腹腔镜治疗小儿交通性鞘膜积液30例

交通性鞘膜积液是小儿外科常见病,传统的疝囊高位缝扎及鞘膜翻转术是公认的行之有效而可靠的手术方法。近年来,我院采用腹腔镜下内环口高位荷包缝扎术 积液抽出术治疗交通性鞘膜积液30例,现报道如下。     

腹腔镜内环结扎法治疗小儿腹股沟疝和鞘膜积液的经验及对策(附216例报告)

目的 探讨腹腔镜内环结扎法治疗小儿腹股沟疝／鞘膜积液手术中、手术后遇到的问题及对策。方法 应用腹腔镜内环结扎法手术治疗小儿腹股沟疝／鞘膜积液216例,通过总结和分析,对手术中及手术后遇到的问题,提出预防和处理方法。结果 1例手术后24h复发,1例术后4个月复发,经手术证实,均因术者漏扎所致。遇到的问题和并发症有14项,都是可以预防并能得到满意处理的。结论 腹腔镜内环结扎法治疗小儿腹股沟疝／鞘膜积液,手术中和手术后遇到的问题多能预防并能得到满意处理,在掌握适应证和提高手术技巧的情况下,可以广泛开展。     

腹腔镜下缝扎内环口治疗小儿鞘膜积液

目的 探讨小儿鞘膜积液腹腔镜治疗的新方法。方法 2000年11月～2003年11月应用微型腹腔镜缝扎内环口方法治疗小儿鞘膜积液453例，年龄1～12岁(平均年龄4岁)。结果 术中经过顺利，手术时间5～8min，伤口不需缝合，未出现严重并发症。术后2～3d出院。随访患儿症状消失，术后无瘢痕。治愈率99．3％。结论 腹腔镜下缝扎内环口治疗小儿鞘膜积液，切口小，损伤小，疼痛轻，恢复快，手术时间及住院时间短，操作简单、安全、疗效可靠。可同时发现及处理隐性内环口未闭，比传统鞘状突高位结扎术优越。值得临床推广应用。     

儿童鞘膜积液发病机制的临床研究

目的传统观念认为,儿童非交通性鞘膜积液患儿内环口处鞘状突均处于闭合状态,鞘膜囊内液体主要来源于囊壁自身分泌。本研究旨在探讨儿童先天性鞘膜积液(尤其非交通性鞘膜积液)的发病机制。方法 2002年1月至2015年12月由本院收治395例年龄大于2岁先天性鞘膜积液患儿,其中交通性鞘膜积液134例,非交通性鞘膜积液261例;均予腹腔镜手术探查,了解鞘状突闭合情况,术后长期随访鞘状突结扎后疗效;对其中25例接受腹腔镜手术的患儿通过在内环口水平向未闭合的鞘状突内滴注美兰液,了解鞘膜积液的液体可能来源。同期选择传统开放手术患儿34例,术中切取少许鞘膜囊囊壁组织送病理检查,了解囊壁的组织学特征。结果 (1)34例开放手术患儿组织病理学检查发现:患儿鞘膜囊壁内膜主要由单层扁平间皮细胞构成,分泌功能非常弱。(2)134例交通性鞘膜积液患儿内环口处鞘状突均未闭合,经2~3 cm的鞘状突管直接连通睾丸鞘膜腔,挤压阴囊鞘膜囊可见清亮液体经内环口流入腹腔;261例非交通鞘膜积液患儿内环口处鞘状突仍呈开放状态,经鞘状突管与精索或睾丸鞘膜囊腔相连,挤压鞘膜囊可见少量液体从其顶部小孔渗出。经内环口向未闭合鞘状突管滴注美兰液,30 min后用细针经皮穿刺交通性和非交通性鞘膜积液囊,均可抽取美兰淡染囊液。(3)395例腹腔镜下手术患儿,术后平均随访时间均超过1年,仅6例于术后1~3个月患侧复发,一期治愈率98.5%。结论与传统观念不同,本研究发现鞘状突发育过程中未闭合是儿童先天性鞘膜积液发病的主要因素,鞘膜囊壁内膜主要由单层扁平间皮细胞构成,囊内积液不是囊壁自身分泌,而是来源于腹腔的正常腹水。非交通性鞘膜积液鞘膜囊顶部小孔处可能存在单向瓣膜样结构,阻止囊内液倒流入腹腔。     

