Kelly Michael E, Behrman Stephen W
Department of Surgery, University of Tennessee, Memphis, USA.
Am Surg. 2002 Jun;68(6):524-8; discussion 528-9.
Prosthetic mesh reinforcement of abdominal wall hernias has gained acceptance as a result of its ease of placement and a favorably low incidence of hernia recurrence. However, its use in contaminated wounds secondary to open bowel exposure is felt to be contraindicated because of potential septic complications and lack of incorporation. The impact of permanent mesh placement in contaminated fields on wound morbidity, hernia recurrence, and mortality was examined. Records of 24 consecutive patients having permanent mesh placement in contaminated wounds for repair of abdominal wall hernias between 1994 and 2001 were reviewed. Factors examined included age, hernia type, body mass index, comorbidity, degree of contamination, concurrent gastrointestinal procedures, wound morbidity, and mortality. The mean age and body mass index were 63 years and 26.1 kg/m2 respectively. Twelve patients had risk factors for wound complications or were immunocompromised. There were 11 incisional, eight parastomal, two femoral, and two inguinal repairs and one obturator hernia repair. Twenty-three were repaired with polypropylene and one with Gore-Tex mesh. Prosthetic herniorrhaphy was performed in nine patients with ostomies already in place and in 15 patients with concomitant bowel resections. Of those with bowel resections five had enterocutaneous fistulae, three had bowel resection because of injury during mobilization, six had resections for necrotic bowel, and one had enterostomy closure. Fourteen cases were clean contaminated and ten contaminated. Eight cases were performed under emergency conditions. Wound-related morbidity occurred in five patients (21%) and in all but one was limited to cellulitis and minor wound infections. Three patients died, but in all cases death was unrelated to the surgical procedure. No patient required mesh removal. One patient had a recurrent hernia after parastomal repair. Placement of permanent mesh prostheses in clean-contaminated and contaminated operative fields can be performed with minimal wound-related morbidity and patient mortality. Utilization of permanent mesh in these wounds is associated with a low incidence of hernia recurrence and eliminates the need for further surgery.
腹壁疝的人工补片加固术因其易于放置且疝复发率较低而被广泛接受。然而，由于存在潜在的感染并发症以及补片难以融合，人们认为在开放性肠管暴露导致的污染伤口中使用补片是禁忌的。本研究探讨了在污染区域放置永久性补片对伤口并发症、疝复发及死亡率的影响。回顾了1994年至2001年间连续24例在污染伤口中放置永久性补片以修复腹壁疝患者的记录。研究因素包括年龄、疝类型、体重指数、合并症、污染程度、同期胃肠道手术、伤口并发症及死亡率。平均年龄和体重指数分别为63岁和26.1kg/m²。12例患者存在伤口并发症风险因素或免疫功能低下。其中有11例切口疝修补、8例造口旁疝修补、2例股疝修补、2例腹股沟疝修补及1例闭孔疝修补。23例使用聚丙烯补片修补，1例使用戈尔泰克斯补片修补。9例已有造口的患者及15例同期行肠切除的患者接受了人工疝修补术。行肠切除的患者中，5例有肠皮肤瘘，3例因分离过程中损伤而行肠切除，6例因肠坏死而行切除，1例为肠造口关闭。14例为清洁-污染伤口，10例为污染伤口。8例在急诊情况下进行手术。5例患者（21%）发生与伤口相关的并发症，除1例患者外，其余均局限于蜂窝织炎和轻度伤口感染。3例患者死亡，但所有病例死亡均与手术操作无关。无患者需要取出补片。1例患者在造口旁疝修补术后出现复发性疝。在清洁-污染和污染的手术区域放置永久性补片假体，伤口相关并发症和患者死亡率极低。在这些伤口中使用永久性补片与疝复发率低相关，且无需进一步手术。
