自固定补片行开放无张力疝修补.ppt
ProGrip自固定补片行腹股沟疝开放式无张力修补,陕西省人民医院普外一科王小强,腹股沟疝无张力修补的现状方法多材料多个体化治疗重视并发症,Lichtenstein(李金斯坦)Tension free(无张力)，1989李金斯坦手术简单，易学，适合大多数疝仍是欧洲应用最多的方法分离范围大，缝合多材料和缝合技术仍在演变,IL Lichtenstein,理想的李金斯坦手术补片适合的形状和大小有一定的弹性并且不皱缩对组织的刺激最小最小的残量和足够的支撑张力,缝合的演变,连续缝合,间断缝合,不缝合,腹股沟疝术后慢性疼痛持续6个月以上Amid 防治腹股沟疝术后慢性疼痛国际指南发生率0.56%；1012%原因神经源性（缝扎，卡压，粘连）非神经源性（瘢痕，骨膜刺激）其他因素（年龄、性别、职业）心理因素,缝合是否是疼痛的主要原因之一不缝合能否降低术后疼痛及术后慢性疼痛不缝合补片如何保证不复发,ProGrip自固定补片的解决之道,自固定半吸收的网片,尾端,头端,预裁式搭扣,通过锚扣将张力均匀分布在整张网片上，不需要缝合,可吸收的的锚扣自动与组织粘合,单股聚丙烯和可吸收聚乳酸,椭圆网片便于适形裁剪,半可吸收网片,半可吸收的轻量网片,有自动固定功能的微型锚扣(micro-grips)是由聚乳酸（PLA）成分制成的。通过水解自然吸收，减少体内的异物质量。micro-grips均匀地分布在整张补片的表面，不需要依靠补片外围的几个缝合固定点来固定补片。并且自动固定的功能可以减少对患者组织穿透的创伤和牵拉神经造成的慢性疼痛的风险。micro-grips式补片对小白鼠的输精管没有任何不良影响Influence of a new self-gripping hernia mesh on male fertility in a rat modelThomas Kolbe Christian Hollinsky Ingrid Walter Anja Joachim Thomas RlickeSurg Endosc,临床资料,时间：2011年11月2012年1月单侧原发腹股沟疝15例男性15例年龄：45-78岁斜疝13例、直疝2例麻醉局麻11例、硬膜外麻醉4例手术时间：3555分钟；平均42分钟,【手术步骤】,（1）56cm斜切口（2）切开皮下脂肪和腹外斜肌腱膜（3）游离精索结构（4）分离疝囊并高位结扎斜疝疝囊高位游离切断结扎或还纳，直疝疝囊直接还纳或切除连续缝合腹横筋膜缺损。,放置ProGrip补片,根据腹股沟区实际大小对补片进行裁剪从补片尾端卷起补片从耻骨结节端向内环方向平铺补片，头端覆盖耻骨结节超过1cm预裁式搭扣包绕精索可吸收缝线缝合腹外斜肌腱膜和皮下脂肪及皮肤,疼痛评价及随访结果,患者术后疼痛评分（使用视觉模拟评分法测定，The visual analog scale VAS法）术后1天 2.40.4 术后一月 0.10.3术后不适感评估,其他并发症尿储留 0 皮下血肿 0血清肿 0伤口感染 0慢性疼痛 0 近期复发 0,结论,ProGrip自固定补片行腹股沟疝开放式无张力修补是安全可行的修补方法源自李金斯坦手术手术步骤简单不进入腹膜前间隙单一平面补片不需缝合,复发率低我们的结果（近期0/15复发）文献0/70复发.P.Chastan.2/181复发（1.1%）Nicols Pedano,术后疼痛轻我们的对照研究（进行中）a,AbstractINTRODUCTION:Secure fixation of the mesh in groin hernia repair is essential to avoid mesh dislocation.The fixation,however,is also thought to be a source of chronic postoperative pain.We tested the new self-fixating mesh Parietene progrip vs.traditional suture fixating Lichtenstein repair in a double-blinded randomized study evaluating postoperative pain and the use of analgesics.METHODS:Fifty patients were randomized into two groups:Patients of group A(24 patients)were operated with the new self-fixating Parietene progrip mesh without fixation sutures and patients of group B(26 patients)were operated with the traditional Lichtenstein repair.Postoperative course including pain and the use of analgesics were monitored.Patients were reinvestigated after 6 months regarding pain score and the amount of analgesics used during this interval.Primary end point was pain on the first operative day.,RESULTS:The visual analog scale pain score showed at the first postoperative day a significantly lower level in group A than in group B(mean 17.9 vs.32.3 mm,p=0.03).Additionally,the cumulative dose of postoperatively required analgesics was lower in group A than in group B.The operative time in group A was significantly shorter than in group B.Six months after the operation,a trend toward a lower pain score was observed in group A,but this did not reach statistical significance.CONCLUSIONS:This is the first randomized study to show a beneficial effect of the new self-fixating mesh on pain score.According to our investigations,operative time is reduced,which is a considerable fact with regard to economic aspects as well as the beneficial aspects for the patients.A study with a larger cohort of patients should be conducted to confirm the promising results of this exploratory study.,其它并发症情况不增加其它并发症的发生率,手术的注意事项,ProGrip手术适应症,ProGrip手术适应症,Nyhus（美国Nyhus于1993年公布）型，内环口正常的斜疝；型，内环口扩大的斜疝；型，腹股沟管后壁薄弱的所有直疝、斜疝和股疝；型，复发疝 Gilbert、Rutkow和Robbins（Gilbert于1980年设计了名为CHATS的分类系统，分为5型，1986年Rutkow和Robbins又增加两种类型。）型，内环口正常的斜疝；型，内环口扩大（小于两指宽）的斜疝，后壁完整；型，内环口扩大（大于两指宽）的斜疝，后壁受损；型，大的直疝 型，小的直疝 型，“裤型疝”（“马鞍疝”）型，股疝,充分的游离空间更大的接触面积，更可靠地锚定。耻骨结节要覆盖1cm以上尽可能保留神经，不刻意解剖游离神经，如果神经有损伤，则切断并处理好残端。,疝囊高位游离遵循Bassini和Lichtenstein的原则避免遗漏疝腹横筋膜成型不论直疝还是斜疝，应该缝合腹横筋膜的缺损，使腹股沟管的后壁成为一个整体。,放置网片的技巧,适当的裁剪网片从尾端卷起网片从耻骨结节向内环方向铺设网片,请观看完整手术录像,
