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

Impact of Surgical Timing on Outcomes in Neonatal Inguinal Hernia Repairs: A Systematic Review

Inguinal hernia repair (IHR) is a common surgical procedure among neonates and infants; the time of surgery is one of the major factors affecting its outcomes. Our systematic review aims to evaluate the effects of surgical timing on outcomes in inguinal hernia repairs in the newborn and infant population to establish evidence-based guidelines for optimal surgical timing. A systematic search was performed in PubMed, MEDLINE, and Web of Science databases, following PRISMA guidelines. Studies evaluating neonates and infants undergoing IHR with outcomes of recurrence, complications, and postoperative recovery were included. Data were collaboratively extracted, including patient demographics, surgical approaches, perioperative complications, and long-term outcomes. Early repair (0-28 days of life) decreased the risk of hernia incarceration but also increased the risk of preoperative complications. Delayed repair (29 days to 1 year of life) showed fewer preoperative complications but increased the risk of incarceration. The outcomes were affected by variables including patient maturity and comorbidities, along with hernia severity. Neonates with a high risk for incarceration are best treated with early repair, while stable infants can be managed safely with delayed repair. More randomized trials are needed to develop standardized guidelines that balance the associated risks of neonatal versus infant repair strategies to maximize benefits.

Cost Analysis of Early vs Delayed Outpatient Repair of Inguinal Hernias in Premature Infants

INTRODUCTION

Premature infants treated for inguinal hernias after hospital discharge require overnight post-operative observation for apnea monitoring until 50-60 weeks adjusted gestational age (AGA). This study aimed to compare costs associated with early (at time of diagnosis) versus delayed (at AGA not requiring overnight observation) repair of inguinal hernia in premature infants.

METHODS

Costs were estimated using the average hospital charges at a single institution for three scenarios: 1) delayed repair 2) early repair requiring overnight observation, and 3) incarcerated inguinal hernia reduced but requiring delayed repair at 48 h. A decision analysis model was used to estimate the cost for premature infants undergoing delayed repair of inguinal hernia while considering the risk of incarceration and associated costs. The base model used 50 weeks AGA for delayed repair and an incarceration rate of 0.5%/week. Sensitivity analyses varied incarceration rate from 0.1 to 4%/week and delayed repair to 55 and 60 weeks AGA.

RESULTS

In the base model, delayed repair incurred lower estimated costs than early repair at all time points of diagnosis. In sensitivity analyses, estimated cost for delayed repair only rose above the estimated cost for early repair when estimated incarceration risk reached 3%/week with repair at 60 weeks AGA (if repair before 38 weeks AGA) or 4%/week with repair at 55 weeks AGA (if repair before 39 weeks AGA).

CONCLUSIONS

Using solely cost as a deciding factor, repair of premature inguinal hernias diagnosed as an outpatient should be delayed until overnight observation is no longer necessary.

TYPE OF STUDY

Decision Analysis model.

LEVEL OF EVIDENCE

III.

URGENCY HOSPITALIZATIONS FOR INGUINAL HERNIA IN BRAZIL FROM 2010 TO 2019: MORTALITY AND COSTS IN THE PUBLIC HEALTH SYSTEM

BACKGROUND

It is known that elective inguinal hernioplasties are safe procedures, but in an emergency setting, they have higher rates of complications and hospital costs. Despite this, quantitative studies on the subject in Brazil are still scarce.

AIMS

To evaluate the trend in hospitalization rates, hospital mortality, and costs for inguinal hernia in an emergency, regarding gender and age group.

METHODS

This is a time series study with data from the Unified Health System (SUS), at the national level, from 2010 to 2019.

RESULTS

The overall hospitalization rate (p=0.007; b<0,02) in all age groups (p<0.005; b<0) in both genders indicated a decreasing trend. The general mortality rate in both genders and in most age groups showed an increasing trend (p<0.005), as well as the cost of hospitalization in all age groups of both genders.

CONCLUSIONS

Urgent hospitalization rates for inguinal hernia in Brazil have shown a steady or decreasing trend; however, hospital mortality and costs per hospitalization have demonstrated an increasing trend in recent years.

Costs and recurrence of inguinal hernia repair in premature infants during neonatal admission

BACKGROUND

Timing of inguinal hernia repair (IHR) in premature infants remains variable, yet the impact of IHR timing on procedure costs and recurrence is unclear. We sought to compare cost and recurrence rates of IHR in premature infants based on timing of repair.

METHODS

We performed a retrospective cohort study using MarketScan insurance claims data from 2007 to 2018 to evaluate IHR occurring within 365 days of birth in preterm infants (gestational age [GA]<37 weeks at birth). Patients were stratified based on timing of IHR: those occurring during and after neonatal discharge. Hernia recurrences within one year following IHR were identified. Patient demographic characteristics and costs were compared between groups. Time to recurrence and cumulative recurrence hazards were estimated using Kaplan Meier analysis and Cox proportional hazards regression.

RESULTS

We identified 3,662 preterm infants with IHR within 365 days of birth; 1,054(28.8%) occurred early. Infants with IHR during NICU stay were more likely to have GA at birth≤32 weeks (74.7% vs. 37.2%; p<0.01) and birthweight<1500 g (83.0% vs. 40.3%; p<0.01) compared to post-NICU IHR. The hernia recurrence rate was higher and total procedure costs lower in early IHR. Early IHR (HR:1.86, 95% CI: 1.56-2.22), incarcerated/strangulated hernia (HR:1.86, 95% CI:1.49-2.32), GA≤32 weeks (HR: 1.40, 95% CI: 1.19-1.65), and congenital anomalies (HR: 1.32, 95% CI: 1.12-1.57) were predictors of hernia recurrence.

