腹腔镜腹股沟疝手术关键技术标准及评价

Standardsand evaluations ofkey techniques in laparoscopic inguinal hernia surgery

手术空间的建立、疝囊的处理和补片的平展是腹腔镜腹股沟疝修补术(LIHR)中最关键的手术操作步骤。经腹腹膜前修补术(TAPP)只需打开腹膜,利用气腹的自然扩充,就可进入理想的层面。而全腹膜外修补术(TEP)需要采用一定的技术,经肌后间隙进入壁平面或脏平面,并在不同的区域进行平面转换,才能到达正确的平面。壁平面是TEP的神圣平面,但在分离斜疝时只能转入脏平面操作。直疝疝囊的回纳是腹横筋膜(TF)和腹膜前筋膜(PPF)的分离,操作简单,不要轻易横断。斜疝疝囊的回纳是腹膜与精索成分的分离,操作有难度。较小的疝囊应完整剥离,较大的疝囊可高位横断。补片需覆盖肌耻骨孔并与周围组织有足够的重叠。松解腹膜前环,连通壁、脏平面,才能平展补片。LIHR中几乎不需要采用机械性或穿透性的方法固定补片。

Establishing surgical space,managing the hernia sac and flattening of mesh are the most critical steps in laparoscopic inguinal hernia repair(LIHR).Once the peritoneum is opened in transabdominal preperitoneal(TAPP)repair,the natural expansion of the pneumoperitoneum would help to enter the ideal plane.Totally extraperitoneal(TEP)repair requires specific techniques to enter the parietal or visceral plane via retromuscular space.Plane transition in different areas helps to reach the correct plane.The parietal plane is the holy plane of TEP,however,the reduction of indirect hernias could only be accomplished on the visceral plane.The dissection of direct hernia can be seen as the separation of the transversalis fascia(TF)and the preperitoneal fascia(PPF).The hernia sac is easy to reduce and should not be transected.The reduction of the hernia sac of indirect hernia involves the separation of the peritoneum and the spermatic cord components,which is difficult to perform.Small hernia sacs should be reduced completely,and large ones could be transected at a high position.The mesh should cover the myopectineal orifice and maintain sufficient overlap with the surrounding tissue.After dissecting the preperitoneal loop,the mesh could be flattened in the connected parietal and visceral plane.Mechanical or penetrating fixation of mesh is seldom required in LIHR.