经脐单孔腹腔镜内环口结扎术治疗小儿腹股沟疝及鞘膜积液的探讨

目的探讨经脐单孔腹腔镜内环口结扎术（即疝囊或鞘突高位结扎术）治疗小儿腹股沟斜疝及鞘膜积液的临床应用价值。方法回顾性分析118例（140侧）经脐单孔腹腔镜内环口结扎术治疗小儿斜疝和鞘膜积液的临床资料。结果经脐单孔法内环口疝囊及鞘突高位结扎术治疗小儿斜疝76例（94侧）,鞘膜积液42例（56侧）。118例手术均获成功,术中发现对侧隐性疝20例,交通性鞘膜积液16例,单侧平均手术时间15min,双侧平均手术时间28min。术后平均住院时间1．5d,无并发症,随访1—10个月,无一例复发。结论经脐单孔腹腔镜内环口结扎法治疗小儿腹股沟斜疝及鞘膜积液安全、有效,损伤小,痛苦少,康复快,无明显手术瘢痕、复发率低,值得临床推广应用。     

腹腔镜辅助下鞘状突高位结扎术治疗儿童鞘膜积液327例

目的总结我们10年来采用腹腔镜辅助下鞘状突高位结扎术治疗小儿鞘膜积液的临床经验。方法自2002年1月至2013年1月,我们在腹腔镜辅助下采用"雪橇形"内环口修补针于腹膜外双重结扎未闭合的鞘状突内环口,同时穿刺抽净鞘膜囊内积液的手术方式,治疗2岁以上鞘膜积液患者327例,其中术前诊断为交通性鞘膜积液110例,非交通性鞘膜积液217例。结果 327例中,325例患侧鞘状突内环口未闭,孔径3~5 mm;64例(约占19.6%)术前诊断为单侧的患儿术中发现对侧内环口未闭。术后常规随访1年,4例术后1~3个月出现同侧鞘膜囊内中等量积液(3~6 mL),复发率约1.2%,其中3例门诊观察2~3个月自行消退;1例再次经皮细针抽吸后自愈。病理学检查发现鞘膜囊内膜主要由单层柱状上皮构成,有一定的吸收功能,但分泌功能极弱。结论儿童鞘膜积液发病机制与鞘状突未闭有关,鞘膜囊液体主要来自于腹腔。腹腔镜下鞘状突高位结扎术治疗鞘膜积液长期疗效满意,且可以及时发现对侧隐匿病变,是一种安全有效的治疗手段。     

腹腔镜下单孔套扎和三孔缝扎治疗儿童精索鞘膜积液对肠道黏膜屏障功能的影响

目的比较单孔腹腔镜钩针鞘突管高位套扎术与三孔法腹腔镜鞘突管内口缝扎术治疗儿童精索鞘膜积液对肠道黏膜屏障功能的影响。方法选择2018年1月至2018年7月哈尔滨市儿童医院完成的73例行腹腔镜治疗的小儿精索鞘膜积液临床资料,分为缝扎组(行三孔法腹腔镜鞘突管内口缝扎手术)35例和套扎组(行单孔腹腔镜钩针鞘突管高位套扎手术)38例,对比分析两组一般资料、手术时间、麻醉时间、手术前后尿乳果糖/甘露醇(ratio of lactulose to mannitol,L/M)、血清D-乳酸和尿肠型脂肪酸结合蛋白(intestinal fatty acid binding protein,IFABP)。结果所有患儿均顺利完成手术。两组患儿月龄、性别、侧别比较差异无统计学意义(P>0.05),具有可比性。两组患儿手术时间、麻醉时间比较差异有统计学意义(P<0.05)。两组尿L/M、血清D-乳酸和尿IFABP术前比较差异无统计学意义(P>0.05)。套扎组尿L/M术前与术后1、2 d比较差异无统计学意义(P>0.05),缝扎组尿L/M术后1、2 d高于术前(P=0.000)。套扎组血清D-乳酸术前、术后2 h比较差异无统计学意义(P>0.05),缝扎组术后2 h血清D-乳酸高于术前(P=0.000)。套扎组尿IFABP术前、术后1 d比较差异无统计学意义(P>0.05),缝扎组术后1 d尿IFABP高于术前(P=0.000)。结论单孔腹腔镜钩针鞘突管高位套扎术和三孔法腹腔镜鞘突管内口缝扎术均是治疗小儿精索鞘膜积液安全可行的术式。与缝扎术相比,套扎术对肠道黏膜屏障功能影响更小。     

