2014年IES腹腔镜下腹股沟疝修补术指南

Chapter 1: Perioperative management: evidencefor antibiotic and thromboembolic prophylaxisin endoscopic/laparoscopic inguinal hernia surgery?Chapter 2: Technical key points in TAPP repairWhich is the safest and most effective method ofestablishing pneumoperitoneum and obtaining access tothe abdominal cavity?Level1BIn thin patients (BMI\27), the direct trocar insertion is asafe alternative to the Veress needle technique (strongerevidence).GradeCThe direct trocar insertion (DTI) can be used in order toestablish pneumoperitoneum as a safe alternative toVeress needle, Hasson approach or optical trocar, ifpatient’s risk factors are considered and the surgeon isappropriately trained (new recommendation).What kind of trocars should be used?Is there any relation between the trocar type and riskof injury and/or trocar hernias?Level2BUse of 10-mm trocars or larger may predispose to hernias,especially in the umbilical region or in the obliqueabdominal wall (Stronger evidence). GradeBFascial defects of 10 mm or bigger should be closed(Stronger evidence).Is clinical examination efficient enough?What is the role of TAPP and other techniques inreliable assessment? GradeBA thorough closure of peritoneal incision or biggerperitoneal tears should be achieved (Stronger evidence).Chapter 3: Technical key points in TEPHow should a large direct sac be handled?Level4Alternatively to fixation of the extended fascia transversalisto Copper’s ligament the direct inguinal hernia defect canbe closed by a pre-tied suture loop (new statement).GradeDAs alternative the primary closure of direct inguinal herniadefects with a pre-tied suture loop can be used (newrecommendation).How should a large indirect sac be handled?Level3Transection of a large indirect sac does not lead tosignificant differences in postoperative pain, length ofhospital stay and recurrence, but to a significant higherseroma rate (new statement).GradeCA large indirect sac may be ligated proximally and divideddistally without the risk of a higher postoperative pain andrecurrence rate, but with an increased postoperativeseroma rate (new recommendation).Should a drain be used after a TEP repair? Shouldseromas be aspirated?Level3Drain after TEP significantly reduces the incidence ofseroma formation with increasing the risk of infection orrecurrence (new statement).GradeCA closed-suction drain can be used to reduce the risk ofseroma formation without increased risk of infection(new recommendation).Has extraperitoneal local anesthetic treatment duringTEP a positive effect on postoperative pain? New(added) questionLevel 1AExtraperitonealbupivancaine treatment during endoscopicTEP inguinal hernioplasty is not more efficaciousfor thereduction of pain than placebo.GradeAExtraperitoneal bupivacaine treatment during endoscopicTEP inguinal hernia repair for the reduction ofpostoperative pain should not be performed.Chapter 4: TEP versus TAPP: which is better?Level1ATAPP has a longer hospital stay compared to TEP (new).Level1BPotentially serious adverse events are rare after both TAPPand TEP (stronger evidence).TAPP has a longer operation time compared to TEP (new).Level2CTEP has more intra-operative and postoperative surgicalcomplication rate compared to TAPP (new).GradeABoth techniques are acceptable treatment options foringuinal hernia repair and there is sufficient data toconclude that both TAPP and TEP are effective methodsof laparoscopic inguinal hernia repair (strongerevidence).Chapter 5: Endoscopic/laparoscopic surgeryin complicated hernias: feasibility, risks, and benefitLevel3TEP inguinal-scrotal hernia repair remains an advantageousapproach during the difficult scrotal hernia that requires‘‘conversion’’ to an open repair, because the pre-peritonealdissection performed laparoscopically allows for reductionof the hernia and optimal mesh placement once the herniarepair has been converted and is performed from theanterior approach (new).GradeCTEP approach for the large, difficult scrotal hernia mayserve as an adjunct to dissection and definition of the preperitonealspace allowing for easier hernia and meshplacement once the case is ‘‘converted’’ to open repair(new).Level3Laparoscopic hernia repair for incarcerated inguinal herniahas been successfully and safely performed in the pediatricpopulation (new). GradeCLaparoscopic hernia repair for incarcerated inguinal herniamay be successfully and safely performed in the pediatricpopulation by surgeons with laparoscopic expertise (new).Level4Women are at increased risk of having an occultsynchronous femoral hernia (New).GradeCWhen performing inguinal hernia repair in women, extraeffort should be undertaken to reveal and treat occultsynchronous femoral hernia (New).Chapter 6: Mesh size and recurrenceChapter 7: Heavy or light weight mesh in TAPPand TEP—functional outcome and quality of lifeLevel 1AThe statistical significance that lighter meshes with largerpores results in improvement of quality of life is notconsistent in recently published meta-analyses. Subsetanalysis revealed no higher