TRATAMENTO DAS HÉRNIAS UMBILICAIS E EPIGÁSTRICAS: UMA REVISÃO SISTEMÁTICA

ALVES, José Roberto; SPENGLER, Luis Felipe Mondardo; JUSTINO, Leonardo Busch; JUSTINO, Gustavo Busch; SILVA, Iago Koerich; AMICO, Enio Campos

doi:10.1590/0102-6720202400014e1807

Brasil

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Review Article • ABCD, arq. bras. cir. dig. 37 • 2024 • https://doi.org/10.1590/0102-6720202400014e1807 linkcopiar

TRATAMENTO DAS HÉRNIAS UMBILICAIS E EPIGÁSTRICAS: UMA REVISÃO SISTEMÁTICA

Autoria SCIMAGO INSTITUTIONS RANKINGS

RESUMO

RACIONAL: As hérnias umbilicais e epigástricas estão entre as hérnias mais comuns da parede abdominal, porém falta padronização em relação ao seu tratamento.

OBJETIVOS: Esclarecer as controvérsias acerca das possibilidades terapêuticas, indicações e técnicas cirúrgicas relacionadas ao tratamento das hérnias umbilicais e epigástricas.

MÉTODOS: Foi realizada revisão sistemática e análise qualitativa dos estudos publicados nos últimos 20 anos, envolvendo indivíduos maiores de 18 anos com hérnias umbilicais e/ou epigástricas, por meio de busca nas bases de dados PubMed/Medline, Cochrane, LILACS e SciELO, sendo selecionados estudos do tipo ensaios clínicos randomizados controlados para análise. Foi determinado o risco de viés de cada estudo individualmente de acordo com a ferramenta Cochrane Risk of Bias Tool.

RESULTADOS: Foram inicialmente selecionados 492 estudos e, posteriormente, escolhidos 15 ensaios clínicos randomizados controlados que preencheram os critérios de inclusão e foram submetidos à leitura integral e análise qualitativa, considerando os possíveis viés.

CONCLUSÕES: Esta revisão concluiu que é evidente a superioridade do uso de telas no tratamento das hérnias epigástricas/umbilicais primárias com defeito superior a 1 cm, mesmo em certas situações de emergência. No entanto, o reparo com sutura pode ser uma opção em pacientes com defeito menor que 1 cm. Na abordagem laparoscópica, evidências recentes apontam para possível superioridade na fixação com selantes de fibrina e o fechamento do defeito fascial é recomendado. Ademais, devido à escassez de ensaios clínicos randomizados controlados com baixo risco de viés, foi identificada a necessidade de desenvolver mais estudos sobre os tipos, técnicas de posicionamento e fixação das telas, assim como sobre qual o real papel da cirurgia videolaparoscópica na correção das hérnias, especialmente as umbilicais.

DESCRITORES: Hérnia Umbilical; Hérnia Ventral; Parede Abdominal; Cirurgia Geral

Studies	Random sequence generation	Allocation concealment	Selective reporting	Blinding participants	Blinding outcome assessment	Incomplete outcome data	Other sources of bias
Kaufmann et al.¹⁰	Low risk	Low risk	Low risk	Low risk	Low risk	Low risk	Low risk
Arroyo et al.³	Low risk	Low risk	Low risk	High risk	High risk	Low risk	Low risk
Ponten et al.¹⁹	Low risk	Low risk	Low risk	Low risk	Low risk	Low risk	Low risk
Abdel-Baki et al.¹	Low risk	High risk	Low risk	High risk	High risk	Low risk	Low risk
Christoffersen et al.⁵	Low risk	Low risk	Low risk	High risk	Low risk	Low risk	Low risk
Malik¹¹	Low risk	Low risk	Low risk	High risk	High risk	Low risk	Low risk
Polat et al.¹⁸	Low risk	High risk	Low risk	High risk	High risk	High risk	High risk
Bessa et al.⁴	Low risk	Low risk	Low risk	High risk	High risk	Low risk	Low risk
Eriksen et al.⁸	Low risk	Low risk	Low risk	Low risk	Low risk	Low risk	Low risk
Pietro Díaz et al.²¹	Low risk	Low risk	Low risk	High risk	Low risk	Low risk	Low risk
Purushotham and Madhu²²	Low risk	High risk	Low risk	High risk	High risk	Low risk	Low risk
Abo-Ryia et al.²	Low risk	High risk	Low risk	High risk	High risk	Low risk	Low risk
Tunio²³	Low risk	Low risk	Low risk	High risk	High risk	Low risk	Low risk
Othman et al.¹⁵	Low risk	High risk	Low risk	High risk	High risk	Low risk	Low risk
Christoffersen et al.⁶	Low risk	Low risk	Low risk	Low risk	Low risk	Low risk	Low risk

