腹腔镜腹股沟疝修补术治疗老年腹股沟疝的临床疗效

Clinical efficacy of laparoscopic inguinal hernia repair in elderly patients

目的：探讨腹腔镜腹股沟疝修补术（LIHR）治疗老年腹股沟疝的临床疗效。方法：采用回顾性队列研究方法。收集2001年1月至2013年12月上海交通大学医学院附属瑞金医院收治的3 203例腹股沟疝患者3 847侧疝的临床资料。979例（1 107侧）年龄〈60岁的腹股沟疝患者设为〈60岁组，2 224例（2 740侧）年龄≥60岁的腹股沟疝患者设为≥60岁组。手术由同一组医师完成，手术方式由术者根据患者的具体情况选择：经腹腹膜前修补术（TAPP）、全腹膜外修补术（TEP）、腹腔内修补术（IPOM）。补片类型分为轻量型和重量型。观察指标：（1）总体手术情况。（2）两组患者的手术情况比较。（3）两组患者的术后指标比较。（4）随访情况。采用门诊、电话等方式进行随访。随访内容为恢复非限制性活动时间、疝复发和并发症情况。随访最终点为术后5年。正态分布的计量资料以±s表示，组间比较采用t检验。计数资料比较采用χ2检验或Fisher确切概率法。等级资料比较采用非参数秩和检验。结果：（1）总体手术情况：3 203例腹股沟疝患者（3 847侧疝）均行LIHR，其中TAPP 1 475例（1 677侧）；TEP 1 718例（2 154侧）；IPOM 10例（16侧），其中6例一侧行TAPP，对侧行IPOM。2 206侧疝采用轻量型补片，1 641侧疝采用重量型补片。3 203例腹股沟疝患者手术时间为（31±12）min，其中2 559例单侧疝手术时间为（27±9）min，644例双侧疝手术时间为（44±12）min。3 203例腹股沟疝患者术后住院时间为（1.5±1.2）d。 （2）两组 患者的手术情况比较：〈60岁组腹股沟疝患者中，采用手术方式TAPP、TEP、IPOM分别为567、538、2侧， ≥60岁组分别为1 110、1 616、14侧；〈60岁组采用轻量型和重量型补片分别为751侧和356侧，≥60岁组分别为1 455侧和1 285侧，两组患者上述指标比较，差异均有统计学意义（χ2=37.976，70.022，P〈0.05）。〈60岁组腹股沟疝患者单侧疝手术时间、双侧疝手术时间、总手术时间分别为（27±9）min、（42±10）min、（29±10）min，≥60岁组分别为（27±10）min、（44±12）min、（31±13）min，两组患者上述指标比较，差异均无统计学意义（t=-0.106，-1.768，-4.445，P〉0.05）。（3）两组患者的术后指标比较：〈60岁组腹股沟疝患者术后1 d疼痛分数、术后住院时间分别为（2.4±1.1）分、（1.5±1.1）d，≥60岁组分别为（2.3± 1.0）分、（1.5±1.3）d，两组患者上述指标比较，差异均无统计学意义（t=1.419，-0.126， P〉0.05）。（4）随访情况：所有患者获得随访，随访时间为23～60个月，中位随访时间为43个月。〈60岁组腹股沟疝患者术后2周及术后4周恢复非限制性活动例数分别为973例和978例，≥60岁组分别为2 208例和2 222例，两组患者比较，差异无统计学意义（χ2=0.113，P〉0.05）。〈60岁组腹股沟疝患者术后疝复发、严重并发症、血清肿、感觉异常、肠麻痹分别为1、0、49、5、1侧，≥60岁组分别为11、3、132、16、2侧，两组患者上述指标比较，差异均无统计学意义（χ2=1.556，0.269，0.254，P〉0.05）。〈60岁组和≥60岁组腹股沟疝患者术后尿潴留分别为6侧和44侧，两组患者比较，差异有统计学意义（χ2=6.956，P〈0.05）。结论：老年腹股沟疝患者行LIHR安全、有效，合理选择手术方式、应用补片材料可以使老年患者获得良好的临床效果。

