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1、Lichtenstein Hernia Repair By Dr. PK Amid President of American Hernia Society Dirctor Lichtenstein Hernia Institute 李金斯坦无张力疝修补 PK Amid 医生 美国疝协会主席 李金斯坦疝中心主任,翻译：同济医院普外科,Introduction 简介,In 1996,Liechtenstein attracted the attention of surgeons worldwide by justifying the use of a prosthetic mesh to cr
2、eate a tension-free hernia repair, thereby minimizing postoperative discomfort, one of the supplementary criteria for evaluating the efficacy of hernia repair.Lichtenstein有效地使用了修补网片进行无张力疝修补手术，并在1996年引起了全球外科医生的关注。这种手术方式极大地减轻了患者术后的不适，而这一点正是评价疝修补术疗效的重要标准之一。Liechtensteins team popularized routine use of
3、 polypropylene mesh in 1984 and coined the term “tension-free hernioplasty”. 1984年起，Lichtenstein及其同伴即开始在手术中常规使用聚丙烯网片，并将这种手术方式命名为无张力疝成形术。This technique has become the gold standard in open tension-free hernioplasty.今天，这一技术已成为开放式无张力疝成形手术的金标准。,Anatomy 解剖,For proper performance of this procedure, an exc
4、ellent understanding of the anatomy of the inguinal region is mandatory. The inguinal region may be divided into superficial and deep planes by defining the layers of the inguinal canal.为了正确实施该项手术，充分理解腹股沟区的解剖结构是非常必要的。根据腹股沟管的解剖层次，可将腹股沟区分为浅层和深层两个层面。,Anatomy 解剖 - Superficial tissues 浅层组织,1. Anterior su
5、perior iliac spine髂前上棘2. External oblique muscle腹外斜肌3. Aponeurosis of the external oblique muscle (AEOM)腹外斜肌腱膜（AEOM）4. Femoral vessels股血管5. Spermatic cord精索6. External ring外环,Anatomy 解剖 - Deep tissues 深层组织,1. Inguinal ligament腹股沟韧带2. Internal oblique muscle腹内斜肌3. Transversus muscle腹横肌4. Rectus sheat
6、h腹直肌鞘5. Cremasteric muscle提睾肌6. Deep epigastric vessels腹壁深动静脉,Anatomy 解剖 - Inguinal canal 腹股沟管,1. Transversalis fascia 腹横筋膜 2. Internal ring (IR) 内环（IR） 3. Ducts deferens 输精管 4. Spermatic vessels 精索血管,凹间韧带,Inguinal triangle 腹股沟三角,Anatomy 解剖 - Rethophysiology 病理生理,The role of protease and protease-in
7、hibitor imbalance in the pathogenesis of groin hernias has lead to a new understanding of the etiology of groin hernias and the causes of their surgical failure.蛋白酶-抑制剂失衡在腹股沟疝的发病机制中有重要作用，这一发现使得对腹股沟疝的病因和外科治疗失败的原因有了新的认识。The biochemical evidence that adult male inguinal hernias are associated with impa
8、ired hydroxylation of praline has lead to the theory that these changes lead to weakening of the fibro connective tissue of the groin and subsequent development of inguinal hernias.已有证据证明成年男性腹股沟疝患者通常伴有脯氨酸羟基化作用减弱，这些改变导致了腹股沟纤维连接组织薄弱，并最终导致了腹股沟疝的发生。The utilization of this already defective tissue, espec
9、ially under tension, is a violation of basic principles of surgery.利用这种已经有缺陷的组织进行手术，特别是在有张力的情况下，违背了外科基本原则。,Indications 适应症,This procedure is suitable for all adult patients regardless of their age, weight, general health or the size of the hernia.这种手术适用于所有的成年病人，无论患者的年龄、体重、身体情况或者疝的大小。,Major principle
10、s 主要原则,In tension-free hernioplasty, the entire inguinal floor is reinforced by inserting a sheet of polypropylene mesh. The prosthesis is placed between the transversalis fascia (TF) and the external oblique aponeurosis (EOA). It should extend well beyond the inguinal triangle in order to provide s
11、ufficient mesh/tissue interface. Upon increased intra-abdominal pressure, the EOA applies counter-pressure upon mesh. This allows the increase in intra-abdominal pressure to act as an aide to the repair.无张力疝成形术是在腹横筋膜(TF)和腹外斜肌腱膜(EOA)之间放置一张聚丙烯网片来加固腹股沟管的后壁。网片应延伸至腹股沟三角之外，以提供足够的网片/组织接触界面。在腹内压增加的情况下，腹外斜肌腱
12、膜（EOA）可在网片上产生相应的对抗力。这种反方向的抗张力使得腹内压的增加有助于修补。The mesh reinforcement has both therapeutic and prophylactic benefits. It prevents the entire groin region from herniation due to future mechanical stress factors and/or metabolic derangements.网片对腹股沟区的加固具有治疗和预防双重作用。它可以防止整个腹股沟区因日后机械劳损和代谢异常所引发的疝复发。,Anesthesia
13、 麻醉,Local anesthesia 局部麻醉 Local anesthesia is safe, simple, effective, economical, and without any side effects such as nausea, vomiting, and urinary retention. Furthermore, local anesthesia administered prior to making the incision produces a prolonged analgesic effect via inhibition of the build-u
14、p of local nociceptive molecules (Amid et al., 1994).局部麻醉是一种安全、简单、有效、经济的麻醉方式，而且无恶心、呕吐、尿潴留等副作用。此外，在切开皮肤之前给予局麻药，可以抑制局部炎症介质的合成，从而延长镇痛效果。Epidural anesthesia 硬脊膜外麻醉 Epidural anesthesia is preferable for repair of non-reducible inguinal hernias.硬脊膜外麻醉适用于难复性腹股沟疝的修补。Use of sedative drugs 镇静药物的使用 Sedative dr
15、ugs given by the surgeon or by an anesthesiologist during ”conscious sedation” will reduce the patients anxiety. Infusion of fast-acting, amnesic and anxiolytic agents such as protocol also reduces the amount of local anesthetic agents required, especially with cases such as bilateral inguinal herni
16、a repair in obese patients.在“意识镇静”时，由外科医师或麻醉师给予镇静药物可减轻患者的焦虑。给予起效快、具有遗忘作用的抗焦虑药物，如异丙酚，可以减少术中局麻药物的用量，特别是在对肥胖病人施行双侧腹股沟疝修补术时。,Local anesthesia tech 局部麻醉技术,Injection of local anesthesia is performed by the surgeon as part of the surgical technique. It is placed in dermal and subcutaneous layers prior to the skin incision and deeper planes as the dissection progresses.作为手术的一部分，局麻药物的注射是由外科医师施行的。在切开皮肤前，分别在皮内和皮下进行注射；在切开过程中，再在更深的层面注射药物。 Several safe and effective anesthetic agents are currently available on the market. 现在在市场上可以获得一些安全和有效的麻醉药物。,
