术前渐进性气腹在老年腹壁巨大切口疝修补术中的应用价值
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摘要
目的探讨术前渐进性气腹(preoperative progressive pneumoperitoneum,PPP)辅助治疗老年巨大切口疝的临床应用价值。方法回顾性分析2017年2月至2018年2月,中山大学附属第六医院采用术前渐进性气腹行术前准备治疗的19例巨大切口疝老年患者的临床资料。患者气腹前后行腹部CT扫描、肺功能、动脉血气分析检查。主要观察以下指标:(1)PPP情况:气腹天数、完成情况、注入空气量等;(2)气腹前后,疝囊容积、腹腔容积、肺功能指标及动脉血气(PaO2、PaCO2)变化;(3)手术、术后恢复及随访情况。结果 (1)PPP情况:19例患者气腹时间11～18(15.1±1.6)d,18例患者顺利完成人工气腹准备,注入空气总量4 400～7 200(5 910.5±615.4)m L。(2)气腹前后,疝囊容积、腹腔容积、肺功能指标及动脉血气变化:气腹前后,疝囊容积分别为(1 086.7±438.9)m L、(1 275.8±521.4)m L,二者比较差异具有统计学意义(t=3.228,P<0.05),PPP后增加(189±255.3)m L;腹腔容积分别为(6 144.0±1 758.4)m L、(8 748.5±2 084.5)m L,二者比较差异具有统计学意义(t=8.856,P<0.05),PPP后增加(2 604.5±1 322.3)m L;疝囊容积/腹腔容积分别为10.9～28.5(17.8±5.5)%、7.3～24.9(14.7±5.6)%,二者比较差异具有统计学意义(t=3.327,P<0.05);气腹后腹腔容积增加量远远大于气腹前疝囊容积。气腹后,FVC、FEV1/FVC%、PEF、MEF75、MEF50、MMEF75/25分别平均下降5.11%、2.45%、3.69%、1.73%、4.55%、6.8%,差异均无统计学意义(t=1.595、1.605、0.243、0.663、1.682、1.720,P>0.05);FEV1下降6.52%,差异有统计学意义(t=2.137,P<0.05);PaO2平均下降5.71%,差异无统计学意义(t=1.461,P>0.05);Pa CO2平均下降9.14%,差异有统计学意义(t=3.392,P<0.05)。(3)手术、术后恢复及随访情况:19例患者顺利完成手术,17例患者缺损完全关闭,手术时间137～265(173.9±34.7)min。术后无腹腔间隔室综合征、心肺衰竭等严重并发症发生。术后住院时间4～12(8.1±2.0)d。19例患者均获得随访,随访时间6～18(13.2±3.5)个月,无1例复发。结论 PPP应用于老年腹壁巨大切口疝患者安全有效,值得临床推广和应用。
Objective To investigate the clinical application value of the preoperative progressive pneumoperitoneum(PPP) in the treatment of large incisional hernias in the elderly.Methods The clinical data of 19 elderly patients with large incisional hernia who underwent PPP prior to hernia repair in the Sixth Hospital Affiliated of Sun Yat-sen University from February 2017 to February2018 were analyzed retrospectively. Abdominal computed tomography(CT) scan, pulmonary function and arterial blood gas analysis were performed before and after PPP. The following indicators were mainly observed:(1) PPP situations: insufflation time(days), completion, the median insufflated volume of air;(2) Changes in the volumes of the incisional hernia(VIH), the volumes of the abdominal cavity(VAC), the pulmonary function and arterial blood gas(PaO2 and PaCO2) before and after PPP;(3)operation, postoperative recovery and follow-up situations. Results(1) PPP situations: the insufflation time in 19 patients ranged from 11-18 d, 18 patients successfully completed PPP, the median insufflated volume of air for PPP was 4 400-7 200 mL.(2) Changes in the volumes of the incisional hernia(VIH), the volumes of the abdominal cavity(VAC), the pulmonary function and arterial blood gas(PaO2 and PaCO2)before and after PPP: Before and after PPP, the mean VIH was(1 086.7±438.9) mL and(1 275.8±521.4)m L(t=3.228, P<0.05), the VIH increased by(189±255.3) mL; the mean VAC was(6 144.0±1 758.4) mL and(8 748.5±2 084.5) m L(t=8.856, P<0.05), theVAC increased by(2 604.5±1 322.3) mL; the mean(VIH/VAC)×100% was 10.9% to 28.5% and 7.3% to 24.9%(t=3.327, P<0.05); the VAC increased by 2604.5 mL(P<0.01) and was greater than the mean VIH before PPP. After PPP, dynamic lung volumes fell by 5.11% for FVC, 2.45% for FEV1/FVC%, 3.69% for PEF, 1.73% for MEF75, 4.55% for MEF50, 6.8%for MMEF75/25(t=1.595, 1.605, 0.243, 0.663, 1.682, 1.720, all P>0.05), FEV1 decreased by 6.52%(t=2.137, P<0.05); PaO2 decreased by 5.71%(t=1.461, P>0.05) and PaCO2 decreased by 9.14%(t=3.39).(3) Operation, postoperative recovery and follow-up situations: The operations was performed successfully in 19 patients, the mean operating time was 137 to 265 minutes, fascia closure was possible in 89.5% of cases(n=17). No severe complications such as ACS or cardiopulmonary failure occurred. The mean postoperative length of stay in hospital was 4 to 12 days. All patients were followed up for 6-18 months,and there was no hernia recurrence. Conclustion PPP is safe and effective in elderly patients with large incisional hernia repair, which is worthy of clinical promotion and application.