Studies	Type of hernia included	Selected theme	N	Intervention group	Control group	Criteria for mesh indication	Statistically significant outcome
Kaufmann et al.¹⁰	Umbilical	Mesh use	300	Mesh repair	Suture repair	Defect between 1 and 4 cm	Fewer recurrence rate within two years in the mesh group (3.6% vs 11.4%)
Arroyo et al.³	Umbilical	Mesh use	200	Mesh repair	Suture repair	Defect above 3 cm	Fewer recurrence rate within five years in the mesh group (1% vs 11%)
Ponten et al.¹⁹	Umbilical and epigastric	Mesh use	348	Mesh repair	PVP repair	Defect wider than 2 fingers’ width	Fewer reoperation rate (4.0% vs 10.7%) and local complications rates (22.1% vs 32.5%) in the mesh group
Abdel-Baki et al.¹	Umbilical (acute incarcerated)	Mesh use	42	Mesh repair	Suture repair	Any size defect	Fewer recurrence rate within one and a half year in the mesh group (0% vs 19%)
Tunio²³	Umbilical	Mesh use	86	Mesh repair	Suture repair	Defect above 3 cm	Fewer local complications, post-operative pain, recurrence rate within three years (2.3% vs 7.0%) and hospitalization days (4.30 days vs 6.14) in the mesh group
Bessa et al.⁴	Umbilical	Mesh position	80	Pre-peritoneal position	Pre-aponeurotic position	Defect between 4 and 10 cm	There were no significantly distinct outcomes between different positions
Abo-Ryia et al.²	Umbilical	Mesh position	60	Retrorectal position	Pre-aponeurotic position	Any size defect	Retrorectal position was associated with fewer post-operative pain rate (VAS score of 4.87 vs 7.07)
Eriksen et al.⁸	Umbilical	Mesh fixation	40	Fixation with fibrin sealant	Fixation with titanium grapples	Defect between 1.5 and 5.0 cm	Fixation with fibrin sealant was associated with fewer post-operative pain rate (VAS score of 1.9 vs 4.7)
Malik¹¹	Umbilical	Laparoscopic surgery	337	Laparoscopic repair	Open repair	Any size defect	Fewer hematoma rate (1.61% vs 23.64%), seroma rate (4.03% vs 11.48%), chronic pain rate (2.41% vs 8.7%), and hospitalization days (2 vs 5) in the laparoscopic group
Purushotham et al.²²	Umbilical	Laparoscopic surgery	42	Laparoscopic repair	Open repair	Any size defect	Fewer post-op pain rate (VAS score of 3.05 vs 7.48) and hospitalization days (2 vs 4) in the laparoscopic group
Othman et al.¹⁵	Umbilical	Laparoscopic surgery	40	Laparoscopic repair	Open repair	Any size defect	Fewer post-operative pain rate in the laparoscopic group (VAS score of 2.76 vs 4.73)
Christoffersen et al.⁶	Umbilical	Laparoscopic surgery	80	Fascial defect closure	Without fascial defect closure	Defect between 2 and 6 cm	Fewer than 2-year recurrence (13.88% vs 32.43%) and seroma (35% vs 55%) rate in closure group
Christoffersen et al.⁵	Umbilical and epigastric	Complication prevention	56	Abdominal binders use	Without abdominal binders	Defect between 2 and 8 cm	There were no significantly distinct outcomes in abdominal binder use
Polat et al.¹⁸	Umbilical	New techniques	50	PHS repair	Others techniques	Defect below 4 cm	Fewer post-op pain rate in the PHS group (McGill pain score of 0.6 vs 0.9)
Pietro Díaz et al.²¹	Umbilical	New techniques	82	Transumbilical incision	Infraumbilical incision	Any size defect	There were no significantly distinct outcomes between different incision types

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[1] This table shows four studies classified as low risk of bias in all domains²⁶¹⁰¹⁷