Pediatric Hernias

Ultrasound-Guided Epigastric Hernia Repair in the Pediatric Population: One Institution's Experience and Outcomes

Introduction: Epigastric hernia repair is a common procedure performed on pediatric patients. These hernias have been demonstrated to be readily identified by ultrasound. This manuscript describes and assesses a novel technique in which ultrasound is used to identify and repair the hernias in a minimally invasive manner. Methods: A retrospective chart review evaluates all the ultrasound-guided epigastric hernia repairs done with prolene suture at one institution over 20 months. Operative details and postoperative complications were compared to patients who underwent traditional open epigastric hernia repair at the same institution during the same time frame. Results: Thirty-two pediatric patients underwent epigastric hernia repair between May 2021 and December 2022. Thirteen (41%) underwent the ultrasound-guided technique with prolene suture and using only a meniscus needle and no incision. Nineteen (59%) underwent standard open repair. There were no recurrences or postoperative complications in either group. The average operative time for the ultrasound hernia repair was 24.4 minutes, which was shorter than the average operative time of 33.6 minutes for the open repair (P = .08). In 3 ultrasound cases (23%), an additional epigastric hernia that had not been clinically apparent was identified and simultaneously repaired. Conclusions: Ultrasound-guided epigastria hernia repair is a feasible alternative to traditional open repair. It has a comparable safety and efficacy profile, has a short operative time, and has the advantages of being minimally invasive and having the ability to identify and repair concurrent epigastric hernias.

No Reason to Use Mesh in Groin Hernia Repair in Adolescents

Groin hernias are common and hernia repair is one of the most frequent surgical procedures performed worldwide. Despite this, there is no international guideline on the management of groin hernias in adolescents. Mesh reinforcement is used for repair in adults but not in young children. Adolescents, positioned between these age groups, pose unique challenges for surgeons due to their varying growth patterns. Placing a synthetic mesh in growing patients is a concern, particularly in relation to chronic pain. Traditionally, the hernia literature has defined adults as individuals aged 18 years and above. Considering that growth can continue until age 19, this review proposes a revised definition of adolescence for patients with groin hernias encompassing ages 10 to 19. Symptomatic groin hernias in adolescents should be repaired with an open non-mesh technique because of acceptable recurrence rates and the desire to avoid introducing synthetic foreign materials into young patients with ongoing growth potential. Watchful waiting is suggested for asymptomatic groin hernias, postponing repair until the adolescent has become a fully grown adult and symptoms from the hernia develop. Most groin hernias in adolescents are lateral hernias, but before pursuing a watchful waiting strategy in females, an ultrasound or magnetic resonance imaging scan is suggested to rule out the presence of a femoral hernia that may need repair.

Introduction of pediatric laparoscopic inguinal hernia repair in Guatemala

PURPOSE

Introducing new surgical techniques in a developing country can be challenging. Inguinal hernias in children are a common surgical problem, and open repair is the standard surgical approach. Laparoscopic repair has gained popularity in developed countries because of similar results. This study aimed to determine the outcomes following the introduction of laparoscopic repairs in Guatemala.

METHODS

This retrospective analysis of prospectively collected data from all patients under 18 years who underwent laparoscopic repair at Corpus Christi Hospital in Patzun, Guatemala, from September 5th to September 8th, 2022.

RESULTS

A total of 14 patients were included in the study. A board-certified pediatric surgeon and a Guatemalan physician performed all cases. The mean patient age was 7.6 years; 7 boys and 7 girls. All patients were interviewed at 7 days, 30 days, and 6 months. There were no postoperative infections, pain requiring re-evaluation, gonadal atrophy, or hernia recurrence.

CONCLUSION

Under controlled circumstances with limited but proper equipment and disposables, laparoscopic inguinal hernia repairs can be introduced and performed in a developing country with a risk complication profile comparable to that in developed countries. This study provides promising evidence of laparoscopic repair feasibility and safety where surgical resources are limited.

Incarcerated Richter's congenital umbilical hernia in a young male: A case report

INTRODUCTION AND IMPORTANCE

Richter's hernia is a protrusion of a portion of the circumference of anti-mesenteric side of intestine through the fascial defect. It is a rare type of hernia and typically occurs in elderly patients. Richter's hernia could result in grave complications. The objective of the study was to describe a rare case of incarcerated Richter's congenital umbilical hernia in a 20-year-old male patient.

CASE PRESENTATION

A 20-year-old male presented with a complaint of intermittent crampy peri-umbilical pain of three days duration associated with non-reducible umbilical bulge and vomiting. On examination, there was 4 cm by 4 cm oval, firm, tender, non-reducible mass over the umbilical area without cough impulse. He was kept nothing per os, broad spectrum antibiotic started, consent taken & operated. A loop of the ilium which was mildly ischemic found in the hernia sac. Sac and entrapped intestine were thoroughly cleaned with warm saline and reduction and herniorrhaphy done. The client discharged on the 2nd postoperative day.

CLINICAL DISCUSSION

There have been very few reports of Richter's congenital umbilical hernia. Richter's hernia progresses more rapidly to gangrene than other strangulated hernias however patients often have no intestinal obstruction. Raised suspicion therefore is important to take timely surgical intervention before the disease advance and complications occurred.

CONCLUSION

Richter's hernia has subclinical symptoms and late presentation which could result in grave complications and increased mortality. The early decision for surgery has paramount importance in reducing complication and associated mortality.

Analysis of the efficacy of laparoscopic high hernia sac ligation in adolescent indirect hernia

OBJECTIVE

Inguinal hernias are a common disease that may present at all ages. Adolescents are a unique patient population between children and adults. The etiology and the surgical treatment strategies of adolescent indirect hernias are not clear. Specifically, whether these kinds of hernias should be treated by high ligation or mesh repair remains controversial. We aimed to evaluate the efficacy of laparoscopic high hernia sac ligation in adolescent indirect hernia.

