急诊腹股沟疝的诊断与治疗分析

Diagnosis and treatment of emergency inguinal hernia

目的探讨急诊腹股沟疝的诊断与治疗。方法采用回顾性横断面研究方法。收集2015年1月至2020年5月苏州大学附属第一医院收治的236例急诊腹股沟疝病人的临床资料;男194例,女42例;年龄为(69±30)岁。病人需行常规血液生化检查,以及影像学检查判断疝内容物性状及肠梗阻情况。根据病人自身情况选择手法复位和手术治疗。观察指标:(1)治疗情况。(2)随访情况。采用门诊和电话方式进行随访,了解病人疝腹发和迟发性补片感染情况。随访时间截至2020年8月。计量资料以M(范围)或M(P25,P75)表示,组间比较采用Wilcoxon秩和检验;计数资料以绝对数表示,组间比较采用χ^(2)检验。结果(1)治疗情况:236例病人中,手法复位成功106例,行急诊手术124例,拒绝手术6例。①106例病人手法复位成功(4例经B超检查引导),手法复位时间为5 min(2 min,7 min);其中93例复位后行择期手术,斜疝89例、直疝和复合疝各2例,择期手术时机为手法复位后3 d(2 d,5 d),常规行补片修补术,手术时间为44 min(29 min,66 min),术中出血量为10 mL(5 mL,20 mL),术后首次肛门排气时间为1 d(1 d,2 d),术后住院时间为1 d(1 d,2 d)。11例病人未行择期手术。2例病人手法复位成功后出现腹痛、发热,急诊手术探查示小肠穿孔,行小肠部分切除+疝囊高位结扎术。②124例行急诊手术病人中,斜疝93例、股疝18例、闭孔疝6例、复合疝6例、直疝1例;开放手术54例,包括Bassini手术21例,Lichtenstein手术18例,McVay手术9例,疝囊高位结扎术6例;腹腔镜手术70例,包括腹腔镜下经腹膜前疝修补术57例,腹腔镜探查+组织缝合修补术10例,腹腔镜探查+疝环缝合术3例。开放手术和腹腔镜手术病人手术时间、术中出血量、术后首次肛门排气时间、术后近期并发症分别为60 min(50 min,76 min)和56 min(47 min,77 min),20 mL(14 mL,30 mL)和20 mL(10 mL,25 mL)、2 d(1 d,2 d)和2 d(1 d,2 d)、15例和21例,两者上述指标比较,差异均无统计学意义(Z=-0.88、-1.37、-1.56,χ^(2)=0.07,P>0.05);术中置入补片、术后住院时间分别为18例和57例、5 d(3 d,8 d)和3 d(2 d,5 d),两者上述指标比较,差异均有统计学意义(χ^(2)=29.50,Z=-4.32,P<0.05)。(2)随访情况:236例病人中,192例获得随访,随访时间为2~60个月,中位随访时间为19个月。随访期间7例急诊手术病人疝复发,其中疝囊高位结扎术3例、Bassini手术2例、Lichtenstein手术和腹腔镜探查+内环口结扎各1例。1例行急诊Lichtenstein手术病人发生迟发性补片感染,再次手术取出补片后好转。184例病人随访期间未发生疝复发与迟发性补片感染等长期并发症。结论急诊腹股沟疝病情各异,手法复位可治疗部分病人梗阻状态,但手术治疗仍是首选。手术方式需个体化选择。

Objective To investigate the diagnosis and treatment of emergency inguinal hernia.Methods The retrospective cross-sectional study was conducted.The clinical data of 236 patients with emergency inguinal hernia who were admitted to the First Affiliated Hospital of Soochow University from January 2015 to May 2020 were collected.There were 194 males and 42 females,aged(69±30)years.Hospitalized patients received routine blood biochemistry test and imaging examinations for evaluation of characteristics of hernia contents and intestinal obstruction.Manual reduction and surgical treatment were selected according to the conditions of patients.Observation indicators:(1)treatment;(2)follow-up.Follow-up using outpatient examination and telephone interview was performed to detect hernia recurrence and late-onset mesh infection up to August 2020.Measurement data were described as M(range)or M(P25,P75),and comparison between groups was analyzed using the Wilcoxon rank sum test.Count data were represented as absolute numbers,and comparison between groups was done using the chi-square test.Results(1)Treatment:of the 236 patients,106 cases had successful manual reduction,124 cases underwent emergency operation,6 cases refused surgery.①For 106 cases with successful manual reduction(including 4 cases guided by B-ultrasonography),the manual reduction time was 5 minutes(2 minutes,7 minutes).Ninety-three of 106 patients underwent selective operation after manual reduction,including 89 cases with indirect hernia,2 cases with direct hernia and 2 cases with compound hernia.The time to selective operation was 3 days(2 days,5 days)after manual reduction.Patients underwent mesh repair,of which the operation time,volume of intraoperative blood loss,time to postoperative first flatus,duration of postoperative hospital stay were 44 minutes(29 minutes,66 minutes),10 mL(5 mL,20 mL),1 day(1 day,2 days),1 day(1 day,2 days),respectively.Eleven patients didn't undergo selective operation.Two patients with abdominal pain and fever after manual reduction were diagnosed with perforation of intestine by emergency surgical exploration,and then underwent partial intestinal resection combined with high ligation of hernial sac.②There were 93 of 124 patients undergoing emergency operation with indirect hernia,18 cases with femoral hernia,6 cases with obturator hernia,6 cases with compound hernia and 1 case with direct hernia.There were 54 of 124 patients undergoing open operation,including 21 cases with Bassini surgery,18 cases with Lichtenstein surgery,9 cases with Mc Vay surgery,6 cases with high ligation of hernia sac.There were 70 patients undergoing laparoscopic operation,including 57 cases with laparoscopic transperitoneal preperitoneal hernia repair(TAPP),10 cases with laparoscopic explora-tion+tissue repair and 3 cases with laparoscopic exploration+closure of inner inguinal ring.The operation time,volume of intraoperative blood loss,time to postoperative first flatus,cases with short-term postoperative complications were 60 minutes(50 minutes,76 minutes),20 mL(14 mL,30 mL),2 days(1 day,2 days),15 cases for patients undergoing open surgery,respectively.The above indicators were 56 minutes(47 minutes,77 minutes),20 mL(10 mL,25 mL),2 days(1 day,2 days),21 cases for patients under-going laparoscopic surgery.There was no significant difference in the above indicators between the two groups(Z=‒0.88,‒1.37,‒1.56,χ^(2)=0.07,P>0.05).Cases with intraoperative placement of mesh and duration of hospital stay were 18 cases and 5 days(3 days,8 days)for patients undergoing open surgery,versus 57 cases and 3 days(2 days,5 days)for patients undergoing laparoscopic surgery,showing significant differences between the two groups(χ^(2)=29.50,Z=‒4.32,P<0.05).(2)Follow-up:of 236 patients,192 were followed up for 2‒60 months,with a median follow-up time of 19 months.Seven patients had recurrence of hernia after emergency operation,including 3 with high ligation of the hernia sac,2 with Bassini surgery,1 with Lichtenstein surgery,and 1 with laparoscopic exploration+closure of inner inguinal ring.One patient with late-onset mesh infection after Lichtenstein surgery was improved after mesh removal.No long-term complications such as hernia recurrence or late-onset mesh infection occurred to the 184 patients.Conclusions Emergency inguinal hernia had different state of illness,manual reduction is suitable for partial patients with incarceration.Surgery is the first choice,and the surgical procedure needs to be individually selected.