Does timing of neonatal inguinal hernia repair affect outcomes?

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.

Effect of Early vs Late Inguinal Hernia Repair on Serious Adverse Event Rates in Preterm Infants: A Randomized Clinical Trial

Importance

Inguinal hernia repair in preterm infants is common and is associated with considerable morbidity. Whether the inguinal hernia should be repaired prior to or after discharge from the neonatal intensive care unit is controversial.

Objective

To evaluate the safety of early vs late surgical repair for preterm infants with an inguinal hernia.

Design, Setting, and Participants

A multicenter randomized clinical trial including preterm infants with inguinal hernia diagnosed during initial hospitalization was conducted between September 2013 and April 2021 at 39 US hospitals. Follow-up was completed on January 3, 2023.

Interventions

In the early repair strategy, infants underwent inguinal hernia repair before neonatal intensive care unit discharge. In the late repair strategy, hernia repair was planned after discharge from the neonatal intensive care unit and when the infants were older than 55 weeks' postmenstrual age.

Main Outcomes and Measures

The primary outcome was occurrence of any prespecified serious adverse event during the 10-month observation period (determined by a blinded adjudication committee). The secondary outcomes included the total number of days in the hospital during the 10-month observation period.

Results

Among the 338 randomized infants (172 in the early repair group and 166 in the late repair group), 320 underwent operative repair (86% were male; 2% were Asian, 30% were Black, 16% were Hispanic, 59% were White, and race and ethnicity were unknown in 9% and 4%, respectively; the mean gestational age at birth was 26.6 weeks [SD, 2.8 weeks]; the mean postnatal age at enrollment was 12 weeks [SD, 5 weeks]). Among 308 infants (91%) with complete data (159 in the early repair group and 149 in the late repair group), 44 (28%) in the early repair group vs 27 (18%) in the late repair group had at least 1 serious adverse event (risk difference, -7.9% [95% credible interval, -16.9% to 0%]; 97% bayesian posterior probability of benefit with late repair). The median number of days in the hospital during the 10-month observation period was 19.0 days (IQR, 9.8 to 35.0 days) in the early repair group vs 16.0 days (IQR, 7.0 to 38.0 days) in the late repair group (82% posterior probability of benefit with late repair). In the prespecified subgroup analyses, the probability that late repair reduced the number of infants with at least 1 serious adverse event was higher in infants with a gestational age younger than 28 weeks and in those with bronchopulmonary dysplasia (99% probability of benefit in each subgroup).

Conclusions and Relevance

Among preterm infants with inguinal hernia, the late repair strategy resulted in fewer infants having at least 1 serious adverse event. These findings support delaying inguinal hernia repair until after initial discharge from the neonatal intensive care unit.

Trial Registration

ClinicalTrials.gov Identifier: NCT01678638.

Inguinal Hernia in Premature Infants: To Operate Before or After Discharge from Hospital?

INTRODUCTION

This study aims to find out the optimal timing for herniotomy for premature infants with inguinal hernia (IH): early during hospitalisation or delayed after hospital discharge.

METHOD

A retrospective cohort study was conducted on premature infants diagnosed with IH during their initial hospitalization between 2015 and 2020. Demographic data and clinical outcomes were compared between infants undergoing herniotomy before discharge ("early") and those who were discharged without herniotomy ("delayed"). Student's t-test or Mann-Whitney U test and Fisher's exact test were used for statistical analysis.

RESULTS

Of 219 premature infants, 189 (86.3%) underwent early herniotomy, while 30 were discharged with unoperated IH. In the delayed group, 15 (50%) underwent planned delayed herniotomy, and the remaining 15 experienced spontaneous resolution (absence of inguinal bulge over at least 1-year follow-up). The gestational age and birth weight of both groups were similar. At surgery, the delayed group median (interquartile range) was significantly older (42.1[38-49] vs 37.7 [36-40] weeks, p < 0.001) and heavier (3.27 [2.21-4.60] vs 2.22 [2.00-2.70] kg, p < 0.001). Two infants (1%) in the early group presented with incarcerated IH requiring urgent operation. In the delayed group, no infant developed incarcerated IH while awaiting elective operation (time from diagnosis to operation 44 [21-85] days). There was no statistically significant difference in respiratory and surgical complications between the two groups, although the delayed group had lesser surgical complications (0% vs 9.5%).

