单孔腹腔镜肚脐切口缝合教程（多图+视频）

单孔腹腔镜（SILS）由只有单一肚脐切口，美容效果更佳，受到广大外科医生的青睐。但脐部切口部位较深，皮下缝合就变得较为困难和费时。本文作者（日本关西医科大学 Yoichi Matsui医生）设计了一种简便的方法，即使患者的脐部较深，也可以最大限度的达到美容和安全关闭切口的办法，这项外科技术创新刊登在本期的Journal of the American College of Surgeons杂志上。
手术具体如下：经脐作一3cm纵向皮肤切口（图1-1/2）。完成SILS后，关闭脐部切口。关闭腹膜和筋膜后，如图1中3到6所示，两侧皮瓣的表皮下层逢到脐部的底部，此处两点不进行皮下缝合。接下来，第二处表皮下缝合（图1-7，白线），上面的两针将此处的缝线作为固定。如图1-8/9所示，之前的缝线穿过白线处。沿着切口，将第二处白色的缝线打结，如图1-10/11。剪断第一处缝线（图1-12/13）。接着，第三处的缝线利用第二处的缝线作为固定锚点（图1-14）。如图1-15/16，第二处缝线穿过第三处缝线处。沿着切口，拉出第二处缝线，第三处缝线打结（图1-17/18），剪断第二处缝线（图1-19/20）。最后，剪断第三处缝线（图1-21/22）。剩余的切口以此方式依次关闭（图1-23）。

图1 单孔腹腔镜切口简单皮下缝合图示

如果伤口较长，可适当加以缝线。此处的皮内缝合使用的为3-0可吸收线（Opepolyx-N; Alfresa Pharma Corporation）。关闭切口后，涂以适量的类固醇软膏，肚脐凹陷处填一小纱布块。术后2-3拿掉纱布块。

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Surgeon at work
Simple Suturing Technique for Umbilical Dimple Wound after Single-Incision Laparoscopic Surgery

    Yoichi Matsui, MD, PhD, , Sohei Satoi, MD, PhD, FACS, Satoshi Hirooka, MD, PhD, Masanori Kon, MD, PhD

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        doi:10.1016/j.jamcollsurg.2015.07.006
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    Under a Creative Commons license

  Open Access

Single-incision laparoscopic surgery (SILS) was developed recently.1, 2, 3, 4 and 5 This technique has the advantage of better cosmetic outcomes; the most noticeable cosmetic benefit of SILS is cosmetic improvement via a hidden umbilical incision.6, 7 and 8 When SILS is performed through the umbilicus, subcuticular skin closure is technically difficult and time consuming because of the natural deep umbilical dimple.9 However, few reports have described optimal umbilical incision closure methods to maximize the cosmetic benefit. We devised an easy and cosmetic method for closure of umbilical skin wounds, even in patients with very deep umbilical dimples. We have used this simple suturing technique for single-incision laparoscopic cholecystectomy since November 2009. The demographics of the patients who underwent this technique are shown in Table 1.

    Table 1.

    Demographics of Patients Who Underwent Single-Incision Laparoscopic Cholecystectomy Using the Simple Suturing Technique
    Demographics        Data
    n        217
    Age, y, mean ± SD        45.9 ± 10.7
    Sex, n, male/female        60/157
    Diagnosis, n, gallstone/polyp        173/44
    BMI, kg/m2, mean ± SD        23.1 ± 4.0
    ASA classification, n, 1/2        201/16

    ASA, American Society of Anesthesiologists Physical Status Classification.

    Table options

The technique is performed as follows. A 3-cm longitudinal skin incision is created over the umbilicus for SILS (Fig. 1; 1 and 2). On completion of SILS, umbilical wound closure is performed. After closing the peritoneum and fascia, the subcuticle of both sides of the skin flaps are sutured on the bottom of the umbilicus at 2 points without subcutaneous sutures, as shown in Figure 1; 3 to 6. Next, the second subcuticular suture (Fig. 1; 7, white) is placed using 1 of the 2 first bottom sutures as an anchor suture (Fig. 1; 7). The first anchor suture is then passed under the second suture as shown in Figure 1; 8 and 9. The second suture is tied by pulling the first anchor suture along the wound line (Fig. 1; 10 and 11). The first anchor suture is then cut (Fig. 1; 12 and 13). Next, the third subcuticular suture is placed using the second suture as an anchor (Fig. 1; 14). The second suture is passed under the third suture in the same way (Fig. 1; 15 and 16). The third suture is tied by pulling the second suture along the wound line (Fig. 1; 17 and 18), and then the second suture is cut (Fig. 1; 19 and 20). Finally, the third suture is cut (Fig. 1; 21 and 22). The remaining wound should be closed in the same manner to complete the wound closure (Fig. 1; 23). If the wound is longer, extra sutures should be added as needed. All of the subcuticular sutures are placed using 3-0 absorbable suture material (Opepolyx-N; Alfresa Pharma Corporation). After completing the wound closure, an adequate amount of steroid ointment, followed by a small piece of gauze, is placed in the umbilical dimple. The piece of gauze is removed on postoperative day 2 or 3 (Video 1, available online, shows this technique).

This simple suturing technique makes cosmetic wound closure easy to achieve, even if the umbilicus has a deep dimple. Although a conventional closure method could achieve cosmesis, this technique avoids the need for elaborate umbilical dimple wound closure and provides better cosmetic outcomes. We have used this technique in >200 cases of SILS to date. All of the wounds were mostly invisible and sufficiently cosmetic. No wound complications occurred, including wound infections.
Author Contributions

Study conception and design: Matsui

Acquisition of data: Matsui, Hirooka

Analysis and interpretation of data: Matsui, Satoi

Drafting of manuscript: Matsui, Satoi, Kon

Critical revision: Matsui, Satoi, Kon

Supplementary Data

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