A longitudinal cohort study of incidence rates of inguinal hernia repair in 0- to 6-year-old children

Approach to concurrent inguinal hernias during laparoscopic appendectomy for early appendicitis

PURPOSE

Concurrent inguinal hernia can be a challenge for a pediatric surgeon during a laparoscopic appendectomy in children. We aimed to present our approach to inguinal hernias seen during laparoscopic appendectomy.

METHODS

In our pediatric surgery clinic between July 2019 and December 2022, the records of patients aged 0-18 who underwent laparoscopic appendectomy were retrospectively investigated. The clinical findings, surgical procedure, and results of intervened inguinal hernia cases during laparoscopic appendectomy were evaluated.

RESULTS

Between the study dates, 293 laparoscopic appendectomies were performed in our clinic. Patent processus vaginalis was observed in 5 (1.7%) cases. Laparoscopic hernia repair was performed with the Burnia technique in 2 girls. In one case, the omentum was herniated and adhered to the hernia sac seen during laparoscopy. In another case, swelling in the groin occurred during the introduction of air into the abdomen at the beginning of the operation. Patent processus vaginalis seen in 3 asymptomatic cases was not intervened. There were no postoperative complications or recurrences in the two patients who underwent hernia repair.

CONCLUSION

Hernia repair with the Burnia technique might be safely performed in symptomatic inguinal hernia cases seen during laparoscopic appendectomy for early appendicitis.

Should the processus vaginalis sac be opened or closed in pediatric herniotomy? A two-center cohort study

BACKGROUND

Inguinal hernia repair is one of the most common operations in children. To improve outcome, several techniques are used. However, it has not been established if the open or the closed hernia sac preparation technique is superior in (premature) neonates and older children.

METHODS

Retrospective study including all cases of inguinal hernia repair in children at two large centers. Demographic data and outcome parameters including procedure time and intra as well as postoperative complications were evaluated. To compare open vs. closed hernia sack preparation, cases with secondary open preparation were excluded and propensity score matching was performed. Regression analysis was used to determine factors affecting operative time and recurrence rate.

RESULTS

In total 2476 cases of inguinal hernia repair were identified. After exclusion of direct hernias as well as revision cases, 2257 cases were analyzed. Overall mean operative time was 25.8 min. Intraoperative complications occurred in 0.1% and. postoperative complications occurred in 3.0% of all cases, the most frequent postoperative complication being recurrence (1.7%). Closed preparation technique resulted in significantly faster procedure time and lower recurrence rates in premature neonates and older children compared to the open hernia sac preparation technique. Operative technique, prematurity, gender and training of the surgeon are highly associated with operative time, whereas operative technique is the main factor affecting recurrence rate.

CONCLUSIONS

It appears that closed hernia sack preparation is superior to open regarding speed and recurrence. This was true for premature neonates, neonates and older children. All other outcome parameters including intra- and postoperative complications were similar. Thus, we recommend to use the closed preparation technique whenever possible.

Nomogram for the Estimation of Intestinal Necrosis Risk in Incarcerated Inguinal Hernia in Infants under 6 Months

OBJECTIVE

 This article develops a nomogram to estimate intestinal necrosis risk in the incarcerated inguinal hernia (IIH) in infants under 6 months.

METHODS

 A total of 273 infants who underwent an emergency operation due to IIH were investigated retrospectively. Univariate and multivariate logistic regression were used to analyze the relationship between variables and intestinal necrosis and construct a nomogram of intestinal necrosis. The discrimination and concordance of the model were verified by receiver operating characteristic (ROC) analysis and calibration curve, and the bootstrap method was used for internal validation of the model. The clinical applicability of the model was evaluated using the decision curve and the clinical impact curve.

RESULTS

 Intestinal necrosis was found in 37 of 273 infants (13.6%) in this study. The vomiting symptoms, platelet count, C-reactive protein, and neutrophil-lymphocyte ratio were independent risk factors for intestinal necrosis in IIH. We then constructed a nomogram with these four factors. ROC analysis showed that the nomogram had a good diagnostic performance, with the area under the curve (AUC), sensitivity, and specificity of 0.918 (95% confidence interval: 0.880-0.956), 97.3%, and 69.9%, respectively. The nomogram was further validated using 2,000-repetition internal bootstrap validation, and the values of AUC, sensitivity, and specificity were 0.899, 95.7%, and 50.5%, respectively. The decision curve and the clinical impact curve indicated that the predictive model has a favorable clinical application.

