Chapter 1: Perioperative management: evidencefor antibiotic and thromboembolic prophylaxisin endoscopic/laparoscopic inguinal hernia surgery?
Chapter 2: Technical key points in TAPP repair
Which is the safest and most effective method ofestablishing pneumoperitoneum and obtaining access tothe abdominal cavity?
Level1BIn thin patients (BMI\27), the direct trocar insertion is asafe alternative to the Veress needle technique (strongerevidence).
GradeCThe direct trocar insertion (DTI) can be used in order toestablish pneumoperitoneum as a safe alternative toVeress needle, Hasson approach or optical trocar, ifpatient’s risk factors are considered and the surgeon isappropriately trained (new recommendation).
What kind of trocars should be used?
Is there any relation between the trocar type and riskof injury and/or trocar hernias?
Level2BUse of 10-mm trocars or larger may predispose to hernias,especially in the umbilical region or in the obliqueabdominal wall (Stronger evidence). GradeBFascial defects of 10 mm or bigger should be closed(Stronger evidence).
Is clinical examination efficient enough?
What is the role of TAPP and other techniques inreliable assessment? GradeBA thorough closure of peritoneal incision or biggerperitoneal tears should be achieved (Stronger evidence).
Chapter 3: Technical key points in TEP
How should a large direct sac be handled?
Level4Alternatively to fixation of the extended fascia transversalisto Copper’s ligament the direct inguinal hernia defect canbe closed by a pre-tied suture loop (new statement).
GradeDAs alternative the primary closure of direct inguinal herniadefects with a pre-tied suture loop can be used (newrecommendation).
How should a large indirect sac be handled?
Level3Transection of a large indirect sac does not lead tosignificant differences in postoperative pain, length ofhospital stay and recurrence, but to a significant higherseroma rate (new statement).
GradeCA large indirect sac may be ligated proximally and divideddistally without the risk of a higher postoperative pain andrecurrence rate, but with an increased postoperativeseroma rate (new recommendation).
Should a drain be used after a TEP repair? Shouldseromas be aspirated?
Level3Drain after TEP significantly reduces the incidence ofseroma formation with increasing the risk of infection orrecurrence (new statement).
GradeCA closed-suction drain can be used to reduce the risk ofseroma formation without increased risk of infection(new recommendation).
Has extraperitoneal local anesthetic treatment duringTEP a positive effect on postoperative pain? New(added) question
Level 1AExtraperitonealbupivancaine treatment during endoscopicTEP inguinal hernioplasty is not more efficaciousfor thereduction of pain than placebo.
GradeAExtraperitoneal bupivacaine treatment during endoscopicTEP inguinal hernia repair for the reduction ofpostoperative pain should not be performed.
Chapter 4: TEP versus TAPP: which is better?
Level1ATAPP has a longer hospital stay compared to TEP (new).
Level1BPotentially serious adverse events are rare after both TAPPand TEP (stronger evidence).TAPP has a longer operation time compared to TEP (new).
Level2CTEP has more intra-operative and postoperative surgicalcomplication rate compared to TAPP (new).
GradeABoth techniques are acceptable treatment options foringuinal hernia repair and there is sufficient data toconclude that both TAPP and TEP are effective methodsof laparoscopic inguinal hernia repair (strongerevidence).
Chapter 5: Endoscopic/laparoscopic surgeryin complicated hernias: feasibility, risks, and benefit
Level3TEP inguinal-scrotal hernia repair remains an advantageousapproach during the difficult scrotal hernia that requires‘‘conversion’’ to an open repair, because the pre-peritonealdissection performed laparoscopically allows for reductionof the hernia and optimal mesh placement once the herniarepair has been converted and is performed from the
anterior approach (new).
GradeCTEP approach for the large, difficult scrotal hernia mayserve as an adjunct to dissection and definition of the preperitonealspace allowing for easier hernia and meshplacement once the case is ‘‘converted’’ to open repair(new).
Level3Laparoscopic hernia repair for incarcerated inguinal herniahas been successfully and safely performed in the pediatricpopulation (new). GradeCLaparoscopic hernia repair for incarcerated inguinal herniamay be successfully and safely performed in the pediatricpopulation by surgeons with laparoscopic expertise (new).
Level4Women are at increased risk of having an occultsynchronous femoral hernia (New).
GradeCWhen performing inguinal hernia repair in women, extraeffort should be undertaken to reveal and treat occultsynchronous femoral hernia (New).
Chapter 6: Mesh size and recurrence
Chapter 7: Heavy or light weight mesh in TAPPand TEP—functional outcome and quality of life
Level 1AThe statistical significance that lighter meshes with largerpores results in improvement of quality of life is notconsistent in recently published meta-analyses. Subsetanalysis revealed no higher risk of recurrence after usinglightweight meshes in laparoscopic inguinal herniarepair (New).
Level2BThe middle- and long-term results of prospective studies inmen do notsupport the hypothesis that bilateral inguinalhernia repair with alloplastic meshprosthesis causesmale infertility or decreasing the sperm motility (New).
GradeBA monofilament implant with a pore size of at least1.0–1.5 mm (usually meaning low-weight) consisting of aminimum tensile strength in all directions (includingsubsequent tearing force) of 16 N/cm appeared to be mostadvantageous;
however, this assumption mainlysummarizes personal and published clinical and experimental experiences (stronger evidence).The application of large porepolypropylene meshes inendoscopic hernia repair is harmless concerningazoospermia and should therefore further used (New).
Chapter 8: Slitting or not slitting of mesh—does itinfluence outcome?
Level1Cutting a slit in the mesh to allow the structures of thefunicel to pass does not compromise testicular perfusionand testicular volume (New).
GradeBBased on available evidence we recommend not to cut a slitin the mesh although cutting does not compromise testisperfusion (New).
Chapter 9: Mesh fixation modalities: is therean association with acute or chronic pain?
Level1AFixation and non-fixation of the mesh in TEP areassociated with equally risk of postoperative pain orrecurrence (New).