METHODS

The data of adolescent patients who underwent laparoscopic high hernia sac ligation at the The First People's Hospital of Foshan,China, from January 2012 to December 2019 were analyzed retrospectively. Data collected included their age, gender, weight, surgical method, hernia ring diameter, operation time, postoperative recurrence rate and postoperative complications.

RESULTS

A total of 70 patients were enrolled, including 61 males (87.14%) and 9 females (12.86%),all patients were aged 13-18 years old (mean 14.87 ± 1.56years), weighed 28-92 kg (mean 53.04 ± 10.60 kg). All 70 patients underwent laparoscopic surgery except 2 patients with irreducible hernias who converted to laparotomy.The hernia ring diameter ranged from 0.5 to 3 cm (mean 1.39 ± 0.49 cm), and was ≤ 2 cm in 68 cases (97.14%).The operative length ranged from 12 to 105 min (average 24.96 ± 12.61 min), There were 37(52.9%) right-sided hernias, 32 (45.7%) left-sided hernias, 1 (1.4%) bilateral hernia.There were 67(95.7%)reducible hernias,2(2.9%)irreducible hernias ,and 1(1.4%)incarcerated hernia.Hospital stays ranged from 1 to 5 days (mean 2.37 ± 1.05 days). Follow-ups were performed from 30-119months (mean 74.27 ± 28.14months). There were no cases of recurrence, howere, incision infection occured in 1 patient, who underwent a second operation 6 months after surgery, and 4 (5.7%) patients had complaints of intermittent pain around the ligation incision site, mostly during exercise .

CONCLUSION

Laparoscopic high hernia sac ligation is feasible for treatment of adolescent indirect hernias with a hernia ring diameter of ≤ 2 cm.

Epigastric hernias in children and the use of ultrasound in its diagnosis

Introduction

There is a paucity of clinical data on pediatric epigastric hernias despite them accounting for up to 6% of all hernia repairs in children. We aimed to provide additional data to supplement those 117 cases of a recent systematic review and to further clarify the role of ultrasound in diagnosing pediatric epigastric hernia.

Methods

We retrospectively included all 60 patients treated for epigastric hernias in children in two tertiary pediatric surgical departments within 12 years. Associations were tested via point-biserial correlation analyses.

Results

Epigastric hernias primarily affected preschool children with a median age of 39 months. The vast majority of patients (88%) presented with swelling that was occasionally (30%) accompanied by pain. Fascial defects could be found during clinical examination in 45% of patients with a median size of 5 mm (95% CI 3 to 10). Smaller defects were less likely to be palpable (r=−0.44, 95% CI −0.08 to −0.7, p=0.021). Likewise, ultrasound was used more frequently with smaller fascial defect sizes (r=−0.51, 95% CI −0.16 to −0.74, p=0.007). Laparoscopic repair was used in 11 patients (19%) and more often (4/11) in combination with another simultaneous procedure than open repair (11/48).

Conclusions

Epigastric hernias are primarily a condition of the preschool child. Ultrasound can be beneficial if the diagnosis cannot be made clinically; otherwise, it is abdicable if it does not change the management of the patient’s epigastric hernia. Laparoscopic repairs might be beneficial for children with multiple defects or simultaneous procedures.

Metachronous Contralateral Occurrence of Hydrocele After Unilateral Hydrocelectomy in Children Younger Than 8 Years

BACKGROUND

Hydrocele on the contralateral side after surgical repair is an uncommon condition compared to surgical site recurrence. Although there has been much research on metachronous contralateral inguinal hernia in children, metachronous contralateral hydrocele, which share a common pathology with inguinal hernias, has not yet been investigated. We have investigated the incidence and risk factors for metachronous contralateral occurrence of communicating and noncommunicating hydroceles in children younger than 8 years.

METHODS

From January 2017 to June 2020, 302 children younger than 8 who were diagnosed with unilateral hydroceles were treated in our hospital without surgical exploration of contralateral hydrocele. The disease was classified into communicating and noncommunicating hydroceles. We divided patients into two groups according to the presence of metachronous contralateral hydrocele and analyzed the differences between the two groups.

RESULTS

Among 302 patients, the mean age was 36.4 ± 20.9 months. Metachronous contralateral hydrocele occurred in 15 (4.9%) patients as communicating hydroceles. Comparison between the two groups showed statistically significant differences in type of hydrocele (P = 0.047) at first diagnosis.

CONCLUSION

Clinically evident risk of metachronous contralateral hydrocele after unilateral hydrocelectomy was 4.9%. Despite the relatively low incidence rate, the risk of metachronous contralateral occurrence should always be consulted with parents before surgical treatment of hydroceles.

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.

Sutureless versus purse string with complete sac dissection in laparoscopic inguinal hernia repair in children: a randomized clinical trial

Introduction

Pediatric inguinal hernia is a common surgical condition with a cumulative incidence of 4.2%. Minimal invasive surgery is playing a growing role in the treatment of this condition. We compared the outcomes of laparoscopic sutureless herniotomy and purse string with sac dissection repair with regards to complications and operative time.

Methods

One hundred fifty-two patients were operated on in two centers with two different techniques: sac dissection and purse-string suture, and sutureless repair. Operative time and recurrence were the main outcomes for comparison.

Results

Sutureless repair has a shorter operative time (29 ± 10 min) compared to purse string repair (38 ± 13 min). The recurrence rate showed no statistical significance difference. However, the recurrence rate of sutureless repair was three times higher than that of purse string repair, and all recurrences were in large defects of 10–15 mm.

Conclusions

Sutureless repair is safe for defects up to 10 mm with excellent operative time. However, it had an unfavorable outcome in larger defects.

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

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

Adolescent inguinal hernia repair: a review of the literature and recommendations for selective management

BACKGROUND

The choice of how to repair inguinal hernias in adolescents has historically been a matter of experience and differed between pediatric surgeons who traditionally performed a high ligation of the sac and general surgeons who typically perform a repair using mesh. This up-to-date review thoroughly examines the subject and discusses the suitability of both types of repairs in this unique age group.

