Incidence of metachronous contralateral inguinal hernias in children following unilateral repair - A meta-analysis of prospective studies

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.

Laparoscopic inguinal hernia repair (LIHR): the benefit of the double stitch in the largest single-center experience

AIM

To review our experience of laparoscopic inguinal hernia repair (LIHR) regarding complication rates, the practice of closing the asymptomatic patent processes vaginalis (PPV), and comparison of complication rates between pre-term (< 37 week gestation) and term infants.

METHODS

Retrospective review of LIHR performed between 2009 and 2021. Repair was performed by intracorporal single or double purse string/purse string + Z-stitch using a non-absorbable suture. Data were analyzed using Chi-squared/Mann-Whitney and are quoted as median (range).

RESULTS

1855 inguinal rings were closed in 1195 patients (943 (79%) male). 1378 rings (74%) were symptomatic. 492 (41%) patients were pre-term. Corrected gestational age at surgery was 55 weeks (31 weeks-14.6 years) and weight 5.9 kg (1-65.5). Closure of contralateral PPV was higher in the premature group (210/397 [53%] vs. 265/613 [43%] p = 0.003). There were 23 recurrences in 20 patients, of whom 10 had been born prematurely. The only factor significantly associated with a lower recurrence was use of a second stitch (p = 0.011).

CONCLUSION

This is the largest single-center reported series of LIHR. LIHR is safe at any age, the risk of recurrence is low, and can be corrected by re-laparoscopy. Use of a Z-stitch or second purse string is associated with a significantly lower rate of recurrence.

Patent processus vaginalis: role of ultrasound in pediatric population with unilateral inguinal hernia and other predictors

INTRODUCTION

Inguinal hernia (IH) repair is a common procedure in the daily practice of pediatric surgeons. In a developing country with limited facilities, it is important to be able to predict and diagnose contralateral patent processus vaginalis (CPPV) to avoid the risk and cost of further surgery.

OBJECTIVES

To assess the accuracy of ultrasound for the detection of CPPV, using laparoscopic evaluation as a confirmatory test. We also looked for various predictors of CPPV in our study population.

METHODS

141 patients were included in this 2-year, cross-sectional prospective study. Inclusion criteria were unilateral inguinal hernia elective patients with no major comorbidities and aged between 2 months and 8 years. Each patient was assessed in outpatient clinics and then a pre-operative ultrasound was conducted. This was followed by laparoscopic evaluation during repair of the hernia.

RESULTS

Of the 141 patients included, 110 (78%) were males, 121 (85.9%) were born at full term, and 96 (68.1) had right-sided hernia. Mean age was 2.64 ± 1.9 years. Ultrasound was 85.7% sensitive in the detection of CPPV, 90.8% specific, and 90.1% accurate. In our analysis of patients younger than 1 year, right-sided hernia and defect size more than 10 mm were statistically significant predictors for a CPPV.

CONCLUSIONS

Ultrasound has a high accuracy profile and is a useful alternative in limited resource settings with restricted access to minimally invasive surgery for the prediction of CPPV. Patients younger than 1 year with a right-sided hernia or a manifested hernia defect larger than 10 mm are at a higher risk of having a CPPV.

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.

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.

Laparoscopic extraperitoneal technique versus open inguinal herniotomy in children: historical controlled intervention study

Objective

To compare surgical outcomes of percutaneous extraperitoneal simple purse string method of laparoscopic hernia (LH) repair with a traditional open inguinal hernia (OH) repair in children with indirect inguinal hernia in a single center.

Methods

This study is a historical-controlled intervention study of two groups of patients: patients in the controlled group had OH repair performed from January 2016 to December 2017, and patients in the study group had LH repair from January 2018 to December 2019 at a single institution. Outcomes of the OH and LH groups, in terms of operative time, recurrence, complications, incidence of metachronous contralateral inguinal hernia (MCIH) and contralateral patent processus vaginalis (CPPV) were analyzed.

Results

Three hundred and five patients were enrolled in the study. Among them, 95 cases underwent laparoscopic percutaneous extraperitoneal closure herniotomy (LH group), and 210 cases underwent conventional open herniotomy (OH group). In terms of operative time, only unilateral herniotomy in females of the OH group was significantly less than that of the LH group (15.7±7.1 vs 20.5±7.4 min, p=0.004). No significant difference in overall complication was observed between the two groups of patients. The incidence of CPPV in the LH group was 15.7% (15/95), and MCIH in OH group was 10.9% (23/210).

Conclusions

Laparoscopic herniotomy may prevent the need for a second operation of metachronous contralateral hernia. Both open and laparoscopic techniques are equivalent in pro and cons.

Comparison study of three laparoscopic ligation procedures for pediatric inguinal hernia: a multicenter cohort of 5523 cases

PURPOSE

Single-site laparoscopic percutaneous extraperitoneal ligation (SLPEL) for pediatric inguinal hernia has gained popularity worldwide. However, complications associated with extraperitoneal knotting are not rare. This study evaluated the effectiveness of a modified SLPEL (M-SLPEL) to decrease adverse events associated with ligation knotting by comparing it with two other methods: classical SLPEL (C-SLPEL) and intracorporeal purse-string suturing (IPS).