腹腔镜辅助经皮腹膜外结扎内环治疗腹股沟疝

目的探讨改良的腹腔镜经皮腹膜外结扎内环辅助治疗小儿腹股沟疝的疗效。方法选择2009年1月-2011年10月本科收治的小儿腹股沟疝患儿29例。年龄7个月～13岁,平均2岁。29例患儿中,术前诊断右侧腹股沟疝26例,左侧腹股沟疝6例,其中双侧腹股沟疝3例,复发性腹股沟疝2例。29例均经脐部穿刺后进入改良的腹腔镜,在监视下,在疝环相应的体表腹部,经直径2 mm的皮肤切口,分别用一个弯曲的硬膜外麻醉导管针和一自制的钩针套管刺入疝环(疝囊内环口)腹膜外,避开精索血管和输精管将内环结扎。结果患儿手术操作均顺利,手术时间为15～52(32.2±11.6)min,无严重术中和术后并发症发生。随访5～24(16.0±2.5)个月,无精索损伤、睾丸萎缩、术后疝复发和鞘膜积液等并发症发生。结论腹腔镜经皮腹膜外结扎内环辅助治疗小儿腹股沟疝简单、安全、微创、效果好,并发症少,复发率低。     

不同操作通道下腹腔镜经皮腹膜外环扎术治疗儿童鞘膜积液——两中心950例经验总结

目的总结传统两孔、单部位两孔和单孔三种操作通道下腹腔镜技术经皮腹膜外环扎术治疗儿童各种类型鞘膜积液的临床经验。方法回顾性分析两所专业儿童医疗中心自2013年8月至2015年8月收治的950例不同类型男性儿童鞘膜积液病例资料。年龄4个月至14岁,平均年龄(3.68±2.20)岁。患儿均采用腹腔镜下经皮腹膜外环扎术。依据操作通道的不同分为:传统两孔组387例,单部位两孔组468例,单孔组95例。比较各组患儿手术过程、疗效与并发症情况。结果 950例均顺利完成手术,共关闭未闭鞘状突1 383侧。发现对侧隐性鞘状突未闭288例(35.8%)。4例因术中腹腔镜下未发现开放的鞘状突内口,改为经阴囊的睾丸鞘膜翻转手术。三组手术时间无明显差异(χ~2=5.76,P=0.07)。术后随访时间中位数为16.5个月(8~32个月)。两医疗中心在并发症方面比较差异无统计学意义(P0.05)。传统两孔组、单部位两孔组、单孔组分别发现对侧隐性鞘状突未闭122例、148例、18例,发生腹膜后血肿例数分别为4例、2例、0例,术后复发例数分别为4例、4例、2例,术后对侧异时性鞘膜积液分别为0例、0例、2例,脐部切口感染分别为1例、0例、0例。单孔组与其他两组相比,在发现对侧隐性鞘状突未闭和术后对侧异时性鞘膜积液的比例上差异有统计学意义(P0.05)。记录三组各15例患儿术后6 h疼痛FLACC评分,均在0~2分。随机调查50例患儿术后1年脐部伤口外观情况,单部位两孔组与单孔组术后伤口外观无差别。结论腹腔镜经皮腹膜外环扎术治疗各种类型儿童鞘膜积液操作简便,疗效确切。环脐单部位两孔法手术操作较单孔手术更加简便,术后伤口外观优于传统两孔法,并可与单孔手术伤口相媲美。在对侧隐性鞘状突未闭的探查上两孔法较单孔法更有优势。     

