腹股沟疝无张力修补术后补片感染的外科治疗策略

Surgical treatment strategies of mesh infection after tension⁃free repair of inguinal hernia

目的探讨腹股沟疝无张力修补术后补片感染的外科治疗策略。方法采用回顾性描述性研究方法。收集2013年3月至2018年5月首都医科大学附属北京朝阳医院收治的88例腹股沟疝无张力修补术后补片感染患者的临床资料;男85例,女3例;平均年龄为58岁,年龄范围为14~84岁。患者均行清创手术。观察指标:(1)手术及术后情况。(2)随访情况。采用门诊或电话方式进行随访,了解患者术后伤口愈合情况,术后疝复发,术后疼痛及再感染情况。随访时间截至2019年7月。正态分布的计量资料以x􀭰±s表示,偏态分布的计量资料以M(范围)表示,计数资料以绝对数表示。结果(1)手术及术后情况:88例患者均顺利施行清创手术。88例患者中,71例行清创手术前先行腹腔镜探查,17例直接行开放清创手术。71例行腹腔镜探查患者中,63例经探查腹腔,分离肠管、网膜粘连后,未见肠管、膀胱等组织明显受感染累及,腹膜完整,遂中转行开放清创手术;4例经探查证实为小肠瘘,分离粘连后中转行开放清创手术,并行小肠部分切除吻合术;3例经探查证实为网塞感染,经腹腔镜切开腹膜自后入路取出感染网塞;1例经探查证实为膀胱瘘,经腹腔镜清除感染补片后行膀胱缝合修补术。88例患者中,82例为补片感染,其中31例完整清除补片,51例清除补片感染部分,术中发现合并线结感染28例,予以清除;6例仅为浅表感染,予以切除窦道等感染组织。84例行开放清创手术患者中,65例伤口放置引流管后行一期缝合;19例伤口敞开,视术后换药情况,13例放置负压封闭引流装置行持续引流,6例行换药治疗。88例患者手术时间为60 min(15~175 min),术中出血量为14 mL(2~200 mL),术后住院时间为22 d(1~101 d),术后均顺利拔管。88例患者术后切口愈合情况包括甲级愈合56例,乙级愈合15例,丙级愈合17例。88例患者中,71例术中留取脓液及缝线线结行细菌培养检查,其中结果阴性27例,金黄色葡萄球菌32例,溶血葡萄球菌5例,铜绿假单胞菌5例,屎肠球菌5例,人葡萄球菌亚种4例,奇异变形菌3例,黏质沙雷菌2例,无乳链球菌2例,大肠埃希菌2例,木糖氧化无色杆菌亚种1例,部分患者合并≥2种细菌感染。(2)随访情况:88例患者均获得术后随访,随访时间为14~76个月,中位随访时间为32个月。88例患者中,术后腹股沟疝复发5例,其中3例行经腹腔腹膜前腹股沟疝修补术,1例行开放腹膜前修补术,1例行经腹腔部分腹膜外疝修补术。1例患者术后疼痛,视觉模拟评分为2~4分,未予特殊处理。17例患者术后再次感染,3例经换药后伤口愈合,14例再次行清创手术完整清除感染组织后伤口愈合,其中合并残余补片感染7例,合并残余线结感染2例。结论腹股沟疝无张力修补术后补片感染处理情况复杂,手术清除感染补片是有效治疗手段。

Objective To investigate the surgical treatment strategies of mesh infection after tension⁃free repair of inguinal hernia.Methods The retrospective and descriptive study was conducted.The clinical data of 88 patients with mesh infection after tension⁃free inguinal hernia repair who were admitted to Beijing Chaoyang Hospital Affiliated to Capital Medical University from March 2013 to May 2018 were collected.There were 85 males and 3 females,aged from 14-84 years,with an average age of 58 years.All patients underwent debridement.Observation indicators:(1)surgical and postoperative situations;(2)follow⁃up.Follow⁃up using outpatient examination or telephone interview was conducted to detect wound healing,recurrence of inguinal hernia,postoperative pain and reinfection after operation up to July 2019.Measurement data with normal distribution were represented as Mean±SD,and measurement data with skewed distribution were represented as M(range).Count data was described as absolute numbers.Results(1)Surgical and postoperative situations:88 patients underwent debridement successfully.Of the 88 patients,71 cases underwent laparoscopic exploration before undergoing debridement,and 17 cases underwent open debridement directly.Of the 71 patients who underwent laparoscopic exploration,63 cases had intact peritoneum with no infection observed in intestine and bladder after laparoscopic abdominal exploration,and then were transferred to open debridement.Four cases with small bowel fistula confirmed by laparoscopic exploration were transferred to open debridement combined with small bowel resection and anastomosis after separating tissue adhesion.Three cases with mesh infection confirmed by laparoscopic exploration underwent the treatment of opening peritoneum and removing the infection mesh through posterior approach under laparoscopy.One case with bladder fistula confirmed by laparoscopic exploration underwent bladder repair after removing infection mesh under laparoscopy.Of the 88 patients,82 cases had mesh infection including 31 cases with mesh completely removed,51 cases with the infected part of mesh removed;28 cases had the sutures co⁃infected removed.Six of the 88 patients who only suffered from superficial infection underwent the treatment of removal of infected sinus tract.Of the 84 patients who underwent open debridement,65 cases underwent primary suture after indwelling drainage tube,19 cases kept incision opening including 13 cases undergoing continuous drainage with vacuum sealing drainage device after postoperative dressing change and 6 cases undergoing the treatment of dressing change.The operation time,volume of intraoperative blood loss and duration of postoperative hospital stay of 88 patients were 60 minutes(range,15-175 minutes),14 mL(range,2-200 mL)and 22 days(range,1-101 days),respectively.All patients underwent postoperative extubation successfully.There were 56 cases of class A healing,15 cases of class B healing and 17 cases of class C healing in 88 patients.Seventy⁃one of 88 patients underwent bacterial culture examination of intraoperative pyogenic fluid and sutures,of which 27 cases had negative results,32 cases had staphylococcus aureus infection,5 cases had staphylococcus haemolyticus infection,5 cases had pseudomonas aeruginosa infection,5 cases had enterococcus faecium infection,4 cases had staphylococcus hominis subsp infection,3 cases had proteus mirabilis infection,2 cases had serratia marcescens infection,2 cases had streptococcus agalactiae infection,2 cases had escherichia coli infection and 1 case had achromobacter xylose oxidation subsp infection.There were some cases undergoing more than 2 kinds of bacterial infection.(2)Follow⁃up:88 patients underwent postoperative follow⁃up for 14 to 76 months,with a media follow⁃up time of 32 months.Of the 88 patients,5 cases underwent postoperative recurrence of inguinal hernia including 3 undergoing transabdominal preperitoneal inguinal hernia repair,1 undergoing open preperitoneal inguinal hernia repair and 1 undergoing partial extraperitoneal inguinal hernia repair.One case had postoperative pain with the visual simulation score of 2-4 and received no special treatment.Seventeen cases had postoperative reinfection,in which 3 achieved wound healing after dressing change and 14 achieved wound healing after surgical removal of the infected tissue completely including 7 cases with residual mesh infection and 2 cases with residual suture infection.Conclusions Surgical strategy of mesh infection after tension⁃free repair of inguinal hernia is complicated.Removal of the infected mesh by surgery is an effective treatment.