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

Inguinal hernias in children: Update on management guidelines

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

Cost Analysis of Early vs Delayed Outpatient Repair of Inguinal Hernias in Premature Infants

INTRODUCTION

Premature infants treated for inguinal hernias after hospital discharge require overnight post-operative observation for apnea monitoring until 50-60 weeks adjusted gestational age (AGA). This study aimed to compare costs associated with early (at time of diagnosis) versus delayed (at AGA not requiring overnight observation) repair of inguinal hernia in premature infants.

METHODS

Costs were estimated using the average hospital charges at a single institution for three scenarios: 1) delayed repair 2) early repair requiring overnight observation, and 3) incarcerated inguinal hernia reduced but requiring delayed repair at 48 h. A decision analysis model was used to estimate the cost for premature infants undergoing delayed repair of inguinal hernia while considering the risk of incarceration and associated costs. The base model used 50 weeks AGA for delayed repair and an incarceration rate of 0.5%/week. Sensitivity analyses varied incarceration rate from 0.1 to 4%/week and delayed repair to 55 and 60 weeks AGA.

RESULTS

In the base model, delayed repair incurred lower estimated costs than early repair at all time points of diagnosis. In sensitivity analyses, estimated cost for delayed repair only rose above the estimated cost for early repair when estimated incarceration risk reached 3%/week with repair at 60 weeks AGA (if repair before 38 weeks AGA) or 4%/week with repair at 55 weeks AGA (if repair before 39 weeks AGA).

CONCLUSIONS

Using solely cost as a deciding factor, repair of premature inguinal hernias diagnosed as an outpatient should be delayed until overnight observation is no longer necessary.

TYPE OF STUDY

Decision Analysis model.

LEVEL OF EVIDENCE

III.

Scientific Output by Latin American Women in Pediatric Surgical Sciences Over the Past 11 Years: A Bibliometric and Visual Analysis

INTRODUCTION

This academic article discusses the historical underrepresentation of female in science, with a focus on Latin America. It highlights the importance of both technical and non-technical skills in the medical-surgical field, particularly the role of research skills. The study aims to quantify and characterize the scientific output of Latin American female researchers over the past decade, providing insights into the challenges and opportunities in low and middle-income countries.

MATERIAL AND METHODS

A retrospective cross-sectional bibliometric study was conducted in 2023, focusing on pediatric surgical science journals in Scopus and PubMed. It assessed Latin American female participation, journal details, and interaction networks, using SPSS and Gephi software. The period analyzed was from January 2012 to December 2022.

RESULTS

Between 2012 and 2022, 727 articles with Latin authorship in pediatric surgery were analyzed across 304 journals. Of these, 63.69% had female co-authors. The majority were original articles (53.13%), with contributions from Brazil, Mexico, and Chile. Notable journals included the Journal of Pediatric Surgery and Child's Nervous System. Keywords like Laparoscopy and Cardiac surgery were common. A growth trend in female Latin American publications was observed, despite temporary declines.

CONCLUSIONS

This study highlights a growing trend in Latin American females' scientific contributions to pediatric surgery from 2012 to 2022, although a gender gap persists. The research mainly consists of primary data studies, with a focus on Brazil and Mexico from public institutions. The Journal of Pediatric Surgery featured prominently, and common topics included Laparoscopy, Cardiac surgery, Liver transplant, Congenital heart defects, and COVID-19.

LEVEL OF EVIDENCE

IV.

Analysis of Techniques in Laparoscopic Inguinal Hernia Repairs across Pediatric Age Groups: EUPSA Trainees of European Pediatric Surgery Survey

AIM

 This survey analyzed techniques in laparoscopic inguinal hernia repair (LIHR) across pediatric age groups.

MATERIALS AND METHODS

 Data were collected through an online survey for pediatric surgeons, comprising of 38 questions, conducted by the European Pediatric Surgeons' Association (EUPSA) Trainees of European Pediatric Surgery (TEPS) LIHR Working Group.