小儿腹腔镜联合手术41例

目的探讨小儿腹腔镜联合手术的可行性,总结该术式的优越性、适应证及注意事项。方法回顾性分析2006年6月至2012年6月实施的41例小儿腹腔镜联合手术临床资料。联合手术涉及阑尾切除术,内环缝扎术,睾丸松解固定术,肠套叠复位术,精索静脉结扎术,卵巢囊肿切除术,肠系膜囊肿切除术,肠切除吻合术,幽门环肌切开术,美克尔憩室切除术,胆道造影、肝活检术。结果全部手术均顺利完成,无中转开腹病例,无并发症出现,无一例因联合手术延长禁食时间或住院时间。结论腹腔镜联合手术微创优势明显,适合在儿童手术中开展,但需要严格掌握联合手术的指征及其特点。     

应用腹腔镜治疗小儿对侧未闭隐匿性鞘状突

目的 通过对小儿单侧腹股沟斜疝经腹腔镜与开放手术诊治的病例进行回顾性研究,探讨腹腔镜技术对对侧未闭隐匿鞘状突病例的诊治及其与异时性腹股沟斜疝的相关性.方法 回顾性分析2011年1月至2013年12月间,在两个医疗中心分别经腹腔镜和普通开放手术治疗的单侧腹股沟斜疝的患儿病例,分别为2 855例和2 538例.统计分析患儿性别、年龄、单侧斜疝发病部位;腹腔镜发现对侧未闭的隐匿鞘状突(contralateral patent processus vaginalis,CPPV)病例数;普通开放术后对侧异时性腹股沟斜疝(metachronous inguinal hernia,MIH)病例数及间隔时间;两组术后斜疝的复发率.分别统计分析相关参数进行比较.结果 开放组共2 538例,男83.6％,女16.4％;平均年龄(2.45±2.18)岁;右侧66.0％,左侧34.0％.MIH组共62例,男51例,右侧MIH 26例,左侧MIH25例,MIH发生率2.4％;女11例,右侧MIH 4例,左侧MIH 7例,MIH发生率2.6％.隐匿平均时间间隔为(18.71±13.80)个月.术后复发率1.02％,复发平均时间(9.93±8.58)个月.腹腔镜组共2 855例,男82.5％,女17.5％;平均年龄(2.44±2.15)岁;右侧60.4％,左侧39.6％.CPPV共1469例(51.5％),右侧CPPV 603例(41.0％),左侧CPPV 866例(59.0％).侧别和性别在CPPV发病率上都差异无统计学意义(53.4％比50.2％;50.7％比55.1％,P＞0.05).术后复发率0.25％,相比开放组差异有显著的统计学意义(x2=13.42,P＜0.01).复发平均时间(6.43±3.99)个月,相比开放组差异无统计学意义(t=1.04,P＞0.05).腹腔镜组发生MIH 3例.MIH/CPPV的风险率比(RR)为0.05(95％CI:0.03～0.06).结论 腹腔镜下治疗小儿单侧腹股沟斜疝相比普通开放手术,斜疝复发率及MIH的发生率明显减少.腹腔镜技术在治疗单侧腹股沟斜疝的同时,能准确检测出CPPV,但对其常规手术,尽管明显减少MIH的发生率,但造成过度医疗,因为要阻止1例MIH的发生,需要对20例CPPV进行手术.MIH的低发生率不支持常规对对侧无临床症状的腹股沟区进行普通手术探查.     

Uterus and ovary hernia of the canal of Nuck

Hernia of the canal of Nuck is a rare condition occurring in female infants. The canal of Nuck is a portion of the processus vaginalis of the peritoneum within the inguinal canal. The processus vaginalis is an evagination of parietal peritoneum of the embryonic lower anterior abdominal wall that passes into the inguinal canal. Normally, it loses its connection with the peritoneal cavity, but when it fails to close a hydrocele or hernia may result. We present a 2-month-old girl with a palpable movable mass in the right inguinal region. Ultrasonography revealed a hernia containing uterus and ovary. Ultrasonography is the examination of choice in female infants with a pathological mass in the groin. Its availability and accuracy facilitate diagnosis and proper surgical treatment.     