CONCLUSION

 The nomogram can be used to predict intestinal necrosis in IIH, and allow us to estimate the severity of IIH more accurately and arrange the treatment process more reasonably.

Laparoscopic repair of bilateral inguinal hernias each containing sigmoid colon in a premature infant

Inguinal hernias are rare in the general population but are more frequently seen in premature infants. Risk factors include male gender, small for gestational age, low birth weight and respiratory distress. Infant inguinal hernias most frequently contain small bowel. Other contents can include the appendix and cecum, and rarely, the sigmoid colon. Sigmoid colon as content of inguinal hernia in children has only been reported twice in literature, and in both cases it was unilateral. We present the first reported case of bilateral inguinal hernias containing the sigmoid colon in a premature boy, who additionally had the appendix and the cecum in the right hernia. This is also the first reported laparoscopic repair of such a hernia.

A single institution experience with Laparoscopic Hernia repair in 791 children

INTRODUCTION

There are many described technique to performing laparoscopic inguinal hernia repair in children. We describe our outcomes using a percutaneous internal ring suturing technique.

METHODS

A retrospective review of patients under 18 years old who underwent repair between January 2014 - March 2019 was performed. A percutaneous internal ring suturing technique, involving hydro-dissection of the peritoneum, percutaneous suture passage, and cauterization of the peritoneum in the sac prior to high ligation, was used. p < 0.05 was considered significant during the analysis.

RESULTS

791 patients were included. The median age at operation was 1.9 years (IQR 0.37, 5.82). The median operative time for a unilateral repair was 21 min (IQR 16, 28), while the median time for a bilateral repair was 30.5 min (IQR 23, 41). In total, 3 patients required conversion to an open procedure (0.4%), 4 (0.6%) experienced post-operative bleeding, 9 (1.2%) developed a wound infection, and iatrogenic ascent of testis occurred in 10 (1.3%) patients. Twenty patients (2.5%) developed a recurrent hernia. All but two were re-repaired laparoscopically.

CONCLUSIONS

The use of percutaneous internal ring suturing for laparoscopic repair of inguinal hernias in the pediatric population is safe and effective with a low rate of complications and recurrence.

Epidemiology of abdominal wall and groin hernia repairs in children

PURPOSE

We sought to estimate the prevalence, incidence, and timing of surgery for elective and non-elective hernia repairs.

METHODS

We performed a retrospective cohort study, abstracting data on children < 18 years from the 2005-2014 DoD Military Health System Data Repository, which includes > 3 million dependents of U.S. Armed Services members. Our primary outcome was initial hernia repair (inguinal, umbilical, ventral, or femoral), stratified by elective versus non-elective repair and by age. We calculated prevalence, incidence rate, and time from diagnosis to repair.

RESULTS

19,398 children underwent hernia repair (12,220 inguinal, 5761 umbilical, 1373 ventral, 44 femoral). Prevalence of non-elective repairs ranged from 6% (umbilical) to 22% (ventral). Incidence rates of elective repairs ranged from 0.03 [95% CI: 0.02-0.04] (femoral) to 8.92 [95% CI: 8.76-9.09] (inguinal) per 10,000 person-years, while incidence rates of non-elective repairs ranged from 0.005 [95% CI: 0.002-0.01] (femoral) to 0.68 [95% CI: 0.64-0.73] (inguinal) per 10,000 person-years. Inguinal (median = 20, interquartile range [IQR] = 0-46 days), ventral (median = 23, IQR = 5-62 days), and femoral hernias (median = 0, IQR = 0-12 days) were repaired more promptly and with less variation than umbilical hernias (median = 66, IQR = 23-422 days).

CONCLUSIONS

These data describe the burden of hernia repair in the U.S. The large variation in time between diagnosis and repair by hernia type identifies an important area of research to understand mechanisms underlying such heterogeneity and determine the ideal timing for repair.

