Use of Mesh to Prevent Recurrence of Hernias

用补片做无张力疝修补防止复发

Alex G. Shulman, M.D. ,Lichtenstein Hernia Institute Los Angeles, California

Preview 前言

Just over one century ago, Eduardo Bassini, an Italian surgeon, first described the classic hernia repair that is still in vogue today. The recurrence rate of that operation has consistently remained approximately 10% for the past century.

一个世纪以前，意大利医生 Bassini 介绍了传统疝修补手术方法。该方法一直流传到今天，但是，用 Bassini 方法做疝修补，其复发率在过去的一个世纪中一直停留在 10% 左右。

Causes of Early and Late Recurrence of Hernias 早期和晚期复发疝的原因

There is a weak area in the groin, the floor of the inguinal canal, which is covered by the fascia transversalis, a flimsy structure of little strength. This is the only area of the abdominal wall not supported by muscle layers, and is extremely vulnerable to injury. Hernial protrusions commonly result.

腹股沟管后壁是腹股沟的薄弱区。该区仅由一层薄薄的腹外斜肌腱膜覆盖。这是腹壁上唯一没有肌层覆盖的区域，极易受到损伤，为疝易发区域。

Clearly, the canal floor requires reinforcement, to correct what nature has failed to do.

This weak area, in which the strong transversus abdominis tendon is widely separated from the inguinal ligament (iliopubic tract), is present in at least 15% of males. Forced surgical approximation of these semirigid structures to close this gap as is commonly done to correct a hernial defect inevitably creates tension on tissues or on suture lines and can result in early hernia recurrence. It is at this site that 50% of hernia failures are found. Another 40% of recurrences appear initially at the internal ring, along side the site of emergence of the spermatic cord. Here, secure surgical closure is prevented by the presence of the spermatic cord.

很显然，腹股沟管后壁需要加强。在该区域，坚韧的腹外斜肌腱膜与腹股沟韧带被远距离分开的现象至少存在于 15% 的男性当中。通过外科手术方式强行把这些较硬性组织缝合在一起以关闭间隙，就不可避免地在组织上或者缝合处制造了张力，并引起疝的早期复发。 50% 的疝复发出现在这些产生张力的部位。另外 40% 的疝复发出现在内环口。

Late recurrence of hernia repairs can be explained by the steady deterioration of tissue with age. Defective collagen metabolism (either decreased formation or increased degradation) has been shown to result in weakening of tissue with time. This, in addition to a familial predisposition, explains the increasing incidence of hernia in persons over 50 years of age. Thus, despite the many books and countless articles on the subject in the past century, there has been little improvement in results. Why?

随着年龄的增长，组织逐渐退化是晚期疝复发的主要原因。胶原代谢的失衡已经被证明能引起组织弱化。这一因素与家族病史是 50 岁以上的人群疝发病率越来越高的原因。在过去的一个世纪中，尽管无数的书籍和文章都探讨过这个问题，但是，最终效果提高很小。为什么？

As early as 1890, Billroth, the most famous surgeon of his day, suggested that the ideal way to repair hernias was to use a prosthetic material to close the hernial gap. Many materials were tried, but they all fell victim to the triple headed monster of infection, rejection and recurrence and proved to be unacceptable. Compounding the dilemma, was the use of unsuitable multifilamented suture material, which caused their own special problems. Surgeons became disenchanted with the popular cotton and silk sutures because of the frequently tiresome rejection syndrome and the endless recurring infections that often resulted. The use of such sutures to secure mesh in place undoubtedly contributed to and aggravated the existing bias against mesh.

早在 1890 年，当时最著名的医生 Billroth 提出，理想的疝修补方法是用修复性材料关闭疝间隙。从此以后，很多材料被采用过，但是，都成了感染，排异和复发三头怪兽的牺牲品。这些材料都失败了。与此同时，随着带有自身问题的多股编织缝线的使用，情况越发糟糕。随着棉线与丝线引起的排异症状和反复发生的感染，医生对它们越来越失去兴趣。这些缝合材料的使用无疑更加加剧了人们已经存有的对疝补片的偏见。

Polypropylene Mesh 聚丙烯补片

Polypropylene mesh to repair g roin hernia was introduced by Francis Usher in 1962, and its early use was not associated with the complications previously associated with other prosthetics. This record has been maintained for three decades.

Polypropylene mesh is unique in many respects. It is monofilamented and thus cannot harbor infection. (Indeed, it is more resistant to infection than is human tissue.) It is neither allergenic nor oncogenic (able to cause the growth of cancer). It cannot be felt by either patient or physician when placed beneath muscle and is not radiopaque (able to stop the passage of x-rays). It is readily available, permanent, and will not break, shred, or tear with time. Perhaps its most valuable feature is that it stimulates fibroblasts to grow into its interstices, thereby producing an impenetrable collagenous structure that resembles strong, normal tissue.

1962 年， Francis Usher 介绍了用聚丙烯网片修补疝气的方法。早期的使用没有出现象以前尝试过的材料所出现的并发症。这一结论被后来三十多年的实践所证实。聚丙烯补片有多方优势。单股结构不藏匿细菌。（实际上，聚丙烯抗感染能力比人体组织还强）聚丙烯既不会引起过敏，也不会致癌。植入肌层以下时不会被感觉到，而且 X 光可以透过。该材料易得，不会随着时间而磨损，撕裂或折断。它最大的优点是刺激纤维原细胞生长入补片的网孔，形成坚实的纤维组织结构。

Today, many surgeons agree that use of a prosthetic mesh is the preferred way to repair most recurrent hernias. But why not prevent such recurrences by using the mesh for the treatment of all primary repairs? Surgeons who piously insist that no foreign material should ever be used for hernia repair often select nonabsorbable monofilamented polypropylene as their preferred suture for many kinds of operations. Because the mesh and the polypropylene suture are both made of polypropylene, objections to using the mesh because it is a foreign body, become pointless.

