A型肉毒毒素联合术前渐进性气腹在巨大切口疝中的临床应用  

Clinical application of botulinum toxin type A combined with preoperative progressive pneumoperitoneum in giant incisional hernia

作　　者：梁志强 刘付恒 曾兵 甘文昌[1] 侯泽辉 元志龙 周太成[1] 李英儒[1] 陈双[1] LIANG Zhiqiang;LIU Fuheng;ZENG Bing;GAN Wenchang;HOU Zehui;YUAN Zhilong;ZHOU Taicheng;LI Yingru;CHEN Shuang(Department of Gastrointestinal and Hernia Surgery,the Sixth Affiliated Hospital of Sun Yat-sen University/Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases/National Key Clinical Specialized Department,Guangzhou 510655,China)

机构地区：[1]中山大学附属第六医院胃肠,疝和腹壁外科/广东省结直肠盆底疾病研究重点实验室/国家重点临床专科,广东广州510655

出　　处：《中国普通外科杂志》2024年第10期1688-1696,共9页China Journal of General Surgery

基　　金：国家自然科学基金资助项目(81973858,82172790);广东省消化系统疾病临床医学研究中心基金资助项目(2020B1111170004);广东省自然科学基金资助项目(2019A1515011200);广东省医学科学技术研究基金资助项目(A2021061);广东省中医药局科研基金资助项目(20191401,20211086,20221094);广州市科技计划基金资助项目(2023A04J1816)。

摘　　要：背景与目的:巨大切口疝修复是疝的治疗难点,关闭切口疝的巨大缺损可能会产生腹腔间隔室综合征(ACS)等严重危及生命的并发症。A型肉毒毒素(BTA)可以暂时性松弛腹壁肌肉,利于缺损的修补,术前渐进性气腹(PPP)可以扩大腹腔容积,缓解疝内容物重新回纳所导致的腹腔内高压。两者联合用于巨大切口疝修复的术前准备可能起到互补作用。本文目的在于探讨BTA联合PPP在腹壁巨大切口疝修补的临床价值。方法:回顾性分析中山大学附属第六医院2015年12月—2019年12月诊治的213例腹壁巨大切口疝患者的临床资料。患者在接受BTA联合PPP治疗2周后,采用CT测量双侧腹壁肌肉的变化情况、腹腔粘连情况、腹围变化情况、腹腔容积变化、疝囊容积比变化,并记录术中情况、并发症的发生率、术后随访情况。结果:BTA联合PPP治疗后,CT显示213例患者的双侧侧腹壁肌肉长度均向中线延长,其中左侧平均延长2.45(1.53~3.29)cm、右侧平均增加2.54(1.68~3.40)cm;双侧侧腹壁肌肉厚度减少,其中左侧平均减少0.84(0.64~1.00)cm、右侧平均减少0.82(0.62~1.05)cm;内脏与腹壁的距离为平均(7.52±1.78)cm,腹围增加6.1(4.2~6.9)cm;腹腔容积平均增加1802(1494.98~2316.26)mL,疝囊容积比平均减少了9%(6%~12%),以上变化差异均有统计学意义(均P<0.05)。PPP治疗后CT显示,18例(8.45%)患者无腹腔粘连;195例(91.55%)患者腹腔粘连,其中39例(18.31%)片状粘连,156例(73.24%)为点状、线状及片状粘连构成的混合性粘连。粘连物以网膜和肠管组织混合型为主,占59.15%。BTA联合PPP过程仅出现Ⅰ级并发症43例(20.19%),其中合并腹痛28例、肩膀疼痛9例、皮下气肿6例、呼吸困难3例。3例呼吸困难患者予以吸氧对症治疗后症状好转,其余患者无须特殊处理。213例患者顺利完成腹腔镜切口疝修补手术,术中无中转开腹病例,术中无脏器组织切除等减容情况,筋膜完全闭合Background and Aims:The repair of giant incisional hernia is challenging,as closing the significant defect in the abdominal wall can lead to life-threatening complications like abdominal compartment syndrome(ACS).Botulinum toxin type A(BTA)can temporarily relax the abdominal wall muscles,facilitating defect repair,while preoperative progressive pneumoperitoneum(PPP)can increase intraabdominal volume,reducing intra-abdominal pressure caused by hernia content reintegration.Combining BTA with PPP for the preoperative preparation of giant incisional hernia repair may have a complementary effect.This study was conducted to evaluate the clinical value of combining BTA and PPP in the repair of giant abdominal incisional hernia.Methods:The clinical data of 213 patients with giant abdominal incisional hernia treated at the Sixth Affiliated Hospital of Sun Yat-sen University from December 2015 to December 2019 were retrospectively analyzed.Two weeks after receiving combined BTA and PPP treatment,changes in bilateral abdominal wall muscle,intra-abdominal adhesions,abdominal circumference,abdominal cavity volume,and hernia sac volume ratio were assessed using CT.Intraoperative details,incidence of complications,and postoperative follow-up outcomes were recorded.Results:Following combined BTA and PPP treatment,CT scan showed a significant extension of bilateral lateral abdominal wall muscles towards the midline in all 213 patients,with an average increase of 2.45(1.53-3.29)cm on the left side and 2.54(1.68-3.40)cm on the right side;muscle thickness was reduced by an average of 0.84(0.64-1.00)cm on the left and 0.82(0.62-1.05)cm on the right,the average distance between viscera and the abdominal wall increased to(7.52±1.78)cm,with a mean increase of 6.1(4.2-6.9)cm;the mean increase in abdominal cavity volume was 1802(1494.98-2316.26)m L,and the hernia sac volume ratio decreased by an average of 9%(6%-12%),all changes were statistically significant(P<0.05).Post-PPP CT scan revealed no abdominal adhesions in 18 patients(8.45%),

关 键 词：切口疝 疝修补术 肉毒毒素类 气腹 人工 

分 类 号：R656.2[医药卫生—外科学]