Contralateral processus closure to prevent metachronous inguinal hernia: A systematic review

Inguinal hernias in children: Update on management guidelines

Inguinal hernia repair is one of the most performed procedures in children, but aspects of care remain controversial. The aim of this review was to provide a critical appraisal of recently published guidelines on the management of inguinal hernias in children, by the American Academy of Pediatrics (2023) and the European Pediatric Surgeons' Association Evidence and Guideline Committee (2022). This was achieved by delineating areas of controversy and reviewing the most relevant recent literature on these topics. Currently available moderate-to-low quality evidence recommends postponing hernia repair in premature infants until after discharge, to reduce the risk of respiratory difficulties and recurrence. Laparoscopic repair provides similar outcomes to open but may shorten operative time in bilateral cases. No clear recommendation can be made for contralateral exploration, therefore should be evaluated case by case. In preterm infants, consideration of regional anaesthesia may reduce post-operative apnoea and pain, with no difference in neurodevelopment outcomes.

Laparoscopic Sac Disconnection and Peritoneal Closure of Pediatric Inguinal Hernia

Background: Laparoscopic sac disconnection and peritoneal closure represents an alternative to open pediatric hernia repair. We performed a retrospective review of our data to evaluate this alternative method. Materials and Methods: With REB approval, a retrospective chart review of all patients who underwent laparoscopic indirect inguinal hernia repair between June 2013 and July 2016 was conducted. Primary outcome was the recurrence rate. Secondary outcomes included length of surgery, postoperative hydrocele, and perioperative complications. Data were extracted from EPIC Hyperspace onto a standardized data extraction form. Results: A total of 243 patients were included, of which 82% were males. Age ranged from 1 month to 17 years of age. A total of 322 defects were repaired. Eighty (32%) had contralateral patent processus vaginalis. Twelve (4%) patients presented with incarceration and three (1.2%) had a direct inguinal hernia defect. Recurrence rate was 0.6% (n = 2). There were no intraoperative complications. Operative time was an average of 40 and 54 minutes for unilateral and bilateral repairs, respectively. No testicular ascents, testicular atrophy, vas deferens injury, postoperative hydroceles, and wound infections were reported. Conclusion: Laparoscopic sac disconnection and peritoneal closure of pediatric inguinal hernia is a safe, feasible method with one of the lowest reported recurrence rate among the other laparoscopic methods.

Comparison of long-term outcomes of laparoscopic percutaneous internal ring suturing and classic open approach for inguinal hernia repair in children

INTRODUCTION

Inguinal hernia repair is one of the most common surgeries in children. Recently, the use of minimally invasive techniques for inguinal hernia repair has increased in children. Laparoscopic percutaneous internal ring suturing (PIRS) is a technique described for paediatric inguinal hernia repair. The primary objective of this study is to demonstrate the efficacy and reliability of PIRS in paediatric patients through a comparative analysis with an open method.

METHODS

Between January 2017 and June 2023, records of patients who underwent surgery for inguinal hernia were retrospectively reviewed. In total 126 patients were included in the study. They were divided into two groups: 33 patients underwent PIRS (group 1) and 93 patients underwent open repair (group 2). Operation time, cost and complications were compared.

RESULTS

The mean age of the 126 patients was 3.23 ± 2.4 years. The mean unilateral operative time was 25.13 ± 5.32min in group 1 and 30.28 ± 4.73min in group 2, and there was a statistically significant difference in operative time (p < 0.001). Two patients in group 1 underwent surgery owing to patent processus vaginalis, whereas three patients in group 2 underwent surgery owing to metachronous hernia. There were no major complications such as bleeding requiring surgical intervention or conversion to an open approach during surgery in group 1. No recurrent hernia was observed in any of the 126 patients.

CONCLUSIONS

PIRS offers a safe, easy-to-learn method with low complication rates. PIRS has a distinct advantage over open surgical repair because of its capacity to evaluate the contralateral inguinal ring.