Level1BFibrin glue fixation is associated with less chronic painthan stapling. GradeAIf TEP technique is used, non-fixation has to be consideredin all types of inguinal hernias except large direct defects(MIII, EHS classification) (strongerrecommendation).
GradeBIn case of TAPP repair non-fixation should be considered intypes LI, II, and MI, II hernias (EHS classification).For fixation, fibrin glue should be considered to minimizethe risk of acute postoperative pain (modifiedrecommendations).
Chapter 10: Risk factors and prevention of acuteand chronic pain in TAPP and TEP
Level1AThere is no difference of chronic pain after TEP and TAPP(stronger evidence).Fixation and non fixation of the mesh in TEP are associatedwith equally risk of postoperative pain (see chapter‘‘Fixation’’) (new).
Level1BFibrin glue fixation is associated with less chronic painthan stapling (see chapter ‘‘Fixation’’) (new).
Level2AAge below median (40–50 years) is a risk factor for acute
pain (stronger evidence).Age below median (40–50 years) is a risk factor for chronic pain (stronger evidence).Severe acute postoperative pain is a risk factor for chronicpain (stronger evidence).
GradeAIf TEP technique is used non fixation has to be consideredin all types of inguinal hernias except large defects (L III,MIII; EHS classification; see chapter ‘‘Fixation’’) (new).
GradeBIn case of TAPP repair non fixation should be considered intypes LI, LII, MI, MII hernias (EHS classification, see Chapter ‘‘Fixation’’) (new).
Chapter 11: Urogenital complications associatedwith TAPP and TEP
Level2BInguinal hernia repair with mesh is not associated with anincreased risk of, or clinically important risk for, maleinfertility. (new).
GradeBGroin hernia repair using mesh techniques may continue tobe performed without major concern about the risk formale infertility. (new).
Chapter 12: Intraperitoneal onlay mesh (IPOM)for inguinal hernia repair—still a therapeutic option?
Chapter 13: Role for open preperitoneal meshplacement in the era of
endo/laparoscopic inguinalhernia repair
Level1BMinimally invasive open approaches (i.e., Kugel) mayoffer a cost advantage over laparoscopic approaches.(new).
Chapter 14: Single port surgery or reduced portsin endoscopic/laparoscopic hernia repair (New chapter)
Level2BSingle port laparoscopic hernia repair is a safe and feasiblealternative to traditional multiport technique although hasnot been showed to be superior or more effective.Single port laparoscopic hernia repair may offer a bettercosmetic outcome and patient’s satisfaction.Single port laparoscopic hernia repair has no increased risk compared with standard multiport technique.Homemade ports, as an alternative to commerciallyavailable ports, provides a feasible and safe alternatives GradeBSingle port laparoscopic inguinal hernia repair is safe andfeasible alternative options to conventional laparoscopy inselected cases but further RCTs are needed.Both TAPP and TEP can be performed with equal results inselected cases. Chapter 15: Convalescence after hernia surgery (Newchapter)Is post-surgeryphysical strain related to groin herniarecurrence?
Level1BThere is no evidence for an increase in recurrence risk dueto physical strain (including heavy lifting) after groinhernia surgery irrespective of the method ofsurgery.
Level 3 Immediate return to work (within 1–3 days) is notassociated with hernia recurrence.Immediate resumption of activity of daily living (ADL)(within 1–3 days) is not associated with herniarecurrence.Short convalescence is not associated with a higherrecurrence risk, and some studies even show an inverserelation GradeBPatients should be actively assured that physical activity ofany kind does not jeopardize the stability of groin herniarepair.Patients should be encouraged to resume work and ADLafter 1 day.
What are the limiting factors for the resumption ofwork and physical activities after groin hernia repair?Statements
Level2APain is an important limiting factor for the resumption ofwork and physical activities after groin hernia repair.Level 3 Patients’ attitude toward convalescence is heavily influenced by their surgeons’recommendation.Return to work is heavily influenced by the type of sickleavecompensation.
GradeCEffective pain control is a prerequisite of early return towork and ADL. GradeBPatients should be counseled with regard to availability andside effects of analgesics.
What period of physical inactivity, if any, is recommendedafter groin hernia repair?
Level1BNo specific period of physical inactivity is required aftergroin hernia repair. GradeB The patient’s individual wish after counseling is to berespected andfacilitated, e.g., by generous analgesicsprescription; however, extended periods of sick-leave areusually not necessary and should not be supported
In which way, if any, does convalescence pertain to thechoice of surgical procedure?
Level1APostoperative pain is less pronounced after endoscopic ascompared to open
hernia repair.Endoscopy hernia surgery is associated with shortervocational downtime and earlier resumption of ADL ascompared to open hernia repair.
GradeBWith respect to convalescence, endoscopic hernia repair ispreferable over open techniques.
Chapter 16: Sportsman hernia—diagnosisand treatment
Level2BCT scan has high accuracy in detecting posterior walldeficiency (PWD. (new)
Level1BSurgery (endoscopic placement of retropubic mesh) ismore efficient than conservative therapy for the treatment of sportsman’s hernia. (stronger evidence).
In Sportsman’s hernia the re sults of surgical repair to theposterior inguinal wall are excellent. (strongerevidence).For conservative treatment the use of radiofrequency denervation of both ilio-inguinal nerve and inguinalligament in the treatment of refractory Sportsman’sHernia is safe and efficacious at least in the short term,and is superior to anesthetic/steroid injection. (new).
GradeAEndoscopic placement of retropubic mesh must beconsidered a seriousoption for Sportsman hernia.(stronger evidence).For conservative treatment of refractory Sportsman’shernia, radiofrequency denervation of both ilio-inguinalnerve and inguinal ligament must be considered, in theshort term, an alternative toanesthetic/steroid injection.(new).
