable for repair of non-reducible inguinal hernias. 硬脊膜外麻醉适用于难复性腹股沟疝的修补。 Use of sedative drugs 镇静药物的使用 Sedative drugs given by the surgeon or by an anesthesiologist during ”conscious sedation” will reduce the patients anxiety. Infusion of fast-acting, amnesic and anxiolytic agents such as protocol also reduces the amount of local anesthetic agents required, especially with cases such as bilateral inguinal hernia repair in obese patients. 在“意识镇静”时，由外科医师或麻醉师给予镇静药物可减轻患者的焦虑。给予起效快、具有遗忘作用的抗焦虑药物，如异丙酚，可以减少术中局麻药物的用量，特别是在对肥胖病人施行双侧腹股沟疝修补术时。,Local anesthesia tech 局部麻醉技术,Injection of local anesthesia is performed by the surgeon as part of the surgical technique. It is placed in dermal and subcutaneous layers prior to the skin incision and deeper planes as the dissection progresses. 作为手术的一部分，局麻药物的注射是由外科医师施行的。在切开皮肤前，分别在皮内和皮下进行注射；在切开过程中，再在更深的层面注射药物。 Several safe and effective anesthetic agents are currently available on the market. 现在在市场上可以获得一些安全和有效的麻醉药物。,Our preference is a 50:50 mixture of 1% lidocaine and 0.5% bupivacaine, with 1/200,000 epinephrine. An average of 45ml of this mixture is usually sufficient for a unilateral hernia repair and is administered in the following fashion: 我们的选择是1%的利多卡因和0.5%的布比卡因按50:50混合，其中含有1/200,000的肾上腺素。45ml上述的混合物足以进行单侧的疝修补。我们按照以下的步骤进行注射：,Local anesthesia tech 局部麻醉技术 - Subdermal injection 皮下注射,A 25ml syringe is used. 使用25ml的注射器。 About 5ml of the mixture is infiltrated along the line of the incision with a 5cm long needle inserted into the sub dermal tissue parallel with the surface of the skin. 将5cm长的针头插入皮下，与皮面平行沿切口长轴注射5ml药物。 Infiltration continues as the needle is advanced. 针头前进时，持续注射药物。,皮肤切口线,5ml皮下注射,Local anesthesia tech 局部麻醉技术 - Intradermal injection 皮内注射,The needle in the sub dermal plane is withdrawn slowly until the tip of needle reaches the intadermic level. Without extracting the needle completely, the dermis is infiltrated by slow injection of about 3ml of the mixture along the line of the incision. 缓慢将针头退出至皮内层面，不将针头完全拔出，再沿切口长轴于皮内缓慢推注3ml药物。,Local anesthesia tech 局部麻醉技术 - Deep subcutaneous injection 皮下深层注射,A total of 10ml of the mixture is injected deep into the subcutaneous adipose tissue through vertical insertions of the needle (perpendicular to the skin surface) 2cm apart. 将针头每隔2cm间距垂直插入皮下脂肪组织(与皮面垂直)，共注射10ml。 Once more, the mixture is injected as the needle is kept moving to reduce the risk of intravascular infusion. 而且，要在针头运动过程中推注药物，以减少血管内注射的危险。,Local anesthesia tech 局部麻醉技术 - Sub-aponeurotic injection 腱膜下层注射,After incising the skin and subcutaneous fatty tissue, about 10ml of the anesthetic mixture is injected immediately underneath the aponeurosis of the external oblique muscle through a window created in the subcutaneous fat at the lateral corner of the incision. 在切开皮肤和皮下脂肪组织后，在切口外侧角的皮下脂肪内切开一个小窗口，通过这个小窗口迅速将10ml麻醉药物注射在腹外斜肌腱膜下方。 This injection floods the enclosed inguinal canal and anesthetizes all three major nerves in the region while the remaining subcutaneous fat is incised. It also lifts the EOA away from the underlying ilioinguinal nerve , reducing the likelihood of injuring the nerve when the EOA is incised. 当切开剩下的脂肪组织时，所注射的麻醉药物在闭合的腹股沟管内弥散，将3条主要的神经麻醉。这种方法还可将腹外斜肌腱膜与其下方的髂腹股沟神经分开，从而减少切开腹外斜肌腱膜时损伤神经的可能性。,Local anesthesia tech 局部麻醉技术 - Tips 提示,Occasionally, it is necessary to infiltrate a few ml of the mixture at the level of the pubic tubercle, around the neck and inside the indirect hernia sac, to achieve complete local anesthesia. 