METHODS

A multicenter retrospective comparative study was conducted among 5523 pediatric inguinal hernia patients. Cases were divided into three groups according to the surgical procedure: the M-SLPEL, C-SLPEL, and IPS groups. Data describing the clinical characteristics, operative time, and complications were collected.

RESULTS

All procedures were performed uneventfully. There were no significant differences in the age at operation (mean 2.62 ± 1.38 years). The operative time was shorter in the M-SLPEL group both for unilateral hernias (12.5 ± 1.8 min in C-SLPEL, 11.7 ± 1.3 min in M-SLPEL, and 17.6 ± 2.9 min in IPS) and for bilateral hernias (15.1 ± 2.1 min, 14.6 ± 1.7 min, and 23.9 ± 2.3 min, respectively). The overall incidence of adverse events in the inguinal region was 0% for M-SLPEL, 2.2% for C-SLPEL, and 0.5% for IPS. All patients were followed up for 12-93 months (mean 54 months). Recurrence occurred in 8 cases in the C-SLPEL group, 1 case in the M-SLPEL group, and 8 cases in the IPS group, with no significance between groups. No scrotal hematoma, testicular atrophy, or iatrogenic cryptorchidism occurred in any group.

CONCLUSION

The M-SLPEL procedure has time-consumption efficiency equivalent to that of C-SLPEL and even fewer adverse events in the inguinal region than IPS and C-SLPEL.

Cost-Effectiveness of Laparoscopic and Open Pediatric Inguinal Hernia Repair

Aim: Laparoscopic inguinal hernia (IH) repair is an alternative to open surgery. A potential advantage of laparoscopic repair is prevention of contralateral metachronous hernia although some studies report higher recurrence rate. We aim to determine the cost-effectiveness of open versus laparoscopic IH repair taking into account metachronous and recurrence rates. Methods: Retrospective single-center study of children (<5 years) undergoing elective open or laparoscopic repair for a unilateral IH between February 2018 and October 2019. Ten cases in each of four groups were included (open day case, open overnight, laparoscopic day case, and laparoscopic overnight). Cases incurring a higher cost due to comorbidities or additional procedure were excluded. Patient-level information and costing system data were obtained from the hospital finance. Mean (standard deviation [SD]) procedural cost was compared for open and laparoscopic procedures. A financial model was created factoring metachronous and recurrent rates. Results: Cost of open day case repair was £1866.24 (SD: 311.15) compared with £2210.13 (SD: 391.36) for day case laparoscopic repair. For overnight repair, cost of open was £2442.82 (SD: 497.05) compared with £2585.35 (SD: 384.66) for laparoscopic. On calculating the cost-effectiveness point using the difference in metachronous and recurrence rate between the two procedures, laparoscopic is more cost-effective than open day case repair at 18.43%. For overnight repair, the difference rate is 5.84%. Conclusion: Our data suggest that based on metachronous and recurrence rates in the current literature, laparoscopic IH repair is more cost-effective than open repair for cases requiring overnight stay, whereas for day case procedures open IH repair is more cost-effective.

Percutaneous Internal Ring Suturing (PIRS) – The Benefits of Laparoscopic Inguinal Hernia Repair

Introduction

The laparoscopic inguinal hernia repair in children using the PIRS technique is a well-established method. However, there are still opinions that this method does not bring more benefits than open surgery.

Purpose

The study aims to demonstrate the benefits of laparoscopic technique over conventional, open techniques.

Patients and Methods

We conducted a retrospective study that included children aged 0–18 treated using the PIRS technique in 2008–2016. The control group consisted of patients treated with the traditional, open method of inguinal hernia repair. A total of 276 children were qualified for laparoscopic surgery, and there were 274 patients in the control group. A full laparoscopic procedure was performed on 247 patients. Assessment of the pathology of the internal inguinal ring was done in all patients during the laparoscopic procedure. Intraoperatively 79 children had bilateral inguinal hernia diagnosed, 133 right-sided inguinal herniae, and 57 left-sided inguinal herniae. The occurrence of hernia was not confirmed in 7 children, whereas 53 patients had open contralateral patent processus vaginalis. In a case of contralateral patent processus vaginalis, the repair was performed using the PIRS method.

Results

The recurrence of the inguinal hernia was observed in 10 children in the laparoscopic group and in 5 cases in control group. The duration of the procedure was noted and compared to open inguinal hernia repair. There was a statistically shorter duration of the laparoscopic method. In the control group, there were 16 patients with a metachronous contralateral inguinal hernia.

Conclusion

The laparoscopic inguinal hernia repair was associated with a better assessment of hernia pathology, shorter operative time, and lower risk of contralateral hernia repair.

Laparoscopic Hernia Repair with the Extraperitoneal Approach versus Open Hernia Repair in Pediatric Inguinal Hernia: A Systematic Review and Meta-Analysis

OBJECTIVE

This systematic review and meta-analysis investigated the feasibility and effectiveness of laparoscopic hernia repair with the extraperitoneal approach in pediatric inguinal hernias.

