脐疝合并腹水的疝修补手术治疗

Herniorrhaphy of umbilical hernia with ascites

目的探讨脐疝合并腹水时腹水的控制、手术时机及手术方式的选择。方法回顾性分析21例脐疝合并腹水患者的临床资料，少量腹水以口服利尿药为主，中等量腹水以联合利尿为主，顽固性腹水给予腹腔放液（3000ml／次）治疗，同时给了适量的白蛋白和羟乙基淀粉静脉扩容及小剂量的多巴胺和联合利尿等综合治疗，如腹水重新有积聚，间隔2～4d再次腹腔放液。待腹壁张力下降，腹围缩小，疝囊壁松软出现皱缩，再开始手术。术前经过1～2次放液治疗后如仍有较明显的腹水，术中需缓慢腹腔放液控制在4000ml以下，术后继续联合利尿巩固治疗．本组21例，行传统缝合修补1例，无张力疝修补20例。结果本组21例手术均顺利，手术时间25～90min，平均45min。术后切口感染1例，为脐疝破裂患者，3周后死丁肝功能哀竭；血清肿1例自愈；余患者未发现肝肾及心脑肺并发症。术后随访19例，失访1例。随访时间2～52个月，平均23个月，无复发病例。结论对脐疝合并腹水的患者，加强围手术期处理，把握好手术时机，无张力疝修补术同样具有手术安全、术后恢复快、疗效满意和复发率低等优点。

Objective To discuss the control of ascites, timing and skill of herniorrhaphy for the treatment of umbilical hernia with ascites. Methods The management of 21 patients of umbilical hernia with ascites were retrospectively analyzed. Preoperative small amount of ascites was managed with oral diuretics, medium amount of ascites was treated with combined oral and intravenous diuretics, refractory ascites was treated with paracentensis （3000ml each time）. In the meantime, intravenous albumin, dopamine and fluid therapy were administered. In relapsing aseites, repeated paracentensis in a time interval of 2- 4 days was applied. It was time for surgery when abdominal wall tension ameliorated, abdominal circumference reduced and the hernia sac shrank. In case of ascites refractory to all preoperative management an intraoperative slow extraction of the aseites to the amount below 4000 ml is mandatory. Perioperative diuretic therapy is the key for a successful herniorrhaphy. There were 21 cases in our group, 19 cases underwent selective operation, 2 cases were treated with emergency operation; 20 cases by tension-free hernia repair, 1 case by suture herniorrhaphy. Results Surgei.＇y was successful in all patients, the mean operative time was 45 min （ 25 - 90min）, 1）uring the follow-up period from 2 to 52 months （ meanly 23 months） , only 1 ease lost and the other 19 eases healed with no recurrence. 20 patients healed well with no hernia recurrence or complications. One case who was treated with suture herniorrhaphy suffered from incisional infection, and died of hepatic failure 3 weeks after surgery. Conclusions Umbilical hernia with ascites is not an absolute surgical contraindication. By intensive management of the ascites in perioperative period and prudent selection of the timing of surgery, tension-free herniorrhaphy is a safe and effective treatment for umbilical hernia.