2016年 · 第31卷第09期

With the development of basic surgical theories, anatomical concepts, surgical techniques and repair materials, the development of hernia and abdominal wall surgery is also very rapid. At present, the treatment of abdominal wall hernia follows the principle of modern surgery, that is, the principle of "applying prosthetic materials" to repair the defect, improve the treatment effect, save life, restore function and improve the quality of life^[1]。

In addition to some hot issues in hernia and abdominal wall surgery, such as the development of repair materials, the application prospect of synthetic absorbable materials, the diagnosis and treatment guidelines of abdominal wall hernia, I would like to put forward some opinions on several related issues in the clinical practice of hernia and abdominal wall surgery in China.

Inguinal hernia repair surgery is an extremely common procedure in the field of general surgery. In the eyes of many surgeons, hernia surgery is only a minor operation, and it is a "introductory" operation for young surgeons to gain surgical experience. However, a "failed" hernia surgery can be disastrous for the patient. Since 1989, American doctors Lichtenstein et al.^[1]Since the concept of "tension-free repair" was put forward, modern hernia repair surgery has undergone revolutionary changes, and hernia surgery has gradually embarked on the development road of specialization, specialization and standardization. In recent years, hernia surgery centers dedicated to this cause have appeared in China one after another. The medical level of hernia and abdominal wall surgery in China has improved rapidly, but its overall medical treatment, scientific research, teaching and training are still far behind those of western developed countries. This article discusses and summarizes some problems and challenges in the development of hernia surgery in China.

Inguinal hernia accounts for about 90% ~95% of the total number of external abdominal hernias, and is a common disease in general surgery. Inguinal hernia repair is one of the oldest and most common surgical procedures. Since Lichtenstein put forward the concept of tension-free hernia repair, the use of artificial materials makes hernia surgery simple, easy and effective, and tension-free repair has become the mainstream of hernia surgery today. However, patch is a double-edged sword. With the passage of time and the increase of the number of patch applications, the complications related to patch are also increasing. Among them, patch infection is one of the hot spots that has attracted much attention in recent years. Coupled with the special relationship between doctors and patients in China, this problem has become an unavoidable problem for surgeons. In this paper, the problem of patch infection is explained as follows, combined with my own experience in dealing with it.

Since Usher applied synthetic patch to repair abdominal wall hernia in the late 1950s, the repair technology of primary abdominal wall hernia and incisional hernia (hereinafter collectively referred to as abdominal wall hernia) has undergone great changes. Especially in recent 20 years, with the introduction of laparoscope, robot and new material patch, the repair technology and effect of abdominal wall hernia have achieved remarkable achievements. However, despite the remarkable achievements, there are still controversies over what patching techniques and materials to use. In addition, how to prevent the complications caused by the patch and obtain a better treatment effect after surgery still needs further exploration. The present situation and trend of abdominal wall hernia repair at home and abroad are described below.

Robotic systems have been introduced into surgery in the 1990s^[1,2]At present, the most widely used is Da Vinci robotic surgical system. The robotic surgical system has broken through the limitations of traditional laparoscopic technology in imaging field of view, instrument activity and ergonomic mechanics in one fell swoop. With its unique 3D imaging, EndoWrist, the instrument carried by the robotic arm, has 7 degrees of freedom, can filter tremor and more reasonable ergonomic mechanics design, it has improved the surgical accuracy to a new height and pushed minimally invasive surgery into a new era. Robotic hernia repair (hiatal hernia, inguinal hernia, incisional hernia) has been carried out in foreign countries, and its safety and effectiveness have been reported in numerous literatures^[3,4,5]。 The development of robotic hernia repair surgery in China started late, and at present, only a few hospitals including the author's unit have carried out it in a small number. The status and application prospect of robotic hernia surgery in China are analyzed as follows.

