腹股沟疝修补术切口浸润对术后疼痛并发症的影响

【摘要】 目的探讨切口浸润对腹股沟疝修补术术后疼痛并发症的影响。方法将我院2007年1月至2009年12月收治的腹股沟疝病例264例按随机数字表法分为术后切口浸润组和对照组,手术方法均采用充填式无张力疝修补,实验组在手术结束时给予0.5%20 ml左旋布比卡因切口局部浸润,对照组给予20ml生理盐水,两组患者术后随访三月,观察其术后慢性疼痛的发生情况。结果切口浸润组和对照组的术后伤口并发症发生率比较,差异均无统计学意义( P >0. 05);术后早期疼痛发生率、麻醉并发症(恶心/呕吐)及慢性疼痛发生率,切口浸润组均明显低于对照组,两组差异有统计学意义( P < 0. 05)。结论术后切口浸润对腹股沟疝修补术术后疼痛的预防具有积极意义。

【关键词】腹股沟疝修补 切口浸润 术后疼痛

【中图分类号】R656.2+1【文献标识码】 A 【文章编号】1005-0515(2010)005-003-03

Investigating the effect of intra-operative infiltration on post-operative pain after inguinal hernia repair。

AbstractObjectiveTo investigate the effect of intra-operative infiltration on post-operative pain after inguinal hernia repair.MethodsA total of 132 inguinal hernia cases from 2007 to 2009 were allocated and randomly divided into the intra-operative infiltration group( Group I ) and placebo group(Group II). Patients in Group I receive a local injection of 20 ml Carbostesin 0.5% at the end of the operation according to a standardised procedure. Group II patients get a 20 ml placebo (0.9% Saline) injection. Patient in two groups had finished their 3-months follow-up to allow for study of the complications of post-operative pain. ResultsIt was found that the occurrence of postoperative pain and the anesthetic complications in intra-operative infiltration group were significantly less than those in the placebo of group ( P < 0. 05). There was no significant difference of incision complications between two groups ( P> 0. 05) .ConclusionsIntra-operative infiltration has a positive effect on the prevention of post-operative pain after inguinal hernia repair.

Key wordsInguinal hernia repairIntra-operative infiltrationpost-operative pain

临床上无张力疝修补术的推广应用,使腹股沟区疝的术后复发率明显降低,但术后腹股沟区疼痛已成为影响患者术后生活质量的突出问题。腹股沟疝术后的慢性疼痛发生较疝的复发更为常见(张力性修补复发率10%~15%之间,无张力修补复发率

1 资料与方法

1.1 临床资料以2007年1月至2009年12月我院收治的腹股沟疝患者入组,入组标准为单侧疝和初发疝,滑疝和急性嵌顿疝不进入本研究。共264例,经患者本人同意,采用数字表法随机分为术后切口浸润组(实验组)和对照组各132例,两组在性别构成比、平均年龄及疝分型对比,差异均无统计学意义。

1.2 手术方法

研究组每位手术医生均为普外科资深住院医师以上职称,能独立完成疝手术。斜疝、直疝采用腹股沟韧带上斜切口,应用网塞+ 平片修补,修补材料全部采用美国巴德公司生产的Bard Mesh Perfix Plug 产品,两组切口均采用可吸收线作皮内缝合。

1.3 麻醉方法

两组术前用药均用阿托品0.5 mg ,海俄辛0.3 mg肌注。所有患者麻醉方法均采用硬膜外麻醉,穿刺部位为L1、L2,用2%利多卡因[7]。在完成腹股沟疝修补术后,根据分组,实验组采用0.5% 20 ml 左旋布比卡因切口局部浸润,对照组采用生理盐水20ml同法注射,浸润方法为:距离髂前上棘2横指顺切口方向作“扇形状”注射药物约10ml,切口旁两侧分别注射药物约4ml,以切口延线远侧与耻骨联合垂直线交点做穿刺点,注射药物约2ml。

1.4 临床资料记录

记录相关临床数据: 术后辅助药物使用率、伤口并发症发生率;术后早期疼痛发生率、术后并发症(恶心/呕吐)及慢性疼痛等。出院后常规1周门诊复查,第1个月、3个月门诊或电话随访,如有任何异常情况或并发症均记录在案。

1. 5 统计分析

采用SPSS软件对所得数据进行分析,计量资料用t 检验,计数资料用卡方检验进行统计处理,比较两组相应指标间差异有无统计学意义,检测水准α= 0. 05。

2 结果与分析

2.1两组术后麻醉并发症及切口并发症比较结果(见表1)

在麻醉并发症方面,实验组术后恶心/ 呕吐率发生率低于对照组,两组差异有统计学意义(P = 0.018,P 0. 05);两组病人均有两人出现伤口相关并发症,实验组有两例患者出现切口感染,对照组有一例患者出现切口感染,一例患者出现伤口血肿。

表1 两组麻醉并发症及切口并发症的比较

组别术后麻醉并发症切口并发症

实验组恶心/呕吐2例(1.515%)切口感染两例

对照组恶心/呕吐10例(7.576%)切口感染一例,伤口血肿一例

2.2 两组术后疼痛相关并发症及随访情况比较(见表2)

