Lord R S, Crozier J A, Snell J, Meek A C
Surgical Professional Unit, St. Vincent's Hospital, Sydney, Australia.
J Vasc Surg. 1994 Jul;20(1):27-33. doi: 10.1016/0741-5214(94)90172-4.
Both midline and transverse abdominal incisions are used for exposing the infrarenal aorta. Transverse incisions are said to cause less pulmonary and systemic complications, but the claimed advantages may be because most transverse incisions are extraperitoneal, whereas midline incisions are intraperitoneal. This study compares intraperitoneal transverse and midline incisions with respect to perioperative and late complications, especially incisional hernia.
Three hundred twenty-nine patients undergoing infrarenal aortic reconstruction (239 aneurysms; 90 occlusive disease) were analyzed retrospectively according to whether the abdominal wall incision was midline (154 patients) or transverse (175 patients). In all patients, the subsequent dissection was transperitoneal and not retroperitoneal.
Perioperative survival rates and intraoperative blood loss were comparable, but the transverse incision tended to be followed by a shorter period of postoperative ileus (p = 0.07), perhaps because the small bowel was not always exteriorized during operation with transverse incisions. Mean time spent in the intensive care unit was not different between the groups, but those with transverse incisions remained in hospital 5 days less than those receiving midline incisions (p = 0.0005). When an aortic graft greater than 18 mm in diameter was used, survival was reduced compared with that after smaller grafts (p = 0.028). At 1 to 6 years follow-up in 235 patients (109 midline; 126 transverse), 35 (14.9%) incisional hernias were detected, with no statistical difference according to incision (16.5% midline; 13.4% transverse). Analysis by univariate and multivariate logistic regression showed that blood loss at operation exceeding 1000 ml increased the risk of later incisional hernia by a factor of 3.07. Wound infection increased the risk of hernia by 3.70.
Excess blood loss and wound infection exerted this predisposition to incisional herniation independent of other variables.
中线腹部切口和横形腹部切口均用于暴露肾下腹主动脉。据说横形切口引起的肺部和全身并发症较少，但所宣称的优势可能是因为大多数横形切口是腹膜外的，而中线切口是腹膜内的。本研究比较了腹膜内横形切口和中线切口在围手术期及远期并发症方面的情况，尤其是切口疝。
对329例行肾下腹主动脉重建术的患者（239例为动脉瘤；90例为闭塞性疾病）进行回顾性分析，根据腹壁切口是中线切口（154例患者）还是横形切口（175例患者）进行分组。所有患者随后的解剖均为经腹腔而非经腹膜后。
围手术期生存率和术中失血量相当，但横形切口术后肠梗阻时间往往较短（p = 0.07），这可能是因为横形切口手术时小肠不一定总是被外置。两组患者在重症监护病房的平均停留时间无差异，但横形切口患者的住院时间比中线切口患者少5天（p = 0.0005）。当使用直径大于18 mm的主动脉移植物时，与使用较小移植物后的生存率相比有所降低（p = 0.028）。在235例患者（109例中线切口；126例横形切口）1至6年的随访中，检测到35例（14.9%）切口疝，根据切口类型无统计学差异（中线切口16.5%；横形切口13.4%）。单因素和多因素逻辑回归分析显示，术中失血量超过1000 ml会使后期切口疝的风险增加3.07倍。伤口感染会使疝形成风险增加3.70倍。
失血过多和伤口感染导致切口疝形成的这种易感性独立于其他变量。