gastroesophageal reflux disease (GERD) is a kind of upper digestive tract motility disorder. Because of its various clinical symptoms and wide range of harm, it has been paid more and more attention. In recent years, the incidence of gastroesophageal reflux disease has gradually increased, according to a new study in the United States^[1], the incidence of gastroesophageal reflux disease has increased by 50% compared with the 1990s, according to Tan et al.^[2]And Jiang Xuan et al.^[3]According to statistics, the incidence of gastroesophageal reflux disease in China has risen to 5% ~10%, which seriously endangers people's daily life. With the improvement of surgical anti-reflux surgical technique and the development of laparoscopic technique, the surgical treatment of gastroesophageal reflux disease has also received increasing attention. The surgical treatment of gastroesophageal reflux disease has undergone a complex, long development process that has changed dramatically. Although there is no unified standard for the surgical treatment of gastroesophageal reflux disease in China so far, it is mainly based on the clinical experience of surgeons or referring to similar surgical data abroad, but the surgical treatment of gastroesophageal reflux disease is effective, and the overall satisfaction of postoperative follow-up can reach 90%. According to the experience of our team in recent years and the progress abroad, the surgical treatment of gastroesophageal reflux disease is introduced as follows.

Morgagni hernia is a relatively rare disease in clinic. Because it has no special clinical symptoms and signs, it is easy to be misdiagnosed and missed. From January 2008 to April 2014, a total of 3 patients with Morgagni hernia were treated in our hospital with surgical treatment, and the curative effect was satisfactory. Now, its clinical characteristics, diagnosis and treatment plan are discussed, in order to improve the diagnosis and treatment level of Morgagni hernia.

Two commonly used procedures for laparoscopic inguinal hernia repair are laparoscopic total extraperitoneal hernia repair (TEP) and laparoscopic transabdominal preperitoneal hernia repair (TAPP). This article discusses some special situations that may be encountered in laparoscopic inguinal hernia repair and their corresponding treatment methods, which are reported as follows.

Rapid recovery surgery is an advanced theory of improving, optimizing and combining various conventional perioperative treatment measures with the aim of reducing or reducing surgical stimulation and accelerating postoperative recovery^[1,2]。 Hepatic hydatid is a special disease and high incidence in pastoral areas of Xinjiang, and surgical resection is still the first choice of treatment. We treated patients with hepatocystic hydatid with traditional perioperative treatment and rapid recovery surgery, and compared the clinical effects of these two methods, which are now reported as follows.

gallstone ileus (GI) was first proposed by Bartolin in 1654. The incidence of this disease in patients with cholelithiasis<1%, is a rare complication of cholelithiasis, accounting for 1% to 4% of patients with intestinal obstruction, and is more common in elderly women^[1]。 Biliary and gastrointestinal fistulas of GI are more common in cholecystoduodenal fistula, but less common in cholecystogastric fistula and bile duct duodenal fistula^[1]Gallstone obstruction mostly occurs in the terminal ileum. We report the clinical experience of diagnosis and treatment of GI caused by gallbladder gastric fistula and bile duodenal fistula.

In recent years, the incidence of colon cancer in China is on the rise, and surgical resection is still the first choice for the treatment of right colon tumors. Traditional (2D) laparoscopic complete mesocolic excision (CME) has been widely carried out at home and abroad, and has achieved good clinical results^[1]。 However, 2D laparoscopy has certain limitations, such as the lack of layering and depth in two-dimensional imaging, and it is easy to cause secondary injury during operation. 3D laparoscopic surgery system can effectively solve these defects. This study retrospectively analyzed the clinical data of 104 patients who underwent CME surgery for right colon cancer admitted to our hospital from March 2014 to September 2015 to explore the safety and short-term efficacy of 3D laparoscopic CME for right colon cancer.

Gastrointestinal lipoma is relatively rare in clinic. The tumor is mostly single and grows slowly, accounting for about 4% of benign tumors of digestive tract. In this study, the clinical data of 40 patients with gastrointestinal lipoma were retrospectively analyzed to explore the clinical manifestations and treatment methods of gastrointestinal lipoma.

The clinical incidence of acute superior mesenteric artery embolism (MAE) is low, but the course of disease is short, harmful, and the course of disease progresses rapidly, and the mortality rate of patients is as high as 40%. Therefore, early diagnosis and treatment is helpful to reduce the mortality rate of patients and is of great significance to save patients' lives. From September 2009 to June 2013, 25 patients with MAE were admitted to Daqing Oilfield General Hospital. They were treated with Fogarty catheter thrombectomy, and at the same time, urokinase, papaverine and 5% sodium bicarbonate were injected into the artery. The reports are as follows.

homeobox genes (HOX) are dominant genes in embryonic development and cell differentiation^[1]It regulates the transcriptional process of DNA synthesis. In recent years, it has been found that this gene plays a certain role in the occurrence and development of tumors, and abnormal expression of HOX gene can be found in many kinds of tumors^[2,3]。 This study investigated the expression of HOX D8 in colorectal cancer, to investigate whether HOX D8 has a correlation with the occurrence and development of colorectal cancer, and to further investigate whether HOX D8 can be used as a marker for diagnosis, recurrence and metastasis of colorectal cancer.

