Tobias Adam M, Low David W
Division of Plastic and Reconstructive Surgery, University of Pennsylvania Health System, Philadelphia 19104, USA.
Plast Reconstr Surg. 2003 Sep;112(3):766-76. doi: 10.1097/01.PRS.0000070175.10990.51.
Damage control laparotomy for life-threatening abdominal conditions has gained wide acceptance in the management of exsanguinating trauma patients as well as septic patients with acute abdomen. Survivors considered too ill to undergo definitive abdominal wall closure are temporized, often with skin grafting on granulated viscera. These maneuvers compromise the integrity of the anterior abdominal wall and result in a subset of patients with loss of abdominal domain and massive, debilitating ventral hernias. A retrospective review was conducted of 21 such patients (16 men, five women) who underwent elective abdominal wall reconstruction at the Hospital of the University of Pennsylvania between November of 1998 and October of 2000. The purpose of this study was to report the authors' experience with these complex abdominal wall reconstructions. A double-layer, subfascial Vicryl mesh buttress was used in all repairs to aid in reestablishing abdominal wall integrity. The mean hernia size was 813 cm2 (range, 75 to 1836 cm2), and the average interval to definitive repair was 24.4 months (range, 3 weeks to 11 years). Mean follow-up was 13.5 months (range, 1 month to 40 months). Twenty patients (95 percent) had successful ventral hernia repair. Four patients with massive hernias (924 to 1836 cm2) required submuscular Marlex mesh implantation. Two patients (10 percent) developed abdominal compartment syndrome that required surgical decompression. One patient (5 percent) developed an incisional hernia at a prior colostomy site. Four patients (19 percent) had superficial skin dehiscence that healed secondarily with daily wound care. There were no mesh infections. In most cases, successful single-stage repair of large ventral hernias following damage control laparotomy can be achieved using a subfascial Vicryl mesh buttress in combination with other established reconstructive techniques. Massive defects exceeding 900 cm2 typically require permanent mesh implantation to achieve fascial closure and to minimize the risk of postoperative abdominal compartment syndrome and recurrent herniation. This technique represents an improved solution to a complicated problem and optimizes the aesthetic and functional outcome for these debilitated patients.
损伤控制剖腹术用于治疗危及生命的腹部疾病，在救治出血性创伤患者以及患有急腹症的脓毒症患者方面已得到广泛认可。对于那些被认为病情过重无法进行确定性腹壁闭合的幸存者，通常采取临时措施，常在肉芽组织化的内脏上进行皮肤移植。这些操作损害了前腹壁的完整性，导致一部分患者出现腹腔容积丧失和巨大、使人衰弱的腹侧疝。对1998年11月至2000年10月期间在宾夕法尼亚大学医院接受择期腹壁重建的21例此类患者（16例男性，5例女性）进行了回顾性研究。本研究的目的是报告作者在这些复杂腹壁重建方面的经验。所有修复均使用双层、筋膜下的可吸收聚丙交酯网片支撑物，以帮助重建腹壁完整性。平均疝面积为813平方厘米（范围为75至1836平方厘米），确定性修复的平均间隔时间为24.4个月（范围为3周至11年）。平均随访时间为13.5个月（范围为1个月至40个月）。20例患者（95%）腹侧疝修复成功。4例巨大疝（924至1836平方厘米）患者需要植入肌下聚丙烯网片。2例患者（10%）发生腹腔间隔室综合征，需要手术减压。1例患者（5%）在先前的结肠造口部位出现切口疝。4例患者（19%）出现浅表皮肤裂开，经每日伤口护理后二期愈合。没有发生网片感染。在大多数情况下，使用筋膜下可吸收聚丙交酯网片支撑物并结合其他成熟的重建技术，可成功对损伤控制剖腹术后的大型腹侧疝进行一期修复。超过900平方厘米的巨大缺损通常需要植入永久性网片以实现筋膜闭合，并将术后腹腔间隔室综合征和复发性疝的风险降至最低。该技术为一个复杂问题提供了改进的解决方案，并优化了这些虚弱患者的美学和功能效果。