CONCLUSION

Using insurance claims data, IHR performed during initial neonatal admission was associated with lower cost, but higher recurrence rate, when compared to delayed repairs in preterm infants.

TYPE OF STUDY

Retrospective study LEVEL OF EVIDENCE: Level III.

Cost analysis of inguinal hernia repair: the influence of clinical and hernia-specific factors

Introduction

As in the rest of the world, in Germany, inguinal hernia operations are among the most common operations. From an economic standpoint, very little is known about the influence of demographic, clinical or hernia-related parameters on the cost of inguinal hernia repair. We, therefore, evaluated individual patient parameters associated with higher costs with a special focus on multimorbidity.

Methods

A total of 916 patients underwent hernia repair for primary or recurrent inguinal hernia between 2014 and 2017 at a single university center and were included in the analysis. The clinical and financial data of these patients were analyzed to identify cost-increasing parameters.

Results

A majority of patients were male (90.7%), with a mean age of 55 years. The surgical methods utilized were mainly the TAPP (57.2%) and Lichtenstein (41.7%) procedures, with an average duration of surgery of 85 min and an average duration of anesthesia of 155 min. The mean cost of all procedures was 3338.3 € (± 1608.1 €).

Older age, multimorbidity, emergency operations with signs of incarceration, longer hospital stays and postoperative complications were significant cost-driving factors. On the other hand, sex, the side of the hernia (left vs. right) and the presence of recurrent hernias had no influence on the overall direct costs.

Conclusion

From a purely economic point of view, older age and multimorbidity are demographic cost-driving factors that cannot be influenced. The national hospital reimbursement system needs to consider and compensate for these factors. Emergency operations need to be prevented by early elective treatment. Long postoperative stays and postoperative complications need to be prevented by proper preoperative check-ups and accurate treatment.

Complications while awaiting elective inguinal hernia repair in infants: Not as common as you thought

BACKGROUND

The dogma of early inguinal hernia repair in infants, especially those born prematurely, has dominated clinical practice owing to reports of a high frequency of incarceration and significant complications associated with untreated inguinal hernias. We aim to evaluate the frequency of complications after discharge with delayed surgery for inguinal hernia repair.

METHODS

The Nationwide Readmissions Database (2010-2014) was queried to identify infants diagnosed with inguinal hernia. We compared the frequency and characteristics of inguinal hernia repair performed during the index admission, discharge from the index admission without hernia repair, and unplanned readmissions.

RESULTS

We identified 33,530 infants (16,624 preterm and 16,906 full-term) diagnosed with an inguinal hernia during an index admission. For those infants diagnosed with an inguinal hernia at birth, inguinal hernia repair was performed during the birth admission for only a minority of both preterm (35%) and full-term infants (18%; P < .001). Of the infants discharged without hernia repair, 15% required nonelective readmission up to 1 year later, but only 2% of preterm and 1% of full-term infants actually underwent inguinal hernia repair during these unplanned readmissions. None of the readmitted infants underwent additional procedures suggestive of a strangulated hernia.

CONCLUSION

Complications among infants awaiting inguinal hernia repair may be substantially less common than previously reported, and the occurrence of significant associated morbidity is quite rare.

Inguinal Hernia in Premature Infants

Inguinal hernia is a common problem affecting infants in the NICU. As a group, preterm infants have the highest incidence of inguinal hernia and this risk increases as gestational age decreases. The etiopathologic factors leading to the development of an inguinal hernia are not clear and interventions to alter these factors have not been thoroughly investigated. Diagnosis of an inguinal hernia is often straightforward, but occasionally it may be difficult to determine if the hernia is strangulated or simply obstructed. Rarely, investigative modalities, such as ultrasonography, may be needed to rule out other potential causes. The ideal timing of surgical repair in this population is unknown and complicated by comorbid conditions and limited randomized controlled trials. During surgery, the choice of regional versus general anesthesia requires a team-based approach and studies have found that greater clinical experience is associated with lower morbidity. The techniques of hernia surgery range from open to laparoscopic repair and have been investigated in small prospective studies, while larger databases have been used to analyze outcomes retrospectively.

Inguinal hernia repair among Jordanian infants; A cohort study from a university based tertiary center

BACKGROUND

Inguinal hernia is the most common surgical procedure performed in infants. Still, there is major debate about the optimal timing of performing this procedure. The goal of this review is to determine the incidence of inguinal hernia among our infant population in Jordan, review the current practice regarding the timing of repair, and identify the risk of incarceration and postoperative apnea.

METHODS

A retrospective cohort study of chart review of infants admitted with inguinal hernia in the period 2012-2016. Data collected about demographics, timing of diagnosis, timing of repair, exploration of contralateral side, incarceration, and postoperative apnea.

RESULTS

A total of 272 infants were diagnosed with inguinal hernia. The overall incidence was 1.9%, compared with 11% among premature babies <32-week gestation. Half were term, and 23% less than 32-week gestation. Male to female ratio was 5 : 1. Of the 172 babies admitted to the neonatal ICU, only 19 cases (11%) were diagnosed during their NICU stay, and one case got repaired emergently. All cases were repaired by open herniorrhaphy. The median postconceptional age at time of repair was 49 weeks (IQR 45-55), and the median interval between diagnosis and repair was 8 days (IQR 1-17). Incarceration affected 9% and the main risk factor was >7-day delay in repair. Only one case developed apnea and required intubation postoperatively.

CONCLUSIONS

Our approach of elective inguinal hernia repair seems to be safe without increasing risk of complications like incarceration or postoperative apnea if performed within seven days following diagnosis.