切口疝腹腔镜IPOM修补七步法操作指南（2022版）

doi:10.7659/j.issn.1005-6947.2022.04.001

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切口疝腹腔镜IPOM修补七步法操作指南（2022版）
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                        10.7659/j.issn.1005-6947.2022.04.001
                    
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通信作者:陈双，Email: chensh223@mail.sysu.edu.cn
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Guidelines for performing laparoscopic IPOM repair of incision hernia by seven-step method (2022 edition)

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切口疝修补手术近年来逐步得到推广，多年来的经验及临床研究显示腹腔镜下腹腔内网片修补术（IPOM）能有效关闭缺损、减少复发，是治疗切口疝的理想方法。规范化腹腔镜下切口疝的IPOM修补术操作势在必行。本团队经过多年培训实践及临床对比研究，发现七步法遵循学习规律、适合操作者掌握，同时可减少手术并发症。因此，广东省医师协会疝与腹壁外科医师分会组织编写了第1版《切口疝腹腔镜IPOM修补七步法操作指南》，旨在针对疝和腹壁外科领域腹腔镜切口疝IPOM修补手术操作进行规范化和标准化，为疝和腹壁外科医生们规范修补操作、缩短学习曲线、减少术后并发症提供帮助。

Abstract:

Incisional hernia repair has been steadily promoted in recent years. Years of experience and clinical studies have shown that laparoscopic intraperitoneal onlay mesh (IPOM) can effectively close the defect and reduce recurrence, so it is an ideal method for the treatment of incisional hernia. Standardization of operation procedure for laparoscopic IPOM repair of incisional hernia is urgently needed. After years of training practice and clinical comparative analyses, our team found that the "seven-step method" follows the learning pattern, is suitable for the operator to master, meanwhile, it can reduce postoperative complications. Therefore, the Hernia and Abdominal Wall Surgeons Branch of Guangdong Medical Doctor Association organized the compilation of the first edition of the "Guidelines for performing laparoscopic IPOM repair of incision hernia by seven-step method", which aims to regularize and standardize the operation of laparoscopic IPOM repair in the field of hernia and abdominal wall surgery, and to provide help for standardizing the repair operation and shortening the learning curve of the hernia and abdominal wall surgeons as well as reducing postoperative complications.

表 1 证据级别和推荐标准Table 1 Levels of evidence and grades of recommendation

图1 切口疝患者使用PPP联合BTA腹腔扩容前后的影像学变化 A-B：CT扫描变化；C-D：CT重建疝囊容积变化（有效指征：疝囊容积比缩小）Fig.1 Image changes in patients with incisional hernia before and after abdominal expansion with PPP plus BTA A-B: Changes in CT scan image; C-D: Changes of the hernial sac in CT reconstruction (effective sign: reduction of hernia sac volume ratio)

图2 患者手术体位与术者站位 A：下腹部切口疝患者采用仰卧位；B：下腹部切口疝术者和助手站位；C：上腹部切口疝术者和助手站位；D：左侧腰部切口疝患者采用右侧卧位；E：左侧腰部切口疝术者和助手站位Fig.2 Surgical positions of patients and surgeons A: Adoption of a dorsal position for patients with lower abdominal incisional hernia; B: The standing positions of the surgeon and the assistants for lower abdominal incisional hernia; C: The standing positions of the surgeon and assistants for upper abdominal incisional hernia; D: Patients with left lumbar incisional hernia using a right lateral position; E: The standing positions of the surgeon and assistants for left lumbar incisional hernia

图3 三角布孔原则（观察孔和左右手操作孔，呈三角形分布，以疝囊缺损为顶角，利于持镜手观察及主刀医生操作） A：下腹部耻骨上方切口疝套管布局；B：靠近脐部切口疝套管布局；C：左侧腰部切口疝套管布局Fig.3 The principle of triangular distribution (triangular distribution of the optic port and the two main operating ports with the hernia sac defect as the vertex angle, convenient for observation of the laparoscopy-holder and the operation of the chief surgeon) A: The layout of the trocars for supra-pubic incisional hernia of lower abdomen; B: The layout of the trocars for incisional hernia in the para-umbilical region; C: The layout of the trocars for left lumbar incisional hernia

