自固定補片行開放無張力疝修補

1、ProGrip自固定補片行腹股溝疝開放式無張力修補,陜西省人民醫(yī)院普外一科王小強,,腹股溝疝無張力修補的現狀方法多材料多個體化治療重視并發(fā)癥,,Lichtenstein(李金斯坦)Tension free(無張力)，1989李金斯坦手術簡單，易學，適合大多數疝仍是歐洲應用最多的方法分離范圍大，縫合多材料和縫合技術仍在演變,IL Lichtenstein,,理想的李金斯坦手術補片適合的形狀和大小有一定的彈性并且不

2、皺縮對組織的刺激最小最小的殘量和足夠的支撐張力,,縫合的演變,連續(xù)縫合,間斷縫合,不縫合,,腹股溝疝術后慢性疼痛持續(xù)6個月以上《Amid 防治腹股溝疝術后慢性疼痛國際指南》發(fā)生率0.5~6%；10~12%原因神經源性（縫扎，卡壓，粘連）非神經源性（瘢痕，骨膜刺激）其他因素（年齡、性別、職業(yè)）心理因素,,縫合是否是疼痛的主要原因之一不縫合能否降低術后疼痛及術后慢性疼痛不縫合補片如何保證不復發(fā),ProGrip自固定補片

3、的解決之道,自固定半吸收的網片,,,,尾端,頭端,預裁式搭扣,通過錨扣將張力均勻分布在整張網片上，不需要縫合,可吸收的的錨扣自動與組織粘合,單股聚丙烯和可吸收聚乳酸,橢圓網片便于適形裁剪,半可吸收網片,,,半可吸收的輕量網片,,,有自動固定功能的微型錨扣(micro-grips)是由聚乳酸（PLA）成分制成的。通過水解自然吸收，減少體內的異物質量。micro-grips均勻地分布在整張補片的表面，不需要依靠補片外圍的幾個縫合固定點來固

4、定補片。并且自動固定的功能可以減少對患者組織穿透的創(chuàng)傷和牽拉神經造成的慢性疼痛的風險。micro-grips式補片對小白鼠的輸精管沒有任何不良影響Influence of a new self-gripping hernia mesh on male fertility in a rat modelThomas Kolbe Æ Christian Hollinsky Æ Ingrid Walter Æ

5、 Anja Joachim Æ Thomas RülickeSurg Endosc,臨床資料,時間：2011年11月~2012年1月單側原發(fā)腹股溝疝15例男性15例年齡：45-78歲斜疝13例、直疝2例麻醉局麻11例、硬膜外麻醉4例手術時間：35~55分鐘；平均42分鐘,【手術步驟】,（1）5~6cm斜切口（2）切開皮下脂肪和腹外斜肌腱膜（3）游離精索結構（4）分離疝囊并高位結扎斜疝疝囊高位

6、游離切斷結扎或還納，直疝疝囊直接還納或切除連續(xù)縫合腹橫筋膜缺損。,放置ProGrip補片,根據腹股溝區(qū)實際大小對補片進行裁剪從補片尾端卷起補片從恥骨結節(jié)端向內環(huán)方向平鋪補片，頭端覆蓋恥骨結節(jié)超過1cm預裁式搭扣包繞精索可吸收縫線縫合腹外斜肌腱膜和皮下脂肪及皮膚,疼痛評價及隨訪結果,患者術后疼痛評分（使用視覺模擬評分法測定，The visual analog scale VAS法）術后1天 2.4±

7、0.4 術后一月 0.1±0.3術后不適感評估,,其他并發(fā)癥尿儲留 0 皮下血腫 0血清腫 0傷口感染 0慢性疼痛 0 近期復發(fā) 0,結論,ProGrip自固定補片行腹股溝疝開放式無張力修補是安全可行的

8、修補方法源自李金斯坦手術手術步驟簡單不進入腹膜前間隙單一平面補片不需縫合,,復發(fā)率低我們的結果（近期0/15復發(fā)）文獻0/70復發(fā).P. Chastan.2/181復發(fā)（1.1%）Nicolás Pedano,術后疼痛輕我們的對照研究（進行中）a,,,AbstractINTRODUCTION: Secure fixation of the mesh in groin hernia repair is

9、essential to avoid mesh dislocation. The fixation, however, is also thought to be a source of chronic postoperative pain. We tested the new self-fixating mesh Parietene progrip vs. traditional suture fixating Lichtenstei

10、n repair in a double-blinded randomized study evaluating postoperative pain and the use of analgesics.METHODS: Fifty patients were randomized into two groups: Patients of group A (24 patients) were operated with the new

11、 self-fixating Parietene progrip mesh without fixation sutures and patients of group B (26 patients) were operated with the traditional Lichtenstein repair. Postoperative course including pain and the use of analgesics w

12、ere monitored. Patients were reinvestigated after 6 months regarding pain score and the amount of analgesics used during this interval. Primary end point was pain on the first operative day.,,,RESULTS: The visual analog

13、scale pain score showed at the first postoperative day a significantly lower level in group A than in group B (mean 17.9 vs. 32.3 mm, p = 0.03). Additionally, the cumulative dose of postoperatively required analgesics wa

14、s lower in group A than in group B. The operative time in group A was significantly shorter than in group B. Six months after the operation, a trend toward a lower pain score was observed in group A, but this did not rea

15、ch statistical significance.CONCLUSIONS: This is the first randomized study to show a beneficial effect of the new self-fixating mesh on pain score. According to our investigations, operative time is reduced, which is

16、a considerable fact with regard to economic aspects as well as the beneficial aspects for the patients. A study with a larger cohort of patients should be conducted to confirm the promising results of this exploratory st

17、udy.,,其它并發(fā)癥情況不增加其它并發(fā)癥的發(fā)生率,手術的注意事項,,ProGrip手術適應癥,ProGrip手術適應癥,Nyhus（美國Nyhus于1993年公布）Ⅰ型，內環(huán)口正常的斜疝； Ⅱ型，內環(huán)口擴大的斜疝； Ⅲ型，腹股溝管后壁薄弱的所有直疝、斜疝和股疝； Ⅳ型，復發(fā)疝 Gilbert、Rutkow和Robbins（Gilbert于1980年設計了名為CHATS的分類系統，分為5型，1986年Rutkow和Robbi

18、ns又增加兩種類型。）Ⅰ型，內環(huán)口正常的斜疝； Ⅱ型，內環(huán)口擴大（小于兩指寬）的斜疝，后壁完整； Ⅲ型，內環(huán)口擴大（大于兩指寬）的斜疝，后壁受損； Ⅳ型，大的直疝 Ⅴ型，小的直疝 Ⅵ型，“褲型疝”（“馬鞍疝”） Ⅶ型，股疝,,充分的游離空間更大的接觸面積，更可靠地錨定。恥骨結節(jié)要覆蓋1cm以上盡可能保留神經，不刻意解剖游離神經，如果神經有損傷，則切斷并處理好殘端。,,疝囊高位游離遵循Bassini和Lichtens