Early repair of inguinal hernia in premature babies

Inguinal hernia (IH) is relatively common in premature newborn infants, and the timing of surgical correction is controversial. We studied 40 premature infants who developed an IH and who were initially treated in a neonatal intensive care unit. Birth weight (BW) ranged from 492 to 2,401 g; 21 infants had a BW less than 1,000 g. The weight of the infants at operation ranged from 1,000 to 4,400 g. Twenty-one patients underwent herniotomy within 2 weeks after the diagnosis (short waiting group), in which 1 case of incarceration occurred; 19 waited longer than 2 weeks between diagnosis and surgery (long waiting group). Two cases of strangulation occurred in this latter group, and in 1 of those testicular necrosis occurred. Operation time was analysed in boys with bilateral herniotomy (n = 25): the short waiting group (n = 12) showed a significantly reduced operation time compared to the long waiting group (n = 13). Patients weighing less than 1,000 g at birth (n = 21) had a longer average waiting period for surgery. In the group of male patients with bilateral herniotomy, average operation time was longer in the group weighing less than 1,000 g at birth (n = 13) than in the group over 1,000 g (n = 12). Body weight at surgery did not affect operation time. It is concluded that early hernia repair should be considered in premature infants to avoid operative difficulties and gonadal ischaemia caused by incarceration. Accepted: 3 July 1997     

A simplified technique for giant inguinal hernia repair in infants

Repair of giant inguino-scrotal hernia (GISH) in male infants is a difficult operation, even in experienced hands. It requires an immaculate technique to avoid known complications such as tearing of the sac, injury to delicate testicular vessels and dividing of vas deferens. Moreover, a recurrence rate of 9% is noted in a number of reports. This article describes a new surgical maneuver to simplify the procedure. All GISH repaired by the author, over a 5-year period (October 2001-September 2006), were reviewed retrospectively. In total, 89 infants with 106 GISH underwent uni- or bilateral herniotomies. A standard inguinal incision is made and Scarpa's fascia is sharply opened; the external inguinal ring and the cord is identified. By gentle manipulation and blunt dissection, the spermatic cord together with the testis is exteriorized. The assistant applies gentle traction to the cord, which allows for easy identification of the inguinal sac and its subsequent separation from vas and vessels. Testis is replaced in the scrotum, hernial sac suture ligated at its base and the wound closed in layers. All cases were managed with the above approach. The average length of the procedure was 11 min for unilateral and 19 min for bilateral cases. Except for minimal scrotal swelling post-operatively, no other surgery-related complications were noted during or immediately after the operation. Testicular atrophy or iatrogenic undescended testes were not encountered in the follow-up period. Ipsilateral recurrent hernia was noted in one infant after 6 months which required re-operation with the same technique. In cases of GISH; dislocating the testis into the wound and applying a gentle stretch on the cord allows for a safe dissection of the hernial sac and subsequent herniotomy. This maneuver converts a difficult procedure into a relatively simple one.     

Impact of wait time on outcome for inguinal hernia repair in infants

Background  Prolonged surgical wait times are a problem in many health care systems. We used data from two pediatric surgical centers, one Canadian and one American, in order to determine if increased wait times are related to rates of incarceration and adverse outcomes. Methods  Data were collected for children under the age of 2 who presented with an inguinal hernia to either the emergency department or clinic in the two hospitals in 2002 and 2003. Results  Infants in the Canadian center were older at presentation and were more likely to present to the emergency department. Wait time for hernia repair was longer in the Canadian than the American hospital (99 ± 103 vs. 27 ± 53 days, P < 0.001). The incidence of incarceration was higher in the Canadian hospital, and infants in the Canadian center were more likely to have episodes of recurrent incarceration. Emergency department usage was greater in the Canadian hospital both at the time of diagnosis as well as during the waiting period for surgery. Discussion  Prolonged wait time for inguinal hernia repair in infants is associated with a higher rate of incarceration as well as greater usage of emergency department resources. These data are important for those surgeons working in systems with limited resources in which strategies to shorten wait times are necessary.     