SUMMARY BACKGROUND DATA

Inguinal hernia repair is the most common operation in pediatric surgical practice. Although open hernia repair (OHR) is a well-established procedure with good outcomes, studies have reported acceptable or even better outcomes of laparoscopic hernia repair with the extraperitoneal approach (LHRE). However, a meta-analysis comparing LHRE with OHR is lacking.

METHODS

PubMed, EMBASE, and Cochrane Library databases were searched for randomized controlled trials (RCTs) and comparative studies (prospective or retrospective). Outcomes were metachronous contralateral inguinal hernia (MCIH), hernia recurrence, surgical site infection, operation time, and hospitalization length. A meta-analysis was performed, and risk ratios (RR), weighted mean difference (WMD), and 95% confidence intervals (CI) were calculated using random-effects models.

RESULTS

Five RCTs and 21 comparative studies involving 24,479 patients were included. Lower MCIH incidence (RR: 0.11, 95% CI: 0.07 to 0.17; p < 0.00001) and a trend of shorter operation time (WMD: -11.90 min, 95% CI: -16.63 to -7.44; p < 0.00001) were found in the LHRE group. No significant differences in ipsilateral recurrence hernias, surgical site infection, and length of hospitalization were found between the groups.

CONCLUSIONS

LHRE presented lower MCIH incidence and shorter operation times, with no increase in hernia recurrence, surgical site infection, or length of hospitalization. As more surgeons are increasingly becoming familiar with LHRE, LHRE would be a feasible and effective choice for pediatric inguinal hernia repair.

Minimally Invasive Total Extraperitoneal Varicocele Repair: First Description in Children

Introduction: The aim of this study was to report the first pediatric case series treated with minimally invasive total extraperitoneal varicocele (MITEV) repair using the total extraperitoneal (TEP) approach. Materials and Methods: Five male adolescents (12-17 years) were included in this study, all with left-sided Grade III varicoceles. A 5 mm camera port was inserted just below the umbilicus and two 5 mm working ports were used, one above the symphysis in the midline and the other in the left lateral hemiabdomen just below the arcuate line. Results: Operation time ranged from 47 to 61 minutes (mean: 53 minutes). There were no intra- or postoperative complications. The peritoneum was not perforated, and the abdominal cavity was not entered. Two patients had resolution from varicoceles on follow-up clinical examination and ultrasonography was performed 6 months after surgery. In 3 patients, long-term follow-up was pending. Conclusion: MITEV repair reflects a new minimally invasive access to the retroperitoneum in children with varicocele.

Inguinal hernia repair in inpatient children: a nationwide analysis of German administrative data

Background

Contrary to adult inguinal hernia surgery, large-scale investigations using registries or administrative data are missing in paediatric surgery. We aimed to fill this gap by analysing German administrative hospital data to describe the current reality of inpatient hernia surgery in children.

Methods

We analysed aggregated data files bought from the German federals statistics office on hospital reimbursement data separately for principal diagnoses of inguinal hernia in children and for herniotomies in inpatients. Developments over time were assessed via regression and differences between groups with nonparametric comparisons.

Results

Principal diagnoses of hernias were decreasing over time with the exception of male bilateral and female bilateral incarcerated hernias in the first year of life which increased. The vast majority of operations were conducted via the open approach and laparoscopy was increasingly only used for females older than 1 year of age. Recurrent hernia repair was scarce. Rates of inguinal hernia repair were higher in both sexes the younger the patient was, but were also decreasing in all age groups despite a population growth since 2012. The amount of inguinal hernia repairs by paediatric surgeons compared to adult surgeons increased by 1.5% per year.

Conclusions

Our results corroborate previous findings of age and sex distribution. It demonstrates that inpatient hernia repair is primarily open surgery with herniorrhaphy and that recurrences seem to be rare. We observed decreasing rates of hernia repairs over time and as this has been described before in England, future studies should try to elucidate this development.

Level of evidence

III.

Contralateral surgical exploration during inguinal hernia repair in infants (HERNIIA trial): study protocol for a multi-centre, randomised controlled trial

BACKGROUND

The incidence of metachronous contralateral inguinal hernia (MCIH) is high in infants with an inguinal hernia (5-30%), with the highest risk in infants aged 6 months or younger. MCIH is associated with the risk of incarceration and necessitates a second operation. This might be avoided by contralateral exploration during primary surgery. However, contralateral exploration may be unnecessary, leads to additional operating time and costs and may result in additional complications of surgery and anaesthesia. Thus, there is no consensus whether contralateral exploration should be performed routinely.

METHODS

The Hernia-Exploration-oR-Not-In-Infants-Analysis (HERNIIA) study is a multicentre randomised controlled trial with an economic evaluation alongside to study the (cost-)effectiveness of contralateral exploration during unilateral hernia repair. Infants aged 6 months or younger who need to undergo primary unilateral hernia repair will be randomised to contralateral exploration or no contralateral exploration (n = 378 patients). Primary endpoint is the proportion of infants that need to undergo a second operation related to inguinal hernia within 1 year after primary repair. Secondary endpoints include (a) total duration of operation(s) (including anaesthesia time) and hospital admission(s); (b) complications of anaesthesia and surgery; and (c) participants' health-related quality of life and distress and anxiety of their families, all assessed within 1 year after primary hernia repair. Statistical testing will be performed two-sided with α = .05 and according to the intention-to-treat principle. Logistic regression analysis will be performed adjusted for centre and possible confounders. The economic evaluation will be performed from a societal perspective and all relevant costs will be measured, valued and analysed.

