闭孔疝的临床特征与诊治分析:附10例报告

Analysis of clinical characteristics and management of obturator hernia:a report of 10 cases

背景与目的:闭孔疝是临床较为罕见的腹外疝,老年女性由于盆底松弛等特点,易罹患此病。由于闭孔疝的疝环狭小缺乏弹性,患者多因嵌顿造成的急腹症就诊,一般在肠梗阻手术时发现。彻底缝闭半坚硬的疝环有一定困难,故疝易复发,再手术率高,使用修补材料可有效降低复发率。本文中笔者通过回顾收治的闭孔疝病例,分析总结闭孔疝的疾病特点及临床诊治方面经验体会,以期为该病的临床诊治提供参考。方法:回顾性总结2019年6月—2021年6月复旦大学附属华东医院和郑州大学附属郑州中心医院胃肠、疝和腹壁外科收治的10例闭孔疝患者的相关临床资料。结果:10例患者均为女性,年龄48~86岁,中位年龄(70.7±11.8)岁。所有患者术前接受腹盆腔CT扫描检查,发现2例左侧闭孔疝,8例右侧闭孔疝。术中证实嵌顿疝内容物中肠管8例,大网膜1例,腹膜外脂肪1例。全组病例中未有无张力修补的绝对禁忌患者,结合腹腔污染情况,2例使用生物补片,其余8例患者使用聚丙烯补片。6例完全在腔镜下完成,1例在腔镜下疝修补完成后观察肠管活力恢复欠佳中转开腹行肠切除,1例腔镜探查后中转开腹行肠切除及疝修补,2例患者腔镜不耐受直接行开腹探查并无张力修补术。手术时间50~120 min,平均75.5 min。术后1例患者死于围术期内科疾病合并症,其余患者顺利出院,住院时间3~28 d。术后6、12、18个月随访,均无复发及补片相关感染。结论:闭孔疝发病率低,起病隐匿容易发生嵌顿。腹盆腔CT扫描对此病诊断有较高价值。使用补片修补并恰当地固定有助于降低复发率。腹腔污染的情况下使用合成补片一期修补具有可行性,污染较重时生物补片更具优势。修补区域严重感染,应放弃使用补片修补。

Background and Aims:Obturator hernia is a relatively rare type of external abdominal hernia,and elderly women are more susceptible to this condition due to characteristics such as pelvic floor laxity.The narrow and non-elastic nature of the obturator ring often leads to patients seeking medical treatment due to acute abdomen caused by bowel incarceration,typically discovered during surgery for intestinal obstruction.Completely suturing the semi-rigid hernia ring can be challenging,which leads to a higher risk of hernia recurrence and a high reoperation rate,but the use of repair materials can effectively reduce this risk.In this article,the authors analyze the disease characteristics and share clinical experiences in the diagnosis and treatment of obturator hernia through review treated cases of obturator hernia,in the hope of providing reference for the clinical diagnosis and treatment of this condition.Methods:The clinical data of 10 patients with obturator hernia treated in the Department of Hernia and Abdominal Wall Surgery,Huadong Hospital Affiliated to Fudan University and Zhengzhou Central Hospital Affiliated to Zhengzhou University from June 2019 to June 2021 were retrospectively summarized.Results:All ten patients were females,aged between 48 and 86 years,with a median age of(70.7±11.8)years.Prior to surgery,all patients underwent abdominal and pelvic CT scans,which identified leftsided obturator hernia in 2 cases and right-sided obturator hernia in 8 cases.The contents of incarcerated hernia identified by intraoperative findings were intestinal canal in 8 cases,greater omentum in 1 case,and extraperitoneal fat in 1 case.There were no absolute contraindications to tension-free repair in the entire group.Based on the degree of abdominal contamination,2 patients received biological mesh,while the remaining 8 patients received polypropylene mesh.Six cases were completely repaired laparoscopically,one case required conversion to an open surgery after laparoscopic repair due to poor recovery of intestinal vitality,and one case underwent laparotomy for intestinal resection and hernia repair after initial laparoscopic exploration.Two patients directly underwent open laparotomy for repair due to poor tolerance of laparoscopic operation.The surgery duration ranged from 50 to 120 min,with an average of 75.5 min.One patient died from concomitant medical condition during perioperative period,while the rest were discharged uneventfully with hospital stay lasting 3 to 28 d.Follow-up at 6,12,and 18 months after operation showed no recurrences or mesh-related infections.Conclusion:Obturator hernia has a low incidence and often presents with concealed symptoms,making incarceration common.Abdominal and pelvic CT scans are valuable for diagnosis.Using mesh repair with appropriate fixation can help reduce the recurrence rate.In cases of abdominal contamination,onestage synthetic mesh repair is feasible,with biological mesh having an advantage in cases of severe contamination.If the repair site is severely infected,mesh repair should be avoided.