Single-port robotic-assisted laparoscopic synchronous surgery in pediatric patent processus vaginalis

PURPOSE

Patent processus vaginalis (PPV) is usually observed in pediatric abdominal surgery; however, robotic single-port surgery in repairing processus vaginalis has not been reported in children. Herein, we present our clinical experiences in single-port robotic surgeries for PPV repair to evaluate both efficacy and safety.

METHODS

Retrospective analysis of patients underwent single-port robotic-assisted laparoscopic surgery for genitourinary diseases from May 2020 and May 2023 in our center. Among these patients, 21 children had PPV repaired at the same time. The case characteristics and follow-up data were recorded.

RESULTS

Twenty-one of the 53 children were found to have PPV during genitourinary surgery. The simultaneous treatment of the primary disease and PPV with a single-port robotic-assisted platform was both convenient and safe. There was no significant increase in total operation time, and no excessive intraoperative hemorrhage was observed in any of the operations. There were no complications observed on follow-up.

CONCLUSION

With a high incidence of PPV in children, a single-port robotic-assisted procedure is feasible and effective if simultaneously performed when addressing a primary abdominal disease.

Effectiveness of preoperative ultrasonography in predicting metachronous contralateral inguinal hernia in children: a single-arm prospective study using a historical control for comparison

PURPOSE

To analyze the value of ultrasonography in predicting metachronous contralateral inguinal hernia (MCIH) and diagnosing contralateral persistent processus vaginalis (CPPV) in children with unilateral inguinal hernia, a prospective study was conducted.

METHODS

All participants underwent a preoperative ultrasound on the contralateral groin. Patients in group A1 received operating procedure according to ultrasound results (patients with negative contralateral US results received hernia repair on the affected side), and patients in group A2 received operation according to laparoscopic results (patients received hernia repair and CPPV ligation). All patients were followed up 2 years and compared to a historical control (group B) who underwent open hernia repair only on the affected side regardless of contralateral US results.

RESULTS

In groups A1 and A2, laparoscopic exploration revealed the presence of a CPPV in 490 cases. Ultrasound was found to be accurate in 104 out of the 490 cases with four false-positive and 386 false-negative results. This yielded an accuracy of 59.3%, a sensitivity of 21.2%, and a specificity of 99.2%. 10 patients in group A1, and 74 patients in group B developed MCIH. The accuracy, sensitivity, and specificity of the value of ultrasonography in predicting MCIH were 89.3%, 52.4%, and 92.5%, respectively.

CONCLUSIONS

Preoperative ultrasonography of the contralateral groin is currently unable to accurately detect CPPV, but it appears to be a promising method in predicting MCIH by using rigorous diagnosing criteria.

Ipsilateral and contralateral patent processus vaginalis in pediatric patients with a unilateral nonpalpable testis

This study aimed to investigate the incidence of patent processus vaginalis (PPV) in pediatric patients with a unilateral nonpalpable testis and explore the associated factors. From May 2014 to April 2017, 152 boys who were diagnosed with a unilateral nonpalpable testis and underwent laparoscopy in Shanghai Children's Hospital (Shanghai, China) were included in this study. The data were collected and reviewed, and the results were analyzed regarding the age at operation, side, development, and position of the nonpalpable testis. The mean age of the patients was 2.6 (standard deviation: 2.3) years. The testis was absent in 14 cases, nonviable in 81 cases, and viable in 57 cases. The incidence of PPV was 37.5% (57 of 152) on the ipsilateral side and 16.4% (25 of 152) on the contralateral side. The ipsilateral PPV was more prevalent when the nonpalpable testis occurred on the right side ( P < 0.01). Besides, patients with a viable testis had a greater incidence of ipsilateral PPV than those with a nonviable or absent testis ( P < 0.01). Moreover, this rate was the highest when the testis was in the abdominal cavity and the lowest when the testis was in the scrotum (both P < 0.01). However, the incidence of contralateral PPV was independent of all the factors. In conclusion, in children with a nonpalpable testis, the incidence of an ipsilateral PPV was significantly related to the side, development, and position of the testis, while it was independent of these factors on the contralateral side.

