Journal of Pediatric Surgery (2005) 40, 1163 – 1166

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Evidence-based change of practice in the management of unilateral inguinal hernia
Sengamalai Manoharan, Udayangani Samarakkody*, Milind Kulkarni, Russell Blakelock, Stuart Brown
Department of Pediatric Surgery, Waikato Hospital, Hamilton 2001, New Zealand Index words:
Inguinal hernia; Contralateral inguinal exploration

Abstract Purpose: Contralateral inguinal exploration in children with unilateral inguinal hernia is still controversial. Only 20% of patients with patent processus vaginalis would develop a clinically apparent hernia [Miltenburg DM, Nutctern JG, Jaksic Tkozinetz CA. Meta-analysis of the risk of metachronous hernia in infants and children. Am J Surg 1997;174:741-4]. In 1999, our unit changed the practice of performing routine contralateral inguinal exploration of male children younger than 2 years and female children younger than 5 years to inguinal herniotomy of the symptomatic side only based on a metaanalysis published by Miltenburg et al [Meta-analysis of the risk of metachronous hernia in infants and children. Am J Surg 1997;174:741-4]. We explored the contralateral inguinal area only in babies with a history of prematurity. Methods: A prospective study of patients subjected to unilateral inguinal herniotomy from 1999 to 2001 was performed. Age, sex, side of the hernia, and incarceration at presentation were recorded. The incidence of metachronous inguinal hernia (MIH) and its risk factors were analyzed. The follow-up ranged from 36 to 72 months. Results: Of the 409 patients who presented with inguinal hernia, 264 underwent unilateral inguinal herniotomy. The rest were either children with bilateral inguinal hernia or premature babies who were offered bilateral inguinal herniotomy. Of these 264 patients, 180 (68%) had right-sided inguinal hernia and 84 (32%) had left-sided inguinal hernia. Fourteen (5%) patients subsequently presented with MIH. Of these 14 patients, 8 were younger than 2 years at the initial presentation and 11 originally presented with left-sided inguinal hernia. No female child presented with MIH. Twelve (85%) re-presentations with MIH occurred within 1 year of the original operation. Conclusions: The treatment of only the symptomatic inguinal hernia has not significantly increased the incidence of MIH. This evidence-based change of practice has avoided 152 operations in 264 patients. Presentation with incarceration and age at presentation have no significant impact on the incidence of MIH. Left-sided presentation has a statistically significant high incidence of MIH. D 2005 Elsevier Inc. All rights reserved.

Contralateral inguinal exploration in children with unilateral inguinal hernia has been the subject of discussion over
T Corresponding author. Tel.: +64 7 8398716; fax: +64 7 839 8765. E-mail address: samaraku@waikatodhb.govt.nz (U. Samarakkody). 0022-3468/$ – see front matter D 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.jpedsurg.2005.03.044

many decades. This was brought about by many reports in the 1950s indicating the presence of patent processus vaginalis (PPV) on the contralateral side. There have been many options taken by pediatric surgeons on the management of potential contralateral hernia. These include (1) observation