METHODS

A 20-year Pub Med search was performed for the following terms: adolescent hernia repair including reports of mesh hernia repair in adolescents and postoperative complications including chronic inguinal pain and recurrences.

RESULTS

The evidence in the literature suggests that while there appears to be no difference between the two types of repairs with regards to recurrence and complications, changes in the pelvic floor physiology in adolescents suggest that a selective, individualized approach can be recommended depending on the size and nature of the presenting pathology.

CONCLUSIONS

A selective approach to the inguinal hernia in adolescent patients based on the size of the defect appears justified.

Comparison of Surgical Outcomes of Laparoscopic Glue and Laparoscopic Suture Hernioplasty in Pediatric Female Inguinal Hernia

This study aimed to report the surgical outcomes of laparoscopic glue hernioplasty (LGH) compared with conventional laparoscopic suture hernioplasty (LSH) in pediatric female inguinal hernia repair. We retrospectively analyzed 465 female pediatric patients who underwent laparoscopic inguinal hernia repair between January 2013 and December 2020. LGH and LSH were performed in 95 and 370 cases, respectively. Surgical outcomes (length of hospital stay, operative time, complications, and recurrences) were compared between the LGH and LSH groups. We found that the operation times for bilateral hernia repair were shorter in the LGH group (LGH: 35.5 ± 8.2 min, LSH: 45.2 ± 11.6 min; p < 0.001). No significant differences in complications or recurrences were observed between the two groups during the follow-up period. Our findings suggest that LGH is a feasible and easily applied surgical technique for the treatment of pediatric female inguinal hernia.

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.

OUP accepted manuscript

Incarceration of an umbilical hernia (UH) rarely occurs in the pediatric population. They usually resolve spontaneously or are treated after the child turns 4–5 years old [1, 2]. Risk factors for incarceration have been identified, but little is understood about how incarceration of an UH occurs.

Laparoscopic surgery: an effective and safe surgical method of pediatric inguinal hernia repair

Purpose

Inguinal hernia (IH) repair is very commonly performed in children. While open repair (OR) is the standard approach, laparoscopic repair is increasingly used. This study was aimed to investigate safety and feasibility of laparoscopic repair of pediatric IH compared to OR.

Methods

We retrospectively enrolled 105 pediatric patients with IH repair between January 2011 and October 2019. The laparoscopic procedures performed were laparoscopic percutaneous extraperitoneal closure (LPEC), and three-port mini-laparoscopic repair (TLR). The OR was performed as per usual technique.

Results

Thirty-nine patients underwent OR, 16 LPEC, and 50 TLR. The preoperative laterality of IH was 45 patients (42.9%) on the right side, 50 (47.6%) on the left side, and 10 (9.5%) on both sides. It was, however, diagnosed postoperatively in 27 patients (25.7%) on the right side, 38 (36.2%) on the left side, and 40 (38.1%) on both sides. Of the 63 patients who presented with unilateral IH in the laparoscopic groups, 32 (50.8%) had synchronous contralateral patent process vaginalis (PPV) which were simultaneously repaired. This was significantly more common in children under 3 years of age. Operative time in unilateral or bilateral repair was significantly shorter in the laparoscopic repair groups (p < 0.001). Ipsilateral recurrence was not observed in any group. Metachronous contralateral IH occurrence was not significantly different between groups.

Conclusion

Laparoscopic IH repair may have benefit in terms of shorter operation time and diagnosis of unpredicted contralateral PPV compared to OR.

A joint analysis using exome and transcriptome data identifiescandidate polymorphisms and genes involved with umbilical hernia in pigs

BACKGROUND

Umbilical Hernia (UH) is characterized by the passage of part of the intestine through the umbilical canal forming the herniary sac. There are several potential causes that can lead to the umbilical hernia such as bacterial infections, management conditions and genetic factors. Since the genetic components involved with UH are poorly understood, this study aimed to identify polymorphisms and genes associated with the manifestation of umbilical hernia in pigs using exome and transcriptome sequencing in a case and control design.

RESULTS

In the exome sequencing, 119 variants located in 58 genes were identified differing between normal and UH-affected pigs, and in the umbilical ring transcriptome, 46 variants were identified, located in 27 genes. Comparing the two methodologies, we obtained 34 concordant variants between the exome and transcriptome analyses, which were located in 17 genes, distributed in 64 biological processes (BP). Among the BP involved with UH it is possible to highlight cell adhesion, cell junction regulation, embryonic morphogenesis, ion transport, muscle contraction, within others.

CONCLUSIONS

We have generated the first exome sequencing related to normal and umbilical hernia-affected pigs, which allowed us to identify several variants possibly involved with this disorder. Many of those variants present in the DNA were confirmed with the RNA-Seq results. The combination of both exome and transcriptome sequencing approaches allowed us to better understand the complex molecular mechanisms underlying UH in pigs and possibly in other mammals, including humans. Some variants found in genes and other regulatory regions are highlighted as strong candidates to the development of UH in pigs and should be further investigated.

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.

Clinical regression of inguinal hernias in premature infants without surgical repair

BACKGROUND

The incidence of inguinal hernias in premature infants is approximately 30%. Due to concerns about a high risk of incarceration, early repair is commonly performed. We present a series of patients whose families opted to delay repair until after 55 weeks corrected gestational age (GA) and experienced safe clinical regression of their hernias.

METHODS

Between June 2015 and July 2020, premature infants (< 37 weeks GA) diagnosed with inguinal hernias on physical examination were identified. Families of eligible infants were offered either immediate or delayed repair after 55 weeks corrected GA. Infants whose families elected to delay were followed until their hernia(s) clinically regressed, or until older than 55 weeks.