Early repair of inguinal hernia in preterm infants with oxygen-dependent bronchopulmonary dysplasia

Despite inguinal hernia being both common and problematic in a significant proportion of preterm infants with bronchopulmonary dysplasia (BPD), there has been a reluctance to intervene surgically for fear of exacerbating the underlying lung disease. We report our experience of early operation in 12 consecutive infants with varying degrees of oxygen-dependent BPD and investigate the effect of general anaesthesia and herniotomy on pulmonary function by measuring oxygen requirements prior to and following operation. Two infants who required oxygen in a concentration in excess of 95% failed to improve and died from the pulmonary disease 6 and 8 weeks following their operation. The remaining infants all showed a reduction in mean oxygen requirements in the weeks following operation. We conclude that, in the short term, hernia repair performed under general anaesthesia in infants with BPD of varying severity had no adverse effects on respiratory function, as determined by oxygen requirements. We suggest that in certain infants early repair may have been beneficial-potential mechanisms are explored.     

Contralateral incidence after repair of unilateral inguinal hernia in infants and children

The parents of 206 patients with unilateral inguinal hernia who underwent hernia repair at Kobe Children's Hospital in 1985 were interviewed by telephone to determine the incidence of contralateral occurence. There were 129 males and 77 females. The side of the initial hernia was the right in 120 patients and the left in 86. The age at presentation of the initial hernia ranged from 11 days to 13 years. There were 12 contralateral occurences (5.8%) These were seen in 8 males (6.6%) and 4 females (4.6%), in 6 after repair on the right side (5.0%) and 6 after repair on the left (6.9%). There was no preponderance of contralateral incidence in relation to age, sex, or original side in our series. Contralateral exploration is recommended only under circumstances in which abdominal pressure is increased by such conditions as ascites or a ventriculoperitoneal shunt. Correspondence to: T. Muraji     

Postoperative apnea after inguinal hernia repair in formerly premature infants: impacts of gestational age, postconceptional age and comorbidities

Purpose

It is common practice for premature infants undergoing elective inguinal hernia (IH) repair to be hospitalized for postoperative apnea monitoring. This study evaluated the risk of apnea after IH repair with regard to gestational age (GA) and postconceptional age (PCA) in formerly premature infants.

Methods

Formerly premature infants who had undergone elective IH repair between 01/2000 and 12/2012 were reviewed retrospectively in terms of GA, PCA, body weight, and comorbidities. All postoperative apneas were evaluated.

Results

A total of 428 formerly premature infant charts were reviewed. Eleven babies had postoperative apnea. Infants younger than 45 weeks PCA were found more prone to develop postoperative apnea after IH repair. In older infants (PCA between 46 and 60 weeks), comorbidities create predisposition to apnea postoperatively. These comorbidities are bronchopulmonary dysplasia, necrotizing enterocolitis and former apnea episodes. Anemia and lower birth weight are also risk factors.

Conclusion

This study suggests that low GA and PCA, low birth weight, anemia, and complicated past medical history affect respiratory complication rates, particularly apnea in formerly premature infants undergoing elective IH repair. Severe apneas occurred earlier than mild ones. Overnight monitoring is mandatory in small infants with low GA and PCA. Otherwise healthy, older infants may be operated on outpatient basis.     

Outcomes following laparoscopic inguinal hernia repair in infants compared with older children

Purpose

Indications for laparoscopic inguinal hernia repair in infants and children remain controversial. The purpose of this study is to compare clinical features and outcome of laparoscopic inguinal hernia repair in infants with older children.

Methods

Retrospective single centre review of all patients <16?years of age (n?=?380) undergoing laparoscopic inguinal hernia repair over a 5-year period (Jan 2005?CDec 2009). Outcomes were compared between infants (??12?months of age) with older children (1?C15?years).

Results

There was a trend towards higher recurrence rate in older children than in infants (4?% vs. 1?%; p?=?0.17). Total complications and complications requiring surgery were similar in both age groups. There was one testicular atrophy in an infant who had an incarcerated inguinal hernia. The incidence of bilateral inguinal hernia and contralateral patent processus vaginalis (PPV) were both significantly higher in infants (total 61?% compared with 35?% in older children).

