Faculdade de Ciências Médicas de Santos, Department of General Surgery, Centro Universitário Lusíada, St. Oswaldo Cruz, 179-Boqueirão, Santos, São Paulo, Brazil.
Hernia. 2024 Oct;28(5):1537-1546. doi: 10.1007/s10029-024-03099-5. Epub 2024 Jul 20.
Currently, inguinal hernias are highly prevalent in the Brazilian population, accounting for 75% of all abdominal wall hernias. The recommended treatment to correct them is inguinal herniorrhaphy, which can be performed through open surgery, mainly using the Lichtenstein technique, or laparoscopically, primarily through Transabdominal Preperitoneal Repair (TAPP) or Total Extraperitoneal Repair (TEP) approaches. Like any surgery, these procedures have post-operative complications, with pain being the most common and debilitating. Currently, in European and Brazilian guidelines, the open Lichtenstein and endoscopic inguinal hernia techniques are recommended as best evidence-based options for repair of a primary unilateral hernia providing the surgeon is sufficiently experienced in the specific procedure. In that matter, the surgeon should make a choice based on assessment of the benefits and risks of performing each of them, and practice shared making decision with it patient. Therefore, the objective of this review was to assess the incidence of chronic postoperative pain by comparing the aforementioned surgical approaches to evaluate which procedure causes less disability to the patient.
The search conducted until May 2024 was performed on Medline (PubMed), Cochrane (CENTRAL), and Lilacs databases. The selection was limited to randomized clinical trials, nonrandomized clinical trials and cohort studies comparing TAPP or TEP to LC, evaluating the incidence of chronic postoperative pain published between 2017 and 2023. Evidence certainty was assessed using the GRADE Pro tool, and bias risk was evaluated with the RoB 2.0 tool and ROBINS I tool. Thirteen studies were included. RESULTS: The meta-analysis showed a significant difference between the groups in both techniques, favoring the laparoscopic approach, which had a lower occurrence of postoperative inguinodynia with a relative risk of 0.49 (95% CI = 0.32, 0.75; I = 66% (P = 0.001); Z = 3.28 (P = 0.001) with low certainty of evidence.
The presence of chronic postoperative pain was lower in laparoscopic TEP/TAPP techniques when compared to the open Lichtenstein technique, meaning that the former can bring more benefits to patients who requires inguinal herniorrhaphy. Nevertheless, further randomized clinical trials are needed to optimize the analysis, minimizing the bias.
目前，腹股沟疝在巴西人群中非常普遍，占所有腹壁疝的 75%。推荐的治疗方法是腹股沟疝修补术，可以通过开放式手术进行，主要采用 Lichtenstein 技术，也可以通过腹腔镜手术进行，主要通过经腹腹膜前修补术（TAPP）或全腹膜外修补术（TEP）进行。与任何手术一样，这些手术都有术后并发症，其中疼痛是最常见和最使人虚弱的。目前，在欧洲和巴西的指南中，开放式 Lichtenstein 和内镜腹股沟疝技术被推荐为修复原发性单侧疝的最佳循证选择，前提是外科医生对特定手术有足够的经验。在这种情况下，外科医生应该根据对每种手术的获益和风险的评估来做出选择，并与患者共同做出决策。因此，本综述的目的是通过比较上述手术方法来评估慢性术后疼痛的发生率，以评估哪种手术对患者的残疾程度更小。
检索截至 2024 年 5 月的 Medline（PubMed）、Cochrane（CENTRAL）和 Lilacs 数据库。选择仅限于比较 TAPP 或 TEP 与 LC 的随机临床试验、非随机临床试验和队列研究，评估 2017 年至 2023 年期间发表的慢性术后疼痛发生率。使用 GRADE Pro 工具评估证据确定性，使用 RoB 2.0 工具和 ROBINS I 工具评估偏倚风险。纳入了 13 项研究。
荟萃分析显示，两种技术组之间存在显著差异，腹腔镜方法具有较低的术后腹股沟痛发生率，相对风险为 0.49（95%CI=0.32，0.75；I=66%（P=0.001）；Z=3.28（P=0.001），证据确定性为低。
与开放式 Lichtenstein 技术相比，腹腔镜 TEP/TAPP 技术的慢性术后疼痛发生率较低，这意味着前者可为需要腹股沟疝修补术的患者带来更多益处。然而，需要进一步的随机临床试验来优化分析，最大限度地减少偏倚。