RESULTS

Families of 68 infants consented to delay repair. 23 infants (33.8%) had hernias that clinically regressed at median follow up from diagnosis of 14.1 weeks. Univariate analysis demonstrated female sex as a significant predictor of hernia clinical regression (OR: 3.08; p = 0.046). Of the 45 infants who underwent repair, 84.4% safely progressed to 55 weeks corrected GA prior to.

CONCLUSION

Delaying inguinal hernia repair in this series of premature infants until after 55 weeks corrected GA revealed that one third of hernias, especially in females, safely regressed upon follow-up examination.

DNA Methylation Alterations in Blood Cells of Toddlers with Down Syndrome

Recent research has provided evidence on genome-wide alterations in DNA methylation patterns due to trisomy 21, which have been detected in various tissues of individuals with Down syndrome (DS) across different developmental stages. Here, we report new data on the systematic genome-wide DNA methylation perturbations in blood cells of individuals with DS from a previously understudied age group—young children. We show that the study findings are highly consistent with those from the prior literature. In addition, utilizing relevant published data from two other developmental stages, neonatal and adult, we track a quasi-longitudinal trend in the DS-associated DNA methylation patterns as a systematic epigenomic destabilization with age.

Initial Experience with Robotic Inguinal Hernia Repair in the Adolescent Population

Purpose: There is no one standard procedure encompassing the needs and differences of the entire pediatric population for inguinal hernia repair (IHR). Several techniques can be used, including open repair, laparoscopic, and robotic-assisted laparoscopic repair. This is a report of a single pediatric hospital's experience performing robotic-assisted IHRs in an adolescent population. Methods: Robotic IHRs performed by the pediatric surgery department were prospectively captured and reviewed. The operation performed was a modified robotic transabdominal preperitoneal approach with ProGrip mesh. Results: Between January 2016 and August 2020, 11 robotic-assisted IHRs occurred. All patients were male, median weight interquartile range (IQR) was 76.6 kg (67.425-90.4 kg) and median age (IQR) was 17 years (17-18.5). All together median (IQR) total operative time was 111 (97.5-126) minutes, median (IQR) total console time was 60 (55.5-75.5) minutes. There were no complications or conversions, with all patients discharged on the day of the operation. Conclusion: This study demonstrates a safe and reliable approach to repairing inguinal hernias using robotics through a small initial case series. Robotic-assisted IHR should be considered a viable technique to optimize the surgical care of adolescents.

The role of scrotal ultrasonography from infancy to puberty

Background

Scrotal ultrasonography is an essential diagnostic tool in daily clinical practice. The availability of new‐generation ultrasound machines characterized by clearly improved image quality, low health cost, and higher patient safety, represents only some characteristics of ultrasound investigation. The usefulness of scrotal ultrasonography is particularly evident in the period of life from infancy to puberty, during which males undergo important morphofunctional changes, and several pathological conditions may occur.

Objectives

This pictorial review primarily aimed to investigate the aspects of ultrasonography related to the normal physiological development of the gonads from mini‐puberty to pubertal onset. This study also aimed to provide an update on the use of ultrasonography in main andrological pathologies that may occur during this period. The conditions that are discussed in depth are: cryptorchidism, inguinoscrotal hernias, and hydrocele in the neonatal phase; acute scrotum, epididymo‐orchitis, and testicular cancers in childhood; and hypogonadism, varicoceles, testicular microlithiasis, and oncohematological pathology in puberty.

Discussion

We provided an ultrasound slant for all the above‐mentioned pathologies while purposely avoiding excessive deepening of the pathogenetic, clinical, and therapeutic aspects. Studying the ultrasound aspects of the gonads also facilitates differential diagnosis between various conditions and represents a good aid in evaluating therapeutic success (e.g., in hypogonadism or postsurgical evaluation of varicoceles and cryptorchidism).

Conclusion

Scrotal ultrasonography is now globally recognized as the necessary completion of clinical–laboratory overview in gonads evaluation. This diagnostic procedure is even more indispensable in the infancy–childhood–puberty period for the evaluation of normal gonadal development as well as diagnosis of other possible diseases.

Inguinal hernia repair with or without mesh in late adolescent males

Purpose

Inguinal hernia repair is one of the most common treatments worldwide, but there are few studies about the use of mesh in late adolescent patients because hernias are rare in this group. This study aimed to evaluate the postoperative outcomes of hernia repair with and without mesh in late adolescent patients.

Methods

We retrospectively reviewed the data of 243 male patients aged between 18 and 21 years who underwent inguinal hernia repair at a single institution from January 2013 to December 2017. We distinguished 2 groups depending on the repair method; mesh (n = 121) and no-mesh (n = 122) groups. We compared the baseline characteristics, immediate postoperative outcomes, and recurrence and chronic pain rates between the 2 groups.

Results

There were no significant differences between the mesh and no-mesh groups on immediate postoperative outcomes (length of stay: 18.5 ± 8.9 days vs. 17.0 ± 6.0 days, P = 0.139; postoperative complications: 8.2% vs. 6.6%, P = 0.821) and 2-year recurrence rate (0.8% vs. 2.6%, P = 0.194). There was a significant difference in the chronic pain rate (9.0% vs. 1.7%, P = 0.023).

Conclusion

Using mesh for inguinal hernia repair in late adolescent male patients increases chronic postoperative inguinal pain.

