陈旧性耻骨联合分离继发膀胱脱垂及腹壁疝

Chronic bladder entrapment and bowel herniation after traumatic symphysis pubis diastasis

目的探讨陈旧性耻骨联合分离继发膀胱脱垂及腹壁疝的临床特征及治疗方法。方法对2002年8月收治的1例陈旧性Tile C2型骨盆骨折、耻骨联合分离合并膀胱脱垂及腹壁疝的患者行X线、CT三维重建、MR及膀胱造影检查。术中采用扩大的髂腹股沟入路,切口分段进行,其主要手术步骤为:(1)首先显露、清理耻骨联合。术中见耻骨联合分离约7.5 cm,腹直肌全层沿中线纵形撕裂,腹横筋膜纤维化并与腹膜粘连形成疝囊,右侧腹外斜肌腱膜于腹直肌外缘处部分缺如,小肠沿腹直肌裂口经膀胱前方及右侧海氏三角区疝出。术中将疝内容物推入腹腔,游离并临时高位结扎疝囊。(2)延长切口,对畸形愈合的左髂骨翼骨折进行截骨、复位,然后应用重建钢板分别沿双侧耻骨支上缘及左侧髂嵴内缘固定。(3)还纳疝出脏器。在缝合修补下腹壁结构的基础上,应用人体软组织补片进行加强重建。结果术后随访半年,腹壁疝获得治愈,骨折坚强愈合,左下肢短缩基本纠正,步态明显改善。阴茎外观及排尿功能恢复正常,自觉排便较术前有力,患者性功能障碍无明显好转。结论骨盆骨折畸形愈合的截骨矫形及复位固定,是关闭耻骨联合、减小盆腔容量、间接紧缩盆底、修补下腹壁缺损、治疗腹壁疝和改善膀胱脱垂的有效方法。

Objective To explore the clinical features and operative treatment of chronic bladder entrapment and bowel herniation after traumatic symphysis pubis diastasis. Methods One patient of late pelvic posttraumatic mal-alignment as Tile C2 type, which was associated with serious symphysis separation and combination of chronic bladder entrapment and bowel herniation, was admitted to our hospital in August 2002. The X-ray, three-dimensional CT reconstruction, MRI, and the bladder cystography were performed respectively in order to confirm the conditions. With the usage of ilioinguinal approach, the symphysis pubis diastasis was exposed and restored firstly; then, the malunion site of the left iliac was corrected; finally, after the reduction and internal fixation of the pelvis, the bowel herniation was resolved and the inferior abdominal wall defect was repaired with artificial materials. During the operation, the abnormal conditions were ob-served as follow: 1) The distance of symphysis pubis separation was about 7.5 cm; 2) the full-thick of the ectus abdominis was torn longitudinally tear along the middle line, and the transversalis fascia was fibrosis and adhered to the peritoneum, which consisted of hernia capsule; 3) the small bowel had been entrapped over the bladder through the gap of rectus abdominis and the right Hesselbach triangle. Results The pa-tient was followed up of 6 months. The limb discrepancy had been corrected satisfactory with a sound frac-ture healing and a good gait recovering after operation. The urinary function has recovered with a normal ap-pearance of penis. The patient felt stronger then to relieve the bowels than he did preoperatively. The erected dysfunction did not improve postoperatively. Conclusion The combined osteotomy and rigid fixation through anterior and posterior pelvic ring in the same stage is an effective method to close the symphysis seperation, decrease the volume of pelvic cavity, construct the pelvic floor indirectly, repair the inferior ab-dominal wall defect, cure the bowel herniation, and improve the bladder entrapment.