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疝氣修補：栓子
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媒體類型
 刊物
2001-03
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普通的
最愛
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數位出版
WeBSurg.com, Mar 2001;1(03).
URL: http://www.websurg.com/doi-ot02tw191.htm
URL: http://www.websurg.com/doi-ot02tw191.htm
疝氣修補：栓子
1. 引言
1974: Lichtenstein首度描述以筒狀栓子治療股骨鼠蹊疝氣和復發鼠蹊疝氣。1992: Gilbert 描述使用圓錐狀栓子治療鼠蹊疝氣。
1993: Rutkow和Robbins構想設計和發表Perfix 栓子。這個預製、打摺的、圓錐狀栓子，為內部的聚丙烯瓣所加強。
根據作者，以聚丙烯栓子關閉裂隙缺損有許多好處：
- 使用局部麻醉進行手術；
- 減少術後疼痛；
- 迅速恢復體力活動；
- 復發率小 (<1%)；
- 複製手術快速。
2. 解剖
• 表面組織
1. 髂骨前上棘(Anterior superior iliac spine )2. 外斜肌(External oblique muscle)
3. 腹斜肌(Aponeurosis of the oblique muscle)
4. 精索(Spermatic cord )
5. 股血管(Femoral vessels )
• 深組織
1. 橫肌(Transverse muscle)2. 提睪肌(Cremaster muscle )
3. 精索(Spermatic cord)
4. 股血管(Femoral vessels)
5. 鼠蹊韌帶(Inguinal ligament )
• 鼠蹊管
1. 橫肌(Transverse muscle)2. 提睪肌(Cremaster muscle )
3. 精索(Spermatic cord)
4. 下腹血管(Epigastric vessels)
5. 腹橫筋膜(Transversalis fascia )
3. 適應症
適應症- 各類型的鼠蹊和股骨疝氣；
- 第一型缺損之外的外斜鼠蹊疝氣，包括復發疝氣；
- 直接疝氣，特別是復發疝氣；
- 大的疝氣缺損，通常需要插入一個非常大的栓子；
手術在局部麻醉下進行：年紀大或整體體能狀況不佳的相關禁忌症很少。
禁忌症
- 年輕病患；
- 血液學的參數(邊界適應症)波動；
- 肝硬化(邊界適應症)；
- 非常大的疝氣；
- 病患拒絕；
- 對局部麻醉過敏。
4. 手術室準備
• 病患
位置對於病患和外科團隊應該都是舒適的。病患仰躺，雙腳伸直和兩手臂在手臂固定器裡面維持在直角。
手術領域的建立應該是寬的，包括下肢、整個胸、上腹部、上肢，使頭部維持最佳自由狀態，讓外科醫生得以看見病患並且與病患交談。
1. 右側疝氣例子
• 團隊
外科醫師站在要進行手術的疝氣側。助手站在外科醫師對面。
不需要刷手護士。
1. 外科醫師 (右側疝氣)
2. 助手
• 設備
1. 麻醉設備2. 手術台
3. 器械桌
4. 電燒
麻醉設備必須足以監視心血管和氧氣。
手術設備維持到最少。
• 器械
1. 注射器2. 刀片式手術刀
3. 無創傷抓取器
4. 剪刀
5. Perfix 栓
6.狹長補體
7. Gauze墊
8. 牽引器
9. 自動靜止牽引器
10. 局部麻醉
5. 麻醉
• 產品
使用100 mL的lidocaine 溶液，含0.5% adrenaline；一般而言，60 mL 到80 mL 足以確保浸潤組織層。• Superficial tissue layer
This step begins by infiltration of the subcutaneous tissues along the path of the incision, going 1 to 2 cm beyond its edges.• Deeper tissue layer
After the cutaneous incision, a pocket is created in the subcutaneous layer at the upper end of the incision to the aponeurosis of the external oblique muscle. 5 mL of lidocaine are then injected, just below the aponeurosis, without injecting into the cord itself.
Anesthesia is established while pursuing the incision of the subcutaneous layer.
• Inguinal canal
After incision of the external oblique muscle, the genital branch of the genitofemoral nerve is infiltrated, on the lower edge of the cord, near the internal ring.During dissection, the hernia sac is infiltrated, notably at its neck.
