人工弓状线切开技术在弓状线变异腹腔镜全腹膜外腹股沟疝修补术中的应用:附视频

Application of artificial arcuate line technique in totally extraperitoneal approach with variation of low or no arcuate line:video attached

目的探讨人工弓状线切开技术在变异弓状线病例腹腔镜全腹膜外腹股沟疝修补术(TEP)应用的可靠性、安全性和有效性。方法回顾性分析2016年7月至2019年8月广东医科大学茶山医院施行TEP的60例弓状线变异患者资料,在脐与耻骨联合连线中点人为切开腹直肌后鞘及其后面的腹横筋膜创建一条人工弓状线,并对其后面的腹膜前间隙进分离。影像记录弓状线的形态和手术步骤。结果低位弓状线50例(83.3%),位于脐下8~12 cm,表现为不完整的腹直肌后鞘,向下呈逐渐变薄、变少的散在纤维。无弓状线10例(16.7%),有完整的腹直肌后鞘并一直延伸至耻骨。以人工弓状线为界分为两个层面,前面的是腹直肌后间隙,后面是腹膜前间隙,位于腹横筋膜(含有后鞘)与腹膜前筋膜浅层之间,是TEP理想的分离层面,沿此间隙向下分离与Retzius间隙相连,然后向外分离Bogros间隙。本组平均手术时间(130±15)min,术中腹膜损伤率8.3%(5/60)。术后发生血肿3例,血清肿2例,皮下气肿3例,无慢性疼痛病例。术后平均随访25个月,无复发病例。结论人工弓状线切开技术在低位和无弓状线患者的TEP手术中安全有效、简单可靠,值得推广。

Objective To explore the reliability,safety and efficacy of artificial arcuate line in totally extraperitoneal(TEP)patients with low or no arcuate line.Methods Sixty patients with variations of arcuate line undergoing TEP from July 2016 to August 2019 in Chashan Hospital of Guangdong Medical University were retrospectively studied.A transverse artificial line was surgically created at the middle of the umbilicus and symphysis pubis,and the preperitoneal space posterior to it was separated.Complication analysis and postoperative follow-up were recorded.Results The low arcuate line showed incomplete posterior rectus sheath(50 cases with 8-12 cm below umbilicus,83.3%)with attenuated fibers extending to the pubic bone,while absent arcuate line presented a long aponeurotic rectus sheath extending onto the pubic bone(10 cases,16.7%).The transverse cleavage in the posterior rectus sheath divided the retropubic space into two different spaces:the anterior space was a continuation of the posterior rectus space;and the posterior to this was the true preperitoneal space situated between the transversalis fascia and the superficial layer of preperitoneal fascia,which extended to Retzius space.Bogros space between the peritoneum and the deeper layer of the preperitoneal fascia was then freed.The mean operation time was(130±15)min.The incidence of peritoneum injury was 8.3%(5/60),no epigastric vessels were injured.There were three hematoma and two seroma.No recurrence was found after an average follow-up of 25 months.Conclusion The special technique of artificial creation of arcuate line in TEP patients with low or absent arcuate line was safe,efficient,and was strongly recommended.