腹腔鏡下鼡径ヘルニア手術 (TAPP) における術前難易度予測スコアの有用性について鹿児島大学医学雑誌 2018 年 4 月

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1 腹腔鏡下鼡径ヘルニア手術 (TAPP) における術前難易度予測スコアの有用性について鹿児島大学医学雑誌 2018 年 4 月

2 Med. J. Kagoshima Univ., April, 2018 腹腔鏡下鼡径ヘルニア手術 (TAPP) における術前難易度予測スコアの有用性について 1,2, * Tel Fax tomomi141414@yahoo.co.jp Preoperative Scoring Technique to Predict the Difficulty of Laparoscopic Surgery for Inguinal Hernia Repair using a Trans-abdominal Preperitoneal Approach Tomomi Hayashi 1, 2,*), Kenzo Yokoyama 1), Hiroshi Higashi 2), Masayuki Yanagi 2), Takashi Kijima 2), Keishi Okubo 2), Shoji Natsugoe 2) 1) Department of Surgery, Sanshu Hospital 2) Department of Digestive Surgery, Breast and Thyroid Surgery, Kagoshima University Graduate School of Medical and Dental Sciences Reccived 2017, Nov. 28; Revised 2018, Jan. 12; Accepted Feb. 9 *Address to correspondence Tomomi Hayashi Department of Surgery, Sanshu Hospital Hanaguri cho 3-14, Miyakonojo, Miyazaki phone : , FAX : tomomi141414@yahoo.co.jp Abstract Laparoscopic surgery for inguinal hernia has been considered technically difficult and in terms of the surgeons procedural competence (learning curve). In a recent study, we investigated the learning curve and the factors that could predict the difficulty of performing laparoscopic surgery for inguinal hernia repair. In 30 such cases performed beginning in 2014, the degree of difficulty and surgeons proficiency were evaluated based solely on the operation time. Learning curves were analyzed using the Wilcoxon test. A multiple regression analysis identified nine factors that predicted the degree of difficulty. Based on these results, we developed a new preoperative prediction score. After applying it clinically, we found that the operation time was significantly shorter than that of the previous routine procedure. Five factors contributed to longer operation times: 60 years of age; adhesions around the hernial hiatus; incarceration into the hernia hiatus; white scar formation; peritoneal thickness and strength. Since then, we have chosen appropriate operators for this surgery based on their preoperative prediction scores. This selection process has resulted in shorter operation times and fewer surgical complications. Key words: TAPP Preoperative prediction score for difficulty Learning Curve

3 8 和文抄録 Wilcoxon はじめに TAPP ) 5 6) TAPP 7-11) TAPP 12) 13) TAPP TAPP TAPP TAPP 対象および方法 TAPP 10mm 1 5 mm 2 3 3D tacker TAPP TAPP TAPP Wilcoxon BMI BMI )

4 腹腔鏡下鼡径ヘルニア手術 (TAPP) における術前難易度予測スコアの有用性について 9

5 Kruskal-Wallis Bonferroni P 0.05 JMP12 SAS Institute Inc.NC,USA) TAPP 15) Cooper myopectineal orifice MPO ) MPO 19) 結果 BMI TAPP p p p p Wilcoxon 60 p p p p p p p p TAPP 5 TAPP Kruskal-Wallis p Wilcoxon Bonferroni 2 p p p 考察 15 TAPP 20-21) TAPP 15 TAPP 9

6 腹腔鏡下鼡径ヘルニア手術 (TAPP) における術前難易度予測スコアの有用性について 11 図 1 定型化前の症例と難易度評価

7 12 図 2 定型化 + 術前難易度予測スコア導入前後の推移 TAPP TAPP 2 TAPP BMI De novo

8 腹腔鏡下鼡径ヘルニア手術 (TAPP) における術前難易度予測スコアの有用性について 13 図 3 定型化 + 術前難易度予測スコア導入前後の比較表 3 定型化 + 術前難易度予測スコア導入前後の比較