LEVEL OF EVIDENCE

Prognosis study II.

Using Point-of-Care Ultrasound to Characterize Acute Inguinal Swelling of Young Children in the Pediatric Emergency Department

Acute inguinal swelling in young children is frequently assumed to be an inguinal hernia, often prompting a bedside reduction attempt. We report 3 cases of inguinal swelling where the use of point-of-care ultrasound changed the patients' management by identifying an alternate diagnosis, thus avoiding unnecessary and painful procedures as well as their associated sedation risks.

Delaying surgery for inguinal hernia in neonates: Is it worthwhile?

Objective

The incidence of inguinal hernia is high in premature infants; however, surgical repair is a high-risk procedure for these patients. The timing of hernia repair is still controversial. This study aimed to determine the optimal timing for inguinal herniotomy in neonates in a general hospital.

Methods

A prospective cohort study was conducted from March 2014 to September 2018. A total of 127 neonates and preterm infants were admitted to the paediatric surgery clinic with uncomplicated inguinal hernia. Herniotomy was performed in all neonates, and the patients were followed up for up to 8 months after surgery for perioperative and postoperative complications. The timing of surgery was based on the surgeon's decision along with the consent of the family to the surgical intervention.

Results

Of 118 neonates, as many as 53 (45%) underwent early repair and 65 (55%) underwent late repair of inguinal hernia. The demographic data were similar between the 2 groups with no significant difference. There were no significant differences in the incidence of inguinal hernia incarceration and hydrocele formation (p = 0.11 and p = 0.8, respectively); however, there was a higher incidence of inguinal hernia recurrence (p = 0.05) and postoperative apnoea (p = 0.02) in the early repair group.

Conclusion

Surgical repair of inguinal hernia is feasible with low morbidity in preterm babies. The risk of hernia incarceration and testicular atrophy did not increase with delayed elective hernia repair in neonates. Delayed hernia repair decreased the risk of perioperative and postoperative complications. This study recommends delaying elective hernia repair in neonates and preterm babies.

Inguinal hernia surgery in Korea: nationwide data from 2007-2015

Purpose

The aim of this study is to analyze inguinal hernia in Korea based on the nationwide data.

Methods

Retrospective analysis of nationwide data obtained from the Health Insurance Review & Assessment Service database for surgical repair of inguinal hernia from January, 2007 to December, 2015 was performed.

Results

A total of 314,238 cases of inguinal hernia surgery were performed during 9 years. The mean number of inguinal hernia surgery per year was 34,604 (range, 30,065–36,928). The proportion of male patient was 87%. Patients between the age of 1 to 5 years (17.3%) and of 60 to 69 years (17.4%) constituted the 2 dominant groups for inguinal hernia repair. A slight increase in repair for recurrent inguinal hernia, 1.9% to 3.2%, was observed from 2007 to 2015. The rate of concurrent bowel resection decreased from 1.9% to 0.6%. The total cost of inguinal hernia surgery was increased up to 1.68 times from 2007 to 2015 ($856 to $1,439), although the number of hospital days was decreased from 4.7 to 3.7 days. The rate of laparoscopic surgery was increased to 29.5% in 2015.

Conclusion

A mean number of 34,604 cases of inguinal hernia surgery have been carried out annually in Korea. The age distribution for inguinal hernia repair demonstrates bimodal peak at early childhood and old age. The proportion of laparoscopic surgery of inguinal hernia has been increasing for the past 9 years. The length of hospital stay and the rate of combined bowel resection have decreased.

Fertility in males after childhood, adolescent, and adult inguinal operations

BACKGROUND/PURPOSE

Inguinal hernia repair and orchidopexy are among the most common operations in boys. The impact on future fertility has not been conclusively defined. This study evaluates sperm quality after previous inguinal surgery.

METHODS

Spermiograms of men with a desire to conceive children were analyzed. History of previous inguinal surgery (hernia repair, orchidopexy, varicocele ligation) was correlated with sperm quality. Other influential factors (age, BMI, chronic medication, tobacco use) were also tested.