6. Incision
• Superficial tissue layer
The 4 to 5 cm oblique cutaneous incision is performed alongside the inguinal canal and centered on the zone of tumefaction. 1. Anterior superior iliac spine
2. Pubic tubercle
• Deep tissue layer
An incision of the subcutaneous layer and of the external oblique muscle is performed, in order to sufficiently open the inguinal canal and visualize the spermatic cord. The incision of these deep layers is oblique, following the direction of the inguinal canal.• Inguinal canal
• Opening/spermatic cord
The cord is placed on a self-retaining grasper. A longitudinal incision of the sheath is made to free the hernia sac. The cremaster muscle is not resected.
• Dissection of hernia sac
The sac is dissected free to the internal ring using scissors and electrocautery.• Reduction of hernia sac
The surgeon then pushes back the sac with a finger into the preperitoneal space. Still using the finger, high dissection is pursued in this space to completely free the sac and create a pocket into which the plug may be inserted.7. Repair
• Generalities
The Perfix plug technique combines a conical plug, which is used to deeply push back the hernia sac, and a precut, slit onlay patch to cover the deep layer of the inguinal canal. The prostheses are made of non-absorbable polypropylene. • Plug and onlay patch
• Plug
Cone-shaped with eight pre-set pleats, it is lined inside by two layers of polypropylene petals. Different sizes are available: 4.1 cm; 4.8 cm.• Onlay patch
A precut, polypropylene patch with a slit terminated by an opening designed to leave a passage for the spermatic cord after positioning in front of the posterior wall of the inguinal canal. Available in one size, the patch may be adapted to the surface, which is to be covered.• Plug and patch placement
• Plug insertion
After pushing back the hernia sac, the plug is inserted, tapered end first, through the internal ring until the wider base of the plug is positioned at the edge of the internal ring delimited by the deep muscular layer. • Plug attachment
Once the plug is in place, it is attached by a small number of interrupted, non-absorbable sutures to the surrounding muscular layer.• Onlay patch placement
The two parts of the split section of the onlay patch are positioned around the spermatic cord and sutured together with one stitch. The patch is then laid in position on the posterior wall of the inguinal canal posterior to the spermatic cord.• Closure
The external oblique aponeurosis is reapproximated over the spermatic cord structures using a continuous, slowly absorbable suture. The subcutaneous tissues are then brought together with interrupted sutures and the skin edges are stitched with a running subcuticular suture.• Variation
• Hernial topography
1. Direct hernia (sometimes recurrent);2. External oblique inguinal hernia (sometimes recurrent);
3. Femoral hernia.
• Direct hernia
The cord is retracted either upwards or downwards to free the posterior wall of the inguinal canal.The patient is made to cough in order to force out the hernia. The hernia sac is freed up against the transversalis fascia, which is incised around the hernia sac (including large sacs) allowing the surgeon to easily push back the peritoneal sac behind the fascia with the plug. The plug is then attached to the edges of the fascia opening.
• Recurrent hernia
In the case of a small recurrent hernia (often direct), dissection of the hernia sac is limited to the immediate area surrounding the sac, preserving the spermatic cord.The transversalis fascia is incised around the sac. The sac is then pushed back inwards by the plug, which is attached to the edges of the fascia opening, in the same manner as for direct hernias.
• Crural hernia
When the diagnosis is certain, a direct femoral incision is performed. The hernia is dissected through the femoral opening, without having to open the inguinal canal. The hernia sac is reduced or resected, and a plug of a suitable size is inserted and fixed to the surrounding structures.8. Postop period
Hospital discharge:Same day as surgery if operation was early in the morning.
Postoperative care
Analgesics:
- surveillance of the wound;
- patient may shower if bandage is waterproof;
- stitches removed and postoperative check-up 10 days after surgery;
- 1 month, then 1 year check-up.
Activities:
- driving >24 hours;
- light loads <15 kg on D2;
- light activity as soon as pain goes away;
- moderate activity >D15;
- sports (biking, jogging, tennis) progressively >D21;
- strenuous activity >D30.
9. Conclusion
The minimally invasive technique is easily performed under local anesthesia. The plug hernia repair technique may be performed in an outpatient setting.
In addition to the postoperative comfort and low recurrence rate associated with this technique, the decrease in hospitalization costs is an advantage for our health systems.