腹腔开放疗法研究进展

正腹腔开放疗法(open abdomen technique)是由英国的Ogilvie医生于1940年提出,用于战伤致腹壁毁损的救治。随后将腹腔开放疗法纳入损伤控制外科,用于创伤病人的救治。此外,为治疗腹腔感染、血管瘤破裂及重症急性胰腺炎合并腹腔间室综合征(abdominal compartment syndrome,ACS)常须采用主动的腹腔开放。本文就腹腔开放疗法的适应证、暂时性关腹措施及后期的腹壁重建等做一综述,为开放腹腔的管理及后续治疗提供证据支持。     

腹腔开放患者的肠内营养支持

目的观察腹腔开放患者能否安全有效地应用肠内营养（EN）。方法回顾近3年因腹腔间室综合征行腹腔开放的患者的临床资料。通过空肠行EN支持超过3d者入选。所有患者腹腔敞开后均以聚丙烯网覆盖,根据肠功能恢复情况,决定EN开始时机和方案。采用输注泵连续输注,分别于EN前和结束时检测血浆蛋白水平和氮平衡。使用Harris—Benedict方程式计算或间接能量测定仪测定实际能量消耗和呼吸商。结果21例患者EN实施时间平均（51．5±33．6）d,开始于腹腔开放后（8．8±5．5）d,达到目标值的93％～95％。治疗前血各项蛋白水平低于正常值,但经过EN支持后均有改善,其中纤维连接蛋白增加明显,相关并发症未有增加。结论腹腔开放患者肠管虽外露,但在感染得到控制,外加聚丙烯网的覆盖情况下,及时给予EN,肠黏膜和肠壁组织获得营养和循环改善．使组织修复功能趋向健康。EN可以安全有效地应用于腹腔开放的患者。     

腹壁切口疝术后腹腔高压的预警及处理策略

<正>切口疝是腹部手术后常见的并发症之一,发生率为2%～11%[1]。切口疝是腹内脏器经手术切口所致缺损而突出于体表所形成的疝。欧洲疝学会将其定义为:在临床体检影像学检查中可看到或     

术前渐进性人工气腹在治疗复杂腹壁缺损中的应用

人工气腹曾是一种传统的治疗方法,早期用于结核性腹膜炎和肺结核的治疗~([1]),后来将这一方法用于巨大切口疝病人的术前准备~([2])。经过临床实践的不断改进和发展,术前渐进性人工气腹已成为国外许多学者推荐的复杂腹壁缺损有效的术前准备方式之一,应用越来越广泛~([3-5])。目前国内尚未引起重视,也未见报道方法。本文结合笔者在临床应用     

A型肉毒毒素在复杂腹壁缺损治疗中的应用

腹壁缺损的修复与重建一直是研究的难点,尤其是复杂腹壁缺损。各种腹壁外科技术及补片材料的出现,为腹壁缺损的治疗带来了更多的选择。但对于合并腹壁功能不全的复杂巨大腹壁缺损的治疗,仍然是一个具有挑战性的问题。A型肉毒毒素（BTA）侧腹壁肌肉注射由于能够麻痹侧腹壁肌肉、缩小腹壁缺损,在腹壁缺损治疗领域成为研究的热点之一。本文结合笔者临床应用的经验,就BTA在复杂腹壁缺损治疗中的应用作一综述。     

创伤性腹壁巨大缺损一期修复1例

病人男,25岁.左侧腹壁机器皮带绞伤6h于2005年11月急诊入院.曾在当地医院就诊,行小肠破裂修补术后因腹壁缺损无法处理转院.入院查体:生命体征平稳,左侧腹壁中下部盖大碗包扎.立即全麻下行探查清创术.     

