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Journal of Pediatric Surgery (2013) 48, 1972–1976

www.elsevier.com/locate/jpedsurg

Cardiorespiratory complications after laparoscopic hernia


repair in term and preterm babies
Christine Burgmeier a,⁎, Felix Schier b
a
Department of General and Pediatric Surgery, University Medical Center Ulm, 89081 Ulm, Germany
b
Department of Pediatric Surgery, University Medical Center Mainz, Mainz, Germany

Received 4 November 2012; revised 29 June 2013; accepted 30 June 2013

Key words:
Abstract
Laparoscopy;
Purpose: The aim of this study was to clarify the incidence of postoperative complications in infants
Hernia repair;
undergoing laparoscopic hernia repair within the first six months of life.
Preterm;
Methods: Retrospective, single-institution study comparing term and preterm babies undergoing surgery
Term infants;
between March 2005 and September 2012. The charts were reviewed for postoperative complications
Cardiorespiratory
and pre-existing diseases.
complications
Results: In the term group 188 of 199 babies (94.5%) had an uneventful postoperative course. Eleven
patients (5.5%) presented postoperative complications, three of them (1.5%) developed severe respiratory
complications. A relation between pre-existing diseases and postoperative complications could be
identified in two patients. Laparoscopy possibly induced cardiorespiratory instability in one infant.
In the preterm group 109 of 137 babies (79.6%) had an uneventful postoperative course. 28 preterm
infants (20.4%) developed postoperative complications, seven of them (5.1%) presented severe
respiratory complications. Pre-existing diseases were identified as an influencing factor in 22 preterm
infants. In one patient laparoscopy possibly caused minor instability of a pre-existing cardiac anomaly.
Conclusions: Postoperative complications are low in both groups, although the incidence is increased in
preterm infants. Pre-existing diseases are a major influencing factor for preterm infants. In very few infants
laparoscopy may have induced instability of cardiac anomalies.
© 2013 Elsevier Inc. All rights reserved.

Laparoscopic hernia repair has become a routine been criticized for the need of general anesthesia including
procedure in children and is even feasible in small babies relaxation and the risk of postoperative complications
including premature infants [1–5]. According to our induced by increased intra-abdominal pressure during
experience, age, size, and weight of the child are not limiting laparoscopy. Reports suggest that premature infants have
factors for the laparoscopic approach in terms of the surgical an increased risk of post-anesthetic cardiorespiratory com-
technique [4,5]. However, the laparoscopic approach has plications when compared with full-term infants undergoing
similar surgery [6]. Therefore, several authors advocate open
⁎ Corresponding author. Tel.: + 49 731 500 53701; fax: + 49 731 500 inguinal hernia repair during regional anesthesia, especially
53702. in preterm infants [7–9]. The aim of this study was to
E-mail address: burgmeierch@yahoo.de (C. Burgmeier). evaluate early postoperative complications after laparoscopic

0022-3468/$ – see front matter © 2013 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.jpedsurg.2013.06.031
Cardiorespiratory complications after hernia repair 1973

