Khajanchee Y S, Urbach D R, Swanstrom L L, Hansen P D
Department of Minimally Invasive Surgery and Surgical Research, Legacy Health Systems, 501 N. Graham, Suite 120, Portland, OR 97227, USA.
Surg Endosc. 2001 Oct;15(10):1102-7. doi: 10.1007/s004640080088.
Recently there has been interest in performing laparoscopic herniorrhaphies without the use of staples or tacks to fix the mesh. Although mesh fixation has been linked to an increased incidence of nerve injury and involves increased operative costs, many surgeons feel that fixation is necessary to reduce the risk of hernia recurrence. This study evaluates the outcomes of laparoscopic herniorrhapies performed with and without mesh fixation at our institution.
We retrospectively evaluated our last 172 laparoscopic herniorrhaphies, which span a period of conversion from staple fixation to nonfixation of total extraperitoneal herniorrhaphies using systematic chart review and follow-up self-administered questionnaires. The outcomes assessed were the incidences of postoperative neuralgia and hernia recurrence. Adjustment for important prognostic factors was achieved using Cox regression for estimating the risk of recurrence, and multiple logistic regression for estimating the risk of neuropathic complications.
Of 172 laparoscopic herniorrhaphies performed in 129 patients since July 1993, 105 were accomplished without mesh fixation, and 67 were performed with fixation of mesh to the abdominal wall. There were no significant differences in demographics between the two groups. A trend toward a higher incidence of neuropathic complications was observed in the mesh-fixation group (risk ratio [RR], 2.2; 95% CI, 0.5-10). A nonsignificant increased risk of hernia recurrence with fixation of mesh was observed (4.2 vs 1.6 per 100 hernia-years at risk; RR, 2.3; 95% CI, 0.4-13.10), but this finding may be associated with a selection bias with regard to giant hernia defects.
Our data suggest that mesh fixation to the abdominal wall may be avoided in total extraperitoneal repairs without increasing the risk of hernia recurrence and neuropathic complications. The increased risk of recurrence observed with mesh fixation possibly results from selection bias. Large randomized controlled studies are needed to determine whether mesh fixation is truly related to neuropathic complications and the incidence of recurrence.
近来，人们对在不使用吻合钉或缝钉固定补片的情况下进行腹腔镜疝修补术产生了兴趣。尽管补片固定与神经损伤发生率增加有关，且手术成本较高，但许多外科医生认为固定对于降低疝复发风险是必要的。本研究评估了在我们机构进行的有或无补片固定的腹腔镜疝修补术的结果。
我们回顾性评估了我们最近的172例腹腔镜疝修补术，这些手术涵盖了从使用吻合钉固定到完全腹膜外疝修补术不固定的转变时期，采用系统的病历审查和随访自行填写的问卷。评估的结果是术后神经痛和疝复发的发生率。通过Cox回归估计复发风险以及通过多元逻辑回归估计神经病变并发症风险，对重要的预后因素进行了调整。
自1993年7月以来，在129例患者中进行了172例腹腔镜疝修补术，其中105例在不进行补片固定的情况下完成，67例进行了补片与腹壁的固定。两组之间的人口统计学特征无显著差异。在补片固定组中观察到神经病变并发症发生率有升高趋势（风险比[RR]，2.2；95%可信区间，0.5 - 10）。观察到补片固定时疝复发风险有非显著增加（每100个疝年的风险为4.2对1.6；RR，2.3；95%可信区间，0.4 - 13.10），但这一发现可能与巨大疝缺损的选择偏倚有关。
我们的数据表明，在完全腹膜外修补术中可以避免将补片固定到腹壁，而不会增加疝复发和神经病变并发症的风险。补片固定时观察到的复发风险增加可能是由选择偏倚导致的。需要进行大型随机对照研究来确定补片固定是否真的与神经病变并发症和复发发生率有关。