Laparoscopic percutaneous extraperitoneal closure (LPEC) method for the exploration and treatment of inguinal hernia in girls

We recently introduced the laparoscopic percutaneous extraperitoneal closure (LPEC) method for the treatment of girls with inguinal hernia. Using the LPEC method, 129 girls underwent laparoscopic herniorrhaphy. A 5 mm laparoscope was inserted via the umbilicus. A 3 mm “snake retractor” was advanced through the lateral abdominal wall to measure the length of the hernia sac and contralateral patent processus vaginalis (PPV), respectively. The hernia sac and PPV were closed at the level of the internal inguinal ring with a 2-0 non-absorbable purse-string suture using Lapaherclosure™, a special 19G needle that can hold a suture at the tip. The length of the hernial sac was significantly longer than that of contralateral PPV (mean 41 mm; range 18–70 mm; P<0.05). There were no serious complications associated with the procedure. No recurrence of hernia or metachronous contralateral hernia has been identified so far. This approach enables us to perform contralateral exploration without any additional techniques, followed by immediate and accurate closure of the hernia sac and PPV. We conclude that the LPEC method is a safe and efficacious procedure with a low recurrence rate that should be viewed as an acceptable alternative to the traditional open approach.     

Inguinal hernia: what we have learned from laparoscopic evaluation of the contralateral side

PURPOSE OF REVIEW: The evaluation for and management of a contralateral patent processus vaginalis in children presenting with a unilateral inguinal hernia has been debated for over 60 years. The emergence of transinguinal laparoscopy as an evaluative tool has changed the landscape of the debate, offering a safe and minimally invasive option. The review will highlight some of the significant recent contributions to this debate. RECENT FINDINGS: Recent studies have confirmed the safety of transinguinal laparoscopy, and demonstrated a high level of sensitivity and specificity for it in the evaluation of the contralateral inguinal ring. In comparison, the practice of physical examination under anesthesia for evaluation of the contralateral inguinal region has proven to be ineffective. Further, age and gender differences in the incidence of contralateral patent processus vaginalis have recently been challenged. These data call into question the practices of routine or selective open inguinal exploration and present laparoscopy as the most effective means of evaluation. SUMMARY: Transinguinal laparoscopy offers a safe and effective means of evaluating the contralateral inguinal ring during ipsilateral hernia repair. The relatively high incidences of both contralateral patent processus vaginalis and contralateral metachronous hernia development in children justify the use of routine laparoscopic evaluation.     

Intraoperative diagnostic pneumoperitoneum in pediatric patients with unilateral inguinal hernias: Goldstein test

Over a 4-year period, 321 infants and children with unilateral inguinal hernias underwent intraoperative diagnostic pneumoperitoneum to evaluate the contralateral groin for a patent processus vaginalis. Seventy-four patients had positive results and underwent contralateral hernia repair at the same time. Of the 247 patients with negative tests, 3 presented later with a hernia (false-negative rate 1,21%). There were no complications related to the procedure itself. Intraoperative diagnostic pneumoperitoneum (Goldstein test) is a useful, safe, simple, and highly accurate means to evaluate the contralateral groin.     

Outcomes following laparoscopic inguinal hernia repair in infants compared with older children

Purpose

Indications for laparoscopic inguinal hernia repair in infants and children remain controversial. The purpose of this study is to compare clinical features and outcome of laparoscopic inguinal hernia repair in infants with older children.

Methods

Retrospective single centre review of all patients <16?years of age (n?=?380) undergoing laparoscopic inguinal hernia repair over a 5-year period (Jan 2005?CDec 2009). Outcomes were compared between infants (??12?months of age) with older children (1?C15?years).

Results

There was a trend towards higher recurrence rate in older children than in infants (4?% vs. 1?%; p?=?0.17). Total complications and complications requiring surgery were similar in both age groups. There was one testicular atrophy in an infant who had an incarcerated inguinal hernia. The incidence of bilateral inguinal hernia and contralateral patent processus vaginalis (PPV) were both significantly higher in infants (total 61?% compared with 35?% in older children).

Conclusions

Laparoscopic inguinal hernia repair in infants is safe and carries acceptable complication and recurrence rates. The laparoscopic approach may be particularly beneficial in infants since it allows simultaneous closure of a contralateral PPV and bilateral herniae. The outcome of laparoscopic inguinal hernia repair in older children requires further evaluation.     

