不同操作通道下腹腔镜经皮腹膜外环扎术治疗儿童鞘膜积液——两中心950例经验总结

Laparoendoscopic percutaneous extraperitoneal closure using different approaches for various types of hydroceles in children

目的总结传统两孔、单部位两孔和单孔三种操作通道下腹腔镜技术经皮腹膜外环扎术治疗儿童各种类型鞘膜积液的临床经验。方法回顾性分析两所专业儿童医疗中心自2013年8月至2015年8月收治的950例不同类型男性儿童鞘膜积液病例资料。年龄4个月至14岁,平均年龄(3.68±2.20)岁。患儿均采用腹腔镜下经皮腹膜外环扎术。依据操作通道的不同分为:传统两孔组387例,单部位两孔组468例,单孔组95例。比较各组患儿手术过程、疗效与并发症情况。结果 950例均顺利完成手术,共关闭未闭鞘状突1 383侧。发现对侧隐性鞘状突未闭288例(35.8%)。4例因术中腹腔镜下未发现开放的鞘状突内口,改为经阴囊的睾丸鞘膜翻转手术。三组手术时间无明显差异(χ~2=5.76,P=0.07)。术后随访时间中位数为16.5个月(8~32个月)。两医疗中心在并发症方面比较差异无统计学意义(P>0.05)。传统两孔组、单部位两孔组、单孔组分别发现对侧隐性鞘状突未闭122例、148例、18例,发生腹膜后血肿例数分别为4例、2例、0例,术后复发例数分别为4例、4例、2例,术后对侧异时性鞘膜积液分别为0例、0例、2例,脐部切口感染分别为1例、0例、0例。单孔组与其他两组相比,在发现对侧隐性鞘状突未闭和术后对侧异时性鞘膜积液的比例上差异有统计学意义(P<0.05)。记录三组各15例患儿术后6 h疼痛FLACC评分,均在0~2分。随机调查50例患儿术后1年脐部伤口外观情况,单部位两孔组与单孔组术后伤口外观无差别。结论腹腔镜经皮腹膜外环扎术治疗各种类型儿童鞘膜积液操作简便,疗效确切。环脐单部位两孔法手术操作较单孔手术更加简便,术后伤口外观优于传统两孔法,并可与单孔手术伤口相媲美。在对侧隐性鞘状突未闭的探查上两孔法较单孔法更有优势。

Objective To sum up the experiences of different approaches of conventional two-port sur-gery,transumbilical single-site two-port surgery and single-site surgery of laparoendoscopic percutaneous extra-peritoneal closure （LPEC）for various typeshydroceles in children. Methods At two children＇s medical centers from August 2013 to August 2015,retrospective analyses were conducted for 950 boys with a mean age of 3.68 ±2.20 （1/3-14）years.They underwent LPEC by the following three approaches：conventional two-port surgery group （n=387）,single-site two-port surgery group （n=468）and single-site surgery group （n=95）.Statistical analyses were conducted for clinical data and complications.Results Among 950 success-fully operated cases,1383 sides of patent processus vaginalis （PPV）were closed.And 288 cases （35.8%） had potential contralateral patent processus vaginalis （cPPV ）.Four patients with their internal rings closed during exploration were converted into scrotum incision procedure.No significant difference existed in operative duration among three groups （χ2 =5.76,P =0.07）.The median follow-up period was 16.5 （8 -32） months.No significant differences existed in clinical data and complications between two centers （P〉0.05）. In conventional two-port,single-site two-port and single-site surgery groups,cPPV were found in 122,148 and 18 cases while retroperitoneal hematoma （RH）in 4,2 and 0 cases,recurrences in 4,4 and 2 cases,con-tralateral metachronous hernia or hydroceles in 0,0 and 2 cases,postoperative umbilical infection in 1 ,0 and 0 case respectively.Significant differences existed between single-site and other two groups in cPPVs and con-tralateral metachronous hydroceles （P〈0.05）.FLACC pain scores after 6-hour surgery were recorded and all scores were 0—2 points.A random survey of umbilical incision in 50 patients after 1 —year surgery showed no significant difference between single-site and single -site two -port surgical groups. Conclusions LPEC is safe,feasible and effective in the treatment for pediatric hydroceles.Transumbilical single-site two-port sur-gery is more convenient.It offers the same incision cosmetics as single-site surgery,but superior to explora-tion of cPPV.