腹腔镜完全腹膜外疝修补手术难点及操作技巧

Difficulties and Operating Skills of Laparoscopic Total Extraperitoneal Hernia Repair

目的探讨腹腔镜完全腹膜外疝修补术（totally extraperitoneal，TEP）难点及操作技巧。方法2006年5月～2010年5月，施行257例腹腔镜疝修补手术，对术中遇到的操作难点及手术技巧进行总结分析。结果254例行TEP，3例因腹膜破裂中转为经腹腔腹膜前疝修补术（transabdominalpreperitoneal，TAPP）。术后5例出现阴囊血肿，经非手术治愈；1例出现疝囊残端血肿，手术行血肿清除及残留疝囊切除。257例随访时间6～51个月，平均28个月，其中3例（1.2％）分别于术后6、14、23个月出现对侧疝，再次行TEP；2例分别于术后20、60d复发，行二次开放无张力疝修补手术；1例7个月后出现疝钉处疼痛，局麻取出疝钉后痛疼消失，其余患者均无异常。结论TEP的技术关键点主要是腹膜前间隙的建立、镜下解剖标志的应用、正确的疝囊分离方法、补片放置及固定和隐匿疝的恰当处理。

Objective To investigate the difficulties and operating skills of laparoscopic total extraperitoneal hernia repair. Methods Totally 257 patients underwent laparoscopic hernia repair from May 2006 to May 2010 in our hospital, and the difficulties and operating skills were analyzed. Results Among the patients, TEP was carried out in 254 patients, the other 3 patients were converted to transabdominal preperitoneal prosthesis （TAPP） for rupture of the peritoneum. After the operation, 5 patients showed hematoma of the scrotum, and then was cured by conservative therapies. Hematoma in the hernial sac stump was detected in 1 patient, who thus underwent hematoma evacuation and residual hernia capsule resection. A mean of 28 months （6 -51 months） follow-up was achieved in the patients, during the period, 3 cases （ 1.2% ） developed contralateral hernia at 6, 14 and 23 months, and thus received a second TEP; 2 cases had recurrent hernia at 20 and 60 days postoperation, and then underwent second non-tension hernia repair; one patient complained of pain at the nail site, and was cured by removing the nail under local anesthesia. No complications were shown in the other patients. Conclusions The key techniques of TEP include setting up accurate extraperitoneal space, using anatomic landmark in laparoscopy, detaching hernial sac accurately, and placing and fixing the patch and treating occult inguinal hernia reasonably.