Felix E, Scott S, Crafton B, Geis P, Duncan T, Sewell R, McKernan B
Center for Hernia Repair, 6191 N. Fresno St., Fresno, CA 93710, USA.
Surg Endosc. 1998 Mar;12(3):226-31. doi: 10.1007/s004649900640.
To determine if there are common factors beyond the learning curve that lead to recurrence after laparoscopic hernioplasty, we analyzed failures seen in seven centers specializing in laparoscopic hernia repair.
We performed a retrospective review of patients who had a laparoscopic hernioplasty (Tapp or Tep) between 1990 and 1996 at centers specializing in laparoscopic repairs (>500 repairs at each center).
In all, 7661 patients had 10,053 hernias repaired by the transabdominal preperitoneal or the totally extraperitoneal approach; they were followed for 1 month to 6 years. In patients followed for >/=6 months with a median follow-up of 36 months, 35 repairs failed (0.4%), and all but one of these patients underwent a remedial operation. Twenty-nine had a laparoscopic repair, four had a combined laparoscopic and anterior repair, and one had an anterior repair alone. The cause of failure was determined in all 34 patients. The mechanism of recurrence was inadequate lateral fixation of the mesh in 11 cases, inadequate lateral fixation compounded by too small a mesh in three cases, missed lipoma of the cord in four cases, inadequate fixation of the mesh medially to Cooper's ligament in eight cases (seven of which were associated with too small a mesh), a missed hernia in four cases, and a hernia through a keyhole in the mesh in five cases. As surgeons gained experience, the incidence of recurrence due to missed hernias or too small a mesh decreased.
This large multicenter study demonstrated that the incidence of recurrence after laparoscopic hernioplasty performed by experienced surgeons was extremely low and that some causes could be corrected by experience, whereas others will require changes in technique or equipment.
为了确定在腹腔镜疝修补术后导致复发的、超出学习曲线之外的常见因素，我们分析了7个专门从事腹腔镜疝修补术的中心所出现的手术失败情况。
我们对1990年至1996年间在专门从事腹腔镜修补术的中心（每个中心>500例修补术）接受腹腔镜疝修补术（Tapp或Tep）的患者进行了回顾性研究。
共有7661例患者的10053处疝通过经腹腹膜前或完全腹膜外途径进行了修补；对他们进行了1个月至6年的随访。在随访时间≥6个月、中位随访时间为36个月的患者中，35例修补失败（0.4%），除1例患者外，所有这些患者均接受了补救手术。29例接受了腹腔镜修补，4例接受了腹腔镜与前路联合修补，1例仅接受了前路修补。在所有34例患者中确定了失败原因。复发机制为：11例是补片外侧固定不充分，3例是补片外侧固定不充分且补片过小，4例是精索脂肪瘤漏诊，8例是补片在内侧未充分固定于Cooper韧带（其中7例与补片过小有关），4例是疝漏诊，5例是疝通过补片上的小孔形成。随着外科医生经验的增加，因疝漏诊或补片过小导致的复发率降低。
这项大型多中心研究表明，经验丰富的外科医生进行腹腔镜疝修补术后的复发率极低，一些原因可通过经验得到纠正，而其他原因则需要技术或设备的改进。
