【作者】 段升军；

【导师】 牛军；

【作者基本信息】 山东大学 ， 外科学（专业学位）， 2014， 博士

【摘要】 第一部分嵌顿疝动物模型的建立与肠坏死程度系统评价研究背景及目的肠坏死可表现为早期的非特异性症状和晚期延迟性特异性症状。临床中各种原因导致的肠缺血性疾病均可导致肠坏死,而嵌顿疝作为常见的导致肠缺血疾病之一,如不能及时解除嵌顿,可以导致肠绞窄坏死,最终导致局部及全身严重的临床后果。就单纯评价肠管坏死程度而言,肠管壁可以由粘膜、肌层到透壁性全层梗死过渡,但作为人体系统而言,嵌顿疝所导致的肠坏死除肠管组织形态学改变外,可导致局部炎症(红肿,甚至蜂窝织炎、肠外瘘)、肠梗阻、腹膜炎、感染性休克等局部及全身的表现。究其原因是随着坏死时间的延长肠坏死程度是不同的,所导致的临床后果不同,同时处理方式及预后不同。目前的实验室检查因为缺乏特异性,尚没有一种快速且可靠的检测指标来预测肠缺血并判定肠坏死时间,临床中更没有一种系统来评判肠坏死的程度。因为嵌顿疝导致的肠坏死与其他原因导致的肠坏死临床表现不同,比较适合建立一种系统来评价肠坏死的程度并体现该病的进展过程。本研究的目的为建立一种大鼠腹壁嵌顿疝模型,模拟肠绞窄坏死的过程,观察肠坏死后局部及全身表现并系统赋分,为临床中嵌顿疝肠坏死程度分级的建立提供实验依据。方法选取成年健康雄性Wistar大鼠,制作腹壁嵌顿疝动物模型。根据肠管嵌顿时间的增加,依次将模型分为12组,嵌顿时间自2h起,分别于2h、4h、6h、8h、12h、16h、20h、24h、28h、32h、36h、>36h作为时间节点处死大鼠,依据不同时间节点的坏死肠管形态及组织学观察、局部炎症及全身表现等对肠管坏死的程度进行系统赋分,比较与对照组及各组之间肠管坏死程度的差异。结果1.肠管损伤在嵌顿时间4-6h实现组织学全层坏死,腹部可出现肠梗阻体征。嵌顿时间16h,肠管可破溃,局部呈炎症表现并查见细菌,腹部可有腹膜炎表现。嵌顿时间超过32h嵌顿肠管形态消失,局部可呈蜂窝织炎,至72h左右大鼠逐步休克死亡。2.与对照组比较,各实验组肠管坏死系统评分依嵌顿时间递增排序,至嵌顿时间超过36h直至大鼠死亡,系统评分达最高值。各实验组间,嵌顿时间相差8h及以上者,系统评分存在明显的差异；且嵌顿4-6h组间、16-20h组间、32-36h组间系统评分有显著性差异,P值均小于0.05。结论1.本实验制备的大鼠腹壁嵌顿疝模型较好地模拟了肠管绞窄到坏死的过程,同时呈现了该过程中临床表现及最终结局。2.随着嵌顿时间的延长,肠坏死系统评分呈现出较明显的时间相关性,肠坏死系统评分可以客观反映嵌顿疝肠坏死的病情进展。第二部分嵌顿疝肠坏死程度临床分级的建立与患者临床特点的关系研究背景及目的临床中嵌顿疝需要紧急的外科干预治疗,但是非择期情况下其手术的并发症及死亡率增加。腹股沟疝嵌顿后作为常见外科急腹症能显著增加肠梗阻及肠绞窄风险。大约15%的腹股沟嵌顿疝患者可发展为肠坏死而不得不行肠切除,其死亡率达5%。虽然嵌顿疝绞窄后的最终结局是肠坏死,但随着坏死时间的延长,其局部及全身症状及体征是不同的。坏死早期,绞窄的肠管虽然已部分或全层坏死,但尚未发生穿孔,手术区域和腹腔也未受到明确或明显的污染,局部及全身症状较轻。但是在坏死后期,肠管可以形态消失或穿孔,局部可表现为蜂窝织炎,创面属于明确污染或感染伤口；腹部可表现为肠梗阻、腹膜炎；全身可表现为感染性休克甚至死亡。所以作为系统而言,嵌顿疝肠坏死程度是不同的,相应的临床结局及处理方式不同。但目前临床中尚无对肠坏死程度的系统定义。在之前的研究中我们通过动物实验对大鼠腹壁嵌顿疝肠坏死病情进展进行初步观察与系统评价分析。本研究是在临床中通过对腹股沟嵌顿疝并发肠坏死患者肠管形态学、局部及全身症状及体征的临床观察,目的建立一种肠坏死分级系统来客观反映肠坏死的程度,分析肠坏死分级与患者临床特点关系,尤其是与患者预后的关系。研究方法对2003年1月至2013年1月期间的所有急症入院并手术治疗的成人嵌顿疝患者进行前瞻性并排除性研究,对符合纳入研究标准的腹股沟嵌顿疝并发肠坏死患者的局部及全身表现进行系统观察,根据嵌顿时间、肠管坏死后形态、疝囊的完整性及疝外被盖组织的炎症程度、疝内容物性状,有无肠梗阻、腹膜炎及休克体征等,对肠坏死程度进行临床分级,分析影响肠坏死分级的临床因素以及肠坏死分级与患者预后的关系。结果1.共有68例患者纳入本研究并据其建立3级肠坏死分级系统,共有49例(72.1%)Ⅰ级坏死患者,14例(20.1%)Ⅱ级坏死患者,5例(7.4%)Ⅲ级坏死患者。术后并发症及死亡率分别为32.4%和7.4%。2.年龄≥65岁(P=0.035)、伴随疾病(P=0.008)和高ASA评分(P=0.014)是导致肠坏死程度加重而影响肠坏死分级的因素。3.随着肠坏死分级的提高,其全身并发症(5.9%、35.7%和60.0%)及腹部和伤口并发症(6.1%、28.6%和60.0%)相应增加,同时死亡率增加(2.0%、14.3%和40.0%),各组之间均有显著性差异(P<0.05)。结论1.肠坏死分级能够客观反映肠坏死后肠管损伤的程度及其相应的患者预后,尤其是有合并症的高龄、高ASA评分患者。2.肠坏死分级能够指导临床及时干预治疗并预测和提高预后；外科应尽早干预以避免肠坏死发生或坏死程度加重从而影响患者预后。第三部分嵌顿疝肠坏死和预后影响因素与肠坏死指数的建立研究背景及目的目前关于导致嵌顿疝肠坏死的因素以及影响嵌顿疝患者预后因素的研究报道较少。毫无疑问,嵌顿时间的长短是导致(或影响)肠坏死的主要因素,而其他因素,如年龄、性别、合并症、疝类型是否是影响肠坏死的因素结果差异较大。大部分研究表明肠坏死后肠切除是影响预后的主要因素,但其他因素,如年龄、有无合并症、能否耐受手术等因素在预后中亦扮演重要角色,但各研究结果差异较大。再者嵌顿疝,尤其是合并肠坏死者应用补片修补是否可行争议更大。本研究的目的是在通过对嵌顿疝患者临床资料回顾性分析,目的分析导致嵌顿疝患者肠坏死并肠切除的危险因素,以及影响嵌顿疝患者预后的因素,尤其是探讨肠坏死和修补方式与患者预后的关系。同时依据引起肠坏死的因素和加重肠坏死的因素,建立肠坏死指数以客观判断肠坏死及其程度来指导临床预测肠管绞窄发生和肠坏死程度分级,最终指导临床预后判断。研究方法对2003年1月至2013年12月1168例急症手术治疗的成人嵌顿性腹股沟疝患者的临床资料进行回顾性分析,采用单变量及多变量统计方法分析导致肠坏死并肠切除的危险因素以及影响嵌顿疝患者预后的因素,探讨修补方式与预后的关系。对于有意义的导致肠坏死的因素,结合第二部分研究结果中影响肠坏死程度的因素,作为危险因素赋分并制定肠坏死指数,划定赋分范围确定肠坏死的有无及坏死程度分级。结果1.所有患者均急症手术并疝修补,共有1147例患者纳入本研究,其中195例(17%)患者因肠坏死而行肠切除,952例(83%)无肠坏死患者。术后并发症及死亡率分别为16.9%和5.1%。