今天，很多医生都认同补片修补是治疗复发疝的首选方法。为什么不用补片做所有的原发疝的修补以防止复发呢？那些虔诚地坚持在疝修补时不要任何异物植入人体的医生却常常在许多手术缝合时选择使用聚丙烯缝线。既然使用聚丙烯缝线，认为聚丙烯网片是异物而拒绝使用的观点就不攻自破了。

Use of the "Patch" 补片的使用

There is an inherent disadvantage of forcibly bringing together the two sides of a hernia defect. With distorted muscle fibers and later contraction of muscles, as they normally tense the abdominal wall, stress can result in the tearing of tissue and the beginning of a recurrence. However, a simple patch can be expeditiously placed over the defect thereby correcting the hernia in this way, with no tension whatsoever 。

把疝两侧的组织强行拉在一起，进行缝合有其固有的缺陷。扭曲的肌肉纤维和随之而来的肌肉收缩引起组织撕裂，疝由此而复发。用补片覆盖缺损来做疝修补不会产生任何张力。

Employing this principle, we began in 1984 to use a tension-free repair, suturing a polypropylene mesh patch over the defect without attempting to close the hernial hole. Only 4 failures have occurred in more than 2,975 primary hernia repairs. Upon analysis, these failures were readily explained by our use of too small a patch in the early days of our experience, an error which we quickly corrected. Since reporting our own success with the polypropylene patch, we have investigated the results obtained by surgeons in four other different geographical areas who are now using the same technique. Less than 1% of wound infections has been reported in approximately 5,000 operations, and there have been no instances of mesh rejection.

应用这一原则，我们从 1984 年开始做无张力疝修补，把补片缝合于缺损部位上而不是试图将疝缺损强行拉合在一起。在 2975 例原发疝修补中，仅有 4 例复发。经过分析，复发的原因很快被找到，是我们早期用的补片尺寸太小所致。这一失误很快得到更正。自报道了我们自己成功应用聚丙烯网片以来，我们对来自于四个不同地区，使用同样方法的医生的临床结果作了调查。在 5000 多例手术中，感染率低于 1% 。没有一例聚丙烯网片被组织排斥的现象。

The advantages of using the polypropylene mesh prosthesis are self-evident. The operation is simple to perform and can be done rapidly. Since it does not create tension on tissues, there is no post-operative restriction of activity on the part of patients after operation. It produces permanent repairs with a success rate approaching 100%, and is virtually free of complications.

用聚丙烯网片做疝修补的优势已经不言而喻。手术简单快捷。因为该修补方法不制造组织张力，所以就病人而言术后活动不受限制。该方法提供永久性修补，成功率几乎达到 100% 。几乎没有并发症。

The problem with the standard methods of hernia surgery in patients with Ehlers-Danlos syndrome is the slow and often inadequate healing of tissues forcibly held together by sutures. It is this failing which has produced a long saga of repeated recurrences following hernia operations.

传统（张力）手术的最大问题是被不恰当牵拉，缝合在一起的组织恢复很慢，或者恢复不完全充分。传统手术的这一缺陷导致了历经一个多世纪的，连续不断的疝复发。

In June of 1992, a woman with EDS, with a troublesome hernia had been turned down for surgical operation by six surgeons in her home area in another state. She was referred to us because we are known for popularizing the tension-free repair of applying mesh and not sewing together the hernial defect.
Using this approach, she sustained a successful and uneventful repair, the operation having been carried out on an outpatient basis, under local anesthetic. She was able to fly back to her home on the second day after surgery, and has remained well.

While this represents only one patient, it seems logical that the method should be applicable to others with the same problem or even to those with recurrent hernias. Should this continue to be successful when used for other such patients, it may represent a breakthrough in the ability to offer some help to people with the Ehlers-Danlos syndrome.

1992 年 6 月，一位患有埃勒斯－当洛斯综合症（ Ehlers-Danlos Syndrome ）的严重疝气女患者在被家乡的 6 名医生拒绝后来到我们中心。因为我们用补片做无张力疝修补的名声，她被推荐到我们这里。

应用这一办法，该女士手术进行得很顺利。手术在日间手术室，局麻下完成。手术的第二天，她就乘飞机返回家乡。术后一直很好。

这个例子虽然仅仅是一个病人，但是，局麻下用聚丙烯补片作无张力修补这一办法应该同样适用于其它类似该女士的病人，甚至适用于疝复发。如果此类修补继续在此类病人身上得以成功，可能意味着我们在为埃勒斯－当洛斯综合症（ Ehlers-Danlos Syndrome ）病人提供帮助方面有了突破。

References
1. Lichtenstein IL, Shulman AG, Amid PK, Monttlor MM. The tension-free hernioplasty. Am J Surgery 1989;157:188-93

2. Lichtenstein IL, Shulman AG, Amid PK Twenty questions about hemioplasty Am Surg 1991;57:730-3.

3. Shulman AG, Amid PK, Lichtenstein IL. The safety of mesh repair for primary inguinal hernias - results of 3,019 operations from five diverse surgical sources. Am Surg 1992;58.-255-7.

4. Shulman AG, Amid PK, Lichtenstein IL. The "plug" repair of 1,402 recurrent inguinal hernia. Arch Surg 1990;125.265-7

5. Shulman AG, Amid PK Lichtenstein IL. Plug repair of recurrent inguinal hernias. Cont Surg 1992;40:30-

6. Shulman AG, Amid PK, Lichtenstein IL. Prosthetic mesh repair of femoral and recurrent inguinal hernias: the American experience. Ann R Coll Surg Engl 1992;74:97-9.