DISCUSSION

This study evaluates the effectiveness and cost-effectiveness of contralateral surgical exploration during unilateral inguinal hernia repair in children younger than 6 months with a unilateral inguinal hernia.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03623893 . Registered on August 9, 2018 Netherlands Trial Register NL7194. Registered on July 24, 2018 Central Committee on Research Involving Human Subjects (CCMO) NL59817.029.18. Registered on July 3, 2018.

The Operative Time for Unilateral Inguinal Hernia Repair in Children Performed with Percutaneous Internal Ring Suturing (PIRS) or Open Approach Method

In this study, we compared the operative time for unilateral inguinal hernia repair in children performed with either an open approach (OA) or the Percutaneous Internal Ring Suturing (PIRS) method. It was a retrospective chart review of all patients ages 0 to 18 who underwent unilateral inguinal hernia repair in the Department of Pediatric Surgery, Urology and Traumatology of the Regional Hospital in Kielce between January 2011 and December 2018. Patients with bilateral hernias or additional problems were excluded. Of 878 patients qualified for the study, 701 were in the OA group and 177 in the PIRS group. Overall, the time needed to complete the procedure was significantly longer for the OA method. The operative time was longer if the hernia was left-sided (p = 0.024). Analysis by gender showed that operative time was generally longer in males. For both genders, surgery was shorter if the PIRS method was used. For males in the PIRS group the operative time was affected by the location of the hernia, and it was longer for a left-sided hernia. The take-home message is that the PIRS procedure is faster than the OA for inguinal hernia repair in children and it might be considered as a preferred method, especially in females.

Abdominal Wall Defects-Current Treatments

Gastroschisis and omphalocele reflect the two most common abdominal wall defects in newborns. First postnatal care consists of defect coverage, avoidance of fluid and heat loss, fluid administration and gastric decompression. Definitive treatment is achieved by defect reduction and abdominal wall closure. Different techniques and timings are used depending on type and size of defect, the abdominal domain and comorbidities of the child. The present review aims to provide an overview of current treatments.

Comparison of surgical outcomes between laparoscopic percutaneous extracorporeal closure (LPEC) and open repair for pediatric inguinal hernia by propensity score methods and log-rank test analysis

BACKGROUND

Despite a number of studies comparing laparoscopic inguinal hernia repair (LH) and open herniorrhaphy (OH), the putative advantage of LH remains controversial due to a paucity of firm evidence. We hypothesized that LH has both advantages and disadvantages compared to OH and sought to clarify them by comprehensively analyzing the retrospective data using the combination of multiple statistical methods.

METHODS

Operative data for inguinal hernia during the period from February 1999 to December 2019 were examined. The patients were assigned into two groups according to the surgical procedure: laparoscopic percutaneous extraperitoneal closure (LPEC, n = 2410) and OH (n = 2038). Operative and anesthesia times and incidence of postoperative complications were evaluated using the propensity score methods and log-rank test.

RESULTS

In comparison with OH, operative time of LPEC was longer for unilateral repair (21.59 ± 8.1 min vs 18.01 ± 8.0 min; p < 0.001) and shorter for bilateral repairs (28.55 ± 10.1 min vs 33.23 ± 11.7 min; p < 0.001), while anesthesia times were longer for both unilateral repair (57.67 ± 10.1 min vs 40.62 ± 11.9 min; p < 0.001) and bilateral repairs (65.95 ± 12.5 min vs 56.35 ± 15.1 min; p < 0.001). LPEC significantly reduced the risk of metachronous contralateral hernia (MCLH) (0.52% vs 9.29%; p < 0.001), but the recurrence rate was higher (0.21% vs 0.04%; p = 0.002) than OH. Orchiectomy due to testicular atrophy or torsion was required in 3 cases of OH (0.19%), whereas it was not seen in LPEC.

CONCLUSIONS

LPEC had a less risk of MCLH and testicular complications but was associated with a higher recurrence rate and longer anesthesia time. Propensity scoring techniques can enhance the robustness of retrospective comparisons between groups over several years of data collection, which is frequently required in pediatric surgery studies.

Establishment of Single-Port, Laparoscopic, Pediatric Hernia Repair in a Developing Country

Background: Single-port, laparoscopic, needle-assisted, inguinal hernia repair (LNAR) in children intends to reduce surgical trauma and enables contralateral assessment and closure of contralateral patent processus vaginalis if necessary. The aim of the present study was to demonstrate that laparoscopic inguinal repair can be performed safely and cost-effectively in a developing country where laparoscopy is not yet commonly used. Methods: In this single-center study, we included all children undergoing LNAR between January 2017 and December 2018. Intraoperative and postoperative complications and hospital costs were assessed. Results: We performed 148 hernia repair operations in 117 children (age range 1 month to 15 years). Mean operative time was 20.8 ± 9.4 minutes. Mean length of hospital stay amounted to 10 ± 7.6 hours, with 77.7% of patients discharged within 6 hours. No intraoperative complications occurred in any patient. Complications occurred in six (5.1%) patients. Three (2.5%) patients experienced residual hydrocele, two (1.4%) patients suffered wound site seroma, and one (0.67%) patient experienced recurrent inguinal hernia 6 months after the initial repair. All complications occurred during the first year of the study period. Likewise, operative time (P < .0001) as well as duration of hospital stay (P < .0001) was significantly shorter in the second year. Total costs for complete treatment were below USD 80 per patient, which is comparable with the costs associated with open herniotomy at the same institution. Conclusion: Single-port LNAR and hydrocele repair in children were established safely and cost-effectively in a developing country. Nevertheless, the procedure was associated with a steep learning curve.