有时，需在耻骨结节水平、斜疝疝囊颈周围以及疝囊内注射少量麻醉药物，以达到完全麻醉的效果。 The local anesthesia can be further prolonged by the pooling of 10ml of the mixture in the subcutaneous space before skin closure (Amid et al., 1994). 在缝合皮肤前，可在皮下注射10ml麻醉药物以延长局麻效果。,Inguinal canal/opening 腹股沟管切开,The EOA is incised for 5-6cm starting from the pubic tubercle and extending laterally to the langers skin lines, giving excellent exposure of the pubic tubercle and the internal ring. 从耻骨结节开始，将腹外斜肌腱膜切开5-6cm,向外延至Langer线，以充分暴露耻骨结节和内环。,Inguinal canal/opening 腹股沟管切开- Dissection of the EOA 腹外斜肌腱膜切开,The lower leaf of the EOA is freed from the spermatic cord. The upper leaf is then freed from the underlying internal oblique muscle and aponeurosis for a distance of 3cm above the inguinal floor. The plane between these two layers is avascular and the dissection can be done rapidly and atraumatically. 将腹外斜肌腱膜下叶与精索分离。再将腹外斜肌腱膜上叶与其下方的腹内斜肌/腱膜分离，并游离至腹股沟管壁上方3cm。这两层之间的层面没有血管，可以快速地无损伤地切开。 Wide separation of these layers has a dual benefit, as it allows visualization of the iliohypogastric nerve, and creates sufficient space for insertion of a wide sheet of mesh. The mesh should overlap the internal oblique by at least 3cm above the upper margin of the inguinal floor. 充分地游离腹外斜肌腱膜上下两叶有两个好处。第一，可以充分显露髂腹下神经；第二，可以创造足够的空间植入大块的网片。网片应当覆盖腹内斜肌(至腹股沟管壁上方至少3cm)。,Inguinal canal/opening 腹股沟管切开 - Freeing the spermatic cord 游离精索,The cord, with its covering of cremater muscle fibers, is lifted and separated from the floor of the inguinal canal and the pubic bone for a distance of about 2cm beyond the pubic tubercle. The anatomic plane between the cremasteric sheath and the aponeurotic tissue attached to the pubic bone is avascular, so there is little risk of damaging the spermatic vessels. 将精索及其上的提睾肌纤维向上提起，以从腹股沟管后壁和耻骨上分离，在耻骨结节上方游离出约2cm的距离。在提睾肌和耻骨筋膜之间的解剖层面是无血管的，所以损伤精索血管的风险是很小的。,Inguinal canal/opening 打开腹股沟管 - Preserving the nerves 保护神经,When lifting the cord, care should be taken to include the ilioinguinal nerve, external spermatic vessels and the genital nerve with the cord. This assures that the genital nerve, which is always in juxtaposition to the external spermatic vessels, is preserved. 提起精索时，应当注意保护髂腹股沟神经、精索外血管、和与精索伴行的生殖神经。这样就能确保始终与精索外血管伴行的生殖神经不被损伤。 The present author found this method of preserving the genital nerve safer and easier (Amid et al., 1993) than the originally described “lesser cord” method (a method in which the genital nerve and external spermatic vessels are separated from the cord in form of a bundle, referred to as “lesser cord”, and passed through a gap along the mesh-inguinal ligament suture line). 目前作者发现，与以前的方法相比，这种方法可以更安全和方便的保护生殖神经。以前的方法被称为“小精索”法（将生殖神经和精索外血管从精索上分离，以形成较小的精索束，即“小精索”，再沿网片与腹股沟韧带缝合线空隙处穿过）。 The iliohypogastric nerves should also be preserved. 髂腹下神经也应该注意保护。,Hernia sac/freeing 游离疝囊,Once the inguinal canal is opened, the hernia sac must be identified and isolated. The difficulty of this part of the procedure depends on the type and chronicity of the hernia. At this time, the region is examined thoroughly in order to identify a combined hernia, taking care to preserve the anatomy of the region. Regardless of the type of hernia, the principle is the same. The peritoneal sac can be easily identified by having the patient cough. It is then freed either by opening the cremasteric fibers (indirect hernias), or by retracting the spermatic cord (direct hernias). 腹股沟管打开后，需确认和分离疝囊。