目标:目前,腹股沟疝在巴西人群中非常普遍,占所有腹壁疝的75%。纠正它们的推荐治疗方法是腹股沟疝修补术,可以通过开放手术进行,主要使用列支敦士登技术,或者腹腔镜检查,主要通过经腹腹膜前修复(TAPP)或完全腹膜外修复(TEP)方法。像任何手术一样,这些手术有术后并发症,疼痛是最常见和最虚弱的。目前,在欧洲和巴西的指导方针中,开放Lichtenstein和内镜腹股沟疝技术被推荐为原发性单侧疝修复的最佳循证选择,前提是外科医生在特定手术方面有足够的经验.在这个问题上,外科医生应该根据对每一种手术的益处和风险的评估做出选择,并与它耐心地分享决策。因此,本综述的目的是通过比较上述手术方法来评估慢性术后疼痛的发生率,以评估哪种手术方法对患者造成的残疾较少。
方法:在Medline(PubMed)上进行了直到2024年5月的搜索,科克伦(中部),和紫丁香数据库。选择仅限于随机临床试验,将TAPP或TEP与LC进行比较的非随机临床试验和队列研究,评估2017年至2023年间发表的慢性术后疼痛的发生率。使用GRADEPro工具评估证据确定性,使用RoB2.0工具和ROBINSI工具评估偏倚风险。共纳入13项研究。结果:荟萃分析显示两种技术的组间差异显著,有利于腹腔镜手术,术后腹股沟痛发生率较低,相对危险度为0.49(95%CI=0.32,0.75;I2=66%(P=0.001);Z=3.28(P=0.001),证据确定性较低.
结论:与开腹Lichtenstein技术相比,腹腔镜TEP/TAPP技术术后慢性疼痛的发生率较低,这意味着前者可以为需要腹股沟疝修补术的患者带来更多的好处。然而,需要进一步的随机临床试验来优化分析,最小化偏差。
OBJECTIVE: Currently, inguinal hernias are highly prevalent in the Brazilian population, accounting for 75% of all abdominal wall hernias. The recommended treatment to correct them is inguinal herniorrhaphy, which can be performed through open surgery, mainly using the Lichtenstein technique, or laparoscopically, primarily through Transabdominal Preperitoneal Repair (TAPP) or Total Extraperitoneal Repair (TEP) approaches. Like any surgery, these procedures have post-operative complications, with pain being the most common and debilitating. Currently, in European and Brazilian guidelines, the open Lichtenstein and endoscopic inguinal hernia techniques are recommended as best evidence-based options for repair of a primary unilateral hernia providing the surgeon is sufficiently experienced in the specific procedure. In that matter, the surgeon should make a choice based on assessment of the benefits and risks of performing each of them, and practice shared making decision with it patient. Therefore, the objective of this review was to assess the incidence of chronic postoperative pain by comparing the aforementioned surgical approaches to evaluate which procedure causes less disability to the patient.
METHODS: The search conducted until May 2024 was performed on Medline (PubMed), Cochrane (CENTRAL), and Lilacs databases. The selection was limited to randomized clinical trials, nonrandomized clinical trials and cohort studies comparing TAPP or TEP to LC, evaluating the incidence of chronic postoperative pain published between 2017 and 2023. Evidence certainty was assessed using the GRADE Pro tool, and bias risk was evaluated with the RoB 2.0 tool and ROBINS I tool. Thirteen studies were included. RESULTS: The meta-analysis showed a significant difference between the groups in both techniques, favoring the laparoscopic approach, which had a lower occurrence of postoperative inguinodynia with a relative risk of 0.49 (95% CI = 0.32, 0.75; I2 = 66% (P = 0.001); Z = 3.28 (P = 0.001) with low certainty of evidence.
CONCLUSIONS: The presence of chronic postoperative pain was lower in laparoscopic TEP/TAPP techniques when compared to the open Lichtenstein technique, meaning that the former can bring more benefits to patients who requires inguinal herniorrhaphy. Nevertheless, further randomized clinical trials are needed to optimize the analysis, minimizing the bias.