Is it worth to explore the contralateral side in unilateral childhood inguinal hernia?: A PRISMA-compliant meta-analysis

BACKGROUND

It is still not clear if the contralateral side should be explored in children with unilateral inguinal hernias. The primary aim of the present study was to assess the incidence of metachronous contralateral inguinal hernias (MCIHs) in the pediatric population. The second aim was to assess factors associated with increased risk of MCIH development.

METHODS

Prospective studies including patients from 0-19 years undergoing unilateral inguinal hernia repair without surgical exploration of the contralateral side between 1947 and April 2020 with a minimal follow-up of one year were searched. Searches included EMBASE, MEDLINE, and the Cochrane Central Register of Controlled Trials.

RESULTS

Seven studies involving 1774 children (1452 boys (82%) and 322 girls (18%) were identified. Overall the incidence of MCIH was 6%. Incidence of MCIH development was significantly higher in children with initial left-sided (9%) versus right-sided (3%) hernia (OR 2.55 with 95% CI from 1.56 to 4.17; P = 0.0002), in female (8%) versus male (4%) children (OR 1.74 with 95% CI from 1.01 to 3.01; P = 0.0469) and in patients with open (14%) versus closed (3%) contralateral processus vaginalis (CPV) (OR 4.17 with 95% CI from 1.25 to 13.9; P = 0.0202). There was no significant difference in MCIH development depending on follow-up duration (follow-up of ≤2 years (i.e. 1-2 years): calculated MCIH incidence 5% (95% CI from 0.00 to 0.11%; 3 studies; 569 patients), follow-up of ≥3 years (i.e. 3-4 years): 6% (95% CI from 0.03 to 0.09; 3 studies, 983 patients)) or patients' age (MCIH incidence in children <1 year: 6.9%; older children: 4.5%; OR 1.87 with 95% CI from 0.97 to 3.62; P = 0.0618).

CONCLUSIONS

Overall incidence of MCIH development is 6%. Initial left-sided hernia, female gender and open CPV are risk factors for MCIH development.

Percutaneous hernia repair in children: Safe to introduce

BACKGROUND AND OBJECTIVE

In 2014 we introduced percutaneous internal ring suture as an alternative to open surgery for the treatment of inguinal hernia. This study aims to evaluate the introduction of the procedure at our institution.

METHODS

In total, 100 consecutive patients operated with percutaneous internal ring suture were compared with 100 consecutive patients operated with open surgery. The patients were operated from August 2014 until November 2017. Patient demographics, clinical history, operative time, time in theater, and postoperative complications were extracted from charts.

RESULTS

The mean operative time for percutaneous internal ring suture was 26.54 min and for open surgery 39.94 min, P < 0.0001. The total mean operative theater time for percutaneous internal ring suture was 108.95 min and for open surgery 118.4 min, P = 0.0343. During follow-up, two percutaneous internal ring sutures were operated for recurrent hernia. In the open surgery-group, three patients were operated for recurrent hernia, three for secondary testicular retention, and three for metachronous contralateral hernia.

CONCLUSIONS

Even when established as a new technique, the percutaneous internal ring suture procedure is safe and results in shorter operative time and shorter theater time compared to open surgery.

Short-term outcomes of pediatric laparoscopic inguinal hernia repair in Korea based on Korean Health Insurance Big Data: 2011-2015

PURPOSE

For pediatric inguinal hernia repairs (IHRs), open IHR (high ligation) has long been a gold standard. Recently laparoscopic IHR (LIHR) was introduced as a new treatment modality and has been performed more frequently in Korea. Unlike adults, LIHR in children is still controversial. In the present study, we investigate the short-term outcomes of pediatric LIHR in Korea using nationwide inpatient data.

METHODS

We analyzed clinical practice for IHRs from 2011 to 2015 using Korean Health Insurance Review and Assessment Service-National Inpatient Sample.

RESULTS

A total of 5281 patients 15 years old or younger underwent 5356 IHRs: 4507 OIHRs and 849 LIHRs. M:F ratio was 2.4:1. The proportion of LIHRs was only 1.8% at the beginning but had been continuously increased up to 29.8% at the end of the study period. LIHRs were closely related to synchronous bilateral inguinal hernia repairs (SBIHRs). Overall, SBIHRs were performed in 10.9% of open and 49.2% of LIHRs. Metachronous contralateral IHRs (MCIHRs) after initial unilateral IHRs were significantly more frequent after OIHRs (1.7%, 69/3, 951) than after LIHRs (0.2%, 1/427). Recurrence rate per side during study period was 0.1% (6/4, 993) after OIHRs and 0.2% (2/1, 259) after LIHRs, respectively (statistically insignificant).

