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ORIGINAL ARTICLE
Year : 2019  |  Volume : 7  |  Issue : 1  |  Page : 21-25

Inguinal herniotomy: A national survey


Department of Surgery, Faculty of Medicine, Umm Al-Qura University, Mecca; Department of Surgery, King Faisal Specialist Hospital and Research Centre, Jeddah, Saudi Arabia

Date of Web Publication14-Mar-2019

Correspondence Address:
Dr. Osama Abdullah Bawazir
Associate Professor, Department of Surgery, Faculty of Medicine, Umm Al-Qura University, P. O. Box 715, Makkah 21955
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ssj.ssj_48_18

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  Abstract 

Objectives: The objective of this study was to evaluate and describe the current practice of surgical repair of inguinal herniotomy among pediatric surgeons working in Saudi Arabia.
Materials and Methods: Between May and June 2018, a questionnaire of 15 multiple choices was sent to all pediatric surgery consultants working in pediatric surgery units across the kingdom of Saudi Arabia. The responses to the questionnaire were analyzed and categorized as shown in the results section.
Results: A total of 215 questionnaires were sent, over half of the practitioners fill the questionnaire 56.3% (121). With fair distribution, among type of hospitals were 33% in children hospital, 33% in tertiary hospital, 7% in private hospital, and 8% in general or academic hospitals. Regarding the diagnosis, almost all the surgeons depend on the mother history of a swelling in the groin that comes and goes. The majority (97%) of surgeon will do a standard open herniotomy for male infants, and only 2% will do laparoscopic hernia repair. For ex-premature infants with an inguinal hernia and already discharged from the neonatal intensive care unit, 35% will repair the hernia at presentation regardless of the age, 27% will do it after 50 weeks of postmenstrual age, 18% will do it after 60 weeks of postmenstrual age, 12% will do it after 2 months or above 5 kg weight, and only 8% will do it on urgent basis.
Conclusions: The majority of pediatric surgeons depend on a clinical diagnosis of inguinal hernia. Although the timing of surgical repair is still controversial, the majority of pediatric surgeons will repair inguinal hernia as soon as possible. Still, there is no consensus on when or if contralateral inguinal exploration is necessary.

Keywords: Inguinal herniotomy, pediatric surgeons, survey


How to cite this article:
Bawazir OA. Inguinal herniotomy: A national survey. Saudi Surg J 2019;7:21-5

How to cite this URL:
Bawazir OA. Inguinal herniotomy: A national survey. Saudi Surg J [serial online] 2019 [cited 2019 May 26];7:21-5. Available from: http://www.saudisurgj.org/text.asp?2019/7/1/21/254114


  Introduction Top


Pediatric inguinal herniotomy is the second most commonly performed operations done by pediatric surgeons for male children in Saudi Arabia after circumcision. It is the most frequently performed operation performed by pediatric surgeons worldwide.[1],[2],[3] Open inguinal herniotomy continues to be the main method of inguinal hernia repair among all pediatric surgeons. There is, however, significant variability in the timing of the repair and exploration of the contralateral site. There is also an increasing variability in the method of inguinal herniotomy, laparoscopic versus open repair. These variations are not very clear among pediatric surgeons working in Saudi Arabia. This study was undertaken to evaluate and describe the current practice of the surgical repair of inguinal herniotomy among pediatric surgeons working in Saudi Arabia.


  Materials and Methods Top


In June 2017, a questionnaire of 15 multiple choices was sent to all pediatric surgery consultants working in pediatric surgery units across the kingdom of Saudi Arabia. This questionnaire was approved by the Institutional Review Board. There were 15 multiple choice questions that included several aspects of inguinal hernia in children. The responses to the questionnaire were analyzed and categorized as shown in the results section.


