腹腔镜腹股沟疝修补术式选择的回顾性分析

Retrospective analysis on the selection of surgical procedures for laparoscopic inguinal hernia repair

目的:探讨腹腔镜腹股沟疝修补术(laparoscopic inguinal hernia repair,LIHR)的术式选择。方法:回顾性分析2001年1月至2011年12月我院2 056例(2 473侧)接受LIHR病人的临床资料,其中经腹腹膜前修补术(transabdominal preperitoneal,TAPP)871例(1 005侧),全腹膜外修补术(totally extraperitoneal,TEP)1 175例(1 458侧),腹腔内修补术(intraperitoneal onlay mesh,IPOM)10例(10侧)。手术由同组医师完成,中位随访时间42(15～60)个月。结果:TAPP和TEP两组病人的性别、年龄、病程时间、下腹部手术史、疝的分型和类型均有统计学差异(P<0.05)。TAPP组女性病人多于TEP组(P<0.001),年龄小于TEP组(P=0.006),病程时间长于TEP组(P<0.001),有下腹部手术史病人多于TEP组(P<0.001);Ⅳ型疝(81.4%)多于TEP组,Ⅰ型疝(27.4%)、Ⅱ型疝(29.2%)和Ⅲ型疝(44.3%)少于TEP组;股疝(61.1%)和复发疝(81.4%)多于TEP组,斜疝(41.6%)、复合疝(35.0%)和直疝(22.9%)少于TEP组。前3年开展术式以TAPP为主,之后TEP开展比例逐渐上升并超过TAPP。10例IPOM均为复发疝修补。TAPP组中有1例中转行Lichtenstein术,TEP组无中转;TAPP组手术时间(P=0.021)、住院天数(P<0.001)长于TEP组;两组病人的术后视觉模拟疼痛量表评分(P=0.173)、恢复活动人数比例无统计学差异(P=0.479)。TAPP组和TEP组病人术后复发率分别为0.3%和0.2%,无统计学差异(P=0.693);总并发症发生率分别为9.3%和6.6%,差异有统计学意义(P=0.014)。TAPP组有2例发生严重并发症(需要手术干预),分别为戳孔疝和肠梗阻;TEP组有1例,为肠道损伤。结论:TAPP和TEP都是安全、有效的手术方法,TEP可作为首选;对于女性、病程长、有下腹部手术史、巨大难复性疝、腹膜前间隙植入过补片的复发疝病人,可选择TAPP;多次复发者,可选择IPOM。

Objective To investigate the choice of approach to laparoscopic inguinal hernia repair(LIHR).Methods The clinical data of 2 056 consecutive patients(2 473 hernias) undergoing LIHR between Jan 2001 and Dec 2011 at our hospital was retrospectively analyzed.There were 1 005 TAPP in 871 cases,1 458 TEP in 1 175 cases and 10 IPOM in 10 cases.All procedures were performed by the same surgical team,and the selection of the techniques was based by the surgeons.The follow-up period ranged from 15-60 months(median 42 months).Results There was significant difference between TAPP and TEP with respect to sex,age,disease duration,history of lower abdominal surgery,hernia type and classification(P<0.05).TAPP was preferable procedure for female(P<0.001),younger patients(P=0.006),and those with longer disease duration(P <0.001) and with history of lower abdominal surgery(P <0.001).TAPP was used more frequently in type Ⅳ(81.4%),while less frequently in type Ⅰ(27.4%)、 type Ⅱ(29.2%) and type Ⅲ(44.3%).TAPP was much more used for femoral hernias(61.1%) and recurrent hernias(81.4%),but less for indirect hernias(41.6%),combined hernias(35.0%) and direct hernias(22.9%).TAPP was the prior procedure in the first 3 years of study,and TEP was more frequently later.IPOM was used in 10 cases all recurrent hernias.One conversion to Lichtenstein was done in TAPP,while no conversion in TEP.The mean operation time(P=0.021) and postoperative hospital stay(P<0.001) were in favor of TEP.No significant difference was found in visual analogue pain scale(P=0.173) and proportion of patients returning to usual activities between TAPP and TEP(P =0.479).The recurrence rate in TAPP and TEP were 0.3% and 0.2% respectively with no significant difference between them(P=0.693).The morbidity of TAPP and TEP were 9.3%,6.6%,