2.肠坏死患者和非肠坏死患者两组在年龄、性别、有无伴随疾病、疝类型、嵌顿时间、有无肠梗阻及腹膜炎等各因素之间均有显著性差别(P<0.05)。Logistic回归多因素分析显示,嵌顿时间≥6h(OR=8.32, P<0.001)、股疝(OR=10.47, P=0.018)和腹膜炎(OR=4.79,P=0.005)是导致肠坏死并肠切除的独立危险因素。3.嵌顿疝肠坏死指数5-10分无肠坏死,11～18分Ⅰ级肠坏死,19～26分Ⅱ级肠坏死,>26分Ⅲ级肠坏死。4.单变量分析显示伴随疾病、ASA评分、麻醉类型、修补方式和肠坏死与患者并发症有关(P<0.05)；而年龄、伴随疾病、ASA评分和肠坏死与患者病死率有关(P<0.05)。但Logistic回归显示只有肠坏死是影响预后(并发症和病死率)的独立危险因素(P<0.01)。5.嵌顿疝并肠坏死患者补片修补的总体并发症大于一期缝合修补患者(P<0.05),但对于Ⅰ级坏死患者应用补片修补的伤口感染率与一期缝合没有差别(P>0.05),多变量分析显示补片的应用不是影响预后的危险因素(p>0.05)。结论1.嵌顿时间大于6h、疝类型为股疝和腹膜炎是嵌顿疝肠坏死并肠切除的独立危险因素,而肠坏死后肠切除是影响嵌顿疝患者预后的独立因素。2.嵌顿疝肠坏死指数的建立能够指导临床客观评判肠坏死的有无以及预测肠坏死的分级,结合肠坏死分级更能提前预测和提高预后。3.补片的应用能增加术后总体并发症的发生,尤其是Ⅱ、Ⅲ级坏死患者伤口并发症的发生,但不是影响预后的独立因素。第四部分腹股沟嵌顿疝并肠坏死的一期无张力疝修补研究背景及目的嵌顿疝并发肠坏死能否一期无张力疝修补有争议。传统的观点认为行肠切除后创面污染,容易导致切口感染从而导致修补失败而最终不得不取出补片。也有入认为嵌顿疝绞窄后肠管虽然已坏死,但如尚未发生穿孔,手术区域也未受到明确或明显的污染,使用补片修补是可行的。也有研究发现切口的感染与是否应用补片无关。对于择期无张力疝修补,创面属于清洁伤口,手术可行毋庸置疑。对于并发肠坏死患者,虽然临床上有许多一期无张力疝修补的成功报告,但不是所有的肠管坏死后一期无张力疝修补是可行的。因为随着坏死时间的延长,创面由污染到感染过渡。早期坏死创面属于污染或潜在污染伤口,而后期可以明显的坏死化脓,创面属于明确污染或感染伤口,显然不能修补。此条件下勉强修补只能导致手术失败。根据创面的污染情况来决定是否应用补片修补是首先考虑的,但患者的一般状况在决定手术的成功与否中亦非常关键。而术中如何避免或减少污染及术后的综合治疗在手术的成功中亦扮演重要角色。在之前的研究中我们通过动物实验及临床观察首次对肠坏死程度进行分级,并且研究表明肠坏死程度与患者年龄及伴随疾病以及ASA评分有关,并影响患者预后,且证实肠坏死是影响预后的独立因素。同时研究表明对于Ⅰ级坏死患者,补片的应用没有增加伤口等并发症发生。本研究的目的为探索不同坏死分级下结合患者一般状况行一期无张力疝修补的可行性,总结一期无张力疝修补的成功经验。研究方法对2005年1月至2013年6月40例腹股沟嵌顿疝并发肠坏死患者,依据肠坏死分级标准对肠坏死程度进行分级,对其中一般状况较好(ASAⅠ、Ⅱ)的21例Ⅰ级坏死、4例Ⅱ级坏死患者根据个体化原则的综合治疗下行肠切除吻合并一期无张力疝修补,对其余一般状况较差(ASAⅢ、Ⅳ)或(和)坏死程度较重的7例Ⅰ级坏死、5例Ⅱ级坏死和3例Ⅲ级坏死患者行单纯缝合修补。记录术后并发症并分析坏死等级与ASA评分和术后并发症的关系。结果选择性25例一期无张力疝修补患者没有死亡病例,其余患者死亡4例。全部患者术后血肿5例；切口感染8例,其中Ⅰ级坏死补片修补患者1例,为皮下感染,经换药未除去网片痊愈,Ⅱ级坏死患者4例,其中补片修补2例,1例因深部组织感染(合并补片感染)而不得不取出补片。术后随访6月以上补片修补患者无排异反应发生。术后复发4例,其中1例为Ⅱ级坏死感染后取出补片患者。统计分析示肠坏死分级与ASA评分相关(r=0.388,P=0.018),随者坏死程度加重和ASA评分增加,术后并发症逐步增加(P<0.05)。结论1.对于肠坏死程度Ⅰ级、ASA评分Ⅰ、Ⅱ的患者,一期无张力疝修补可以取得成功,是可行的。2.正确评价肠坏死的程度,结合患者的一般状况来选择性一期无张力疝修补是嵌顿疝并发肠坏死手术的合理选择。更多还原

【Abstract】 PART1THE ESTABLISHMENT OF INCARCERATED HERNIA IN ANIMAL MODEL AND SYSTEMATIC EVALUATION OF THE DEGREE OF BOWEL NECROSISBackground and ObjectiveBowel necrosis (BN), or intestinal necrosis, displays early non-specific and delayed bowel-specific symptoms. There are many schemic bowel diseases (SBD) which can cause BN in clinical practice. While incarcerated hernia is a common cause of SBD which can lead to bowel strangulation and necrosis. The ultimate clinical outcomes will very serious if not timely release the incarceration.It is simple to evaluate the extent of bowel wall necrosis, which can transform from mucosal to transmural infarction of full-thickness of necrosis. But as a human system, besides the morphological changes of intestinal tissues, it can present with local and systemic manifestations of inflammations, cellulitis, intestinal obstruction, and systemic shock. So with the extension of BN time, the result of clinical outcomes is different, and the treatments and prognosis are different correspondingly.There is no reliable and prompt test that