Implementing Contralateral Surgical Exploration during Hernia Repair in Children with Unilateral Inguinal Hernia: A Dutch Qualitative Study

A total of 10-15% of children undergoing unilateral inguinal hernia repair develop a metachronous contralateral inguinal hernia (MCIH) that necessitates second anesthesia and surgery. Contralateral exploration can be performed to prevent MCIH development. This study investigates (1) factors that promote or hinder the adoption and (de-)implementation of contralateral groin exploration in children ≤ 6 months undergoing unilateral hernia repair and (2) strategies to overcome these barriers. A qualitative interview study was conducted using 14 semi-structured interviews and two focus groups involving healthcare professionals, stakeholders involved from a patients' perspective and stakeholders at the organizational/policy level. The results show that the effectiveness of surgical treatment and stakeholders' motivation and attitudes towards the intervention were reported as barriers for implementation, whereas patient and family outcomes and experience and strategies to overcome these barriers were identified as facilitating factors for future implementation. This study is unique in its contributions towards insights into facilitators and barriers for (de-)implementation of contralateral groin exploration in children with a unilateral inguinal hernia. In case the HERNIIA trial shows that contralateral exploration is beneficial for specific patient and family outcomes or a subgroup of children, the results of this study can help in the decision-making process as to whether contralateral exploration should be performed or not.

Review and Quality Assessment of Systematic Reviews and Meta-analyses on the Management of Pediatric Inguinal Hernias: A Descriptive Study

INTRODUCTION

Research quality in pediatric surgery has been challenged by multiple factors, including the low incidence of some congenital pathologies and rare event rates. With the rapid increase of pediatric surgical literature, there is a need for systematic reviews to synthesize evidence. It is important to assess the quality of these systematic reviews.

OBJECTIVE

This study aims to examine the reporting of systematic reviews and meta-analyses, using inguinal hernia repair as an index diagnosis.

METHODS

MEDLINE, Embase, and CINAHL databases were searched for systematic reviews and/or meta-analyses of interventions on inguinal hernia in the pediatric population. The quality reporting was assessed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and A MeaSurement Tool to Assess Systematic Reviews (AMSTAR) 2 tools.

RESULTS

Of 1449 unique reports, 21 studies were included (15 meta-analyses and six systematic reviews). Median percent reported items for PRISMA and AMSTAR 2 were 72.2% and 70.5%, respectively. The least reported items in PRISMA were protocol registration (27.6%), synthesis of results (13.0%), and a risk of bias across studies (20.6%). For AMSTAR 2, the least reported items were reporting of source of funding (14.3%), appropriate methods for statistical combination of results (25.0%), and pre-establishment of protocol (28.6%). All critical items were completely or partially fulfilled in 5/21 (23.8%) of the studies and completely absent in 1/21 (4.8%) studies.

CONCLUSIONS

The results of this study highlight relatively good reporting quality, yet a poor methodological quality of systematic reviews/meta-analyses in the pediatric surgery literature on inguinal hernia management.

Laparoscopic versus open inguinal hernia repair in infants: an initial experience

BACKGROUND

Inguinal hernia repair is a common operation performed in children. In Australia, open repair (OR) continues to be the preferred method of treatment in infants, despite laparoscopic repair (LR) gaining popularity amongst some international centres. Our aim was to analyse initial outcomes with LR at our paediatric centre.

METHODS

We conducted a retrospective review of all patients <1 year of age who received LR or OR between January 2017 and July 2021 at our institution. Data were retrieved from both electronic and scanned medical records. Data were analysed using an unpaired t-test, Mann-Whitney test, Fisher's exact test or simple linear regression. A P-value <0.05 was considered significant.