hernia repair in term and preterm infants. The influence of 13.0, Chicago, IL) statistical software. Variables were term
the past medical history and pre-existing diseases was and preterm group, postnatal operative day, weight at the
investigated. Additionally, the association of increased intra- time of surgery, birth weight and gestational age at birth. P
abdominal pressure during the laparoscopic procedure as a values less than 0.05 were considered significant.
potential risk factor for the development of early postoper-
ative complications was evaluated.
2. Results
1. Patients and methods
All operations were successfully performed using lapa-
In this retrospective study, 336 children (249 male and 87 roscopic technique. There were no immediate surgical
female) underwent laparoscopic hernia repair under general complications in either group.
anesthesia within the first six months of life. Between March
2005 and September 2012 199 term (term group, 152 male and 2.1. Group I (term infants, n = 199)
47 female) and 137 preterm infants (preterm group, 97 male
and 40 female) were identified. The charts were reviewed for One hundred eighty-eight of 199 term infants (94.5%) had
early postoperative complications, pre-existing diseases and an uneventful postoperative course on normal ward and 168
the past medical history. Prematurity was defined as less than (84.4%) could be discharged from the hospital on the first
37 weeks of gestational age. Median gestational age at birth postoperative day. Postoperative complications after laparo-
was 32 weeks (range 24 to 36 weeks) in the preterm and scopic hernia repair were noted in 11 term infants (5.5%): six
39 weeks (range 37 to 42 weeks) in the term group. In the babies (3.0%) presented minor respiratory distress in the
preterm group the birth weight varied from 0.45 kg to 4.0 kg postoperative course, including bronchial obstruction, apnea
(median 2.0 kg) and the median weight at the time of surgery and short-duration decreases of oxygen saturation. Three
was 3.4 kg (range 1.6 kg to 6.6 kg). In the term group birth term babies (1.5%) developed severe respiratory problems in
weight ranged from 1.8 kg to 5.0 kg (median 3.5 kg) and the postoperative course: in one infant re-intubation and in
median weight at the time of surgery was 4.7 kg with a range two babies prolonged ventilator support were necessary. One
from 2.6 kg to 8.3 kg. On average, the operation was of these three babies required high frequency oscillation
performed on the 69th postnatal day in the preterm group ventilation (HFOV) due to an acute respiratory distress
and on the 45th postnatal day in the term group. syndrome. Overall, three term infants developed non-
respiratory complications in the postoperative course: three
1.1. Operative procedure term babies (1.5%) developed signs of infection and one of
them additionally had bradycardia. Table 1 summarizes the
During the study period, the practice at our institution was postoperative complications after laparoscopic hernia repair
to perform laparoscopic hernia repair in term and preterm in term infants. The total number of complications exceeds
babies using general anesthesia and tracheal intubation. The 11 because several babies developed more than one
infants were placed in a supine position. A Veress needle was complication in the postoperative course.
inserted at the umbilicus and carbon dioxide was insufflated The required interventions in the postoperative course
to intra-abdominal pressures between 8 and 15 mm Hg, on of these 11 babies included prolonged ventilator support
average 12 mmHg. The Veress needle was then exchanged (n = 1), re-intubation (n = 1), high frequency oscillation
for a 2- or 5- mm laparoscope. Two additional 2 mm trocars ventilation (n = 1) and administration of oxygen (n = 5).
were advanced through the right and left anterior abdominal All three babies presenting signs of infections were treated
wall. The clinically diagnosed open inguinal ring was closed with intravenous antibiotics (n = 3).
using a 4-0 monofilament, non-resorbable purse-string or Z- In the entire group of term infants 175 babies (87.9%) had
type suture and 2 mm instruments. Incarcerated hernias were neither pre-existing diseases nor a complicated past medical
first reduced by combined external pressure and internal history. Only seven infants with postnatal respiratory distress
laparoscopic pulling. If an open processus vaginalis was (3.5%) were identified. One of them required postnatal
identified contralaterally, it was closed in the same way. All intubation (0.5%). Table 2 demonstrates the pre-existing
infants were monitored for postoperative complications for a diseases in the group of term infants. The total number of
minimum of one overnight stay. pre-existing diseases exceeds the number of patients because
several babies presented a combination of postnatal diseases.
In the next step, we tried to identify a relation between
1.2. Statistical analysis early postoperative complications and pre-existing diseases,
and the laparoscopic procedure or general anesthesia. In the
Univariate, multivariable logistic regression was used to group of term infants, one baby with postnatal respiratory
identify risk factors for the development of early postoper- distress in the past medical history required prolonged
ative complications. Data were analyzed with SPSS (Version ventilator support after laparoscopic hernia repair. One
1974 C. Burgmeier, F. Schier