risk of recurrence after usinglightweight meshes in laparoscopic inguinal herniarepair (New).Level2BThe middle- and long-term results of prospective studies inmen do notsupport the hypothesis that bilateral inguinalhernia repair with alloplastic meshprosthesis causesmale infertility or decreasing the sperm motility (New).GradeBA monofilament implant with a pore size of at least1.0–1.5 mm (usually meaning low-weight) consisting of aminimum tensile strength in all directions (includingsubsequent tearing force) of 16 N/cm appeared to be mostadvantageous;however, this assumption mainlysummarizes personal and published clinical and experimental experiences (stronger evidence).The application of large porepolypropylene meshes inendoscopic hernia repair is harmless concerningazoospermia and should therefore further used (New).Chapter 8: Slitting or not slitting of mesh—does itinfluence outcome?Level1Cutting a slit in the mesh to allow the structures of thefunicel to pass does not compromise testicular perfusionand testicular volume (New).GradeBBased on available evidence we recommend not to cut a slitin the mesh although cutting does not compromise testisperfusion (New).Chapter 9: Mesh fixation modalities: is therean association with acute or chronic pain?Level1AFixation and non-fixation of the mesh in TEP areassociated with equally risk of postoperative pain orrecurrence (New).Level1BFibrin glue fixation is associated with less chronic painthan stapling. GradeAIf TEP technique is used, non-fixation has to be consideredin all types of inguinal hernias except large direct defects(MIII, EHS classification) (strongerrecommendation).GradeBIn case of TAPP repair non-fixation should be considered intypes LI, II, and MI, II hernias (EHS classification).For fixation, fibrin glue should be considered to minimizethe risk of acute postoperative pain (modifiedrecommendations).Chapter 10: Risk factors and prevention of acuteand chronic pain in TAPP and TEPLevel1AThere is no difference of chronic pain after TEP and TAPP(stronger evidence).Fixation and non fixation of the mesh in TEP are associatedwith equally risk of postoperative pain (see chapter‘‘Fixation’’) (new).Level1BFibrin glue fixation is associated with less chronic painthan stapling (see chapter ‘‘Fixation’’) (new).Level2AAge below median (40–50 years) is a risk factor for acutepain (stronger evidence).Age below median (40–50 years) is a risk factor for chronic pain (stronger evidence).Severe acute postoperative pain is a risk factor for chronicpain (stronger evidence).GradeAIf TEP technique is used non fixation has to be consideredin all types of inguinal hernias except large defects (L III,MIII; EHS classification; see chapter ‘‘Fixation’’) (new).GradeBIn case of TAPP repair non fixation should be considered intypes LI, LII, MI, MII hernias (EHS classification, see Chapter ‘‘Fixation’’) (new).Chapter 11: Urogenital complications associatedwith TAPP and TEPLevel2BInguinal hernia repair with mesh is not associated with anincreased risk of, or clinically important risk for, maleinfertility. (new).GradeBGroin hernia repair using mesh techniques may continue tobe performed without major concern about the risk formale infertility. (new).Chapter 12: Intraperitoneal onlay mesh (IPOM)for inguinal hernia repair—still a therapeutic option?Chapter 13: Role for open preperitoneal meshplacement in the era ofendo/laparoscopic inguinalhernia repairLevel1BMinimally invasive open approaches (i.e., Kugel) mayoffer a cost advantage over laparoscopic approaches.(new).Chapter 14: Single port surgery or reduced portsin endoscopic/laparoscopic hernia repair (New chapter)Level2BSingle port laparoscopic hernia repair is a safe and feasiblealternative to traditional multiport technique although hasnot been showed to be superior or more effective.Single port laparoscopic hernia repair may offer a bettercosmetic outcome and patient’s satisfaction.Single port laparoscopic hernia repair has no increased risk compared with standard multiport technique.Homemade ports, as an alternative to commerciallyavailable ports, provides a feasible and safe alternatives GradeBSingle port laparoscopic inguinal hernia repair is safe andfeasible alternative options to conventional laparoscopy inselected cases but further RCTs are needed.Both TAPP and TEP can be performed with equal results inselected cases. Chapter 15: Convalescence after hernia surgery (Newchapter)Is post-surgeryphysical strain related to groin herniarecurrence?Level1BThere is no evidence for an increase in recurrence risk dueto physical strain (including heavy lifting) after groinhernia surgery irrespective of the method ofsurgery.Level 3 Immediate return to work (within 1–3 days) is notassociated with hernia recurrence.Immediate resumption of activity of daily living (ADL)(within 1–3 days) is not associated with herniarecurrence.Short convalescence is not associated with a higherrecurrence risk, and some studies even show an inverserelation GradeBPatients should be actively assured that physical activity ofany kind