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