  Results Top


Diagnosis

Regarding the diagnosis, almost all the surgeons depend on the mother history of a swelling in the groin that comes and goes, and 57% of them will confirm the diagnosis by a positive glove silk sign on physical examination. Only 15% of them will ask for ultrasound of the groin to confirm the diagnosis [Figure 1].
Figure 1: Diagrammatic representation of the diagnosis of inguinal hernia

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Inguinal herniotomy for male infants

The majority (97%) of surgeon will do a standard open herniotomy and only 2% will do laparoscopic hernia repair [Figure 2]. In full-term infants with reducible inguinal hernia, 48% will repair it electively (4 weeks or more) while 43% will try to do it within 1–2 weeks of diagnosis. Only 5% of them will do it on urgent basis. For full-term male infants weighing 3 kg or less with reducible inguinal hernia, 53% of the surgeons will repair it regardless of the weight or gestational age, 18% will operate when the gestational age is 44 weeks or more, and only 17% will wait until the baby is more than 2 months old or his weight above 5 kg [Figure 3] and [Figure 4]. Regarding contralateral exploration, 68% will not explore the contralateral side if not clinically apparent, 23% will explore if a contralateral hernia was identified by preoperative ultrasound, 15% will explore if the presenting hernia is on the left, and only 15% will treat a contralateral hernia if they find a patent process vaginalis during laparoscopic hernia repair
Figure 2: Diagrammatic representation of the method of inguinal herniotomy for full-term infants

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Figure 3: Diagrammatic representation of the management of full-term infants with reducible inguinal hernia

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Figure 4: Diagrammatic representation of inguinal herniotomy for full-term infants who are 3 weeks old and weighing 3 kg with reducible inguinal hernia

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Inguinal herniotomy for female infants

The majority (95%) of surgeon will do a standard open herniotomy and only 5% will do laparoscopic hernia repair. In full-term girls with reducible inguinal hernia, 48% will repair it electively (4 weeks or more) and 48% will repair within 1–2 weeks from the diagnosis. Only 3% will repair it on urgent basis. In full-term infant girls with asymptotic but palpable ovaries in the groin, 40% will repair it on the urgent basis, and 55% will repair in next available opportunity (within 1–2 weeks). Regarding contralateral exploration, 55% will not explore the contralateral side, 20% will explore if the contralateral hernia is identified by preoperative ultrasound, 15% will explore if the hernia was discovered initially on the left, and 18% will explore if they find patent process vaginalis during laparoscopic hernia repair.

Inguinal herniotomy for ex-premature infants

For ex-premature infants diagnosed to have an inguinal hernia and are still in neonatal intensive care unit (NICU), 80% will repair the hernia before discharge and 13% will do it after 50 weeks of postmenstrual age. For ex-premature infants with an inguinal hernia and already discharged from the NICU, 35% will repair the hernia at presentation regardless of the age, 27% will do it after 50 weeks of postmenstrual age, 18% will do it after 60 weeks of postmenstrual age, 12% will do it after 2 months or above 5 kg weight, and only 8% will do it on urgent basis. All the surgeons will do the repair by open standard technique and 20% of surgeon will explore the contralateral site in preterm babies [Figure 5] and [Figure 6].
Figure 5: Diagrammatic representation of inguinal herniotomy for ex-premature infants 31 weeks, 1.5 kg in the neonatal intensive care unit with reducible hernia

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Figure 6: Diagrammatic representation of inguinal herniotomy for ex-premature infants already discharged from the neonatal intensive care unit with reducible hernia

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Anesthesia

For full-term babies, 72% are given general anesthesia with caudal block and 18.3% use general anesthesia only. For the ex-premature infants, only 32% will use general anesthesia with caudal block, 35% will use general anesthesia only, and 15% will use general anesthesia with local block.

Pain control

Almost all surgeons use paracetamol or Tylenol for postoperative analgesia in addition to local anesthesia (27%), regional anesthesia (18%), and 12% with nonsteroid anti-inflammatory drug (12%).


