Department of Electrical and Electronic Engineering, EPSRC Centre for Doctoral Training in Digital Health and Care, University of Bristol, Bristol, UK.
Department of Academic Obstetrics & Gynaecology, Liverpool Women's Hospital, Liverpool, UK.
BJS Open. 2023 May 5;7(3). doi: 10.1093/bjsopen/zrad047.
Safe primary entry at laparoscopy could present challenges in obese patients. Various techniques have been proposed in previous studies, however, the characteristics of the actual device utilized may be more influential than the technique in achieving successful abdominal entry in patients with increased BMI.
This systematic review and meta-analysis included both randomized and non-randomized studies gathered with no date filters from MEDLINE, Embase, Scopus, Web of Science and Clinicaltrials.gov. PRISMA guidelines underpinned the conduct and reporting of the review. The meta-analysis of proportions was conducted using a generalized linear mixed model and analyses included random-effects models. The primary outcome was the proportion of first access vascular and visceral injuries incurred in the process of laparoscopic abdominal surgery in patients with a BMI >30 kg/m2. Subgroup analysis was performed for optical versus non-optically enabled devices.
In total, 5403 patients were analysed across 13 observational studies with a mean BMI of 45.93 kg/m2. In 216 patients from two randomized studies, the mean BMI was 39.92 kg/m2. The overall incidence using a random-effects model was 8.1 per 1000 events of visceral and vascular injuries (95 per cent c.i. 0.003 to 0.024). Heterogeneity was statistically significant at I2 = 80.5 per cent (69.6 per cent; 87.5 per cent, P< 0.0001). In a subgroup analysis, a tendency towards reduced injuries when optical devices were employed was observed with one per 100 injuries in these trocars (95 per cent c.i. 0.001 to 0.018) versus four per 100 (95 per cent c.i. -0.019 to -0.102) in non-optically enabled devices.
Injuries during primary laparoscopic entry undertaken in obese patient groups are uncommon. Due to considerable heterogeneity in the small number of examined studies, evidence was insufficient and largely of low quality to ascribe differences in the incidence of injuries to the characteristics of the primary entry trocar utilized.
腹腔镜下安全的初次进入可能会给肥胖患者带来挑战。在之前的研究中已经提出了各种技术，然而，在 BMI 增加的患者中实现成功腹部进入时，实际使用的器械的特点可能比技术更有影响力。
本系统评价和荟萃分析包括从中收集的随机和非随机研究，没有使用 MEDLINE、Embase、Scopus、Web of Science 和 Clinicaltrials.gov 进行日期筛选。PRISMA 指南为审查的进行和报告提供了依据。使用广义线性混合模型进行比例的荟萃分析，分析包括随机效应模型。主要结果是在 BMI>30kg/m2 的腹腔镜腹部手术过程中初次进入时发生的血管和内脏损伤的比例。对光学与非光学器械进行了亚组分析。
总共对 13 项观察性研究中的 5403 名患者进行了分析，平均 BMI 为 45.93kg/m2。在两项随机研究的 216 名患者中，平均 BMI 为 39.92kg/m2。使用随机效应模型的总体发生率为每 1000 次内脏和血管损伤事件 8.1 例（95%可信区间 0.003 至 0.024）。异质性具有统计学意义（I2=80.5%，69.6%，87.5%，P<0.0001）。在亚组分析中，当使用光学器械时，观察到损伤减少的趋势，这些套管每 100 个损伤中有 1 个（95%可信区间 0.001 至 0.018），而非光学器械则为每 100 个损伤中有 4 个（95%可信区间 -0.019 至 -0.102）。
在肥胖患者群体中进行的腹腔镜初次进入时发生的损伤并不常见。由于所检查研究数量较少，异质性较大，证据不足，且主要质量较低，无法将损伤发生率的差异归因于所使用的初次进入套管的特点。