腹腔内高压与腹腔间室综合征

目的：研究腹腔内高压和腹腔间室综合征的概念及其病理生理变化。方法：采用文献回顾的方法对腹腔内高压和腹腔间室综合征的概念及病理生理学进展加以综述。结果：腹腔内高压和腹腔间室综合征的概念已逐渐被接受，其病理生理变化主要有：①胃肠血流减少；②呼吸道阻力增加，肺顺应性下降；③心输出量减少，周围循环阻力增加；④少尿甚至无尿；⑤颅内压升高；⑥肝脏血流减少；⑦腹壁顺应性降低。结论：腹腔内高压和腹腔间室综合征的概念应用增多，最易累及呼吸系统、心血管系统和泌尿系统，其次是胃肠道、中枢神经系统、肝脏和腹壁。心输出量减少和肺顺应性下降是引起脏器功能障碍的始动因素。     

利用腹外斜肌腱膜翻转修补下部腹壁肌性缺损

目的 探讨腹外斜肌腱膜在下腹部腹壁肌性缺损修补中的应用。方法 用腹外斜肌及其腱膜翻转修补先天性腹壁肌肉缺损综合征6例,巨大腹壁切口疝5例。结果 全组11例术后近期效果满意,随访7月～10年,腹壁完整无膨出,发育正常,功能良好。结论 用腹外斜肌腱膜修补下部腹壁肌性缺损有其可行性和优越性,临床效果满意。     

腹腔扩容术在腹部外科的应用

Intra-abdominal volume increment is a new abdominal surgery, which is used to prevent the abdominal compartment syndrome caused by intra-abdominal hypertension.In this article, the author emphasizes the concept, indications,operative principles of intra-abdominal volume increment. Firstly,laparotomy was performed, active bleeding and source of infection were controlled. Then greater omentum was put under the incision, vacuseal dressings were apphed on the greater omentum,and the abdominal incision was sutured. If the intra-abdominal pressure was less than 12 mm Hg (1 mm Hg=0. 133 kPa) for 48 hours during 7-14 days after operation, abdominal incision could be closed, while if the intra-abdominal pressure was more than 12 mm Hg, dermatoplasty was used to close abdominal incision to form a ventral hernia, then definitive abdominal wall reconstruction was performed 6 months after operation.     

Single-stage closure of enterocutaneous fistula and stomas in the presence of large abdominal wall defects using the components separation technique

Background

Closure of an enterocutaneous fistula and/or stomas in the presence of large abdominal wall defects is a challenging problem. In the present study, the results of the components separation technique are described.

Methods

All patients with an enterocutaneous fistula and/or stomas in the presence of large abdominal wall defects (ie, laparostomy of ventral hernia) who underwent a single-stage repair using the components separation technique in the period from January 2000 to July 2007 were reviewed retrospectively.

Results

A total of 32 patients were included. The median operating time was 204 minutes (range 87-573). In 18 patients, additionally to the components separation, an absorbable mesh was used. Postoperatively, in 16 patients 22 complications were reported. There were 9 patients with local wound problems. The median postoperative hospital stay was 12 days (range 5-74). Seven patients developed a ventral hernia. Four of them were small asymptomatic recurrences. Four out of the 15 patients with an enterocutaneous fistula developed a recurrent fistula. The median follow-up was 20 months (range 3-54).

Conclusion

Closure of enterocutaneous fistula and/or stomas and simultaneous repair of large abdominal wall defects is feasible using the components separation technique but morbidity is considerable. Early recurrence of abdominal hernia and fistula is acceptable.     

腹壁肿瘤切除术后巨大/超大腹壁缺损的外科修复重建策略

腹壁肿瘤、尤其是恶性肿瘤R0切除术后会导致巨大、甚至超大腹壁缺损,选择合理的腹壁修复重建技术是治疗关键。本文总结了腹壁恶性肿瘤的临床特点、治疗现状、肿瘤扩大切除后腹壁缺损的术前评估和腹壁缺损修复重建的术式选择;重点阐释了腹壁缺损类型、缺损大小、缺损周围组织情况和患者全身情况对术式选择的重要性。     

One hundred percent fascial approximation with sequential abdominal closure of the open abdomen

