腹腔鏡手術はより良いか？ 4,000例を超える腹腔鏡および開腹鼠径ヘルニア修復術を比較したメタアナリシス

The optimal surgical approach for inguinal hernia repair, whether open mesh or laparoscopic techniques, remains a subject of debate. This meta-analysis of randomized controlled trials (RCTs) was conducted to compare the clinical outcomes of laparoscopic versus open inguinal hernia repair.

A systematic search of PubMed, Embase, and the Cochrane Central Register of Controlled Trials (CENTRAL) was performed for studies published through June 2025. The search identified RCTs comparing laparoscopic (Transabdominal Preperitoneal [TAPP] or Totally Extraperitoneal [TEP]) repair with open mesh (Lichtenstein) repair in adult patients. Outcomes were pooled using random-effects models and reported as odds ratios (OR) or mean differences (MD) with 95% confidence intervals (CI). The review protocol was registered with PROSPERO (CRD420251158200), and the review was conducted in accordance with the PRISMA 2020 guidelines to ensure transparent reporting. The certainty of the evidence was assessed using the GRADE (Grading of Recommendations, Assessment, Development, and Evaluations) approach to contextualize the findings.

Twelve RCTs, encompassing approximately 4,000 patients with a mean follow-up ranging from 1.2 to 5.0 years, met the inclusion criteria. The analysis revealed no significant difference in the rate of hernia recurrence between laparoscopic and open repair at short- to medium-term follow-up. While overall complication rates were similar, a post-hoc severity analysis using the Clavien-Dindo classification showed that serious intra-abdominal complications (Grade IIIb) occurred exclusively in the laparoscopic groups, whereas wound-related complications (Grade I-II) were more common in the open group. Although laparoscopic procedures had a longer mean operative time (approximately 16 min longer, p < 0.001), they were associated with a significantly faster recovery, with patients returning to normal activities about one week earlier than those who underwent open repair. Patients in the laparoscopic group also reported less early postoperative pain and had approximately half the odds of developing chronic groin pain compared to the open repair group. Furthermore, the risk of wound infection was lower with laparoscopy.

Laparoscopic and open mesh repairs yield similarly low rates of hernia recurrence. However, laparoscopic repair offers distinct advantages in terms of early postoperative recovery and a reduction in chronic pain, albeit at the cost of a modestly longer operative duration and the requirement for general anesthesia. Both techniques are effective, and the choice of procedure should be individualized based on patient-specific factors and surgeon expertise. The GRADE analysis indicates high-certainty evidence for equivalent recurrence rates and reduced chronic pain with the laparoscopic approach, which supports current clinical guidelines that favor laparoscopy in appropriate patient populations.