Chapter 17: Evidence based training for endoscopic/laparoscopic hernia repair (New chapter)
Level1ASimulation training improves trainee satisfaction, traineeknowledge, time and process measure of skills,behaviors, compared to no training and tonon-simulationtraining.
Level1AComputer simulation and box trainers improve operativeperformance.
Box training is as effective as computer simulation andresults in higher learner satisfaction
Level1BCognitive training plus mastery learning on box trainersimproves patient outcome
Level2BGOALS-GH is an objective and valid measure of skillsrequired to perform LIHR (TAPP and TEP).Training on fresh frozen cadaver has higher face validity than training on a VR trainer.
GradeAA simulation trainer should be available to all learners toimprove operative performance.At the current time, box trainers are preferred overcomputer-assisted simulation for inguinal hernia repair.
GradeBA proficiency-based curriculum for the available trainertool should be established to improve patient outcomes.A validated assessment tool should be used to assessproficiency.
Chapter 18: Costs in endoscopic/laparoscopic and openhernia surgery (New chapter)
Level1AWhen using disposable trocars and instruments direct costs(hospital) are higher for laparoscopic inguinal herniarepair.Total costs (hospital and societal) are lower forlaparoscopic inguinal hernia repair compared to open.Operation time is a cost-relevant factor.Time for anesthesia is a cost-relevant factor.Experience and
quality of performance are cost-relevantfactors.Simulator-training may improvequality of performance.
Level2CHernia surgery is cost-effective. It may be superior to‘‘watchful waiting’’ in the long https://www.doczj.com/doc/571693311.html,paroscopic hernia surgery offers a higher cost-utilitycompared to open.Hospitals costs for laparoscopic hernia repair may besimilar or lower compared to open but there is a largevariation in cost per QALY generated by individualproviders.In hospitals with a high case load costs are lower.
GradeANon-disposable trocars and instruments must be considered.Non-fixation techniques should be considered. Use of no orindigenous balloon must be considered. Operative performance and education of the surgeons mustbe improved.To shorten the learning curve of traineesurgeons, simulatortraining should be introduced. GradeB In hernia disease surgery might be superior to ‘‘watchful waiting’’.From the point of cost-utility laparoscopic inguinal herniarepair may be considered.Toenhance the case load centralization of hernia surgeryshould be considered.
腹腔镜腹股沟疝修补术 在美国，腹股沟疝修补术是最常见的手术之一,同时也是普外科一个既定的核心。用于治疗腹股沟直疝和腹股沟斜疝，每年要做750000个这样的手术。修补术已经发展了两个世纪（表3-1），包括Bassini, McVay, Shouldice 以组织为基础的修补术。紧随这些修补术之后就过度到了一种试图减少复发率和术后疼痛的无张力修补术（以补片为基础）。二十世纪九十年代早期腹腔镜修补术被引入（表3-2）,目前14%的修补术是通过腹腔镜来完成的。有几 1556 1756 1778 1793 1804 1806 1809 1871 1884 1889 1898 1942 1920 1936 1960s 1975 1969 1970 1989 人名法国 英国 德国 西班牙 英 德 意大利 波士顿 意大利 巴尔的摩 奥地利 南达科塔 英 芝加哥 西雅图，芝加哥 都柏林，开罗 加拿大 洛杉矶 洛杉矶 解剖的时代 第一次记录了一例绞窄性疝手术的描述 发表关于疝气的论文（包括首次先天性腹股沟斜疝 的描述） 描述腔隙韧带（Gimbernat’s ligament） 描述耻骨上韧带，腹横筋膜，以及腹内斜肌、腹横 肌的快门机制 描述髂耻束和“腹股沟三角” 发表关于提睾肌筋膜（“Scarpa’筋膜 ”）和滑动疝的经典论文 早期外科修补术 描述通过腹横筋膜和腹股沟韧带的连接来重建腹股 沟管后壁（Bassini法） 描述通过精索换位来重建腹股沟管后壁（Halster I 法） 描述Cooper韧带（耻骨梳韧带）修补术 再次介绍并普及Cooper韧带（耻骨梳韧带）修补术 （McV ay法） 介绍腹膜前修补术 重新发现腹膜前修补术 普及髂耻束腹膜前修补术 报告“巨大疝修补术；”现代的修复 描述腹股沟管后壁连续、多层的修补术（Shouldice 法） 推广门诊疝手术 介绍“无张力”原始补片修补术