Objective To investigate the clinical application value of the preoperative progressive pneumoperitoneum(PPP) in the treatment of large incisional hernias in the elderly.Methods The clinical data of 19 elderly patients with large incisional hernia who underwent PPP prior to hernia repair in the Sixth Hospital Affiliated of Sun Yat-sen University from February 2017 to February2018 were analyzed retrospectively. Abdominal computed tomography(CT) scan, pulmonary function and arterial blood gas analysis were performed before and after PPP. The following indicators were mainly observed:(1) PPP situations: insufflation time(days), completion, the median insufflated volume of air;(2) Changes in the volumes of the incisional hernia(VIH), the volumes of the abdominal cavity(VAC), the pulmonary function and arterial blood gas(PaO2 and PaCO2) before and after PPP;(3)operation, postoperative recovery and follow-up situations. Results(1) PPP situations: the insufflation time in 19 patients ranged from 11-18 d, 18 patients successfully completed PPP, the median insufflated volume of air for PPP was 4 400-7 200 mL.(2) Changes in the volumes of the incisional hernia(VIH), the volumes of the abdominal cavity(VAC), the pulmonary function and arterial blood gas(PaO2 and PaCO2)before and after PPP: Before and after PPP, the mean VIH was(1 086.7±438.9) mL and(1 275.8±521.4)m L(t=3.228, P<0.05), the VIH increased by(189±255.3) mL; the mean VAC was(6 144.0±1 758.4) mL and(8 748.5±2 084.5) m L(t=8.856, P<0.05), theVAC increased by(2 604.5±1 322.3) mL; the mean(VIH/VAC)×100% was 10.9% to 28.5% and 7.3% to 24.9%(t=3.327, P<0.05); the VAC increased by 2604.5 mL(P<0.01) and was greater than the mean VIH before PPP. After PPP, dynamic lung volumes fell by 5.11% for FVC, 2.45% for FEV1/FVC%, 3.69% for PEF, 1.73% for MEF75, 4.55% for MEF50, 6.8%for MMEF75/25(t=1.595, 1.605, 0.243, 0.663, 1.682, 1.720, all P>0.05), FEV1 decreased by 6.52%(t=2.137, P<0.05); PaO2 decreased by 5.71%(t=1.461, P>0.05) and PaCO2 decreased by 9.14%(t=3.39).(3) Operation, postoperative recovery and follow-up situations: The operations was performed successfully in 19 patients, the mean operating time was 137 to 265 minutes, fascia closure was possible in 89.5% of cases(n=17). No severe complications such as ACS or cardiopulmonary failure occurred. The mean postoperative length of stay in hospital was 4 to 12 days. All patients were followed up for 6-18 months,and there was no hernia recurrence. Conclustion PPP is safe and effective in elderly patients with large incisional hernia repair, which is worthy of clinical promotion and application.
引文
[1]Deerenberg EB,Timmermans L,Hogerzeil DP,et al.A systematic review of the surgical treatment of large incisional hernia[J].Hernia,2015,19(1):89-101.
[2]Slater NJ,Montgomery A,Berrevoet F,et al.Criteria for definition of a complex abdominal wall hernia[J].Hernia,2014,18(1):7-17.
[3]Kroese LF,Sneiders D,Kleinrensink GJ,et al.Comparing different modalities for the diagnosis of incisional hernia:a systematic review[J].Hernia,2018,22(2):229-242.
[4]Patel NG,Ratanshi I,Buchel EW.The best of abdominal wall reconstruction[J].Plast Reconstr Surg,2018,141(1):113e-136e.
[5]Van Geffen HJ,Simmermacher RK.Incisional hernia repair:abdominoplasty.Tissue expansion and methods of augmentation[J].World J Surg,2005,29(8):1080-1085.
[6]Flum DR,Horvath K,Koepsell T.Have outcomes of incisional hernia repair improved with time?A population-based analysis[J].Ann Surg,2003,237(1):129-135.
[7]Allen LL.Pneumoperitoneum in the treatment of pulmonary tuberculosis[J].J Natl Med Assoc,1941,33(2):57-60.
[8]Moreno IG.Chronic eventrations and large hernias;preoperative treatment by progressive pneumoperitomeum;original procedure[J].Surgery,1947,22(6):945-953.
[9]Mc Adory RS,Cobb WS,Carbonell AM.Progressive preoperative pneumoperitoneum for hernias with loss of domain[J].Am Surg,2009,75(6):504-509.
