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Medicina Baseada em EvidênciasHérnia Ventral Laparoscópica
Leandro Totti Cavazzola
Evidence-Based ReviewOpen vs Laparoscopic Approaches
Ventral Hernia Repair
Leandro Totti Cavazzola
Medicina Baseada em Evidências
Níveis de EvidênciaGraus de Recomendação
http://www.cebm.netMeakins JL. Am J Surg. 2002;183:399-405
Oxford 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
Dimensão do Problema
• 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
Observação é aceitável ?
Bellows CF, Robinson C, Fitzgibbons RJ et al. Am Surg 2014 ; 80(3):245-52
2b, BCoorte prospectiva 42 pacientes
11 perdas FU7 mortes outras causas
1 encarceramento em 2 anos FUconsiderado seguro subgrupo
Amostra calculada de 636 pcts16 centros2 anos FUendpoint: dor atividades diáriasprimeiro pacientes - nov 2011
Lauscher JC, Martus P, Stroux A et al. Trials. 2012 Feb 7;13:14. doi: 10.1186/1745-6215-13-1
Hérnia Ventral é diferente de Hérnia Incisional ?
• 3B, C• Estudo retrospectivo 10 anos• 201 pacientes 2 instituições• Piores resultados no grupo incisional
Bittner R, Bingener-Casey J, Dietz U et al Surg Endosc. 2014; 28(1):2-29
Importância da Classificação Defeitos
Bittner R, Bingener-Casey J, Dietz U et al Surg Endosc. 2014; 28(1): 2-29
Hérnia Ventral LaparoscópicaSéries 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
LeBlanc KA, Booth WV. Surg Lap Endosc 1993; 3(1):39-41
Heniford TB, Park A, Ramshaw BH, Voeller G. Ann Surg 2003; 283: 391-400
2b, B4 cirurgiões insituições acadêmicascoorte prospectivatécnica consistenteFU: 1-2 semanas
3 e 6 mesesanual
Heniford TB, Park A, Ramshaw BH, Voeller G. Ann Surg 2003; 283: 391-400
Heniford TB, Park A, Ramshaw BH, Voeller G. Ann Surg 2003; 283: 391-400
850 pacientesDefeito: 118 cm2 (1-1600 cm2)Tela: 344 cm2 (24-2500 cm2)
(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%)
Heniford TB, Park A, Ramshaw BH, Voeller G. Ann Surg 2003; 283: 391-400
Hérnia Ventral LaparoscópicaSéries 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%)
Bingener J, Buch L, Richards M et al. Arch Surg 2007; 142: 562-7
Bisgaard T. BJS 2009; 96: 1452-7
4, CBase de dados populacional DinamarcaEndopoint primário: complicações 30 dias2896 cirurgias: 1872 abertas1024 lap95% 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, A8 estudos, 526 pacientesSem ≠ recorrência complicações FO internação 6/8
Sajid MS, Bokari SA, Mallick AS et al. Am J Surg 2009; 197: 64-72
Ia, A5 studies, 336 pctes< complication rate LOS surgical time ?without ≠ pain and recurrence
1B, A146 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
Itani K, Hur K, Kim LT et al. Arch Surg 2010; 145 (4): 322-328
Mason RJ. Ann Surg 2011; 254: 641-52
4, CNational Surgery Quality Improving Program83% cirurgias abertas< morbidade geral (6x3,8%, OR 0,62)< morbidade grave (2,5x1,2%, OR 0,61)mortalidade similarRESULTADOS SUPERIORES EM PACIENTES COMPLICADOS
ENCARCERAMENTO/ESTRANGULAMENTO
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
1a, A
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
1a, A
4, C20% pacientes internados nos EUA18223 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%)
Colavitta P, Tsirline VB, Valters A et al. Surg Endosc 2013; 27: 109-117
Rogmark P, Peterson U, Bringman S. Ann Surg 2013; 2588: 37-45
1B, A133 pacientes (69 Lap)dor similarmelhor QOL (atividade física)uma infecção FO grupo lap (x 17 )
Rogmark P, Peterson U, Bringman S. Ann Surg 2013; 2588: 37-45
1B, A710 reparos (308 Lap)diminuição QOL curto prazosimilar QOL 6-12 mesesnível complicações similarmenor permanência menos infecções
Conclusões
Existem vantagens claras em relação ao reparo aberto para morbidade de ferida operatória e infecções da tela
Resultados a longo prazo demonstram recorrência similar e durabilidade do reparo
Perspectivas
"The final word on hernia will probably never be written. In collecting, assimilating and distilling the wisdom of today we must provide a base from which further advances may be made."
Sir John Bruce 1905-1975
cavazzola gmail.com
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