A 38-year-old male was admitted to hospital 3 years ago due to the discovery of a "right lower abdominal mass for 2 weeks". Physical examination: The right lower abdominal mass has good mobility, medium quality and no tenderness. CT examination showed that a round-like mass shadow was seen in the right lower abdomen, 10.5 cm ×10.2 cm ×10.7 cm in size, with uniform density and clear boundary. It was locally adjacent to the right psoas major muscle, seeming to see a gap, and the boundary between the mass and the appendix was unclear (Figure 1)。 Intraoperative observations: The tumor was located on the mesangium of the appendix, about 10 cm in diameter, with an intact capsule and medium texture. Pathological report: A mass with a diameter of 10 cm protrudes from the mesangial side of the appendix, with a smooth surface, and one side is tightly adhered to the serous surface of the appendix. The section of the mass is gray-white, woven and tough. Under the light microscope, the tumor cells were mainly spindle-shaped or irregular, arranged in bundles and spokes, with obvious nuclear pleomorphism, some nuclei deeply stained, mild abnormality, occasionally megakaryocytes with multiple nucleolus, abundant collagen and small blood vessels in the tumor stroma, mucinous degeneration, and tumor cells infiltrating the serous layer of the intestinal wall. Immunohistochemical staining showed that Vimentin positive, CD34 vascular positive, Desmin, SMA and Actin were all focal positive, CD117, Dog1, S-100 and NSE were all negative, and Ki-67 proliferation index was 0-5%. Diagnosis: desmoid fibromatosis. The patient was readmitted 3 years after surgery when "abdominal mass" was found during physical examination. Surgical exploration showed: extensive adhesion in the abdominal cavity, an irregular mass of about 4 cm ×3 cm near the hepatic flexure of the colon, surrounded by the omentum, invading the seromuscular layer of the colon; There is an oval mass of about 15 cm ×10 cm in the mesenteric mesenteric mesenteric mesenteric mesenteric mesenteric mesenteric mesenteric mesenteric mesenteric mesenteric mesenteric mesenteric mesenteric mesenteric mesenteric mesenteric mesenteric mesenteric mesenteric mesenteric mesenteric mesenteric Pathological report: The size of the mesenteric mass is 11 cm ×8 cm ×6 cm, with gray-red surface and envelope, gray-white cut surface, braided, tough texture, and bleeding area can be seen; The size of the paracolonic tumor was 3 cm ×2 cm ×2 cm, and the cut surface was gray and tough. The light microscope showed that the tumor cells were long spindle-shaped, bundle-shaped and braided, the nucleus was irregular, oval or rod-shaped, and some of them were slightly abnormal. The interstitial collagen and small blood vessels were abundant, and mucus degeneration was observed. A small amount of lymphocytes infiltrated at the edge, and lymphoid follicles were formed. The tumor cells infiltrated the serous muscle layer of the intestinal wall and the surrounding adipose tissue (Figure 2)。 Immunohistochemical staining showed that Vimentin was positive, CD99 and CD68 were weakly positive, CD34 was positive, CD117, Dog1, Desmin and S-100 were all negative, and Ki-67 nuclear proliferation index was 0-5%. Pathological diagnosis: Intra-abdominal desmoid fibromatosis.

A 29-year-old male was admitted for 3 d with abdominal pain. The patient had sudden upper abdominal pain after eating greasy food 3 days ago. Abdominal CT in the local hospital showed acute pancreatitis, perisplenic and perihepatic effusion. Diagnosed as "acute pancreatitis", the symptoms were relieved after medical treatment, but blood routine showed that hemoglobin continued to decline, the reason was unknown, so he came to our hospital for treatment. Physical examination: heart rate 118 beats/min, blood pressure 117/66 mmHg, abdominal swelling, total abdominal tenderness, positive mobile voiced sound, weak intestinal sound. Laboratory test: Hemoglobin 78 g/L. A large amount of reddish-brown non-coagulating blood was drained by abdominal puncture. Considering intraabdominal hemorrhage, peritoneal angiography was performed in an emergency department, and no obvious bleeding site was found. Splenic infarction was reported by abdominal CT after 3 days of medical treatment (Figure 1)。 Considering that the patient's hemodynamic indexes were still stable, peritoneal drainage was continued and medical treatment was adopted. After 9 days, the patient's peritoneal drainage fluid gradually decreased and he recovered well. He got better and was discharged.