RESULTS

 The survey was completed by 183 surgeons from 22 countries. Seventy-seven percent of respondents had performed LIHR at least once. Regarding preferences about the patient's gender, 7% respondents perform LIHR only in selected females, 9% routinely in females, 15% in both genders with age/weight restrictions, 24% routinely in both genders, 31% in selected cases, and 14% never perform LIHR. Percutaneous internal ring suturing (PIRS) was the preferred technique in all age groups, with totally extraperitoneal and transabdominal preperitoneal repairs preferred by 9% in adolescents. The majority (59%) repaired a contralateral patent processus vaginalis if present. Hydro-dissection (21%) and additional intra-abdominal instruments (42%) were preferred more often for male patients. The distal hernia sac was left intact by most respondents (92%). Responses regarding recurrence rates varied: 40% responded that LIHR had recurrence rates comparable to open surgery, whereas 10% reported increased recurrences and hence limited its use, and 10% consider that slightly increased recurrences are outweighed by lower complication rates associated with laparoscopic methods and thus continue LIHR.

CONCLUSIONS

 PIRS is the preferred choice for pediatric LIHR. Surgical techniques vary and are influenced by patient gender and age. The survey gives insights into demographics, case selection, and approaches among pediatric surgeons with regard to LIHR.

Outpatient Factors Implicated in Timing of Delayed Elective Inguinal Hernia Repair in Premature Neonates: Single Center Analysis Brings Up a Touchy Issue and Balancing Metric

INTRODUCTION

Among premature infants, the incidence of inguinal hernias (IH) has been reported to be as high as 10-30%. We performed this study to characterize the association between individual and systemic variables that may affect diagnosis to definitive operative repair of the premature neonatal IH in the outpatient setting.

METHODS

A single center cohort retrospective review analyzing IH repair in the premature neonatal (<37 GA) population was performed. Data was collected between 2013 and 2022. The cohort was defined as patients who underwent repair before the age of 1 and excluded patients with major medical comorbidities or underwent simultaneous major abdominal surgeries.

RESULTS

Of the 836 premature neonates who underwent IH repair, the majority (73%) were repaired electively. Patients were characterized into risk cohorts a-priori. High-risk patients (HR, n = 43) were more likely to have Government insurance (67%). There was a significant difference in HR patient time to surgery between Government versus Commercial insurance, 10.6 versus 4.7 days, respectively (95% CI -11.09 to -0.4396, p = 0.0345). HR patients were also seen more frequently (clinic or emergency department) prior to operative repair (2.51 vs 1.72 95% CI -1.296% to -0.289%, p = 0.0021). A multivariate linear regression model demonstrated that risk class (p = 0.0244), touches (p < 0.0001), GA (p < 0.001), and prior authorization (p < 0.0001) were significantly associated with time to hernia repair.

CONCLUSIONS

Systemic variables such as insurance type may increase average wait time for elective outpatient IH repair. This increase in wait time is associated with an increased number of healthcare visits. Therefore, timely access to surgical care prevents potential harm and may decrease health system burden.

TYPE OF STUDY

Retrospective comparative study/cohort study.

LEVEL OF EVIDENCE

III.

Pediatric incarcerated inguinal hernia: Traditional open or laparoscopic-assisted approach?