can predict intestinal ischemia and determine the necrosis time. On the reason of particular clinical manifestations of BN in incarcerated hernia, there is currently no a systematic clinical system to evaluate the extent of BN. The purpose of this study was to establish a rat model of incarcerated ventral hernia and simulate the process of BN from strangulation to the ultimate outcomes. We also drawed up a systematic score system based on the quantitative score of the local and systemic manifestations of BN, and ultimately, to provide experimental basis for the clinical classification of BN.MethodsWe selected104healthy adult male Wistar rats and made animal models of incarcerated ventral hernia. These rates were divided into13groups (including one control group) according to incarceration time, with increasing time of1h (control group),2h,4h,6h,8h,12h,16h,20h,24h,28h,32h,36h,>36h, respectively, and were sacrificed at corresponding time. We observed the morphological and histological changes of bowel wall, the inflammation extent of local areas, systemic manifestations, and developed a systematic score system of BN and counted the scores of each point. We compared the difference of BN score with the control group and within the experimental groups.Results1. The bowel wall damage achieved full-thickness of necrosis at4-6h’s incarceration, and the abdomen showed mechanical bowel obstruction at corresponding time. The bowel wall cracked, the local side presented with inflammation and there was evidence of bacterial growth at16-20h’s incarceration, meanwhile, the abdomen presented with obvious peritonitis. Incarcerated for longer than32h, the bowel morphology disappeared, the local side presented with cellulitis, and all the rats died at near72h.2. The systematic BN score of the experimental groups increased with increasing time and reached maximum with death at longer than72h’s incarceration compared with the control group. There was significant difference of BN score between4-6h,16-20h,32-36h groups and longer than8h’s incarceration (all P<0.05).Conclusions1. This model of strangulated ventral hernia in rats can better simulate the process of bowel wall from strangulation to necrosis, while showing the clinical manifestations of the process and final outcomes.2. With the extension of incarceration time, the systematic intestinal necrosis score showed an obvious correlation with incarceration time. The systematic intestinal necrosis score system can objectively reflect the consequences of BN in incarcerated hernia. PART2THE ESTABLISHMENT OF BOWEL NECROSIS GRADING SYSTEM AND EXAMINATION OF THE RELATIONSHIP WITH CLINICAL CHARACTERISTICS IN INCARCERATED GROIN HERNIA PATIENTSBackground and ObjectiveIncarcerated hernia cases may necessitate emergency interventions in clinical practice, but under such circumstances morbidity and mortality rates may increase. Groin hernias