CONCLUSION

Deferring herniotomy after discharge for premature infants is safe with close monitoring and associated with a chance of spontaneous resolution.

LEVEL OF EVIDENCE

Level III, treatment study.

Immediate Versus Delayed Surgical Management of Infant Cryptorchidism With Inguinal Hernia

INTRODUCTION

Cryptorchidism is commonly treated with orchiopexy at 6-12 months of age, often allowing time for undescended testicle(s) (UT) to descend spontaneously. However, when an inguinal hernia (IH) is also present, some surgeons perform orchiopexy and inguinal hernia repair (IHR) immediately rather than delaying surgery. We hypothesize that early surgical intervention provides no benefit for newborns with both IH and UT.

METHODS

The Nationwide Readmissions Database was used to identify newborns with diagnoses of both IH and UT from 2010 to 2014. Patients were stratified by management: IHR performed on initial admission (Repair) or not (Deferral). Demographics, outcomes, and complications were compared. Results were weighted for national estimates.

RESULTS

We analyzed 1306 newborns (64% premature) diagnosed with both IH and UT. IHR was performed at index admission in 30%. Repair was more common in premature babies (43% vs. 8% full-term, p < 0.001) and patients with congenital anomalies (33% vs. 27% without congenital anomaly, p = 0.012). There was no difference in readmission rates. Repair patients had higher rates of orchiectomy than did Deferral. No Deferral patients were readmitted for bowel resection, and <1% were readmitted for orchiectomy or hernia incarceration.

CONCLUSION

In newborns with UT and IH, immediate repair is not associated with improved outcomes. Even with incarceration on initial presentation, rates of readmission with incarceration or bowel compromise for patients who undergo Deferral of surgery are minimal. Moreover, Repair newborns have higher rates of orchiectomy. We found no benefit to early operative intervention; thus, we recommend waiting until 6-12 months of age to reassess for surgery.

LEVEL OF EVIDENCE

Level III TYPE OF STUDY: Retrospective Comparative Study.

AI's deep dive into complex pediatric inguinal hernia issues: a challenge to traditional guidelines?

OBJECTIVE

This study utilized ChatGPT, an artificial intelligence program based on large language models, to explore controversial issues in pediatric inguinal hernia surgery and compare its responses with the guidelines of the European Association of Pediatric Surgeons (EUPSA).

METHODS

Six contentious issues raised by EUPSA were submitted to ChatGPT 4.0 for analysis, for which two independent responses were generated for each issue. These generated answers were subsequently compared with systematic reviews and guidelines. To ensure content accuracy and reliability, a content analysis was conducted, and expert evaluations were solicited for validation. Content analysis evaluated the consistency or discrepancy between ChatGPT 4.0's responses and the guidelines. An expert scoring method assess the quality, reliability, and applicability of responses. The TF-IDF model tested the stability and consistency of the two responses.

RESULTS

The responses generated by ChatGPT 4.0 were mostly consistent with the guidelines. However, some differences and contradictions were noted. The average quality score was 3.33, reliability score was 2.75, and applicability score was 3.46 (out of 5). The average similarity between the two responses was 0.72 (out of 1), Content analysis and expert ratings yielded consistent conclusions, enhancing the credibility of our research.

CONCLUSION

ChatGPT can provide valuable responses to clinical questions, but it has limitations and requires further improvement. It is recommended to combine ChatGPT with other reliable data sources to improve clinical practice and decision-making.

Fatality in the perioperative period: A case report on refractory hypoxemia in an infant following open inguinal herniotomy

INTRODUCTION AND IMPORTANCE OF THE CASE

Post-operative adverse respiratory events are not uncommon among infants.

PRESENTATION OF CASE

A 2-month-old male infant with an acyanotic heart disease underwent an elective open inguinal herniotomy under general anaesthesia. The intraoperative period was uneventful. The infant developed intermittent respiratory apnea and low oxygen saturation, followed by bradycardia in the post-anaesthesia care unit. Despite continued resuscitative efforts, the baby succumbed. The autopsy did not reveal new pathology. A period of interrupted monitoring during the recovery was noted. This could have led to undetected apnoea following an obstructed airway and resultant prolonged hypoxemia, further complicated by underlying structural heart disease.