The objective of this study was to compare the safety and efficacy of laparoscopic-assisted surgery and traditional open surgery for pediatric incarcerated inguinal hernia. A total of 58 pediatric patients with indirect incarcerated inguinal hernia between January 2014 and January 2020 were included in this study. The patients were divided into 2 groups; observational group who underwent laparoscopic-assisted surgery (n = 36), and a control group who underwent traditional open surgery (n = 22). The overall operation time, intraoperative blood loss, postoperative recovery time, length of hospital stay, occurrence of postoperative scrotal or vulvar hematomas, incidence of postoperative surgical site infection, and hernia recurrence were analyzed and compared between the 2 groups. Compared with the control group, the operation time (38.28 ± 5.90) minutes, intraoperative blood loss (1.15 ± 0.54 mL), postoperative recovery time (8.39 ± 1.42 h), and length of hospital stay (1.64 ± 0.59) were significantly lower in the observational group (P < .05). There was no incidence of scrotal or vulvar hematoma or surgical site infection in the observation group, which was significantly lower than that in the control group (P < .05). However, no statistically significant difference was found in the rate of postoperative hernia recurrence between the 2 groups (P > .05). In conclusion, laparoscopic-assisted surgery appears to be a safe and effective alternative approach to traditional open surgery for the treatment of pediatric incarcerated inguinal hernia. Its advantages include reduced trauma, faster recovery, shorter hospital stays, and fewer complications.

European Pediatric Surgeons' Association Survey on Timing of Inguinal Hernia Repair in Premature Infants

AIM

 This article evaluates the practice patterns of European Pediatric Surgeons' Association (EUPSA) members regarding the timing of inguinal hernia (IH) repair in premature infants.

METHODS

 Online survey containing 29 questions distributed to EUPSA members during January 2023.

RESULTS

 A total of 180 responds were received. Overall, IH repair prior to discharge was favored by 60% of respondents when there was a history of incarceration and 56% when there was not. In the case of very/extremely premature infants (< 32 weeks) with no history of incarceration, fewer (43%) respondents postpone the surgery until after discharge. The majority of respondents cited the risk of incarceration as the reason for advocating surgery prior to discharge, whereas a reduced risk of apnea was the most cited reason for respondents who prefer delayed surgery. Open approach under general anesthesia was favored by 54% of respondents, with 27% of them preferring open approach with spinal anesthesia. Laparoscopic surgery for premature infants is used in 11% while 7% of them preferred in all premature infants including extremely/very premature ones. Contralateral side evaluation was never done by 40% of respondents and 29% only performed it only during laparoscopic repair. The majority of respondents (77%) indicated that they have an overnight stay policy for premature infants < 45 weeks of gestation.

CONCLUSION

 There is variation in the practice patterns of pediatric surgeons in the treatment of IH in premature infants. Due to the concern for the high risk of incarceration, IH repair before discharge was the most prevalent practice. Lower risk of postoperative apnea was cited as the most common reason for delaying surgery. Randomized studies are required to establish the optimal timing for IH repair in premature infants.

Single-Port Laparoscopic Extraperitoneal Repair of Pediatric Inguinal Hernias and Hydroceles by Using Hernia Crochet Needle With a Cannula

PURPOSE

Numerous modifications laparoscopic techniques have mushroomed in recent years. Here we describe a modified technique of extracorporeal ligation of processus vaginalis in children using a hernia crochet needle with a cannula.

METHODS

Processus vaginalis repair was carried out on patients diagnosed with inguinal hernia or hydroceles using this novel technique between June 2021 and June 2022. The processus vaginalis was closed extracorporeally using a hernia crochet needle with a cannula. In the presence of patent processus vaginalis, the same procedure would be performed on the contralateral side. The primary outcomes was the safety and efficiency of this modified procedure, and the secondary outcomes was the post operative complications.

RESULTS

A total of 212 (165 inguinal hernia and 47 hydroceles) children were corrected by this novel technique. The mean operation time was 27.49 min for unilateral inguinal hernia cases and 36.55 min for bilateral cases. The unilateral hydrocele median operation time was 27.83 min and that for the bilateral cases was 37.30 min. During the mean of 10.92 months of follow-up, there was only a boy subject to a metachronous contralateral occurrence of hernia 10 months after surgery, and no other complications (knot reactions, testicular atrophy, postoperative hydrocele or iatrogenic) have been observed yet.

CONCLUSION

This study shown a unique procedure with using a hernia crochet needle with a cannula to be simple, safe, and effective in managing inguinal hernias and hydroceles in the pediatric population.