74 . 1. 3 developed MIH ( P = . Both patients had incarcerated hernias at first presentation. the number of male children younger than 2 years was 119 (45%) and that of female children younger than 2 years was 18 (6. 2 re-presented with MIH with no associated UDT on that side. Hospital charges for unilateral and bilateral hernia repair at this hospital were estimated. These patients were excluded from the study. Results Of the 409 children. Of the 14 patients with MIH. 2 developed an MIH ( P = .8%) 14 (6. 8 were younger than 2 years at first presentation. 1-10 months). Fourteen of these children had ipsilateral orchidopexy for undescended testis (UDT) at the same time. These 14 patients were followed up separately as a different group from the main body of the study population. Fisher’s Exact test).7%) 6 (6.005. all male children younger than 2 years and all female children younger than 5 years underwent routine contralateral exploration in the Waikato Hospital Department of Pediatric Surgery. Hernia was considered incarcerated when an unsuccessful attempt was made to reduce it by the primary referring medical officers such as general practitioners.0003 . Manoharan et al. hernia was able to be reduced by manipulation in 47 of these patients by the attending pediatric surgeons and taken to theater on a semiurgent basis. respectively. The remaining 264 patients who underwent unilateral herniotomy without orchidopexy formed the cohort for this study. sex. The remaining 10 patients underwent emergency surgery (3. Of the 132 telephonic contact attempts. The hernia was on the right side in 180 (68%) patients and on the left side in 84 (32%).0%) 8 (6. Of them. and the need for postoperative cardiorespiratory monitoring [6]. However. When these babies presented with a hernia at or before the postconceptual age of 56 weeks. The incidence of MIH and its risk factors were analyzed.3%) Total no. Of the 264 patients. and pediatricians. Fifty-seven (21%) patients presented with incarceration to the emergency department. S. Materials and methods This is a prospective study of 409 children who underwent inguinal herniotomy in the pediatric surgical unit of the Waikato Hospital between March 1999 and December 2001. 132 of the 264 children were selected randomly and their parents were contacted for a telephone interview to check for any unlikely presentation of MIH managed outside our hospital. Followup was done routinely at 1 month and 1 year after the surgery.074).08 2. of patients 180 84 57 207 214 50 119 95 P Characteristics Side Right Left Incarcerated Nonincarcerated Sex Boys Girls Boys b2 y z2 y . The follow-up ranged from 36 to 72 months. In June 2004.3]. (2) routine contralateral groin exploration with repair of a hernia if present (routine exploration) [2.7%). The follow-up attendance rate was 92% (242/264) and 68% (180/264) at 1 month and 1 year. 131 underwent bilateral inguinal herniotomy (99 patients for prematurity. None of the contacted patients reported occurrence of metachronous hernia treated elsewhere. The abovementioned results are tabulated in Table 1. Of the 84 original left-sided presentations. The number of female children younger than 5 years was 33 (12%). Premature babies were defined as babies born at or before 37 weeks of gestation. A total of 278 children underwent unilateral herniotomy.8%).1164 and repair of a metachronous hernia only if it becomes clinically apparent (observation) [1. Of these 14.5%) 0 (0.2]. This practice was changed after the meta-analysis of the risk of metachronous inguinal hernia (MIH) in infants and children as published by Miltenburg et al [5] to unilateral herniotomy with selective open contralateral exploration only in premature babies. the success rate was 102. 12 re-presented within 1 year of the first operation (range. which is a SQL-Server patient costing program. 32 for synchronous 1. Of the separate group of 14 patients who underwent simultaneous orchidopexy. and subsequent presentation with an MIH.0 .7%) 11(13. laterality of the presenting hernia. No female child developed MIH. In this prospective study. and (3) laparoscopy to evaluate the contralateral groin with repair of a contralateral hernia if present (laparoscopy) [4]. Of the 57 children who originally presented with incarcerated hernia. The categorical variables were compared using Fisher’s Exact test. bilateral hernia). high probability of apneas.1%) 2 (3. they were offered contralateral exploration because of the comorbidities. we attempt to identify the incidence of MIH and the risk factors associated with such re-presentations.5%) 12 (5. whereas of the 180 rightsided presentations. Until 1999. 11 cases re-presented with MIH. Cost analysis was done by Costpro. Fourteen (5%) children presented with an MIH. The patients who underwent repair for synchronous bilateral inguinal hernia and premature babies were excluded from the study. emergency department doctors. Table 1 Summary of results No. 214 (81%) were boys and 50 (19%) were girls. of patients with MIH 3 (1. incarceration of the hernia at presentation. The patients who presented with MIH were further followed up after the second operation. All the patients who underwent ipsilateral herniotomy only were followed up with special emphasis on the age at presentation.

