Der Stellenwert der minimalinvasiven Chirurgie bei der Behandlung der Leistenhernie und Pylorusstenose

Zusammenfassung

Hintergrund: Die Leistenhernienkorrektur und die Pyloromyotomie sind 2 der häufigsten Operationen im Kindesalter. In den letzten 2 Jahrzehnten wurde eine zunehmende Anzahl dieser Eingriffe minimalinvasiv durchgeführt. Diese Übersichtsarbeit beschreibt die Entwicklung der laparoskopischen Technik dieser beiden Indikationen zusammen mit dem jeweiligen aktuellen Stellenwert. Material und Methoden: Eine systematische Analyse der kinderchirurgischen Literatur seit 1990 wurde für die laparoskopische Operation der Leistenhernie und der hypertrophen Pylorusstenose durchgeführt. Relevante Publikationen wurden zusammengefasst. Ergebnisse: Die erste laparoskopische Pyloromyotomie wurde im Jahr 1991, die erste Leistenhernienkorrektur bei Kindern 1998 beschrieben. Die Lernkurve für beide Eingriffe ist zunächst steil und erreicht erst nach etwa 20–30 Operationen ein Plateau. Zum Vergleich der laparoskopischen mit der offenen Technik wurden bislang sowohl für die Pyloromyotomie wie auch für die Leistenhernienkorrektur mehrere randomisierte kontrollierte Studien und Metaanalysen publiziert. Die Vorteile der laparoskopischen gegenüber der offenen Pyloromyotomie sind die frühere Rekonvaleszenz und kürzere postoperative Verweildauer bei gleicher Komplikationsrate. Im Falle der laparoskopischen Leistenhernienkorrektur ist die Operationszeit nur bei bilateralem Vorgehen kürzer als bei der offenen Technik, während die Komplikationsrate wiederum vergleichbar ist. Allerdings treten nach einem laparoskopischen Eingriff im Intervall weniger kontralaterale Leistenhernien auf. Schlussfolgerung: Die laparoskopische Pyloromyotomie und die laparoskopische Leistenhernienoperation im Kindesalter erfordern spezielle operative Fähigkeiten. Mindestens die ersten 20 Eingriffe sollten daher unter kompetenter Anleitung durchführt werden. Neben dem subjektiven Nutzen einer kleineren Narbe haben beide Verfahren konkrete Vorteile gegenüber dem offenen Vorgehen bei gleicher Komplikationsrate. Daher können diese Eingriffe derzeit durchaus als Goldstandard betrachtet werden.

Abstract

Background: Inguinal hernia repair and pyloromyotomy are among the most common operations performed on children. In the last two decades minimally invasive surgery has been employed for an increasing number of these procedures. This review describes the development of the techniques involved, and their current role in therapy. Material and Methods: A systematic review of the paediatric surgical literature since 1990 was performed on laparoscopic inguinal hernia repair and pyloromyotomy. Relevant publications were summarised. Results: The first laparoscopic pyloromyotomy was described in 1991, the first laparoscopic inguinal hernia repair in children was published in 1998. The learning curve for both procedures is initially steep and reaches a plateau only after about 20 to 30 cases. Both randomised controlled trials and meta-analyses are available comparing the laparoscopic and open techniques for both procedures. The advantages of laparoscopic versus open pyloromyotomy include faster recovery and shorter hospital stay, at similar complication rates. The operation times of laparoscopic inguinal hernia repair are shorter in bilateral cases, while the complication rate again is similar. However, the incidence of metachronous contralateral inguinal hernia is lower after laparoscopic repair. Conclusion: Laparoscopic pyloromyotomy and paediatric inguinal hernia repair require special skills. As a minimum, a surgeonʼs first 20 cases should therefore be performed under competent supervision. Besides resulting in smaller scars, both procedures have concrete advantages and the same complication rates compared to the open techniques. Therefore, both operations can be regarded as the current gold standard.

Schlüsselwörter

Laparoskopie - Pyloromyotomie - Leistenhernie - Lernkurve - Metaanalyse

Key words

laparoscopy - pyloromyotomy - inguinal hernia - learning curve - meta-analysis

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