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.

Immediate Versus Delayed Surgical Management of Infant Cryptorchidism With Inguinal Hernia

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

Level III TYPE OF STUDY: Retrospective Comparative Study.

Development of an international core outcome set for treatment trials in paediatric inguinal hernia: protocol for a three-phase study including a systematic review and Delphi survey

INTRODUCTION

In children, open inguinal hernia repair has been the gold standard for treatment, but with recent technical advancements in laparoscopy, laparoscopic hernia repair is gaining popularity. Despite available results from comparative studies, there is still no consensus regarding the superiority of open versus laparoscopic treatment strategy. An important reason for lack of consensus is the large heterogeneity in the trials' reported outcomes and outcome definitions, which limits comparisons between studies and precludes conclusions regarding the superiority of treatment strategies. The development and implementation of a core outcome set (COS) is a solution for this heterogeneity in the selection, measurement and reporting of trial outcome measures across studies. Currently, there is no COS for the treatment of paediatric inguinal hernia.

METHODS AND ANALYSIS

The aim of this project is to reach international consensus on a minimal set of outcomes that should be measured and reported in all future clinical trials investigating inguinal hernia repair in children. The development process comprises three phases. First, we identify outcome domains associated with paediatric inguinal hernia repair from a patient perspective and through a systematic review of the literature using EMBASE, MEDLINE and the Cochrane Library databases. Second, we conduct a three-step Delphi study to identify and prioritise 'core' outcomes for the eventual minimal set. In the third phase, an expert meeting is held to establish the final COS and develop implementation strategies with participants from all stakeholder groups: healthcare professionals, parents and patients' representatives. The final COS will be reported in accordance with the COS-Standards for Reporting statement.

ETHICS AND DISSEMINATION

The medical research ethics committee of the Amsterdam UMC confirmed that the Dutch Medical Research Involving Human Subjects Act (WMO) does not apply to this study and that full approval by the committee is not required. Electronic informed consent will be obtained from all participants. Results will be presented in peer-reviewed academic journals and at relevant conferences.

PROSPERO REGISTRATION NUMBER

CRD42021281422.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Testicular and scrotal abnormalities in pediatric and adult patients

Testicular and scrotal abnormalities can occur in children, adolescents, and adults. The lesions, often accompanied by pain and swelling/enlargement of the scrotum, can cause anxiety in patients and their parents. Regardless of age, proper diagnosis is based on adequate anamnesis and physical examination. Color Doppler ultrasound is the first-line test in the differential process of testicular and scrotal diseases. Testicular and scrotal lesions require differentiation for benign and malignant processes as well as therapeutic management, including urgent surgical intervention. The aim of this paper is to present the most common causes of testicular and scrotal abnormalities in pediatric and adult patients and to outline the symptoms and diagnostic and therapeutic management.

Perioperative management of infant inguinal hernia surgery; a review of the recent literature

Inguinal hernia surgery is one of the most common electively performed surgeries in infants. The common nature of inguinal hernia combined with the high-risk population involving a predominance of preterm infants makes this a particular area of interest for those concerned with their perioperative care. Despite a large volume of literature in the area of infant inguinal hernia surgery, there remains much debate amongst anesthetists, surgeons and neonatologists regarding the optimal perioperative management of these patients. The questions asked by clinicians include; when should the surgery occur, how should the surgery be performed (open or laparoscopic), how should the anesthesia be conducted, including regional versus general anesthesia and airway devices used, and what impact does anesthesia choice have on the developing brain? There is a paucity of evidence in the literature on the concerns, priorities or goals of the parents or caregivers but clearly their opinions do and should matter. In this article we review the current clinical surgical and anesthesia practice and evidence for infants undergoing inguinal hernia surgery to help clinicians answer these questions.

Application of multidisciplinary collaborative nursing with family care for enhanced recovery after surgery in children with inguinal hernia

BACKGROUND

Perioperative nursing can reduce the stress reaction and improve the prognosis of children.

