在内镜辅助下经小切口切取游离背阔肌肌瓣修复四肢深度创面的临床效果

侯宏义; 谢松涛; 曹涛; 何香; 张楠; 官浩

doi:10.3760/cma.j.cn501225-20240929-00361

在内镜辅助下经小切口切取游离背阔肌肌瓣修复四肢深度创面的临床效果

doi: 10.3760/cma.j.cn501225-20240929-00361

空军军医大学西京医院烧伤与皮肤外科,西安　　710032

基金项目:

国家自然科学基金面上项目 82272268

详细信息

通讯作者:
官浩,Email：guanhao@hotmail.com

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出版历程
- 收稿日期: 2024-09-29

Clinical effects of free latissimus dorsi muscle flap harvested through small incision under the assistance of endoscopy in repairing deep wounds in limbs

Department of Burn and Skin Surgery, Xijing Hospital, Air Force Medical University, Xi'an 710032, China

Funds:

General Program of National Natural Science Foundation of China 82272268

More Information

Corresponding author: Guan Hao, Email: guanhao@hotmail.com

摘要

摘要: 目的探讨在内镜辅助下经小切口切取游离背阔肌肌瓣修复四肢深度创面的临床效果。方法该研究为回顾性观察性研究。空军军医大学西京医院2015年3月—2024年3月收治38例符合入选标准的四肢深度创面患者,其中男26例、女12例,年龄19~64岁,创面分布于小腿者21例、足踝部者9例、膝关节者3例、前臂者5例。清创后需肌瓣移植覆盖的创面面积为11.0 cm×9.0 cm~28.0 cm×13.0 cm,在内镜辅助下经腋窝顺皮纹横形小切口（长4~5 cm）结合腋后线次切口（长约1 cm）切取游离背阔肌肌瓣,切取的肌瓣大小为12.0 cm×10.0 cm~29.0 cm×14.0 cm,血管蒂长度为6~8 cm。取刃厚皮片覆盖肌瓣及剩余创面。记录游离背阔肌肌瓣切取时间、切取过程中出血量。术后观察移植肌瓣和皮片成活情况、创面愈合情况、供瓣区和受区并发症发生情况。随访时,观察受区外观、供瓣区瘢痕情况及供瓣侧上肢功能。结果游离背阔肌肌瓣切取时间为160~200 min,平均185 min；肌瓣切取过程中出血量为10~30 mL,平均25 mL。2例患者术后受区出现并发症,其中1例患者发生血管危象,急诊手术清除血栓,重新吻合静脉后肌瓣血运恢复,最终创面愈合良好；1例患者肌瓣边缘出现感染,行清创、换药等治疗后创面愈合。其余36例患者移植肌瓣及皮片完全成活。2例患者术后1周左右出现供瓣区囊性积液,通过穿刺引流及加压包扎处理后,术后3周供瓣区恢复良好；其余患者供瓣区无切口感染、裂开等并发症发生。随访6~18个月显示,受区移植肌瓣及皮片外形良好；供瓣区瘢痕隐蔽、轻微,供瓣侧上肢活动不受限。结论在内镜辅助下经腋窝顺皮纹横形小切口切取游离背阔肌肌瓣,供区损伤小、术后恢复快、瘢痕轻微且隐蔽,符合微创化手术目标,值得推广应用。
- 创伤和损伤 /
- 四肢 /
- 皮肤移植 /
- 内窥镜检查 /
- 背阔肌肌瓣 /
- 创面修复
Abstract: Objective To investigate the clinical effects of free latissimus dorsi muscle flap harvested through small incision under the assistance of endoscopy in repairing deep wounds in limbs. Methods This study was a retrospective observational study. From March 2015 to March 2024, 38 patients with deep wounds in limbs, who met the inclusion criteria, were admitted to Xijing Hospital of Air Force Medical University, including 26 males and 12 females, aged 19 to 64 years. The wounds were located in the lower leg in 21 cases, ankle in 9 cases, knee joint in 3 cases, and forearm in 5 cases. After debridement, the wound area required for muscle flap transplantation was 11.0 cm×9.0 cm to 28.0 cm×13.0 cm. The free latissimus dorsi muscle flaps were harvested through a small horizontal incision of 4-5 cm in length along the dermatoglyph in the armpit combined with a secondary incision of about 1 cm in length at the posterior axillary line under the assistance of endoscopy, with area of the muscle flap of 12.0 cm×10.0 cm to 29.0 cm×14.0 cm and length of vascular pedicle of 6-8 cm. The split-thickness skin grafts were harvested to cover the muscle flaps and the residual wounds. The harvesting time and the amount of blood loss during the harvesting process of the free latissimus dorsi muscle flap were recorded. The survivals of the transplanted muscle flap and skin graft, wound healing, and complications in the flap donor and recipient areas were observed after surgery. During follow-up, the appearance in the recipient area, the scar condition in the flap donor area, and the function of the upper limb on the flap donor side were observed. Results The time for harvesting the free latissimus dorsi muscle flap was 160-200 minutes, with an average of 185 minutes. The amount of blood loss during the harvesting process of the muscle flap was 10-30 mL, with an average of 25 mL. Two patients developed complications in the recipient area after surgery. Among them, one patient experienced vascular crisis, the muscle flap recovered blood flow after emergency surgery to remove the thrombus and re-anastomosis of the vein, and ultimately the wound healed well; one patient had an infection at the edge of the muscle flap, and the wound healed after treatment such as debridement and dressing change. The transplanted muscle flaps and skin grafts completely survived in the remaining 36 patients. Two patients developed cystic effusion in the flap donor area about one week after surgery, and the flap donor area recovered well after puncture drainage and pressure bandaging treatment three weeks after surgery; the remaining patients had no complications such as incision infection or rupture in the flap donor area. Follow up for 6 to 18 months showed that the transplanted muscle flap and skin graft in the recipient area had good appearance, the scar in the donor area was concealed and mild, and the upper limb movement on the flap donor side was not restricted. Conclusions Under the assistance of endoscopy, the free latissimus dorsi muscle flap can be harvested through a small horizontal incision along the dermatoglyph in the armpit, with small damage to the donor area, fast postoperative recovery, mild and concealed scar. It is in line with the goal of minimally invasive surgery and worthy of promotion and application.
- Wounds and injuries /
- Extremities /
- Skin transplantation /
- Endoscopy /
- Latissimus dorsi muscle flap /
- Wound repair
侯宏义：数据分析、文章撰写；谢松涛、官浩：研究指导、获取研究经费、论文修改；曹涛：数据整理与分析；何香、张楠：数据采集

