腹壁外科桥接手术常见并发症预防和处理

人工材料桥接修复腹壁缺损是临床上经常采用的手术方式，桥接类似于构造一个结构单一的腱膜性结构，从而达到腹壁结构和功能上的完整。桥接的要点包括：（1）维持补片适度张力。（2）使用轻量型大网孔补片。（3）补片前充分引流。（4）铺平补片并确切固定。桥接手术常见的术中并发症为肠管损伤；术后常见的短期并发症为血清肿、皮肤坏死、切口裂开、补片外露、腹腔间室综合征；术后长期并发症为补片膨出、补片感染和复发。合理处理桥接手术术中及术后出现的各类问题，将有助于病人腹壁结构和功能的有效恢复。     

复合补片修补腹壁肿瘤切除后巨大腹壁缺损的临床疗效

目的探讨复合补片修补腹壁肿瘤切除后巨大腹壁缺损的临床疗效。 方法回顾性分析2015年2月至2017年8月,新疆医科大学第四附属医院收治的55例腹壁肿瘤切除术后巨大腹壁缺损患者临床资料,根据植入补片的不同分为试验组（35例）和对照组（20例）,2组患者均行腹壁肿瘤切除术,试验组植入Proceed补片,对照组植入Composix Kugel补片。比较2组手术相关临床参数、手术前后不同时间疼痛程度、切口愈合情况、并发症、肿瘤复发及转移情况。 结果2组铺置补片时间及术后自主活动时间比较,差异无统计学意义（P>0.05）。术后12 h至7 d,2组患者视觉模拟评分均呈逐渐降低趋势,且均明显低于术前（P<0.05）,但2组间均无明显差异（P>0.05）。拆线后伤口均达到一期愈合,2组总并发症发生率比较,差异无统计学意义（P>0.05）。随访1年,试验组肿瘤原位复发1例,对照组肿瘤远处转移1例,2组患者腹壁修复材料腹腔面光滑,且均未见腹壁修复材料与肠管黏连。 结论采用Proceed补片和Composix Kugel补片对腹壁肿瘤切除后巨大腹壁缺损进行修复和重建,效果均较好,安全性高。     

基于大网膜瓣三明治桥接技术修复巨大腹壁缺损23例疗效分析

目的 探讨基于大网膜瓣的生物补片-带蒂大网膜瓣-合成补片三明治（BOSS）桥接技术修复巨大腹壁缺损的手术方案并分析疗效。方法 回顾性分析2016年1月至2020年12月上海交通大学医学院附属第九人民医院收治的23例巨大腹壁缺损病人临床资料，分析BOSS桥接技术修复巨大腹壁缺损的临床效果及可行性。结果 所有病人均顺利完成手术。腹壁缺损面积为（422.2±334.1）cm2，术中出血量为（450.0±420.0）mL，手术时间为（205.8±80.9）min。术后随访（24.4±17.4）个月，疝复发或补片膨出发生率为4.3%，切口并发症发生率为13.0%。结论 采用BOSS桥接技术修复巨大腹壁缺损可显著改善腹壁修复重建效果。     

腹壁韧带样纤维瘤的术后腹壁重建的治疗研究

目的探讨人工补片在韧带样纤维瘤病术后腹壁重建中的临床疗效。 方法回顾性分析2012年2月至2016年2月,首都医科大学附属北京朝阳医院收治的11例腹壁韧带样纤维瘤病患者的临床资料,所有患者行根治性手术,术后腹壁缺损使用人工补片行腹壁重建,分析其临床疗效。 结果所有患者均使用人工补片行腹壁重建,平均手术时间（97±33）min,平均住院时间（19.2±3.1）d,所有患者术后恢复良好,伤口Ⅰ期愈合,无伤口感染及局部异物感,无死亡患者,出现皮下积液者1例,经穿刺抽吸后治愈。随访时间7～60个月,平均随访时间（31.8±18.5）个月,肿瘤复发1例,无死亡患者,无补片感染、慢性疼痛及局部异物感等补片相关并发症,无肠梗阻及切口疝发生。 结论人工补片用于腹壁重建具有良好的临床疗效。     

