膜解剖理论在全腹膜外腹股沟疝修补术中的应用

Application of membrane anatomy theory in totally extraperitoneal inguinal hernia repair

中线位镜推法是目前全腹膜外腹股沟疝修补术(TEP)最常用的方法,膜解剖理论对其有指导意义。本文采纳筋膜"圆筒壁"、"多层次"、"筋膜间平面"、"联合筋膜平面"、"平面转换"等概念和理论,来阐述TEP术中空间建立、疝囊分离以及补片平展等关键步骤。镜推法沿腹直肌后鞘前行,首先进入肌后间隙,位于腹直肌和腹横筋膜(TF)之间,内有腹壁下血管及其分支,应避免过度分离。然后向下穿过TF,进入腹膜前间隙。腹膜前间隙被腹膜前筋膜(PPF)分为壁平面和脏平面,膀胱、精索成分均位于脏平面。中央区域应在壁平面即"外科间隙"分离,以保护膀胱。壁平面是TEP的"神圣"平面。斜疝区域应在脏平面即"解剖间隙"分离,以保护精索成分不被离断。直疝分离可理解为TF和PPF的分离,相对容易。斜疝分离则为腹膜和精索成分的分离,有一定难度。壁、脏平面转换中,应切开PPF(腹膜前环),充分完成壁化,以展平补片。

Trocar placement and camera-dissection in the midline is the most commonly applied method for total extraperitoneal inguinal hernia repair(TEP),for which the theory of membrane anatomy has guiding significance.We hereby applies the theories and concepts,such as"fascia lining","multi-layer","inter-fascial planes","combined inter-fascial plane"and"plane transition",to elucidate the key steps of TEP,for instance,space creation,hernia sac dissection,mesh flattening.Camera-dissection is performed along the posterior sheath of the rectus abdominis.Firstly,the camera enters retro-rectus space locating between the rectus abdominis and the transversalis fascia(TF).There are inferior epigastric vessels and their branches in the retro-rectus space,thus over-dissection should be avoided.Secondly,the camera goes downward through the TF into the pre-peritoneal space.The pre-peritoneal space is divided into the parietal plane and visceral plane by pre-peritoneal fascia(PPF).Both bladder and spermatic cord components locate on the visceral plane.Dissection of the median area should be implemented on the parietal plane,namely"surgical space",to protect the bladder.The parietal plane is the"holy plane"of TEP.Dissection of the indirect hernia area should be implemented on the visceral plane,namely"anatomical space",to protect the spermatic cord components.The reduction of direct hernia could be understood as the easy separation of TF and PPF.The reduction of indirect hernia is relatively difficult separation of peritoneum and spermatic cord components.During the transition of parietal and visceral planes,PPF(especially the pre-peritoneal loop)should be dissected for complete parietalization,in order to flatten the mesh.