术后早期疼痛并发症方面,实验组(6例,4.545%)明显低于对照组(16例,12.12%);(P=0.021.,P

表2 术后疼痛相关并发症的比较

组别术后早期疼痛并发症术后远期疼痛并发症

实验组6例,4.545%0例,7.576%

对照组16例,12.12%28例,21.21%

3、讨论

腹股沟疝术后慢性疼痛者发生疝复发更为常见,在本研究随访的264例患者中,疼痛发生率14.4%。因此,腹股沟斜疝术后慢性疼痛更应引起临床的重视。

腹股沟疝术后慢性疼痛的可能机制:(1)在腹股沟区主要分布着髂腹下神经、髂腹股沟神经、生殖股神经。髂腹下神经前支走行于腹外斜肌腱膜与腹内斜肌之间,并传出分布于耻骨表面;髂腹股沟神经沿腹股沟管上行经外环穿出;生殖股神经生殖支通过内环进入腹股沟管,伴随精索或子宫圆韧带。主要支配下腹壁、会、的感觉[8]。在腹股沟疝手术中,对内环、外环、精索处的不恰当处理都可能造成不同程度的神经全部或部分被结扎、切断,从而导致腹股沟疝手术后局部不适和慢性疼痛[9];(2)神经纤维束与周围组织粘连、扭曲、收缩、卡压或被粘入网片也是造成术后局部不适和慢性疼痛的主要原因[9];(3)补片缝合固定时进针过深而缝在耻骨骨膜造成术后耻骨炎也会形成慢性疼痛[10]。

腹股沟疝术后慢性疼痛的防治措施:各国外科学家均从改进手术技术及补片材料的角度作过尝试,但慢性疼痛发生率并未得到明显下降[11~12]。近年来,国外部分学者用麻醉剂术后切口浸润,结果证明对于术后早期急性疼痛的预防有积极意义[5~6],本研究证明,此方法对于术后慢性疼痛并发症的预防也有一定积极意义,且方法简单易行,可操作性强,费用低廉。VAS在很多研究中被誉为评定慢性疼痛的“金标准”,本研究以VAS评分系统评定慢性疼痛程度,准确可靠[13~14]。但本研究中,切口局麻药浸润导致的正性效应,即局麻药物产生的远期镇痛效应的机制尚有待于在后续研究中进一步阐明。

参考文献

1. Callesen T, Bech K, Kehlet H: Prospective study of chronic pain after groin hernia repair. Br J Surg 1999, 86(12):1528-1531.

2. Poobalan AS, Bruce J, King PM, Chambers WA, Krukowski ZH, Smith WC: Chronic pain and quality of life following open inguinal hernia repair. Br J Surg 2001, 88(8):1122-1126.

3. Poobalan AS, Bruce J, Smith WC, King PM, Krukowski ZH, Chambers WA: A review of chronic pain after inguinal herniorrhaphy. Clin J pain 2003,19(1):48-54.

4. Page B, Paterson C, Young D, O'Dwyer PJ: Pain from primary inguinal hernia and the effect of repair on pain. Br J Surg 2002,89(10):1315-1318.

5. LeBlanc KA, Bellanger D, Rhynes VK, Hausmann M: Evaluation of continuous infusion of 0.5% bupivacaine by elastomeric pump for postoperative pain management after open inguinal hernia repair. J Am Coll Surg 2005, 200(2):198-202.

6. Ausems ME, Hulsewe KW, Hooymans PM, Hoofwijk AG: Postoperative

analgesia requirements at home after inguinal hernia repair: effects of wound infiltration on postoperative pain. Anaesthesia 2007, 62(4):325-331.

7. Amid PK, Shulman AG, Lichtenstein IL. Local anest hesia for inguinal hernia repair step2by2step procedure [J ] . Ann Surg , 1994 ; 220 (6) ∶735

8. 韩永坚,刘牧之.临床解剖学丛书:腹盆部分册.北京:人民卫生出版社,1992,43-45,69-70.

9. 何田霖.不同人工补片修补疝的临床对比.中华普通外科杂志,2002,17(6):304.

10. 陈杰.普理灵疝装置和疝塞在无张力腹股沟疝修补中的对比研究.中华普通外科杂志,2003,18(9):543.

11. Mui WL, Ng CS, Fung TM, Cheung FK, Wong CM, Ma TH, Bn MY, Ng EK: Prophylactic ilioinguinal neurectomy in open inguinal hernia repair: a double-blind randomized controlled trial.

Ann Surg 2006, 244(1):27-33.

12. Ravichandran D, Kalambe BG, Pain JA: Pilot randomized controlled study of preservation or division of ilioinguinal nerve in open mesh repair of inguinal hernia. Br J Surg 2000, 87(9):1166-1167.

13. Lundeberg T, Lund I, Dahlin L, Borg E, Gustafsson C, Sandin L, Rosen A, Kowalski J, Eriksson SV: Reliability and responsiveness of three different pain assessments. J Rehabil Med 2001, 33(6):279-283.

14. DeLoach LJ, Higgins MS, Caplan AB, Stiff JL: The visual analog scale in the immediate postoperative period: intrasubject variability and correlation with a numeric scale. Anesth Analg 1998, 86(1):102-106

(责任审校:赵旭)