小儿嵌顿性腹股沟斜疝研究进展与诊疗现状

Research Advances and Current Status of Diagnosis and Management of Pediatric Incarcerated Indirect Inguinal Hernia

摘要: 背景：嵌顿性腹股沟斜疝(IIH)是儿科急症，源于腹膜鞘状突未闭。及时诊断与处理对于预防肠管或性腺缺血坏死等严重并发症至关重要。方法：本文综述了当前关于小儿IIH的胚胎学、流行病学、临床表现、诊断方法及治疗策略的文献，重点关注当代存在的争议与管理细节。结果：IIH的诊断基于临床检查，并辅以彩色多普勒超声评估疝内容物活力及睾丸血供。对于无并发症的病例，初始处理可尝试手法复位。手术治疗仍是根治方法，其中腹腔镜技术因其微创优势及可同时处理对侧未闭鞘状突(PPV)的能力，日益成为标准术式。主要的管理争议包括：1) 男性IIH中是否需常规探查睾丸以及对缺血睾丸的处理；2) 女性卵巢嵌顿的最佳手术时机，目前强烈倾向于保留卵巢；3) 针对早产儿及低出生体重儿的手术时机，近期证据支持出院后择期手术；以及4) 对于腹腔镜术中发现的对侧PPV，应采取基于风险分层的个体化处理策略。结论：尽管小儿IIH的微创治疗已取得显著进展，但在性腺管理、高危婴儿手术时机等关键方面仍缺乏统一标准。临床决策应个体化，综合考虑外科医生经验、家属意愿及最新证据。未来需要高质量、长期的随访研究来解决现有争议，以优化患者诊疗。

Abstract: Background: Incarcerated indirect inguinal hernia (IIH) is a critical surgical emergency in pediatric patients, arising from the failure of the processus vaginalis to close. Prompt diagnosis and management are essential to prevent severe complications such as intestinal or gonadal ischemia and necrosis. Methods: This review synthesizes current literature on the embryology, epidemiology, clinical presentation, diagnostic approaches, and therapeutic strategies for pediatric IIH, with a focus on contemporary controversies and management nuances. Results: IIH diagnosis relies on clinical examination, supported by color Doppler ultrasonography to assess the viability of the hernia content and testicular blood flow. Initial management for uncomplicated cases involves attempted manual reduction. Surgical intervention remains the definitive treatment, with laparoscopic techniques increasingly becoming the standard due to their minimally invasive advantages and ability to address contralateral patent processus vaginalis (PPV). Key management controversies include: 1) the necessity of routine testicular exploration and the management of ischemic testes in male IIH; 2) the optimal timing of surgery for ovarian incarceration in females, with a strong consensus favoring ovarian preservation; 3) the debate between pre-discharge and post-discharge elective repair for premature and low-birth-weight infants, with recent evidence favoring the latter; and 4) the individualized, risk-stratified approach to managing contralateral PPV discovered during laparoscopic surgery. Conclusion: While significant advances have been made in the minimally invasive management of pediatric IIH, standardized protocols for several critical aspects, including gonadal management and timing of repair in high-risk infants, are lacking. Decision-making should be individualized, incorporating the surgeon’s experience, family preferences, and the latest evidence. Future high-quality, long-term outcome studies are needed to resolve existing controversies and optimize patient care.