腹股沟疝的修复（图文演示）

10. 4DDOMER 穹隆的放置



4DDOMER 准备：
盒子打开，用无损伤镊子夹住穹隆内小的网状结构，植入腹股沟内环，4D穹隆沿着精索中间边缘移动，以便把疝囊稳定的定位在腹膜外。

Introduction into internal inguinal ring:
4DDOMER is pushed along the medial edge of the spermatic cord in order to maintain the hernia sac deep into the preperitoneal space.

位置和调整
校正位置是否正确，可以通过让患者咳嗽或行瓦氏手法检查，对于肌力好的可以放置3个可吸收或不可吸收的单丝结构。

11. 前网状的放置
• 原理
对于无张力的李奇登斯坦（Lichtenstein）疝根治手术，网状支架结构是用来加强腹股沟平面，支架放置在腹部横筋膜和外斜腱膜间。它延伸过腹股沟三角，确保支架和组织间有足够的连接。适当调整支架，以抵御临近组织的影响，防止复发。这样可以有限的保护支架前部免受过大压力，因此在手术后一个月内必须注意防止支架移位。

• 网状支架

聚丙烯制造的支架，74%的聚合左旋乳酸和26%的聚丙烯有助于增加硬度和便于放置

• 李奇登斯坦（Lichtenstein）疝根治手术

对于无张力的李奇登斯坦（Lichtenstein）疝根治手术，网状支架必须调整使其正好位于外斜腱膜下，前面是腹部横筋膜，后面是精索。这个腔隙的侧面是精索中部，该修补术需要几个固定支点的位置，精索就是该位置。

• 4DDOMER 4D穹隆技术









网状支架的放置技术和上面提到的相似，尽管它不需要太多的固定点。4D穹隆是一个抵御腹腔内压力的屏障。一个支点在耻骨棘，2或3个在腹股沟韧带，1或2个在腹股沟镰，1或2个在接近修复手术的侧后面。这样有助于减少手术时间和减轻因调整位置给患者带来的疼痛。

12. 程序结束


网状支架的放置技术和上面提到的相似，尽管它不需要太多的固定点。4D穹隆是一个抵御腹腔内压力的屏障。一个支点在耻骨棘，2或3个在腹股沟韧带，1或2个在腹股沟镰，1或2个在接近修复手术的侧后面。这样有助于减少手术时间和减轻因调整位置给患者带来的疼痛。

13. 其他类型的疝
• 直疝



疝囊后部对精索，位于腹股沟管的中部。解剖位置靠近颈部，有时腹部膜的解剖位置就在其颈部。这样有助于使囊尾缩回腹膜前。4D穹隆可以植入腹膜前并且用6到8脚的可吸收或不可吸收的穹隆调整腹部横筋膜。

• 相关的疝




对于上腹部静脉血管重叠疝，血管应该仔细分离进囊，这样有利于4D穹隆进入后部空间。对于距离较远（深）的疝，可以使用两个4D穹隆。

14. 手术后管理


手术后立即处理:
手术后经过唤醒患者马上可以起床，手术后疼痛比较轻，可以口服NASID1到4天，手术后恢复工作情况，要依赖于手术意愿、手术前准备、教育情况，一般患者行无张力疝根治手术后，依工作职业和医院检查，2到14天可以恢复工作。

随诊:
4D穹隆修复手术在腹壁留下的伤口比较小。在手术后2到6个月观察穹隆的变化。聚合左旋乳酸制成的穹隆，基本可以完全吸收。由聚丙烯和聚合左旋乳酸合成的网架会少炎症反映（和纯的聚丙烯制造的比较）。但它也可能因体积大而引起Ⅱ型纤维细胞增生。
手术后超声波回顾分析1和6个月的患者。4D穹隆结构和聚合左旋乳酸在6个月的时候基本消失

15. 讨论

不可吸收的支架获得比较长的作用时间 (Goldstein, 1999; Bringman et al., 2003)，单丝聚丙烯支架近来被全球接受(Folscher et al., 2000; Usher and Gannon, 1959)，然而，修复支架周遍的异物反映(Klosterhalfen et al., 2002; Klosterhalfen et al., 1998)，都是大量不可吸收材料引起的。现在也引起了聚丙烯支架的使用争议(Klinge et al., 1999)。

复合材料支架的目标是减少炎症反映，特别是对简单修复手术中使用聚合左旋乳酸和筋膜植入。4D穹隆是完全满足持批评观点而设计的。它通过前支架的后表面来减少腹腔压力，可以使疝囊缩小，当然它不是用在需要进行疝囊切除的病例。

16. 结论
4D穹隆植入是简单的治疗观点，操作简单，可以减少长期疼痛的风险；可以在局部麻醉（我机构80%患者）或浸润麻醉下进行，手术后早期不适感降低；PLLA较少的吸收残余物，较低的局部Ⅰ型和Ⅲ型胶元纤维反应，对于中等口径的腹股沟疝的年轻和体型小的患者都可以使用 ；手术后复发的风险依手术记录看是比较少的。

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