Rosen Michael J, Williams Christina, Jin Judy, McGee Michael F, Schomisch Steve, Marks Jeffrey, Ponsky Jeffrey
Case Medical Center, University Hospitals of Cleveland, 11100 Euclid Ave., Cleveland, OH 44106, USA.
Am J Surg. 2007 Sep;194(3):385-9. doi: 10.1016/j.amjsurg.2007.03.003.
The ideal surgical treatment for complicated ventral hernias remains elusive. Traditional component separation provides local advancement of native tissue for tension-free closure without prosthetic materials. This technique requires an extensive subcutaneous dissection with division of perforating vessels predisposing to skin-flap necrosis and complicated wound infections. A minimally invasive component separation may decrease wound complication rates; however, the adequacy of the myofascial advancement has not been studied.
Five 25-kg pigs underwent bilateral laparoscopic component separation. A 10-mm incision was made lateral to the rectus abdominus muscle. The external oblique fascia was incised, and a dissecting balloon was inflated between the internal and external oblique muscles. Two additional ports were placed in the intermuscular space. The external oblique was incised from the costal margin to the inguinal ligament. The maximal abdominal wall advancement was recorded. A formal open-component separation was performed and maximal advancement 5 cm superior and 5 cm inferior to the umbilicus was recorded for comparison. Groups were compared using standard statistical analysis.
The laparoscopic component separation was completed successfully in all animals, with a mean of 22 min/side. Laparoscopic component separation yielded 3.9 cm (SD 1.1) of fascial advancement above the umbilicus, whereas 4.4 cm (1.2) was obtained after open release (P = .24). Below the umbilicus, laparoscopic release achieved 5.0 cm (1.0) of advancement, whereas 5.8 cm (1.2) was gained after open release (P = .13).
The minimally invasive component separation achieved an average of 86% of the myofascial advancement compared with a formal open release. The laparoscopic approach does not require extensive subcutaneous dissection and might theoretically result in a decreased incidence or decreased complexity of postoperative wound infections or skin-flap necrosis. Based on our preliminary data in this porcine model, further comparative studies of laparoscopic versus open component separation in complex ventral hernia repair is warranted to evaluate postoperative morbidity and long-term hernia recurrence rates.
复杂腹疝的理想手术治疗方法仍不明确。传统的成分分离术通过推进自体组织来实现无张力缝合，无需使用人工材料。该技术需要广泛的皮下剥离，并切断穿支血管，这易导致皮瓣坏死和复杂的伤口感染。微创成分分离术可能会降低伤口并发症发生率；然而，肌筋膜推进的充分性尚未得到研究。
对5头体重25千克的猪进行双侧腹腔镜成分分离术。在腹直肌外侧做一个10毫米的切口。切开腹外斜肌腱膜，在腹内斜肌和腹外斜肌之间充入一个剥离球囊。在肌间隙再置入另外两个端口。从肋缘至腹股沟韧带切开腹外斜肌。记录腹壁的最大推进距离。进行一次正式的开放成分分离术，并记录脐上5厘米和脐下5厘米处的最大推进距离以作比较。使用标准统计分析对各组进行比较。
所有动物的腹腔镜成分分离术均成功完成，平均每侧用时22分钟。腹腔镜成分分离术在脐上实现了3.9厘米（标准差1.1）的筋膜推进，而开放松解术后为4.4厘米（1.2）（P = 0.24）。在脐下，腹腔镜松解术实现了5.0厘米（1.0）的推进，而开放松解术后为5.8厘米（1.2）（P = 0.13）。
与正式的开放松解术相比，微创成分分离术平均实现了86%的肌筋膜推进。腹腔镜手术方法不需要广泛的皮下剥离，理论上可能会降低术后伤口感染或皮瓣坏死的发生率或复杂性。基于我们在这个猪模型中的初步数据，有必要对复杂腹疝修补术中腹腔镜与开放成分分离术进行进一步的对比研究，以评估术后发病率和长期疝复发率。