The patient was a 37-year-old female. He was admitted to hospital for one week because of the discovery of a mass in his left neck. B-ultrasound examination in external hospital revealed left thyroid mass with multiple calcifications. Physical examination: A mass of about 2 cm ×2 cm can be palpable on the left neck, which is hard in texture and does not move up and down with swallowing. During the operation, a substantial mass in the middle and lower poles of the left thyroid lobe was seen, with unclear boundary, severe adhesion to esophagus and trachea, and unpalpable swelling of the surrounding lymph nodes. All the left thyroid glands were removed and sent to the pathology department for rapid frozen examination. It was revealed that the left thyroid gland was malignant, so most of the isthmus and right side were removed. Pathological examination showed that the tumor was separated by fibrous stroma in island-shaped and cord-shaped shapes of different sizes. The tumor cells were squamous cell-like or syncytic cell-like, the nucleus was oval-shaped, pale-colored and vacuolate-like, and small nucleoli were visible, and mitotic images were rare. More lymphocyte and plasma cell infiltration can be seen in tumor cell nests and stroma (Figure 1)。 Immunohistochemical examination showed that the tumor cells expressed CD5 (Figure 2), CD117 (Figure 3), PCK, EMA, P63, 34 β E12, Bcl-2, focally expressing CEA, but not TTF-1 (Figure 4), calcitonin, CK7, syn, cgA. The pathological diagnosis was a carcinoma of the left thyroid gland showing thymoid differentiation. The patient recovered smoothly after surgery. There was no recurrence and metastasis in this case.

It is well known that until now surgery is the only effective method in the treatment of hernia disease. In the era of mesh hernia repair, the cure rate of inguinal hernia surgery is nearly perfect. Donati analyzed a group of 3 000 data from mesh-plain film surgery to repair inguinal hernia, and the overall recurrence rate was only 0.2%^[1]。 Various popular surgical procedures have their advantages, and the comparison of the advantages and disadvantages of the surgical procedures has tended to be calm in recent years. Net plug-plain film surgery is still one of the mainstream surgical procedures for inguinal hernia treatment, and it has played a leading and foundation-laying role in the development of hernia surgery in China.

Inguinal hernia is a common and frequently occurring disease, and surgery is the only way to cure inguinal hernia at present. Since Bassini's hernia repair to strengthen the posterior wall of inguinal canal in 1887, the repair method of inguinal hernia has been continuously improved and perfected. In 1986, American physician Lichtenstein first put forward the concept of tension-free hernia repair. At present, there are many tension-free hernia repair procedures, and anterior approach preperitoneal space hernia repair is one of them.

Organ transplantation is currently the most effective treatment for end-stage organ failure. Studies have shown that donor organ harvesting, preservation and ischemia-reperfusion injury after transplantation are important factors affecting the prognosis of transplantation. Since the mid-20th century, various research centers have continuously developed and improved organ protection solutions, such as Collins solution, the University of Wisconsin solution (UW), and HTK solution (HTK). The rapid development of static cold storage (SCS) technology based on organ protective solution has been promoted, which has further eliminated the time and geographical restrictions of organ preservation, and the organ protection technology has entered a brand-new era, which has greatly promoted the progress of organ transplantation. SCS technology is still the most commonly used technique for organ protection, and it is widely used by most organ transplant centers around the world. At present, organ donation transplantation after the death of citizens has become the main source of organ donation in China. However, the donor organ itself and the long time of hot ischemia and cold ischemia lead to more serious ischemic reperfusion injury (IRI), which significantly affects the prognosis of transplantation. Therefore, how to improve the quality of donor organs is particularly important. Recently, the emerging machine perfusion (MP) technology has been applied to organ preservation and repair again. However, MP is affected by pressure, perfusion speed, oxygenation and other parameters comprehensively, and its wide application needs a large number of multi-center clinical trials to verify.