BACKGROUND: Damage-control surgery and the recognition of the abdominal compartment syndrome have improved patient outcomes but at the cost of an open abdomen. Multiple techniques have been introduced to obtain fascial closure for the open abdomen to minimize morbidity and cost of care. We performed a modification of the vacuum-assisted closure (VAC) technique that provided constant fascial tension, hypothesizing this would result in a higher rate of primary fascial closure. METHODS: After initial temporary closure of the abdomen after post-injury damage control or decompressive laparotomy for abdominal compartment syndrome, we began the sequential closure technique. The technique begins by covering the bowel with the multiple white sponges overlapped like patchwork, and the fascia is placed under moderate tension over the white sponges with #1-PDS sutures. Large black VAC sponges are placed on top of the white sponges and affixed with an occlusive dressing and standard suction tubing is placed. Patients are returned to the operating room for sequential fascial closure and replacement of the sponge sandwich every 2 days, with a resulting decrease in the fascial defect. RESULTS: Fourteen patients underwent sequential abdominal closure during the study period: 9 owing to damage control surgery and 5 owing to secondary abdominal compartment syndrome. Average time to closure was 7.5 +/- 1.0 days (range 4-16) and average number of laparotomies to closure was 4.6 +/- 0.5 (range 3-8). All patients attained primary fascial closure. CONCLUSION: We propose a modification of the previously described vacuum-assisted closure technique that achieves 100% fascial approximation in our limited experience. Further application and refinement of this technique may eliminate the need for delayed complex and costly reconstructive abdominal wall procedures for the open abdomen.     

Use of tissue expanders in the repair of complex abdominal wall defects

Background/Purpose

Closure of abdominal wall defects in children poses a challenge for pediatric surgeons. We describe a technique using tissue expanders placed either intraperitoneally or in the abdominal wall to aid in the reconstruction of a variety of complex abdominal wall defects.

Methods

The tissue expanders are inserted under general anesthesia. Initial expansion is done in the operating room with attention to peak airway pressure, urine output, and end-tidal carbon dioxide. The expanders are inflated in the outpatient setting via percutaneous access until the calculated inflation volume is achieved. They are then removed; and definitive closure is accomplished using a combination of native tissue flaps, abdominal component separation techniques, biomaterials, and synthetic material.

Results

Six children underwent tissue expansion for treatment of abdominal wall defects (omphalocele, n = 3), trauma (n = 1), and thoracopagus twins (n = 1 pair). One to 4 expanders were used per patient, with all having a successful reconstruction of their abdominal walls. Two to 3 operations were required to restore abdominal domain and consisted of expander insertion, removal with reconstruction, and possible revision of the reconstruction.

Conclusions

Tissue expanders possess a broad range of applications for abdominal wall reconstruction and can be used in patients of all ages.     

Outcomes in surgical versus medical patients with the secondary abdominal compartment syndrome

BACKGROUND: Secondary abdominal compartment syndrome (SACS) is a well-recognized sequelae of massive fluid resuscitation in surgical patients, but has only anecdotally been reported in the medical patient population. The purpose of this study was to compare the clinical scenarios, physiologic indices, and outcomes of patients with SACS due to medical versus trauma etiologies. METHODS: Patients undergoing decompression for SACS from January 1999 to January 2006 were identified using our computerized operative records. RESULTS: During the 7-year study period, 54 patients developed SACS (41 postinjury patients and 13 medical patients). There were no significant differences in demographics, physiologic indices, or fluid resuscitation between the medical and postinjury groups: age (46.6 +/- 4.7 vs 40.6 +/- 2.3), bladder pressure (33.5 +/- 1.1 vs 32.8 +/- 1.8), peak airway pressures (45.9 +/- 2.4 vs 49.3 +/- 2.1), base deficit (14.6 +/- 1.4 vs 13.6 +/- 1.1), and fluids (18.5 +/- 1.8 vs 16.0 +/- 1.5 liters). Patients with a medical cause of SACS had a significantly longer time to decompression (21 +/- 3.6 versus 6.5 +/- 1.9 hours), significantly higher incidence of MOF (62% v 27%), and trend toward greater mortality (54% versus 34%). CONCLUSIONS: Patients with diverse disease processes may develop SACS. Despite similar age and physiologic indices, the MOF and mortality rates associated with medical SACS are markedly higher. These findings highlight the need for routine monitoring in at-risk patients, prevention of pathologic intra-abdominal hypertension, and a low threshold for decompression.     