图4 Palmer点Fig.4 Palmers point

图5 PPP后，CT平扫了解腹腔内粘连情况，避免放置穿刺套管时的损伤 A：显示腹腔内黑色的安全区域及腹腔内组织分布；B：显示腹腔内疝囊及疝囊内的肠管；C：显示腹腔内粘连的网膜分布Fig.5 Detection of the abdominal adhesions by CT scanning after PPP to avoid the visceral injury during trocar placement A: Showing the black safety area and tissue distribution in the abdominal cavity; B: Showing the abdominal hernia sac and the intestines in the hernia sac; C: Showing the distribution of adhesive omentum in the abdominal cavity

图6 Hasson法腹腔穿刺套管置入方式 A-B：开放逐层进入腹腔；C：将套管置入作为观察孔Fig.6 Open laparoscopic entry using Hassons technique A-B: Incision of the abdominal wall layer by layer into the abdominal cavity; C: Insertion of the trocar into the abdominal cavity for observation port

图7 粘连松解 A：使用剪刀分离肠管致密粘连；B：使用超声刀分离网膜致密粘连Fig.7 Separation of the adhesions A: Separation of intestinal dense adhesions with scissors; B: Separation of dense omental adhesions with ultrasonic scalpel

图8 缺损关闭方法 A：“立体缝合”模式（用缝合将疝囊顶部、侧壁一起缝合，并在肌肉筋膜层对合后，形成新的腹壁）；B：耻骨上方切口疝缺损的“立体缝合”Fig.8 Method for defect closure A: Multidimensional suture (suturing the top and side walls of the hernia sac together to create a new abdominal wall after alignment with the muscle fascia layer); B: Defect closure of the supra-pubic incisional hernia by multidimensional suture

图9 各种不同的缝合线 A：鱼骨线；B：V-loc倒刺线；C：倒刺线Fig.9 Different types of sutures A: Fish-bone suture; B: V-loc barbed suture; C: Barbed suture

图10 TAPE修补距离耻骨5 cm以内下腹部切口疝 A：补片；B：将膀胱前间隙游离后，将补片置入间隙，并将补片下缘钉合固定于耻骨梳；C：将补片固定好以后，再关闭腹膜（将腹膜连续缝合于补片上），防止肠管进入膀胱前间隙Fig.10 TAPE for a lower abdominal incision hernia with a distance less than 5 cm from the pubis A: Mesh; B: After dissociating the anterior bladder space, placing the mesh into the space, and nailing and fixing the lower edge of the mesh to the pectineal ligament; C: Closing the peritoneum after fixation of the mesh (by continuous suture of the peritoneum on the mesh) to prevent the bowel entering the anterior bladder space

图11 补片覆盖范围与定位 A：修剪一片与补片同等形状大小的纸片；B：将需要覆盖的范围，在腹壁比划并标记；C：确定补片覆盖范围；D：通过亚甲蓝注射转化至腹腔内；E：将补片覆盖范围上重要的点，通过亚甲蓝注射于腹膜前（图中蓝点）；F：将补片置于腹腔内，在覆盖范围上的重要点（图中蓝点）予以对合Fig.11 The coverage area and positioning of the mesh A: Triming a piece of paper with the same shape and size as the mesh; B: Marking the area that needs to be covered on the abdominal wall; C: Determination of coverage area of the mesh; D: Transferring the coverage area into the abdominal cavity by methylene blue injection; E: Navigating the important points on the coverage area of the mesh into the preperitoneal plane through methylene blue injection (blue dot in the picture); F: Placing the mesh in the abdominal cavity and sewing close the important points in the coverage area (the blue dot in the picture)

图12 补片固定 A：计划性的覆盖（L型线表示缝合好的缺损，线上的点为预先设计的固定点）；B：双圈plus固定（除了内外两圈外还需要中间缺损的固定）Fig.12 Mesh fixation A: Planned coverage (the L-shaped line showing the stitched defect, with the predefined fixation points); B: Double-circle plus fixation (a fixation plus of the middle defect besides the internal and external circles)

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.切口疝腹腔镜IPOM修补七步法操作指南（2022版）[J].中国普通外科杂志,2022,31(4):421-432.
DOI:10.7659/j. issn.1005-6947.2022.04.001

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收稿日期:2022-03-03
最后修改日期:2022-03-25
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在线发布日期: 2022-05-07

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