腹腔镜经腹腹膜前疝修补术的临床疗效及术后并发症危险因素分析

Clinical efficacy of laparoscopic transabdominal preperitoneal hernia repair and risk analysis affecting postoperative complications

目的探讨腹腔镜经腹腹膜前疝修补术（TAPP）的临床疗效及影响术后并发症的危险因素。方法采用回顾性病例对照研究方法。收集2008年2月至2016年8月苏州大学附属第一医院收治的595例行腹腔镜TAPP腹股沟疝患者的临床资料。手术由同一组医师完成，患者均行腹腔镜TAPP治疗。观察指标：（1）手术情况。（2）术后情况。（3）随访情况。（4）影响腹腔镜TAPP术后并发症的危险因素分析。采用门诊、电话等方式进行随访。随访内容为恢复非限制性活动时间，术后并发症及疝复发情况。随访时间截至2017年2月。正态分布的计量资料以3f＋S表示。单因素分析采用X。检验，多因素分析采用Logistic回归模型。结果（1）手术情况：595例患者均行腹腔镜TAPP．均使用重型补片。595例患者总体手术时间为（55±25）min，其中502例单侧疝手术时间为（50±20）min，93例双侧疝手术时间为（81±29）min；总体术中出血量为（7±5）mL。595例患者中，嵌顿疝34例，嵌顿内容物为：大网膜21例、小肠11例、乙状结肠2例；嵌顿时间为2～21h；其中4例嵌顿小肠坏死行腹腔镜辅助小肠切除＋吻合术，1例乙。状结肠坏死行坏死肠管切除＋乙状结肠造口术，29例疝内容物复位后行修补术。34例嵌顿疝患者手术时间为（84＋39）min，术中出血量为（12＋6）mL。595例患者中，复发疝13例（斜疝10例、直疝3例），手术时间为（75±26）min，术中出血量为（10±5）mL。（2）术后情况：595例患者术后肛门首次排气时间为（19±12）h。595例患者中，590例术后6h进食流质食物；5例行肠切除术，术后24h进食流质食物。患者术后第1天疼痛指数评分为（2．5±1．4）分，术后住院时间为（2．1±1．9）d。（3）随访情况：595例患者中，593例术后2周恢复非限制性活动，2例术后2周未恢复非限制性活动。542例获得中长期随访，随访时间为6～60个月，中位随访时间为31个月；术后并发症血清肿57例、术区疼痛25例、尿潴留13例、肠麻痹1例．同一例患者可合并多种并发症，经对症支持治疗后均好转；术后未出现需要手术干预的血管损伤、肠管损伤、戳孔疝等严重并发症。2例患者疝复发，1例为右侧斜疝腹腔镜TAPP术后复发直疝，行李金斯坦无张力疝修补术；1例于外院就诊。（4）影响腹腔镜TAPP术后并发症的危险因素分析：单因素分析结果显示：患者的年龄、疝囊直径、嵌顿疝、复发疝、手术时间和术中出血量均是腹腔镜TAPP术后并发症发生的相关因素（x^2=6．657，55．296，44．305，5．253，117．461，100．722，P〈0．05）。多因素分析结果显示：疝囊直径≥4cm，嵌顿疝、手术时间≥100min、术中出血量≥10mL是腹腔镜TAPP术后并发症发生的独立危险因素（OR=3．610，11．315，12．401，7．346，95％可信区间：2．009～6．486，3．579～35．772，5．408．28．437，3．739～14．434，P〈0．05）。结论腹腔镜TAPP是一种安全、有效治疗腹股沟疝的手术方式，而疝囊直径≥4cm，嵌顿疝、手术时间≥100min、术中出血量≥10mL是腹腔镜TAPP术后并发症发生的独立危险因素。

