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中华疝和腹壁外科杂志(电子版)

中华疝和腹壁外科杂志(电子版) ›› 2022, Vol. 16 ›› Issue (05) : 587 -594. doi: 10.3877/cma.j.issn.1674-392X.2022.05.022

循证医学

儿童腹股沟疝腹腔镜与开放手术效果与安全性的Meta分析
薛小军1,†(), 锜和强1, 屈振南1, 钟伟1, 李冉冉1, 陈宇凡1, 周松1   
  1. 1. 363000　福建漳州，中国人民解放军联勤保障部队第909医院（厦门大学附属东南医院）普通外科
  • 收稿日期:2022-01-20 出版日期:2022-10-18
  • 通信作者: 薛小军

Comparison of efficacy and safety of laparoscopic and open inguinal herniorrhaphy in children: a Meta-analysis

Xiaojun Xue1,†(), Heqiang Qi1, Zhennan Qu1, Wei Zhong1, Ranran Li1, Yufan Chen1, Song Zhou1   

  1. 1. Department of General Surgery, the 909th Hospital of PLA (the Southeast Affiliated Hospital of Xiamen University), Zhangzhou 363000, China
  • Received:2022-01-20 Published:2022-10-18
  • Corresponding author: Xiaojun Xue
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薛小军, 锜和强, 屈振南, 钟伟, 李冉冉, 陈宇凡, 周松. 儿童腹股沟疝腹腔镜与开放手术效果与安全性的Meta分析[J/OL]. 中华疝和腹壁外科杂志(电子版), 2022, 16(05): 587-594.

Xiaojun Xue, Heqiang Qi, Zhennan Qu, Wei Zhong, Ranran Li, Yufan Chen, Song Zhou. Comparison of efficacy and safety of laparoscopic and open inguinal herniorrhaphy in children: a Meta-analysis[J/OL]. Chinese Journal of Hernia and Abdominal Wall Surgery(Electronic Edition), 2022, 16(05): 587-594.

目的

比较腹腔镜与开放疝囊高位结扎术治疗儿童腹股沟疝的安全性和效果。

方法

制定严格的纳入标准与排除标准，检索中国生物医学文献检索分析系统光盘数据库、中国期刊全文数据库、万方数据库、PubMed、EMbase等数据库，收集1987至2018年腹腔镜疝囊高位结扎术（LH）和传统疝囊高位结扎术（OH）治疗儿童腹股沟疝的随机对照试验，按照Cochrane协作网推荐的方法对纳入研究进行系统分析。

结果

11篇随机对照试验（1508例患者）纳入分析，LH组757例，OH组751例。LH组与OH组比较睾丸萎缩发生率[OR=0.15，95% CI（0.03~0.84），P=0.03]、术后总并发症发生率[OR=0.15，95% CI（0.08~0.26），P<0.000 01]、复发率[RR=0.33，95% CI（0.18~0.62），P=0.000 5]均较低。与OH组比较，双侧疝亚组，LH组的手术时间较短[MD=－8.82，95% CI（－11.80~－5.83），P<0.000 01]，而对于单侧疝亚组，2组的手术时间无明显差异[MD=－2.71，95% CI（－7.96~2.54），P=0.31]。恢复正常活动的时间[MD=－0.06，95% CI（－0.66~0.53），P=0.84]和止痛药物的使用剂量[MD=－0.84，95% CI（－0.36~1.93），P=0.55]，组间均无明显差异。

结论

Meta分析显示，LH较OH有明显的优势，特别是减少术后并发症及疝复发方面，但仍需要高质量的随机对照试验进一步支持。

关键词: 疝，腹股沟, 腹腔镜, 疝修补术, 儿童, 随机对照试验, Meta分析
Objective

To analyze the safety and efficacy of laparoscopic herniorrhaphy (LH) compared with open high ligation of the hernia sac herniorrhaphy (OH) in children.

Methods

Strict inclusion and exclusion criteria were set up. Databases including CBMdisc, CNKI, Wanfang, PubMed and EMbase were searched. All the randomized controlled trials (RCT) on LH and OH for inguinal hernia from 1987 to 2018 were collected. Systematical analysis was performed according to the recommendation by the Cochrane handbook.

Results

Eleven RCTs including 1508 patients were included in the analysis. They were divided into LH group (n=757) and OH group (n=751). Rate of testicular atrophy [OR=0.15, 95% CI (0.03, 0.84), P=0.03], total complications [OR=0.15, 95% CI (0.08, 0.26), P<0.000 01] and recurrence [RR=0.33, 95% CI (0.18, 0.62), P=0.000 5] were significantly lower in LH group compared to OH group. Compared with OH group, the operative time was significantly shorter in LH group for bilateral hernia repairs [MD=-8.82, 95% CI (-11.80, -5.83), P<0.000 01]. There was no difference between the two groups regarding operative time for unilateral hernia repairs [MD=-2.71, 95% CI (-7.96, 2.54), P=0.31]. There were no significant differences in the time before full activity [MD=-0.06, 95% CI (-0.66, 0.53), P=0.84] and analgetic dosage [MD=-0.84, 95% CI (-0.36 1.93), P=0.55] between the two groups.