CLINICAL DISCUSSION

Hypoxemia in the postoperative period in infants could be multifactorial. Airway obstruction due to secretions, airway spasms, and apnoea are common causes.

CONCLUSION

Prolonged hypoxia among paediatric patients could rapidly progress to cardiovascular collapse, hypoxic brain injury, and even death. This warrants close monitoring and active management during impaired oxygenation and ventilation during perioperative LMA use.

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.

Optimal Timing of Inguinal Hernia Repair in Premature Infants: A NSQIP-P Study

INTRODUCTION

Among premature infants, the incidence of inguinal hernias is reported to be as high as 30%. Despite being one of the most commonly performed procedures, the optimal setting of inguinal hernia repair (IHR) that is inpatient versus outpatient remains debatable. We sought to compare the 30-day outcomes of each approach by querying the National Surgical Quality Improvement Program-Pediatric database.

MATERIALS AND METHODS

A retrospective cohort study comparing inpatient versus outpatient IHR using the National Surgical Quality Improvement Program-Pediatric database from 2013 to 2019 was performed. Demographic and clinical data were initially compared using univariate analysis. Continuous variables are presented as median and interquartile range and categorical variables are presented as n (%). Subsequently, cohorts were propensity matched using clinically and statistically significant patient characteristics.

RESULTS

928 patients underwent IHR, 634 (68.3%) while inpatient, 294 (31.7%) following hospital discharge. Inpatient IHR was associated with lower age at the time of surgery (120 versus 147 d; P < 0.0001), younger gestational age (27 versus 33 wk; P < 0.0001), decreased probability of repair in elective setting (87.2% versus 97.3%; P < 0.0001), and increased preoperative supplemental oxygen need (42% versus 4.4%; P < 0.0001). Comparison of propensity matched cohorts revealed that inpatient IHR was associated with increased procedure time (82 versus 51 min; P < 0.0001) and anesthetic duration (146 versus 102 min; P < 0.0001), wound infection rates (3.8% versus 0%; P = 0.007), blood transfusions (4.2% versus 0.5%; P = 0.036), unplanned intubations (2.8% versus 0%; P = 0.03), ventilator days (0 versus 0; range [0,30 versus 0,2]; P = 0.002), reoperation rate (5.6% versus 0%; P < 0.001), postoperative hospital length of stay (4 versus 1 d; P < 0.0001), and unplanned readmissions (8.9% versus 0.9%; P = 0.002).

CONCLUSIONS

Inpatient IHR in premature neonates were associated with different postoperative outcomes than outpatient IHR. At least in the elective setting among premature infants, outpatient IHR can be considered safe in select patients while we await higher quality prospective data.

Comparing Outcomes of Single-Incision Laparoscopic Herniorrhaphy in Newborns and Infants

BACKGROUND

As surgical techniques progress, laparoscopic herniorrhaphy is now performed more often in premature babies. The aim of this study was to analyze the outcomes of newborns and infants who underwent single-incision laparoscopic herniorrhaphy (SILH) at our center.

METHODS

We retrospectively reviewed patients younger than 12 months old who received SILH at our department from 2016 to 2020. SILH involved a 5 mm 30-degree scope and 3 mm instruments with a 3-0 Silk purse-string intracorporeal suture for closure of the internal ring. At the time of surgery, Group 1 newborns, whose corrected age was 2 months and below, were compared to the Group 2 infants, whose age was above 2 months. We assessed the patients' characteristics, anesthesia, surgical data, and complications.

RESULTS

A total of 197 patients were included (114 newborns in Group 1 and 83 infants in Group 2). The mean age and body weight in Group 1 were 1.2 months and 3.8 kg, respectively, whereas in Group 2, they were 3.2 months and 6.7 kg, respectively. There were no significant differences in operative time (Group 1 = 34.1 min vs. Group 2 = 32.3 min, p = 0.26), anesthetic time (Group 1 = 80.0 min vs. Group 2 = 76.3 min, p = 0.07), length of hospitalization (Group 1 = 2.3 days vs. Group 2 = 2.4 days, p = 0.88), postoperative complications including omphalitis (Group 1 = 5.3% vs. Group 2 = 1.2%, p = 0.13), wound infection (Group 1 = 0.9% vs. Group 2 = 1.2%, p = 0.81), and hydrocele (Group 1 = 0.35% vs. Group 2 = 8.4%, p = 0.14). No recurrence, testicular ascent or atrophy, or mortality was observed in either group during the 2-year follow-up period.