腹外斜肌转移肌瓣技术修补腹直肌缺失的临床应用

目的探讨肿瘤或外伤等导致腹直肌缺失的患者使用腹外斜肌转移肌瓣技术行腹壁缺损修补和重建的临床应用效果。 方法2014年12月至2018年12月,浙江大学医学院附属杭州市第一人民医院收治腹直肌缺失患者10例,采用腹外斜肌转移肌瓣技术进行腹壁缺损修补和重建。收集并回顾性分析患者的临床资料。通过问诊、查体和腹壁CT检查评估患者腹壁重建和恢复情况。 结果10例腹直肌缺失患者中,腹直肌肿瘤9例（其中男性1例,女性8例）,腹直肌外伤毁损1例（男性）。平均年龄（46.90±13.25）岁,体质量指数（23.10±3.98）kg/m²。9例腹直肌肿瘤中,原发性肿瘤8例,转移性肿瘤1例,均行腹直肌复合体屏障性切除。腹直肌外伤患者行毁损腹直肌切除。切除后腹壁缺损平均宽度为（11.70±1.89）cm,均采用单侧腹外斜肌转移肌瓣技术进行腹壁缺损修补和功能重建,并采用补片加强修补。补片均为聚丙烯补片,平均大小为（420.00±154.91）cm²。平均手术时间（132.50±38.96）min,平均术中出血量（107.00±74.54）ml,平均住院时间（11.50±4.30）d。术后无腹外斜肌肌瓣缺血坏死,无切口裂开、手术部位感染、肠瘘等并发症。在术后随访行问诊、体格检查及腹壁CT检查,显示患者腹壁完整,功能恢复良好。平均随访时间（35.50±11.35）个月,随访期内未发现肿瘤复发、切口疝形成或腹壁膨出病例。 结论腹外斜肌转移肌瓣修补技术是一种安全有效腹壁缺损修补技术,在腹直肌缺失患者中具有较好的临床效果。     

CT三维表面遮盖与容积重建在骨盆肿瘤切除与重建中应用

目的:探讨螺旋CT三维表面遮盖重建（SSD）及容积重建（VRT）在骨盆肿瘤切除与重建中的临床应用。方法:使用SiemensPlus4螺旋CT机对17例骨盆肿瘤患者（男11例,女6例,年龄15⁷1岁,平均38岁）术前进行扫描,在Siemens工作站进行三维SSD及VRT。结果:术后创口延迟愈合1例,经引流Ⅱ期闭合伤口;术后16个月复发1例,行半骨盆切除及人工半骨盆重建后恢复健康,患者行走正常;肺部转移1例;其余病例在随访期内未发现局部复发。结论:螺旋CT三维表面SSD及VRT图像清晰地显示了术前骨盆肿瘤的细节,以最易理解的形式立体直观地显示了病变及与周围结构的关系及手术应切除的范围,有助于术前正确诊断和制定手术计划,有效地减少术后局部复发。     

开放人工材料桥接修复腹壁巨大缺损（附58例报告）

目的 :探讨开放人工材料桥接修复手术治疗腹壁巨大缺损的应用。方法 :回顾性分析2007年6月至2020年6月我科收治的58例腹壁巨大缺损病人临床资料,其中19例腹壁占位性病变切除后缺损,35例巨大切口疝,3例腹壁外伤、感染后肌层毁损,1例先天性膈疝修补后腹腔容积不足延迟关腹,随访观察疗效。结果:本研究所有病人均达到预期重建效果。术后发生血清肿5例,通过重置双套管负压抽吸治愈。皮肤坏死、切口裂开、补片外露1例,用负压封闭引流(vacuum sealing drainage,VSD)技术引流愈合。血肿1例,加压包扎保守治疗。补片感染1例,取出上层补片,应用VSD技术引流愈合。1例腹腔容积不足采用腹腔内修补(intraperitoneal onlay mesh,IPOM)+Inlay桥接、补片外露的临时性关腹,通过3次VSD分期拉拢、关闭皮肤伤口。1例补片膨出,持续随访,未行特殊处理。随访12～156个月,3例失访,随访率为94.8%,未见疝或缺损复发。结论:对于肌筋膜层无法关闭的腹壁巨大缺损,开放人工材料桥接修补手术是腹壁外科不可或缺的一项技术,并发症可以防控。     