AIM

To elucidate the influence of multidisciplinary collaborative nursing for enhanced recovery after surgery (ERAS) with family care in perioperative nursing children with an inguinal hernia and its impact on the prognosis.

METHODS

The data of 100 children with inguinal hernia were retrospectively analyzed. The participants were divided into three groups according to different nursing methods: Groups A (n = 38), B (n = 32), and C (n = 30). Group A received multidisciplinary collaborative ERAS nursing combined with family care nursing; Group B received multidisciplinary collaborative nursing for ERAS; and Group C received routine nursing. The postoperative recovery results of the three groups were compared, including intraoperative blood loss and postoperative feeding time, time of getting out of bed, hospitalization time, and defecation time. Furthermore, the incidence of common complications was also compared between the three groups.

RESULTS

There was less intraoperative blood loss in Groups A and B than in Group C (P < 0.05), and the time of getting out of bed and postoperative hospitalization and defecation times were also decreased in Group C (P < 0.05). There was no significant difference in postoperative feeding time among the three groups (P > 0.05). Each index had no statistical significance between Groups A and B (P > 0.05). The incidence of urinary retention, infection, hematoma, and hernia recurrence in Group A was less than that in Group C (P < 0.05). No significant difference was observed in the overall complication rate between Groups A and B and between Groups B and C (P > 0.05).

CONCLUSION

The application of multidisciplinary collaborative nursing combined with family care in the perioperative care of children with an inguinal hernia for ERAS may promote postoperative rehabilitation for children and reduce the incidence of complications.

Anesthetic management of inguinal hernia in an ex-premature infant with subglottic stenosis: a case report

BACKGROUND

We report the anesthetic management of inguinal hernia repair for an infant with subglottic stenosis. A previously scheduled operation had been cancelled due to unexpected airway trouble during the induction.

CASE PRESENTATION

A boy was born at 24 weeks of gestation and his trachea was intubated for 45 days. At 16 months old, surgery for inguinal hernia was planned, but cancelled due to unexpected narrow airway, and subglottic stenosis was first suspected. At 17 months old, he was transferred to us for inguinal hernia surgery. After careful discussion between the surgical team and the anesthesiologists, a strategy to manage this patient was developed. He underwent open hernia surgery under spinal anesthesia and diagnostic rigid bronchoscopy under tubeless general anesthesia separately, which revealed low-grade stenosis and some subglottic cysts. The postoperative course was uneventful.

CONCLUSION

Interdepartmental discussion weighing risks and benefits may deduce the safest and most appropriate anesthesia method.

Comparison of Postoperative Outcome in Children Undergoing Inguinal Hernia Repair Using Regional With General Versus General Anesthesia Alone: A Single Center Study

BACKGROUND

Inguinal hernia repair is one of the most common general surgical procedures. It has been performed under local, regional, or general anesthesia. We hypothesized that using regional plus general anesthesia rather than general anesthesia alone would improve outcomes in neonates and pediatric patients undergoing hernia repair.

METHODS

This is a retrospective cohort study, including all pediatric patients who underwent inguinal hernia repair from 2015-2021. We divided patients into two groups. The first group was labeled "general anesthesia" (GA), while the second group was labeled "combined general and regional anesthesia" (GA+RA). We compared both groups in terms of demographic data, intraoperative outcome variables, and postoperative outcome variables.

RESULTS

 212 children fulfilled the study criteria, with 57 in the GA group and 155 in the GA+RA group. Demographic and preoperative data were comparable between both groups except for age, which was 60.3±49.4 months in the GA group versus 26.7±33.13 months in the GA+RA group (p<.0001). Outcome variables demonstrated statistically significant improvement in postoperative pain occurrence, length of hospital stay, incidence of bradycardia, and need for mechanical ventilation in the GA+RA group in comparison to the GA group with P values of 0.031, 0.02, 0.005, and 0.02, respectively.

