Journal of Pediatric Surgery (2010) 45, 1007–1011

www.elsevier.com/locate/jpedsurg

Incarceration rates in pediatric inguinal hernia:

do not trust the coding☆
Suad Gholoum, Robert Baird, Jean-Martin Laberge, Pramod S. Puligandla ⁎
Division of Pediatric General Surgery, The Montreal Children's Hospital, McGill University Health Center, Montreal,
Quebec, Canada H3H 1P3

Received 30 January 2010; accepted 3 February 2010

Key words: Abstract

Pediatric inguinal hernia;
Purpose: Although recent reports have suggested optimal wait times for inguinal hernia repair to
Incarceration;
prevent incarceration, these may not apply to all patients or be feasible in the context of limited
Wait time;
resources. We evaluated our experience to determine if patient age and interval to operation increased
Elective surgery;
the risk of incarceration.
ICD-10
Methods: A retrospective review of children younger than 2 years old undergoing inguinal hernia repair
from 2004 to 2007 was performed. Patients were divided based on age at diagnosis (A, 0-28 days; B, 4-
26 weeks; C, 27-52 weeks; and D, 53-104 weeks). We evaluated incarceration rates in each group,
defined as the need for sedation to achieve reduction, and compared these to International
Classification of Diseases, version 10 (ICD-10), coding. Wait times were evaluated, and the rate and
daily risk of incarceration were calculated for each age group.
Results: Two hundred sixty-eight patients were included in our analysis, with an overall mean wait time
of 43 ± 50 days between diagnosis and surgery. Forty-five patients were labeled as incarcerated by ICD-
10 coding, although 23 patients (51%) were reduced without sedation, leaving a true incarceration rate
of 8% (22/268). Of these 22 patients, 18 were incarcerated at index presentation. There was no
difference in incarceration rates between groups (A, 5.3%; B, 8.0%; C, 11.5%; and D, 8.8%), although
older patients had significantly longer wait times.
Conclusions: Our study suggests that ICD-10 coding of incarceration is an inaccurate parameter of
actual irreducibility. Hernia incarceration in children awaiting repair represented a minority of overall
incarcerations in our cohort, suggesting strict wait times may not alter incarceration risk.
© 2010 Elsevier Inc. All rights reserved.

Inguinal hernia repair is the most common operation
performed by pediatric surgeons, and most of these cases
are performed on an elective basis. Timely hernia repair
Presented at the 41st Annual Meeting of the Canadian Association of
Paediatric Surgeons, Halifax, Nova Scotia, Canada, October 1-3, 2009.
☆
Podium presentation at the 41st annual meeting of the Canadian
Association of Pediatric Surgeons, Halifax, Nova Scotia, Canada, October
1-3, 2009.
⁎ Corresponding author. Tel.: +1 514 412 4438; fax: +1 514 412 4289.
E-mail address: pramod.puligandla@mcgill.ca (P.S. Puligandla).
has been advocated to reduce the risk of hernia
incarceration while awaiting surgery. This risk ranges
from 3% to 16% for most patients [1] but may be much
higher in younger infants [2,3]. Recent evidence has
suggested that stricter wait times are required for hernia
repair in all children less than 2 years of age because their
incarceration risk is noted to double if surgery is delayed
more than 14 days from the time of diagnosis [4]. The
purpose of the current study was to evaluate our own
institutional experience with inguinal hernia repair in

