Spontaneous regression of clinical inguinal hernias in preterm female infants

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

Importance

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

Objective

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

Design, Setting, and Participants

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

Interventions

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

Main Outcomes and Measures

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

Results

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

Conclusions and Relevance

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

Trial Registration

ClinicalTrials.gov Identifier: NCT01678638.

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

INTRODUCTION

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

METHOD

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

Level III, treatment study.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

Treatment study, level 3.

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.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Inguinoscrotal hernia in infants: Three case reports in ultrasound diagnosis

An inguinal hernia occurs when an intestinal loop or part of the omentum or genital organs passes into the scrotal cavity or labia through an incompletely obliterated processus vaginalis. Inguinal hernias are most common in preterm neonates, especially at 32-weeks gestation. Content of hernia is mostly bowel and ovary/testicles. Presence of uterus in herniated sac is rare, and only few cases are reported in literature. Hernia is more frequently located on the right side because the right processus vaginalis closes later than the left. Physical examination is sufficient to enable diagnosis in most cases. Ultrasound examination is indicated in patients with inconclusive physical findings, in patients with acute scrotum, and to investigate contralateral involvement in patients in whom only a unilateral hernia is clinically evident. Routinely, color or power Doppler imaging is used in inguinal-scrotal hernia to investigate intestinal and testicular/ovarian perfusion. Urgent surgery is indicated in patients with an akinetic dilated bowel loop (a sign of strangulation) or impaired testicular/ovarian perfusion.

Inguinal hernia in very low-birthweight infants: Follow up to adolescence

BACKGROUND

This study reviewed the medical records of very low-birthweight infants (VLBWI) followed up to adolescence, with emphasis on inguinal hernia (IH), to discuss the ideal time for IH repair in VLBWI.

METHODS

Medical records from 274 VLBWI treated in the neonatal intensive care unit (NICU) between 1994 and 1999 were collected retrospectively. Outpatient data after NICU discharge were included. Additionally, a follow-up study was undertaken via questionnaire sent to the families of VLBWI in 2011.

RESULTS

During NICU hospitalization, IH was diagnosed in 39 of 274 VLBWI, and two developed incarceration. Thirty-eight VLBWI were discharged with known hernia, and elective repair was performed in 19. Three developed incarceration before elective repair at the mean age of 316 days. In the remaining 18 cases of IH, spontaneous regression occurred at a mean age of 180 days and repair was not performed. New IH appeared in 25 VLBWI after NICU discharge.

CONCLUSIONS

The high incidence of IH in VLBWI was confirmed during follow up to adolescence. The rate of incarceration was low and the incidence of spontaneous regression was high. Observation up to 6 months without surgery, with the expectation of spontaneous regression, is one option to avoid unnecessary surgery, but repair should be performed before 10 months to reduce the risk of incarceration. Further large, prospective, and randomized controlled studies with a long follow up are necessary to validate the present results and to define the ideal time for IH repair in VLBWI.

Foetal inguinoscrotal hernia—its prenatal diagnosis and its spontaneous regression

A foetal inguinoscrotal hernia is a rare abnormality. We report a case of foetal inguinoscrotal hernia diagnosed by ultrasonography at 37 weeks gestation and its spontaneous regression during the perinatal period. The imaging features, differential diagnosis, pregnancy management and outcome are discussed.

The inguinal herniation of the ovary in the newborn: ultrasound and color Doppler ultrasound findings

Inguinal hernias in the newborn age group are seldom encountered. In the affected female patient, the ovaries, fallopian tubes, and the intestines may settle in the hernia sac. The early diagnosis of torsion in cases in which the ovary is herniated into the inguinal canal is of utmost importance in order to give surgery the chance of reduction and correction. In this paper, a case of an ovarian herniation into the inguinal canal without the presence of torsion is being presented, and the place of US and CDUS in the differential diagnosis of the situation is being discussed.

Laparoscopic inguinal hernia repair in children using the percutaneous internal ring suturing technique - own experience

INTRODUCTION

Percutaneous internal ring suturing (PIRS) is a method of laparoscopic herniorrhaphy, i.e. percutaneous closure of the internal inguinal ring under the control of a telescope placed in the umbilicus.

AIM

To evaluate the usefulness of the PIRS technique.

MATERIAL AND METHODS

Fifty-five children (39 girls and 16 boys) underwent surgery using this method in our institution between 2008 and 2010.

