Fansler R F, Taheri P, Cullinane C, Sabates B, Flint L M
Tulane University School of Medicine, Department of Surgery, Tulane Medical School, New Orleans, Louisiana 70112, USA.
Am J Surg. 1995 Jul;170(1):15-8. doi: 10.1016/s0002-9610(99)80244-x.
Closure of the abdominal wall in the face of fascial necrosis or massive intestinal edema remains a difficult problem with frequent complications. Prior studies have addressed both the utility and the pitfalls of placing polypropylene mesh in this setting.
We performed a retrospective evaluation of our experience with polypropylene mesh in traumatic and nontraumatic difficult abdominal closures. Timing of mesh placement and removal relative to the initial operation were recorded, as were abdominal complications, number of operative procedures, and type of ultimate abdominal closure.
Between 1988 and 1993, polypropylene mesh was placed in 26 critically ill or injured patients requiring celiotomy, of whom 23 survived more than 3 weeks. Ultimate wound management was delayed mesh removal and primary closure (17%), myocutaneous flap coverage over mesh (4%), split-thickness skin grafting to the granulating wound (35%), or closure by secondary intention over mesh (43%). Split-thickness skin grafting and closure by secondary intention resulted in enterocutaneous fistulas in 50% and 40% of cases, respectively. Full-thickness closure with or without mesh removal resulted in no fistulas.
Mesh provided adequate fascial closure, even with gross wound contamination. Coverage of polypropylene mesh by secondary intention or split-thickness skin grafting resulted in unacceptably high rates of fistulous complications, and this procedure should be replaced by either mesh removal or full-thickness coverage.
面对筋膜坏死或大量肠水肿时腹壁的关闭仍然是一个难题，且并发症频发。先前的研究探讨了在这种情况下放置聚丙烯网片的效用和缺陷。
我们对在创伤性和非创伤性困难腹壁关闭中使用聚丙烯网片的经验进行了回顾性评估。记录了网片放置和移除相对于初次手术的时间，以及腹部并发症、手术操作次数和最终腹壁关闭的类型。
1988年至1993年间，在26例需要剖腹手术的重症或受伤患者中放置了聚丙烯网片，其中23例存活超过3周。最终的伤口处理方式为延迟移除网片并一期缝合（17%）、在网片上覆盖肌皮瓣（4%）、对肉芽创面进行中厚皮片移植（35%）或在网片上二期愈合（43%）。中厚皮片移植和二期愈合分别导致50%和40%的病例发生肠皮肤瘘。无论是否移除网片进行全层缝合均未导致瘘管形成。
即使伤口严重污染，网片也能提供足够的筋膜关闭。二期愈合或中厚皮片移植覆盖聚丙烯网片导致瘘管并发症发生率高得令人无法接受，该方法应由移除网片或全层覆盖取代。
