Koehler R H
Martha's Vineyard Hospital, One Hospital Road, Oak Bluffs, MA 02557, USA.
Surg Endosc. 2002 Mar;16(3):512-20. doi: 10.1007/s00464-001-8166-y. Epub 2001 Nov 16.
The incidence of bilateral inguinal hernias reported for total extra peritoneal (TEP) laparoscopic hernia repair, which reaches 45%, appears to be higher than that seen in studies of transabdominal laparoscopic and open repair. Given the unique ability of diagnostic laparoscopy to diagnose occult contralateral hernias (OCH) accurately, this study looked at how concurrent transabdominal diagnostic laparoscopy (TADL) would influence planned TEP repairs.
A prospective study oF 100 consecutive TEP cases was conducted. All patients had diagnostic laparoscopy via a 5-mm 45 degrees scope through an umbilical incision with 15 mmHg of pneumoperitoneum, followed by laparoscopic TEPrepair. A contralateral occult hernia was diagnosed and repaired if a true peritoneal eventration through the inguinal region was observed.
Among the 100 patients, preoperative diagnosis suggested 31 bilateral hernias (31%), whereas TADL confirmed 25 bilateral hernias (25%). Of these 25 bilateral hernias, TADL confirmed 16 that had been diagnosed preoperatively (64%), but excluded 15 contralateral hernias that were incorrectly diagnosed (37%). Transabdominal diagnostic laparoscopy found nine OCHs, representing 36% of all bilateral hernias and 13% of the 69 preoperatively determined unilateral hernias. The preoperative physician examination false-negative rate for contralateral hernias was 36%, and the false-positive rate was 37%. In 26 cases (26%), TADL changed the operative approach.
In this study, patients believed to have unilateral inguinal hernias had OCHs in 13% of cases when examined by TADL. The actual bilateral hernia incidence was 25%, with a 37% false-positive rate for preoperatively diagnosed bilateral hernias. The high rate of bilateral hernias reported by the TEP approach alone suggests that some OCH findings may be an artifact of the TEP dissection. However, failure to search for an OCH could result in up to 13% of patients subsequently requiring a second repair. Because some surgeons are concerned about unnecessary TEP dissection of the asymptomatic contralateral side, the approach described here may offer a solution to accurate diagnosis of the contralateral inguinal region during planned laparoscopic TEP hernia repair.
据报道，完全腹膜外（TEP）腹腔镜疝修补术双侧腹股沟疝的发生率达45%，这似乎高于经腹腹腔镜和开放修补术的相关研究结果。鉴于诊断性腹腔镜检查具有准确诊断隐匿性对侧疝（OCH）的独特能力，本研究探讨了同期经腹诊断性腹腔镜检查（TADL）对计划进行的TEP修补术有何影响。
对连续100例TEP病例进行前瞻性研究。所有患者均通过脐部切口，使用5毫米45度腹腔镜，在15毫米汞柱气腹压力下进行诊断性腹腔镜检查，随后进行腹腔镜TEP修补术。若观察到腹股沟区有真正的腹膜膨出，则诊断并修补对侧隐匿性疝。
100例患者中，术前诊断提示31例双侧疝（31%），而TADL确诊25例双侧疝（25%）。在这25例双侧疝中，TADL确诊了术前诊断的16例（64%），但排除了15例假性诊断的对侧疝（37%）。经腹诊断性腹腔镜检查发现9例OCH，占所有双侧疝的36%，占术前确定的69例单侧疝的13%。对侧疝术前医生检查的假阴性率为36%，假阳性率为37%。26例（26%）患者中，TADL改变了手术方式。
在本研究中，经TADL检查，被认为患有单侧腹股沟疝的患者中有13%存在OCH。实际双侧疝发生率为25%，术前诊断双侧疝的假阳性率为37%。仅TEP方法报告的双侧疝高发生率表明，一些OCH发现可能是TEP解剖的人为结果。然而，不探查OCH可能导致高达13%的患者随后需要二次修补。由于一些外科医生担心对无症状对侧进行不必要的TEP解剖，本文所述方法可能为计划进行的腹腔镜TEP疝修补术中准确诊断对侧腹股沟区提供一种解决方案。