that occur with incarceration are a serious surgical emergency associated with increased risk of obstruction and strangulation. Approximately15%of patients with incarcerated groin hernia developed bowel necrosis (BN) and underwent bowel resection, with a mortality of5%.Although the final outcome of the incarcerated bowel is strangulation and necrosis, the performance of local and systemic symptoms and signs are different with the extension of necrosis time. At early stage of BN, the bowel wall manifest full-thickness necrosis but with no perforation, the surgical field is not clearly or obviously polluted. But at late stage of BN, the bowel wall loss its normal form and collapsed or cracked. The surgical field can present with cellulitis, and the wound will be clearly contaminated. So the BN degree is different as an extension of necrosis time. But there is currently no grading system for the degree of BN in clinical practice.We have established the incarcerated hernia animal model and preliminary evaluated the degree of BN with systematic evaluations in the previous study. In this study, we screened for inclusion in a prospective study of incarcerated groin hernia patients and aimed to establish a novel classification system for BN based on the observation of bowel morphology, local and systemic sighs changes. We also analyzed the correlations between clinical characteristics with BN stages, especially for the relationship with patient outcomes.MethodsIncarcerated groin hernia patients treated with emergency hernia repair and bowel resection from January2003to January2013were screened for inclusion in a prospective study. A novel three-grade classification system was proposed for BN (grade Ⅰ-Ⅲ) based on incarceration time (4-12,>12-36, or>36h), bowel function, qualitative assessment of bowel morphology and hernia sac, and presence/absence of bacterial growth, peritonitis, mechanical obstruction, and systemic shock. Correlations between clinical characteristics, morbidity and mortality with BN grade were determined.Results1.68patients were included, with49,14, and5grade I, II, and III according to the grading system, respectively. The overall morbidity and mortality was32.4%and7.4%, respectively.2. Age>65years, presence of comorbidities, and high American Society of Anesthesiologists (ASA) score significantly correlated to higher BN grade (all P<0.05).3. Morbidity which included wound and abdominal complications and other systemic complications increased with higher.BN grade (P<0.05). Mortality increased with BN grade, with2.0%,14.3%, and40.0%mortality at grade I, II, and III, respectively (P<0.05).Conclusions1. The proposed BN classification system can objectively reflect the degree of bowel damage and its corresponding adverse outcomes, especially for older patients with comorbidities and poor ASA scores.2. It is a good clinical guidance for selection of