基于腹壁张力和筋膜锁定缝合的肠造口技术  

Enterostomy based on abdominal wall tension and fascial locking: a theory of preventing stoma complications and parahernia

作　　者：王林[1] 赵玉洲 丁永斌[3] 韩加刚[4] 马君俊[5] 吴永友[6] 汪欣[7] 马腾辉[8] 张洁[1] 李子禹[1] 步召德[1] 苏向前[1] 武爱文[1] Wang Lin;Zhao Yuzhou;Ding Yongbin;Han Jiagang;Ma Junjun;Wu Yongyou;Wang Xin;Ma Tenghui;Zhang Jie;Li Ziyu;Bu Zhaode;Su Xiangqian;Wu Aiwen(Gastrointestinal Cancer Center,Unit III,Peking University Cancer Hospital&Institute,Key Laboratory of Carcinogenesis and Translational Research(Ministry of Education),Beijing 100142,China;Department of General Surgery,the Affiliated Cancer Hospital of Zhengzhou University,Zhengzhou 450008,China;Department of General Surgery,The First Affiliated Hospital,Nanjing Medical University,Nanjing 210029,China;Department of General Surgery,Beijing Chaoyang Hosptial,Capital Medical University,Beijing 100020,China;Department of General Surgery,Ruijin Hospital,Shanghai Jiaotong University School of Medicine/Shanghai Clinical Medical Center for Minimally Invasive Surgery,Shanghai 200025,China;Department of Gastrointestinal Surgery,Second Affiliated Hospital of Soochow University,Suzhou 215004,China;Department of General Surgery,Peking University First Hospital,Beijing 100034,China;Department of Colorectal Surgery,Division of Radiation Enterology,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases,Guangdong Institute of Gastroenterology,the Sixth Affiliated Hospital,Sun Yat-sen University,Guangzhou 510655,China)

机构地区：[1]北京大学肿瘤医院暨北京市肿瘤防治研究,所恶性肿瘤发病机制及转化研究教育部重点实验室,胃肠肿瘤中心三病区,北京100142 [2]郑州大学附属肿瘤医院(河南省肿瘤医院)普通外科,郑州450008 [3]南京医科大学第一附属医院普通外科,南京210029 [4]首都医科大学附属北京朝阳医院普通外科,北京100020 [5]上海交通大学医学院附属瑞金医院普通外科,上海市微创外科临床医学中心,上海200025 [6]苏州大学附属第二医院胃肠外科,苏州215004 [7]北京大学第一医院普通外科,北京100034 [8]中山大学附属第六医院结直肠肛门外科,放射性肠病专科,广东省结直肠盆底疾病研究重点实验室,广东省胃肠病学研究所,广州510655

出　　处：《中华胃肠外科杂志》2022年第11期1025-1028,共4页Chinese Journal of Gastrointestinal Surgery

摘　　要：肠造口手术技术细节尚无统一标准,外科学教材中的手术原则存在较大异质性。在回顾腹壁结构和腱膜的精细解剖基础上,结合作者们的实践经验,尝试提出一种基于腹壁张力和筋膜锁定缝合的肠造口技术。技术操作细节为:(1)临时性造口选择右腹直肌外缘,永久性造口选择左侧腹直肌内促进粘连;(2)皮肤行适合尺寸的圆形开孔(临时性也可一字型),皮下组织和深筋膜行钝性分离;(3)沿腹外斜肌腱膜纤维方向切开筋膜层,钝性扩开肌肉组织,腹横筋膜层水平切开小口后,扩张腹壁隧道至适合尺寸,临时性造口肠袢能恰好无阻力地提出腹壁为适宜,永久性造口稍有阻力为适宜,但均不要预留运针空间以免致死腔形成;(4)永久性造口可考虑在筋膜切线两端单纯或8字锁定缝合,避免慢性筋膜撕裂;(5)肠壁提出后,与皮肤简单固定4~8针;通常临时性回肠造口黏膜可自行翻出,无需外翻缝合;永久性造口可视情况黏膜外翻缝合。理论上讲,该技术可降低术后短期并发症和远期造口疝的发生率。期待能够在未来的研究中,验证该技术的安全性和有效性。No consensus on standardized technique of enterostomy creation has been made meanwhile high heterogeneity of surgical procedure exists in'stoma creation'chapters of textbooks or atlases of colorectal surgery.The present article reviews the anatomy of tendinous aponeurotic fibers which is crucial for abdominal wall tension and integrity.Through empirical practice we hypothesize a procedure of enterostomy creation basied on abdominal wall tension plus anchor suture for fascia fixation which could theoretically decrease short-term stoma complication rates and long-term parastomal hernia rates.Surgical techniques are as followed:(1)preoperative stoma site mark for de-functioning ileostomy should be positioned at the lateral border of rectus abdominis muscle(RAM)to decrease the difficulty of stoma reversal and for permanent colostomy should be placed overlying the RAM to promote adhesion;(2)Optimal circular removal or lineal opening of skin,and avoid dissection of subcutaneous tissue;(3)Lineal dissection of natural strong fascia(rectus sheath)at stoma site and blunt separation of muscular fibers.The tunnel of the fascia should be made with appropriate size without undue tension.To prevent the formation of dead space,additional suturing at fascia layer is unnecessary.(4)Anchor suture for fascia fixation at two ends of fascia opening could be considered to avoid delayed fascia disruption and parastomal hernia.(5)After pull-through of ileum or colon loop,4-8 interrupted seromuscular sutures could be placed to attach loop to skin.For ileostomy,self-eversion of mucosa can be successful in vast majority of cases and a Brooke ileostomy is not necessary.The efficacy and safety of this procedure should be tested in future trials.

关 键 词：肠造口制作 腹壁张力 筋膜锁定缝合 造口并发症 造口旁疝 

分 类 号：R657.1[医药卫生—外科学]