背景:当肠的一部分通过腹肌突出时,就会发生腹股沟疝。在成年人中,男性比女性更容易患这种常见病。腹股沟疝可以通过“观察等待”进行监测,但如果症状持续或恶化,通常需要手术,可以是开放式或腹腔镜。成人腹股沟疝的腹腔镜(锁孔)修复通常使用经腹腹膜前(TAPP)或完全腹膜外(TEP)方法进行。两种方法都包括使用放置在腹壁腹膜衬里前面的网片,但是对于TAPP技术,需要进入腹腔放置网孔,对于TEP技术,整个过程是在腹壁的腹膜衬里外侧进行的。一种方法是否优于另一种方法尚未确定,关于它们的相对好处和危害存在争议。TEP的一个优点是它避免了腹腔;缺点是它需要临床医生更陡峭的学习曲线。TAPP被认为更简单,可以检查对侧,但与TEP相比,TAPP可能有更高的内脏损伤风险.这是对2005年首次发布的Cochrane评论的更新。
目的:比较腹腔镜TAPP技术与腹腔镜TEP技术在成人腹股沟疝修补术中的利弊。
方法:2022年10月25日,作者在Cochrane图书馆搜索了Cochrane中央对照试验注册中心(CENTRAL);OvidMEDLINE(R)Epub在打印前,过程中和其他非索引引文,OvidMEDLINE(R)日报,和OvidMEDLINE(R);和OvidEmbase,已发表的随机对照试验。为了确定正在进行的研究,我们检索了ClinicalTrials.gov和WHO国际临床试验注册平台(ICTRP).
方法:所有前瞻性随机,准随机化,将腹腔镜TAPP技术与腹腔镜TEP技术在成人腹股沟疝修补术中进行比较的成群随机试验也符合纳入标准.如果我们可以提取腹股沟疝的数据,我们包括涉及不同类型腹股沟疝的混合研究。研究还可能包括一组通过开放手术接受疝气修复的参与者,但这些组不包括在我们的审查中。
方法:两位综述作者独立评估了试验资格,从纳入的研究中提取数据,并评估纳入研究的偏倚风险。审查的主要结果是严重不良事件,慢性疼痛(手术后至少持续六个月),和疝气复发。我们还评估了围手术期的各种次要结局,术后早期,和术后晚期时间点。我们使用随机效应模型进行了统计分析,并将结果表示为二分结果的比值比(OR)和连续结果的平均差(MD),与他们各自的95%置信区间(CI)。我们使用等级来评估关键结果的证据的确定性,中度,低或非常低。
结果:我们在本综述更新中纳入了23项研究,将1156人随机分配给TAPP,将1110人随机分配给TEP,都需要腹股沟疝的修复.研究样本量从40到316不等。绝大多数研究参与者是男性。我们认为大多数研究存在“高”或“不清楚”的偏倚风险。对于我们评估的所有结果,我们对证据确定性的判断都很低或很低。TAPP和TEP腹腔镜技术在严重不良事件方面可能几乎没有差异(0.4%对0.7%;OR0.58,95%CI0.15至2.32,P=0.45,I2=0%;19项研究,1735名参与者;证据确定性低);和疝气复发(1.2%对1.1%;OR1.14,95%CI0.49至2.62,P=0.97,I2=0%;17项研究,1712名参与者;证据确定性低)。关于TAPP与TEP技术对慢性疼痛的影响的证据非常不确定(OR0.62,95%CI0.20至1.97,P=0.68,I2=0%;6项研究,860名参与者;证据确定性非常低)。就次要结果而言,TAPP与TEP技术治疗围手术期内脏和血管损伤的证据非常不确定(15项研究,1523名参与者;证据的确定性非常低),以及术后早期(≤30天)的血肿或血清肿(OR0.86,95%CI0.54至1.37,P=0.3861,I2=0%;15项研究,1423名参与者;证据的确定性非常低)。与TAPP相比,TEP技术转换为另一种疝修补术(TAPP技术或开放手术)的风险更高(2.5%对0.7%;OR0.28,95%CI0.09至0.84,P=0.02,I2=0%;13项研究,1178名参与者;证据确定性低)。只有两项研究(474名参与者)报告了术后晚期(>30天)的生活质量;总体而言,从术前到术后评估,生活质量有所改善,但证据表明技术之间几乎没有差异(证据的确定性低)。
结论:本综述更新发现,TAPP和TEP技术在严重不良事件方面可能几乎没有差异,疝气复发,或慢性疼痛(低到非常低的确定性证据)。关于使用哪种方法的决定将最有可能反映外科医生和患者的偏好,直到获得高确定性证据。与需要从TAPP转换为开放手术的风险相比,需要从TEP转换为TAPP或开放手术的风险可能更高(低确定性证据)。如果外科医生选择TEP作为他们的标准腹腔镜方法,他们可以考虑有一个策略来处理潜在的转换需求。这可能包括对TAPP方法的熟练程度或已告知患者转换为开放手术的风险。对于外科医生或外科部门来说,腹腔镜技术的选择应涉及患者及其家属或护理人员的共同决策.未来的研究可能集中在患者报告的结果上,比如生活质量。
BACKGROUND: An inguinal hernia occurs when part of the intestine protrudes through the abdominal muscles. In adults, this common condition is much more likely in men than in women. Inguinal hernia can be monitored by \'watchful waiting\', but if symptoms persist or worsen, surgery is usually required, which can be open or laparoscopic. Laparoscopic (keyhole) repair of inguinal hernias in adults is generally performed using either the transabdominal preperitoneal (TAPP) or the totally extraperitoneal (TEP) method. Both methods include the use of mesh placed in front of the peritoneal lining of the abdominal wall, but for the TAPP technique, the abdominal cavity needs to be entered to place the mesh, and for the TEP technique, the whole procedure is done on the outside of the peritoneal lining of the abdominall wall. Whether one method is superior to the other has not been established, and there is debate about their relative benefits and harms. An advantage of TEP is its avoidance of the abdominal cavity; the downside is that it requires a steeper learning curve for clinicians. TAPP is considered simpler and makes it possible to inspect the contralateral side, but TAPP may have a higher risk of visceral injury compared to TEP. This is an update of a Cochrane review first published in 2005.
