Sugerman H J, Kellum J M, Reines H D, DeMaria E J, Newsome H H, Lowry J W
Department of Surgery, Medical College of Virginia, Virginia Commonwealth University, Richmond, USA.
Am J Surg. 1996 Jan;171(1):80-4. doi: 10.1016/S0002-9610(99)80078-6.
Incisional hernia is a serious complication of abdominal surgery. We compared incisional hernia frequency following gastric bypass (GBP) for morbid obesity versus total abdominal colectomy and ileal pouch-anal anastomosis (IPAA) for ulcerative colitis. A prefascial polypropylene mesh repair was also evaluated.
All patients had midline incisions, xiphoid to umbilicus in GBP patients and midepigastrium to pubis in IPAA patients. Fascia were closed with running No. 2 polyglycolic acid suture. Ninety-eight patients underwent prefascial polypropylene mesh repair; 80 were GBP patients, 46 had 1 previous repair, and 17 had 2 to 9 previous repairs (6 with properitoneal mesh).
Incisional hernia occurred in 20% (198/968) of GBP patients (19% without versus 41% with a previous hernia, P < 0.001) versus 4% (7/171) of the IPAA patients (P < 0.001), of whom 102 (60%) were taking prednisone (32 +/- 2 mg/d) and 5 were quite obese (body mass index > or = 30 kg/m2). Additional risk factors for hernia in GBP patients included wound infection, diabetes, sleep apnea, and obesity hypoventilation. For the 98 patients who underwent prefascial polypropylene mesh repair, the mean follow-up was 20 +/- 2 months (range 6 to 104), and complications occurred in 35% of patients, including minor wound infection (12%), major wound infection (5%), seroma (5%), hematoma (3%), chronic pain (6%), and recurrent hernia (4%).
Severe obesity is a greater risk factor for incisional hernia and hernia recurrence than chronic steroid use in nonobese colitis patients. A prefascial polypropylene mesh repair minimizes recurrence.
切口疝是腹部手术的一种严重并发症。我们比较了病态肥胖患者接受胃旁路手术（GBP）与溃疡性结肠炎患者接受全腹结肠切除术及回肠储袋肛管吻合术（IPAA）后切口疝的发生率。还评估了一种筋膜前聚丙烯网片修补术。
所有患者均采用正中切口，GBP患者的切口从剑突至脐，IPAA患者的切口从上腹部中部至耻骨。用2号聚乙醇酸缝线连续缝合筋膜。98例患者接受了筋膜前聚丙烯网片修补术；80例为GBP患者，46例曾接受过1次修补，17例曾接受过2至9次修补（6例使用腹膜前网片）。
GBP患者中20%（198/968）发生切口疝（无既往疝者为19%，有既往疝者为41%，P<0.001），而IPAA患者中为4%（7/171）（P<0.001），其中102例（60%）正在服用泼尼松（32±2mg/d），5例为极度肥胖（体重指数≥30kg/m²）。GBP患者发生疝的其他危险因素包括伤口感染、糖尿病、睡眠呼吸暂停和肥胖低通气综合征。对于接受筋膜前聚丙烯网片修补术的98例患者，平均随访时间为20±2个月（范围6至104个月），35%的患者出现并发症，包括轻度伤口感染（12%）、重度伤口感染（5%）、血清肿（5%）、血肿（3%）、慢性疼痛（6%）和复发性疝（4%）。
与非肥胖结肠炎患者长期使用类固醇相比，严重肥胖是切口疝和疝复发的更大危险因素。筋膜前聚丙烯网片修补术可将复发率降至最低。
