Knolmayer T J, Cornell K M, Bowyer M W, McCullough J S, Koenig W
Department of Surgery, David Grant Medical Center, Travis AFB, California 94535, USA.
Am J Surg. 1996 Nov;172(5):506-10; discussion 511. doi: 10.1016/S0002-9610(96)00229-2.
The purpose of this study was to determine whether imbrication of native fascia versus excision and closure of new raw fascia forms a stronger union.
We utilized the anterior rectus sheath fascia of Sprague-Dawley rats as the model. Sixty rats underwent fascial tightening procedures. Each rat had the anterior rectus sheath shortened by 1 cm, 30 by imbrication and 30 by excision and closure. Ten of each group were harvested at 7 days' healing, 10 at 14 days, and 10 of each group at 28 days' healing. The anterior rectus sheath was removed, a "dumbbell" shape constructed, and the cross sectional area at the point of interest determined. The fascia was placed on an Instron tensiometer to determine the breaking strength. Tensile strength was calculated and the data analyzed by ANOVA and the Kruskall-Wallis test. Tissue samples of the closures were histologically analyzed for fibroblast counts, degree of inflammation, and presence of dense fibrous connective tissue. Tissue samples were also analyzed for enzymatic collagen crosslinking.
There was a statistically significant difference in tensile strength between the two groups at 7, 14, and 28 days. Results show that at 7 days the mean tensile strength of excision was 0.133 kg/mm2 +/- 0.056 and the mean tensile strength of imbrication was 0.083 kg/mm2 +/- .048 (P < 0.05); at 14 days the mean tensile strength of excision was 0.105 kg/mm2 +/- 0.033 and the mean tensile strength of imbrication was 0.057 kg/mm2 +/- 0.014 (P < 0.002), and at 28 days the mean tensile strength of excision was 0.279 kg/mm2 +/- 0.143 and the mean tensile strength of imbrication was 0.145 kg/mm2 +/- 0.061 (P < 0.03). Histologic findings showed no statistical significance between the two closure methods when comparing degree of inflammation or the number of fibroblasts present. However, at 7 and 14 days there is a significantly greater presence of dense fibrous connective tissue in the excision group (P < 0.03 at 7 days and P < 0.044 at 14 days by ANOVA). Collagen crosslink analysis showed that by day 28 there is a significantly greater amount (P < 0.05 by ANOVA) of the difunctional crosslink dihydroxylysinonorleucine (DHLNL) and a greater ratio between DHLNL and the difunctional crosslink hydroxylysinonorleucine (HLNL) in the excision and closure group.
We conclude that at 7, 14, and 28 days healing, excision provides a significantly stronger closure than imbrication. According to the crosslinking analysis, it is likely that this strength advantage may continue to increase over time. These findings suggest that excision and closure may be the preferred method for fascial tightening procedures.
本研究的目的是确定对天然筋膜进行叠瓦状缝合与切除并闭合新形成的粗糙筋膜相比，哪种方式能形成更强的愈合。
我们采用Sprague-Dawley大鼠的腹直肌前鞘筋膜作为模型。60只大鼠接受了筋膜收紧手术。每只大鼠的腹直肌前鞘缩短1厘米，其中30只采用叠瓦状缝合，30只采用切除并闭合。每组分别在愈合7天、14天和28天时各取10只大鼠。取出腹直肌前鞘，制成“哑铃”形状，并测定感兴趣部位的横截面积。将筋膜置于Instron拉力试验机上以确定断裂强度。计算拉伸强度，并通过方差分析和克鲁斯卡尔-沃利斯检验对数据进行分析。对闭合处的组织样本进行组织学分析，以计数成纤维细胞、评估炎症程度以及检测致密纤维结缔组织的存在情况。还对组织样本进行酶促胶原交联分析。
两组在7天、14天和28天时的拉伸强度存在统计学显著差异。结果显示，在7天时，切除组的平均拉伸强度为0.133千克/平方毫米±0.056，叠瓦状缝合组的平均拉伸强度为0.083千克/平方毫米±0.048（P<0.05）；在14天时，切除组的平均拉伸强度为0.105千克/平方毫米±0.033，叠瓦状缝合组的平均拉伸强度为0.057千克/平方毫米±0.014（P<0.002）；在28天时，切除组的平均拉伸强度为0.279千克/平方毫米±0.143，叠瓦状缝合组的平均拉伸强度为0.145千克/平方毫米±0.061（P<0.03）。组织学结果显示，在比较炎症程度或成纤维细胞数量时，两种闭合方法之间无统计学显著差异。然而，在7天和14天时，切除组中致密纤维结缔组织的存在明显更多（方差分析显示，7天时P<0.03，14天时P<0.044）。胶原交联分析显示，到28天时，切除并闭合组中双功能交联二羟基赖氨酰正亮氨酸（DHLNL）的含量显著更高（方差分析P<0.05）以及DHLNL与双功能交联羟赖氨酰正亮氨酸（HLNL）的比例更高。
我们得出结论，在愈合7天、14天和28天时，切除提供的闭合强度明显高于叠瓦状缝合。根据交联分析，这种强度优势可能会随着时间的推移而持续增加。这些发现表明，切除并闭合可能是筋膜收紧手术的首选方法。