Conclusions

Laparoscopic inguinal hernia repair in infants is safe and carries acceptable complication and recurrence rates. The laparoscopic approach may be particularly beneficial in infants since it allows simultaneous closure of a contralateral PPV and bilateral herniae. The outcome of laparoscopic inguinal hernia repair in older children requires further evaluation.     

Needlescopic inguinal hernia repair in children

 The object of the present study was to assess the value and outcome of needlescopy in the treatment of inguinal hernia (IH) in 150 children operated upon in Al-Mishary Hospital, Riyadh, between October 1997 and October 1999. Their ages ranged between 6 and 96 months, (mean 61.6 ± 28.32 months). There were 130 males and 20 females; 81 (54%) presented with a right-sided IH and among these patients a hidden contralateral hernia was diagnosed in 12 cases (8%). A left-sided IH was present in 30 (20%) bilateral IHs in 19 cases (12.66%), a recurrent hernia in 15 (10%), and an incarcerated hernia in 5 (3.33%). All patients were subjected to needlescopic herniotomy using a 2.7-mm telescope and two 2-mm needle holders to close the internal ring with a 4/0 PDS suture. The mean duration of surgery was 20.6 ± 4.65 min for unilateral and 26.4 ± 1.6 min for bilateral hernia repair. The mean hospital stay was 18 ± 3.23 h. The study showed that laparoscopic closure of the internal ring in children is feasible, easy, and preferable to open surgery. The fact that laparoscopy can diagnose a hidden contralateral hernia is an additional advantage. Accepted: 21 March 2001     

Why do so many small infants develop an inguinal hernia?

Prevalence and incidence of inguinal hernia in a representative sample of low birthweight survivors were determined by tracing children at 3 years of age. Prevalence was examined in relation to perinatal factors recorded in hospital case notes, using a logistic regression model to allow for confounding variables. Of the 1074 two year survivors, 995 (93%) were assessed. Seventeen per cent of 497 boys and 2% of 498 girls had a hernia by 3 years of age, a total cumulative prevalence of 9.2%: it was significantly increased by lower birth weight, male sex, neonatal intravenous feeding, and lack of respiratory disease. Neonatal illnesses were otherwise not associated with herniation, and most infants were well when they presented. Peak incidence was at the expected full term of gestation. Bilateral hernias were increasingly more common than unilateral hernias at lower gestational ages. It is proposed that causes of increased abdominal pressure in healthy neonates are important causes of herniation during a critical period of inguinal development.     

Spinal anesthesia for inguinal hernia repair in infants: a feasible and safe method even in emergency cases

Background

Inguinal hernia repair is the most frequently performed surgical procedure in infants and children. Especially in premature infants, prevalence reaches up to 30 % in coincidence with high rates of incarceration during the first year of life. These infants carry an increased risk of complications due to general anesthesia. Thus, spinal anesthesia is a topic of growing interest for this group of patients. We hypothesized that spinal anesthesia is a feasible and safe option for inguinal hernia repair in infants even at high risk and cases of incarceration.

Methods

Between 2003 and 2013, we operated 100 infants younger than 6 months with inguinal hernia. Clinical data were collected prospectively and retrospectively analyzed. Patients were divided into two groups depending on anesthesia procedure (spinal anesthesia, Group 1 vs. general anesthesia, Group 2).

Results

Spinal anesthesia was performed in 69 infants, and 31 infants were operated in general anesthesia, respectively. In 7 of these 31 infants, general anesthesia was chosen because of lumbar puncture failure. Infants operated in spinal anesthesia were significantly smaller (54 ± 4 vs. 57 ± 4 cm; p = 0.001), had a lower body weight (4,047 ± 1,002 vs. 5,327 ± 1,376 g; p < 0.001) and higher rate of prematurity (26 vs. 4 %; p = 0.017) compared to those operated in general anesthesia. No complications related to surgery or to anesthesia were found in both groups. The number of relevant preexisting diseases was higher in Group 1 (11 vs. 3 %; p = 0.54). Seven of eight emergent incarcerated hernia repairs were performed in spinal anesthesia (p = 0.429).