保留乳头乳晕皮下腺体切除加假体联合补片乳房一期重建与保乳整形手术治疗乳腺癌比较的单中心回顾性研究

背景与目的 中国女性乳腺癌发病年龄早,保乳手术和乳腺切除术后乳房重建是避免乳腺癌患者失去乳房的合理选择。近年来保乳整形术式的推广使得小乳房患者保乳术后仍能维持较好外形。使用假体联合钛网补片（TiLoop Bra）的乳房重建技术相对简单,便于推广,也能在乳房全切后较好重塑乳房外形。本研究通过回顾性分析评估两种方法在手术效果与满足患者术后美观需求方面的优劣,以期为临床决策提供参考。方法 回顾性分析2019年1月—2021年10月在中南大学湘雅医院乳腺外科接受以上两种手术的早期乳腺癌患者资料,其中接受保乳整形手术（保乳组）与保留乳头乳晕皮下腺体切除加假体联合补片一期乳房重建手术（乳房重建组）的患者各40例。收集患者的基本临床病理特征信息,两组的手术时间、术后留置引流管时间、术后住院时间、住院费用以及手术相关并发症等信息,使用Breast-Q量表评估患者术后满意度。结果 保乳组在手术时间、术后留置引流管时间、术后住院时间以及住院费用上均明显优于乳房重建组（均P<0.001）。乳房重建组乳头麻木的发生率明显高于保乳组（P<0.001）;乳房重建组发生皮瓣坏死4例,保乳组无皮瓣坏死发生,但差异无统计学意义（P=0.079）;两组间血肿、切口感染、脂肪坏死和组织挛缩的发生率差异均无统计学意义（均P>0.05）。两组患者的心理健康、身体健康、性健康及对乳房外形的满意度差异均无统计学意义（均P>0.05）。结论 两种手术方式的美学效果相似。皮瓣坏死为假体联合补片一期乳房重建中的严重并发症,背阔肌肌皮瓣覆盖创面可作为补救治疗手段。满足保乳手术适应证的患者,应优先考虑保乳整形的手术方式;存在保乳手术禁忌证的患者,但有乳房外形要求的,合理评估后实施保留乳头乳晕腺体切除加假体联合补片一期乳房重建也是一个可选方案。     

腹壁肿瘤切除术后遗留腹壁巨大缺损39例修复与重建

目的探讨采用聚丙烯（Polypropylene,PP）补片或复合补片修复腹壁肿瘤切除术后遗留腹壁巨大缺损的方法和效果。方法收治的39例腹壁巨大肿瘤患者均采取了手术切除治疗。采用直接缝合腹膜关闭腹腔,并在腹膜外用PP补片修复缺损6例,采用带蒂大网膜加PP补片修复缺损19例,采用复合补片修补腹壁缺损14例。结果 39例中因术后发生急性心肌梗塞死亡1例。术后肺部感染1例,经抗感染治疗治愈。术后出现皮下积液5例,经穿刺抽吸,理疗和引流等措施治愈。随访34例,随访时间1～5年。在访的4例结肠癌患者和4例胃癌患者术后12～27个月均因肿瘤腹腔内复发及肝脏广泛转移死亡,术后肿瘤局部复发1例,随访的全部患者未发生腹壁切口疝和肠梗阻等并发症。结论采用PP补片或复合补片修复腹壁肿瘤切除后遗留腹壁巨大缺损并发症发生率低,效果良好。     