RESULTS

A total of 333 patients were included. Overall, 12.6% of the subjects had undergone previous inguinal surgery. Of these, 17 (43%) were inguinal hernia repairs, 8 (20%) orchidopexies, and 6 (15%) varicocele ligations, while 9 (22%) could not give an exact history. Abnormal spermiograms were found in 60% (n = 24) of those with previous inguinal surgery versus 48% in controls (p = 0.16). On multivariate analysis, pathologic spermiogram parameters were associated with previous inguinal surgery, orchidopexy, use of chronic medication, and smoking, but NOT with inguinal hernia or varicocele repair alone.

CONCLUSIONS

Previous inguinal hernia or varicocele repair does not seem to impact negatively on quality of sperm later in life. Orchidopexy, smoking, and use of chronic medication, however, were all associated with pathologic sperm quality parameters.

TYPE OF STUDY

Prospective comparative study.

LEVEL OF EVIDENCE

Level II.

Is contralateral inguinal exploration necessary in preterm girls undergoing inguinal hernia repair during the first months of life?

BACKGROUND

To assess the need for contralateral surgical exploration in preterm girls with symptomatic unilateral inguinal hernia.

METHODS

The medical data of girls operated for inguinal hernia between 2004 and 2016 in a single pediatric surgery center were retrospectively collected. Preterm girls operated for unilateral hernia before 6 months of life were selected (55/517 cases) to assess the incidence and risk factors for contralateral metachronous inguinal hernia (CMIH).

RESULTS

CMIH was observed in 7% of cases (4 girls with a right inguinal hernia in 3 cases) at a mean age of 4.2 years. Only one case occurred early (3 months). Birth weight and term were comparable (1674 ± 620 g and 32 ± 5 WA without CMIH vs. 1694 ± 582 g and 33 ± 3 WA with CMIH).

CONCLUSION

Contralateral inguinal hernia is very rare and generally occurs several years after inguinal repair surgery in preterm girls, which should encourage practitioners to follow these children throughout childhood for the subsequent development of inguinal hernia. This study did not find any arguments in favor of systematic contralateral exploration in preterm girls.

Surgical practice and outcome in 711 neonates and infants undergoing hernia repair in a large multicenter RCT: Secondary results from the GAS Study

BACKGROUND

The GAS study is an international RCT to evaluate neurodevelopmental outcome comparing general plus regional anesthesia versus regional anesthesia alone in 722 neonates and infants who had inguinal hernia repair up to 60 weeks of postmenstrual age. This paper comprises a secondary descriptive analysis of hernias, aspects of surgery and outcomes.

METHODS

The incidence of unilateral and bilateral hernias, side preponderance, predictive factors for bilateral hernias and surgical approaches were collated. Follow-up outcome data were examined at 2 years.

RESULTS

Of 711 eligible patients, there were 679 with hernia data showing that 321 hernias were right-sided, 190 left and 168 bilateral. Male to female ratio was 5:1. Of those with unilateral hernias, 25.8% underwent contralateral exploration and in these cases a patent processus vaginalis was found in 68.9%. Bilateral hernias were more common in younger and female patients. At 2 years there was a recurrence rate of 0.99% and in 2.7% of patients a hernia was evident on the contralateral side (metachrony), and this was unrelated to the anesthesia technique.

CONCLUSIONS

Bilateral hernias are associated with lower gestational age at birth and female gender. There was a low incidence of complications and the anesthesia technique did not affect surgical outcome.

LEVEL OF EVIDENCE

Level 1 evidence from prospective treatment study.

Evidence supporting laparoscopic hernia repair in children

PURPOSE OF REVIEW

Pediatric inguinal hernias are a commonly performed surgical procedure. Currently, they can be approached via open or laparoscopic surgery. We summarize the current evidence for laparoscopic inguinal hernia repairs in children.

RECENT FINDINGS

Laparoscopic and open inguinal hernia repair in children are associated with similar operative times for unilateral hernia, as well as similar cosmesis, complication rates and recurrence rates. Bilateral hernia repair has been shown to be faster through a laparoscopic approach. The laparoscopic approach is associated with decreased pain scores and earlier recovery, although only in the initial postoperative period. Laparoscopy allows for easy evaluation of the patency of contralateral processus vaginalis, although the clinical significance of and need for repair of an identified defect is unclear.