Conclusions

Spinal anesthesia is a feasible and safe option for inguinal hernia repair in infants, especially in high-risk premature infants and in cases of hernia incarceration.     

Testicular atrophy following inguinal hernia repair in children

Purpose

We sought to determine the incidence and timing of testicular atrophy following inguinal hernia repair in children.

Methods

We used the TRICARE database, which tracks care delivered to active and retired members of the US Armed Forces and their dependents, including?>?3 million children. We abstracted data on male children?<?12 years who underwent inguinal hernia repair (2005–2014). We excluded patients with history of testicular atrophy, malignancy or prior related operation. Our primary outcome was the incidence of the diagnosis of testicular atrophy. Among children with atrophy, we calculated median time to diagnosis, stratified by age/undescended testis.

Results

8897 children met inclusion criteria. Median age at hernia repair was 2 years (IQR 1–5). Median follow-up was 3.57 years (IQR 1.69–6.19). Overall incidence of testicular atrophy was 5.1/10,000 person-years, with the highest incidence in those with an undescended testis (13.9/10,000 person-years). All cases occurred in children \(\le\)?5 years, with 72% in children <?2 years. Median time to atrophy was 2.4 years (IQR 0.64–3), with 30% occurring within 1 year and 75% within 3 years.

Conclusion

Testicular atrophy is a rare complication following inguinal hernia repair, with children?<?2 years and those with an undescended testis at highest risk. While 30% of cases were diagnosed within a year after repair, atrophy may be diagnosed substantially later.

Level of evidence

Prognosis Study, Level II.

     

Incarcerated inguinal hernia in premature babies--a report of two cases

We highlight the morbidity of incarcerated inguinal hernia in very low birthweight (VLBW) infants by presenting a report of two cases. Our aim is to raise the question of the optimal timing of surgery when this common problem presents on the neonatal unit. In each of our cases the hernia was diagnosed but surgery was delayed, as per normal policy on the unit, pending growth of the baby and improvement in respiratory status. Both babies suffered significant morbidity when the hernias subsequently became acutely incarcerated. Conclusion: In conclusion, we question whether the widespread practice of delayed surgery for inguinal hernia in VLBW infants should be reconsidered.     

经脐双孔腹腔镜手术在小儿腹股沟嵌顿性斜疝中的应用

目的：探索经脐双孔腹腔镜手术在小儿腹股沟嵌顿性斜疝中的临床应用价值。方法回顾性分析2014年1月至2014年6月本院实施的125例腹股沟嵌顿性斜疝患儿腹腔镜手术治疗资料,并与95例传统开放手术病例进行比较。结果腹腔镜组右侧腹股沟嵌顿性斜疝89例,左侧36例。其中85例麻醉后复位;35例腹腔镜直视下手法复位;5例难复性嵌顿疝经腹股沟小切口打开外环口后腹腔镜下复位。13例患儿合并其它临床问题,其中2例嵌顿肠管浆肌层撕裂;4例嵌顿肠管合并穿孔;3例合并阑尾炎;4例美克尔憩室,同时手术处理。平均住院时间（4.4±0.3）d,术后无切口感染、阴囊血肿发生。随访9～15个月,无睾丸萎缩、复发等并发症发生。对照组右侧嵌顿80例,左侧15例,平均住院（7.4±4.3）d,术后切口感染3例,阴囊血肿10例,睾丸萎缩3例,复发3例。结论经脐双孔腹腔镜手术治疗婴幼儿腹股沟嵌顿性斜疝是一种安全的微创手术,具有损伤小、恢复快、住院时间短等优点,特别是在处理复杂性嵌顿疝时优点更突出,值得临床推广。     

Laparoscopic repair of sliding inguinal hernia in female children

Purpose

To evaluate the safety and feasibility of laparoscopic repair of sliding inguinal hernia in female children.

Methods

Laparoscopic percutaneous extraperitoneal closure (LPEC) was performed in 482 female inguinal hernia children between 2006 and 2015. Fourteen of these patients were associated with sliding inguinal hernia, and these 14 patients were enrolled and reviewed retrospectively.