Objective：To explore the clinical efficacy of laparoscopic inguinal hernia repair （LIHR） in elderly patients. Methods：The retrospective cohort study was adopted. The clinical data of 3 203 patients with inguinal hernias （3 847 sides） who were admitted to the Ruijin Hospital of Shanghai Jiaotong University School of Medicine between January 2001 and December 2013 were collected. Of 3 203 patients, 979 （1 107 sides） with age〈60 years and 2 224 （2 740 sides） with age≥60 years were respectively allocated into the under 60 years group and 60 years or older group. The surgical procedures including transabdominal preperitoneal （TAPP） approach, total extraperitoneal （TEP） approach and intraperitoneal onlay mesh （IPOM） approach were selected and performed by doctors in the same team. There were lightweight and heavyweight patches. Observation indicators included （1） overall operation situations, （2） surgical comparison between the 2 groups, （3） comparison of postoperative indicators between the 2 groups, （4） followup. Followup using telephone interview and outpatient examination was performed to detect the recovery time of nonrestricted activity, recurrence of hernia and complications. Measurement data with normal distribution were represented as ±s and comparison between groups was done by the t test. Comparisons of count data were analyzed using the chisquare test or Fisher exact probability. Ranked data were compared by the nonparametric rank sum test. Results：（1） Overall operation situations： 3 203 patients with inguinal hernias （3 847 sides） underwent LIHR, including 1 475 （1 677 sides） using TAPP approach, 1 718 （2 154 sides） using TEP approach and 10 （16 sides） using IPOM approach （6 using TAPP and IOPM approaches in each side）. The lightweight patch was used in 2 206 sides and heavyweight patch was used in 1 641 sides. Operation time was （31±12）minutes in all 3 203 patients, （27±9）minutes in 2 559 patients with unilateral hernia and （44±12）minutes in 644 patients with bilateral hernia, respectively. Duration of postoperative hospital stay was （1.5±1.2）days. （2） Surgical comparison between the 2 groups： TAPP approach, TEP approach, IPOM approach, lightweight patch and heavyweight patch were performed to 567, 538, 2, 751, 356 sides in the under 60 years group and 1 110, 1 616, 14, 1 455, 1 285 sides in the 60 years or older group, respectively, with statistically significant differences in above indicators between the 2 groups （χ2=37.976, 70.022, P〈0.05）. Operation time in unilateral hernia and bilateral hernia and total operation time were （27±9）minutes, （42±10）minutes, （29±10）minutes in the under 60 years group and （27±10）minutes, （44±12）minutes, （31±13）minutes in the 60 years or older group, respectively, with no statistically significant difference between the 2 groups （t=-0.106,-1.768,-4.445, P〉0.05）. （3） Comparison of postoperative indicators between the 2 groups： the pain score at postoperative day 1 and duration of postoperative hospital stay were 2.4±1.1, （1.5±1.1）days in the under 60 years group and 2.3±1.0, （1.5±1.3）days in the 60 years or older group, respectively, with no statistically significant difference between the 2 groups （t=1.419,-0.126, P〉0.05）. （4） Followup： all the patients were followed up for 23-60 months, with a median time of 43 months. Cases with nonrestricted activity recovery at postoperative week 2 and 4 were 973, 978 in the under 60 years group and 2 208, 2 222 in the 60 years or older group, respectively, showing no statistically significant difference between the 2 groups （χ2=0.113, P〉0.05）. The recurrence of hernia, severe complications, serum tumescence, paresthesia and enteroparalysis were detected in 1, 0, 49, 5, 1 sides in the under 60 years group and 11, 3, 132, 16, 2 sides in the 60 years or older group, respectively, with no statistically significant difference between the 2 groups （χ2=1.556, 0.269, 0.254, P〉0.05）. The urinary retention in the under 60 years group and 60 years or older group was respectively detected in 6 and 44 sides, showing a statistically significant difference between 2 groups （χ2=6.956, P〈0.05）. Conclusion：LIHR is safe and effective in elderly patients, and it can achieve good clinical efficacy under selecting reasonable operation procedures and patches.