OBJECTIVE: To compare the benefits and harms of laparoscopic TAPP technique versus laparoscopic TEP technique for inguinal hernia repair in adults.
METHODS: On 25 October 2022, the authors searched the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library; Ovid MEDLINE(R) Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Ovid MEDLINE(R) Daily, and Ovid MEDLINE(R); and Ovid Embase, for published randomised controlled trials. To identify studies in progress, we searched ClinicalTrials.gov and the WHO International Clinical Trial Registry Platform (ICTRP).
METHODS: All prospective randomised, quasi-randomised, and cluster-randomised trials that compared the laparoscopic TAPP technique with the laparoscopic TEP technique for inguinal hernia repair in adults were eligible for inclusion. We included studies that involved a mix of different types of groin hernia if we could extract data for the inguinal hernias. Studies may have also included a group of participants receiving hernia repair by open surgery, but these groups were not included in our review.
METHODS: Both review authors independently evaluated trial eligibility, extracted data from included studies, and assessed the risk of bias in the included studies. The review\'s primary outcomes were serious adverse events, chronic pain (persisting for at least six months after surgery), and hernia recurrence. We also assessed a variety of secondary outcomes at perioperative, early postoperative, and late postoperative time points. We performed statistical analyses using the random-effects model, and expressed the results as odds ratios (ORs) for dichotomous outcomes and mean differences (MDs) for continuous outcomes, with their respective 95% confidence intervals (CIs). We used GRADE to assess the certainty of evidence for key outcomes as high, moderate, low or very low.
RESULTS: We included 23 studies in this review update, which randomised 1156 people to TAPP and 1110 people to TEP, all requiring repair of inguinal hernias. Study sample sizes varied from 40 to 316 participants. The vast majority of study participants were male. We judged most studies to be at \'high\' or \'unclear\' risk of bias. Our judgements of the certainty of the evidence were low or very low for all outcomes we assessed. There may be little to no difference between TAPP and TEP laparoscopic techniques for serious adverse events (0.4% versus 0.7%; OR 0.58, 95% CI 0.15 to 2.32, P = 0.45, I2 = 0%; 19 studies, 1735 participants; low certainty of evidence); and hernia recurrence (1.2% versus 1.1%; OR 1.14, 95% CI 0.49 to 2.62, P = 0.97, I2 = 0%; 17 studies, 1712 participants; low certainty of evidence). The evidence is very uncertain about the effects of TAPP versus TEP techniques on chronic pain (OR 0.62, 95% CI 0.20 to 1.97, P = 0.68, I2 = 0%; 6 studies, 860 participants; very low certainty of evidence). In terms of secondary outcomes, the evidence is very uncertain for TAPP versus TEP techniques for perioperative visceral and vascular injury (15 studies, 1523 participants; very low certainty of evidence), and for haematoma or seroma during the early (≤ 30 days) postoperative phase (OR 0.86, 95% CI 0.54 to 1.37, P = 0.3861, I2 = 0%; 15 studies, 1423 participants; very low certainty of evidence). TEP technique may carry a higher risk of conversion to another hernia repair method (either TAPP technique or open surgery) when compared to TAPP (2.5% versus 0.7%; OR 0.28, 95% CI 0.09 to 0.84, P = 0.02, I2 = 0%; 13 studies, 1178 participants; low certainty of evidence). Only two studies (474 participants) reported quality of life in the late (> 30 days) postoperative phase; overall, there was an improvement in quality of life from the pre- to post-operative assessment, but the evidence suggests little to no difference between the techniques (low certainty of evidence).
CONCLUSIONS: This review update found that there may be little to no difference between the TAPP and TEP techniques for serious adverse events, hernia recurrence, or chronic pain (low- to very-low-certainty evidence). Decisions about which method to use will most likely reflect surgeon and patient preference until high-certainty evidence becomes available. There may be a higher risk of needing to convert from TEP to TAPP or open surgery when compared to the risk of needing to convert from TAPP to open surgery (low-certainty evidence). If surgeons opt for TEP as their standard laparoscopic method, they could consider having a strategy for how to handle the potential need for conversion. This might include proficiency in the TAPP approach or having informed the patient about the risk of conversion to open surgery. For surgeons or surgical departments, the choice of a laparoscopic technique should involve shared decision-making with patients and their families or carers. Future research could focus on patient-reported outcomes, such as quality of life.