基于数据分析与计算的模型化布孔法在腹腔镜腹壁切口疝修补术中的应用

Application of modelized port arrangement based on data analysis and calculation in laparoscopic repair of abdominal wall incisional hernia

背景与目的:随着微创理念及技术的发展,经腹腔镜完成腹壁切口疝手术已成为趋势,但由于腹壁切口疝位置大小不定,暂无成熟的布孔方法供术者参考,使得手术术式的学习难度较大,不合理的布孔还易导致手术难度加大。笔者在此介绍一种基于数据分析与计算的模型化布孔方法,并通过与传统经验性布孔法进行比较,探讨其优势和临床效果。方法:选择2017年1月—2018年5月中山大学附属第六医院收治并拟行腹腔内补片植入术(IPOM)的44例腹壁切口疝患者,用随机数字表法将患者分为对照组(21例)和研究组(23例),对照组采用术中放置观察孔后以手术经验放置操作孔的布孔方法,研究组采用术前腹部轮廓分析,并按照步骤划定限制条件,根据操作器械尺寸计算合理距离的方法指导穿刺孔放置位置的方法。比较两组患者术中及术后的相关临床指标。结果:两组患者一般资料差异无统计学意义(均P>0.05)。与对照组比较,研究组的平均布孔时间(7.28 min vs.9.93 min)、平均手术时间(67.62 min vs.79.10 min)、术中加孔率(17%vs.48%)均明显减少(均P<0.05)。研究组与对照组患者的术后并发症发生率(4.3%vs.19.0%),术后住院时间(5.13 d vs.5.76 d)及术后复发率(4.3%vs.4.8%)差异均无统计学意义(均P>0.05)。结论:在腹腔镜腹壁切口疝IPOM手术采用模型化布孔法可以缩短布孔时间,合理的操作孔布置可以降低腹腔镜下粘连分离、缺损缝合及补片固定的难度,降低手术总时间及术中增加操作孔的几率,并不增加术后并发症发生率,住院时间及复发疝的几率。模型化布孔法以客观数据+定量计算代替传统布孔法的经验决策,在方法步骤上更明晰,并可以在使用中不断更新改进,将有助于腹腔镜腹壁切口疝手术的规范与推广。

Background and Aims:With the development of minimally invasive concepts and techniques,laparoscopic incisional hernia surgery has become a major trend.However,due to the varied size and location of the abdominal incisional hernia,there are no established trocar arrangement criteria to apply for surgeons,which makes the learning process of this procedure more difficult,and the inappropriate trocar arrangement will also likely lead to increased surgical difficulty.Here,the authors introduce a modelized trocar arrangement method based on data analysis and calculation,and show its advantages and clinical efficacy by comparison with the conventional trocar arrangement method based on experience.Methods:A total of 44 eligible patients with abdominal wall incisional hernia scheduled to undergo laparoscopic intraperitoneal onlay mesh repair(IPOM)in the Sixth Affiliated Hospital of Sun Yat-sen University from January 2017 to May 2018 were enrolled,and randomly designated to control group(21 cases)and study group(23 cases)by computer generated randomization.During operation,the arrangement of the operating trocars after the observation trocar placement was performed according to the surgical experience in control group,while the layout of the trocar ports was directed by calculation of the reasonable distance according to the operation instruments size after preoperative abdominal contour analysis and stepwise determination of the restrictive parameters.The main intra-and postoperative clinical variables between the two groups were compared.Results:There were no significant differences in the general characteristics between the two groups of patients(all P>0.05).In study group compared with control group,the average trocar placement time(7.28 min vs.9.93 min),the average operative time(67.62 min vs.79.10 min),and the intraoperative trocar addition rate(17%vs.48%)were all significantly reduced(all P<0.05).There were no significant differences between study group and control group in terms of the incidence of postoperative complications(4.3%vs.19.0%),the length of postoperative hospital stay(5.13 d vs.5.76 d)and postoperative recurrence rate(4.3%vs.4.8%)between the two groups(all P>0.05).Conclusion:In laparoscopic IPOM repair of abdominal wall incisional hernia,using the modelized trocar arrangement method can shorten the trocar placement time after operation initiation,and its rational placement of the operating trocars can reduce the difficulty of adhesion separation,defect suturing and mesh fixation,reduce the total operative time and the probability of additional operating trocar requirement during the operation,and meanwhile,it will not increase the incidence of postoperative complications,hospitalization time and the probability of hernia recurrence.The modelized trocar arrangement method that uses the objective data plus quantitative assessment to replace the experience-oriented decision-making of the conventional port arrangement,is more explicit in the using process,and also can be continuously updated and improved in practice.So,it is helpful for the standardization and promotion of laparoscopic abdominal wall incisional hernia surgery.