传统疝修补术与腹腔镜疝修补术优缺点比较 目的：为了进一步研究和比较传统疝修补术与腹腔镜疝修补术的临床优缺点，从而为临床同类研究提供一些借鉴和参考依据。方法：选取2010年12月-2013年12月笔者所在医院收治的腹外疝患者152例为研究对象，采用随机数字表法分为传统疝修补术组和腹腔镜疝修补术组，每组76例。观察和比较两组患者实施不同手术治疗后的手术时间、出血量和疼痛持续时间、临床复发率和并发症发生率。结果：（1）传统疝修补术组患者的手术时间长于腹腔镜疝修补术组，出血量高于腹腔镜疝修补术组，疼痛持续时间长于腹腔镜疝修补术组，差异均有统计学意义（均P＜0.05）；（2）腹腔镜疝修补术组复发率和并发症发生率均显著低于传统疝修补术组，差异有统计学意义（均P＜0.05）。结论：与传统疝修补术相比较，采用腹腔镜疝修补术治疗腹股沟疝的临床优势明显，是临床治疗腹股沟疝的理想可靠选择之一。 标签：传统疝修补术；腹腔镜疝修补术 在临床实践的过程中：腹股沟疝属于最为常见的普外科疾病类型之一[1]。目前临床针对腹股沟疝的有效治疗方法主要以手术治疗为主。而不同手术方法在临床应用效果上存在一定的差异。在此背景下，为了进一步研究和比较传统疝修补术与腹腔镜疝修补术的临床优缺点，从而为临床同类研究提供一些借鉴和参考依据，本研究选取了笔者所在医院收治的腹外疝患者为研究对象进行了如下比较研究。 1 资料与方法 1.1 一般资料 选取2010年12月-2013年12月笔者所在医院收治的腹外疝患者152例为研究对象，其中男122例，女30例；年龄最大66岁，最小16岁，平均（47.34±4.34）岁。采用随机数字表法分为传统疝修补术组和腹腔镜疝修补术组，每组76例。两组患者一般临床基线资料比较差异无统计学意义（P>0.05），具有可比性。 1.2 方法 1.2.1 传统疝修补术术前排空膀胱，麻醉后患者采用平卧式体位。在复发疝患者腹股沟韧带上方2 cm与之平行位置进行切口，切口长约2～3 cm，在外环切开腹外斜肌膜到达内环，把精索游离，稍微分离提睾肌和筋膜，在精索的外前方找到疝囊，进行传统疝修补技术[2]。 1.2.2 腹腔镜疝修补术术前排空膀肤，全身麻醉，采取头低脚高15°～30°体位，建立气腹，在适当位置制两个孔，分别置入5 mm腹腔镜和3 mm操作钳。通过腹腔镜观察，首先找到对应患侧的内环口，并在内环口体表投影处再制一小孔，大约2～3 mm，置入带线针和针钩，和操作钳配合缝合内环口半轴腹膜，带
【关键词】腹腔镜腹股沟疝修补术常规 腹腔镜腹股沟疝修补术是一种安全、技术合理的无张力修补手术。 腹腔镜腹股沟疝修补术适用于Ⅰ型、Ⅱ型、Ⅲ型和IV型的腹股沟直疝、斜疝和股疝（中华外科学会疝与腹壁外科学组2003年8月修订稿）。 腹腔镜腹股沟疝修补术主要包括两种方法：经腹腹膜前补片植入术（TAPP），全腹膜外补片植入术（TEP）。 前瞻性研究显示，腹腔镜腹股沟疝修补术复发率为１％～２％，等同于开放式无张力修补术，低于开放式有张力修补术。 前瞻性研究显示，腹腔镜腹股沟疝修补术与开放式手术相比，患者切口小、疼痛轻、恢复正常体力活动早。 前瞻性研究显示，腹腔镜腹股沟疝修补术总并发症发生率等同于开放式修补术。 腹腔镜腹股沟疝修补术最常见的并发症是血清肿。 腹腔镜腹股沟疝修补术的费用高于开放式修补术 手术方法 综观腹腔镜腹股沟疝修补术的发展史，可归纳为6种方法： 1内环口关闭术：相当于开放式手术中疝囊的高位结扎，因未对腹股沟管后壁进行修补，仅适用于小儿腹股沟斜疝。 2植入物填塞术（plug and patch）：将植入物直接植入缺损处。因植入物容易移位，且修补局限，故复发率和再发率高，目前已很少应用,建议不要用这种方法修补腹股沟疝。 3腹腔内补片植入术（intra peritoneal onlay mesh，IPOM）:在腹腔内将补片钉合在疝缺损的腹膜上。IPＯM是目前治疗切口疝的主要方法。在修补腹股沟疝时，因补片容易移位，需做一定的改良：如补片中央固定，补片四周缝合，打开腹膜将补片与耻骨结节或Cooper′s 韧带固定等。为防止腹腔粘连，必须使用聚丙稀和聚四氟乙稀复合材料（如Composix Mesh）或膨体聚四氟乙稀（eＰTFE）双面材料（如Dual Mesh），补片价格较贵。 4IPOM＋内环口成形术：在IPOM的基础上加行内环口成形术，即将腹横筋膜与髂耻束对合以缩小内环口，相当于开放式Marcy术。此方法操作难度高，目前已很少应用。 5经腹腹膜前补片植入术（transabdominal preperitonea1，TAPP）在腹腔内打开腹膜，解剖腹膜前间隙，将补片与Cooper′s韧带、耻骨结节、腹直肌外缘和联合肌腱钉合，再关闭腹膜。原则等同于Rives、Stoppa在２０世纪８０年代提出的开放式经前腹膜补片植入术。 ６全腹膜外补片植入术（totally extraperitonea1，TEP）：直接进入腹膜前间隙而无需
腹腔镜腹股沟疝手术操作指南（最全版） 为了推广腹腔镜腹股沟疝修补理念、规范手术操作流程、推动学科发展，中华医学会外科学分会疝和腹壁外科学组、中华医学会外科学分会腹腔镜与内镜外科学组、大中华腔镜疝外科学院对2013年制定的《腹股沟疝腹腔镜手术的规范化操作指南》予以修订。本次修订在原版本的基础上，参照国内外最新的技术进展和相关指南，结合国内专家的临床经验和具体国情，进行了深入讨论并广泛听取意见，不断修订和完善，于2017-03-18在杭州举行的工作会议上完成全面修订和定稿。现公布如下。 证据级别： 1A：随机对照试验的系统评价（各个研究具有同质性）。 1B：高质量的随机对照试验。 2A：2B级别研究的系统评价（各个研究具有同质性）。 2B：前瞻性对照研究（或质量略低的随机对照试验）。 2C：结果性研究（大样本分析，群体数据等）。 3：回顾性对照研究，病例对照研究。 4：病例研究（即无对照组的研究）。 5：专家意见，动物或实验室研究。
推荐级别： A：基于1级证据= 强烈推荐（“标准”，“必须执行”）。 B：基于2级或3级证据，或基于1级证据推论= 推荐（“推荐”；“应该执行”）。 C：基于4级证据，或2级或3级证据推论= 建议（“选择”；“可以执行”）。 D：基于5级证据，或缺乏一致性、或不确定级别的证据= 不做推荐，仅叙述。 本文的证据和推荐级别来源于文献［1-5］。 2.1 麻醉和体位行经腹腔腹膜前疝修补术（TAPP）建议全身麻醉。病人头低脚高10～15?仰卧位，双臂紧贴身体两侧。主刀医师位于疝的对侧，助手位于患侧或头侧。监视器置于手术台尾侧。 2.2 手术步骤 2.2.1 置入套管脐孔穿刺，建立CO2气腹至12～15 mmHg（1 mmHg=0.133 kPa）。置入3个套管：脐部10～12 mm套管放置30?腹腔镜作为观察孔，患侧腹直肌外侧平脐水平和对侧腹直肌外侧脐下水平分别置入5 mm套管作为操作孔。直径＞10 mm的套管可能会增加戳孔疝的发生率（2B级证据）。双侧疝时两侧的套管可置于对称位置。
腹腔镜腹股沟疝修补术 邵毅山东大学医学院硕士 智绪亭山东大学齐鲁医院普外科主任医师，教授，博士生导师腹股沟疝是普外科常见病和多发病。无张力疝修补术是使用人工合成网片材料进行无张力疝修补的方法。腹腔镜腹股沟疝修补术是在无张力疝修补术基础上发展起来的一种微创技术。限制腹腔镜疝修补术快速发展的主要原因有：尚不能确定该手术方式安全性和有效性、认为手术操作难度大，手术的费用高等。本文对腹腔镜腹股沟疝修补术的应用解剖、术式及术后并发症等做一综述，以期增加临床医生对此手术技术及发展状况的了解。 一、腹腔镜疝修补术的应用解剖 熟悉腹膜前间隙内腹股沟区解剖结构是新近开展腹腔镜疝修补术手术医师需要完成的首要任务。经前腹膜腹股沟区解剖的重要标志包括：①脐侧韧带：这是腹腔镜下最显著的解剖标志。此韧带是一条纵向走行的腹膜皱襞，紧靠正中线，邻近膀胱，起于髂内动脉，一直延伸到脐部。②腹壁下动脉：始于髂外动脉，形成斜疝内环口的内界，镜下可见其搏动，有助于斜疝与直疝的鉴别诊断。③输精管：白色条索状物，向中下走行，跨过Cooper韧带于镜下右侧8点钟，左侧4点钟位置进入内环。④髂耻束：由腹横筋膜至腹股沟韧带向后的游离缘处加厚所形成，在腹腔镜无张力疝修补中需特别重视腹横肌腱膜弓和髂耻束。