“对位对线”补片放置法在腹腔镜食管裂孔疝修补术中应用：单中心120例分析

背景与目的 腹腔镜下食管裂孔疝（HH）补片修补术以创伤小、恢复快、并发症少等优势已成为治疗HH的主要手术方法。腹腔镜下的补片放置及固定技术仍然是一个难点。本研究介绍一种新式的HH补片放置方法并探讨其临床应用效果。方法 回顾性分析2019年1月—2020年12月中山大学附属第六医院疝和腹壁外科收治的120例行腹腔镜HH补片修补术患者的临床资料。入组患者均采用“对位对线”的补片放置方法。结果 全组患者的平均手术时间为（112±27）min，术后平均住院时间为（4.5±2.2）d，围手术期无死亡病例。手术后早期并发症包括吞咽困难7例，其中5例2周后缓解，2例手术后4周仍诉有吞咽困难，予以胃镜下行球囊扩张治疗后症状可缓解；手术后尿潴留2例，予以留置尿管对症处理后症状缓解；术后腹腔出血1例，予以急诊行腹腔镜探查止血；术后肠梗阻2例，予以保守治疗后痊愈。随访中位时间为26个月，其中14例（11.7%）失访。随访患者中有5例诉临床症状与手术前相比未得到明显改善，其余患者诉临床症状得到完全改善或部分改善。所有随访病例均无确切依据的解剖学复发。所有随访病例未发现补片相关并发症如补片移位、感染、补片侵蚀食管以及大血管等。结论 腹腔镜HH补片修补术中采用“对位对线”的补片放置方法是安全有效的，此方法操作简单容易实施，便于临床推广使用。     

Evaluation of Surgisis for patch repair of abdominal wall defects in children

BackgroundAbdominal wall defects in children are not always amenable to primary repair and may require a patch. The ideal material has yet to be established. We sought to evaluate our experience using the bioabsorbable material Surgisis (Cook Surgical, Bloomington, IN) for abdominal closure.MethodsA retrospective chart review of abdominal wall defects repaired with Surgisis in our institution from 2000 to 2010 was performed. Data extracted included cause of defect, age at operation, possibility of skin coverage, recurrence, length of follow-up, and rate of wound infection.ResultsThirteen patients were identified. Cause of defect was gastroschisis (n = 2), ventral hernia after diaphragmatic hernia repair (n = 2), and omphalocele (n = 9). At median follow-up of 60 months (range, 10-90), 5 (38%) of 13 patients recurred, and 1 patient recurred twice. All recurrences required subsequent patch closure. Six instances of wound infection required antibiotics. None required patch removal. There was a trend toward more frequent recurrence among infants undergoing patch repair (3/4 recurrences in this group) than neonates (1/4 recurrences) or children older than 18 months (1/5 recurrences).ConclusionOur data suggest that Surgisis is moderately successful in the repair of pediatric abdominal wall defects. We noted a trend toward a higher recurrence rate in infants. Further studies investigating timing of repair and alternative biosynthetic materials are warranted.     

腹壁韧带样瘤六例诊治分析及文献复习

目的探讨腹壁韧带样瘤的诊断和治疗。方法回顾性分析攀钢集团总医院1999年3月至2015年1月收治的6例腹壁韧带样瘤病人的临床资料。病人以腹部包块入院,无特异性的临床表现。治疗上均选择以手术治疗为主,术中保留皮肤及皮下组织,沿肿瘤边缘完整游离肿瘤,距离肿瘤边缘大于2 cm完整切除肿瘤,将切除的肿瘤送冰冻病理检查,若切除的肿瘤边缘为阳性,则继续扩大切除范围。手术后若腹壁缺损较大,则用补片予以修补,术后予以放疗。结果 6例病人中女性5例,均为经产妇,1例为男性;均因为发现腹壁包块入院就诊,术前经过彩超或CT检查证实肿块位于腹壁,肿瘤最长径在2.7~7.9 cm之间,平均为5.6 cm。6例病人均经手术广泛切除治疗,其中2例接受术后放疗。术后随访7~361个月,复发者1例(未接受术后放疗),复发率为16.67%。结论腹壁韧带样瘤为临床少发疾病,发展缓慢,无特异性临床表现,以女性好发,治疗上以外科手术为主,术后放疗可降低复发率。     

Experience with Porcine Acellular Dermal Collagen Implant in One-stage Tension-free Reconstruction of Acute and Chronic Abdominal Wall Defects

