A defect in the abdominal wall through which organs can protrude is called hernia. Hernias may occur spontaneously (primary hernia) or at the site of a previous surgical incision (incisional hernia). A hernia is usually recognized as a bulge or tear under the abdominal skin. Occasionally it causes no discomfort for the patient but it can hurt while lifting heavy objects, coughing, or having bowel movements. Also after prolonged standing or sitting it can cause heavy discomfort.
For the repair of these hernias many different surgical techniques are in use. The conventional technique is the open technique, where with either a suture or a mesh prosthesis the defect of the abdominal wall will be closed. A mesh prosthesis is a synthetic material that reinforces the tissue or bridges the defect. On the other hand the laparoscopic hernia repair is a technique to repair the defect in the abdominal wall also with a mesh but using small incisions and a laparoscope. In this case, the mesh is always placed in the abdominal cavity. This review analysed randomised controlled trials, comparing the conventional, open technique with the laparoscopic technique.
Based on the results of nearly 1000 adult patients, the laparoscopic technique appears to be effective at least in the short-term evaluation. As laparoscopic surgery requires smaller incisions than open surgery, wound infection was fourfold less likely to occur in patients with laparoscopic repair. However, there is a rare but theoretically higher risk that intraabdominal organs are more likely to be injured during a laparoscopic procedure. Length of hospital stay after laparoscopic hernia repair was found to be shorter in the majority of trials. As most studies had evaluated only a follow-up of 1 or 2 years, data on the long-term effectiveness are still lacking. Most importantly, the risks of the hernia coming back (i.e. recurrence) are relatively unknown.
Therefore, the authors of the review believe that further studies are necessary, before laparoscopic repair can be considered a standard procedure for primary ventral or incisional hernia repair. Short-term results, however, are promising.
阅读完整摘要
There are many different techniques currently in use for ventral and incisional hernia repair. Laparoscopic techniques have become more common in recent years, although the evidence is sparse.
研究目的
We compared laparoscopic with open repair in patients with (primary) ventral or incisional hernia.
检索策略
We searched the following electronic databases: MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, metaRegister of Controlled Trials. The last searches were conducted in July 2010. In addition, congress abstracts were searched by hand.
纳入排除标准
We selected randomised controlled studies (RCTs), which compared the two techniques in patients with ventral or incisional hernia. Studies were included irrespective of language, publication status, or sample size. We did not include quasi-randomised trials.
资料收集与分析
Two authors assessed trial quality and extracted data independently. Meta-analytic results are expressed as relative risks (RR) or weighted mean difference (WMD).
主要结果
We included 10 RCTs with a total number of 880 patients suffering primarily from primary ventral or incisional hernia. No trials were identified on umbilical or parastomal hernia. The recurrence rate was not different between laparoscopic and open surgery (RR 1.22; 95% CI 0.62 to 2.38; I2 = 0%), but patients were followed up for less than two years in half of the trials. Results on operative time were too heterogeneous to be pooled. The risk of intraoperative enterotomy was slightly higher in laparoscopic hernia repair (Peto OR 2.33; 95% CI 0.53 to 10.35), but this result stems from only 7 cases with bowel lesion (5 vs. 2). The most clear and consistent result was that laparoscopic surgery reduced the risk of wound infection (RR = 0.26; 95% CI 0.15 to 0.46; I2= 0%). Laparoscopic surgery shortened hospital stay significantly in 6 out of 9 trials, but again data were heterogeneous. Based on a small number of trials, it was not possible to detect any difference in pain intensity, both in the short- and long-term evaluation. Laparoscopic repair apparently led to much higher in-hospital costs.
作者结论
The short-term results of laparoscopic repair in ventral hernia are promising. In spite of the risks of adhesiolysis, the technique is safe. Nevertheless, long-term follow-up is needed in order to elucidate whether laparoscopic repair of ventral/incisional hernia is efficacious.