CONCLUSION

Nationwide inpatient data showed that LIHRs in pediatric patients had recently been increasingly performed in Korea. LIHRs facilitated SBIHRs, which, in turn, decreased the needs of MCIHRs. However limited numbers of patients might actually have benefited from them. Early recurrence after primary IHRs in children is quite low regardless of way of approach.

Transinguinal laparoscopic evaluation of contralateral side during unilateral inguinal hernia repair for children

BACKGROUND

Inguinal hernia repair is a common procedure in daily pediatric surgical practice.

OBJECTIVES

The present study was planned to find out whether transinguinal laparoscopic exploration (TILE) of the contralateral groin is effective in reducing the need of operation for contralateral metachronous inguinal hernia (CMIH) in children.

STUDY DESIGN

Charts of 1103 children who underwent inguinal hernia repair between 2006 and 2016 were retrospectively analyzed. Eighty-eight children with bilateral hernia at the presentation were excluded, and 705 patients whose parents could be contacted by phone to get the latest information about children's condition were included in the study.

RESULTS

Of the 705 children with unilateral inguinal hernia repair, 362 (51.4%) and 343 (48.6%) of them had right-sided and left-sided inguinal hernia, respectively. Transinguinal laparoscopic exploration was performed in 479 of the 705 children with unilateral hernia and a hernia or contralateral patent processus vaginalis (PPV) was found and ligated in %28.3 (n = 136) of them. Mean follow-up time was 60 ± 36 months. Fifteen (4.3%) of 479 patients who had TILE and 31 (13.6%) of 226 the patients who did not have TILE developed CMIH. When the videos of 15 patients who developed CMIH were reviewed, overlooked PPV was found in 10 (3.3%) patients who had TILE during early phases of institutional learning curve.

DISCUSSION AND CONCLUSIONS

TILE of the contralateral side during pediatric inguinal hernia repair is a simple and effective method to evaluate contralateral PPV. This approach clearly and significantly reduces the need of operation for a metachronous hernia at a later date.

The clinical significance of an incidentally detected open internal inguinal ring

INTRODUCTION AND OBJECTIVE

An open internal inguinal ring (IIR) may be discovered incidentally either in the context of correcting pathology involving the contralateral side or at the time of surgical exploration for reasons unrelated to a patent processus vaginalis (PPV). The aim of this study is to determine the evolution of an incidentally encountered open IIR in patients undergoing laparoscopy for reasons not associated with unilateral inguinal hernia or cryptorchidism.

MATERIALS AND METHODS

The authors conducted a prospective study of all patients who underwent laparoscopic surgery in the department of pediatric surgery at Agios Loukas hospital between 2004 and 2013 for various indications. Patients operated for inguinal hernia and cryptorchidism were excluded. During this period, 572 patients underwent laparoscopy for reasons not related to PPV. The median age at time of initial laparoscopy was 9,4 years (range 2 days-16 years). The IIRs were always inspected. No attempt was made to repair the open IIRs, as they were asymptomatic. Parents were informed after the operation, and instructions were given to inform us, in case that inguinal hernia symptoms manifested. The duration of the follow-up was 4 years.

RESULTS

Among these 572 patients, 39 patients with 44 open IIRs were found (6,82%). From the 39 patients, 35 were male and four were female; 22 had a right open IIR, 12 had a left one, and five of them a bilateral open IIR. The median age was 7,82 years (3-14 years). Four patients were lost during follow-up. Of the remaining 35 patients with 40 open IIRs, four developed an inguinal hernia (11,43%) and were operated on with laparoscopically assisted (subcutaneous endoscopically assisted ligation [SEAL]) technique at the time of diagnosis. The study results are demonstrated on Fig. 1.

DISCUSSION

The percentage of an incidentally discovered open IIR in this study is lower in comparison with studies including patients with PPV pathologies. There is a possibility, in those patients, of underlying pathology which can affect both sides. It is also lower in comparison with previous studies including younger patients. However, gender and side predominance is in accordance with most published studies. In this study group, the possibility of developing a symptomatic hernia from an asymptomatic open IIR is rather small.

CONCLUSIONS

An incidentally discovered open IIR in patients without symptoms, excluding those with contralateral inguinal hernias or cryptorchidism, has relatively low chance of developing an inguinal hernia. Thus, the authors support the strategy of close follow-up in these patients.

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.

Variation in the use of laparoscopy with inguinal hernia repairs in a sample of pediatric patients at children's hospitals

INTRODUCTION/BACKGROUND

Metachronous contralateral inguinal hernias (MCH) occur in approximately 10% of pediatric patients following unilateral inguinal hernia repairs (UIHR). Laparoscopic evaluation of the contralateral internal ring is a method of identifying high-risk individuals for prophylactic contralateral exploration and repair.

OBJECTIVE

The objective of this study was to assess variation in utilization of diagnostic laparoscopy, and report costs associated with the evaluation of a contralateral patent processus vaginalis during hernia repair in pediatric hospitals.