髂耻束被腹股沟韧带覆盖，有时不易辨认而与腹股沟韧带混淆，手术中需仔细辨认此结构。⑤内环口：系腹壁下动脉、输精管、精索血管的交汇点。如无斜疝，内环口扁平。小的斜疝内环口呈浅陷窝状，如斜疝较大则呈宽而浅的盆状或洞穴状。⑥Cooper韧带：白色，较坚韧，向正中起行，止于耻骨结节。该韧带与髂耻束、联合腱、腹直肌外侧缘等构成一个坚强肌-腱膜-骨性结构支架，是镜下固定网状结构的主要承受体。⑦毁灭三角：腹壁下动脉构成斜疝内环口的内侧边界，可见输精管从内下进入内环，而生殖血管从外中下进入内环，两者之间的间隙称为毁灭三角。此区有髂外动静脉及股神经从其下方通过，在缝合或钉合网状结构时应避开该三角，以免损伤血管神经。 二、腹腔镜疝修补术 经腹腔镜疝修补术属微创外科的范畴。其术式包括单纯内环口关闭术(PET)、假体填塞术、腹腔内补片植入法(IPOM)、经腹膜前补片植入法(TAPP)、完全腹膜外补片植入法(TEP)。1982年Ger等实施了世界上首例腹腔镜疝修补术。Shultz等1990年首次应用腹腔镜关闭内环和聚丙烯补片充填缺损。1991年Toy和Smoot联合报道了腹腔镜腹腔内补片植入术(IPOM)，此手术将补片固定在腹壁上未对腹股沟区进行解剖干预。同年，Arregui首次报道了经腹腔腹膜前补片植入术(TAPP)，其方法是在腹腔内打开腹膜，并在腹膜前间隙将补片植入。1992年McKernan报道了全腹膜外补片植入术(TEP)，与TAPP相比其进路不同，TEP是直接进入腹膜前间隙植入补片而未进入腹
Chapter 1: Perioperative management: evidencefor antibiotic and thromboembolic prophylaxisin endoscopic/laparoscopic inguinal hernia surgery? Chapter 2: Technical key points in TAPP repair Which is the safest and most effective method ofestablishing pneumoperitoneum and obtaining access tothe abdominal cavity? Level1BIn thin patients (BMI\27), the direct trocar insertion is asafe alternative to the Veress needle technique (strongerevidence). GradeCThe direct trocar insertion (DTI) can be used in order toestablish pneumoperitoneum as a safe alternative toVeress needle, Hasson approach or optical trocar, ifpatient’s risk factors are considered and the surgeon isappropriately trained (new recommendation). What kind of trocars should be used? Is there any relation between the trocar type and riskof injury and/or trocar hernias? Level2BUse of 10-mm trocars or larger may predispose to hernias,especially in the umbilical region or in the obliqueabdominal wall (Stronger evidence). GradeBFascial defects of 10 mm or bigger should be closed(Stronger evidence). Is clinical examination efficient enough? What is the role of TAPP and other techniques inreliable assessment? GradeBA thorough closure of peritoneal incision or biggerperitoneal tears should be achieved (Stronger evidence). Chapter 3: Technical key points in TEP How should a large direct sac be handled? Level4Alternatively to fixation of the extended fascia transversalisto Copper’s ligament the direct inguinal hernia defect canbe closed by a pre-tied suture loop (new statement). GradeDAs alternative the primary closure of direct inguinal herniadefects with a pre-tied suture loop can be used (newrecommendation). How should a large indirect sac be handled? Level3Transection of a large indirect sac does not lead tosignificant differences in postoperative pain, length ofhospital stay and recurrence, but to a significant higherseroma rate (new statement). GradeCA large indirect sac may be ligated proximally and divideddistally without the risk of a higher postoperative pain andrecurrence rate, but with an increased postoperativeseroma rate (new recommendation). Should a drain be used after a TEP repair? Shouldseromas be aspirated? Level3Drain after TEP significantly reduces the incidence ofseroma formation with increasing the risk of infection orrecurrence (new statement). GradeCA closed-suction drain can be used to reduce the risk ofseroma formation without increased risk of infection(new recommendation). Has extraperitoneal local anesthetic treatment duringTEP a positive effect on postoperative pain? New(added) question Level 1AExtraperitonealbupivancaine treatment during endoscopicTEP inguinal hernioplasty is not more efficaciousfor thereduction of pain than placebo.
