Birolini C, Utiyama E M, Rodrigues A J, Birolini D
Department of Surgery, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Brazil.
J Am Coll Surg. 2000 Oct;191(4):366-72. doi: 10.1016/s1072-7515(00)00703-1.
Wound infection and sepsis leading to incisional hernia development are common after emergency colonic operations. Later on, while being operated on to correct an incisional hernia, most of these patients will need colonic resection or bowel continuity reestablishment. Simultaneous treatment of incisional hernias in patients with colostomy or colonic disease remains a difficult challenge, considering the reluctance of most surgeons to treat both conditions at the same time, especially when prosthetic repair is needed.
The aim of this study was to analyze the short-term results of patients undergoing colonic resection or bowel continuity reestablishment and simultaneous incisional hernia repair with an onlay polypropylene mesh technique. Over a period of 6 years, 20 patients were operated on for colonic problems associated with incisional hernias, including 8 Hartmanns' colostomies, 6 colostomies or ileostomies with colonic mucous fistulas, 3 postoperative colocutaneous fistulas, a paracolostomic hernia, a Chagas' megacolon, and a pseudotumoral diverticulitis. A "rule of three" statistical analysis was used to estimate the maximum risk of adverse effects, concerning mesh-related morbidity, after 1- and 2-year followup.
A major complication occurred in a patient who developed an anastomotic leakage and secondary wound infection; the patient was treated with parenteral nutrition and antibiotics. Other complications included a minor wound infection, a seroma, and a chronic sinus. One patient died from postoperative problems unrelated to the surgical technique. The occurrence of postoperative wound infection did not prevent mesh incorporation. Followup ranging from 1 to 7 years detected no hernia recurrences; 13 patients were followed for 2 years or more. Our results suggest that risk of mesh-related morbidity does not exceed 15.8% (3 of 19) within the first year and 23.1% (3 of 13) for 2 years followup, with 95% confidence.
We concluded that prosthetic repair of incisional hernias associated with simultaneous colonic operations was possible, allowing abdominal wall anatomy reestablishment. There is no reason to believe that abdominal wall prostheses must be avoided in contaminated operations when an adequate surgical technique is used.
急诊结肠手术后，伤口感染和败血症导致切口疝形成很常见。之后，在进行手术纠正切口疝时，这些患者中的大多数将需要结肠切除术或恢复肠道连续性。考虑到大多数外科医生不愿同时治疗这两种情况，尤其是在需要假体修复时，对结肠造口术或结肠疾病患者同时治疗切口疝仍然是一项艰巨的挑战。
本研究的目的是分析采用聚丙烯补片外置技术进行结肠切除术或恢复肠道连续性并同时进行切口疝修补的患者的短期结果。在6年的时间里，对20例因切口疝相关的结肠问题进行手术的患者进行了研究，其中包括8例Hartmann结肠造口术、6例伴有结肠黏液瘘的结肠造口术或回肠造口术、3例术后结肠皮肤瘘、1例结肠旁疝、1例恰加斯巨结肠和1例假性肿瘤性憩室炎。采用“三法则”统计分析来估计1年和2年随访后与补片相关的并发症的最大风险。
1例患者发生吻合口漏和继发性伤口感染，出现了严重并发症；该患者接受了肠外营养和抗生素治疗。其他并发症包括轻微伤口感染、血清肿和慢性窦道。1例患者死于与手术技术无关的术后问题。术后伤口感染的发生并未妨碍补片的融合。随访1至7年未发现疝复发；13例患者随访2年或更长时间。我们的结果表明，在95%的置信度下，与补片相关的并发症风险在第一年不超过15.8%（19例中的3例），2年随访时不超过23.1%（13例中的3例）。
我们得出结论，与结肠手术同时进行的切口疝假体修复是可行的，能够重建腹壁解剖结构。没有理由相信，当采用适当的手术技术时，在污染手术中必须避免使用腹壁假体。