猪脱细胞真皮基质修复兔腹壁缺损的实验研究

目的研究猪脱细胞真皮基质修复兔腹壁缺损的效果,探讨异种脱细胞真皮基质应用的可行性。方法健康小白猪1头,取背部及两侧皮肤制备脱细胞真皮基质。26只日本大耳白兔,雌雄不限,体重2.2～2.3 kg,随机分为对照组(n=6)和实验组(n=20)。对照组制备5.0 cm×0.5 cm腹壁缺损,单纯缝合关闭缺损。实验组制备5.0 cm×2.5 cm腹壁缺损,用同样大小的猪脱细胞真皮基质补片(简称"补片")修复,补片基底膜面朝向肠管。术后观察是否有疝形成,比较两组腹腔内脏器粘连情况,以及对照组腹壁肌筋膜单纯缝合处和实验组补片-腹壁肌筋膜吻合处的最大张力,组织学观察补片是否有纤维血管组织长入及其在体内的生物学转归。结果实验动物均无疝形成。术后5周,实验组补片和腹壁融为一体,补片皮肤面和脏器面均有纤维血管组织长入,补片处于新生组织掺入重建过程。实验组1只动物补片和腹腔内脏器粘连较重(2级),5只发生了轻微粘连(1级),12只无粘连(0级);对照组1只轻微粘连(1级),5只无粘连(0级);两组粘连分级比较差异无统计学意义(Z=—0.798,P=0.425)。术后5周,实验组补片-腹壁肌筋膜吻合处的最大张力为(13.0±5.5)N,对照组腹壁肌筋膜单纯缝合处为(13.6±4.0)N,差异无统计学意义(t=—0.410,P=0.683)。组织学观察显示,术后5周,实验组补片中有大量小血管,并有中性粒细胞及淋巴细胞为主的炎性浸润,补片边缘偶见巨噬细胞,补片-腹壁肌筋膜吻合处由纤维结缔组织连接;术后6个月,补片及周围炎性反应消退,胶原纤维结构发生了改建,补片和肌筋膜层由有纤维结缔组织愈合。结论补片修复兔腹壁缺损取得了较好效果,补片-腹壁肌筋膜层愈合,其吻合处的力学强度达到了自体腹壁单纯缝合吻合的力学强度,补片胶原纤维结构发生了改建。     

Systematic review and meta-analysis of the repair of potentially contaminated and contaminated abdominal wall defects

Background

Repair of contaminated abdominal wall defects entails the dilemma of choosing between synthetic material, with its presumed risk of surgical site complications, and biologic material, a costly alternative with questionable durability.

Data sources

Thirty-two studies published between January 1990 and June 2015 on repair of (potentially) contaminated hernias with ≥25 patients were reviewed. Fifteen studies solely described hernia repair with biologic mesh, 6 nonabsorbable synthetic meshes, and 11 described various techniques. Surgical site complications and hernia recurrence rates were evaluated per degree of contamination and mesh type by calculating pooled proportions.

Conclusions

Analysis showed no benefit of biologic over synthetic mesh for repair of potentially contaminated hernias with comparable surgical site complication rates and a hernia recurrence rate of 9% for biologic and 9% for synthetic repair. Biologic mesh repair of contaminated defects showed considerable higher rates of surgical site complications and a hernia recurrence rate of 30%. As only 1 study on synthetic repair of contaminated hernias was available, surgical decision making in the approach of contaminated abdominal wall defects is hampered.