从循证医学角度谈腹腔镜腹股沟疝修补术20年进展

Progression of laparoscopic inguinal hernia repair in 20 years:Evidence based medicine interpretation for IEHS Guideline

解读国际腔镜疝协会(IEHS)发布的《腹腔镜腹股沟疝治疗指南(2011版)》,可以看到从循证医学角度评价腹腔镜腹股沟疝修补术(LIHR)在最初20年中(1990—2009年)的一些主要变化和进展。术式的进展包括:腹腔内修补术(IPOM)目前不作为腹股沟疝的主流术式(B级建议);而经腹腹膜前修补术(TAPP)或全腹膜外修补术(TEP)均为可选术式,无证据显示孰优孰劣,具全麻禁忌证病人可选择区域性麻醉行TEP(B级建议)。技术的进展包括:补片尺寸至少为10 cm×15 cm(A级建议),更大的缺损可应用更大的补片(≥12 cm×17 cm)(D级建议);Ⅰ、Ⅱ型疝可不固定补片,如固定,采用医用胶可降低急慢性疼痛的风险(B级建议);Ⅲ型直疝建议固定补片,但不能降低补片的尺寸(D级建议)。材料学进展包括:轻量型补片(LWM)至少可减少术后3个月内与补片相关的不适感(B级建议)。

To interpret the Guidelines for Laparoscopic （TAPP） and Endoscopic （TEP） Treatment of Inguinal Hernia constituted by International Endohernia Society （IEHS） in 2011,and evaluate the improvement and progression of laparoscopic inguinal hernia repair （LIHR） in the first 20 years （1990-2009） in an evidence-based way. Progression in operation methods：IPOM is not recommended for main stream inguinal hernia repair at present （Grade B）. Both TAPP and TEP are acceptable options for inguinal hernia repair,but there is insufficient data to allow conclusion to be made about relative effectiveness of TAPP compared with TEP. In selected patients having a contraindication for general anesthesia,TEP in region anesthesia can be done （Grade B）. Progression in surgical technique： A mesh size of at least 10 cm × 15 cm is recommended （Grade A）; For larger hernias,a bigger mesh （12cm×17cm or greater） can be used （Grade D）;In TAPP/TEP technique,nonfixation could be considered in typesⅠandⅡhernias; If for fixation,fibrin glue should be considered to minimize the risk of postoperative acute and chronic pain （Grade B）;For big direct defects （types Ⅲ）,the mesh should be fixated; However, fixation does not compensate for inadequate mesh size or overlap （Grade D）. Progression in materialogy： Light-weight mesh （LWM） decrease the rate of mesh-related complaints at least within the first 3 mouths （Grade B）.