腹股沟疝的腹腔镜TEP和TAPP的外科解剖和手术技巧1.简史 腹腔镜疝修补术（laparoscopic inguinal hernia repair，LIHR）在1982年就有了报道，不过当时Ger医生是直接钳闭疝囊，没有用补片加强腹膜前。目前我们所用的腹腔镜疝修补术是从20世纪90年代初起步的。1991年，Arregui首次报道了经腹腔途径腹膜前补片置入术(transabdominal preperitoneal prosthetic,TAPP)。公元1992年，Fitzgibbongs首次实施了腹腔内网片修补术（intraperitoneal onlay mesh, IPOM）。公元1993年，Phillips、Mckernan及Law各自实施了全腹膜外补片修补术（totally extraperitoneal prosthetic, TEP）。 2. 腹腔镜疝修补术出现的意义 腹腔镜疝修补术到目前还是有争议的，但争议的声音好像越来越小。越来越多的RCT显示腹腔镜疝修补术和开放式疝修补术相比，有更快的术后恢复，更低的复发率，更低的疼痛不适率，同时兼有切口小、美观和探查对侧疝、隐匿疝和股疝的优点。 腹腔镜疝修补术的开展也使得腹膜前修补得到了迅猛的推广。因为在开展腹腔镜疝修补术前，“外科医生对于腹股沟管后壁几乎一无所知，它隐藏在医生的视野之外”（W. J. LYTLE，1945）。大部分医生很难相像PHS补片或者Kugel补片放在腹膜前是个什么情形，所以就觉得腹膜前技术很难。但自从有了腹腔镜技术，大家何以很清楚的看到腹膜前的结构，进而对其解剖有了一个直观的正确的认识。即使大部分医生不做腹腔镜疝修补术，这种对腹膜前解剖的认识，对于他们做开放式后入路腹膜前修补术也有莫大的帮助。 目前，国内外也出现了机器人做TAPP的报道，除了费用昂贵外，机器人手术彰显了很多优势，如三维立体画面、操作杆可以关节样弯曲而灵活异常等。 3.TAPP的手术步骤： ①戳孔位置： 一般选用脐孔（10mm）做为观察孔，在脐平面的稍下的两层腹直肌外缘各打一个5mm的操作孔。如果是单侧疝，也可以将健侧的操作孔移至脐下5cm处。 ②腹膜的切开： 进人腹腔后，首先要辨认5条韧带:①脐中韧带:位于中线，是脐尿管闭塞后的残留痕迹;②脐内侧韧带:是覆盖在闭塞的脐动脉表面的腹膜皱褶，位于脐中韧带的两侧，膀胧位于两条脐内侧韧带之间;③脐外侧韧带:是覆盖在腹壁下动脉表面的腹膜皱褶，位于脐内侧韧带的外侧。通常在疝缺损上缘3cm弧形切开腹膜，内侧不能超过脐内侧韧带，以免损伤膀胧，切开中间的腹膜时应避免损伤腹壁下动脉。 ③疝囊的分离： 斜疝疝囊突入内环口，疝囊外往往会有一些脂肪组织或“脂肪瘤”，较大的“脂肪瘤”应予切除，否则“脂肪瘤”会滑入腹股沟管，引起类似滑疝的复发。斜疝疝囊应尽可能剥离，残留的疝囊会增加血清肿的概率，但与精索粘连致密的大疝囊宜横断，强行剥离会引起术后阴囊血肿。腹腔镜手术中，精索须充分“盆壁化”(perietalization)，即将疝囊与后方的精索血管及输精管充分游离6～8cm，这一步骤非常重要，否则补片会覆盖在疝囊上，引起斜疝的复发。同时要注意的是，男性患者疝囊的内下侧是输精管，外下侧是睾丸动静脉，剥离疝囊时勿粗暴
腹腔镜腹股沟疝修补术常规 腹腔镜腹股沟疝修补术是一种安全、技术合理的无张力修补手术。 腹腔镜腹股沟疝修补术适用于I型、II型、III型和IV型的腹股沟直疝、斜疝和股疝（中华外科学会疝与腹壁外科学组2003年8月修订稿）。 腹腔镜腹股沟疝修补术主要包括两种方法：经腹腹膜前补片植入术（TAPP），全腹膜外补片植入术（TEP）。 前瞻性研究显示腹腔镜腹股沟疝修补术复发率为1～2%，等同于开放式无张力修补术，低于开放式有张力修补术。 前瞻性研究显示腹腔镜腹股沟疝修补术与开放式手术相比，切口小、疼痛轻、恢复正常体力活动早。 前瞻性研究显示腹腔镜腹股沟疝修补术总并发症发生率等同于开放式修补术。 腹腔镜腹股沟疝修补术最常见的并发症是血清肿。 腹腔镜腹股沟疝修补术的费用高于开放式修补术 手术方法 综观腹腔镜腹股沟疝修补术的发展史，可归纳为6种方法： 内环口关闭术：相当于开放式手术中疝囊的高位结扎，因未对腹股沟管后壁进行修补，仅适用于小儿腹股沟斜疝。 