RESULTS

A total of 376 patients were identified: LR was performed in 73 patients, and OR in 303 patients. Bilateral repair was more common amongst patients receiving LR: 56.2% versus 21.5%, P = 0.0001, treating either a symptomatic hernia or an intra-operative contralateral inguinal defect (70%). All LR patients received general anaesthetic, compared to 82.8% of patients in the OR group, P = 0.0001. There were no recurrences following LR and 3 with OR (P = 1.0). The metachronous contralateral inguinal hernia rate following OR was 10% (21/206). There was no significant difference in other complications, including wound infection, haematoma, testicular atrophy, and hydrocele formation.

CONCLUSION

In our population OR was performed more often than LR. Operative complication rates were equivalent between OR and LR groups. However, infants that underwent OR were significantly more likely to develop a MCIH.

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.

Contralateral patent processus vaginalis repair in boys: a single-center retrospective study

To ascertain the prevalence of contralateral patent processus vaginalis (CPPV) in life and the significance of the prevalence trends for treatment. We performed a retrospective review of all inguinal hernias (IHs) that underwent repair in our hospital from 2014 to 2018. We analyzed the frequency of occurrence and treatment in boys. We assessed and compared the history, initial sides of hernia, CPPV and prognoses in different age groups. We assessed all IH cases repaired in our hospital and selected male patients of a variety of ages, including boys and men. Recurrent cases were not enrolled. A total of 3243 cases were enrolled: 2489 [right-sided IH 1411 (56.69%) vs. left-sided IH 975 (39.17%), bilateral IH 103 (4.14%)] in children and 754 [right-sided IH 485 (64.32%) vs. left-sided IH 236 (31.30%), bilateral IH 33 (4.38%)] in adults. A total of 1124 CPPVs were identified in children with unilateral IH (2386), and 12 were identified in adults (267) (p < 0.0001). There were no significant differences in recurrence rate between different subgroups of children (p > 0.05). The incidence of IH in boys was significantly higher than that in men. The number of incident cases declines rapidly with age in boys. The processus vaginalis is normally obliterated and involuted but may instead remain patent for a long period before closure; routine exploration on the contralateral side may eliminate the possibility of spontaneous PPV closure.

The relationship between contralateral patent processus vaginalis and metachronous contralateral inguinal hernia in children with unilateral inguinal hernia: a prospective observational study

PURPOSE

Laparoscopic contralateral patent processus vaginalis (CPPV) repair in children is debatable due to the high CPPV rate, but low metachronous contralateral inguinal hernia (MCIH) rate. We conducted this study to find risk factors for MCIH.

METHOD

We conducted a prospective, observational trial with patients recruited from Shanghai Children's Hospital. Eligible participants were patients under 16 years old with unilateral inguinal hernia whose parents did not opt for simultaneous CPPV repair. The subjects were followed for 24 to 34.1 months. Patients who developed MCIH were analyzed to identify the relationship between CPPV and MCIH.

RESULTS

Between October 17, 2018, and July 31, 2019, we included 184 patients and 182 completed follow-up. MCIH occurred in ten patients, of which 7 (7.53%) had CPPV and three (3.37%) had no CPPV. Univariate analysis showed that age (p = 0.025, OR = 0.938) and CPPV diameter (p = 0.003, OR = 1.783) were related to the development of MCIH. In multivariate analysis, only diameter of CPPV (p = 0.008, OR = 1.411) was associated with MCIH. The receiver operating characteristic (ROC) curve was used to test, and it was found that when the diameter of CPPV was greater than 4 mm, the Youden index was the highest, with a specificity of 62.8% and a sensitivity of 100%.

CONCLUSION

The incidence of MCIH was not statistically higher in patients with CPPV compared with those without CPPV, so there is no indication for routine CPPV repair. The risk of MCIH development increases with CPPV diameter. 4 mm is the optimal cutoff point. Large CPPVs (> 4 mm) could be treated to prevent future hernias.