High incidence of inguinal hernias among patients with congenital abdominal wall defects: a population-based case-control study

The aim of this nationwide population-based case-control study was to assess the incidence of inguinal hernia (IH) among patients with congenital abdominal wall defects. All infants born with congenital abdominal wall defects between Jan 1, 1998, and Dec 31, 2014, were identified in the Finnish Register of Congenital Malformations. Six controls matched for gestational age, sex, and year of birth were selected for each case in the Medical Birth Register. The Finnish Hospital Discharge Register was searched for relevant diagnosis codes for IH, and hernia incidence was compared between cases and controls. We identified 178 infants with gastroschisis and 150 with omphalocele and selected randomly 1968 matched, healthy controls for comparison. Incidence of IH was significantly higher in gastroschisis girls than in matched controls, relative risk (RR) 7.20 (95% confidence interval [CI] 2.25-23.07). In boys with gastroschisis, no statistically significant difference was observed, RR 1.60 (95% CI 0.75-3.38). Omphalocele was associated with higher risk of IH compared to matched controls, RR 6.46 (95% CI 3.90-10.71), and the risk was equally elevated in male and female patients.Conclusion: Risk of IH is significantly higher among patients with congenital abdominal wall defects than in healthy controls supporting hypothesis that elevated intra-abdominal pressure could prevent natural closure of processus vaginalis. Parents should be informed of this elevated hernia risk to avoid delays in seeking care. We also recommend careful follow-up during the first months of life as most of these hernias are diagnosed early in life. What is Known: • Inguinal hernia is one of the most common disorders encountered by a pediatric surgeon. • Prematurity increases the risk of inguinal hernia. What is New: • Children with congenital abdominal wall defects have a significantly higher risk of inguinal hernia than general population. • Families should be informed of this elevated hernia risk to avoid delays in seeking care.

Herniation of the uterus, ovaries and fallopian tubes into the canal of Nuck in a 4-month-old child: A rare entity

Partial or complete failure of obliteration of the processus vaginalis in the female results in the formation of a potential space known as the canal of Nuck, into which various organs and/or collections can herniate. A 4-month-old female presented with a left labial mass related to herniation of the uterus, ovaries and fallopian tubes through the canal of Nuck. Early diagnosis is important as there is a high risk of ovarian torsion and incarceration.

Clinical and Economic Value of Routine Pathological Examination of Hernia Sacs and Scheduled Clinic Follow-Ups After Inguinal Hernia and Hydrocele Repair in a Canadian Tertiary Care Children's Hospital

BACKGROUND

The clinical and economical value of routine submission of hernia sacs for pathological examination and scheduled clinic follow-ups after inguinal hernia and hydrocele repair has been questioned. Herein, we assessed the institutional variability in these routine practices.

METHODS

We retrospectively reviewed patients who underwent unilateral or bilateral inguinal hernia and/or hydrocele repair, open or laparoscopically, at our institution from 2015 to 2018.

RESULTS

1181 patients were included (1074 inguinal hernias and 157 hydroceles). Of 531 specimens obtained from 446 (38%) patients, 515 (97%) were normal. 16 (3%) abnormal pathological findings included 7 with mesothelial hyperplasia, 5 with nonfunctional genital ductal remnants, 3 with ectopic adrenal cortical tissues, and 1 epidydimal structure which was not recognized at the time of surgery. 418 (35%) patients had scheduled clinic follow-ups 65 (IQR 46-94) days postoperatively. 44 (4%) patients with unexpected postoperative Emergency Department visits within 30 days of surgery were identified. Only one patient required inpatient treatment, and the rest did not require intervention or admission. The total direct cost of analyzing specimens during the study period was $30,798 CAD ($10,266/year). The average cost to detect a potentially significant finding was $1924.88/specimen and $2053.20/patient.

CONCLUSIONS

Routine pathological examination of hernia sacs and scheduled clinic follow-ups were associated with significant costs and predominantly nonsignificant findings. They should therefore be reserved for patients with a high clinical suspicion of injuries/abnormalities or risk factors for potential complications.

LEVEL OF EVIDENCE

This is a level III evidence study.

Single-site laparoscopic percutaneous extraperitoneal closure (SLPEC) of hernia sac high ligation using an ordinary taper needle: a novel technique for pediatric inguinal hernia

PURPOSE

Laparoscopic high ligation of the internal inguinal ring is an alternative procedure for treatment of pediatric inguinal hernia (PIH), with a major trend toward increasing use of extracorporeal knotting and decreasing use of working ports. We have utilized this laparoscopic technique to treat the entire spectrum of PIH (including incarcerated cases) for more than 17 years, and the technique continues to evolve and improve. We herein report our latest modification of this minimally invasive technique, namely single-site laparoscopic percutaneous extraperitoneal closure (SLPEC) of hernia sac high ligation using an ordinary taper needle, and evaluate its safety and efficacy.

METHODS

From July 2016 to July 2019, 790 children with indirect PIH were treated by laparoscopic surgery. All patients underwent high ligation surgery with a modified single-site laparoscopic technique mainly performed by extracorporeal suturing with an ordinary closed-eye taper needle (1/2 arc 11 × 34). The clinical data were retrospectively analyzed.

RESULTS

All surgeries were successful without serious complications. A contralateral patent processus vaginalis (CPPV) was found intraoperatively and subsequently repaired in 190 patients (25.4%). The mean operative time was 15 min (8-25 min) for 557 unilateral hernias and 21 min (14-36 min) for 233 bilateral hernias. The mean postoperative stay was 20 h. Minor complications occurred in five patients (0.63%) and were managed properly, with no major impact on the final outcomes. No recurrence was noted in the patients who were followed up for 6-42 months. No obvious scar was present postoperatively.

CONCLUSION

Modified SLPEC of hernia sac high ligation using an ordinary taper needle for repair of indirect PIH is a safe, reliable, and minimally invasive procedure with satisfactory outcome, with no special device being needed. It is easy to learn and perform and is worthy of popularization in the clinical setting.

Our Laparoscopic Surgical Technique and Experience in Treating Pediatric Inguinal Hernia Over the Past Decade

Background:

Over the past decade, laparoscopic hernia repair was the most performed operation in our department. Equally, it compromises 15% of all pediatric operations performed. We aim, in this study, to review all the cases performed and extrapolate important information like reoccurrences, the incidence of metachronous inguinal hernia, complications amongst other information.