CONCLUSIONS

Single-incision laparoscopic herniorrhaphy is a safe and effective operation for inguinal hernia repair in infants, even those with prematurity, lower body weight at the time of surgery, or cardiac and/or pulmonary comorbidities. Comparable results revealed no significant differences in perioperative complications despite younger ages and lower body weights.

Delayed versus early repair of inguinal hernia in preterm infants: A systematic review and meta-analysis

OBJECTIVES

To evaluate the clinical outcomes of herniotomy in preterm infants undergoing early versus delayed repair, the risk factors for complications, and to identify best timing of surgery.

METHODS

Medline, Embase and Central databases were searched from inception until 25 Jan 2021 to identify publications comparing the timing of neonatal inguinal hernia repair between early intervention (before discharge from first hospitalization) and delayed (after first hospitalisation discharge) intervention. Inclusion criteria was preterm infants diagnosed with inguinal hernia during neonatal intensive care unit admission. Results were analyzed using fixed and random effects meta-analysis (RevManv5.4).

RESULTS

Out of 721 articles found, six studies were included in the meta-analysis. Patients in the early group had lower odds of developing incarceration [odds ratio (OR) 0.43, 95% confidence interval (CI) 0.34-0.55, I² = 0%, p < 0.001]; but higher risk of post-operative respiratory complications (OR 4.36, 95% CI 2.13-8.94, I² = 40%, p < 0.001). No significant differences were reported in recurrence rate (OR 3.10, 95% CI 0.90-10.64, I² = 0%, p = 0.07) and surgical complication rate (OR 0.94, 95% CI 0.18-4.83, I² = 0%, p = 0.94) between early and delayed groups.

CONCLUSION

While early inguinal hernia repair in preterm infants reduces the risk of incarceration, it increases the risk of post-operative respiratory complications compared to delayed repair. Surgeons should discuss the risks and benefits of delaying inguinal hernia repair with the caregivers to make an informed decision best suited to the patient physiology and circumstances.

LEVEL OF EVIDENCE

Treatment study, level 3.

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.

Association Between COVID-19 Related Elective Surgery Cancellations and Pediatric Inguinal Hernia Complications: A Nationwide Multicenter Cohort Study

Background

Optimal inguinal hernia repair timing remains controversial. It remains unclear how COVID-19 related elective surgery cancellations impacted timing of inguinal hernia repair and whether any delays led to complications. This study aims to determine whether elective surgery cancellations are safe in pediatric inguinal hernia.

Methods

This multicenter retrospective cohort study at 14 children’s hospitals included patients ≤18 years who underwent inguinal hernia repair between September 13, 2019, through September 13, 2020. Patients were categorized by whether their inguinal hernia repair occurred before or after their hospital’s COVID-19 elective surgery cancellation date. Incarceration and emergency department encounters were compared between pre and postcancellation.

Results

Of 1,404 patients, 604 (43.0%) underwent inguinal hernia repair during the postcancellation period, 92 (6.6%) experienced incarceration, and 213 (15.2%) had an emergency department encounter. The postcancellation period was not associated with incarceration (odds ratio 1.54; 95% confidence interval 0.88–2.71; P = .13) or emergency department encounters (odds ratio 1.53; 95% confidence interval 0.94–2.48; P = .09) despite longer median times to inguinal hernia repair (precancellation 29 days [interquartile range 13–55 days] versus postcancellation 31 days [interquartile range 14–73 days], P = .01). Infants were more likely to have the emergency department be their index presentation in the postcancellation period (odds ratio 1.69; 95% confidence interval 1.24–2.31; P < .01).