CONCLUSION

Using regional and general anesthesia techniques rather than general anesthesia alone is associated with a decrease in postoperative pain, length of hospital stay, incidence of bradycardia, and need for mechanical ventilation. Further studies are still warranted to validate our conclusions.

Pediatric Minimally Invasive Surgery-A Bibliometric Study on 30 Years of Research Activity

Background: Pediatric minimally invasive surgery (MIS) is a standard technique worldwide. We aimed to analyze the research activity in this field. Methods: Articles on pediatric MIS (1991−2020) were analyzed from the Web of Science™ for the total number of publications, citations, journals, and impact factors (IF). Of these, the 50 most cited publications were evaluated in detail and classified according to the level of evidence (i.e., study design) and topic (i.e., surgical procedure). Results: In total, 4464 publications and 53,111 citations from 684 journals on pediatric MIS were identified. The 50 most cited papers were published from 32 institutions in the USA/Canada (n = 28), Europe (n = 19), and Asia (n = 3) in 12 journals. Four authors (USA/Europe) contributed to 26% of the 50 most cited papers as first/senior author. Hot topics were laparoscopic pyeloplasty (n = 9), inguinal hernia repair (n = 7), appendectomy, and pyloromyotomy (n = 4 each). The majority of publications were retrospective studies (n = 33) and case reports (n = 6) (IF 5.2 ± 3.2; impact index 16.5 ± 6.4; citations 125 ± 39.4). They were cited as often as articles with high evidence levels (meta-analyses, n = 2; randomized controlled trials, n = 7; prospective studies, n = 2) (IF 12.9 ± 22.5; impact index 14.0 ± 6.5; citations 125 ± 34.7; p > 0.05). Conclusions: Publications on laparoscopic pyeloplasty, inguinal hernia repair, appendectomy, and pyloromyotomy are cited most often in pediatric MIS. However, the relevant number of studies with strong evidence for the advantages of MIS in pediatric surgery is missing.

One-Stop Surgery: An Innovation to Limit Hospital Visits in Children

INTRODUCTION

 One-stop surgery (OSS) allows for same-day outpatient clinic visit, preoperative assessment, and surgical repair. This study aims to determine the efficiency, (cost-)effectiveness, and family satisfaction of one-stop inguinal hernia surgery compared with usual care.

MATERIAL AND METHODS

 Children (≥ 3 months) with inguinal hernia and American Society of Anesthesiologists (ASA) grades I-II, scheduled for OSS (intervention) or regular treatment (control) between March 1, 2017, and December 1, 2018, were eligible for inclusion. Exclusion criteria consisted of age less than 3 months and ASA grades III-IV. The primary outcome measure was treatment efficiency (i.e., total number of hospital visits and waiting time [days] between referral and surgery). Secondary outcome measures were the effectiveness in terms of complication and recurrence rate, and parent-reported satisfaction and cost-effectiveness using the Dutch Pediatric Quality of Life Healthcare Satisfaction and Institute for Medical Technology Assessment Productivity Cost Questionnaire.

RESULTS

 Ninety-one (intervention: 54; control: 37) patients (56% boys) were included. Median (interquartile range) number of hospital visits was lower in the intervention group (1 vs 3; p < 0.001). All but one of the OSS patients (98%) were discharged home on the day of surgery. Postoperative complication (1.9% vs 2.7%; p = 0.787) and recurrence rates (0% vs 2.7%; p = 0.407) did not differ between the intervention and control patients. "General satisfaction," "satisfaction with communication," and "inclusion of family" were higher after OSS, while satisfaction about "information," "technical skills," and "emotional needs" were similar. Median (range) follow-up was 28 (15-36) months.

CONCLUSIONS

 Pediatric one-stop inguinal hernia repair seems to be an effective treatment strategy that limits the number of hospital visits and provides enhanced family satisfaction without compromising the quality of care.