Material and Methods:

All patients under the age of 18 whom underwent elective laparoscopic hernia repair between 03/01/2007 till the 18/05/2016 were included in our study. We recorded important clinical features and studied their post-operative follow up. Equally reoccurrences, the incidence of metachronous inguinal hernia, complications and other parameters were recorded and studied.

Results:

A total of 916 patients were operated on during the defined study period. There was a 0.17% reoccurrence rate and a 0.46% incidence of metachronous inguinal hernia. Equally a contralateral patent processus vaginalis was diagnosed and closed in 17.10%. There were no postoperative complications and we had a 0% postoperative hydrocele rate.

Conclusion:

Laparoscopic hernia repair is safe and carries all the benefits of minimally invasive surgery. We recommend that it is offered to patients and would like to refute previously claimed reports that it carries a higher reoccurrence rate or takes a long time to perform. Our reoccurrence rate of 0.17% is actually lower than many published reoccurrence rates after open repair.

Laparoscopic versus open inguinal hernia repair in children: which is the true gold-standard? A systematic review and meta-analysis

PURPOSE

Hernia repair is one of the most common operations performed in children. Traditionally, an open surgical approach has been utilized; however, laparoscopic repair has been gaining favour within the surgical community. We aimed to determine whether open or laparoscopic hernia repair is optimal for pediatric patients by comparing recurrence rates and other outcomes.

METHODS

We searched CENTRAL, MEDLINE, and EMBASE from 1980 onwards, including studies that compared laparoscopic and open repair for pediatric inguinal hernia.

RESULTS

Our initial search yielded 345 unique citations. Of these, we reviewed the full text of 28, and included 21 in meta-analysis. The results showed that patients who underwent laparoscopic surgery were more likely to experience wound infection (p = 0.003), but less likely to experience ascending testis (p = 0.05) and metachronous hernia (p = 0.0002). There were no differences in recurrence rates (p = 0.95), surgical time (p = 0.55), length of hospitalization (p = 0.50), intra-operative injury, bleeding, testicular atrophy, or hydrocele.

CONCLUSION

Laparoscopic and open surgeries are equivalent in terms of recurrence rates, surgical time, and length of hospitalization. Laparoscopic repair is associated with increased risk of wound infection, but decreased risk of ascending testis. Laparoscopic surgery allows the opportunity to explore and repair the contralateral side, preventing metachronous hernia.

LEVEL OF EVIDENCE

III.

Transumbilical repair of umbilical hernia in children: The covert scar approach

BACKGROUND

Umbilical hernia repairs are one of the most commonly performed operations in children. The traditional repair involves an infraumbilical incision, which produces a visible scar. We report a novel technique of umbilical hernia repair through a transumbilical incision, which eliminates the scar by hiding it within the umbilicus.

METHODS

We performed a retrospective chart review of 134 patients who had undergone a transumbilical hernia repair at a single institution between 2008 and 2016. Satisfaction with cosmesis and the presence of complications were assessed through parental interviews during follow up visit or by telephone survey. These data were compared to a large volume retrospective analysis of the standard infraumbilical approach.

RESULTS

121 of the 134 patients were evaluated in the clinic or by telephone interview. The overall complication rate was 7.44%. Parents of 118 patients reported satisfaction with the cosmetic result (97.52%). In comparison to the largest study of pediatric infraumbilical repair, there was an improvement in subjective cosmesis without a significant increase in complications.

CONCLUSION

Transumbilical hernia repair is a safe and cosmetically appealing technique for umbilical hernia repair in children.

LEVEL OF EVIDENCE

Treatment study, level III.

Concurrent testicular torsion and acute incarcerated inguinal hernia in an adolescent boy

Testicular torsion and acute incarcerated inguinal hernia are both common surgical emergencies in the paediatric population. We present the unusual case of a 16-year-old adolescent boy who presented with both of these conditions concurrently. He had a history of a right inguinal hernia, but ultrasound confirmed a testicular torsion and we employed manual detorsion in the emergency department prior to taking him to the operating room. We successfully salvaged the testicle in addition to performing inguinal hernia reduction and repair. The goal of this report is to emphasise the importance of maintaining a broad differential and early utilisation of ultrasound in the patient with acute groin pain.

Single-Site Laparoscopic Percutaneous Extraperitoneal Closure Versus Modified Transumbilical Two-Port Laparoscopic Suturing of the Hernia Sac for the Treatment of Pediatric Inguinal Hernia: Comparison of the Outcomes of Two Different Approaches

OBJECTIVE

To evaluate the surgical outcomes of single-site laparoscopic percutaneous extraperitoneal closure (SLPEC) and modified transumbilical two-port laparoscopic suturing (M-TTLS) of the hernia sac for the treatment of pediatric inguinal hernia (PIH) and determine whether one approach was superior to another.

METHODS

From January 2014 to June 2017, a total of 599 children had undergone SLPEC or M-TTLS in our department. SLPEC and M-TTLS were the most frequently performed single-site laparoscopic procedures for PIH in our department, which represented the extraperitoneal and intraperitoneal approaches, respectively. All patients were followed up at the out-patients' clinics and the medical records were reviewed with respect to all operative outcomes.

RESULTS

There were 412 patients undergoing SLPEC and 187 patients undergoing M-TTLS, of which 358 hernias were on the right side, 172 on the left and 69 bilaterally. Two hundred and thirty-one unilateral hernias with contralateral patent processus vaginalis underwent contralateral repair at the same session. Mean operation time was 10.81 minutes in unilateral repair and 17.00 minutes in bilateral repairs, respectively. The perioperative complications included minor extraperitoneal hematoma in four (0.44%) patients, recurrence in one (0.11%), hydrocele in five (0.56%), and contralateral metachronous inguinal hernia in three (1.00%). No other complication developed in either group. There was no significant difference of complications between the two approaches except for the longer operation time in M-TTLS.