SUMMARY

Laparoscopic surgery for pediatric inguinal hernias offers some advantages over open repair with most outcomes being equal. It should be considered a safe alternative to open repair to children and their caregivers.

A nationwide survey of incidence rates and risk factors of inguinal hernia in preterm children

PURPOSE

Clinical observations showed a higher incidence rate of inguinal hernia (IH) in preterm infants. In this study, we calculated the incidence rate of preterm IH from the National Health Insurance Research Database (NHIRD) of Taiwan.

METHODS

From NHIRD, 92,308 subjects born in the year of 1997-2005 were randomly selected as the study cohort. The medical claims of these subjects from birth to 6th year of age were analyzed. Preterm births were defined using ICD code 765.1*. Risk factors such as birth weight, lung disorders, and ventilator supports before IH repairs were investigated. The risk of incarceration and bowel resection were also evaluated.

RESULTS

From 92,308 subjects, 2560 preterm births were identified. IH was repaired in 231 preterm (9.02%) and 3650 term subjects (4.07%). Male (preterm 13.3% and non-preterm 6.3%) had more hernia repairs than female (preterm 3.8% and non-preterm 1.6%). The incidence rate of IH is 13.7% for those under 1500 g, 8.2% for those 1500-1999 g, 7.7% for those 2000-2499 g, and 6.3% for those above 2500 g. The incidence rate of IH in preterms with past history of lung disorders and ventilation supports is 8.7 and 13.6%, respectively. There was no significant difference in the incidences of incarceration and bowel resection between preterms and non-preterms.

CONCLUSIONS

Birth weight under 2500 g is a significant risk factor for IH repairs. Other risk factors are male gender, past history of lung diseases, and ventilator supports.

Laparoscopic intra-abdominal patent processus vaginalis ligation in pediatric urology practice

INTRODUCTION AND OBJECTIVE

Inguinal hernias and communicating hydroceles from a patent processus vaginalis (PPV) are common problems in children. This study provides a detailed description of the laparoscopic intra-abdominal patent processus vaginalis ligation (LIPPL) procedure along with its results in pediatric urology patients.

METHODS

Prospectively collected data were captured from children (<18 years) who underwent LIPPL from 2012 to 2014. Demographics as well as postoperative characteristics were reviewed and descriptively analyzed. LIPPL is performed using a 5-mm camera through the umbilicus. A loop of polypropylene suture is passed through a spinal needle percutaneously on one side of the internal ring. The needle is reinserted on the opposite side and the tail of the suture is fed through the original loop such that a purse-string is created around the peritoneum of the internal ring above the spermatic vessels and the vas; the suture is tied extracorporeally.

RESULTS

142 patients (3 female) were evaluated with 197 PPV sites repaired using LIPPL at median 24 (1-216) months of age. Median operating time was 35 (20-91) and 43 (27-85) minutes for unilateral and bilateral repairs, respectively. There were no intraoperative complications. During the 14 (1-34) months from surgery, there were no hernia recurrences, one surgical site infection, seven patients with residual small non-communicating hydroceles, and one patient who developed a suture granuloma.

CONCLUSIONS

LIPPL is a safe and effective technique with minimal rate of hernia recurrence and few complications. LIPPL allows for easy repair of all sizes of PPV, with patients receiving the benefits of minimally invasive surgery including the ability to evaluate the contralateral inguinal ring.

Male Gender and Prematurity are Risk Factors for Incarceration in Pediatric Inguinal Hernia: A Study of 922 Children

Objectives:

The purpose of this study was to document clinical features of inguinal hernia (IH) in the pediatric population. It provides data to evaluate associated risk factors of incarcerated hernia, its recurrence as well as the occurrence of contralateral metachronous hernia.

Materials and Methods:

We report a retrospective analytic study including 922 children presenting with IH and operated from 2010 to 2013 in our pediatric surgery department.