0022-3468/$ – see front matter © 2010 Elsevier Inc. All rights reserved.
doi:10.1016/j.jpedsurg.2010.02.033
1008
young children and to assess the risk of incarceration in
different age groups relative to wait times.
1. Methods
Research ethics board approval was obtained for this
study through the office of the Director of Professional
Services at our institution. The study was performed as a
retrospective review of the records of all the children less
than 24 months old that underwent inguinal hernia repair at
the Montreal Children's Hospital from 2004 to 2007.
Patients were divided into 4 groups according to their age
at diagnosis (A, 0-28 days; B, 4-26 weeks; C, 27-52 weeks;
and D, 53-104 weeks). Premature patients were defined as
those being born at less than 37 weeks of gestational age;
these were analyzed both alone and as a part of the total
cohort. We excluded all patients initially diagnosed with a
hydrocele and who were subsequently found to have a hernia
at time of surgical repair.
We evaluated our actual incarceration rates in each group
and compared this to the International Classification of
Diseases, version 10 (ICD-10), coding obtained from the
medical record. We defined incarceration as the need for the
administration of parenteral sedation (ketamine, fentanyl,
morphine) to achieve hernia reduction. Emergency depart-
ment (ED) use was also investigated by documenting all
visits related to inguinal hernias in our population. We also
noted patients who had an incarceration at their initial ED
visit. A daily risk of incarceration for all groups was
calculated by dividing the total number of incarcerations that
were not index presentations by the total number of days
waiting for elective repair.
Surgical wait times for elective hernia repair were also
calculated. Wait time-1 (WT-1) was defined as the period
from a diagnosis by a health professional until the date seen
by a pediatric surgeon. Wait time-2 (WT-2) was defined as
the period between surgical consultation to the time of the
hernia repair. The total wait time was calculated by adding
WT-1 and WT-2. Patients were observed for a minimum of
1 year after repair.
Statistical analysis was conducted and the results are
expressed as mean (±SD) for the age and as median with
interquartile ranges for the wait times. The difference
between the actual and ICD-10 coding of incarceration
Table 1 Incarceration data
Group (age in wk) A (0-28 d)
No. of patients (%) 38 (14)
Patients with ICD-10 coding for incarceration (%) 7 (17.5)
True incarceration rate (%) 2 (5)
P value P = .15
⁎ P values less than .05 were considered significant.
S. Gholoum et al.
was evaluated using the Fischer's Exact test. The rate and
daily risk of incarceration was evaluated for each age group.
P values less than .05 were considered statistically significant.
2. Results
A total of 268 children met the inclusion criteria for
evaluation in our study. Most patients were boys (90.7%),
and 96 (36%) patients were premature. Eighty percent of
hernias were unilateral, whereas the remaining 20% were
bilateral. The mean age at the time of diagnosis was 27 weeks
(±30). Fifty-one percent of the study cohort was diagnosed
with an inguinal hernia between 4 and 26 weeks of age
(group B).
Table 1 summarizes the incarceration data for our study
groups. We found an overall incarceration rate of 16.8% (45
infants) by ICD-10 coding, whereas only 8.2% (22 infants)
were truly incarcerated based on our definition (P = .004).
All of these incarcerated patients were successfully reduced
with sedation before operation. When analyzing each group,
the discrepancy in incarceration rates was significant only in
group B (4-26 weeks of age) (23 vs 11; P = .04). The true
rate of incarceration in our premature group was also 8%.
Ninety-two patients (35.5%) presented to our ED with a
diagnosis of inguinal hernia (Table 2). Seventy-four patients
presented to the ED without incarceration, of whom 56
(77%) had not seen a physician before their ED visit, and 17
(23%) presented to the ED with a consult or referral.
Eighteen (19.6%) of the 92 patients who presented to the ED
had an incarcerated hernia as their index presentation. This
left only 4 patients in the whole cohort of 268 patients who
developed incarceration while awaiting inguinal hernia
repair, and each of these was a premature infant who was
still admitted in the neonatal intensive care unit (NICU). One
of these events occurred in group A (0-28 days), producing a
daily risk of incarceration of 0.07%. Three patients in group
B (4-26 weeks) incarcerated while waiting, also leading to a
daily risk of incarceration of 0.07%. There were no instances
of incarceration while waiting for operative repair in either
groups C or D.
The overall wait time for all patients from the time of
diagnosis by a health professional to the surgical repair date
was 43 days (±50). The median total wait time to hernia
repair (WT1 + WT2) was 28 days (interquartile range, 13-51
B (4-26) C (27-52) D (53-104) Overall
136 (51) 26 (9.7) 68 (25.4) 268
23 (18.2) 5 (19.2) 10 (14.7) 45 (16.8)
11 (8) 3 (11.5) 6 (8.8) 22 (8.2)
P = .04 ⁎ P = .17 P = .43 P = .004 ⁎
Incarceration rates in pediatric inguinal hernia
Table 2 Emergency department visits for pediatric inguinal hernia
Group
No. of patients
No. of patients with at least 1 ED visit
No. of incarcerated hernias as index presentation to ED (%)
days). Table 3 summarizes the wait time data and is stratified
by patient subgroup, whereas Table 4 summarizes the data