Conclusion

Overall, COVID-19 elective surgery cancellations do not appear to increase the likelihood of incarceration or emergency department encounters despite delays in inguinal hernia repair, suggesting that cancellations are safe in children with inguinal hernia. Assessment of elective surgery cancellation safety has important implications for health policy.

Factors associated with inguinal hernia repair in premature infants during neonatal admission

INTRODUCTION

Timing of inguinal hernia repair (IHR) in premature infants is variable and influenced by surgeon preference and complication profile. The purpose of this study was to evaluate factors related to early IHR, defined as hernia repair during initial neonatal admission, in premature infants.

METHODS

Neonatal hospitalizations of premature infants (gestational age at birth < 37 weeks and ≤ 28 days old at admission), with a diagnosis of inguinal hernia from 2010 to 2017 in HCUP National Inpatient Sample and Kid's Inpatient Sample databases were evaluated. Multivariable Cox proportional hazard models was used to estimate associations between demographics, additional procedures, hospital characteristics, and early IHR.

RESULTS

Overall, 30,298 neonatal hospitalizations of premature infants with inguinal hernia were identified; 13,228 (43.3%) underwent early IHR. Early IHR was more likely with older gestational age at birth (35-36 weeks vs < 24 weeks, HR 6.05, 95% CI 4.17, 8.79), female sex (HR 1.20, 95% CI 1.07, 1.34), and undergoing concomitant gastrostomy (HR 2.51, 95% CI 1.72, 3.66). Non-Hispanic Black infants (HR 0.84, 95% CI 0.75, 0.95), infants at urban non-teaching hospitals (HR 0.15, 95% CI 0.07, 0.33), and infants at rural hospitals (HR 0.81, 95% CI 0.70, 0.97) were less likely to undergo early IHR.

CONCLUSIONS

Using a nationally representative database, early IHR in premature neonates was more commonly performed in non-Hispanic White, female neonates and at urban teaching hospitals. Patient race and hospital type were determinants of early IHR in premature neonates. There is a need to further evaluate the impact of race and socioeconomic factors on outcomes of common pediatric operations like inguinal hernia repairs.

LEVEL OF EVIDENCE

Level III.

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.

Laparoscopy is increasingly used for pediatric inguinal hernia repair

INTRODUCTION

Inguinal hernia repairs (IHR) are commonly performed by pediatric surgeons in the United States. The operative approach depends on surgeon preference with no definitive prospective studies comparing laparoscopic inguinal hernia repair (LIHR) versus traditional inguinal hernia repair (TIHR). We aim to assess current practice, hypothesizing that laparoscopy is increasingly used for pediatric IHR.

MATERIAL & METHODS

The Children's Hospital Association (CHA) Pediatric Health Information System was queried for IHRs performed between 01/01/2009 and 12/31/2018. Demographics, procedure type, hernia laterality, and cost were obtained. Patients were grouped by procedure type (laparoscopic/traditional).

RESULTS

125,249 IHRs were performed at 32 CHA hospitals during the ten-year study period. 115,782 (92.4%) were TIHR and 9467 (7.6%) LIHR. Use of laparoscopy increased 5-fold from 3% to 15% over the study period. When comparing laparoscopic to traditional IHR groups, there were more females (28.3% vs 12.6%), African-Americans (19.7% vs 14.4%), government-insured (50% vs 45.2%), younger patients (4.2 vs 4.4 years), bilateral IHRs (11.4% vs 7.9%), and higher adjusted total hospital cost ($3,791 vs $2995) in the laparoscopic group (p<0.0001, all comparisons).

CONCLUSIONS

Laparoscopy for pediatric IHR is increasing at CHA hospitals where nearly 1 in 6 children currently undergoes a laparoscopic repair. The long-term outcomes with laparoscopic repair are worthy of future study.

Awareness of Common Pediatric Surgical Entities among Practicing Indian Pediatricians

Aim:

Common pediatric surgical entities often get a delayed referral to the pediatric surgeon in the average Indian scenario. This study was conducted to assess the awareness about management of select common pediatric surgical entities among practicing pediatricians.

Materials and Methods:

An online multiple-choice questionnaire consisting of twenty questions related to the diagnosis and management of common pediatric surgical entities encountered by pediatricians in their routine office practice was prepared, and the electronic link was circulated among the practicing pediatricians of India. Each question had one correct response.

