膜解剖平面在腹腔镜全腹膜外修补术中临床意义

The clinical significance of surgical plane in laparoscopic totally extraperitoneal inguinal hernia repair

全腹膜外腹股沟疝修补术(TEP)是腹膜前间隙手术,可将腹横筋膜(TF)和腹膜组成的间隙理解为单层TF和多层次腹膜前筋膜(PPF)所构成的筋膜间平面。PPF将腹膜前间隙分为壁平面和脏平面。中央区域分离应在壁平面操作,过浅或过深有损伤腹壁下血管或膀胱的风险。壁平面是TEP的"神圣"平面,但在斜疝区域时,为了分离疝囊和保护精索,必须转入脏平面进行。"平面转换"对于疝囊回纳、腹膜前环分离以及补片展平等操作具有重要的临床意义。现代疝外科对腹膜前间隙的认知逐渐从"膜"转向"面",核心是强调TEP应在不同区域进入相对应的平面,而非寻找所谓的"膜"。

Totally extraperitoneal(TEP)is a preperitonealprocedure.It is more appropriate to understand the space oftransversalis fascia(TF)and peritoneum as the interfascialplane formed by a single-layer TF and multi-layerpreperitoneal fascia(PPF).PPF membranes divides thepreperitoneal space into the parietal plane and the visceralplane.Dissections of the median area should be performed inthe parietal plane,otherwise the inferior epigastric vessels orthe bladder could be damaged.The parietal plane is the"holyplane"of TEP.However,we must transit into the visceralplane,in order to reduce hernia sac and protect the elementsof spermatic cord while dissecting the indirect hernia zone.The"plane transition"plays an important clinical role in theprocedures such as hernia sac reduction,preperitoneal loopseparation and mesh flattening.Modern hernia surgery hastransferred the cognition of the preperitoneal space from"membrane"to"plane",which emphasize the key role ofperforming TEP within corresponding planes in differentzones,instead of identifying those membranes.