南京医科大学附属南京第一医院,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,*,*,腹腔镜腹股沟疝修补术,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,:,etiology of inguinal hernia,肌耻骨孔,myopectineal orifice,腹腔镜腹股沟疝修补术（LIHR）Laparoscopic,肌耻骨孔,myopectineal orifice,肌耻骨孔,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,Extra-transverse fascia repair,（,2,）腹横筋膜后的腹膜前修补,Extra-peritoneal repair,（,3,）腹腔内修补,Intra-peritoneal repair,腹股沟疝修补的目标完整覆盖肌耻骨孔,腹腔镜腹股沟疝修补术（,LIHR,）,Laparoscopic inguinal hernia repair,（,1,）完全腹膜外修补术（,totally extraperitoneal TEP,）,（,2,）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（,intraperitoneal onlay mesh IPOM,）,腹腔镜腹股沟疝修补术（LIHR）Laparoscopic,LIHR,手术的合理性,1.,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冲击,Buffer the pressure of peritoneal cavity,WHY LIHR?,LIHR手术的合理性1.符合病因学说，腹横筋膜重建。WHY,LIHR,手术的适应证,Indication,优先考虑：双侧疝和复发疝,Ideally suitable for relapse hernia and bilateral hernia,适用于：,I,型、,II,型、,III,型和,IV,型的腹股沟直疝、斜疝和股疝,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,2003,年,8,月修订稿）,LIHR手术的适应证 Indication优先考虑：双侧疝和,LIHR,手术的禁忌证,Contra-indication,1.,不能耐受麻醉和气腹者。,intolerance of anesthesia and pneumoperitoneum,2.,严重出血倾向者。,serious hemorrhagic tendency,3.,嵌顿疝、绞窄疝。,incarcerated hernia and strangulated hernia,4.,腹腔镜手术后严重粘连者。,severe Post-laparoscopic operation adhesion,5.,复杂滑动疝。,complicated sliding hernia,6.,合并妊娠者。,combined with pregnancy,LIHR手术的禁忌证 Contra-indication1.,LIHR,手术的优点,Advantages,1.,切口小，疼痛轻，美观。,Small 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。,Small wound area Low risk of infection and tissue damage,3.,局部的紧张感，异物感轻微。,Tension-free More comfortable,4.,空间大，视野清晰，解剖标志明显，补片易于放置到位，展平。,Allowed clear visualization of all preperitoneal fascial planes and anatomic landmarks,Easy to fix the mesh to planned place,LIHR手术的优点 Advantages1.切口小，疼痛轻,LIHR,手术的优点,Advantages,5.,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,6.,治疗双侧疝、复合疝与复发疝具有一定的优势。,Ideally suitable for relapse hernia,、,bilateral hernia and complicated hernia,7.,允许患者术后更早的回复非限制性活动。,Quicker recovery,a shorter hospitalization period,LIHR手术的优点 Advantages5.术中可探查是否,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,LIHR,的最佳术式。,No opening of the peritoneum,hence no risk of damaging abdominal organs,TEP is the best approach among LIHR.,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。,Since no ready operation space,better exposure of the extraperitoneal space needs adequate experience,which raises the difficulty.,全腹膜外腹腔镜腹股沟疝修补术（TEP）Totally Ex,TEP,手术的操作要点,KEY POINTS,1.,病人的体位,。,Body Position,2.Trocar,的放置,。,Port placement,3.,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。,Dissection with the scope,5.,解剖结构的辨认,。,Know the working anatomy,6.,疝囊剥离。,Dissection of the hernia sac,7.,补片的放置。（,常用,3D,补片,）,Mesh placement,TEP手术的操作要点 KEY POINTS1.病人的体位,病人的体位,Position,-,建立气腹：,帮助医生有足够空间观察操作,患者通常为头低脚高位,15-30,CO,2,维持压力,10-15mmHg,-Start the insufflation of the extraperitoneal space with a pressure of 10-15mmHg,（,CO,2,）,-Low head and high legs(15-30),-Both contribute to better exposure,病人的体位 Position-建立气腹：-Start t,Trocar,的位置,Port Position,Trocar的位置 Port Position,15,腹膜前间隙,pre-peritoneal space,15腹膜前间隙 pre-peritoneal space,解剖结构的辨认,the working Anatomy,解剖结构的辨认 the working Anatom,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 Space,Cooper,韧带,Coopers Ligament,直疝区,Direct Space,解剖结构的辨认 Anatomy腹壁下血管Epigast,解剖结构的辨认,Anatomy,解剖结构的辨认 Anatomy,解剖结构的辨认,Anatomy,解剖结构的辨认 Anatomy,解剖结构的辨认,Anatomy,解剖结构的辨认 Anatomy,解剖结构的辨认,Anatomy,解剖结构的辨认 Anatomy,解剖结构的辨认,Anatomy,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,常用的3D补片通用 Aspide Mesh,通用,3D,补片,Aspide 3D Mesh,材料特点,Features,聚丙烯材料经特殊工艺热压成形,A reinforcement net made of non-woven,non-knitted and non-resorbable polypropylene,具有皱缩率低（,5%,）,Less shrinkage,组织长入性好,Excellent colonization,术后慢性疼痛发生率低,Less post-operative chronic pain,通用3D补片Aspide 3D Mesh材料特点 Featu,非编织补片,vs,编织补片,non-woven mesh vs woven mesh,网片类型,特点,&,优点,编织补片,(1970,年代技术）,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,(2000,年代技术）,皱缩率低,，最少的术后异物感、慢性疼痛,组织长入性好,12,天组织完全长入,生物相容性好，耐受感染能力强,更软、更柔顺,非编织补片特点：皱缩低,柔软,非编织补片 vs 编织补片non-woven mesh v,通用,3D,补片,Aspide 3D Mesh,结构特点,1,三维立体定位补片 解剖立体结构,2,透视定位孔 提高医生手术精准率,3,左右侧兼容，便于操作,4,更少固定，降低术后 慢性疼痛,规格：,15*11cm,13*10cm,精索血管分叉,Cooper,韧带,通用3D补片Aspide 3D Mesh,巴德,3D,补片,Bard 3D Mesh,材料特点,Features,1.,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3D补片Bard 3D Mesh材料特点 Feature,巴德,3D,补片,结构特点：,与腹股沟区拟合的三维结构,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