appropriate management and a useful tool for improving poor prognosis linked to BN. Urgent surgical treatment should be performed to avoid BN exacerbation. PART3THE ESTABLISHMENT OF BOWEL NECROSIS INDEX AND FACTORS AFFECTING BOWEL NECROSIS AND PATIENT OUTCOMES IN INCARCERATED GROIN HERNIABackground and ObjectiveCurrently, there were few reports of factors affecting BN and patient outcomes in incarcerated hernias. It was undoubted that incarceration time was the main factor that cause and exacerbate BN. While other factors, such as age, sex, comorbidities, and hernia type, was whether or not affecting factors were quite different. Most studies indicated that BN followed by bowel resection was the main factor affecting the outcomes. But other factors, such as age, comorbidities, the tolerance to surgery also played important roles in prognosis, and the results were quite different. Furthermore, there were more controversials of the use of mesh in incarcerated hernias, especially for BN patients.In this study, we retrospectively studied the clinical data of the incarcerated groin hernia patients. The aim of this study was to investigate risk factors for BN and factors that affecting morbidity and mortality, especially for the relationship between BN degree and repair method with patient outcomes. We also established bowel necrosis index (BNI) based on the factors that cause and aggravate BN to judge the extent of BN and ultimately estimate the prognosis.MethodsWe retrospectively studied1168incarcerated groin hernia patients who underwent urgent surgical interventions between January2003and December2013. Factors that increasing the risk of BN, affecting morbidity and mortality, were analyzed using univariate and multivariate statistic analysis. Based on the factors that increasing BN risk and causing BN degree, quantitative score was made to establish BNI.Results1. All the patients were performed urgent surgical interventions with hernia repair. The final sample was1147, included195(17%) cases of BN patients underwent bowel resection and952cases of no BN patients. Morbidity and mortality occurred in194(16.9%) and58(5.1%) patients, respectively.2. Pearson’s chi-squared tests analysis showed there were significant differences in age, gender, accompanying disease, the incarceration time, hernia type, with or without bowel obstruction and peritonitis between two groups (P<0.05). While the incarceration time longer than6h (P<0.001, odds ratio=8.32), hernia type of femoral (P=0.018, odds ratio=10.47), and obvious peritonitis (p=0.005, odds ratio=4.79) was the independent factor for BN.3. There was no BN with BNI score5-10, Grade I BN with BNI score11～18, Grade II BN with BNI score19～26, and Grade III BN with BNI score>26.4. Presence of accompanying disease, high ASA score, general anesthesia, mesh repair, and BN was found to affect morbidity by univariate analysis (P<0.05), Advanced age, presence of accompanying disease, high ASA score, and BN were found to affect mortality by univariate analysis (P<0.05). But multivariate analysis of Logistic regression showed BN was the sole factor affecting morbidity and mortality (P<0.05).5. The wound infection rate of mesh repair patients with Grade II&III necrosis was significantly higher than primary suture patients, and leading to the increase of overall morbidity (P<0.05). But for Grade I necrosis patients with mesh repair, the wound infection rate had no difference comparing with primary suture patients (P>0.05). The use of mesh did not influence the morbidity and mortality with multivariate analysis (P>0.05).Conclusions1. Incarceration time longer than6h, femoral hernia, and obvious peritonitis was the independent risk factors for BN in incarcerated groin hernia patients. Intestinal necrosis, which was followed by bowel resection, was the sole factor affecting morbidity and mortality.2. The BNI of incarcerated hernia can guide clinicians objectively judge the presence or absence of BN and estimate the degree of BN. It is a useful clinical tool for predicting and improving poor prognosis linked to BN combined BN staging system.3. The use of mesh can significantly increase the overall morbidity, especially for postoperative wound complications, but is not the sole factor affecting the outcome. PART4THE PRIMARY TENSION-FREE HERNIOPLASTY IN INCARCERATED GROIN HERNIA WITH BOWEL NECROSISBackground and ObjectiveThere is no consensus yet with regard to the use of prosthesis in incarcerated hernia with a bowel resection. The traditional view of hernia surgery for incarcerated hernia with BN was negative of Tension-free hernioplasty. The reason was that the operation field has been contaminated and it was not safe to use a mesh for correction because of wound infection could increase the risk for recurrence-in many cases, leading to repair failure and had to reoperation. But some others deemed that the use of mesh for hernia repair was feasible. Their reasons were that the bowel wall has not yet perforation and the surgical field was not clearly or obviously polluted. Other studies have found that wound infections were unrelated with the use of mesh.It was no doubt that prosthetic mesh repair should be performed only under clean conditions of elective ones. Although there were many successful reports of simultaneous bowel resection and tension-free hernioplasty for incarcerated hernia with BN, not all patients with different degree of BN could be feasibly performed mesh repair. With the extension of necrosis time, the wound will transform from pollution to infection. At early stage of BN, the surgical field belongs to contaminated or potentially contaminated wound. But at late stage, the surgical field can present cellulites and the wound belong to clearly contaminated or infectious wound. Barely