Results

The mean age and the body weight at the operation was 9.6 months and 7.8 kg. Seven patients required the reduction of the ovary under general anesthesia. Laparoscopy, however, revealed that five patients had severe sliding of fallopian tube into the inguinal canal. One of these five patients received a simple LPEC, but developed the recurrence due to the low ligation of the hernia sac, and needed the second hernia repair under inguinal approach. Other four patients with fallopian tube sliding required the dissection of the fallopian tube and peritoneal repair, or the conversion to inguinal approach; therefore they had longer surgical time compared to those without fallopian tube sliding.

Conclusion

LPEC is safe and feasible for the sliding inguinal hernia repair except the cases with fallopian tube sliding. Patients with fallopian tube sliding required additional procedure or conversion to inguinal approach.

     

Scrotal approach for inguinal hernia and hydrocele repair in boys.

PURPOSE: The scrotal approach to repairing inguinal hernias and hydroceles in boys is a relatively new approach, which offers the paediatric surgeon the choice of leaving a more cosmetically acceptable scar. This paper reports the experience of one centre using this approach. METHODS: 195 consecutive repairs in 176 boys were studied. The operative technique is described. RESULTS: With an average follow-up of 13 months, there was one recurrence. There were no wound infections. Testicular size was equal or larger than the contralateral testicle in all but two cases. All boys had an excellent cosmetic result. CONCLUSION: The scrotal approach for inguinal hernia or hydrocele repair is a safe procedure without added morbidity and with excellent cosmetic results.     

腹腔镜手术治疗婴幼儿食管裂孔疝的探讨

目的 探讨腹腔镜手术治疗婴幼儿食管裂孔疝的安全性和疗效.方法 2001年9月至2010年1月对34例婴幼儿食管裂孔疝患儿施行食管裂孔修补Nissen胃底折叠术.其中3例产前超声诊为"膈疝",术前造影1例合并肠旋转不良同时在腹腔镜下行Ladd's手术,1例合并胃排空延迟同时在腹腔镜下完成幽门成形术,1例合并右侧腹股沟斜疝同时在腹腔镜下完成疝囊高位结扎手术.结果 34例中1例中转开腹,其余33例均在腹腔镜下完成食管裂孔修补Nissen胃底折叠术.年龄最小2 h,手术时间平均122min(100～210min);术中出血量平均5ml(1～10ml);术后24～48 h进奶,术后住院4～12 d,平均6.5 d.26例术后随访1个月～6年,1例术后6 d出现呕吐,给予胃动力药物(吗丁啉)治疗后好转;2例患儿于术后1年及1年半复发,均再次行腹腔镜食管裂孔修补术治愈;其余生长发育正常,无明显并发症发生.结论 本研究证实了腹腔镜手术治疗婴幼儿食管裂孔疝具有明显优势,创伤小,疗效确切,可以联合治疗其他疾病,不会造成脏器粘连,对复发病例二次手术时仍可采用腹腔镜技术;即使食管旁疝和混合疝无症状也应早期手术.术者应具备新生儿手术经验及熟练的腔镜操作基础.     

Risk of testicular lesions following incarcerated inguinal hernia in infants

Several reports with conflicting results have been published describing the incidence of testicular lesions resulting from incarcerated inguinal hernia. At the Department of Pediatric Surgery of the University of Graz, 178 children were treated for 180 incarcerated inguinal hernias from 1978 to 1985; 124 infants with suspected testicular lesions were followed up in 1984. The size of the testicles was determined using the Prader of the testicles was determined using the Prader orchidometer and comparing both testicles. In 18 children (14.4%) distinct testicular lesions were found. Infants less than 2 months old showed a significantly higher incidence of testicular lesions than older children (33.3% vs. 6.8%). Children in whom operative reduction of the incarcerated hernia was necessary had a significantly higher incidence of testicular atrophy than children in whom preoperative reduction was successful (29.0% vs. 9.6%). Our study shows that risk factors such as age, time of reduction, histologically proven hemorrhagic infarction, and undescended testis are of prognostic value. Offprint requests to: G. Fasching