The risk of MIH in children with unilateral incarcerated hernia has been analyzed by Tackett et al [1]. Therefore.70 Average theater time (min) 64 77 1165 Treatment/Procedure Unilateral hernia repair Bilateral hernia repair Baseline costs for children undergoing unilateral and bilateral hernia repair in Waikato hospital are shown in Table 2. Since the publication in 1997 of the metaanalysis by Miltenburg et al [5]. 137 were younger than 2 years. including our study. and reduction of fertility rate.8% to 4. did not include premature babies. a recommendation for a contralateral exploration cannot be made when the initial presentation is with incarceration. recurrent hernia. The rarity of incarceration at re-presentation should assist in reducing the parental anxiety of the morbidity associated with incarceration such as wound infection. intraoperative probing of the opposite processus vaginalis. The incidence of metachronous hernia in our study is 5%. and laparoscopy. Eight of these 137 patients developed MIH as opposed to 6 of the 127 patients who are older than 2 years (no statistical significance). The reported incidence of MIH is much lower than that of PPV. (2) an increased incidence of incarceration and potential damage to the spermatic cord and the testis from incarceration [12]. specific. However.005. Their study was confounded by the fact that premature babies also contributed to the cohort. 20 months). were excluded from our study group and offered contralateral exploration because they have (1) a high rate of bilaterality (28. the patients who had a metachronous presentation were signif- icantly younger (median. The risks associated with the contralateral exploration are the damage to the spermatic cord structures including the vas deferens. In our study. Discussion The incidence of inguinal hernia in the younger-than18-years age group varies from 0.15]. testicular atrophy. and (3) an increased incidence of postoperative apnea in former premature infants up to the postconceptual age of 56 weeks [6]. Demirkan et al [16] recommend contralateral exploration for left-sided presentations if the patient is a girl younger than 2 years [16]. However. 3. Fisher’s Exact test). Many studies have indicated the initial presentation of left-sided inguinal hernia as a risk factor for metachronous presentation [14. Our study failed to demonstrate a higher incidence of MIH in the incarcerated group (2/57 vs 12/207). In their meta-analysis.4% [7]. intestinal obstruction.44 NZ $1737. Many studies. ultrasound scan.0%) and MIH (14. Perhaps more studies that include premature babies are necessary to vindicate the importance of the side of the initial presentation. The few options available are preoperative herniography. testicular atrophy. These 11 representations with MIH of the 84 initial left-sided presentations are statistically significant when compared with the 3 re-presentations with MIH of the 180 initial right-sided presentations ( P = . and intestinal necrosis. Tackett et al [1] included premature babies in their study and failed to demonstrate left-sided hernia as a risk factor. Most of these patients present with a unilateral hernia. the practice was changed to unilateral herniotomy for the unilateral presentation except in premature infants. Laparoscopy may be the ideal tool to diagnose a contralateral PPV intraoperatively—it is sensitive. The rate of patency of the processus vaginalis is inversely related to the age of a baby. Laparoscopy is an . These complications are interrelated. there is a 7% chance that an MIH requiring surgical treatment will develop subsequently [5] whereas the rate of PPV could be up to 61% [8-10] Many diagnostic tools are used by pediatric surgeons to identify the group that is likely to present with an MIH so that unnecessary inguinal explorations are eliminated and future hernias are detected and treated at the same time. None of the girls developed an MIH in our study. up to the postconceptual age of 56 weeks. and safe. Observation of the contralateral side results in the lowest incidence of injury to the spermatic cord as compared with the routine exploration or laparoscopy [2]. In the study by Ikeda et al [13]. fast. The premature and former premature babies. its clinical significance is open to debate because one would have to perform 84 contralateral explorations to avoid 11 representations. 11 initially presented with a left-sided hernia. This is also confirmed by Ikeda et al [13] on their follow-up of 2935 patients. Our study has the advantage of excluding premature babies who have a higher incidence of incarceration at presentation.8%) [1]. 14 months) than the control patients (median. among the 14 patients who developed MIH. the presence of a PPV does not imply that a patient will go on to develop a metachronous hernia.Evidence-based change of practice in the management of unilateral inguinal hernia Table 2 Baseline costs Estimated charge NZ $1413. Miltenburg et al [5] could not demonstrate a statistically significant risk at a younger age. A similar observation has been made in the maximum achievable fertility rate [2]. Among the children undergoing unilateral inguinal repair. The knowledge that there is a higher chance of a hernia occurring on the other side when initial presentation is on the left side may help warn parents rather than justify the contralateral exploration. diagnostic pneumoperitoneum (Goldstein’s test). Our data show that being female is predictive of being at reduced probability of developing an MIH relative to being male. Of the 264 patients in our study group. We were practicing routine open exploration in a selective group of patients guided by previous reports of the high incidence of PPV on the contralateral side in young patients [11]. Many studies have shown that there is no statistically higher incidence of MIH related to younger age or sex [5]. Identifying and ligating a patent processus should certainly prevent the development of an indirect inguinal hernia [4].