Inguinal hernia in the newborn A 15-year review

Seventy consecutive neonates presented with inguinal hernia during a 15-year period. There were 69 males and 1 female. Fifty-one infants were born at full-term and 19 were premature. Sixty-one (87%) neonates presented as an emergency with incarverated inguinal hernia. Only 3 babies with incarceration required emergency operation and in the remaining 58 (95%) patients it was possible to reduce the incarcerated hernia manually and do an elective herniotomy. At follow-up, 3 (5%) of the boys who presented with incarceration were noted to have testicular atrophy. Contralateral inguinal exploration revealed a hernial sac or a patent processus vaginalis in 70% of babies. Two of the 6 boys who had an orchidopexy performed for cryptorchism at the time of herniotomy required a subsequent revision orchidopexy.     

Intraoperative laparoscopy in unilateral hernia repair to detect a contralateral patent processus vaginalis

The controversy over the need to explore the asymptomatic contralateral groin for the existence of a hernia sac in children who undergo inguinal hernia repair is not easy to resolve. To detect the patency of the contralateral processus vaginalis, we used intraoperative nonpuncture laparoscopy. By insufflating carbon dioxide and inserting a laparoscope through the open hernia sac, the opening of the contralateral processus vaginalis was clearly seen. A patent processus vaginalis on the opposite side is considered to be a potential hernia. A total of 74 children, 56 boys and 18 girls, were involved in the study. All of them had inguinal dissection on the symptomatic side and laparoscopy was performed through the opened hernial sac. A contralateral patent processus vaginalis was found in 22 children, 14 boys and 8 girls, by laparoscopy. The results were confirmed by surgical exploration of the opposite groin. There were no false-positive and no false-negative results. Intraoperative non-puncture laparoscopy is a simple, safe, and accurate method of detecting patency of a contralateral processus vaginalis. When used instead of routine bilateral exploration, this procedure can avoid many unnecessary surgical operations. Correspondence to: C.-c. Chu     

小儿隐匿性腹股沟斜疝的诊疗进展

小儿隐匿性腹股沟斜疝又称为小儿隐性疝,是小儿腹股沟斜疝的一种特殊表现,由于鞘状突未闭或疝囊较小,腹腔内组织不能突入腹股沟管形成肿块,临床上无任何不适症状,因而易延误治疗。若不及时诊治,待发展到症状体征明显时被迫再次手术,易引起不必要的医疗纠纷。目前,绝大多数小儿隐匿性腹股沟斜疝是手术探查时发现的,尤其是在腹腔镜广泛应用之后。现主要从诊断与治疗方面对近年来小儿隐匿性腹股沟斜疝的研究进展作一综述。     

A long-term prospective analysis of pediatric unilateral inguinal hernias: Should laparoscopy or anything else influence the management of the contralateral side?

PurposeTo prospectively determine if children who present with a unilateral inguinal hernia can be identified as at risk for developing a metachronous inguinal hernia (MIH) based on risk factors and laparoscopic findings of the contralateral internal ring.Materials and methodsBetween April 2000 and October 2004, 299 patients with a unilateral inguinal hernia were followed prospectively. Laparoscopy was attempted in each child. Bilateral repair was only performed in those with contralateral swelling or crepitus during laparoscopic evaluation. All other children were followed regardless of laparoscopic findings. Risk factors to include premature delivery, family history and increased abdominal pressure were recorded. Clinical follow up and annual phone interviews were performed to determine the development of a MIH.ResultsThirteen patients underwent initial bilateral inguinal hernia repair. Of the remaining 286 patients (272 boys, 14 girls; ages 54 ± 50.8 months), laparoscopy revealed 127 closed, 48 cleft and 67 open (contralateral patent processus vaginalis) contralateral internal rings, and in 44 laparoscopy was not possible due to a small hernia. Of 222 patients followed for 53.2 months (30.1–82.5 months), 15 (6.8%) developed a MIH. When comparing age, gender, laterality, laparoscopic findings, family history, premature birth and intra-abdominal pressure, only family history exhibited a significant risk for MIH (33% vs 7.7%). However, 16/21 children with a family history never developed a MIH, and 47/53 children with a contralateral patent processus vaginalis have yet to develop one.ConclusionsRisk factors and laparoscopic findings failed to predict the few children who would develop a MIH. The contralateral side should not be routinely explored by any methodology.