STUDY DESIGN

The Pediatric Health Information System database was searched to identify outpatient surgical encounters for pediatric patients with a diagnosis of inguinal hernia during a 1-year period (2014). Records were identified that contained diagnostic codes for unilateral or bilateral inguinal hernia in combination with a procedure code for open hernia repair with or without diagnostic laparoscopy.

RESULTS

After exclusions there were 3952 hernia repairs performed at 30 hospitals; median age was 4 years (IQR 1-7), 78.8% were male, and 64.9% Caucasian. Three-quarters (76.7%) had UIHR, 8.6% had unilateral repairs with laparoscopy (UIHRL), 12.2% had bilateral inguinal hernia repairs (BIHR), and 2.4% had bilateral repairs with laparoscopy (BIHRL). Where laparoscopy was used, 78% resulted in a unilateral repair and 22% in a bilateral procedure. The percent of patients undergoing laparoscopy varied from 0 to 57% among hospitals, and 0-100% among surgeons. Pediatric surgeons were more than three times more likely to perform a diagnostic laparoscopy compared with pediatric urologists. Median adjusted costs were $2298 (IQR 1659-2955) for UIHR, $2713 (IQR 1873-3409) for UIHRL, $2752 (IQR 2230-3411) for BIHR, and $2783 (IQR 2233-3453) for BIHRL. Median costs varied over two-fold among hospitals ($1310-4434), and over four-fold among surgeons ($948-5040).

DISCUSSION

Data suggested that <10% of patients with clinically unilateral inguinal hernias developed MCH. A negative diagnostic laparoscopy ensured that 0.9-1.31% developed MCH. However, up to 30% of patients underwent contralateral exploration/repair when diagnostic laparoscopy was used. The current study found increased costs associated with the use of laparoscopy, with considerable variation in costs among surgeons and hospitals. These data elucidate competing financial and clinical consequences associated with the use of diagnostic laparoscopy with clinically unilateral hernias.

CONCLUSIONS

Variation existed in the use of laparoscopy during inguinal hernia repairs and associated costs within the current sample from children's hospitals in the United States. The additional costs of laparoscopic evaluation must be considered against the clinical utility and therapeutic consequences of identifying individuals with a higher risk of metachronous contralateral inguinal hernia.

Pre-operative Spermatic Cord Ultrasonography Helps to Reduce the Incidence of Metachronous Inguinal Hernia in Boys

Background/purpose: Thickening of the spermatic cord is a clinical sign of an inguinal hernia. We therefore tested whether pre-operative spermatic cord ultrasonography could reduce the incidence of metachronous inguinal hernia (MIH). Methods: Boys under 2 years old with an initial unilateral inguinal hernia were enrolled in this study. In whom the width of the asymptomatic-sided spermatic cord was ≥0.5 cm, these patients underwent contralateral groin exploration. Age at initial operation, weight, initial operation side, the sonographic width of the spermatic cord, the operative findings and presence of MIH were recorded, and the relationship among them was studied. Boys in the US group underwent an open herniorrhaphy with pre-operative ultrasound examination; the non-US group included boys who did not undergo a pre-operative ultrasound examination. A receiver operator curve (ROC) analysis was performed to evaluated predictive value of the sonographic width of the spermatic cord for contralateral hernia. Results: A total of 24 months' follow-up data were obtained from 1,793 boys (US group 1,162, non-US group 631). In the US group, the width of the hernia-sided spermatic cord (0.75 ± 0.18 cm) was larger than the normal side (0.37 ± 0.05 cm, P < 0.001). And the width of normal side spermatic cord had no significant difference between the groups regarding other factors such as age and weight. In whom the width of the asymptomatic-sided spermatic cord was ≥0.5 cm, the corresponding incidence of CIH was 86.4% (57/66). The width of the spermatic cord predicted the presence of contralateral hernia with ROC area under the curve = 0.943 (95% CI = 0.919-0.966). The total incidence of MIH was 4.1% (74/1793). The incidence of MIH in the US group was 2.2% (25/1162) much lower than 7.8% (49/631) in the non-US group (P < 0.001). If the width of the asymptomatic-sided spermatic cord was 0.5 cm and 0.54 cm, the corresponding sensitivity was 0.682 and 0.294, respectively, the corresponding specificity was 0.991 and 1.000, respectively. Conclusion: If the width of the asymptomatic-sided spermatic cord of boys with initial unilateral inguinal hernia sonographic width was ≥0.5 cm, contralateral groin exploration was recommended, and it help to reduce the incidence of MIH.

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.

A systematic review of the quality of conduct and reporting of systematic reviews and meta-analyses in paediatric surgery

OBJECTIVE

Our objective was to evaluate quality of conduct and reporting of published systematic reviews and meta-analyses in paediatric surgery. We also aimed to identify characteristics predictive of review quality.

BACKGROUND

Systematic reviews summarise evidence by combining sources, but are potentially prone to bias. To counter this, the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) was published to aid in reporting. Similarly, the Assessing the Methodological Quality of Systematic Reviews (AMSTAR) measurement tool was designed to appraise methodology. The paediatric surgical literature has seen an increasing number of reviews over the past decade, but quality has not been evaluated.