The average theater time for a unilateral herniotomy is approximately 64 minutes and that for bilateral herniotomy is approximately 77 minutes. Nuchtern JG.5. References [1] Tackett LD.9.171:287 . If we had followed our previous practice of contralateral exploration. Bass J. Jaksic T. [6] Charles J.161:596 .52 in direct costs. Downes J. There can be added costs that may not be easy to define such as lost parental wages and cost of fertility assessment and treatment later in life. [3] Hrabovszky Z. Inguinal hernia repair in early infancy.90. Inguinal hernia in children—a study of 1000 cases and a review of the literature. J Pediatr Surg 1995.287.7. Laparoscopic evaluation of the paediatric inguinal hernia—a meta-analysis. Elbonim C. [13] Ikeda H. Routine bilateral exploration for inguinal hernia in infancy and childhood. Manoharan et al. Rubin S. Abrahams MW. J Pediatr Surg 1969.1.4.30:1195 . J Pediatr Surg 2001. A significant increase in costs can be attributed to routine contralateral exploration. The morphology of the contralateral internal inguinal rings is age dependent in children with unilateral inguinal hernia. [14] Tepas J. Meta-analysis of the risk of metachronous hernia in infants and children. Clatworthy HW. However. J Pediatr Surg 1999. The patent processus vaginalis and the inguinal hernia.7. Jaksic Tkozinetz CA. However. [7] Bronsther B.35:1746 .7. Parenzan L. The contralateral hernia repair on these children costing NZ $11. 12 had the MIH presenting within 1 year.1166 accurate and safe tool in the intraoperative diagnosis of PPV [4] in a selective group of patients who have risk factors for hernia development such as raised intraabdominal pressure and connective tissue disorders [15].08. there were no patients with these risk factors. which is a SQL-server patient costing program used in our hospital. Applying the same formula as above.5:152 . among the children who re-presented with MIH. left-sided presentation has a statistically significant impact on the development of MIH compared with a right-sided presentation.52 equates to a net saving of NZ $40. Takahashi A. Am Surg 1986. Teague JL. Ikeda et al [13] demonstrated that almost 50% of the children who went on to develop an MIH did so within 1 year of the original surgery and 90% did so within 5 years. .44 and $1737. [8] Kieswetter WB. number of male children who are younger than 2 years and the female children younger than 5 years). In our series.36:1190 . Risk of contralateral manifestation in children with unilateral inguinal hernia: should hernia in children be treated contralaterally? J Pediatr Surg 2000. Unilateral inguinal hernia in girls: is routine contralateral exploration justified? J Pediatr Surg 1995. J Pediatr Surg 1995.9. The change in the practice of selective contralateral exploration has not significantly increased the incidence of MIH. Incidence of contralateral inguinal hernia: a prospective analysis. Pinter AB. Clatworthy HW. The optimal approach for management of metachronous hernias in children: a decision analysis. J Pediatr Surg 1998.8. respectively. The patent processus vaginalis and the inguinal hernia. this is an area that needs further evaluation. Avanuglu A.30:1663 . we would have explored the contralateral side in 152 children (ie. J Am Med Womens Assoc 1972.535. Inguinal hernia associated with UDT may need further study to evaluate the risk of metachronous presentation. Our subset of 14 patients who underwent ipsilateral orchidopexy with the herniotomy for associated UDT had a 14% incidence of MIH. Arikan A. Stafford P.5. Copelson LW. the risk to the spermatic cord is offset by the higher risk for MIH. This was analyzed by Costpro. contralateral exploration in the leftsided presentation cannot be clinically justified. Am J Surg 1991. only 8 were younger than 2 years old. Liu C.6. [9] Rowe MI. Timing of automatic contralateral groin exploration in male infants with inguinal hernias. Copelson LW. Age at presentation and the presence of incarceration are not predictive risk factors for the occurrence of MIH. Luks FI.574. hindering any valid statistical conclusion. Heffington SH.22. In this group. J Pediatr Surg 1969. [15] Moss RL. However. Zaslaysky A. The direct cost of a unilateral hernia repair and a bilateral herniotomy performed in the New Zealand public hospital system is approximately NZ $1413. Am J Surg 1997. 33:874 .5. it may be useful information to warn parents of the potential occurrence of a contralateral hernia and to counsel them with the instructions on observing signs of a contralateral hernia for early detection and treatment. A S. J Pediatr Surg 1995. [11] Rowe MI. we have saved 1568 minutes of valuable theater time. [12] Walc L. 82:809 .307. [4] Miltenburg DM.70. This has saved NZ $49. [16] Demirkan IU. [5] Miltenburg DM. Suzuki N. Hatch EI. Almost 70% of patients who developed an MIH did so within 2 years in Miltenburg et al’s meta-analysis [5].7. Breuer CK. When should hernia in the infant be treated bilaterally? JAMA 1959. Of the 14 children in our study. 52:70 .34:684 . Anaesthesiology 1995. Testicular fate after incarcerated hernia repair and/or orchidopexy performed in patients under 6 months of age. Wei C. [2] Burd RS. Although the number of patients in this group is small. [10] Chin T. Postoperative apnea in former preterm infants after inguinal herniorraphy.30:1684 .4(1):102 . This practice has brought about a significant reduction in the cost and time of surgical care for children presenting with unilateral hernia.174:741 . Nuchtern JG.27:5222 .4:102 .