  Discussion Top


The incidence of inguinal hernias is approximately 3%–5% in term infants and 13% in infants born at <33 weeks of gestational age.[1],[4] Inguinal hernia repair is one of the most common pediatric operations performed worldwide.[1],[2] This is also the case in Saudi Arabia where inguinal herniotomy is the second most common operation performed after neonatal circumcision. All pediatric inguinal hernias require operative treatment to prevent the development of complications, mostly inguinal hernia incarceration or strangulation and gonadal infarction and atrophy.[1],[2],[5],[6] However, these risks must be balanced against the risk of potential operative and anesthetic complications. Inguinal herniotomy in infants is a routine day surgery procedure. However, numerous issues, including timing of the repair, the need to explore the contralateral side, laparoscopic versus open repair, and anesthetic and analgesia approach, remain unsettled. The purpose of this study was to answer some of these controversies among pediatric surgeons working in Saudi Arabia.

The timing of inguinal herniotomy in infants is important to avoid well-known and serious complications, namely, incarceration and strangulation. In an analysis of a Canadian administrative database containing more than 1000 children with inguinal hernia, Zamakhshary et al. showed that children younger than 1 year had a twofold greater risk of inguinal hernia incarceration when repair was performed ≥14 days after the diagnosis compared with children who had repair performed between 1 and 2 years of age.[7] In Saudi Arabia, 48% of pediatric surgeons will repair it electively (4 weeks or more) while 43% will do it within 1–2 weeks of diagnosis and only 5% of them will do it on urgent basis. This, however, is not the case for ex-premature with inguinal hernia where 80% will repair the hernia before discharge from NICU and 13% will do it after 50 weeks of postmenstrual age. For ex-premature infants with an inguinal hernia and already discharged from the NICU, 35% will repair the hernia at presentation regardless of the age, 27% will do it after 50 weeks of postmenstrual age, 18% will do it after 60 weeks of postmenstrual age, 12% will do it after 2 months or above 5 kg weight, and only 8% will do it on urgent basis. Vaos et al. reported a retrospective analysis of preterm infants undergoing inguinal hernia repair at one of two institutions.[8] They noted that infants undergoing repair later than 1 week after diagnosis were at significantly greater risk of inguinal hernia incarceration, postoperative hernia recurrence, and testicular atrophy compared with infants undergoing earlier repair. Lautz et al. analyzed the risk of inguinal hernia incarceration in approximately 49,000 preterm infants.[9] They found that the overall rate of inguinal hernia incarceration was approximately 16% and that the risk was greatest in infants in whom surgery was delayed beyond 40 weeks' corrected gestational age (21%) compared with those repaired between 36 and 39 weeks' (9%) corrected age or <36 weeks' corrected gestational age (11%). Furthermore, it was found that 28% of preterm infants undergoing repair following discharge from NICU and during a subsequent hospitalization were noted to have inguinal hernia incarceration, suggesting an even greater risk with further delay. Lee et al., on the other hand, reported only a 4.6% rate of hernia incarceration in 172 former preterm infants and of 127 infants who were discharged from the NICU with known inguinal hernias and scheduled for a planned elective outpatient hernia repair, there were no episodes of inguinal hernia incarceration while awaiting repair.[10] Uemura et al. reported comparable inguinal hernia incarceration rates in 19 preterm infants who underwent repair at more than 2 weeks after diagnosis when compared with 21 preterm infants who underwent inguinal hernia repair at more urgent basis.[11] The timing of inguinal hernia repair in infants continues to be controversial and although some studies suggest that inguinal hernia repair can be delayed, these studies not as compelling as those suggesting inguinal herniotomy on a more urgent basis. This is more so in ex-premature infants with inguinal hernia where the majority will repair the hernia before discharge from the NICU. In a 2005 survey of members of the American Academy of Pediatrics Section on Surgery, 63% reported routinely performing hernia repairs just before discharge from the NICU, 18% performed repairs at a specific-corrected gestational age, and 5% performed repairs when it was convenient.[12] It is also important to keep in mind that inguinal herniotomy is associated with operative complications, including postoperative apnea in preterm infants which can be as high as 49%, hernia recurrence, vas deferens injury, and testicular atrophy, the rates of which vary from 1% to 8%.[2],[5],[6],[7],[8],[9],[10],[11],[12],[13],[14] Vaos et al. noted that preterm infants undergoing inguinal hernia repair within 1 week of diagnosis experienced a significantly greater rate of apnea compared with those undergoing repair later.[8] On the other hand, Melone et al. reported only two infants who experienced episodes of apnea among a cohort of 127 former preterm infants (mean gestational age, 32.7 weeks) who underwent outpatient inguinal hernia repair at a mean-corrected gestational age of 45.3 weeks.[15] Lee et al. reported no episodes of apnea in a cohort of preterm infants (30.7 weeks' gestation at birth) undergoing outpatient elective hernia repair, but 13 of 45 former preterm infants who underwent elective inguinal hernia repair before discharge from the NICU remained intubated for longer than 2 days postoperatively.[10]