Background Elective or emergency reconstruction of abdominal wall defects (AWD) is often difficult. Various techniques have been proposed for reconstructing AWD, including the use of synthetic implants. Porcine acellular dermal collagen (Permacol^TM) is a biologic implant (PADCI) derived from porcine dermis. We report our experience with the use of PADCI in the management of large AWD in both emergency and elective surgery. Methods Twenty consecutive patients with chronic AWD (CAWD) arising from large incisional hernia or acute AWD (AAWD) arising from visceral edema or tumor resection were studied prospectively. After musculofascial mobilization, the AWD was closed using sheets (10 × 15 cm) of PADCI as an “underlay” interposition graft. Patients were followed up to a median of 18 months postoperatively. Results All 20 defects were closed without tension using PADCI. Eight and 12 patients had reconstruction for large AAWD and CAWD, respectively. The mean size of the defects was 180 cm² (range = 96–850 cm²). The median number of PADCI used to repair the defects was one sheet (range = 1–7). Twelve patients (60%) had an uneventful recovery and were discharged within seven days. One patient (5%) died from multiple-organ failure. Seven patients (35%) developed a complication (two seromas, two minor wound infections, one wound hematoma, one skin edge necrosis, one superficial wound dehiscence, and wound sinus). Overall there were three recurrences (15%). Conclusion PADCI has the potential for reconstruction of large acute and chronic abdominal wall defects. Medium-term recurrence rate is comparable to synthetic mesh repairs.     

The use of acellular dermal matrix for contaminated abdominal wall defects: wound status predicts success

BACKGROUND: Contaminated abdominal wall fascial defects present a challenging problem. The use of human acellular dermal matrix (AlloDerm; LifeCell Corp., Branchburg, NJ) provides a novel method of primary closure of abdominal wall defects in this setting. The aim of the current study was to determine what factors predicted fascial wall failure as determined by the presence of hernia on follow-up exam after AlloDerm placement. METHODS: All patients who underwent surgery for contaminated abdominal wall fascial defects with placement of AlloDerm from June 2003 to September 2005 at a tertiary care Veterans Affairs hospital were included in the analysis. Patients were followed until hernia recurrence or last clinic visit. RESULTS: Eighteen patients had AlloDerm placed for contaminated fascial defects and all were included in the analysis. Primary wound closure was performed on 12/18 (67%) patients, with 6/18 (33%) patients initially left with open wounds. Patients with open wounds were treated with wound vacuum-assisted closure (VAC) devices (4/6) or saline dressings (2/6). Overall ventral hernia recurrence rate was 50% (9/18) with an average follow up of 9.1 months. Patients who had primary wound closure at the completion of the operation had a 33% (4/12) recurrence rate. Patients who did not have primary wound closure had an 83.3% (5/6) recurrence rate. The significant difference shows (P = .03) that open wound status predicts recurrence. The average size of AlloDerm sheets used was 164.0 cm2 in the closed group and 146.2 cm2 in the primary open wound group (P = .64). Average cost per patient was 4680 dollars for AlloDerm. CONCLUSION: These data suggest that an open wound in the postoperative period after AlloDerm placement for treatment of contaminated fascial defects is associated with a high probability of hernia recurrence. Our data do not support the use of this expensive material unless there is a good chance of having a closed wound.     

Repair of giant abdominal wall hernias with full-thickness skin transplants in high-risk patients

The repair of giant abdominal hernias in high-risk obese patients remains a great challenge. There is no single simple surgical procedure to provide correction for this condition, and the risk for recurrence of hernia is high. Moreover, the insertion of a foreign material, i.e., synthetic mesh, adds an increased risk of infection, particularly in the presence of concomitant immunosuppressant therapy or diabetes. Eight patients, classified ASA 3–4, with giant abdominal wall hernias had 3 months pre-treatment with a custom-made compressive garment before abdominal wall repair. Four patients had a stoma at the time of surgery. Abdominal wall reconstruction was undertaken by realignment of the rectus muscles and fascia under tension. The fascia repair was stabilized with a full-thickness skin overlay graft. Early complications included two wound infections and one seroma. Two patients had pulmonary insufficiencies and required intensive care management. One complete recurrence of hernia was noted at follow-up. Full-thickness skin overlay grafts can be recommended in high-risk patients with abdominal wall hernias when the use of foreign material such as synthetic mesh is contraindicated.     

