输精管-髂外血管间隙在免水分离SPLPEC手术治疗内环皱褶明显儿童斜疝中的应用

Application of vas deferens-external iliac vascular space during single-port laparoscopic percutaneous extraperitoneal closure using an inner grappler without hydrodissection in inguinal hernia with folded peritoneum around orifice in children

目的内环处后腹膜皱褶明显增加了单孔腹腔镜经皮腹膜外闭合(single port laparoscopic percutaneous extraperitoneal closure,SPLPEC)手术的难度,本研究将探讨借助输精管-髂外血管间隙实施免水分离SPLPEC手术治疗内环皱褶明显儿童斜疝的安全性及可行性。方法2017年11月至2018年12月,首都儿科研究所附属儿童医院对126例内环皱褶明显斜疝男性患儿实施了借助输精管-髂外血管间隙实施免水分离SPLPEC术(操作流程:在脐单孔腹腔镜监视下,将改良钩针钩挂丝线经腹横纹内环体表投影处穿刺至内环前壁腹膜外,钩针沿内环口内侧缘的输精管-髂外血管之间的间隙向Doom三角内潜行,潜行过程中缓慢向左右两侧摆动带线钩针以松弛该间隙,并将冗厚的后腹膜向Doom三角方向推动,随着该间隙的松弛和覆盖输精管的冗厚后腹膜的减少,输精管逐渐显露。回退带线钩针,顶起显露的输精管和其上后腹膜,在输精管-后腹膜间隙穿行至Doom三角内),并回顾性分析患儿手术和随访资料。结果术中证实单侧疝90例,双侧疝36例,共162侧。162侧中126侧内环皱褶明显,其中17侧实施改良钩针完全腹膜外抛掷丝线,未借助其他操作器械进行辅助,余109侧实施传统钩针刺破腹膜抛掷丝线。单侧皱褶明显斜疝平均手术时间为(17.5±3.5)min,合并对侧隐形疝平均手术时间为(23.2±2.2)min,无一例发生术中并发症,患儿均在术后24 h内出院。随访6~18个月,无一例出现伤口感染、医源性隐睾或睾丸萎缩等并发症,无一例复发疝、鞘膜积液和皮肤结肉芽肿形成。结论对于内环皱褶明显的儿童斜疝,带线钩针借助输精管-髂外血管间隙可有效松解冗厚的后腹膜,降低跨越输精管实施免水分离SPLPEC手术的难度,具有较好的安全性、可行性。

Objective Folded peritoneum around orifice increases the difficulty during single-port laparoscopic percutaneous extraperitoneal internal ring closure(SPLPEC).The aim of this study was to explore the safety and feasibility of SPLPEC via previous separation and loosening deferens-external iliac vascular space using an inner grappler without hydrodissection for inguinal hernia in children.Methods Between November2017 and December 2018,126 inguinal hernias children with folded peritoneum around orifice undertook SPLPEC via separation and loosening deferens-external iliac vascular space using an inner grappler without hydrodissection.Under single-port laparoscopic vision,an inner grappler with a non-absorbable suture was inserted at abdominal transverse striation into extraperitoneal space and fixed in an identical subcutaneous path.The inner grappler with suture passed through deferens-external iliac vascular space.Folded peritoneum around orifice was separated and loosened by enlarging this space and decreasing the attachment between vas deferens and retroperitoneum.After that,inclined surface of an inner grappler reached backward and passed through vas deferens without using hydrodissection technique.The same technique was applied for passing through spermatic vessel beyond hernia,followed by ligating and closing the orifice of inner hernia.Results A total of 162 sides of orifices(90 cases of unilateral hernia,n=90;bilateral hernia,n=36)were successfully completed using LPEC without hydrodissection via separating and loosening deferens-external iliac vascular space.Complete extroperitoeneal closure was performed without any assistances of extra instrument(n=17)and orifices were closed through retroperitoneal puncture(n=109).The average operative durations of unilateral and bilateral repairs were(17.5±3.5)and(23.2±2.2)min respectively.No intraoperative complications occurred and discharge was within 24 hours.During an average follow-up period of 6-18 months,there was no onset of wound infection,recurrence,iatrogenic cryptorchidism,testicular atrophy or granuloma.Conclusion Employing separating and loosening deferens-external iliac vascular space using an inner grappler without hydrodissection,SPLPEC is both safe and feasible for inguinal hernia children with folded peritoneum around orifice.