1例腹股沟滑动疝患者腹股沟疝修补术后肠瘘事件的根本原因分析

RCA analysis of intestinal fistula after TAPP for inguinal sliding hernia:a case report

腹股沟疝是普通外科常见病,常表现为腹股沟区局部隆起的包块,全球发病率为1%~6%,手术是唯一的治愈方法。腹腔镜腹股沟疝修补术(TAPP)开始于20世纪90年代初,优点是切口小、创伤轻、并发症少、美观、康复快,且可在术中发现对侧隐匿疝并同时进行修补。滑动疝是一种特殊类型的腹股沟疝,一般术中才能确诊,文献报道较少见,常被忽视,术中处理可能损伤周围脏器及肠壁,但术后发生肠瘘的并发症国内外少见报道,一旦发生,需要手术取出补片,切除瘘口行肠道重建,处理不当可能危及生命。为了提高医疗、护理质量,针对此次腹股沟疝患者TAPP术后肠瘘事件的不良事件,应用科学的品管工具,通过严重度评估矩阵本案伤害程度属重度伤害,经异常事件决策树评估本案属系统问题,判定此次事件适用于根本原因分析(RCA)法。应用RCA四个阶段找到TAPP术后肠瘘发生的根本原因并提出有效预防措施,降低TAPP术后肠漏并发症风险。

Inguinal hernia is a common disease in general surgery,it often presents as a lump in the groin area,the incidence rate is 1%to 6%,surgery is the only cure method.Laparoscopic inguinal hernia repair(TAPP)began in the early 1990s,it has the advantages of small incision,light trauma,less complications,beautiful appearance and quick recovery,and the contralateral occult hernia can be found and repaired at the same time.Sliding hernia is a special type of inguinal hernia,which can only be diagnosed during operation,literature reports are rare and it's often overlooked,intraoperative management may damage the surrounding organs and intestinal wall,complications of postoperative intestinal fistula are rarely reported at home and abroad,once it happens,it is necessary to remove the patch and remove the fistula for intestinal reconstruction,improper treatment may be life-threatening.In order to improve the quality of medical treatment and nursing,according to the adverse events of intestinal fistula after TAPP in inguinal hernia patients,we use scientific quality control tools and severity assessment matrix to determine the severity of the injury for severe injury,through the decision tree of abnormal events,we evaluate the case as a system problem and determined that the event is suitable for RCA analysis.We use four stages of RCA to find out the root cause of intestinal fistula after TAPP,and put forward effective preventive measures to reduce the risk of complications of intestinal fistula after TAPP.