Table 1 Postoperative complications after laparoscopic hernia postoperative day. In 28 preterm infants (20.4%) postoper-
repair in term and preterm infants. ative complications were noted after laparoscopic hernia
Term group Preterm repair. Eighteen of these patients (13.1%) developed minor
(n = 199) group respiratory distress postoperatively, including short-term
(n = 137) oxygen desaturations, bronchial obstruction and apnea.
Seven infants (5.1%) had severe respiratory complications
Postoperative complications n = 11 n = 28
Minor postoperative respiratory n=6 n = 18 in the postoperative course after laparoscopic hernia repair:
complications (including short-term three babies required prolonged ventilator support and in
oxygen desaturation, bronchial four patients re-intubation became necessary. Three infants
obstruction and apnea) (2.2%) presented seizures in the postoperative course, two of
Severe postoperative respiratory n=3 n=7 these patients required re-intubation. Both infants were
complications (including neurologically impaired and presented with seizures preop-
re-intubation and prolonged eratively. Bradycardia was recorded in three babies (2.2%)
ventilator support) and was combined with minor respiratory distress in two
Postoperative seizure n=0 n=3 cases. One preterm patient (0.7%) showed signs of infection
Postoperative bradycardia n=1 n=3
in the postoperative course. Table 1 compares the postop-
Postoperative signs of infection n=3 n=1
erative complications in preterm and term infants. The total
The total number of complications exceeds the number of patients number of complications exceeds 28 because several infants
with complications because several patients developed more than
one complication.
developed more than one complication in the postoperative
course.
The required interventions in the postoperative course of
patient with Arnold–Chiari syndrome presented with apnea these 28 patients included prolonged ventilator support (n = 3),
and oxygen desaturation during the postoperative course. It re-intubation (n = 4), inhalation (n = 3) and administration of
should be noted that this patient showed central apnea and oxygen (n = 11). In other patients the administration of
repeated oxygen desaturations preoperatively. According to antiepileptic drugs (n = 2), diuretics (n = 1), naloxone (n = 1)
these similar clinical presentations in their past medical or intravenous antibiotics (n = 1) was necessary. Six preterm
history, a relationship between early postoperative compli- infants required no interventions (n = 6). In several patients
cations and pre-existing diseases was assumed in these two combinations of treatments were necessary, so the total number
patients (18.2%). exceeds 28.
Another term baby (9.0%) with a preoperatively hemo- On chart review, 111 of 137 preterm babies (81.0%)
dynamic stable persistent foramen ovale (PFO) developed undergoing laparoscopic hernia repair under general anes-
acute respiratory distress and required high frequency thesia had pre-existing diseases or a complicated past
oscillation ventilation (HFOV) in the postoperative course. medical history. 103 infants (75.2%) presented postpartum
Echocardiography showed hemodynamically relevant shunt- respiratory distress and 28 of them (20.4%) had severe
ing of a PFO and reduced right-ventricular function respiratory problems including postnatal intubation, pneu-
postoperatively. The influence of laparoscopic surgery mothorax or bronchopulmonary dysplasia (BPD) in their
remains unclear, but the development of shunt-inversion past medical history. Table 2 summarizes the pre-existing
after increased intra-abdominal pressure during laparoscopic diseases of preterm infants in comparison with term infants.
surgery is conceivable. The total number of pre-existing diseases exceeds the
Six term infants (54.5%) showed decreased oxygen number of patients because several patients presented more
saturation and required short-term administration of oxygen than one disease in their past medical history.
in the postoperative course. None of these infants was known Similar to the term patients we tried to relate early
to have pre-existing diseases or showed similar clinical signs postoperative complications to pre-existing diseases, laparo-
in their past medical history. A relation to general anesthesia scopic surgery and general anesthesia. 28 preterm babies
was assumed in these six patients. developed early postoperative complications, 22 of them
Two patients (18.2%) showed signs of infection in the (78.6%) showed similar clinical presentations in their past
postoperative course, but no relation to anesthesia, laparos- medical history. 20 patients had postnatal respiratory distress
copy or pre-existing diseases could be identified. and developed oxygen desaturation and apnea in the
Table 3 demonstrates the assumed relations between early postoperative course. One preterm infant was known to have
postoperative complications in the group of term infants. repeated episodes of apnea and bradycardia preoperatively and
showed bradycardia postoperatively. Another patient with
2.2. Group II (premature infants, n = 137) posthemorrhagic hydrocephalus presented with a seizure after
laparoscopic hernia repair. According to these similar clinical
In the preterm group 109 of 137 babies (79.6%) had an presentations in their past medical history, we assumed a
uneventful postoperative course and 59 infants (43.1%) relation between early postoperative complications and pre-
could be discharged from the hospital on the first existing diseases in these 22 preterm infants (78.6%).
Cardiorespiratory complications after hernia repair 1975

