Medicina Baseada em Evidências
Hérnia Ventral Laparoscópica
Evidence-Based Review
Open vs Laparoscopic Approaches
Ventral Hernia Repair
Níveis de Evidência
Graus de Recomendação
http://www.cebm.net Meakins JL. Am J Surg. 2002;183:399-405Oxford Center
for EBM
Níveis de Evidência em
Shein M. Crucial Controversies in Surgery, 1999
VI – “Na minha experiência pessoal
(nunca
publicada)
, não existem complicações..”
VII – “Eu me lembro de um caso...”
VIII – “Esse é o jeito que eu faço e é o melhor !!”
Cirurgia
• 154278 casos internados nos EUA 2006
• 193543 casos ambulatoriais
• 348000 reparos nos EUA em 2006
• Custo internado – US$ 15899
• Custo ambulatorial – US$ 3873
• Custo total – US$ 3.2 bilhões
Bellows CF, Robinson C, Fitzgibbons RJ et al. Am Surg 2014 ; 80(3):245-52
2b, B
Coorte prospectiva 42 pacientes
11 perdas FU
7 mortes outras causas
1 encarceramento em 2 anos FU
Amostra calculada de 636 pcts
16 centros
2 anos FU
endpoint: dor atividades diárias
primeiro pacientes - nov 2011
Hérnia Ventral é diferente de
Hérnia Incisional ?
• 3B, C
• Estudo retrospectivo 10 anos
• 201 pacientes 2 instituições
Hérnia Ventral Laparoscópica
Séries Históricas
Laparoscopic Repair of Ventral Hernias Using an
Intraperitoneal Onlay Patch: Report of Current
Results
LeBlanc KA, Booth WV, Whitaker JM. Comtemp Surg 1994; 45(4):211-214
Laparoscopic Repair of Incisional Abdominal Hernias
Using Expanded Polytetrafluoroethylene: Preliminary
Findings
2b, B
4 cirurgiões insituições acadêmicas
coorte prospectiva
técnica consistente
FU: 1-2 semanas
3 e 6 meses
anual
Heniford TB, Park A, Ramshaw BH, Voeller G. Ann Surg 2003; 283: 391-400
850 pacientes
Defeito: 118 cm
2
(1-1600 cm
2
)
Tela:
344 cm
2
(24-2500 cm
2
)
(Mesh/Hernia – 2.9)
Tempo cirúrgico: 120 min (11-420 min)
Sangramento: 30 cc (70 -350 cc)
Conversões:
31 (3.6%)
Internação:
2.3 dias (
0-33)
Complicações:
128 em 112 pcts (13.2%)
15 FO (1,83%)
Mortalidade:
1 (0.1%) – IAM
FU 20.6 m (1-92)
35 recorrências (4.7%)
Hérnia Ventral Laparoscópica
Séries Contemporâneas
2b, B
360 pctes consecutivos (233 aberta 127 lap)
centro único, FU médio 30-36 meses
recurrência similar (9 x 12%)
15% morbidade aberta x 7% lap
Readmissão > grupo aberto (28 x 16%)
Bisgaard T. BJS 2009; 96: 1452-7
4, C
Base de dados populacional Dinamarca
Endopoint primário: complicações 30 dias
2896 cirurgias: 1872 abertas1024 lap
95% hérnias ventrais
internação, readmissão
morbidade (10,7 x 11,8%)
mortalidade
Forbes SS, Eskicioglu C, McLeod RS, Okrainec A. BJS 2009; 96: 851-8
1a, A
8 estudos, 526 pacientes
Sem ≠ recorrência
complicações FO
internação 6/8
Sajid MS, Bokari SA, Mallick AS et al. Am J Surg 2009; 197: 64-72
Ia, A
5 studies, 336 pctes
< complication rate
LOS
surgical time ?
1B, A
146 patients
Laparoscópica
Aberta
P value
Tamanho Defeito (cm2)
46
46
0.99
Complicações Totais
32%
48%
0.03
Infecção FO
3%
22%
0.01
Recorrência
12%
8%
0.44
Mason RJ. Ann Surg 2011; 254: 641-52
4, C
National Surgery Quality Improving Program
83% cirurgias abertas
< morbidade geral (6x3,8%, OR 0,62)
< morbidade grave (2,5x1,2%, OR 0,61)
mortalidade similar
RESULTADOS SUPERIORES EM PACIENTES
COMPLICADOS
LAPAROSCOPIC VERSUS OPEN SURGICAL TECHNIQUES FOR VENTRAL OR INCISIONAL HERNIA REPAIR
Sauerland Stefan, Walgenbach Maren, Habermalz Brigitte, Seiler Christoph M, Miserez Marc
Cochrane Database of Systematic Reviews, Issue 04, 2011 - DOI: 10.1002/14651858.CD007781.pub3
Main results
We included 10 RCTs with a total number of 880 patients suffering primarily from primary ventral or incisional 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.
Authors' conclusions
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.
Cochrane BVS
LAPAROSCOPIC VERSUS OPEN SURGICAL TECHNIQUES FOR VENTRAL OR INCISIONAL HERNIA REPAIR
Sauerland Stefan, Walgenbach Maren, Habermalz Brigitte, Seiler Christoph M, Miserez Marc
Cochrane Database of Systematic Reviews, Issue 04, 2011 - DOI: 10.1002/14651858.CD007781.pub3
Main results
We included 10 RCTs with a total number of 880 patients suffering primarily from primary ventral or incisional 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.
Authors' conclusions
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.
Cochrane BVS
4, C
20% pacientes internados nos EUA
18223 casos, lap em 27%
< complicações (8,24 x 3,97%)
< internação (5.2 x 3.5 days)
< custos totais ($45,708 x $35,947)
mortalidade (0.88 x 0.36%)
Rogmark P, Peterson U, Bringman S. Ann Surg 2013; 2588: 37-45
1B, A
133 pacientes (69 Lap)
dor similar
melhor QOL (atividade física)
Rogmark P, Peterson U, Bringman S. Ann Surg 2013; 2588: 37-45