这一过程的难度取决于疝的类型和病程长短。此时，还应该仔细检查该区域，以确认是否存在合并疝，同时注意保护该区的解剖结构。无论哪种类型的疝，处理原则是相同的。让病人咳嗽，疝囊可以容易的被确认，然后通过分离提睾肌纤维（斜疝），或提拉精索（直疝），可以游离疝囊。 It is necessary to search for an associated hernia. 检查是否存在合并疝也是非常必要的。,Hernia sac/freeing 游离疝囊 - Indirect hernia 斜疝,The indirect hernia sac is isolated from the spermatic cord structures after the fibers of the cremasteric sheath have been longitudinally opened. The sac is then freed beyond its neck. 纵向打开提睾肌纤维后，将斜疝疝囊从精索上分离。疝囊需分离至疝囊颈部。 Complete stripping and excision of the cremasteric fibers is unnecessary, and can result in injury to the nerves, small blood vessels, and the ductus deferens. 完全地剥离和切除提睾肌纤维是不必要的，并且也容易损伤神经、小血管和输精管。,Hernia sac/freeing 游离疝囊 - Direct hernia 直疝,Direct hernias are revealed once the spermatic cord has been lifted and retracted. They are caused by weakness or perforation of the transversals fascia, which should be strongest part of the posterior wall of the inguinal canal. The direct hernia sac is easily isolated. 提起或向后牵拉精索即可暴露直疝。腹横筋膜是腹股沟管后壁最坚固的组成部分，当腹横筋膜薄弱或穿孔时，可引起直疝。直疝的疝囊很容易被分离。 In addition, the internal ring must be explored in search of a combined indirect hernia. To do so, the crematoria sheath is incised either transversely (if extremely thick) or longitudinally at the level of the internal ring. 此外，在寻找是否合并斜疝时，需探查内环。此时须在内环水平纵行切开提睾肌，在肌肉特别厚的情况下也可以横行切开。 A transverse incision may cause crematoria muscle dysfunction and/or cause the testicle to drop lower, hindering or preventing ejaculation. 横形切口可能引起提睾肌功能异常，并且可能造成睾丸位置下降，妨碍射精。,Hernia sac/freeing 游离疝囊 - Search for associated hernias 寻找合并疝,In cases of voluminous direct hernias, a thorough exploration of the groin is necessary to rule out any coexisting intraparietal (interstitial), low lying Spieling or femoral hernias. The femoral ring is routinely evaluated via the retro inguinal space through a small opening in the canal floor. 在巨型直疝时，需彻底探查腹股沟区以排除任何合并存在的腹壁间裂隙疝、低位的外侧腹壁疝（ Spigelian 疝） 或股疝。可以在腹股沟后壁开一个小口，通过腹股沟韧带后间隙常规探查股环。,Hernia sac/reduction 疝囊回纳,Any and all abdominal contents that may be in the hernia sac must be reduced into the abdomen. The hernia sac, itself, should be completely reduced into the pre-peritoneal space to avoid post-operative pain. 疝囊内所有的腹腔内容物都须回纳至腹腔内。疝囊本身也应回纳到腹膜前腔隙，以避免术后的疼痛。 There are several ways of managing the hernia sac: inversion, division, resection or legation. 疝囊的处理方法有许多种，如：翻转、离断、切除和结扎。,Hernia sac/reduction 疝囊回复 - Simple inversion of the sac 疝囊的简单翻转,In small and middle-sized indirect hernias, the freed sac is simply inverted into the pre-peritoneal space without suture legation. The freed sac may drop back down into the abdomen spontaneously. 较小的和中等大小的斜疝，游离的疝囊可以很容易地被翻转，回纳至腹膜前腔隙内，而不需缝合结扎。游离的疝囊可自行落入腹腔内。 In voluminous direct hernias, the sac is inverted and maintained in position by a purse-string suture. 巨大直疝时，翻转疝囊后，用荷包缝合将其固定。,Hernia sac/reduction 疝囊回复 - Division of voluminous sacs 巨大疝囊离断,Voluminous scrotal hernia sacs can be transected at their midpoint along the inguinal canal, leaving the distal part of the sac open and in place to minimize the risk of postoperative ischemic orchitis. The distal portion is transected on its anterior border to prevent postoperative hydrocele formation. The proximal part of the sac is suture ligated. 巨大的滑入阴囊的疝囊可沿腹股沟管在其中点处横断，疝囊的远端部分开放，以减少术后缺血性睾丸炎的发生。疝囊远端部分前壁需被切开，以防止术后积液的发生。近端部分则被缝合结扎。