术前多排螺旋CT检查在巨大腹壁切口疝修补术中的应用价值

Application value of the preoperative multi-slice spiral computed tomography for the repair of huge abdominal incisional hernia

目的探讨术前多排螺旋cT（MSCT）检查在巨大腹壁切口疝修补术中的应用价值。方法采用回顾性横断面研究方法。收集2012年1月至2016年2月新疆维吾尔自治区人民医院收治的61例巨大腹壁切口疝患者的临床资料。患者术前行MSCT检查及三维重建，测定疝囊容积与腹腔容积百分比。根据术前疝囊容积与腹腔容积百分比选择手术方式和计算行主动减容联合onlay术患者切除小肠长度。观察指标：（1）术前及术中情况：疝囊容积与腹腔容积百分比、术前住院时间、手术方式、行主动减容联合onlay术患者切除小肠长度、手术时间、术中出血量。（2）术后恢复情况：术后48h腹腔内压力、术后胃肠功能恢复时间、术后腹腔引流管拔除时间、术后并发症情况、术后住院时间。（3）随访情况：患者术后巨大腹壁切口疝复发及其他远期并发症情况。采用门诊或电话方式进行随访，了解患者术后巨大腹壁切口疝复发及其他远期并发症情况。随访时间截至2017年3月。正态分布的计量资料以元±s表示，偏态分布的计量资料以M（范围）表示。结果（1）术前及术中情况：61例患者疝囊容积与腹腔容积百分比为19％±4％，术前住院时间为（7±5）d。61例患者均成功完成手术，其中onlay术48例，主动减容联合onlay术13例，无中转手术方式。13例行主动减容联合onlay术患者切除小肠长度为（48±8）cm。61例患者手术时间为（2．6±0．8）h，术中出血量为（82±50）mL。（2）术后恢复情况：61例患者术后48h腹腔内压力为（9．6±2．9）mmHg（1mmHg=0．133kPa），术后胃肠功能恢复时间为（2．1±0．9）d，术后腹腔引流管拔除时间为（3．5±1．1）d。12例患者术后发生并发症，包括腹腔高压Ⅰ级、腹腔高压Ⅱ级、切口积液、切口感染、切口窦道形成、补片感染、尿潴留，行onlay术患者上述术后并发症例数分别为4、2、4、2、1、1、1例，行主动减容联合onlay术患者分别为2、1、1、0、0、0、0例。部分患者同时合并两种及以上并发症。无腹腔间隔室综合征发生和围术期死亡患者。所有并发症经对症处理后好转或痊愈。61例患者术后住院时间为（8±4）d。（3）随访情况：61例患者均获得术后随访，随访时间为6—36个月，中位随访时间为19个月。随访期间，2例患者巨大腹壁切口疝复发，暂行随访，建议患者治疗复发危险因素后再行手术治疗。其余患者未发生远期并发症。结论MSCT检查可在巨大腹壁切口疝修补术前精确提供疝囊容积与腹腔容积百分比等数据，对个体化选择手术方式，以及在主动减容联合onlay术中最大限度保留正常器官，提高手术疗效具有重要价值。

Objective To explore the application value of the preoperative multi-slice spiral computed tomography （MSCT） for the repair of huge abdominal ineisional hernia. Methods The retrospective cross- sectional study was conducted. The clinical data of 61 patients with huge abdominal incisional hernia who were admitted to the Xinjiang Uygur Autonomous Region People＇s Hospital from January 2012 to February 2016 were collected. All patients underwent preoperative MSCT and three-dimensional reconstruction to measure the percentage of volumes of the hernia sac and abdominal cavity and then selected the individualized surgical methods according to the percentage, and length of small intestine reseeted was calculated in patients undergoing initiative volume reduction combined with onlay repair. Observation indicators： （1） pre- and post-operative situations： percentage of volumes of the hernia sac and abdominal cavity, duration of preoperative hospital stay, surgical procedure, length of small intestine resected in patients undergoing initiative volume reduction combined with onlay repair, operation time and volume of intraoperative blood loss; （2） postoperative recovery situation： intra- abdominal pressure at postoperative 48 hours, recovery time of postoperative gastrointestinal function, removal time of postoperative abdominal drainage-tube, postoperative complications and duration of postoperative hospital stay; （3） follow-up. Follow-up using outpatient examination and telephone interview was performed to detect the postoperative hernia recurrence and long-term complications up to March 2017. Measurement data with normal distribution were represented as x±s and measurement data with skewed distribution were described as M （range）. Results （ 1 ） Pre- and post-operative situations ： percentage of volumes of the hernia sac and abdominal cavity in 61 patients was 19% ± 4%, and duration of preoperative hospital stay was （ 7 ± 5 ） days. All the 61 patients underwent successful operation, including 48 receiving onlay repair and 13 receiving initiative volume reduction combined with onlay repair, without conversion to other surgery. Length of small intestine resected in 13 patients undergoing initiative volume reduction combined with onlay repair was （48± 8 ）cm. Operation time and volume of intraoperative blood loss in 61 patients were （ 2.6 ± 0.8 ） hours and （ 82 ± 50） mL. （2） Postoperative recovery situation： intra-abdominal pressure at postoperative 48 hours, recovery time of postoperative gastrointestinal function and removal time of postoperative abdominal drainage-tube in 61 patients were （ 9.6 ± 2.9 ） mmHg （ 1 mmHg=0.133kPa）, （ 2.1 ±0.9） days and （ 3.5± 1.1 ） days, respectively. Twelve patients had postoperative complications, and grade I intra-abdominal hypertension, grade II intra-abdominal hypertension, incisional effusion, incisional infection, incisional sinus, mesh infection and urinary retention were respectively detected in 4, 2, 4, 2, 1, 1, 1 in patients undergoing the onlay repair and 2, 1, 1, 0, 0, 0, 0 in patients undergoing initiative volume reduction combined with onlay repair. Some patients had 2 or more of complications. There was no occurrence of abdominal compartment syndrome and perioperative death. Patients with complications were cured or improved by symptomatic treatment. Duration of postoperative hospital stay in 61 patients was （8±4）days. （3） Follow-up： all the patients were followed up for 6-36 months, with a median time of 19 months. During follow-up, 2 patients with recurrence of huge abdominal incisional hernia received tentative follow-up, and were suggested to treat risk factors of recurrence firstly and then undergo reoperations. Other patients didn＇t have long-term complications. Conclusion MSCT can provide the accurate data of percentage of volumes of the hernia sac and abdominal cavity before repair of huge abdominal incisional hernia, it also has the important clinical value of choosing the individualized surgical method, preserving the maximum out of normal organs in initiative volume reduction combined with onlay repair and increasing surgical outcomes.