CONCLUSIONS

Both SLPEC and M-TTLS were the safe and effective methods for PIH. The complications were comparable for M-TTLS and SLPEC, but operation time was significantly longer in M-TTLS than in SLPEC.

Pediatric inguinal hernias, are they all the same? A proposed pediatric hernia classification and tailored treatment

PURPOSE

To propose a new clinical classification for pediatric inguinal hernias modified from a similar classification system for adult inguinal hernia and to propose a tailored repair for each type. The impact of this approach on hernia recurrence will be assessed.

METHODS

This prospective and retrospective cross-sectional study was conducted in two tertiary teaching university hospitals in Egypt (Alexandria and Tanta University Children's Hospitals) from January 2013 to December 2014 on children below 12 years of age with indirect inguinal hernias who were divided into two groups: (a) prospective group I, classified according to our proposed pediatric hernia classification and tailored treatment (PHCTT) into types: pediatric Nyhus 1 (PNI) assigned for herniotomy alone, pediatric Nyhus II (PNII) assigned for herniotomy plus deep ring narrowing, and type pediatric Nyhus III (PNIII) assigned for herniotomy plus posterior wall repair. (b) Retrospective unclassified group II where all cases were assigned to herniotomy alone (open). Data about patient characteristics, assigned hernia type, operative findings, procedures done, and postoperative complications were documented and analyzed by comparing the outcomes of the two groups.

RESULTS

A total of 371 patients were included in this study with 401 hernias (30 bilateral); group I included of 217 patients, while group II included 154 patients. There was a male preponderance in group I (173/217 = 80%) and in group II (130/154 = 85%); the majority in both groups were less than 12 months of age, in group I (132/217 = 66%) and in group II (120/154 = 85%). The median age was 4 months and the median duration of symptoms was 2 months. For group I, PNII hernias formed the predominant cluster making 40% (94/235) followed by PNI hernias making 34.8% (82/235), while PNIII hernias were the least group being 25% (59/235) only. The mean follow-up period was 9.2 months ± 4.8 SD (and 9.1 months ± 2 SD in group II). The pooled recurrence rate was 1.9% (8/401) of the whole series, a weighted mean of the individual recurrence rates of 0% (0/235) of group I and 4.8% (8/166) of group II patients, all males. This difference in the recurrence rates between the two groups was statistically significant (P = 0.004).

CONCLUSIONS

Pediatric inguinal hernias are not the same and there is extreme variation in the presentation regarding the size of the defect. We proposed a nouvelle pediatric hernia classification modified from the original Nyhus classification for adult inguinal hernia with tailored surgical approach to each type (PHCTT). Applying this (PHCTT), it has the benefit of a significant reduction of recurrence rate.

The Met Needs for Pediatric Surgical Conditions in Sierra Leone: Estimating the Gap

BACKGROUND

In low- and middle-income countries, there is a gap between the need for surgery and its equitable provision, and a lack of proxy indicators to estimate this gap. Sierra Leone is a West African country with close to three million children. It is unknown to what extent the surgical needs of these children are met.

AIM

To describe a nationwide provision of pediatric surgical procedures and to assess pediatric hernia repair as a proxy indicator for the shortage of surgical care in the pediatric population in Sierra Leone.

METHODS

We analyzed results from a nationwide facility survey in Sierra Leone that collected data on surgical procedures from operation and anesthesia logbooks in all facilities performing surgery. We included data on all patients under the age of 16 years undergoing surgery. Primary outcomes were rate and volume of surgical procedures. We calculated the expected number of inguinal hernia in children and estimated the unmet need for hernia repair.

RESULTS

In 2012, a total of 2381 pediatric surgical procedures were performed in Sierra Leone. The rate of pediatric surgical procedures was 84 per 100,000 children 0-15 years of age. The most common pediatric surgical procedure was hernia repair (18%), corresponding to a rate of 16 per 100,000 children 0-15 years of age. The estimated unmet need for inguinal hernia repair was 88%.

CONCLUSIONS

The rate of pediatric surgery in Sierra Leone was very low, and inguinal hernia was the single most common procedure noted among children in Sierra Leone.

Ultrasound-guided rectus sheath block, caudal analgesia, or surgical site infiltration for pediatric umbilical herniorrhaphy: a prospective, double-blinded, randomized comparison of three regional anesthetic techniques

Background

Umbilical hernia repair is a common pediatric surgical procedure. While opioid analgesics are a feasible option and have long been a mainstay in the pharmacological intervention for pain, the effort to improve care and limit opioid-related adverse effects has led to the use of alternative techniques, including regional anesthesia. The current study prospectively compares the analgesic efficacy of three techniques, including caudal epidural blockade, peripheral nerve blockade, and local wound infiltration, in a double-blinded study.

Patients and methods

A total of 39 patients undergoing umbilical hernia repair were randomized to receive a caudal epidural block (CDL), ultrasound-guided bilateral rectus sheath blocks (RSB), or surgical site infiltration (SSI) with local anesthetic. Intraoperative anesthetic care was standardized, and treatment groups were otherwise blinded from the intraoperative anesthesiology team and recovery nurses. Postoperatively, the efficacy was evaluated using Hannallah pain scores, Aldrete recovery scores, the need for intravenous fentanyl, and the time to discharge.

Results

Each cohort was similar in terms of age, weight, premedication dosing, length of case, intraoperative and postoperative fentanyl requirements, and time to tracheal extubation. Among the three cohorts, there were no significant differences noted in terms of pain scores or time to recovery.

Conclusion

All the three techniques provided effective analgesia following umbilical hernia repair. Our findings offer effective and safe analgesic options as alternatives to the neuraxial (caudal) approach.

