腹腔镜下不同手术路径及缝合方法个体化治疗小儿疝的临床分析

Clinical analysis of different operational approach and suture method of laparoscopic individual treatment for pediatric hernia

目的：探讨腹腔镜下不同手术路径及缝合方法治疗小儿疝的可行性、安全性、有效性及便捷性。方法：将2009年6月至2012年12月收治的106例腹股沟疝患儿根据具体情况分为3组，60例行腹腔镜单纯疝囊高位结扎术（A组），26例于腹腔镜下双重结扎内环口（B组），20例行腹腔镜疝囊高位结扎术并用脐内侧韧带覆盖内环12（c组），观察对比3组患儿手术时间、术中出血量、操作难度、围手术期并发症、复发率等指标。结果：3组手术均顺利完成，A组术后1例脐部切12发生线结反应，余均无大出血、肠管损伤、切口感染等并发症发生，术后均无明显疼痛。3组患儿手术时间、术中出血量差异无统计学意义；术后随访5个月-3年，A组复发2例，B组术后2年复发1例，c组无一例复发。A、B两组复发率与C组相比差异有统计学意义（P〈0．05）。结论：腹腔镜下小儿疝应依据患儿年龄、疝环类型与大小、初发复发等因素采取个体化的治疗方案，在主要步骤“疝环高位缝扎”不变的基础上，灵活选择附加术式，以期取得更完美的疗效。对于巨大疝及年长患儿单纯行腹腔镜单重或双重高位结扎疝囊是不够的，镜下用脐内侧韧带覆盖内环口是有必要的，且操作便捷、安全、有效。

Objective： To explore the feasibility, safety, effectiveness and convenience of different pathways and suture methods in the laparoscopic treatment of children$ hernia. Methods：From Jun. 2009 to Dec. 2012,106 patients of pediatric hernia who under- went laparoscopic operation were divided into 3 groups according to the specific situation of hernia, group A underwent the high ligation of the hernia sac （ 60 cases ） ; group B received double ligation of internal ring （ 26 cases ） ; group C was applied high ligation of the her- nia sac and coverage of the inner ring with the medial umbilical ligament （ 20 cases ）. The operation time, bleeding volume, operation difficulty, perioperative complications and recurrence rate were compared among the 3 groups. Results ：All operations were successful, 1 patient in group A suffered from knotting reaction at umbilical incision, there were not other complications, such as hemorrhage,intesti- nal injury or incisional infection. No obvious pain was found in any patients. The operative time and intraoperative blood loss were not statistically significant different among the 3 groups. The patients were followed up for 5 months to 3 years, 2 cases of recurrence in group A, 1 case of recurrence 2 years after operation in group B, and no recurrence in group C were found. The recurrence rate of group A and B was statistically significant different from that of group C （ P 〈 0.05 ）. Conclusions ： The laparoscopic treatment method for pe- diatric hernia should be chosen according to the age, type and size of the hernia ring, primary attack and relapse. The main procedure is high ligation of hernia ring,which should not be changed. While the additional operation should be flexibly chosen in order to acquire better therapeutic effect. Laparoseopic single and double high ligation of hernia sac is not enough for older children and huge hernia. It is necessary, convenient, safe and effective to cover the inner ring with medial umbilical ligament.