Results:

One hundred and seventy-five responses were obtained, collated, grouped, and analyzed. Overall, 35% of all responses were correct. Individually, 56% of respondents marked 51%–75% of answers correctly; only 7% scored above 75%. Some clinical observations were disparate: 65% were unfamiliar with preputial adhesions and 51% would discharge a preterm neonate with inguinal hernia without a surgical consult. There is a tendency toward unnecessary imaging (60% – localization of undescended testis, 91% – wet umbilicus, and 51% – postanal dimple) and overzealous medical management (propranolol for the involuting hemangioma). However, 82%–88% concurred on the standard conservative or surgical management in index conditions such as hypospadias and umbilical problems.

Conclusion:

There was a concurrence in the principles of management of common pediatric surgical entities between pediatricians and pediatric surgeons in 35%. Misdiagnosis, unwarranted investigations, overzealous medical management, and delayed surgical consults figured in 65%. A systematic professional interaction between the physicians and surgeons would facilitate a coordinated management. A larger study would yield more meaningful data.

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.

Long-term outcomes of pediatric laparoscopic needled-assisted inguinal hernia repair: A 10-year experience

PURPOSE

Laparoscopic inguinal hernia repair (LIHR) has gained wide acceptance over the past decade, although studies with longer term follow-up are lacking. We present one of the largest cohorts of children undergoing laparoscopic needle-assisted repair (LNAR) with long-term follow-up.

METHODS

A clinical quality database was maintained for children ≤14 years of age who underwent laparoscopic needle-assisted repair between 2009 and 2017 with review of follow-up through 2019. De-identified data was reviewed.

RESULTS

1023 patients with 1457 LNAR were included during the 10-year period. Mean age at surgery was 2.56 years (2 days to14 years). The overall hernia recurrence rate was 0.75% (11/1457). A total of four postoperative hydroceles required intervention. Preterm infant repair done <60w post conceptional age had a significantly lower recurrence rate (0.63%) than other patients (0.82%) (p < 0.01). 64.2% of patients had clinical follow-up over a period of 11 years with a mean follow-up of 5.97 years.

CONCLUSION

We present a large cohort study of consecutive pediatric laparoscopic hernia repairs followed over an 11-year period. LNAR is safe and effective for term and preterm patients with similar complication rates to other techniques, including open repair. Additionally, our results suggest that preterm infants may have superior outcomes with this method.

LEVEL OF EVIDENCE

Level III - Retrospective Comparative Study.

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.

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.

Optimal timing for inguinal hernia repair in premature infants: a systematic review and meta-analysis

BACKGROUND

The optimal timing of repair for inguinal hernia in premature infants remains a controversial topic. Our objective was to assess the clinical effects of inguinal hernia repair done before or after neonatal intensive care unit (NICU) discharge.

METHODS

MEDLINE, Embase, CINAHL, and CENTRAL were searched in July 2018. Publications comparing clinical outcomes of the premature infants with inguinal hernia repair before (early) and after (delayed) NICU discharge were identified. Two reviewers independently screened studies, extracted data, and assessed for quality. Results were pooled using random effects meta-analysis.

RESULTS

Of 640 publications identified, six comparative studies assessing a total of 1761 premature infants were included. Meta-analysis indicated no statistically significant difference in incarceration rate (odds ratio (OR) 2.15, 95% confidence interval (CI) 0.83-5.58, I² = 0%), surgical complications (OR 2.36, 95% CI 0.66-8.41, I² = 0%) and other secondary complications. However, the odds of recurrence and respiratory difficulty was significantly increase in the early group compared to delayed (OR 4.12, 95% CI 1.17-14.45, I² = 0%; OR 3.59, 95% CI 1.10-11.75, I² = 42%).

CONCLUSIONS

Repair of inguinal hernia in premature infants before NICU discharge may increase the odds of recurrence, but not incarceration or surgical complications.

LEVEL OF EVIDENCE

Level III.