mesh repair under such conditions can only lead to repair failure.It is the first consideration of whether using mesh repair according to the conditions of surgical field, but the patients’general conditions are also very critical in determining the success of the surgery. Furthermore, how to avoid and reduce pollution also play important roles in the success of operation as well as the comprehensive postoperative treatments.We have firstly defined BN degree classification system in incarcerated groin hernia patients in previous studies and have proven that the degree of BN was related with age, presence of comorbidities and high ASA score, and BN was the sole factor affecting morbidity and mortality. On the other hand, the use of mesh in Grade I necrosis patients did not increase the wound infection rate. The purpose of this study is to explore the feasibility of simultaneous bowel resection and tension-free hemioplasty under different BN grades and sum up the successful experience.Methods40cases of incarcerated groin hernia patients with BN were performed emergency hernia repair at our department between January2005and June2013. We used our grading system to grad the degree of BN. According to the patients’general conditions combined with individualized treatment principles,21cases of Grade I necrosis patients and4cases of Grade Ⅱ necrosis patients were selectively performed simultaneous bowel resection and tension-free hernioplasty. The rest of the7patients of Grade I necrosis,5patients of Grade II necrosis, and3patients of Grade III necrosis were repaired by primary sutures. Correlations between ASA score, postoperative complications with BN grade were determined.ResultsThere was no death case in the selectively25cases of tension-free hernioplasty patients. Postoperative complications developed in8patients with wound infection,5patients with hematoma, and4patients with recurrence of hernia. There was1case of Grade I necrosis patient with mesh repair developed superficial wound infection and healed by dressing without removing the mesh.4cases of Grade Ⅱ necrosis patient developed wound infection, including2patients with mesh repair, in which1patient had to remove the mesh because of severe deep wound infection. After6months of follow up, there were4cases of recurrence, including1Grade II necrosis patient with removing the mesh.Pearson’s chi-squared tests revealed that BN grading correlated with ASA score (r=0.388,P=0.018), and complications increased with higher BN grade and poor ASA score (P<0.05).Conclusions1. It can be success for patients with Grade I necrosis and ASA score I, II in incarcerated groin hernia with simultaneous bowel resection and tension-free hernioplasty.2. It should be a rational choice of selective mesh repair both according to the BN degree and according to patient’s general conditions for incarcerated hernia with bowel necrosis.更多还原