应用腹腔镜治疗小儿对侧未闭隐匿性鞘状突

Laparoscopy of contralateral patent processus vaginalis in children with unilateral inguinal hernia

目的通过对小儿单侧腹股沟斜疝经腹腔镜与开放手术诊治的病例进行回顾性研究，探讨腹腔镜技术对对侧未闭隐匿鞘状突病例的诊治及其与异时性腹股沟斜疝的相关性。方法回顾性分析2011年1月至2013年12月间，在两个医疗中心分别经腹腔镜和普通开放手术治疗的单侧腹股沟斜疝的患儿病例，分别为2855例和2538例。统计分析患儿性别、年龄、单侧斜疝发病部位；腹腔镜发现对侧未闭的隐匿鞘状突（contralateral patent processus vaginalis，CPPV）病例数；普通开放术后对侧异时性腹股沟斜疝（metachronous inguinal hernia，MIH）病例数及间隔时间；两组术后斜疝的复发率。分别统计分析相关参数进行比较。结果开放组共2538例，男83．6％，女16．4％；平均年龄（2．45±2．18）岁；右侧66．0％，左侧34．0％。MIH组共62例，男51例，右侧MIH26例，左侧MIH25例，MIH发生率2．4％；女11例，右侧MIH4例，左侧MIH7例，MIH发生率2．6％。隐匿平均时间间隔为（18．71±13．80）个月。术后复发率1．02％，复发平均时间（9．93±8．58）个月。腹腔镜组共2855例，男82．5％，女17．5％；平均年龄（2．44±2．15）岁；右侧60．4％，左侧39．6％。CPPV共1469例（51．5％），右侧CPPV603例（41．0％），左侧CPPV866例（59．0％）。侧别和性别在CPPV发病率上都差异无统计学意义（53．4％比50．2％；50．7％比55．1％，P〉0．05）。术后复发率0．25％，相比开放组差异有显著的统计学意义（x^2=13．42，P〈0．01）。复发平均时间（6．43±3．99）个月，相比开放组差异无统计学意义（t=1．04，P〉0．05）。腹腔镜组发生MIH3例。MIH／CPPV的风险率比（RR）为0．05（95％CI：0．03～0．06）。结论腹腔镜下治疗小儿单侧腹股沟斜疝相比普通开放手术，斜疝复发率及MIH的发生率明显减少。腹腔镜技术在治疗单侧腹股沟斜疝的同时，能准确检测出CPPV，但对其常规手术，尽管明显减少MIH的发生率，但造成过度医疗，因为要阻止1例MIH的发生，需要对20例CPPV进行手术。MIH的低发生率不支持常规对对侧无临床症状的腹股沟区进行普通手术探查。

Objective To explore the application of laparoscopy for diagnosing and treating contralateral patent processus vaginalis and elucidate the relationship of contralateral patent processus vaginalis （CPPV） and metaehronous inguinal hernia （MIH） through laparoscopy and herniorrhaphy in children with unilateral inguinal hernia. Methods At two pediatric surgical centers between January 2011 and December 2013, a total of 2,538 patients with unilateral inguinal hernia underwent open repair while 2,855 patients received laparoscopic evaluations of contralateral inguinal region for determining whether or not CPPV co-existed during unilateral inguinal hernia repair. All CPPVs were repaired. The parameters of demographics, initial hernia sideness and number of CPPV/MIH cases were recorded. Meanwhile interval time between initial repair and an onset of MIH and recurrence rates after initial operation were compared. Follow-ups were conducted until December 2014. Results Among 2,538 cases of initial unilateral inguinal hernia, there were 2,122 （83.6%） boys and 416 （16. 4%） girls with a mean age of 2. 45 ± 2. 18 years. Initial hernia occurred at right （66%） and left （34 %） sides. Among 62 MIH cases, there were 51 （2. 4 %） boys and 11 （2.6 % ） girls （P = 0. 77）.The average interval time between initial repair and an onset of MIH was 18. 71 ± 13.80 months and the rate of recurrence 1.02% at 9. 93 ± 8. 58 months after initial operation. Among 2,855 laparoscopic cases, there were 2,356（82. 5%） boys and 499（17. 5%） girls with a mean age of 2.44±2. 15 years. Laparoscopic examination identified CPPV in 1,469 （51.5 % ） cases, including 603 （41.0%） at right side and 866（59. 0%） at left side. The incidence of CPPV was 53.4% at right side and 50. 2% at left side （x^2 = 2. 73,P〉0. 05）. No association existed between genders in CPPV （50. 7% vs 55.1%, P〉 0. 05）. As compared with recurrence rate of open repair, a lower incidence exhibited for laparoscopic repair （0. 25% vs 1.02%, P〈0. 01）. However the time of postoperative recurrence had no statistical significance （t = 1.04, P〉0. 05）. Furthermore, the incidence of MIH was 0. 1% after negative laparoscopy. And the risk ratio between the incidence of MIH and CPPV was 0. 05 （95%CI： 0. 03- 0. 06）. Conclusions The recurrence rate and incidence of MIH decreases more in laparoscopy than herniorrhaphy after repairing of pediatric unilateral inguinal hernia. Laparoscopy can easily detect contralateral patent processus vaginalis during hernia repairing. However, excessive treatment occurs during routine procedures. Despite a lower incidence of MIH, routine open comralateral inguinal exploration is not recommended for all cases of initial unilateral inguinal hernia.