RESULTS

In 10 cases the presence of an open inguinal canal on the opposite side was also noted during surgery, and umbilical hernia was recognized in 2 patients. In 5 cases it was necessary to convert to the open surgery because of the inability to continue the laparoscopic procedure. In 1 case, male pseudohermaphroditism was diagnosed during surgery. Recurrent inguinal hernia required a conventional method of surgery in 1 child. Other children did not exhibit the characteristics of hernia recurrence. The inguinal canals were followed up with postoperative ultrasound examination in 29 children. In 23 children, the ultrasound examination showed no dilatation of the inguinal canal. In the other 6 children dilatation of the inguinal canal or the presence of fluid within the inguinal canal was observed during ultrasound. In 6 children symptoms such as swelling and soreness around the inguinal canal developed within 3 to 6 months after surgery.

CONCLUSIONS

Inguinal hernia surgery using the PIRS procedure is an alternative, effective, minimally invasive method of surgery. Visualization of the peritoneal cavity allows for detection of other abnormalities, as well as for performing other procedures during the same session (such as closing the contralateral inguinal canal or umbilical hernia surgery).

Gray-scale and color Doppler ultrasound imaging findings of an ovarian inguinal hernia and torsion of the herniated ovary: a case report

Inguinal hernia is extremely rare among girls. The hernia sac may sometimes involve intestinal structures, but ovaries in the sac are uncommon. Early diagnosis of a possible ovarian torsion is essential because potential amenable benefits can be achieved with surgery. A baby girl was admitted to our pediatric emergency unit with the complaints of swelling and erythema of the left groin. Then gray-scale ultrasonography and color Doppler ultrasonography was performed immediately at the emergency radiology room. In our case, ovarian torsion was diagnosed by gray-scale ultrasonography and color Doppler ultrasonography. After the diagnosis of ovarian torsion, the patient underwent surgery. It is possible to diagnose inguinal emergencies by high-resolution ultrasonography and color Doppler ultrasonography.

Detection of an inguinal ovary at controlled ovarian stimulation that was successfully treated by repositioning

OBJECTIVE

To report a rare case of an ectopic ovary placed in the inguinal canal that was detected while performing a controlled ovarian hyperstimulation (COH).

DESIGN

Case report.

SETTING

A university hospital.

PATIENT(S)

A couple with primary infertility for 4 years was referred to our infertility clinic. The woman's medical history revealed a left inguinal operation at age 7. On vaginal ultrasound, only the right ovary could be seen. An infertility workup conducted for the man revealed teratospermia. The couple was subsequently admitted to the in vitro fertilization (IVF) program. While having a COH, the woman experienced a painful swelling in the inguinal area, and an ovarian image with follicular growth on the left inguinal region was observed with ultrasound. Afterward, surgery was performed, and the ectopic ovary in the left inguinal region was detected.

INTERVENTION(S)

Detection of an inguinal ovary with a controlled ovarian hyperstimulation procedure and surgical repositioning of the ectopic ovary.

MAIN OUTCOME MEASURE(S)

Controlled ovarian hyperstimulation, transabdominal ultrasound, transvaginal ultrasound.

RESULT(S)

The ectopic ovary was successfully repositioned with surgery.

CONCLUSION(S)

Patients must be closely monitored while performing COH. In patients who do not have a unilateral ovary, a painful inguinal mass should alert the physician to the possible presence of an ectopic ovary in the inguinal canal.

Ultrasonographic diagnosis for potential contralateral inguinal hernia in children

PURPOSE

The authors describe the diagnostic approach and the reliability of the diagnosis using their ultrasonographic classification for potential contralateral inguinal hernia in children.

METHODS

In children presenting with unilateral inguinal hernia, the contralateral processus vaginalis in the inguinal canal was examined preoperatively by ultrasonography with a 10-MHz transducer. The findings, with increment and decrement of the intraabdominal pressure, were categorized into 6 types as follows: type I, the intraabdominal organ is observed in the inguinal canal; type II, the patent processus vaginalis (PPV) is seen cystlike at the internal ring of the inguinal canal; type III, the PPV is widened with abdominal pressure increment (the length of the PPV is longer than 20 mm); type IV, the PPV contains moving fluid without PPV widening; type V, the PPV is widened with abdominal pressure increment (the length is shorter than 20 mm); type VI, others. Types I through IV were regarded as potential candidates for inguinal hernia. The diagnostic performance of the clinical examination, with or without the assistance of ultrasonography was analyzed retrospectively.

RESULTS

The development rates of contralateral inguinal hernia following unilateral herniorrhaphy, before and after application of ultrasonographic diagnosis, were 10.2% (28 of 274 cases) and 1.5% (4 of 271 cases), respectively. The difference was statistically significant according to Fisher's Exact probability test.

CONCLUSIONS

Contralateral herniorrhaphy should be performed on inguinal hernia candidates when ultrasonography shows types I through IV.