Results:

We managed 143 girls (16%) and 779 boys (84%). The mean age was 2 years; the right side was predominantly affected (66.8%, n = 616). Incarcerated hernia was documented in 16% of cases with an incidence of 33% in neonates. The incarceration occurrence was 15.5% in males versus 2.09% in females. The surgical repair was done according to Forgue technique. Postoperatively, four cases of hernia recurrence were documented, and contralateral metachronous hernia was reported in 33 children with 7.7% females versus 2.8% males. Forty-five percent of them were infants. The mean follow-up period was 4 years. We think that incarceration can be related to several risk factors such as feminine gender, prematurity, and the initial left side surgical repair of the hernia.

Conclusion:

IH occurs mainly in male infants. Prematurity and male gender were identified as risk factors of incarceration. Contralateral metachronous hernia was reported, especially in female infants and after a left side surgical repair of the hernia.

Choice of Repairing Inguinal Hernia in Children: Open Versus Laparoscopy

Inguinal hernia is a common disorder of childhood that requires surgical repair at diagnosis. Traditionally, it is operated upon by open inguinal incision. However, with the introduction of laparoscopic repair in 1990, opinion of scientific community is divided concerning the best method of pediatric herniotomy. Educated parents, who long to have the choicest of the best, often gather information from internet and prefer to discuss their concerns with primary care physicians. This descriptive review is intended to provide practicing pediatricians with updated evidence-based information which will enable them to counsel parents regarding the choice of hernia repair. Based on careful analysis of current literature, unacceptable standards are defined in this paper and rationalized recommendations are proposed. Laparoscopy appears to be beneficial in bilateral hernia of girls, giant hernia, recurrence following failed open repair and in hernia associated with undescended testis or ambiguous genitalia. On the other hand, open herniotomy appears to be advantageous in male inguinal hernia, unilateral female hernia, premature newborns, failed laparoscopic repair and in hernia associated with serious co-morbidity.

Metatropic dysplasia-a skeletal dysplasia with challenging airway and other anesthetic concerns

BACKGROUND

Metatropic dysplasia is a rare form of skeletal dysplasia requiring multiple anesthetics for surgical and imaging procedures, most of which are orthopedic procedures. We provide centralized care to patients with skeletal dysplasia at our tertiary care pediatric hospital, and we were able to collect the largest number of metatropic dysplasia patients reported to date.

AIM

The aim of this retrospective study was to describe and characterize the anesthetic difficulties in this high-risk population.

METHODS

Medical charts of all patients with metatropic dysplasia were reviewed to collect data, including anesthetics performed, difficulties, and complications related to the anesthetic care, co-morbid conditions, and related events.

RESULTS

Twenty-three patients with metatropic dysplasia underwent 188 anesthetics with 61% of the anesthetics having been administered for orthopedic procedures. Fourteen of 23 (60.8%) progressively became difficult to intubate over the course of their care, with 12 out of 14 having undergone cervical spine fusion. These 14 patients had a total of 133 procedures. Sixty procedures (45.1%) had an airway described as difficult. Glidescope was the difficult airway tool most commonly used (68%) with flexible fiberoptic scope used 12% and Miller or Macintosh blade used 18% of the time. In addition to the airway difficulties, spinal canal narrowing or stenosis was widely prevalent, and no neuraxial anesthetic was performed in any of our patients.

CONCLUSION

Difficult airway is the most common co-morbid condition present in patients with metatropic dysplasia, especially if their cervical spine has been fused. Familiarity with the difficulties involving the airway and its management is critical in safe and successful management of anesthesia in this high-risk population.

Regional block via continuous caudal infusion as sole anesthetic for inguinal hernia repair in conscious neonates

PURPOSE

The use of general anesthesia in young children has come under increasing scrutiny due to its potential long-term neurotoxic effects. Meanwhile, regional anesthesia for surgical procedures in neonates has many advantages, including preservation of respiratory status and faster return to feeding. We describe the successful use of 3% 2-chloroprocaine administered via continuous caudal infusion as the sole anesthetic agent during elective surgical procedures in infants.

METHODS

A retrospective chart review of all patients who underwent elective surgical procedures under continuous caudal regional anesthetic at a single institution was performed. Thirty patients (27 males, three females) were identified: 28 patients underwent inguinal hernia repairs. Caudal anesthesia was established via continuous infusion of 3% 2-chloroprocaine through an indwelling catheter.