,Hernia sac/reduction 疝囊回复 - Resection of the sac 疝囊切除,Resection of the sac, once it has been completely freed, is not necessary. It requires ligation at the origin of the sac which may lead to post-operative pain. 只要完全游离疝囊，并不需要切除。由于在切除疝囊时，须在其起始部结扎之，可能会导致患者术后疼痛。,Hernia sac/reduction 疝囊回复 - Ligation of the sac 结扎疝囊,Ligation of the peritoneal sac should not be performed unnecessarily. 在不必要的情况下，不应采取结扎的方法处理疝囊。 It has been shown that the risk of recurrence is not increased when small or medium sized indirect hernia sacs are not ligated. Additionally, this prevents postoperative pain secondary to denervation caused by mechanical pressure and/or ischemia. 对于小斜疝和中等大小斜疝，不结扎疝囊并不会增加其复发的风险性。此外，不结扎疝囊可以防止因机械压力或缺血引起的术后疼痛。,The mesh 网片,To reduce the risk of recurrence, the mesh should be wide enough to overlap tissues 3-4cm beyond the boundary of the inguinal triangle. After tissue incorporation is complete, this overlap results in uniform distribution of intra-abdominal pressure over the much wider surface area, rather than just the line where the mesh is joined to the tissue. 为了减少术后复发的危险，网片需足够大，以覆盖腹股沟三角以外3-4cm的组织。这样，在网片与组织生长融合后，腹内压可以均匀地分布在更大的表面区域，而不仅仅是网片与组织结合边缘。 This overlap of the mesh has also been shown to compensate for future shrinkage of the mesh (Amid, 1997). 这样的大面积覆盖网片也有助于弥补网片将来的收缩（Amid,1997）。 Proper fixation of the margins of the mesh to the groin tissue is another important step in the prevention of recurrence. 正确地将网片边缘与腹股沟组织固定，也是防止疝气术后复发的重要步骤。,The mesh 网片 - Size of the mesh 网片的尺寸,A 816cm sheet of mesh is used. 通常使用816cm大小的网片,The mesh 网片 - Structure of the mesh 网片的结构,We prefer monofilament polypropylene mesh because the surface texture promotes fibroplasia and their monofilament structure does not tend to perpetuate nor harbor infection (Amid, 1997). 我们倾向于使用单纤维的聚丙烯网片，因为这种网片的表面结构可促进纤维增生，而且其单纤维的结构不容易藏匿细菌而引发感染(Amid,1997)。 The mesh should not be placed completely flat (without a ripple) in a patient under conscious sedation in a supine position. It will be placed under tension post-operatively, when the patient strains, or resumes a standing position. 在患者平卧位和意识镇静状态下，网片放置不应完全平坦没有皱褶。否则，术后在患者伸腰，或恢复站立位时，网片局部产生张力。,The mesh 网片 - Shape of the mesh 网片的形状, 1 The medial end of the mesh is rounded to the shape of the medial corner of the inguinal canal by the surgeon. 外科医师应将网片内侧端剪成圆弧形，与腹股沟管内侧端形状做成一致。 2 A slit is made intra-operatively at the lateral end of the mesh creating two tails, a wide one (two-thirds) above and a narrower one (one-third) below. 术中将网片剪开一个裂隙，制成两个尾端，上方较宽(2/3)，下方较窄(1/3)。,Placing/fixing the mesh 放置/固定网片,Operative time for placement and fixation of the mesh has been well standardized. 放置和固定网片的手术步骤已经标准化。 The mesh is placed: 网片被放置在： 1. over the pubic bone; 耻骨上； 2. then around the cord in order to create a prosthetic internal ring; 然后再放置在精索周围，以形成人工内环； 3. cephalad, on the internal oblique aponeurosis; 向头侧放置在腹内斜肌腱膜上； 4. laterally below the EOA. 外侧放置在腹外斜肌腱膜下。,Placing/fixing the mesh 放置/固定网片 - Over the pubic bone 耻骨上,Positioning the mesh over the pubic bone is an essential step in the procedure. The mesh must cover the pubic bone to avoid recurrences. 将网片放于耻骨结节上是手术中的一个重要步骤。必须将网片覆盖在耻骨上，以防止疝复发。,Placing/fixing the mesh 放置/固定网片 - Over the pubic bone 耻骨上,The cord is retracted upwards. The mesh is placed on the posterior wall of the inguinal canal and its rounded corner is sutured to the aponeurotic tissue over the pubic bone with a non-absorbable monofilament suture, overlapping the bone by 1 to 1.5cm. 将精索拉向上方。将网片放置于腹股沟管的后壁，用不可吸收的单股缝线将其圆角缝合在耻骨上的腹直肌鞘，覆盖面须超过耻骨结节约