Rehman Sheik, Hajibandeh Shahin, Hajibandeh Shahab
Department of General Surgery, Royal Bolton Hospital, Bolton.
Department of General Surgery, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham.
Surg Laparosc Endosc Percutan Tech. 2019 Aug;29(4):233-241. doi: 10.1097/SLE.0000000000000627.
As the experience grew with laparoscopic splenectomy (LS) more surgeons appreciate the advantages of lateral approach compared with conventional anterior approach. In view of this we aimed to compare anterior approach and lateral approach in LS.
We conducted a search of electronic information sources to identify all randomized controlled trials (RCTs) and observational studies comparing anterior and lateral approach in patients undergoing LS. Primary outcomes included need for blood transfusion, intraoperative blood loss, and conversion to open surgery. The secondary outcomes included postoperative morbidity, operative time, time to oral intake, length of hospital stay, need for reoperation, and mortality. Random or fixed-effects modeling were applied to calculate pooled outcome data.
We identified 1 RCT and 4 retrospective observational studies, enrolling 728 patients. The baseline characteristics included populations in both groups were comparable. Anterior approach was associated with higher need for blood transfusion [odds ratio (OR), 4.83, 95% confidence interval (CI), 2.31-10.97; P=0.0001]; higher risks of intraoperative blood loss [mean difference (MD), 101.06, 95% CI, 52.05-150.06; P=0.0001], conversion to open surgery (OR, 3.33, 95% CI, -1.32 to 8.43; P=0.01), postoperative morbidity (OR, 3.86, 95% CI, -2.23 to 6.67; P=0.00001) and need for reoperation (OR, 6.91, 95% CI, -1.07 to 44.6; P=0.04); longer operative time (MD, 2.51, 95% CI, -1.43 to 3.59; P=0.00001), time to oral intake (MD, 0.60, 95% CI, -0.14 to -1.07; P=0.01), and length of stay (MD, 2.52, 95% CI, -1.43 to 3.59; P=0.00001) compared with lateral approach. There was no difference in the risk of mortality between the 2 groups (risk difference, 0.00, 95% CI, -0.01 to 0.02; P=0.61).
The best available evidence suggests that the lateral approach is superior to anterior approach in LS as indicated by better access, more secure hemostasis, less conversion to open surgery, less morbidity, earlier recovery, and shorter length of hospital stay. The quality of the available evidence is moderate; high-quality RCTs are required to provide more robust basis for definite conclusions.
随着腹腔镜脾切除术（LS）经验的积累，越来越多的外科医生认识到与传统前路手术相比，侧路手术的优势。鉴于此，我们旨在比较LS中的前路手术和侧路手术。
我们检索了电子信息源，以确定所有比较LS患者前路和侧路手术的随机对照试验（RCT）和观察性研究。主要结局包括输血需求、术中失血和转为开放手术。次要结局包括术后发病率、手术时间、开始经口进食时间、住院时间、再次手术需求和死亡率。应用随机或固定效应模型计算汇总结局数据。
我们确定了1项RCT和4项回顾性观察性研究，共纳入728例患者。两组人群的基线特征具有可比性。与侧路手术相比，前路手术的输血需求更高[比值比（OR），4.83，95%置信区间（CI），2.31-10.97；P=0.0001]；术中失血风险更高[平均差（MD），101.06，95%CI，52.05-150.06；P=0.0001]，转为开放手术的风险更高（OR，3.33，95%CI，-1.32至8.43；P=0.01），术后发病率更高（OR，3.86，95%CI，-2.23至6.67；P=0.00001）以及再次手术需求更高（OR，6.91，95%CI，-1.07至44.6；P=0.04）；手术时间更长（MD，2.51，95%CI，-1.43至3.59；P=0.00001），开始经口进食时间更长（MD，0.60，95%CI，-0.14至-1.07；P=0.01），住院时间更长（MD，2.52，95%CI，-1.43至3.59；P=0.00001）。两组之间的死亡率风险没有差异（风险差，0.00，95%CI，-0.01至0.02；P=0.61）。
现有最佳证据表明，在LS中侧路手术优于前路手术，表现为手术入路更好、止血更可靠、转为开放手术的情况更少、发病率更低、恢复更早以及住院时间更短。现有证据的质量为中等；需要高质量的RCT为明确结论提供更有力的依据。