RESULTS

Successful analgesia by regional block alone was achieved in all patients for the duration of each surgical procedure without need for rescue anesthesia. Mean operative time was 49 min. Patients were able to return to feeding immediately after surgery and were ready for discharge home within that day.

CONCLUSION

Continuous caudal infusion of chloroprocaine is a safe and effective way to maintain adequate analgesia for elective surgeries in infants. This successful regional approach obviates the use of general anesthetic which reduces post-operative recovery time and avoids concerns for neurotoxicity.

Pediatric inguinal and scrotal surgery - Practice patterns in U.S. academic centers

PURPOSE

Both pediatric urologists and pediatric surgeons perform hernia repairs, hydrocelectomies and orchiopexies. We hypothesized that surgeons perform more incarcerated and female hernia repairs while urologists perform more orchiopexies and hydrocelectomies.

METHODS

The Vizient-AAMC Faculty Practice Solutions Center® database was queried from January 2009 to December 2014 to identify patients 10years or younger who underwent the above procedures performed by pediatric specialists. Age, gender, race, insurance, geographic region and surgeon volume were examined.

RESULTS

In the study 55,893 surgeries were identified: 26,073 primary hernia repairs, 462 recurrent hernia repairs, 3399 laparoscopic hernia repairs, 9414 hydrocele repairs and 16,545 orchiopexies. Pediatric surgeons performed 89% of primary hernia repairs with an annual median surgeon volume of 4 cases/year. Pediatric urologists performed 62% of hydrocelectomies and 83% of orchiopexies with annual median surgeon volumes of 6 and 24, respectively. Pediatric surgeons performed all procedures in younger patients and performed more female and incarcerated hernia repairs.

CONCLUSIONS

Pediatric surgeons operate on younger patients and treat more patients with inguinal hernias while pediatric urologists care for more boys with undescended testes and hydroceles. This knowledge of referral patterns and care between specialties with overlapping expertise will allow improvements in training and access.

LEVELS OF EVIDENCE

Cost Effectiveness Study, Level of Evidence III.

Emergency repair of inguinal hernia in the premature infant is associated with high direct medical costs

Purpose

Inguinal hernia repair is frequently performed in premature infants. Evidence on optimal management and timing of repair, as well as related medical costs is still lacking. The objective of this study was to determine the direct medical costs of inguinal hernia, distinguishing between premature infants who had to undergo an emergency procedure and those who underwent elective inguinal hernia repair.

Methods

This cohort study based on medical records concerned premature infants with inguinal hernia who underwent surgical repair within 3 months after birth in a tertiary academic children’s hospital between January 2010 and December 2013. Two groups were distinguished: patients with incarcerated inguinal hernia requiring emergency repair and patients who underwent elective repair. Real medical costs were calculated by multiplying the volumes of healthcare use with corresponding unit prices. Nonparametric bootstrap techniques were used to derive a 95 % confidence interval (CI) for the difference in mean costs.

Results

A total of 132 premature infants were included in the analysis. Emergency surgery was performed in 29 %. Costs of hospitalization comprised 65 % of all costs. The total direct medical costs amounted to €7418 per premature infant in the emergency repair group versus €4693 in the elective repair group. Multivariate analysis showed a difference in costs of €1183 (95 % CI −1196; 3044) in favor of elective repair after correction for potential risk factors.

Conclusion

Emergency repair of inguinal hernia in premature infants is more expensive than elective repair, even after correction for multiple confounders. This deserves to be taken into account in the debate on timing of inguinal hernia repair in premature infants.

Second hernia repairs in children-a nationwide study

BACKGROUND

Second inguinal hernia repairs may be needed either owing to contralateral metachronous hernia (MH) or ipsilateral recurrent hernia (RH). In this study, we estimated the incidence rates of MH and RH from a large nationwide database.

METHODS

The information was obtained from the National Health Insurance Database (with 23 million insurants). Subjects with hernia repairs were identified, and information such as age, gender, unilateral/bilateral procedures in the first and second hernia repairs were analyzed.

