背景:切口疝是腹壁切口的常见并发症。手术技术是切口疝发展的重要危险因素。这些更新指南的目的是提供减少切口疝发生率的建议。
方法:MEDLINE系统文献检索,Embase,CochraneCENTRAL于2022年1月22日进行。苏格兰校际指南网络工具用于评估系统评价和荟萃分析,RCT,和队列研究。分级方法(建议分级,评估,开发和评估)用于评估证据的确定性。指南小组由外科专家组成,生物医学信息专家,认证的指导方法学家,患者代表。
结果:包含了39篇论文,涵盖了七个关键问题,对所有这些都提出了薄弱的建议。在安全可行的情况下,建议首选腹腔镜手术和非中线切口。在腹腔镜手术中,建议缝合10mm及更大的套管针位置的筋膜缺损,尤其是单切口腹腔镜手术后和脐部。为了关闭选择性中线剖腹手术,建议使用可缓慢吸收的缝合线进行连续小切口缝合技术。可以考虑在选择性中线剖腹手术后预防性增加网片,以降低切口疝的风险;建议在高架或肌后位置使用永久性合成网片。
结论:这些更新的指南可以帮助外科医生选择腹壁切口的最佳入路和位置。
切口疝是由于腹壁肌肉无力导致脂肪从内部或器官膨出。在先前的切口部位进行腹部手术后,这些疝很常见。有研究讨论了闭合切口的不同方法,这可能与疝形成的机会有关。这项研究的目的是回顾最新的研究,并为外科医生提供有关如何最好地关闭切口以降低疝气发生率的指南。如果可能,通过小切口手术可以降低疝形成的风险。如果使用小切口,如果将它们放置在已经薄弱的区域(例如肚脐)之外,则可能会更好。如果切口大于1厘米,除了皮肤缝合外,它还应该用深层肌肉筋膜缝合。如果腹部中部有一个大切口,应使用紧密的小缝线缝合肌肉,并应使用可缓慢吸收的缝线。对于患疝气风险较高的患者,当闭合切口时,肌肉层可以通过使用一块(合成)网加强。没有关于手术后恢复的良好研究,也没有关于活动水平或粘合剂是否有助于预防疝气形成的明确指南。
Incisional hernia is a frequent complication of abdominal wall incision. Surgical technique is an important risk factor for the development of incisional hernia. The aim of these updated
guidelines was to provide recommendations to decrease the incidence of incisional hernia.
A systematic literature search of MEDLINE, Embase, and Cochrane CENTRAL was performed on 22 January 2022. The Scottish Intercollegiate
Guidelines Network instrument was used to evaluate systematic reviews and meta-analyses, RCTs, and cohort studies. The GRADE approach (Grading of Recommendations, Assessment, Development and Evaluation) was used to appraise the certainty of the evidence. The
guidelines group consisted of surgical specialists, a biomedical information specialist, certified
guideline methodologist, and patient representative.
Thirty-nine papers were included covering seven key questions, and weak recommendations were made for all of these. Laparoscopic surgery and non-midline incisions are suggested to be preferred when safe and feasible. In laparoscopic surgery, suturing the fascial defect of trocar sites of 10 mm and larger is advised, especially after single-incision laparoscopic surgery and at the umbilicus. For closure of an elective midline laparotomy, a continuous small-bites suturing technique with a slowly absorbable suture is suggested. Prophylactic mesh augmentation after elective midline laparotomy can be considered to reduce the risk of incisional hernia; a permanent synthetic mesh in either the onlay or retromuscular position is advised.
These updated
guidelines may help surgeons in selecting the optimal approach and location of abdominal wall incisions.
An incisional hernia results from a weakness of the abdominal wall muscles that allows fat from the inside or organs to bulge out. These hernias are quite common after abdominal surgery at the site of a previous incision. There is research that discusses different ways to close an incision and this may relate to the chance of hernia formation. The aim of this study was to review the latest research and to provide a guide for surgeons on how best to close incisions to decrease hernia rates. When possible, surgery through small incisions may decrease the risk of hernia formation. If small incisions are used, it may be better if they are placed away from areas that are already weak (such as the belly button). If the incision is larger than 1 cm, it should be closed with a deep muscle-fascia suture in addition to skin sutures. If there is a large incision in the middle of the abdomen, the muscle should be sutured using small stitches that are close together and a slowly absorbable suture should be used. For patients who are at higher risk of developing hernias, when closing the incision, the muscle layer can be strengthened by using a piece of (synthetic) mesh. There is no good research available on recovery after surgery and no clear guides on activity level or whether a binder will help prevent hernia formation.