[10]Mayagoitia JC,Suárez D,Arenas JC,et al.Preoperative progressive pneumoperitoneum in patients with abdominal-wall hernias[J].Hernia,2006,10(3):213-217.
[11]Dumont F,Fuks D,Verhaeghe P,et al.rogressive pneumoperitoneum increases the length of abdominal muscles[J].Hernia,2009,13(2):183-187.
[12]Sabbagh C,Dumont F,Fuks D,et al.Progressive preoperative pneumoperitoneum preparation(the Goni Moreno protocol)prior to large incisional hernia surgery:volumetric,respiratory and clinical impacts.A prospective study[J].Hernia,2012,16(1):33-40.
[13]中华医学会外科学分会疝与腹壁外科学组,中国医师协会外科医师分会疝和腹壁外科医师委员会.腹壁切口疝诊断和治疗指南(2018年版)[J].中国普通外科杂志,2018,27(7):808-812.
[14]Oprea V,Matei O,Gheorghescu D,et al.Progressive Preoperative Pneumoperitoneum(PPP)as an Adjunct for Surgery of Hernias with Loss of Domain[J].Chirurgia(Bucur),2014,109(5):664-669.
[15]Coelho JC,Brenner AS,Freitas AT,et al.Progressive preoperative pneumoperitoneum in the repair of large abdominal hernias[J].Eur JSurg,1993,159(6-7):339-341.
[16]Johnson WC.Preoperative progressive pneumoperitoneum in preparation for repair of large hernias of the abdominal wall[J].Am J Surg,1972,124(1):63-68.
[17]Renard Y,Lardiere-Deguelte S,de Mestier L,et al.Management of large incisional hernias with loss of domain:a prospective series of patients prepared by progressive preoperative pneumoperitoneum[J].Surgery,2016,160(2):426-435.
[2]Slater NJ,Montgomery A,Berrevoet F,et al.Criteria for definition of a complex abdominal wall hernia[J].Hernia,2014,18(1):7-17.
[3]Kroese LF,Sneiders D,Kleinrensink GJ,et al.Comparing different modalities for the diagnosis of incisional hernia:a systematic review[J].Hernia,2018,22(2):229-242.
[4]Patel NG,Ratanshi I,Buchel EW.The best of abdominal wall reconstruction[J].Plast Reconstr Surg,2018,141(1):113e-136e.
[5]Van Geffen HJ,Simmermacher RK.Incisional hernia repair:abdominoplasty.Tissue expansion and methods of augmentation[J].World J Surg,2005,29(8):1080-1085.
[6]Flum DR,Horvath K,Koepsell T.Have outcomes of incisional hernia repair improved with time?A population-based analysis[J].Ann Surg,2003,237(1):129-135.
[7]Allen LL.Pneumoperitoneum in the treatment of pulmonary tuberculosis[J].J Natl Med Assoc,1941,33(2):57-60.
[8]Moreno IG.Chronic eventrations and large hernias;preoperative treatment by progressive pneumoperitomeum;original procedure[J].Surgery,1947,22(6):945-953.
[9]Mc Adory RS,Cobb WS,Carbonell AM.Progressive preoperative pneumoperitoneum for hernias with loss of domain[J].Am Surg,2009,75(6):504-509.
[10]Mayagoitia JC,Suárez D,Arenas JC,et al.Preoperative progressive pneumoperitoneum in patients with abdominal-wall hernias[J].Hernia,2006,10(3):213-217.
[11]Dumont F,Fuks D,Verhaeghe P,et al.rogressive pneumoperitoneum increases the length of abdominal muscles[J].Hernia,2009,13(2):183-187.
[12]Sabbagh C,Dumont F,Fuks D,et al.Progressive preoperative pneumoperitoneum preparation(the Goni Moreno protocol)prior to large incisional hernia surgery:volumetric,respiratory and clinical impacts.A prospective study[J].Hernia,2012,16(1):33-40.
[13]中华医学会外科学分会疝与腹壁外科学组,中国医师协会外科医师分会疝和腹壁外科医师委员会.腹壁切口疝诊断和治疗指南(2018年版)[J].中国普通外科杂志,2018,27(7):808-812.
[14]Oprea V,Matei O,Gheorghescu D,et al.Progressive Preoperative Pneumoperitoneum(PPP)as an Adjunct for Surgery of Hernias with Loss of Domain[J].Chirurgia(Bucur),2014,109(5):664-669.
[15]Coelho JC,Brenner AS,Freitas AT,et al.Progressive preoperative pneumoperitoneum in the repair of large abdominal hernias[J].Eur JSurg,1993,159(6-7):339-341.
[16]Johnson WC.Preoperative progressive pneumoperitoneum in preparation for repair of large hernias of the abdominal wall[J].Am J Surg,1972,124(1):63-68.
[17]Renard Y,Lardiere-Deguelte S,de Mestier L,et al.Management of large incisional hernias with loss of domain:a prospective series of patients prepared by progressive preoperative pneumoperitoneum[J].Surgery,2016,160(2):426-435.