Table 2 Preexisting diseases and past medical history of term Table 4 Logistic regression analysis to identify risk factors for
and preterm infants undergoing laparoscopic hernia repair. early postoperative complications after laparoscopic hernia repair.
Term Preterm P OR CI
group group Group [term; preterm] 0.300 0.527 0.157 to 1.770
Pre-existing diseases n = 24 n = 111 Postnatal operative 0.038 0.979 0.959 to 0.999
Postnatal respiratory distress n=7 n = 103 day [days]
Severe postnatal respiratory distress n=1 n = 28 Weight at the time 0.586 1.000 1.000 to 1.001
(including intubation, pneumothorax of surgery [kg]
and bronchopulmonary dysplasia) Birth weight [kg] 0.105 1.001 1.000 to 1.001
Episodes of apnea and bradycardia n=1 n = 43 Gestational age at 0.001 0.736 0.619 to 0.880
Cardiac anomalies n = 12 n = 34 birth [weeks]
Neurological anomalies n=7 n=9 P = p value lower, OR = odds ratio, CI = 95% confidence range.
The total number of pre-existing diseases exceeds the number of patients
because several patients presented more than one disease in their past
medical history.

3. Discussion
In one preterm infant (3.6%) with prior hemodynamically
non-relevant persistent ductus arteriosus (PDA) and PFO, Until recently, laparoscopic hernia repair was avoided in
postoperative administration of diuretics was necessary due term and preterm babies because of the need for general
to a hemodynamically relevant PDA without cardiorespira- anesthesia with relaxation and the risk of postoperative
tory instability. In this case we assumed a possible influence complications in this fragile group of patients. In this
of increased intra-abdominal pressure during laparoscopy to retrospective study postoperative complications after lapa-
be decisive for the development of a hemodynamically roscopic hernia repair in term and preterm babies were
relevant PDA. evaluated. Additionally, we tried to identify a relation
Three preterm infants developed oxygen desaturations between pre-existing diseases, the laparoscopic procedure
postoperatively without similar clinical presentations in their and anesthesia. Limiting our investigations to infants
past medical history. Two of them required prolonged younger than six months inherently selects patients at higher
ventilator support and in one of them administration of risk of complications. Lung-related diseases, such as apnea
naloxone was necessary. A relation to general anesthesia was and BPD are well-known in premature infants. Besides,
assumed in these three patients (10.7%). In two patients medical problems associated with prematurity are frequently
(7.1%) no relation to general anesthesia, laparoscopy or pre- complex. Pre-existing diseases have been described to be a
existing diseases could be identified. One baby developed risk factor for the development of postoperative complica-
signs of infection and another presented with a seizure tions, especially in preterm infants [10]. As expected, in this
without prior history of epilepsy. Table 3 demonstrates the study more infants in the preterm group than in the term
assumed relations between early postoperative complications group had pre-existing diseases and a complicated past
in the group of preterm infants. medical history (12.1% vs. 81.0%). A possible relation
between pre-existing diseases and early postoperative
2.3. Statistical analysis complications after laparoscopic hernia repair was found in
18.2% of term and 78.6% of preterm infants. Regarding the
Statistical significance was found for gestational age at incidence of early postoperative complications probably
birth (p = 0.001) and postnatal operative day (p = 0.038). being associated with the laparoscopic procedure, we
Logistic regression showed that there was no statistically identified one term and one preterm infant. Both were
significant difference between the two groups (p = 0.300). known to have hemodynamically stable cardiac anomalies
Table 4 demonstrates logistic regression analysis including p preoperatively. During the study period, the practice at our
values (P), odds ratio (OR) and 95% confidence range. institution was the performance of laparoscopic hernia repair

Table 3 Assumed relation of postoperative complications after laparoscopic hernia repair to pre-existing diseases, the laparoscopic
procedure and general anesthesia.
Relation to Relation to Relation to Unrelated
pre-existing laparoscopic anesthesia postoperative
disease procedure complications
Term group (n = 11) n=2 n =1 n=6 n=2
Preterm group (n = 28) n = 22 n=1 n=3 n=2
1976 C. Burgmeier, F. Schier

under general anesthesia in stable infants without hemody- preterm babies, although the incidence is increased in
namically relevant cardiac anomalies. Only in a very small preterm infants. Pre-existing diseases and a complicated
number of patients open herniotomy during regional past medical history are a risk factor for the development of
anesthesia was performed. early postoperative complications, especially in preterm
In the literature there is a lack of reports about early babies. The laparoscopic approach provides a low risk of
postoperative complications, especially for preterm babies shunt-inversion and cardiorespiratory instability in term and
and little is known about the influence of increased intra- preterm infants with stable cardiac anomalies.
abdominal pressure during the laparoscopic procedure,
especially in patients with cardiac anomalies. In preterm
infants immaturity of organs implicates an increased risk for
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