TRIAL REGISTRATION

The Chinese Clinical Trial Registry ( www.chictr.org.cn ), number ChiCTR2000041307.

Surgical Management of Pediatric Inguinal Hernia: A Systematic Review and Guideline from the European Pediatric Surgeons' Association Evidence and Guideline Committee

INTRODUCTION

 Inguinal hernia repair represents the most common operation in childhood; however, consensus about the optimal management is lacking. Hence, recommendations for clinical practice are needed. This study assesses the available evidence and compiles recommendations on pediatric inguinal hernia.

MATERIALS AND METHODS

 The European Pediatric Surgeons' Association Evidence and Guideline Committee addressed six questions on pediatric inguinal hernia repair with the following topics: (1) open versus laparoscopic repair, (2) extraperitoneal versus transperitoneal repair, (3) contralateral exploration, (4) surgical timing, (5) anesthesia technique in preterm infants, and (6) operation urgency in girls with irreducible ovarian hernia. Systematic literature searches were performed using PubMed, MEDLINE, Embase (Ovid), and The Cochrane Library. Reviews and meta-analyses were conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) statement.

RESULTS

 Seventy-two out of 5,173 articles were included, 27 in the meta-analyses. Laparoscopic repair shortens bilateral operation time compared with open repair. In preterm infants, hernia repair after neonatal intensive care unit (NICU)/hospital discharge is associated with less respiratory difficulties and recurrences, regional anesthesia is associated with a decrease of postoperative apnea and pain. The review regarding operation urgency for irreducible ovarian hernia gained insufficient evidence of low quality.

CONCLUSION

 Laparoscopic repair may be beneficial for children with bilateral hernia and preterm infants may benefit using regional anesthesia and postponing surgery. However, no definite superiority was found and available evidence was of moderate-to-low quality. Evidence for other topics was less conclusive. For the optimal management of inguinal hernia repair, a tailored approach is recommended taking into account the local facilities, resources, and expertise of the medical team involved.

Laparoscopic versus open inguinal hernia repair in children: A systematic review

Purpose

Considerable debates exist regarding the preferable technique to repair a paediatric inguinal hernia (PIH). This systematic review aims to compare the efficacy and safety of laparoscopic herniorrhaphy (LH) and open herniorrhaphy (OH) in PIH.

Methods

The randomised controlled trials (RCTs) that compared the outcomes of LH and OH in PIH without region and language restrictions searched from the following databases: PubMed, Web of Science Database, Cochrane Library, SciELO Citation Index, Russian Science Citation Index, China National Knowledge Infrastructure, WanFang Data and China Science and Technology Journal Database.

Results

A total of 13 RCTs that involving 1207 patients included in the review. The LH displayed a shorter operative time for bilateral hernia repair (weighted mean difference = -8.23, 95% confidence interval [CI]: -11.22~-5.23, P < 0.00001), a lower complication rate (odds ratio [OR] = 0.32, 95% CI: 013-0.83, P = 0.02) along with a lower wound infection (OR = 0.14, 95% CI: 0.04-0.55, P = 0.005) and major male-specific post-operative complications (OR = 0.10, 95% CI: 0.04-0.24, P < 0.00001) and a less contralateral metachronous inguinal hernia (CMIH) incidence rate (OR = 0.09, 95% CI: 0.02-0.42, P = 0.002). No significant difference was found for unilateral operative time, time to full recovery, length of hospital stay, recurrence and hydrocele rates between the two techniques.

Conclusion

The present review reiterates that both the LH and OH techniques for the PIH repair are comparable. However, in some aspects, the LH is superior to the OH in terms of operative time for bilateral hernias, post-operative complications rate and CMIH incidence rate. Rigorously designed RCTs are anticipated to confirm the clinical effects of both LH and OH.

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.