for premature infants. The median WT-1 in all groups was
approximately 7 days. However, the median WT-2 in the
younger patients (groups A and B) was shorter (10 days)
compared to the older patients (groups C and D, 30 days).
3. Discussion
Inguinal hernia is a common problem affecting approx-
imately 5% of all children [5]. Timely repair of these hernias
is recommended to reduce the risk of incarceration. Indeed,
recent evidence suggests that wait times greater than 2 weeks
from the time of diagnosis lead to significant increases in
incarceration and ED visits in young children [4]. Our single
center experience with inguinal hernia repair in children
younger than 2 years demonstrates several interesting
findings: (a) although the overall rate of incarceration
using ICD-10 coding system was 16.8%, its true rate,
based on a strict definition of hernia incarceration, was
actually 8.2%; (b) we did not identify any significant
variation in the rate of hernia incarceration based on age; and
(c) none of the cases of hernia incarceration occurred in
patients awaiting elective surgical repair.
Hernia incarceration mandates urgent reduction to
prevent damage to the incarcerated contents and to prevent
testicular ischemia. Classically, this was achieved through
an emergency operation. This trend to early intervention has
been supplanted by an attempt at nonoperative reduction via
gentle compression with or without the aid of sedation [6].
The advantages of manual reduction and hernia repair 24 to
48 hours later include relieving associated edema and
rendering the surgical repair less difficult, minimizing the
use of urgent care resources, and allowing for an urgent
Table 3 Wait times
Group A (0-28 d)
Wait time-1 (d) 6 (0-17)
Health professional—surgeon
Wait time-2 (d) 12 (1-15)
Surgeon to operating room
Total wait time (d) 26 (1-44)
Health professional—operating room
Data are presented as median (interquartile range).
1009
A (0-28 d) B (4-26 wk) C (27-52 wk) D (53-104 wk) Total
38 136 26 68 268
12 46 12 22 92
1 (8.3) 8 (17.4) 3 (25) 6 (27.3) *18 (6.7)
operative time that benefits both the parents and the
surgeon. The disadvantage of such a strategy is the potential
inability to reduce the hernia and subsequent worsening
inguinal edema, as well as the potential for reincarceration
while awaiting urgent repair [2,7]. To minimize the
potential for early reincarceration, operative repair is
generally organized within 24 to 48 hours after reduction
at our institution. On the basis of our current practice, we
defined incarceration as any hernia requiring sedation for
reduction. We observed that the improper classification of
hernias as incarcerated, particularly by primary care and
emergency physicians, made the ICD-10 coding for these
patients inaccurate. Indeed, careful evaluation of the
medical records in this study clearly demonstrated that
50% of “incarcerated” hernias were reduced without
sedation, and thus, not irreducible.
The importance of proper ICD coding cannot be
understated. The ICD-10 classification system is used around
the world to record vital health information, including that
contained within the medical dossier. This information is
often used by governmental agencies as a benchmark of the
acuity and complexity of medical care that is provided by an
institution, and this is commonly linked to the provision of
health care resources. Furthermore, ICD-10 data are also
used for study or audit in administrative databases, and
careful evaluation and interpretation of the data obtained
from these studies is essential before using it as a framework
to effect widespread policy change [8]. At our institution, the
ICD miscoding could have been because of the use of the
improper diagnosis by a health care professional, that is,
classifying a hernia as incarcerated even if it was easily
reduced without sedation or as a result of the automatic
transfer of the ED triage diagnosis to the final diagnosis upon
discharge. In the end, several “system” problems with ICD-
10 coding could have been responsible for the discrepancy in
incarceration rates identified in this study.
B (4-26 wk) C (27-52 wk) D (53-104 wk)
7 (2-16) 7 (0.5-14) 7 (0-13)
10 (4.5-22.5) 34 (8-66.5) 29 (19-61)
22 (12-40.5) 54 (17-93) 41 (25-69)
1010
Table 4 Characteristics of premature infants undergoing hernia repair
Group A (0-4 d)
No. of patients 18
True incarceration (%) 1/18 (5.5)
Location of index presentation
NICU 1 3
ED
Wait time-1 (d) 8 (4-28)
Health professional—surgeon
Wait time 2 (d) 13 (5-27.5)
Surgeon to operation
Total wait time (d) 34 (23-62)
Health professional—operation
Data are presented as median (interquartile range).
The young infant has generally been thought to have a
higher risk of incarceration [2]. Our management strategy
regarding infants less than 6 months of age with an inguinal
hernia has been to schedule the repair ideally within 1 to 2
weeks of diagnosis while older infants would be scheduled
within several weeks. Premature infants in this study were
generally monitored as inpatients and had other comorbid-
ities that required hospitalization. Our practice for such
premature patients is to repair the hernia before discharge
once their general and pulmonary status is optimal. On the
basis of this practice strategy, we chose to divide our study
cohort into 4 groups, with patients less than 1 year of age
separated into 3 distinct categories. Although other studies
have grouped all children under the age of 1 or 2 together [4],