RESULTS

Among the 92,308 newborns observed from their births to the end of 6th year, 3881 had first hernia repairs. Among the 3068 subjects with first unilateral repairs, 307 had second repairs, and among the 813 with first bilateral repairs, 15 had second repairs. The incidence of second repairs was 10.85% (13.71% if <1year old) after first unilateral repairs and was 1.23% (0.63% if <1year old) after first bilateral repairs.

CONCLUSIONS

The incidence of RH (estimated from second hernia repairs after first bilateral repairs) was 1.23%. The incidence of MH (from second repairs after first unilateral repairs) was 9.62%. These incidence rates are consistent with other published reports.

The incidence of inguinal hernia and associated risk factors of incarceration in pediatric inguinal hernia: a nation-wide longitudinal population-based study

PURPOSE

This study uses a national database to evaluate the incidence of inguinal hernia and associated risk factors of incarcerated hernia in children from birth to 15 years of age.

METHODS

The study selected children born from 1997 to 2005 from a randomly selected cohort of 1,000,000 from an insured population of 23 million. We regarded children that were classified with code 550 and hernia surgery in accordance to the International Classification of Diseases, 9th Revision, as having inguinal hernia. We used the 2 chi-square test and logistic regression modeling for statistical analyses.

RESULTS

In total, 79,794 children (41,767 male and 38,027 female) were enrolled in the study. The cumulative incidence of inguinal hernia in males and females from birth to 15 years old were 6.62 and 0.74 %, respectively (p < 0.01). The peak incidence of inguinal hernia was at 0 years of age for males and 5 years of age for females. The ratio of unilateral vs. bilateral repair was 5.54:1. Females tend to have more bilateral inguinal hernia than males (25.4 vs. 12.9 %, p < 0.01). Incarcerated hernia occurred in 4.19 % children with inguinal hernia without significant gender discrepancy. Approximately 40 % of incarcerated hernia underwent hernia repair immediately after visiting the emergent department. In patients who presented with reducible hernia, we did not find significant correlation between waiting time to hernia repair and occurrence of incarceration.

CONCLUSIONS

The cumulative incidence of inguinal hernia from birth to 15 years of age was 6.62 and 0.74 % in males and females, respectively. Incarceration was not related to prematurity or the waiting time for surgery.

An estimate of hernia prevalence in Nepal from a countrywide community survey

BACKGROUND

Herniorrhaphy is one of the most frequently performed general surgical operations worldwide. However, most low- and middle-income countries (LMICs) are unable to provide this essential surgery to the general public, resulting in considerable morbidity and mortality. This study aimed to estimate the prevalence, barriers to care and disability of untreated hernias in Nepal.

METHODS

Nepal is a low-income country in South Asia with rugged terrain, infrastructure deficiencies and a severely under-resourced healthcare system resulting in substantial unmet surgical need. A cluster randomized, cross-sectional household survey was performed using the validated Surgeons OverSeas Assessment of Surgical (SOSAS) tool. Fifteen randomized clusters consisting of 30 households with two randomly selected respondents each were sampled to estimate surgical need. The prevalence of and disability from groin hernias and barriers to herniorrhaphy were assessed.

RESULTS

The survey sampled 1350 households, totaling 2695 individuals (97% response rate). There were 1434 males (53%) with 1.5% having a mass or swelling in the groin at time of survey (95% CI 1.8-4.0). The age-standardized rate for inguinal hernias in men ranged from 1144 per 100,000 persons between age 5 and 49 years and 2941 per 100,000 persons age≥50 years. Extrapolating nationally, there are nearly 310,000 individuals with groin masses and 66,000 males with soft/reducible groin masses in need of evaluation in Nepal. Twenty-nine respondents were not able to have surgery due to lack of surgical services (31%), fear or mistrust of the surgical system (31%) and inability to afford care (21%). Twenty percent were unable to work as previous or perform self-care due to their hernia.

CONCLUSIONS

Despite the lower than expected prevalence of inguinal hernias, hundreds of thousands of people in Nepal are currently in need of surgical evaluation. Given that essential surgery is a necessary component in health systems, the prevalence of inguinal hernias and the cost-effectiveness of herniorrhaphy, this disease is an important target for LMICs planning surgical capacity improvements.