Trevisonno M, Kaneva P, Watanabe Y, Fried G M, Feldman L S, Andalib A, Vassiliou M C
Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, McGill University, 1650 Cedar Avenue, Montreal, QC, H3G 1A4, Canada.
Department of Gastroenterological Surgery II, Hokkaido University Graduate School of Medicine, Sapporo, Japan.
Hernia. 2015 Oct;19(5):725-33. doi: 10.1007/s10029-015-1358-5. Epub 2015 Mar 10.
The selection of a laparoscopic approach for inguinal hernias varies among surgeons. It is unclear what is being done in actual practice. The purpose of this study was to report practice patterns for treatment of inguinal hernias among Quebec surgeons, and to identify factors that may be associated with the choice of operative approach.
We studied a population-based cohort of patients who underwent an inguinal hernia repair between 2007 and 2011 in Quebec, Canada. A generalized linear model was used to identify predictors associated with the selection of a laparoscopic approach.
49,657 inguinal hernias were repaired by 478 surgeons. Laparoscopic inguinal hernia repair (LIHR) was used in 8 % of all cases. LIHR was used to repair 28 % of bilateral hernias, 10 % of recurrent hernias, 6 % of unilateral hernias, and 4 % of incarcerated hernias. 268 (56 %) surgeons did not perform any laparoscopic repairs, and 11 (2 %) surgeons performed more than 100 repairs. These 11 surgeons performed 61 % of all laparoscopic cases. Patient factors significantly associated with having LIHR included younger age, fewer comorbidities, bilateral hernias, and recurrent hernias.
An open approach is favored for all clinical scenarios, even for situations where published guidelines recommend a laparoscopic approach. Surgeons remain divided on the best technique for inguinal hernia repair: while more than half never perform LIHR, the small proportion who perform many use the technique for a large proportion of their cases. There appears to be a gap between the best practices put forth in guidelines and what surgeons are doing in actual practice. Identification of barriers to the broader uptake of LIHR may help inform the design of educational programs to train those who have the desire to offer this technique for certain cases, and have the volume to overcome the learning curve.
外科医生在腹股沟疝腹腔镜手术方式的选择上存在差异。目前尚不清楚实际临床实践中的具体情况。本研究旨在报告魁北克外科医生治疗腹股沟疝的实际操作模式，并确定可能与手术方式选择相关的因素。
我们研究了2007年至2011年在加拿大魁北克接受腹股沟疝修补术的基于人群的队列患者。采用广义线性模型来确定与腹腔镜手术方式选择相关的预测因素。
478名外科医生共为49657例腹股沟疝患者实施了手术。所有病例中，8%采用了腹腔镜腹股沟疝修补术（LIHR）。LIHR用于修补28%的双侧疝、10%的复发性疝、6%的单侧疝和4%的嵌顿疝。268名（56%）外科医生未进行任何腹腔镜修补手术，11名（2%）外科医生进行了超过100例修补手术。这11名外科医生完成了所有腹腔镜手术病例的61%。与接受LIHR显著相关的患者因素包括年龄较小、合并症较少、双侧疝和复发性疝。
对于所有临床情况，开放手术方式更受青睐，即使在已发表的指南推荐腹腔镜手术方式的情况下也是如此。外科医生在腹股沟疝修补的最佳技术上仍存在分歧：超过一半的医生从未进行过LIHR，而少数进行大量手术的医生在其大部分病例中采用该技术。指南中提出的最佳实践与外科医生的实际操作之间似乎存在差距。识别LIHR广泛应用的障碍可能有助于设计教育项目，以培训那些希望在特定病例中提供该技术且有足够手术量以克服学习曲线的医生。