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图 1 在内镜辅助下切取游离背阔肌肌瓣的主要器械及术中操作。1A.带吸引器的内镜置入器；1B.硬质柱形内镜；1C.L形直角拉钩；1D.U形拉钩；1E.超声刀；1F.双极电凝钩；1G.内镜显示屏显示的术中背阔肌切取视腔情况；1H.内镜显示屏清晰显示胸背血管在背阔肌的走行情况；1I.内镜显示屏显示的用电凝钩剥离疏松组织过程中；1J.内镜显示屏显示的超声刀通过腋后线处次切口进入术区切断背阔肌过程中

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图 2 在内镜辅助下切取游离背阔肌肌瓣结合刃厚头皮修复患者左小腿皮肤软组织坏死及骨质和内固定物外露创面的效果。2A.入院时左小腿开放性骨折术后皮肤软组织坏死；2B.左小腿清创后胫骨及内固定物外露；2C.术前切口及肌瓣设计；2D.术中肌瓣剥离完成断蒂前；2E.术后腋窝顺皮纹小切口及腋后线处次切口缝合后；2F.将游离背阔肌肌瓣移植到左小腿填塞深腔并覆盖创面后；2G.术后10 d,左小腿创面移植肌瓣及皮片均成活；2H.术后12个月随访时,左小腿创面外形良好；2I.术后12个月随访时,背部供瓣区瘢痕轻微

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