自固定補(bǔ)片行開放無張力疝修補(bǔ)

1、ProGrip自固定補(bǔ)片行腹股溝疝開放式無張力修補(bǔ),陜西省人民醫(yī)院普外一科王小強(qiáng),,腹股溝疝無張力修補(bǔ)的現(xiàn)狀方法多材料多個(gè)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(shù)簡單，易學(xué)，適合大多數(shù)疝仍是歐洲應(yīng)用最多的方法分離范圍大，縫合多材料和縫合技術(shù)仍在演變,IL Lichtenstein,,理想的李金斯坦手術(shù)補(bǔ)片適合的形狀和大小有一定的彈性并且不

2、皺縮對(duì)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(shù)后慢性疼痛持續(xù)6個(gè)月以上《Amid 防治腹股溝疝術(shù)后慢性疼痛國際指南》發(fā)生率0.5~6%；10~12%原因神經(jīng)源性（縫扎，卡壓，粘連）非神經(jīng)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(shù)后疼痛及術(shù)后慢性疼痛不縫合補(bǔ)片如何保證不復(fù)發(fā),ProGrip自固定補(bǔ)片

3、的解決之道,自固定半吸收的網(wǎng)片,,,,尾端,頭端,預(yù)裁式搭扣,通過錨扣將張力均勻分布在整張網(wǎng)片上，不需要縫合,可吸收的的錨扣自動(dòng)與組織粘合,單股聚丙烯和可吸收聚乳酸,橢圓網(wǎng)片便于適形裁剪,半可吸收網(wǎng)片,,,半可吸收的輕量網(wǎng)片,,,有自動(dòng)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(nèi)的異物質(zhì)量。micro-grips均勻地分布在整張補(bǔ)片的表面，不需要依靠補(bǔ)片外圍的幾個(gè)縫合固定點(diǎn)來固

4、定補(bǔ)片。并且自動(dòng)固定的功能可以減少對(duì)患者組織穿透的創(chuàng)傷和牽拉神經(jīng)造成的慢性疼痛的風(fēng)險(xiǎn)。micro-grips式補(bǔ)片對(duì)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(shí)間：2011年11月~2012年1月單側(cè)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(shù)時(shí)間：35~55分鐘；平均42分鐘,【手術(shù)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(jié)構(gòu)（4）分離疝囊并高位結(jié)扎斜疝疝囊高位

6、游離切斷結(jié)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(bǔ)片,根據(jù)腹股溝區(qū)實(shí)際大小對(duì)補(bǔ)片進(jìn)行裁剪從補(bǔ)片尾端卷起補(bǔ)片從恥骨結(jié)節(jié)端向內(nèi)環(huán)方向平鋪補(bǔ)片，頭端覆蓋恥骨結(jié)節(jié)超過1cm預(yù)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(píng)價(jià)及隨訪結(jié)果,患者術(shù)后疼痛評(píng)分（使用視覺模擬評(píng)分法測(cè)定，The visual analog scale VAS法）術(shù)后1天 2.4±

7、0.4 術(shù)后一月 0.1±0.3術(shù)后不適感評(píng)估,,其他并發(fā)癥尿儲(chǔ)留 0 皮下血腫 0血清腫 0傷口感染 0慢性疼痛 0 近期復(fù)發(fā) 0,結(jié)論,ProGrip自固定補(bǔ)片行腹股溝疝開放式無張力修補(bǔ)是安全可行的

8、修補(bǔ)方法源自李金斯坦手術(shù)手術(shù)步驟簡單不進(jìn)入腹膜前間隙單一平面補(bǔ)片不需縫合,,復(fù)發(fā)率低我們的結(jié)果（近期0/15復(fù)發(fā)）文獻(xiàn)0/70復(fù)發(fā).P. Chastan.2/181復(fù)發(fā)（1.1%）Nicolás Pedano,術(shù)后疼痛輕我們的對(duì)照研究（進(jìn)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(shù)的注意事項(xiàng),,ProGrip手術(shù)適應(yīng)癥,ProGrip手術(shù)適應(yīng)癥,Nyhus（美國Nyhus于1993年公布）Ⅰ型，內(nèi)環(huán)口正常的斜疝； Ⅱ型，內(nèi)環(huán)口擴(kuò)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(fù)發(fā)疝 Gilbert、Rutkow和Robbins（Gilbert于1980年設(shè)計(jì)了名為CHATS的分類系統(tǒng)，分為5型，1986年Rutkow和Robbi

18、ns又增加兩種類型。）Ⅰ型，內(nèi)環(huán)口正常的斜疝； Ⅱ型，內(nèi)環(huán)口擴(kuò)大（小于兩指寬）的斜疝，后壁完整； Ⅲ型，內(nèi)環(huán)口擴(kuò)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(jié)節(jié)要覆蓋1cm以上盡可能保留神經(jīng)，不刻意解剖游離神經(jīng)，如果神經(jīng)有損傷，則切斷并處理好殘端。,,疝囊高位游離遵循Bassini和Lichtens