腹腔镜腹股沟疝修补术后复发的原因及再手术治疗

Causes of recurrence following laparoscopic inguinal hernioplasty and strategy of reoperation

目的分析腹腔镜腹股沟疝修补术(LIHR)术后复发的原因,探讨再次手术治疗的策略。方法回顾性分析2001年1月—2010年12月在上海交通大学医学院附属瑞金医院接受LIHR的1 557例(1 864侧)疝患者的临床资料,其中,行经腹腹膜前修补术(TAPP)628例(726侧),全腹膜外修补术(TEP)922例(1128侧),腹腔内修补术(IPOM)7例(10侧)。手术由同组医师完成,术式的选择由术者决定,随访时间为8～60个月(中位随访时间为36个月)。结果术后共有6例6侧复发,复发率为0.33%(6/1 864)。TAPP和TEP各有3例3侧复发,复发率分别为0.41%(3/726)和0.27%(3/1 128),差异无统计学意义(P=0.586)。6例复发者分别为第8、19、34、92、255、409例次,前100例中有4例复发,其中3例在术后3个月内复发;100例后仅2例复发,复发时间在术后3年以上。6例患者的复发部位均为前次手术疝发生的部位,4例为直疝复发,其中3例有前列腺手术史;2例为斜疝复发。再次手术时1例行TAPP修补,5例行Lichtenstein修补,均未再复发。结论 LIHR术后复发与学习曲线有关,与手术方式无关;直疝患者、有下腹部手术史患者的术后复发概率增加;再次手术时应避开腹膜前入径,可选择开放式前入路手术或腹腔镜腹腔内手术。

Objective To analyze the causes of recurrence after laparoscopic inguinal hernia repair （LIHR） and to explore the strategy of reoperation. Methods The clinical data of 1 557 consecutive patients （1 864 hernias） undergoing LIHR between January 2001 and December 2010 was retrospectively analyzed. A total of 726 transabdominal preperitoneal （TAPP） procedures were performed in 628 patients, 1 128 extraperitoneal （TEP） in 922 patients, and 10 intraperitoneal onlay mesh （IPOM） in 7 patients. All procedures were performed by the same surgical team, and the selection of the techniques was decided by the surgeons. The follow-up ranged from 8 to 60 months （median 36 months）. Results A total of 6 patients developed recurrence with the recurrence rate of 0.32%. Recurrences occurred after TAPP in 3 cases and TEP in 3 cases, respectively, with a recurrence rate of 0.41% and 0.27% （ P = 0. 586）. The recurrence occurred at the 8th, 19th, 34th, 92th, ＂255th, 409t＂ patients. Four developed in the first 100 cases （three occurred within 3 months postoperatively）-, while only two happened after the 100thcases, with a recurrence time more than three years. The six recurrent hernias were the same as the primary hernias, of which four were direct hernia, with three having history of prostatectomy, the other two were indirect hernias; the reoperations for recurrence were done by TAPP in one patient and Lichtenstein in five patients, and no re-recurrence happened after re-repair. Conclusion Recurrence following LIHR is associated with learning curve, and not related to the operative approach （TAPP or TEP）. The patients with direct hernias or history of lower abdominal surgery develop recurrence easily. For treatment of recurrent hernia following LIHR, preperitoneal approach should be avoided, and an anterior open operation or laparoscopic IPOM would be suitable.