The challenging sonographic inguinal canal evaluation in neonates and children: an update of differential diagnoses

Bulging of the inguinal region is a frequent complaint in the pediatric population and sonographic findings can be challenging for radiologists. In this review we update the sonographic findings of the most common disorders that affect the inguinal canal in neonates and children, with a focus on the processus vaginalis abnormalities such as congenital hydroceles, indirect inguinal hernias and cryptorchidism, illustrated with cases collected at a quaternary hospital during a 7-year period. We emphasize the importance of correctly classifying different types of congenital hydrocele and inguinal hernia to allow for early surgical intervention when necessary. We have systematically organized and illustrated all types of congenital hydrocele and inguinal hernias based on embryological, anatomical and pathophysiological findings to assist readers in the diagnosis of even complex cases of inguinal canal ultrasound evaluation in neonates and children. We also present rare diagnoses such as the abdominoscrotal hydrocele and the herniation of uterus and ovaries into the canal of Nuck.

Direct bladder hernia after indirect hernia repair in extremely low birth weight babies: two case reports and a review of the literature

BACKGROUND

Inguinal hernia repair is the most common surgical procedure in babies. Despite a meticulous technique, relapses may occur. The occurrence of a direct bladder wall hernia in relapses has never before been reported in the literature.

CASE PRESENTATION

Here, we report two cases of direct bladder herniation: a white baby boy born after 25 weeks of gestation and a white baby boy born after 26 weeks of gestation. Both of the formerly extremely low birth weight babies were affected after open bilateral hernia repair. Recurrent hernias developed on the right side, and direct bladder herniation was identified intraoperatively. In one case, laparoscopy was applied to identify a supravesical type of hernia. Immaturity and a difficult postnatal course might have contributed to hernia relapse in these cases.

CONCLUSIONS

Misinterpretation of bladder herniation might have disastrous consequences. Laparoscopy is a helpful tool in comparable cases.

Laparoscopic Pediatric Inguinal Hernia Repair: A Pilot Study in a Novel Guinea Pig Animal Model

BACKGROUND

The purpose of this study was to compare different techniques for pediatric laparoscopic inguinal hernia repair. We hypothesize that the amount of dissection performed at the internal ring, with or without division of the peritoneum, will impact healing and thus long-term success of the repair.

METHODS

Following the Institution's Animal Care and Use Committee approval (708024-4), 20 Hartley guinea pigs underwent laparoscopic repair of their natural open internal rings. The guinea pigs were divided equally into four surgical groups: intracorporeal suture repair (IS), hernia dissection and division with intracorporeal suture (DDIS) repair, subcutaneous endoscopically assisted ligation (SEAL), and Yueng (HOOK) repair. After a 6-week survival period, a necropsy was performed. Repairs were evaluated and tested under pressures up to 30 mmHg. The suture was then removed to assess primary healing. Experimental data were analyzed using chi-square test.

RESULTS

There were no perioperative or postoperative complications. On initial evaluation, before suture removal, repair integrity was as follows: 5/10 IS, 10/10 DDIS, 7/10 SEAL, and 7/10 HOOK (P = .09). After suture removal, repair integrity was as follows: 3/10 IS, 10/10 DDIS, 5/10 SEAL, and 6/10 HOOK (P = .01).

CONCLUSION

Overall, dissecting and dividing the sac with intracorporeal suture (DDIS) closure had the best outcome. This method appears to best replicate standard open high ligation.

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.

Morphology-based investigation of metachronous inguinal hernia after negative laparoscopic evaluation - is it acquired indirect inguinal hernia?

PURPOSE

Patients who developed apparent metachronous contralateral inguinal hernia (MCIH) after negative laparoscopic diagnosis have been reported. We performed this study to investigate the morphological characteristics and etiology of this phenomenon.

PATIENTS AND METHODS

A consecutive series of 1,747 patients (858 boys and 889 girls) with symptomatic unilateral inguinal hernia were studied. During laparoscopic percutaneous completely extraperitoneal closure, morphological appearances at the asymptomatic groin were inspected for contralateral patent processus vaginalis (CPPV) with definitive criteria. If positive CPPV was identified, it was closed by the same technique used for the affected side. The patients were reviewed for occurrence of metachronous contralateral hernia.

RESULTS

A total of 755 patients (43.2%) had positive CPPV. Of the 992 patients whose CPPVs were evaluated as true negative, eight (seven boys, one girl) developed MCIH (time taken, three months to five years six months). During second-look operations, morphological appearances of the CPPV that was originally considered as true negative CPPV was found to be wide open.

CONCLUSIONS

Despite a true negative evaluation by laparoscopy, there was a 0.8% chance of developing a MCIH. This phenomenon was male-oriented and may be acquired indirect inguinal hernia without preceding of CPPV.

Amyand's hernia: 11years of experience

PURPOSE

Presence of the vermiform appendix in an inguinal hernia sac is known as Amyand's hernia. This may present as a tender inguinal swelling and is often misdiagnosed as irreducible or strangulated hernia.

METHODS

Between January 2003 and December 2013 we treated 4498 patients with inguinal hernias and performed 3267 appendectomies. Among these; 46 had an Amyand's hernia. Age, sex, presenting symptoms, treatment modality, histopathological findings, duration of hospitalization, and post-surgical outcomes were analyzed retrospectively.

RESULTS

All patients were boys. The mean age was 16.7months (15days-8years). 37 (80.4%) right, 2 (4.3%) left and 7 (15.2%) bilateral hernioplasties were performed. Nine patients underwent emergency surgery with an initial diagnosis of incarcerated hernia; Amyand's hernia was an incidental finding in the remaining 37 patients. Operative findings included 33 normal appendices, 9 inflamed appendices, one perforated appendix, and three appendices adherent to the hernia sac. Eighteen patients had appendectomy during hernia repair, and the other 33 had hernia repair without appendectomy. None of the patients developed recurrent hernia or appendicitis within the follow-up period.

CONCLUSION

In Amyand's hernia the appendix should be examined carefully. A classification of Amyand's hernia according to the presenting symptoms and inflammatory status of the appendix may help to determine whether or not to proceed with appendectomy.