Preoperative cardiopulmonary evaluation in specific neonatal surgery

Preoperative assessment of surgical neonates often relates to issues of prematurity, low birth weight, or associated malformations. This review explores the preoperative cardiopulmonary evaluation in specific newborn surgical populations, the role of echocardiography in congenital diaphragmatic hernia perioperative management, the impact of bronchopulmonary dysplasia in the ex-preterm surgical neonate and a brief discussion on the risk of general anesthesia and specific anesthetic considerations for any surgical neonate. Newborns with congenital anomalies requiring early general surgical intervention should have an assessment for congenital heart disease. In the asymptomatic neonate, a thorough physical exam may be sufficient preoperatively. Neonates born with esophageal atresia or anorectal malformations should have a full evaluation for VACTERL associations. Initial echocardiography in congenital diaphragmatic hernia is used to evaluate anatomy, but there is emerging evidence to suggest the use of echocardiography in the ongoing surveillance of CDH to influence the timing of surgical intervention. Bronchopulmonary dysplasia is present in up to 40% of ex-premature neonates and increases the risk of postoperative apneas and need for ventilatory support. However, all surgical neonates have an increased risk of post-operative apneas, and the need for surgical intervention should be balanced with the risk of general anesthesia.

Risk of incarceration in children with inguinal hernia: a systematic review

BACKGROUND

Surgical repair is recommended for all children with inguinal hernia due to fear of incarceration. The aim of this study was to assess the risk of incarceration and strangulation of inguinal hernias in children treated with delayed surgery or no surgery.

METHODS

Systematic searches were conducted in three databases. We included studies reporting on children with inguinal hernia, with the majority ≤ 10 years old. The interventions were non-acute inguinal hernia surgery or no surgery. The main outcomes were incarceration and strangulation. Secondary outcomes were postoperative complications. Randomized controlled trials, non-randomized controlled trials, and observational studies were included.

RESULTS

We included 22 studies with 14,959 children. All studies reported on elective repairs. None of the studies specifically reported on watchful waiting. Of the studies reporting wait time as mean or median, the median wait time was 46 days (range 1-552). The crude incarceration rate across the included studies was 7% for all children and 11% for preterm children. The testicular atrophy rate was 1% and the recurrence rate was 1%.

CONCLUSIONS

The risk of incarceration in children awaiting inguinal hernia surgery is substantial. In general, we cannot support delaying surgery unnecessarily. However, there may be benefits of delaying surgery in individual cases. In such cases, the surgeon should assess if the benefits may overrule the risk of incarceration.

Inguinal hernias in premature neonates: exploring optimal timing for repair

PURPOSE

Inguinal hernias have been reported in as many as 10-30% premature neonates, making inguinal herniorrhaphy (IHR) one of the most commonly performed surgical procedures. The timing of surgery remains controversial. The purpose of this report is to compare outcomes of IHR while in the NICU (inpatient) versus repair following discharge (outpatient) to determine optimal timing.

METHODS

Premature neonates having undergone IHR over a 5-year period were identified and a retrospective case cohort analysis was performed.

RESULTS

263 patients underwent IHR during the 5-year study period with 115 (43.7%) having surgical repair inpatient (IP; prior to discharge) and 148 having outpatient herniorrhaphy (OP). Patients with IHR performed IP had significantly lower birth weight (p < 0.001), gestational age (p < 0.001), longer duration of surgery (p = 0.01) and were more likely to have post-operative ventilator dependence following repair; however, there were no differences in the rate of recurrence (p = 0.44) and incarceration (p = 0.45).

CONCLUSION

Our study demonstrated no significant differences in the rates of incarceration or recurrence, following in- or out-patient IHR. These findings suggest that IHR can potentially be offered as an outpatient procedure following hospital discharge in appropriate patients. The optimal timing of IHR in premature infants remains elusive and will likely require additional multicenter investigation.

A multi-institution analysis of predictors of timing of inguinal hernia repair among premature infants

PURPOSE

Inguinal hernias are common in premature infants, but there is substantial variation with regards to timing of repair. We sought to quantify and explain this variation.

METHODS

Cohort study of infants <34weeks gestation diagnosed with an inguinal hernia and discharged from one of 329 neonatal intensive units between 1998 and 2012. Multivariable logistic regression clustered by site was used to evaluate demographic, clinical, maternal, and socioeconomic variables associated with pre-discharge repair.

