Gardner G P, Josephs L G, Rosca M, Rich J, Woodson J, Menzoian J O
Division of Surgery, Boston University Medical Center, Mass.
Arch Surg. 1994 Jul;129(7):753-6. doi: 10.1001/archsurg.1994.01420310085015.
To determine if intercostal nerve injury is related to postoperative flank "bulge" and to determine whether the extent of the retroperitoneal incision is related to the incidence of flank bulge following abdominal aortic aneurysm repair.
Bilateral dissection of the 11th intercostal nerve on seven cadavers; neurophysiological evaluation of five patients, three with a flank bulge and two without; and retrospective analysis of the extent of retroperitoneal incision and incidence of postoperative flank bulge in 63 consecutive patients.
Urban academic medical center.
Sixty-three consecutive patients who underwent retroperitoneal repair of an abdominal aortic aneurysm and neurophysiological evaluation of five volunteer patients.
Retroperitoneal repair of abdominal aortic aneurysms.
Reduction of injury to the 11th intercostal nerve by avoiding extension of the retroperitoneal incision into the intercostal space.
Of 14 dissections of 11th intercostal nerves, there were bifurcations of the main trunk within the intercostal space in four, at the tip of the 11th rib in seven, and at least 2 cm distal to the tip of the rib in three. Neurophysiological evaluation revealed iterative discharges, polyphasia, fibrillation potentials, and altered recruitment patterns compatible with intercostal nerve injury in patients with a bulge but not in the opposite abdominal wall musculature or in patients without a bulge. Seven (11.11%) of 63 patients had a bulge. Thirty-one of 63 patients had incisions into the 11th intercostal space in which a bulge developed in six (19.35%). Thirty-two patients had incisions that avoided extension into the intercostal space; a bulge developed in one (0.03%) (P = .53).
Postoperative bulge is related to intercostal nerve injury with subsequent paralysis of abdominal wall musculature. Intercostal nerve injury can be reduced by avoiding extension of the incision into the 11th intercostal space.
确定肋间神经损伤是否与术后侧腹“膨出”有关，并确定腹膜后切口范围是否与腹主动脉瘤修复术后侧腹膨出的发生率有关。
在7具尸体上对第11肋间神经进行双侧解剖；对5例患者进行神经生理学评估，其中3例有侧腹膨出，2例无侧腹膨出；对63例连续患者的腹膜后切口范围和术后侧腹膨出发生率进行回顾性分析。
城市学术医疗中心。
63例连续接受腹膜后腹主动脉瘤修复术的患者以及5例志愿患者的神经生理学评估。
腹膜后腹主动脉瘤修复术。
通过避免腹膜后切口延伸至肋间间隙来减少对第11肋间神经的损伤。
在对第11肋间神经的14次解剖中，主干在肋间间隙内分叉的有4例，在第11肋尖分叉的有7例，在肋尖远端至少2 cm处分叉的有3例。神经生理学评估显示，有膨出的患者存在与肋间神经损伤相符的反复放电、多相波、纤颤电位和募集模式改变，而对侧腹壁肌肉组织或无膨出的患者则未出现。63例患者中有7例（11.11%）出现膨出。63例患者中有31例的切口延伸至第11肋间间隙，其中6例（19.35%）出现膨出。32例患者的切口未延伸至肋间间隙；其中1例（0.03%）出现膨出（P = 0.53）。
术后膨出与肋间神经损伤及随后的腹壁肌肉麻痹有关。通过避免切口延伸至第11肋间间隙可减少肋间神经损伤。
