riktlinjer ljumskbråck
DESCRIPTION
Riktlinjer ljumskbråck. Sven Bringman Södertälje Sjukhus Karolinska Institutet. Europeiska rekommendationer. EHS- European Hernia Society. http://www.herniaweb.org/fileadmin/downloads/library/EHS_Guidelines.pdf. Nationella rekommendationer. SBU - PowerPoint PPT PresentationTRANSCRIPT
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KIRUB-dagarna 2014
Riktlinjer ljumskbråck
Sven BringmanSödertälje Sjukhus
Karolinska Institutet
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Europeiska rekommendationer
EHS- European Hernia Society
http://www.herniaweb.org/fileadmin/downloads/library/EHS_Guidelines.pdf
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Nationella rekommendationer
SBU
http://www.socialstyrelsen.se/SiteCollectionDocuments/nationella-indikationer-operation-ljumskbrack.pdf
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Hur ska man välja?
• Inguinalt– Man
• Unilateralt primärt • Bilateralt• Recidiv
– Kvinna
• Femoralt
?
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Hur många ljumskbråck har du opererat som förste operatör?
1. 02. 1-103. 11-1004. >100
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Man
Unilateralt primärt
1. Lichtenstein2. Shouldice3. TEP4. Öppen preperitoneell
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EHS/SBU
Symtomatiska ljumskbråck hos män ska opereras med nät
Scott N, Go Peter MNYH, Graham P, McCormack K, Ross Sue J, Grant A. Open Mesh versus non-Mesh for groin hernia repair. Cochrane Database of Systematic Reviews. 2001(3)
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Kvinna
Unilateralt primärt
1. Lichtenstein2. Shouldice3. TEP4. Öppen preperitoneell
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Kvinnor
Femorala vanligareKvinna/Man 20/1
Femoralt bråck efter inguinal operationFemale/Male 10/1
Akut operation – tarmresektion 25%
Nilsson H, Stylianidis G, Haapamaki M, et al. Mortality after groin hernia surgery. Annals of surgery 2007; 245(4):656-60.Koch A, Edwards A, Haapaniemi S, et al. Prospective evaluation of 6895 groin hernia repairs in women. The British journal of surgery 2005; 92(12):1553-8.
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Kvinnor
Mortalitet x 4 totalx 7 akutX 20 akut + tarmresektion
Nilsson H, Stylianidis G, Haapamaki M, et al. Mortality after groin hernia surgery. Annals of surgery 2007; 245(4):656-60.Koch A, Edwards A, Haapaniemi S, et al. Prospective evaluation of 6895 groin hernia repairs in women. The British journal of surgery 2005; 92(12):1553-8.
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EHS/SBU
Bråck hos kvinnor:
Preperitoneal operation
TEP lägre recidivrisk
Nilsson H, Stylianidis G, Haapamaki M, et al. Mortality after groin hernia surgery. Annals of surgery 2007; 245(4):656-60.Koch A, Edwards A, Haapaniemi S, et al. Prospective evaluation of 6895 groin hernia repairs in women. The British journal of surgery 2005; 92(12):1553-8.
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Recidiv
1. Lichtenstein2. Shouldice3. TEP4. Öppen preperitoneell
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Recidiv
SHR 1992-20085565 reoperationer med den tidigare operationen registrerad
Sevonius D, Gunnarsson U, Nordin P, et al. Recurrent groin hernia surgery. The British journal of surgery 2011; 98(10):1489-94.
Hazard Ratio
Laparoscopic 1
Sutured 2.6
Lichtenstein 1.5
Plug 2.3
Open preperitoneal mesh 1.4 ns
Other 3.1
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EHS/SBU
Recidivbråck ska opereras:Preperitoneal efter anteriorAnterior efter preperitoneal
Laparoskopisk eller öppen preperitoneal
Kouhia ST, Huttunen R, Silvasti SO, et al. Lichtenstein hernioplasty versus totally extraperitoneal laparoscopic hernioplasty in treatment of recurrent inguinal hernia--a prospective randomized trial. Ann Surg. 2009; 249(3):384-7.Simons MPet al. European Hernia Society guidelines Hernia Aug 2009;13(4):343-403Sevonius D, Gunnarsson U, Nordin P, et al. Recurrent groin hernia surgery. The British journal of surgery 2011; 98(10):1489-94.
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Femoralt
1. Lichtenstein2. Shouldice3. TEP4. Öppen preperitoneell
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Femoralt
EHS/SBU:
TEPÖppen preperitoneal
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Bilateralt
1. Lichtenstein2. Shouldice3. TEP4. Öppen preperitoneell
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Bilateralt
1774 bilaterala operationer i SHR 1992-1999Ingen ökad recidivrisk vid simultan op (lap el öppen)
Socioekonomisk fördel vid bilateral operation - TEP
Simons MPet al. European Hernia Society guidelines Hernia Aug 2009;13(4):343-403Kald A, et al. Outcome of repair of bilateral groin hernias: a prospective evaluation of 1,487 patients. The European journal of surgery 2002; 168(3):150-3.
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Mitt val Lichtenstein
ST-operationNarkos kontraindiceradStort skrotaltRecidiv efter preperitoneal opIncarcererat
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Spelar det någon roll vilket nät vi använder?
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Är inte billigast bäst?
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Vilket är klinikens förstahandsval av nät vid ett litet lateralt ljumskbråck?
1. Standard polypropylen2. Lättviktspolypropylen3. Polyester4. Vet ej
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Faktorer som påverkar
PolymerPor storlekVävens strukturTjocklek
Bringman et al Hernia (2010) 14:81–87
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Polymer
PolypropylenePolyesterePTFE
MonofilamentMultifilament
Bringman et al Hernia (2010) 14:81–87
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Vävens struktur
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Tjocklek
Standard
Composite
Ultratunt
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Porstorlek
Ärr kvalitetÄrr kontraktion
Kraftig i standard polypropylenMindre i lättvikts makroporösa
Högre infektionsriskmultifilament mikroporösa
Bringman et al Hernia (2010) 14:81–87
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Brown Ann R Coll Surg Engl 2010
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Granulom bildning
2005; 12; 63 Surg InnovWilliam S. Cobb, Kent W. Kercher and B. Todd HenifordThe Argument for Lightweight Polypropylene Mesh in Hernia Repair
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Brown Ann R Coll Surg Engl 2010
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Nätvikt (g/m2)PP
Vypro 55 25 Ultrapro 55 28Vypro II 75 30
Ti-Mesh light 35Parietene light 38 Prolene soft 45Bard soft 50
Prolene 85Atrium 85Surgipro 100
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Metaanalys lättvikt vs fullvikt
Uzzaman et al Metaanalysis of randomized controlled trials comparing lightweight and heavyweight mesh for Lichtenstein inguinal hernia repair Hernia March 2012 online first
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Kronisk smärta
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Främmande kropps känsla
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Infektion
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Recidiv
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Konklusion
Lättviktsnät ger lägre främmande kroppskänsla och lägre risk för kronisk smärta utan att öka risken för recidiv
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Konklusion
Megaporöst lättvikt – små / medelstora
Standard polypropylen - stora mediala?