does not jeopardize the stability of groin herniarepair.Patients should be encouraged to resume work and ADLafter 1 day.What are the limiting factors for the resumption ofwork and physical activities after groin hernia repair?StatementsLevel2APain is an important limiting factor for the resumption ofwork and physical activities after groin hernia repair.Level 3 Patients’ attitude toward convalescence is heavily influenced by their surgeons’recommendation.Return to work is heavily influenced by the type of sickleavecompensation.GradeCEffective pain control is a prerequisite of early return towork and ADL. GradeBPatients should be counseled with regard to availability andside effects of analgesics.What period of physical inactivity, if any, is recommendedafter groin hernia repair?Level1BNo specific period of physical inactivity is required aftergroin hernia repair. GradeB The patient’s individual wish after counseling is to berespected andfacilitated, e.g., by generous analgesicsprescription; however, extended periods of sick-leave areusually not necessary and should not be supportedIn which way, if any, does convalescence pertain to thechoice of surgical procedure?Level1APostoperative pain is less pronounced after endoscopic ascompared to openhernia repair.Endoscopy hernia surgery is associated with shortervocational downtime and earlier resumption of ADL ascompared to open hernia repair.GradeBWith respect to convalescence, endoscopic hernia repair ispreferable over open techniques.Chapter 16: Sportsman hernia—diagnosisand treatmentLevel2BCT scan has high accuracy in detecting posterior walldeficiency (PWD. (new)Level1BSurgery (endoscopic placement of retropubic mesh) ismore efficient than conservative therapy for the treatment of sportsman’s hernia. (stronger evidence).In Sportsman’s hernia the re sults of surgical repair to theposterior inguinal wall are excellent. (strongerevidence).For conservative treatment the use of radiofrequency denervation of both ilio-inguinal nerve and inguinalligament in the treatment of refractory Sportsman’sHernia is safe and efficacious at least in the short term,and is superior to anesthetic/steroid injection. (new).GradeAEndoscopic placement of retropubic mesh must beconsidered a seriousoption for Sportsman hernia.(stronger evidence).For conservative treatment of refractory Sportsman’shernia, radiofrequency denervation of both ilio-inguinalnerve and inguinal ligament must be considered, in theshort term, an alternative toanesthetic/steroid injection.(new).Chapter 17: Evidence based training for endoscopic/laparoscopic hernia repair (New chapter)Level1ASimulation training improves trainee satisfaction, traineeknowledge, time and process measure of skills,behaviors, compared to no training and tonon-simulationtraining.Level1AComputer simulation and box trainers improve operativeperformance.Box training is as effective as computer simulation andresults in higher learner satisfactionLevel1BCognitive training plus mastery learning on box trainersimproves patient outcomeLevel2BGOALS-GH is an objective and valid measure of skillsrequired to perform LIHR (TAPP and TEP).Training on fresh frozen cadaver has higher face validity than training on a VR trainer.GradeAA simulation trainer should be available to all learners toimprove operative performance.At the current time, box trainers are preferred overcomputer-assisted simulation for inguinal hernia repair.GradeBA proficiency-based curriculum for the available trainertool should be established to improve patient outcomes.A validated assessment tool should be used to assessproficiency.Chapter 18: Costs in endoscopic/laparoscopic and openhernia surgery (New chapter)Level1AWhen using disposable trocars and instruments direct costs(hospital) are higher for laparoscopic inguinal herniarepair.Total costs (hospital and societal) are lower forlaparoscopic inguinal hernia repair compared to open.Operation time is a cost-relevant factor.Time for anesthesia is a cost-relevant factor.Experience andquality of performance are cost-relevantfactors.Simulator-training may improvequality of performance.Level2CHernia surgery is cost-effective. It may be superior to‘‘watchful waiting’’ in the long paroscopic hernia surgery offers a higher cost-utilitycompared to open.Hospitals costs for laparoscopic hernia repair may besimilar or lower compared to open but there is a largevariation in cost per QALY generated by individualproviders.In hospitals with a high case load costs are lower.GradeANon-disposable trocars and instruments must be considered.Non-fixation techniques should be considered. Use of no orindigenous balloon must be considered. Operative performance and education of the surgeons mustbe improved.To shorten the learning curve of traineesurgeons, simulatortraining should be introduced. GradeB In hernia disease surgery might be superior to ‘‘watchful waiting’’.From the point of cost-utility laparoscopic inguinal herniarepair may be considered.Toenhance the case load centralization of hernia surgeryshould be considered.。