Shah R H, Sharma A, Khullar R, Soni V, Baijal M, Chowbey P K
Minimal Access and Bariatric Surgery Centre, Room no. 200, 2nd floor, Sir Ganga Ram Hospital, New Delhi, 110060, India.
Hernia. 2008 Oct;12(5):457-63. doi: 10.1007/s10029-008-0374-0. Epub 2008 May 6.
The role of laparoscopy in the management of incarcerated (irreducible) ventral hernia remains to be elucidated. We present our experience of the laparoscopic repair of incarcerated primary ventral and incisional hernias over an 8-year period.
A retrospective review of the records of 112 patients undergoing laparoscopic repair for incarcerated primary ventral and incisional hernias from January 1998 to February 2006 was performed. The patient demographics, perioperative data, and postoperative complications were assessed.
The procedure was completed entirely laparoscopically in 103 patients (91.9%) with the placement of intraperitoneal mesh. A sutured tissue repair (without mesh) was performed in seven patients and hernia repair was abandoned after laparoscopy in two patients. Five patients required limited conversion by a targeted skin incision for the resection of nonviable bowel (three patients) and to complete adhesiolysis within multiloculated hernial sacs (two patients). The contents of the hernial sacs were incarcerated omentum (42 patients), small bowel (28 patients), large bowel (six patients), and omentum and small bowel (34 patients). Of these, seven patients presented with signs of acute small-bowel obstruction. The mean size of the largest defect through which incarceration occurred was 3.5 +/- 1.6 cm (range 1.5-7.5 cm) and the mean size of the mesh used was 379 +/- 210 cm2 (range 225-780 cm2). The mean operative time was 96 +/- 40.8 min (range 50-170 min). Inadvertent enterotomy occurred in four patients during bowel reduction and adhesiolysis. In two patients, the enterotomy was repaired by total laparoscopy followed by mesh placement, and two patients required conversion to formal laparotomy due to long-segment tears and peritoneal contamination. The average postoperative hospital stay was 2.8 +/- 1.5 days (range 1-6.5 days). Postoperative complications occurred in 20.5% patients. There was no mortality. Hernia recurred in three patients at a mean follow-up of 48 +/- 28.3 months (range 1-84 months).
Laparoscopic ventral abdominal wall hernia repair can be safely performed with a low complication rate, even in incarcerated hernias. Careful bowel reduction with adhesiolysis and mesh repair in an uncontaminated abdomen with a 5-cm mesh overlap remain key factors for a successful outcome.
腹腔镜检查在嵌顿性（不可复性）腹疝治疗中的作用仍有待阐明。我们介绍了8年来腹腔镜修补嵌顿性原发性腹疝和切口疝的经验。
对1998年1月至2006年2月期间112例行腹腔镜修补嵌顿性原发性腹疝和切口疝患者的记录进行回顾性分析。评估患者的人口统计学资料、围手术期数据和术后并发症。
103例患者（91.9%）完全通过腹腔镜完成手术并放置腹腔内补片。7例患者采用缝合组织修补（未用补片），2例患者腹腔镜检查后放弃疝修补。5例患者因切除无活力肠管（3例）和完成多房疝囊内粘连松解（2例）需要通过有针对性的皮肤切口进行有限的中转。疝囊内容物为嵌顿大网膜（42例）、小肠（28例）、大肠（6例）、大网膜和小肠（34例）。其中，7例患者出现急性小肠梗阻体征。发生嵌顿的最大缺损平均大小为3.5±1.6cm（范围1.5 - 7.5cm），所用补片平均大小为379±210cm²（范围225 - 780cm²）。平均手术时间为96±40.8分钟（范围50 - 170分钟）。4例患者在肠管复位和粘连松解过程中发生意外肠切开。2例患者通过全腹腔镜修复肠切开并放置补片，2例患者因长段撕裂和腹腔污染需要中转至正规剖腹手术。术后平均住院时间为2.8±1.5天（范围1 - 6.5天）。20.5%的患者发生术后并发症。无死亡病例。平均随访48±28.3个月（范围1 - 84个月）时，3例患者疝复发。
即使是嵌顿疝，腹腔镜下腹壁疝修补术也可安全实施，并发症发生率低。在无污染的腹腔内仔细进行肠管复位、粘连松解并采用补片修补，补片重叠5cm仍是手术成功的关键因素。