Conclusion

In this meta-analysis, LH showed obvious advantages over OH, especially in reducing postoperative complications and recurrence. However, more high quality RCTs were needed to further supported it.

Key words: Hernia, inguinal, Laparoscopes, Herniorrhaphy, Children, Randomized controlled trial, Meta-analysis
图1 文献筛选流程图
表1 纳入研究的一般资料
作者 年份 例数 性别(女/男) 单侧/双侧*
LH OH LH OH LH OH
Koivusalo AI[5] 2009 47 42 11/36 12/30 47/0 42/0
姜学辉[6] 2015 112 112 9/103 10/102 95/17 94/18
唐忠斌[7] 2014 100 100 3/97 3/97 100/0 100/0
孙中伟[8] 2015 126 126 12/114 10/116 89/37 113/13
杨泽成[9] 2017 47 47 4/43 5/42 36/11 42/5
彭永辉[10] 2016 60 60 0/60 0/60 54/6 56/4
Gause CD[11] 2016 26 15 7/19 3/12 17/9 10/5
Chan KL[12] 2005 41 42 7/34 9/33 27/14 38/4
Shalaby R[13] 2012 125 125 38/87 33/92 55/70 65/60
Celebi S[14] 2014 32 32 0/32 0/32 0/32 0/32
王建[15] 2017 41 50 4/37 5/45 35/6 46/4
图2 纳入研究的偏倚风险评估Meta总结图
图3 腹腔镜组（LH）和开放组（OH）疝囊高位结扎术后睾丸萎缩发生率比较
图4 腹腔镜组（LH）和开放组（OH）疝囊高位结扎术后总并发症发生率比较
图5 腹腔镜组（LH）和开放组（OH）疝囊高位结扎术后复发率比较
图6 腹腔镜组（LH）和开放组（OH）疝囊高位结扎术手术时间比较
图7 腹腔镜组（LH）和开放组（OH）恢复正常活动时间比较
图8 腹腔镜组（LH）和开放组（OH）使用止痛药物剂量比较
表2 纳入研究中可能影响指标的差异
作者 年份 气腹压力(mmHg) 年龄 戳孔数 内环的处理 对侧隐匿疝 切口镇痛 疝的类型 切口的闭合 麻醉方式
Koivusalo AI[5] 2009 8(<18个月)、10(<10岁)、12(>10岁) 4个月~16岁 5 mm×3 不吸收线高位结扎 不处理 切口镇痛 斜疝 4-0 PDS、5-0单乔、切口闭合胶带 均全身麻醉
姜学辉[6] 2015 6~12 1~13岁 男5 mm、3 mm各一/女5 mm单孔 尼龙线(0-3,LH),4号丝线(OH) N N 斜疝 N 全身麻醉(≤6岁),连续硬膜外麻醉(>6岁)
唐忠斌[7] 2014 8~10 1~12岁 5 mm、3 mm各一 高位结扎 N N 斜疝 1-0丝线缝合皮下缝合+医用胶黏合切口(OH),医用胶黏合切口(LH) N
孙中伟[8] 2015 6~8 <10岁 5 mm、2 mm各一 高位结扎 处理 N 斜疝,包括嵌顿疝 N 静脉麻醉(OH),气管插管全身麻醉(LH)
杨泽成[9] 2017 8 18个月~10岁 5 mm、1.5 mm各一 4-0丝线高位结扎 处理 N 斜疝 N 均气管插管全身麻醉
彭永辉[10] 2016 6~8   3 mm单孔 丝线 N N 斜疝 N 均全身麻醉
Gause CD[11] 2017   ≤3岁 5 mm单孔 4-0丝线缝合法 处理 切口镇痛 斜疝 N 吸入或静脉麻醉
Chan KL[12] 2005 5~8 ≥3个月 5 mm、3 mm×2 高位结扎 处理 切口镇痛 斜疝 N 气管插管全身麻醉(LH)、吸入麻醉(OH)
Shalaby R[13] 2012 N 5~96个月 5 mm、3 mm×2 3-0 Prolene(LH)、可吸收线(OH) 处理 N 斜疝,包括复发疝、合并脐疝 切口拉扣(LH)、可吸收线皮内缝合(OH) 气管插管全身麻醉(LH)、N(OH)
Celebi S[14] 2014 8~10 >6岁 5 mm、3 mm×2 3-0不吸收线荷包缝合 N 患者自控镇痛+切口镇痛 斜疝,复发疝除外 开放用可吸收线缝合 均全身麻醉
王建[15] 2017 8 6个月~8岁 5 mm、3 mm各一 丝线高位结扎 处理 N 斜疝 可吸收线皮内缝合 均气管插管全身麻醉
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