Objective To explore the clinical efficacy of laparoscopic transabdominal preperitoneal （TAPP） hernia repair and risk factors affecting postoperative complications. Methods The retrospective case- control study was conducted. The clinical data of 595 patients who received laparoscopic TAPP hernia repair in the First Affiliated Hospital of Soochow University from February 2008 to August 2016 was collected. Operations were performed by the same doctors＇ team. Observation indicators： （1） surgical situations; （2） postoperative situations; （3） follow-up situations; （4） risk factors affecting complications after laparoscopic TAPP hernia repair. Follow-up using outpatient examination and telephone interview was performed to detect the recovery time of non-restricted activity, postoperative complications and hernia recurrence up to February 2017. Measurement data with normal distribution were represented as x±s. The univariatc analysis and mukivariate analysis were done using the chi-square test and Logistic regression model. Results （ 1 ） Surgical situations： 595 patients underwent laparoscopic TAPP hernia repair using the heavy meshes. Overall operation time and overall volume of blood loss were （55±25） minutes and （7±5）mL, including operation time of （50±20）minutes in 502 unilateral hernias and operation time of （81±29） minutes in 93 bilateral hernias. Of 595 patients, 34 had incarcerated hernia, the contents of hernia： greater omentum, small intestine and sigmoid colon were detected in 21, 11 and 2 patients, respectively, with an incarcerated time of 2-21 hours; 4 with incarcerated hernia induced small intestinal necrosis received laparoscopy-assisted small intestinal resection ＋ anastomosis, 1 with sigmoid colon necrosis received necrotic sigmoid canal resection ＋ sigmoidostomy and 29 received repair after the contents restoration of hernia. Operation time and volume of intraoperative blood loss in 34 patients with incarcerated hernia were （84 ± 39）minutes and （12±6） mL. Thirteen of 595 patients （ 10 with indirect hernia and 3 with direct hernia） had recurrent hernia, and operation time and volume of intraoperative blood loss were （75±26）minutes and （10± 5） mL. （2） Postoperative situations ： time to initial exsufflation of 595 patients was （ 19 ±12） hours. Of 595 patients, 590 took fluid diet at 6 hours postoperatively and 5 undergoing enterectomy took fluid diet at 24 hours postoperatively. The pain score at 1 day postoperatively and duration of hospital stay were respectively 2.5±1.4 and （2. 1± 1.9） days. （3） Follow-up situations ： of 595 patients, 593 recovered non-restricted activity at 2 weeks postoperatively and 2 didn＇t recover non-restricted activity at 2 weeks postoperatively. Of 595 patients, 542 were followed up for 6-60 months, with a median time of 31 months. Fifty-seven, 25, 13 and 1 patients were respectively complicated with seroma, surgical pain, urinary retention and enteroparalysis, they were improved by symptomatic treatment, and the same patient can have multiple complications. There were no severe complications which needed surgical intervention, such as vascular injury, damnify of intestinal canal and poke hole hernia. Of 2 patients with recurrence of hernia, 1 with right indirect hernia had recurrence of direct hernia and then received Lichtenstein tension-free hernia repair, and 1 received treatment in other hospital. （4） Risk factors affecting complications after laparoscopic TAPP hernia repair： results of univariate analysis showed that age, diameter of hernia sac, incarcerated hernia, recurrent hernia, operation time and volume of intraoperative blood loss were related factors affecting complications after laparoscopic TAPP hernia repair （X^2 = 6.657, 55.296, 44.305, 5.253, 117.461, 100.722, P〈 0.05）. Results of multivariate analysis showed that diameter of hernia sac ≥ 4 cm, incarcerated hernia, operation time 〉1100 minutes and volume of intraoperative blood loss ≥10 mL were independent risk factors affecting complications after laparoscopic TAPP hernia repair （OR = 3.610, 11.315, 12.401, 7.346, 95% confidence interval： 2.009-6.486, 3.579-35.772, 5.408-28.437, 3.739-14.434, P〈 0.05）. Conclusion Laparoscopic TAPP approach for inguinal hernia is safe and effective, and diameter of hernia sac ≥ 4 cm, incarcerated hernia, operation time ≥ 100 minutes and volume of intraoperative blood loss ≥10 mL are independent risk factors affecting complications after laparoscopic TAPP hernia repair.