腹股沟疝无张力修补术后慢性疼痛发生率及其影响因素分析

Incidence and influence factors analysis of chronic postoperative inguinal pain after tension-free repair foringuinal hernia

目的：探讨腹股沟疝无张力修补术后慢性疼痛发生率及其相关影响因素。方法： 采用回顾性病例对照研究方法。收集2011年1月至2017年8月新疆维吾尔自治区人民医院收治的1 188例行腹股沟疝无张力修补术患者的临床病理资料。观察指标：（1）手术及术后情况。（2）随访情况。（3）术后慢性疼痛发生的影响因素分析。采用门诊或电话方式进行随访，了解患者术后1、3、6个月及1年腹股沟区疼痛及并发症发生情况。随访时间截至2018年8月。正态分布的计量资料采用±s表示，偏态分布的计量资料采用M（范围）表示。单因素分析采用x2检验，多因素分析采用Logistic回归模型。结果：（1）手术及术后情况：1 188例患者均行腹股沟疝无张力修补术，85例（7.155%，85/1 188）发生术后慢性疼痛，其中行开腹术患者76例（8.370%，76/908），行腹腔镜术患者9例（3.214%，9/280）。（2）随访情况：1 188例患者均获得随访，随访时间为12～36个月，中位随访时间为19个月。术后随访1、3、6个月及1年腹股沟区疼痛（视觉模拟评分〉3分）发生率依次为11.785%（140/1 188）、7.155%（85/1 188）、5.808%（69/1 188）、3.199%（38/1 188）。患者根据病情选择合理的个体化治疗方案，经药物治疗、物理治疗（针灸等）、神经阻滞和心理治疗（严重者可辅助使用抗焦虑药物）等保守治疗后慢性疼痛缓解。有5例腹股沟疝无张力修补术后慢性疼痛患者给予手术治疗，其中1例通过手术解除被结扎的神经，3例疼痛与补片相关取出补片，1例拆除固定缝线等治疗后慢性疼痛缓解。随访期间，161例患者发生切口血肿，75例患者发生切口感染，5例患者发生切口裂开，给予加强切口管理、换药、理疗等对症处理均痊愈。7例患者发生补片感染予去除补片处理。68例患者术后复发，其中53例再次行手术治疗，18例合并有引起严重腹腔内压力增高的疾病，建议治疗合并症后再行手术治疗。（3）术后慢性疼痛影响因素分析：①单因素分析结果显示：患者性别、年龄、体质量指数、手术方式、术前疼痛程度、术中神经牵拉或损伤及切口感染是腹股沟疝无张力修补术后慢性疼痛发生的相关因素（x2=21.002，6.715，6.012，8.563，11.887，49.447，10.025，P〈0.05）。②多因素分析结果显示：患者性别、体质量指数、手术方式、术前疼痛程度、术中神经牵拉或损伤及切口感染是影响腹股沟疝修补术后慢性疼痛发生的独立影响因素（比值比=1.267，2.986，1.661，3.208，2.034，1.871，95%可信区间：1.042～1.392，1.372～4.901，0.998～2.758，1.933～6.013，1.556～3.118，1.095～3.534，P〈0.05）。结论：影响腹股沟疝无张力修补术后慢性疼痛发生的独立影响因素为患者性别、体质量指数、手术方式、术前疼痛程度、术中神经牵拉或损伤及切口感染。临床应加强术前疼痛管理及心理疏导、术中应精细操作、保护腹股沟区神经、加强术后切口管理，以预防和减少腹股沟疝无张力修补术后慢性疼痛的发生。

Objective：To investigate the incidence and influence factors of chronic postoperative inguinal pain （CPIP） after tension-free repair for inguinal hernia. Methods：The retrospective case-control study was conducted. The clinicopathological data of 1 188 patients who underwent tension-free repair for inguinal hernia in the People′s Hospital of Xinjiang Uygur Autonomous Region between January 2011 and August 2017 were collected. Observation indicators： （1） surgical and postoperative situations; （2） follow-up; （3） influence factors analysis of CPIP. follow-up using outpatient examination and telephone interview was performed to detect inguinal pain and complications at 1, 3, 6 months and 1 year postoperatively up to August 2018. Measurement data with normal distribution were represented as ±s. Measurement data with skewed distrubution were described as M （range）. The univariate and multivariate analysis were done using the chisquare test and Logistic regression model. Results：（1） Surgical and postoperative situations： 1 188 patients underwent successful tension-free repair for inguinal hernia. Eightyfive patients （7.155%, 85/1 188） had CPIP, including 76 （8.370%, 76/908） undergoing open surgery and 9 （3.214%, 9/280） undergoing laparoscopic surgery. （2） follow-up： 1 188 patients were followed up for 12-36 months, with a median time of 19 months. Incidence rates of CPIP with visual analogue score 〉 3 were 11.785%（140/1 188）, 7.155%（85/1 188）, 5.808%（69/1 188）, 3.199%（38/1 188） at 1, 3, 6 months and 1 year postoperatively. Patients were given individualized and reasonable treatment according to their own conditions and CPIP was relieved after conservative treatment including drug treatment, physiotherapy such as acupuncture, nerve block and psychotherapy. Of 5 patients with CPIP after tension-free repair for inguinal hernia undergoing surgeries, 1 was relieved nerve ligation by surgery, 3 with mesh related pain were removed meshes, 1 was taken the fixed stiches out. They were relieved CPIP after above treatments. During the follow-up, 161 patients with incisional seroma, 75 with incisional infection and 5 with disruption of wound were cured by symptomatic treatments including reinforced incision management, dressing change and physiotherapy. Seven patients with mesh infection were removed meshes. Of 68 patients with hernia recurrence, 53 had reoperation, 18 complicated with diseases induced severe increased intraabdominal pressure were suggested to undergo surgeries after treatment of complications. （3） Influence factors analysis of CPIP： ① results of univariate analysis showed that sex, age, body mass index, surgical method, degree of preoperative pain, intraoperative nerve stretching or injury and incisional infection were related factors affecting CPIP after tension-free repair for inguinal hernia （χ2=21.002, 6.715, 6.012, 8.563, 11.887, 49.447, 10.025, P〈0.05）. ② Results of multivariate analysis showed that sex, body mass index, surgical method, degree of preoperative pain, intraoperative nerve stretching or injury and incisional infection were independent related factors affecting CPIP after tension-free repair for inguinal hernia （odds ratio=1.267, 2.986, 1.661, 3.208, 2.034, 1.871, 95% confidence interval： 1.042-1.392, 1.372-4.901, 0.998-2.758, 1.933-6.013, 1.556-3.118, 1.095-3.534, P〈0.05）. Conclusions：Sex, body mass index, surgical method, degree of preoperative pain, intraoperative nerve stretching or injury and incisional infection are independent related factors affecting CPIP after tension-free repair for inguinal hernia. Preoperative pain management and psychological counseling, intraoperative refine performance, inguinal nerve protection and postoperative incisional management should be reinforced to prevent and reduce incidence of CPIP.