植入物填塞术（Plug and Patch）：将植入物直接植入缺损处。因植入物容易移位，且修补局限，故复发率和再发率高，目前已很少应用，建议不要用这种方法进行腹股沟疝修补。 腹腔内补片植入术（Intra Peritoneal Onlay Mesh, IPOM）：在腹腔内将补片钉合在疝缺损的腹膜上。IPOM是目前治疗切口疝的主要方法。在修补腹股沟疝时，因补片容易移位，需做一定的改良：如补片中央固定、补片四周缝合、打开腹膜将补片与耻骨结节或Cooper's韧带固定等。为防止腹腔粘连，必须使用聚丙稀和聚四氟乙稀复合材料（如Composix Mesh）或膨体聚四氟乙稀（e-PTFE）双面材料（如Dual Mesh），补片价格较贵。 IPOM+内环口成形术：在IPOM的基础上加行内环口成形术，即将腹横筋膜与髂耻束对合以缩小内环口，相当于开放式Marcy术。该方法操作难度高，目前应用很少。 经腹腹膜前补片植入术（Transabdominal Preperitoneal, TAPP）：在腹腔内打开腹膜，解剖腹膜前间隙，将补片与Cooper's韧带、耻骨结节、腹直肌外缘和联合肌腱钉合，再关闭腹膜。原则等同于Rives、Stoppa在八十年代提出的开放式经前腹膜补片植入术。 全腹膜外补片植入术（Totally Extraperitoneal, TEP）：直接进入腹膜前间隙而
中华普外科手术学杂志（电子版）２０１４年８月第８卷第３期ＣｈｉｎＪＯｐｅｒＰｒｏｃＧｅｎＳｕｒｇ（ＥｌｅｃｔｒｏｎｉｃＥｄｉｔｉｏｎ），Ａｕｇｕｓｔ２０１４，Ｖｏｌ．８，Ｎｏ．３ ?奥林巴斯专栏? 腹腔镜腹股沟疝修补术（ＴＡＰＰ） 李健文 王文瑞 李健文现任上海交通大学医学院附属瑞金医院普外科主任医师，上海市微创外科临床医学中心副主任，疝和腹壁外科诊治中心主任，医学博士，硕士生导师。兼任中华医学会外科分会疝与腹壁外科学组（ＣＨＳ）委员，中国医师协会外科医师分会疝与腹壁外科医师委员会（ＣＨＣＳ）副主任委员，上海医学会外科分会疝与腹壁外科学组副组长，中国医师协会内镜医师分会经自然腔道（ＮＯＴＥＳ）学组常务理事，大中华腔镜疝外科学院院长。枟中华外科杂志枠枟中国实用外科杂志枠枟临床外科杂志枠枟腹腔镜外科杂志枠枟中华疝和腹壁外科杂志（电子版）枠等多家杂志编委或特邀编委。学术方向：消化道肿瘤、胆道疾病、疝和腹壁外科疾病的微创治疗。主编著作２部，发表论文６０余篇。担任１项国家级和２项省部级科研课题的主要负责人。获上海市科技进步二等奖１项。 【摘要】 此病例为女性斜疝患者，应用腹腔镜经腹腹膜前疝修补术（ＴＡＰＰ）治疗。腹腔镜治疗女性腹股沟疝有其特殊性，原因是女性患者的子宫圆韧带与腹膜非常致密，不象男性患者的精索那样可以轻易的做到“腹壁化（Ｐａｒｉｅｔａｌｉｚａｔｉｏｎ）”，因此补片往往无法覆盖在子宫圆韧带和腹膜之间。该手术有两个不同于男性患者的操作步骤：（１）游离疝囊至内环口水平即可，不强调子宫圆韧带的“腹壁化”。（２）补片剪一开口，绕过子宫圆韧带覆盖在其后方，而不是平铺在其前方。补片开口处可用缝合或医用胶等方法关闭，相当于进行内环口整形。 【关键词】 疝，腹股沟； 腹腔镜检查 Ｌａｐａｒｏｓｃｏｐｉｃｄｉａｐｈｒａｇｍａｔｉｃｈｅｒｎｉａｒｅｐａｉｒ ＬｉＪｉａｎｗｅｎ，ＷａｎｇＷｅｎｒｕｉ．ＤｅｐａｒｔｍｅｎｔｏｆＧｅｎｅｒａｌＳｕｒｇｅｒｙ，ＲｕｉｊｉｎＨｏｓｐｉｔａｌ，ＳｈａｎｇｈａｉＪｉａｏｔｏｎｇＵｎｉｖｅｒｓｉｔｙＳｃｈｏｏｌｏｆＭｅｄｉｃｉｎｅ．ＳｈａｎｇｈａｉＣｌｉｎｉｃａｌＭｉｎｉｍａｌｌｙＩｎｖａｓｉｖｅＳｕｒｇｅｒｙＣｅｎｔｅｒ，Ｓｈａｎｇｈａｉ２０００２５，ＣｈｉｎａＣｏｒｒｅｓｐｏｎｄｉｎｇａｕｔｈｏｒ：ＬｉＪｉａｎｗｅｎ，Ｅｍａｉｌ：ｌｊｗ５＠ｙｅａｈ．ｎｅｔ 【Ａｂｓｔｒａｃｔ】 Ｔｈｉｓｐａｔｉｅｎｔｓｕｆｆｅｒｅｄｆｒｏｍｄｉａｐｈｒａｇｍａｔｉｃｈｅｒｎｉａｗｉｔｈｉｎｃｏｍｐｌｅｔｅｃｏｌｏｎｉｃｏｂｓｔｒｕｃｔｉｏｎ．