腹腔镜腹股沟疝修补术.ppt

腹腔腹腔镜腹股沟疝修腹股沟疝修补术腹腔镜腹股沟疝修补术（腹腔镜腹股沟疝修补术（LIHR）Laparoscopic inguinal hernia repair腹股沟疝的发病基础腹股沟疝的发病基础:etiology of inguinal hernia 肌耻骨孔肌耻骨孔 myopectineal orifice 肌耻骨孔肌耻骨孔 myopectineal orifice 腹股沟疝修补的目标腹股沟疝修补的目标完整覆盖肌耻骨孔完整覆盖肌耻骨孔完整覆盖肌耻骨孔有三层不同的修补层次完整覆盖肌耻骨孔有三层不同的修补层次Reconstruction of three differtent layers（1）腹横筋膜前的肌前修补）腹横筋膜前的肌前修补 Extra-transverse fascia repair（2）腹横筋膜后的腹膜前修补）腹横筋膜后的腹膜前修补 Extra-peritoneal repair（3）腹腔内修补）腹腔内修补 Intra-peritoneal repair腹腔镜腹股沟疝修补术（腹腔镜腹股沟疝修补术（LIHR）Laparoscopic inguinal hernia repair（1）完全腹膜外修补术（）完全腹膜外修补术（totally extraperitoneal TEP）（2）经腹腹膜前疝修补术（）经腹腹膜前疝修补术（transabdominal preperitoneal TAPP）（3）腹膜内补片植入术疝修补术）腹膜内补片植入术疝修补术（intraperitoneal onlay mesh IPOM）LIHR手术的合理性手术的合理性1.符合病因学说，腹横筋膜重建。符合病因学说，腹横筋膜重建。Rebuild the transverse fascia 2.符合解剖结构，完全修复了腹股沟部位符合解剖结构，完全修复了腹股沟部位的薄弱区域。的薄弱区域。Cover the entire weak parts of inguinal area 3.符合力学原理，有效缓冲腹腔内压力的符合力学原理，有效缓冲腹腔内压力的冲击冲击 Buffer the pressure of peritoneal cavity WHY LIHRLIHR手术的适应证手术的适应证 Indication优先考虑：双侧疝和复发疝优先考虑：双侧疝和复发疝Ideally suitable for relapse hernia and bilateral hernia适用于：适用于：I型、型、II型、型、III型和型和IV型的腹股沟直疝、斜疝型的腹股沟直疝、斜疝和股疝和股疝Adapt to(type-I/II/III/IV)indirect hernia、direct hernia and femoral hernia -（中华外科学会疝与腹壁外科学组（中华外科学会疝与腹壁外科学组2003年年8月修订稿）月修订稿）LIHR手术的禁忌证手术的禁忌证 Contra-indication1.不能耐受麻醉和气腹者。不能耐受麻醉和气腹者。intolerance of anesthesia and pneumoperitoneum 2.严重出血倾向者。严重出血倾向者。serious hemorrhagic tendency 3.嵌顿疝、绞窄疝。嵌顿疝、绞窄疝。incarcerated hernia and strangulated hernia4.腹腔镜手术后严重粘连者。腹腔镜手术后严重粘连者。severe Post-laparoscopic operation adhesion 5.复杂滑动疝。复杂滑动疝。complicated sliding hernia 6.合并妊娠者。合并妊娠者。combined with pregnancy LIHR手术的优点手术的优点 Advantages1.切口小，疼痛轻，美观。切口小，疼痛轻，美观。Small incision Less pain Better outlookSmall incision Less pain Better outlook 2.避免了由于切口所致的组织损伤，神经损伤，切口感染。避免了由于切口所致的组织损伤，神经损伤，切口感染。Small wound area Low risk of infection and tissue damageSmall wound area Low risk of infection and tissue damage3.局部的紧张感，异物感轻微。局部的紧张感，异物感轻微。Tension-free More comfortableTension-free More comfortable4.空间大，视野清晰，解剖标志明显，补片易于放置到位，展空间大，视野清晰，解剖标志明显，补片易于放置到位，展平。平。Allowed clear visualization of all preperitoneal fascial planes Allowed clear visualization of all preperitoneal fascial planes and anatomic landmarksand anatomic landmarksEasy to fix the mesh to planned placeEasy to fix the mesh to planned placeLIHR手术的优点手术的优点 Advantages5.术中可探查是否有隐匿疝，并得到及时的治疗。术中可探查是否有隐匿疝，并得到及时的治疗。Find and treat mutiple unexpected and concealed hernia Find and treat mutiple unexpected and concealed hernia 6.治疗双侧疝、复合疝与复发疝具有一定的优势。治疗双侧疝、复合疝与复发疝具有一定的优势。Ideally suitable for relapse herniaIdeally suitable for relapse hernia、bilateral hernia and bilateral hernia and complicated herniacomplicated hernia7.允许患者术后更早的回复非限制性活动。允许患者术后更早的回复非限制性活动。Quicker recovery Quicker recovery a shorter hospitalization period a shorter hospitalization period全腹膜外腹腔镜腹股沟疝修补术全腹膜外腹腔镜腹股沟疝修补术（TEP）Totally Extraperitonial TEP 不进入腹腔，对腹腔无干扰，是不进入腹腔，对腹腔无干扰，是LIHR的最佳术式。的最佳术式。