腹壁巨大缺损的修复重建

目的探讨带蒂大网膜加聚丙烯网片修复手术切除致腹壁巨大缺损的临床效果。方法1994年～2004年,采用带蒂大网膜加聚丙烯网片修复12例因腹壁肿瘤切除致腹壁巨大缺损的患者,缺损范围10cm×7cm～25cm×17cm。结果12例患者术后伤口均I期愈合。获随访1～5年,无肿瘤复发,无腹壁切口疝、肠粘连、肠梗阻和肠瘘等并发症发生。结论带蒂大网膜代替腹膜加聚丙烯网片修复腹壁缺损的方法疗效可靠,副作用少。     

Abdominal wall reconstruction with intraperitoneal prosthesis in desmoid tumors surgery

Desmoid tumor (DT), also known as aggressive fibromatosis, is a rare soft tissue neoplasm. For those tumors localized in the anterior abdominal wall, radical resection and reconstruction with mesh are indicated. Due to the rarity of this disease, there have been no randomized trials, but in reported retrospective series, although it is considered a benign lesion, it is clear that local recurrence is not uncommon. Records from seven consecutive patients (1 man, 6 women; mean age 35 years, range 25-60 years) presenting with desmoid tumors of the anterior abdominal wall were analyzed. In all cases the surgical strategy was the same: wide surgical excision and immediate plastic reconstruction with ePTFE mesh after intraoperative confirmation by frozen section of disease-free margins >1 cm. No immediate postoperative complications were recorded, and no patients developed recurrence after a median follow-up period of 60 months. The long-term mean of global health status recorded was 100%. Radical resection aided by intraoperative margin evaluation by frozen sections, followed by immediate mesh reconstruction, is a safe procedure and can provide a definitive cure without functional limitations for patients with desmoid tumors of the anterior abdominal wall.     

Porcine dermal collagen (Permacol) for abdominal wall reconstruction

OBJECTIVE: A review of Eisenhower Army Medical Center's experience using Permacol (Tissue Science Laboratories, Covington, Georgia) for the repair of abdominal wall defects. METHODS: Retrospective review of medical records of patients undergoing abdominal wall reconstruction with Permacol. RESULTS: From July 30, 2003 to February 12, 2005, 9 patients underwent repair of complicated fascial defects with Permacol. Indications for surgery included reoperative incisional hernia repair after removal of a infected mesh (3 patients), reconstruction of a fascial defect after resection of an abdominal wall tumor (2 patients), incisional hernia repair in a patient with a previous abdominal wall infection after a primary incisional hernia repair (1 patient), incisional hernia repair in a patient with an ostomy and an open midline wound (1 patient), emergent repair of incisional hernia with strangulated bowel and multiple intra-abdominal abscesses (1 patient), and excision of infected mesh and drainage of intra-abdominal abscess with synchronous repair of the abdominal wall defect (1 patient). At a median follow-up of 18.2 months, 1 recurrent hernia existed after intentional removal of the Permacol. This patient developed an abdominal wall abscess 7 months after hernia repair secondary to erosion from a suture. Overall, 1 patient developed exposure of the Permacol after a skin dehiscence. The wound was treated with local wound care, and the Permacol was salvaged. Despite the presence of contamination (wound classification II, III, or IV) in 5 of 9 patients (56%), no infectious complications occurred. CONCLUSION: Complex reconstruction of the abdominal wall can be associated with a high complication rate. Placement of a permanent prosthetic mesh in a contaminated field is associated with a high rate of wound infections and subsequent mesh removal. Permacol becomes incorporated by tissue ingrowth and neovascularization. Permacol is a safe and acceptable alternative to prosthetic mesh in the repair of complicated abdominal wall defects.