Another area of debate is contralateral inguinal exploration in children who present with unilateral inguinal hernia.[16] In our review, 68% of pediatric surgeons will not explore the contralateral side if not clinically apparent, 23% will explore if a contralateral hernia was identify by preoperative ultrasound, and 15% will explore if the presenting hernia is on the left. Only 15% will treat a contralateral hernia if they find a patent process vaginalis during laparoscopic hernia repair. This controversy was also apparent in the 2005 survey of the American Academy of Pediatrics Section on Surgery members. This survey revealed that 15% will never explore the contralateral side in a male patient, 12% will always explore the contralateral side, and 73% responded that they had an age cut-off beyond which they would not explore.[12] Marulaiah et al. suggested that routine contralateral inguinal exploration is not indicated, taking in consideration, the risks associated with contralateral exploration, such as spermatic cord injury.[17] Alternatively, given the high incidence of subsequent hernias if a contralateral PPV is encountered, others support routine exploration.[18],[19],[20],[21] Lee et al. indicated that it is cost-effective to perform routine contralateral inguinal explorations.[22] Currently, the number of pediatric surgeons performing routine explorations of the contralateral side is decreasing. This, however, is not the case in those performing laparoscopic hernia repairs as inspection and repair of the contralateral internal ring has become increasingly popular.[23],[24],[25],[26],[27],[28],[29] Surprisingly, in our survey, only 18% of pediatric surgeons who perform laparoscopic inguinal hernia repair will explore the contralateral side. Although there are several reports supporting routine laparoscopic inguinal hernia repair in infants and children, only 2% in our survey will do laparoscopic hernia repair in male children and 5% will do it in females with inguinal hernia. The results of laparoscopic inguinal hernia repair were reported to be comparable to those treated by the open technique. A prospective, randomized, single-blinded trial comparing laparoscopic to open repair of inguinal hernias showed that children who were older than 3 months of age when laparoscopic repair was performed required significantly fewer doses of pain medication.[27]


  Conclusions Top


Inguinal hernia is common in infants and children and should be repaired to avoid the well-known associated complications. The majority of pediatric surgeons depend on a clinical diagnosis of inguinal hernia. Although the timing of surgical repair is still controversial, the majority of pediatric surgeons will repair inguinal hernia as soon as possible. Still, there is no consensus on when or if contralateral inguinal exploration is necessary. Although the results of laparoscopic herniotomy are comparable to the standard open technique, laparoscopic inguinal herniotomy is still not a very popular technique. These continuing controversies call for evidence-based approaches to inguinal hernias in infants, and consideration should be given to large, prospective, randomized, controlled trials to answer these important controversies.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

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Chang SJ, Chen JY, Hsu CK, Chuang FC, Yang SS. The incidence of inguinal hernia and associated risk factors of incarceration in pediatric inguinal hernia: A nation-wide longitudinal population-based study. Hernia 2016;20:559-63.  Back to cited text no. 1
    
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Puri P, Guiney EJ, O'Donnell B. Inguinal hernia in infants: The fate of the testis following incarceration. J Pediatr Surg 1984;19:44-6.  Back to cited text no. 5
    
