evidence based medicine 指導醫師：駱至誠 教授 clerk ：林旻暭、洪俊宇、黃冠慈

Evidence Based Medicine指導醫師：駱至誠 教授Clerk ：林旻暭、洪俊宇、黃冠慈

Clinical ScenarioClinical Scenario A four month-old boy with left side inguinal

hernia receives inguinal herniotomy by the open technique

Question:

Does it benefits from routine contralateral exploration at the time of the primary inguinal herniotomy?

Introduction of Inguinal Hernia

Inguinal Hernia An inguinal hernia develops when the processus

vaginalis fails to obliterate during late gestation, allowing communication between the abdominal cavity and the inguinal canal to persist. Abdominal contents can then herniate into the inguinal canal.

Inguinal Hernia The vast majority of hernias in children are

indirect, with contents protruding through the internal inguinal ring into the inguinal canal.

5 A’s5 A’s

Outcome: Incidence of metachronous contralateral inguinal herniaOutcome: Incidence of metachronous contralateral inguinal hernia

Comparison: Unilateral explorationComparison: Unilateral exploration

Intervention: Contralateral explorationIntervention: Contralateral exploration

Patient/Problem: A 4 month-old child with left side inguinal herniaPatient/Problem: A 4 month-old child with left side inguinal hernia

AcquireAcquireDatabase: PubMedKeywords: Metachronous contralateral inguinal

hernia

Metachronous contralateral inguinal hernia

The evidence pyramid

Level of evidence

Critical Appraisal of systemic review paper

10 question for Critical Appraisal of Systemic review

Is the trial valid?(Q1~Q5)

What are the results?(Q6~Q7)

Will the results help locally?(Q8~Q10)

Q1.Did the review ask a clearly-focused question?

Q2. Did the review include the right type of studies?

Q3.Did the reviewers try to identify all relevant studies?

Q4. Did the reviewers assess the quality of the included studies?

Q5.If the results of the studies have been combined, was it reasonable to do so?

These review article included study with evidence level II-a and II-b so there were no heterogeneity(I2) and Westley score for evaluation

Q6. How are the results presented and what is the main result?

Q7. How precise are the result? Same as Q5

Q8. Can the result be applied to the local population?

Patient 的 data來自 61 個studies

Patients的年齡從 GA 31 wks 到 18 y/o並沒有特別提起 patients的種族

不知道

Q9. Were all important outcomes considered?

Develop MCIH following a unilateral inguinal herniotomy: (49568 patients)

5.76%(95%CI:5.55-5.97%) NNT(number need to treat):18

(95%CI:16.8-18%) Gender

incidence NNT

male 6.13% (95%CI:5.74-6.52%)

17 (95%CI:15.3-17.4)

female 6.37% (95%CI:5.63-7.11%)

16 (95%CI:14.1-17.8)

Age <6 month: 183/1470 >6month: 144/2044 p<0.0001 NNT for age<6 month:9 (95%CI:7.1-

9.3)

Q9. Were all important outcomes considered?

Q9. Were all important outcomes considered? Laterality of initial hernia(22104

patients) P<0.0001

Initial site

Left Right

Incidence 34% 66%

MCIH incidence

12.1% 6.9%

NNT 9 15

yes

Q9. Should policy of practice change as a result of the evidence contained in this review?

Audit

•A four month-old boy with left side inguinal hernia receives inguinal herniotomy by the open technique

•Risk factor: left side 、 four-month•並不作 routine 的 explore,告知 risk factor並和家長討論治療計畫