Ｔｈｅｄｉａｐｈｒａｇｍａｔｉｃｈｅｒｎｉａｄｅｆｅｃｔｌｏｃａｔｅｄａｔｔｈｅｉｎｆｅｒｉｏｒｐｏｌｅｏｆｔｈｅｓｐｌｅｅｎ，ｗｈｉｃｈｗａｓｒｅｐａｉｒｅｄｕｎｄｅｒｌａｐａｒｏｓｃｏｐｙｂｙｕｓｉｎｇｉｎｔｒａｐｅｒｉｔｏｎｅａｌｏｎｌａｙｍｅｓｈｐｒｏｃｅｄｕｒｅ（ＩＰＯＭ）．Ｔｈｅｒｅａｒｅｔｈｒｅｅｋｅｙｐｏｉｎｔｓｏｆｔｈｅｐｒｏｃｅｄｕｒｅ：ｆｉｒｓｔｌｙ，ｔｏｃｌｏｓｅｔｈｅｄｉａｐｈｒａｇｍａｔｉｃｈｅｒｎｉａｄｅｆｅｃｔｂｙｓｕｔｕｒｅｂｅｆｏｒｅｔｈｅｉｎｓｅｒｔｉｏｎｏｆｍｅｓｈ，ｎａｍｅｌｙ“ａｕｇｍｅｎｔａｔｉｏｎ”ｉｎｓｔｅａｄｏｆ“ｂｒｉｄｇｉｎｇ”；ｓｅｃｏｎｄｌｙ，ｔｏｃｕｔｏｆｆｔｈｅｓｐｌｅｎｏｐｈｒｅｎｉｃｌｉｇａｍｅｎｔ，ａｎｄｔｏｍｏｂｉｌｉｚｅｔｈｅｓｐｌｅｎｉｃｆｌｅｘｕｒｅｏｆｔｈｅｃｏｌｏｎ，ｗｈｉｃｈｅｎｓｕｒｅｄｅｎｏｕｇｈｃｏｖｅｒａｇｅｏｆｔｈｅｄｅｆｅｃｔｂｙｍｅｓｈ；ｔｈｉｒｄｌｙ，ｔｏｆｉｘｍｅｓｈｉｎｔｏｔｈｅｄｉａｇｐｈｒａｇｍｂｙｔａｃｋｓｓｈｏｕｌｄｂｅｓｔｒｉｃｔｌｙｆｏｒｂｉｄｄｅｎｅｄ．Ｆｉｂｒｉｎｇｌｕｅｗａｓａｐｐｌｉｅｄｉｎｔｈｉｓｃａｓｅ．【Ｋｅｙｗｏｒｄｓ】 Ｈｅｒｎｉａ，ｉｎｇｕｉｎａｌ； Ｌａｐａｒｏｓｃｏｐｙ 李健文，王文瑞．腹腔镜腹股沟疝修补术（ＴＡＰＰ）［Ｊ／ＣＤ］．中华普外科手术学杂志：电子版，２０１４，８（３）． ＤＯＩ：１０．３８７７／ｃｍａ．ｊ．ｉｓｓｎ．１６７４－３９４６．２０１４．０３．０７９ 基金项目：国家自然科学基金会基金项目（３０８７３０００） 作者单位：２０００２５上海交通大学医学院附属瑞金医院普外科上海市微创外科临床医学中心 通讯作者：李健文，Ｅｍａｉｌ：ｌｊｗ５＠ｙｅａｈ．ｎｅｔ ?２７２?
· 腹股沟疝考题姓名 一、填空题（20分） 1、腹股沟疝指发生在腹股沟区域的腹外疝，即在腹股沟区域腹壁存在缺损，有突向体 表的疝囊结构。 2、耻骨肌孔被位于前面的腹股沟韧带和其后面的髂耻束分隔为上下两个区域,上区有精 索经过，下区的侧面有股血管穿过。 3、针对腹股沟疝发病的两大原因我们就可以做出相应的治疗措施：1、减少腹内压。2、加强腹壁薄弱处。 4、滑动性疝属难复性疝的一种类型，因其有部分疝囊是由腹腔内脏所构成。 5、嵌顿性疝是疝内容物在疝环部位受压，不能还纳，可有某些临床症状（如腹痛和消化道梗阻的表现）但尚未发生血运障碍。 6、典型的腹股沟疝可依据病史、症状和体格检查确立诊断。 : 7、绞窄性疝是嵌顿性疝病程的延续，疝内容物出现了血运障碍，若不及时处理可发生严重的并发症，甚至因肠穿孔、腹膜炎而危及生命。 8、股疝因为发生嵌顿和绞窄概率较大须及时进行手术治疗。 9、腹股沟疝手术预防性抗生素应用时机，推荐在切开皮肤前30min至1h开始静脉给药。 10、腹股沟疝常规手术可进一步分为组织对组织的张力缝合修补（也称为经典手术）手术，和使用疝修补材料的无张力疝修补手术。 11、腹股沟疝就手术方式和方法而言，外科医师应根据患者的情况及自身所掌握的技能加以选择。 11、Bassini、 Shouldice等腹股沟疝修补术，称为常规腹股沟疝手术（经典手术、张力疝修补术） 12、单纯平片修补（Lichtenstein等）和网塞-平片修补（如Rutkow等）称为无张力疝修补手术。 二、判断题（20分） " 1、腹股沟区好发疝的解剖基础是腹股沟区仅一层腹外斜肌的腱膜和一层非薄的腹横筋膜，力量极为薄弱。（） 2、小儿腹股沟疝手术时不用做疝修补。（） 3、小儿腹股沟斜疝治疗方法中手术是唯一治疗手段。（） 4、绞窄性疝可危及生命。（） 5、影像学中的疝囊重建技术是明确腹股沟疝诊断唯一办法。（） 6、成人腹股沟疝可通过外科手术、疝的局部注射等方法而治愈。（） 7、股疝近期发现疝囊增大明显者必须及时进行手术治疗。（） 8、腹股沟区局部有疼痛就是腹股沟疝。（） { 9、对嵌顿性疝的急诊手术推荐使用材料进行疝修补。（） 10、成人的腹股沟疝修补手术是“简单的小手术”。（） 三、选择题（60分） 1、腹股沟疝指发生在腹股沟区域的腹外疝，由以下那些部分组成（） 1）、疝环2）、疝囊3）、疝覆盖4）、疝内容物