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Rescorla FJ, Grosfeld JL. Inguinal hernia repair in the perinatal period and early infancy: Clinical considerations. J Pediatr Surg 1984;19:832-7.  Back to cited text no. 6
    
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Zamakhshary M, To T, Guan J, Langer JC. Risk of incarceration of inguinal hernia among infants and young children awaiting elective surgery. CMAJ 2008;179:1001-5.  Back to cited text no. 7
    
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Vaos G, Gardikis S, Kambouri K, Sigalas I, Kourakis G, Petoussis G, et al. Optimal timing for repair of an inguinal hernia in premature infants. Pediatr Surg Int 2010;26:379-85.  Back to cited text no. 8
    
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Lautz TB, Raval MV, Reynolds M. Does timing matter? A national perspective on the risk of incarceration in premature neonates with inguinal hernia. J Pediatr 2011;158:573-7.  Back to cited text no. 9
    
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Lee SL, Gleason JM, Sydorak RM. A critical review of premature infants with inguinal hernias: Optimal timing of repair, incarceration risk, and postoperative apnea. J Pediatr Surg 2011;46:217-20.  Back to cited text no. 10
    
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Harvey MH, Johnstone MJ, Fossard DP. Inguinal herniotomy in children: A five year survey. Br J Surg 1985;72:485-7.  Back to cited text no. 14
    
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Melone JH, Schwartz MZ, Tyson KR, Marr CC, Greenholz SK, Taub JE, et al. Outpatient inguinal herniorrhaphy in premature infants: Is it safe? J Pediatr Surg 1992;27:203-7.  Back to cited text no. 15
    
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Kaneda H, Furuya T, Sugito K, Goto S, Kawashima H, Inoue M, et al. Preoperative ultrasonographic evaluation of the contralateral patent processus vaginalis at the level of the internal inguinal ring is useful for predicting contralateral inguinal hernias in children: A prospective analysis. Hernia 2015;19:595-8.  Back to cited text no. 16
    
17.
Marulaiah M, Atkinson J, Kukkady A, Brown S, Samarakkody U. Is contralateral exploration necessary in preterm infants with unilateral inguinal hernia? J Pediatr Surg 2006;41:2004-7.  Back to cited text no. 17
    
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Holcomb GW 3rd, Morgan WM 3rd, Brock JW 3rd. Laparoscopic evaluation for contralateral patent processus vaginalis: Part II. J Pediatr Surg 1996;31:1170-3.  Back to cited text no. 18
    
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Valusek PA, Spilde TL, Ostlie DJ, St Peter SD, Morgan WM 3rd, Brock JW 3rd, et al. Laparoscopic evaluation for contralateral patent processus vaginalis in children with unilateral inguinal hernia. J Laparoendosc Adv Surg Tech A 2006;16:650-3.  Back to cited text no. 19
    
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Lee SL, Sydorak RM, Lau ST. Laparoscopic contralateral groin exploration: Is it cost effective? J Pediatr Surg 2010;45:793-5.  Back to cited text no. 22
    
23.
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Shalaby R, Ismail M, Dorgham A, Hefny K, Alsaied G, Gabr K, et al. Laparoscopic hernia repair in infancy and childhood: Evaluation of 2 different techniques. J Pediatr Surg 2010;45:2210-6.  Back to cited text no. 24
    
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Takehara H, Yakabe S, Kameoka K. Laparoscopic percutaneous extraperitoneal closure for inguinal hernia in children: Clinical outcome of 972 repairs done in 3 pediatric surgical institutions. J Pediatr Surg 2006;41:1999-2003.  Back to cited text no. 27
    
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29.
Gause CD, Casamassima MG, Yang J, Hsiung G, Rhee D, Salazar JH, et al. Laparoscopic versus open inguinal hernia repair in children≤3: A randomized controlled trial. Pediatr Surg Int 2017;33:367-76.  Back to cited text no. 29
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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