9 14 図 4 手術前難易度の関与が予想される因子表 4 手術時間別での難易度に関する因子と重回帰分析

10 腹腔鏡下鼡径ヘルニア手術 (TAPP) における術前難易度予測スコアの有用性について 15 図 5 手術時間別と TAPP 難易度スコアとの関係にヘルニア腹の難にる手術難易度にている性のるについて前鼡径の 2 に鼡径ヘルニア術のる TAPP のの 18.3 いる 22) の TAPP る手術の術予るのて手術手のニスにる手のの難易度予測スコアにる術前難易度の 3 て手術ている腹前に手術の難易度予測術スののスるるる TAPPの難易度のに手術にる難い手術難易度のて用い手術に術の手術手度にるの 2 の術てるおてPub Medにて TAPP severity にのにTAPPにおける術前難易度予測スコア

11 16 図 6 総手術時間における難易度別での 3 グループ間の比較おわりに文献 1 Ger R, Monroe K, Duvivier R, Mishrick A, Management of indirect inguinal hernias by a laparoscopic closure of the neck of the sac. Am J Surg Popp LW, Endoscopic patch repair of inguinal hernia in a female patient. Surg Endosc Schultz L, Graber J, Pietrafitta J, Hickok D. Laser laparoscopic herniorrhaphy a clinical trial preliminary results. J Laparoendoscop Surg

12 腹腔鏡下鼡径ヘルニア手術 (TAPP) における術前難易度予測スコアの有用性について ) 腹腔鏡下鼡径ヘルニア術 - TAPP(transabdominal preperitoniar repair). 手術 ) Memon MA, Cooper NJ, Memon B, Memon MI, Abrams KR, Meta-analysis of randomized Clinical trials comparing open and laparoscopic inguinal hernia repair. Br J Surg ) Schmedt CG, Sauerland S, Bittner R, Comparison of endoscopic procedures vs Lichtenstein and other open mesh techniques for inguinal hernia repair, a metaanalysis of randomized trials.surg Endosc ) Bittner R, Sauerland S, Schmedt CG, Comparison of endoscopic techniques vs Shouldice and other open nonmesh techniques for inguinal hernia repair. SurgEndosc )Kuhry E, van Veen RN, Langeveld HR, Steyerberg EW, Jeekel J, Bonjer HJ, Open or endoscopic total extraperitoneal inguinal hernia reair? A systematic review.surg Endosc )Li J,Wang X, Feng X, Gu Y, Tang R, Comparison of open and laparoscopic preperitneal repair of groin hernia. Surg Endsc ) 鏡鏡手術にるア鏡 )Neumayer LA, Gawande AA, Wang J, Giobbie-Hurder A, Itani KM, Fitzgibbons RJ Jr, et al, Proficiency of surgeons in inguinal hernia repair, effect of experience and age. Ann Surg ) ヘルニア鼡径ヘルニア 2015., ) 腹腔鏡下鼡径ヘルニア術 -TAPP の手術手. 手術 ) 腹腔鏡下鼡径ヘルニア術 - 鼡径の. 手術 )Knook MT, van Rosmalen AC, Yoder BE, Kleinrensink GJ, Snijders CJ, Looman CW, Optimal mesh size for endoscopic ingunal hernia repair.surg Endosc )Binnebosel M, Rosch R, Junge K, Flanagan TC, Schwab R, Schumpelick V, Biomechanical analyses of overlap and mesh dislocation in an incisional hernia model in vitro.surgery )Wolloscheck T, Konerding MA, Dimensions of the myopectineal orifice.hernia ) 腹腔鏡下術における術前難易度 ) 腹腔鏡下術におけるニ手術難易度の術前予測 )Krishna A, Misra MC, Bansal VK, Kumar S, Rajeshwari S, Chabra A, Laparoscopic inguinal hernia repair : Transabdominal preperitoneal(tapp)versus totally extraperitoneal(tep)approach, A prospective randomized controlled trial. Surg Endosc

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腹腔鏡下鼡径ヘルニア手術 (TAPP) における術前難易度予測スコアの有用性について 鹿児島大学医学雑誌 2018 年 4 月

腹腔鏡下鼡径ヘルニア手術 (TAPP) における術前難易度予測スコアの有用性について鹿児島大学医学雑誌 2018 年 4 月