No opening of the peritoneum,hence no risk of damaging No opening of the peritoneum,hence no risk of damaging abdominal organs,TEP is the best approach among abdominal organs,TEP is the best approach among LIHR.LIHR.由于没有现成的手术空间，需要人造间隙。而且，人造由于没有现成的手术空间，需要人造间隙。而且，人造的间隙相对较小，增加了手术难度。的间隙相对较小，增加了手术难度。Since no ready operation space,better exposure of the Since no ready operation space,better exposure of the extraperitoneal space needs adequate experience,which extraperitoneal space needs adequate experience,which raises the difficulty.raises the difficulty.TEP手术的操作要点手术的操作要点 KEY POINTS1.病人的体位。病人的体位。Body Position 的放置。的放置。Port placement3.正确的进入腹膜前间隙。正确的进入腹膜前间隙。Push it slowly and check on the screen that Im going in the right way 4.腹膜前间隙的分离。腹膜前间隙的分离。Dissection with the scope 5.解剖结构的辨认。解剖结构的辨认。Know the working anatomy6.疝囊剥离。疝囊剥离。Dissection of the hernia sac7.补片的放置。（常用补片的放置。（常用3D补片）补片）Mesh placement病人的体位病人的体位 Position-建立气腹：建立气腹：帮助医生有足够空间观察操作帮助医生有足够空间观察操作患者通常为头低脚高位患者通常为头低脚高位15-30CO2维持压力维持压力10-15mmHg-Start the insufflation of the extraperitoneal space with a pressure of 10-15mmHg（CO2）-Low head and high legs(15-30)-Both contribute to better exposure Trocar的位置的位置 Port Position15腹膜前间隙腹膜前间隙 pre-peritoneal space解剖结构的辨认解剖结构的辨认 the working Anatomy解剖结构的辨认解剖结构的辨认 Anatomy腹壁下血管Epigastric Vessels睾丸动静脉Testicular Vessels输精管Vas Deferens腹股沟韧带Inguinal Ligament斜疝区Indirect Space髂血管Illiac Vessels腹直肌Rectus Muscle耻骨结节Pubic Tubercle股疝区Femoral SpaceCooper韧带Coopers Ligament直疝区Direct Space解剖结构的辨认解剖结构的辨认 Anatomy解剖结构的辨认解剖结构的辨认 Anatomy解剖结构的辨认解剖结构的辨认 Anatomy解剖结构的辨认解剖结构的辨认 Anatomy解剖结构的辨认解剖结构的辨认 Anatomy常用的3D补片通用 Aspide Mesh巴德 Bard Mesh泰科 Tyco Mesh通用通用3D3D补片补片Aspide 3D Mesh材料特点材料特点 FeaturesFeatures聚丙烯材料经特殊工艺热压成形聚丙烯材料经特殊工艺热压成形A reinforcement net made of non-woven,non-knitted and A reinforcement net made of non-woven,non-knitted and non-resorbable polypropylene non-resorbable polypropylene 具有皱缩率低（具有皱缩率低（5%5%）Less shrinkage Less shrinkage 组织长入性好组织长入性好Excellent colonizationExcellent colonization 术后慢性疼痛发生率低术后慢性疼痛发生率低Less post-operative chronic painLess post-operative chronic pain 非编织补片非编织补片 vs vs 编织补片编织补片non-woven mesh vs woven meshnon-woven mesh vs woven mesh网片类型网片类型特点特点&优点优点编织补片编织补片(1970(1970年代技术）年代技术）形状记忆形状记忆 皱缩率长度达20%体积40%以上 -摘于 疝和腹壁外科解剖图谱 马颂章 2008年出版非编织补片非编织补片(2000(2000年代技术）年代技术）1.1.皱缩率低皱缩率低，最少的术后异物感、慢性疼痛，最少的术后异物感、慢性疼痛2.2.组织长入性好组织长入性好 1212天组织完全长入天组织完全长入3.3.生物相容性好，耐受感染能力强生物相容性好，耐受感染能力强4.4.更软、更柔顺更软、更柔顺 非编织补片特点：皱缩低非编织补片特点：皱缩低 柔软柔软 通用通用3D3D补片补片Aspide 3D Mesh 结构特点结构特点1 三维立体定位补片三维立体定位补片 解剖立体结构解剖立体结构2 透视定位孔透视定位孔 提高医生手术精准率提高医生手术精准率3 左右侧兼容，便于操作左右侧兼容，便于操作4 更少固定，降低术后更少固定，降低术后 慢性疼痛慢性疼痛 规格：15*11cm,13*10cm精索血管精索血管分叉分叉Cooper韧韧带带巴德巴德3D补片补片Bard 3D Mesh材料特点材料特点 Features1.单丝聚丙烯，与组织产生尼龙拉扣效应Monofilament PTEE stitches minimizes the risk of adhesions to the prosthesis 2.加强边缘 reinforced edge 保持形状 Formed防止毛边 Sealed edges provide on overhang of ePTFE without compromising the polypropylene Bard mesh side.巴德巴德3D补片补片结构特点：结构特点：与腹股沟区拟与腹股沟区拟合的三维结构合的三维结构尖端外侧缘隆起部分与腹股沟韧带的轴线相一致凹口与髂外血管位置一致加强边缘内侧指示标志便于放置定位巴德3D补片规格：分左右泰科3D补片Tyco 3D Mesh聚酯材料外侧缘外侧缘内侧缘内侧缘裙边裙边Thank you资料整理仅供参考,用药方面谨遵医嘱