RESULTS

A total of 8037 infants met study criteria, and 3230 (40%) received a pre-discharge repair. The frequency of pre-discharge repair varied by site from 9% to 84%, and increased over the study period from 20% in 1998 to 45% in 2012. Concurrent gastrostomy or fundoplication and lower socioeconomic status were associated with an increased odds of receiving a pre-discharge repair.

CONCLUSION

There is substantial variation with regards to the timing of repair of inguinal hernias in premature infants, with an increasing number of infants receiving repair prior to hospital discharge over time. Concurrent gastrostomy or fundoplication and socioeconomic status are associated with timing of repair.

LEVEL OF EVIDENCE

IV.

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.

Propensity score analysis with partially observed covariates: How should multiple imputation be used?

Inverse probability of treatment weighting is a popular propensity score-based approach to estimate marginal treatment effects in observational studies at risk of confounding bias. A major issue when estimating the propensity score is the presence of partially observed covariates. Multiple imputation is a natural approach to handle missing data on covariates: covariates are imputed and a propensity score analysis is performed in each imputed dataset to estimate the treatment effect. The treatment effect estimates from each imputed dataset are then combined to obtain an overall estimate. We call this method MIte. However, an alternative approach has been proposed, in which the propensity scores are combined across the imputed datasets (MIps). Therefore, there are remaining uncertainties about how to implement multiple imputation for propensity score analysis: (a) should we apply Rubin's rules to the inverse probability of treatment weighting treatment effect estimates or to the propensity score estimates themselves? (b) does the outcome have to be included in the imputation model? (c) how should we estimate the variance of the inverse probability of treatment weighting estimator after multiple imputation? We studied the consistency and balancing properties of the MIte and MIps estimators and performed a simulation study to empirically assess their performance for the analysis of a binary outcome. We also compared the performance of these methods to complete case analysis and the missingness pattern approach, which uses a different propensity score model for each pattern of missingness, and a third multiple imputation approach in which the propensity score parameters are combined rather than the propensity scores themselves (MIpar). Under a missing at random mechanism, complete case and missingness pattern analyses were biased in most cases for estimating the marginal treatment effect, whereas multiple imputation approaches were approximately unbiased as long as the outcome was included in the imputation model. Only MIte was unbiased in all the studied scenarios and Rubin's rules provided good variance estimates for MIte. The propensity score estimated in the MIte approach showed good balancing properties. In conclusion, when using multiple imputation in the inverse probability of treatment weighting context, MIte with the outcome included in the imputation model is the preferred approach.

General endotracheal vs. non-endotracheal regional anesthesia for elective inguinal hernia surgery in very preterm neonates: A single institution experience

BACKGROUND

Very pre-term infants (VP) at <32 weeks post menstrual age PMA have a high incidence of bronchopulmonary dysplasia BPD. BPD places them at risk for pulmonary-related perioperative complications from general endotracheal anesthesia GE during elective inguinal hernia repair.

METHODS

A retrospective cohort study was done to compare pulmonary-related perioperative risks between VP patients undergoing non-emergent inguinal hernia repair prior to NICU discharge under GE (n=58) vs regional anesthesia RA (n=37).

RESULTS

Median PMA (RA 26 vs GE 27 weeks), operative weight (RA 2.2 vs GE 2.27 kg), % with BPD, medical and surgical comorbidities, number of concurrent procedures are similar between groups, except for sac laparoscopy (0% RA vs 36% GE). Procedural anesthesia time was 40 minutes for RA vs 69 minutes for GE, (p < 0.001). GE (17%) vs RA (0%) remained intubated post op (p<0.001). Oral feeding was fully tolerated in RA (97%) vs GE (72%, p=0.002) by 48h after surgery. The statistical differences hold after regression analysis controlling for sac laparoscopy and procedure time. No difference in intraoperative or postoperative hernia complications is found.

CONCLUSION

RA is safe. RA is associated with early resumption of full feed, avoidance of prolonged mechanical intubation. We recommend a randomized controlled trial comparing the safety and efficacy of GE vs RA in VP infants undergoing elective NICU inguinal hernia repair.

LEVEL OF EVIDENCE

II Retrospective study.