METHODS

Adhering to PRISMA guidelines, we performed a systematic review with a priori design to identify systematic reviews and meta-analyses of interventions in paediatric surgery. From 01/2010 to 06/2016, we searched: MEDLINE, EMBASE, Cochrane, Centre for Reviews and Dissemination, Web of Science, Google Scholar, reference lists and journals. Two reviewers independently selected studies and extracted data. We assessed conduct and reporting using AMSTAR and PRISMA. Scores were calculated as the sum of reported items. We also extracted author, journal and article characteristics, and used them in exploratory analysis to determine which variables predict quality.

RESULTS

112 articles fulfilled eligibility criteria (53 systematic reviews; 59 meta-analyses). Overall, 68% AMSTAR and 56.8% PRISMA items were reported adequately. Poorest scores were identified with regards a priori design, inclusion of structured summaries, including the grey literature, citing excluded articles and evaluating bias. 13 reviews were pre-registered and 6 in PRISMA-endorsing journals. The following predicted quality in univariate analysis:, word count, Cochrane review, journal h-index, impact factor, journal endorses PRISMA, PRISMA adherence suggested in author guidance, article mentions PRISMA, review includes comparison of interventions and review registration. The latter three variables were significant in multivariate regression.

CONCLUSIONS

There are gaps in the conduct and reporting of systematic reviews in paediatric surgery. More endorsement by journals of the PRISMA guideline may improve review quality, and the dissemination of reliable evidence to paediatric clinicians.

Complications in common general pediatric surgery procedures

Complications related to general pediatric surgery procedures are a major concern for pediatric surgeons and their patients. Although infrequent, when they occur the consequences can lead to significant morbidity and psychosocial stress. The purpose of this article is to discuss the common complications encountered during several common pediatric general surgery procedures including inguinal hernia repair (open and laparoscopic), umbilical hernia repair, laparoscopic pyloromyotomy, and laparoscopic appendectomy.

Incidence of and Risk Factors for Pediatric Metachronous Contralateral Inguinal Hernia: Analysis of a 17-Year Nationwide Database in Taiwan

Background

Previous prospective, retrospective, and meta-analysis studies revealed that the overall incidence of metachronous contralateral inguinal hernia (MCIH) ranges from 5.76% to 7.3%, but long-term follow-up postoperative data are scant. We identified the incidence and risk factors of MCIH in pediatric patients during the follow-up using the Taiwan National Health Insurance Research Database (NHIRD).

Methods

Between 1996/01/01 and 2008/12/31, all pediatric patients with primary unilateral inguinal hernia repair who were born after 1996/01/01 were collected via ICD-9 diagnostic and procedure codes recorded in NHIRD. Patients with another operation during the same admission, complicated hernia, or laparoscopic procedure were excluded. Several reported risk factors, including age, sex, preterm birth, low body weight, and previous ventriculoperitoneal shunt placement, were used for analysis. The primary endpoint was the repairmen of MCIH following the initial surgery. All patients were followed until 2013/12/31 or withdrawal from national health insurance.

Results

A total of 31,100 pediatric patients underwent unilateral inguinal hernia repair, and 111.76 months of median follow-up data were collected. The overall rate of MCIH was 12.3%. Among the 31,100 patients who had the hernia repair, 63.6% had MCIH within 2 years and 91.5% had MCIH within 5 years. After initial surgery, the incidence of MCIH gradually and significantly decreased with age up to approximately 6 years. Multivariable analysis showed that age <4 y and girls were risk factors for subsequent MCIH.

Conclusions

After 17 years of follow-up, the overall MCIH rate was 12.3%, and 91.7% of patients needed repair for MCIH within the first 5 years after initial surgery. Age <4 years and girls were risk factors for MCIH. The contralateral exploration for inguinal hernia should be considered among these patients.

Long-Term Outcome of Low Scrotal Approach Orchiopexy without Ligation of the Processus Vaginalis

PURPOSE

We performed low scrotal approach orchiopexy in patients with prescrotal cryptorchidism. The processus vaginalis was not ligated if it was not widely patent. We retrospectively evaluated the long-term outcomes of low scrotal approach orchiopexy without processus vaginalis ligation.

MATERIALS AND METHODS

A total of 137 patients (227 testes) were diagnosed with prescrotal cryptorchidism between October 2009 and April 2014. All patients underwent low scrotal approach orchiopexy. Mean age at surgery was 34.9 months. The processus vaginalis was deemed to be not widely patent when a sound could not be passed into the abdominal cavity through the internal inguinal ring, and the processus vaginalis was not ligated in such cases.

RESULTS

Intraoperative findings revealed that the processus vaginalis was widely patent in 10 testes and was not widely patent in 217. A widely patent processus vaginalis was closed via scrotal approach in 5 testes, while an inguinal approach was necessary in 5. Median followup was 44 months (range 20 to 73). Postoperative complications included reascending testis in 1 case where an inguinal approach was necessary. No patient manifested testicular atrophy or inguinal hernia.

CONCLUSIONS

Low scrotal approach orchiopexy is a useful and safe procedure for treating patients with prescrotal cryptorchidism. Ligation is unnecessary when the processus vaginalis is not widely patent.