we felt that the subgrouping of patients better reflected our
practice philosophy. Indeed, the rates of incarceration for
each group were not significantly different from each other
using this scheme. Although this could be related to the fact
that younger infants were subjected to repair sooner, we
found that the daily incarceration rate did not vary between
groups, suggesting that younger infants were not at an
intrinsically higher rate of incarceration based on their age.
Patients presenting with incarceration in this study
consisted of 2 unique groups: (i) those with an index
presentation of incarceration and (ii) premature infants. Chen
et al [9], comparing the impact of wait times for inguinal
hernia repair in infants at a Canadian and an American
hospital, noted much higher rates of incarceration as an index
presentation in the Canadian hospital. The authors of this
report surmised that these higher rates were the result of
longer wait times to see a specialist because “no inherent
physiologic difference” between these 2 groups of infants
could be identified. In our study, the median wait time to see
a specialist in the groups studied was 7 days, and no patient
developed incarceration while waiting for elective repair.
The only difference that existed was the delay to operation
once a decision to operate was made (WT-2). Infants less
than 6 months of age waited a total of 10 to 12 days for hernia
repair after surgical consultation. This number increased
S. Gholoum et al.
B (4-26 wk) C (27-52 wk) D (53-104 wk)
65 7 7
6/65 (9.2) 1/7 (14.3) 0/7 (0)
3 1
8 (2-21) 8 (0-14) 2 (0-4)
10 (3-21) 43 (12-59) 21 (13-71)
25 (11-46) 51 (24-64.5) 21 (15-71)
significantly to almost 1 month in older infants and young
children but had no effect on the daily rates of incarceration
in each group. Most important, none of the patients awaiting
elective surgery had incarceration. Instances of incarceration
occurred only in patients with an index presentation to the
ED or those in the NICU. Thus, our results demonstrate that
strict wait time policies may not benefit all patients and that
proper “triaging” by the surgeon, based on operative
urgency, may be a better method to assess the appropriate
timing for hernia repair [8].
Premature infants represent a special subgroup of
patients, and there is no clear consensus as to the optimal
timing of hernia repair. Many factors may affect this,
including the age and clinical state of the infant. Proponents
of immediate repair in premature infants state that higher
rates of incarceration occur with long delays [10]. Some
also argue that waiting for hernia repair may complicate
surgery because of the development of adhesions between
the hernia sac and the cord structures [11]. Our philosophy
is based on the clinical state of the infant, in which we offer
hernia repair as infants approach discharge from the NICU.
Of the 8 premature infants with incarcerated hernia in this
study, representing 8% of this cohort, 4 presented with
incarceration as their index presentation to the ED, whereas
the remainder occurred within the monitored setting of a
NICU. Although the small number of premature infants in
this series precludes definitive conclusions, it seems
prudent to operate on these infants as soon as they are
clinically stable and before discharge. This strategy may
have prevented the incarceration in the 4 premature infants
in this study who were discharged home by other NICUs
before surgical repair.
In conclusion, our study has demonstrated the discrepan-
cy between ICD-10 coding and the true incidence of
incarcerated hernia in young children undergoing hernia
repair when using a definition of incarceration reflective of
actual clinical practice. All incarcerations in this study
presented either as an index presentation to the ED or
occurred in a monitored NICU setting. We feel that all
Incarceration rates in pediatric inguinal hernia
inguinal hernias should be repaired in an expeditious fashion,
but the institution of strict wait times for all patients younger
than 2 years would not have changed the occurrence of
incarceration in our study. Premature infants may represent a
special group for whom repair should be strongly considered
before discharge and when they clinically stable. Additional
refinements in the evaluation of incarceration rates may be
required before widespread practice guidelines are adopted.
Acknowledgment
We thank Dr George Melich for his assistance with
this study.
References
[1] Rescorla FJ, Grosfeld JL. Inguinal hernia repair in the perinatal period
and early infancy: clinical considerations. J Pediatr Surg 1984;19:832-7.
1011
[2] Lau ST, Lee YH, Caty MG. Current management of hernias and
hydroceles. Semin Pediat Surg 2007;16:50-7.
[3] Nagraj S, Sinha S, Johnson P, et al. The incidence of complications
following primary inguinal herniotomy in babies weighing 5 kg or
less. Pediatr Surg Int 2006;22:500-2.
[4] Zamakhshary M, To T, Langer JC. Risk of incarceration of inguinal
hernia among infants and young children awaiting elective surgery.
Can Med Assoc J 2008;179:1001-5.
[5] Bronsther B, Abraham MW, Elboim C. Inguinal hernia in children-a
study of 1000 cases and review of the literature. J Am Med Women
Assoc 1972;27:522-5.
[6] Grosfeld JL. Current concepts in inguinal hernia in infants and
children. World J Surg 1989;53:762-6.
[7] Stylianos S, Jacir NN, Harris BH. Incarceration of inguinal hernia in
infants prior to elective repair. J Pediatr Surg 1993;28:582-3.
[8] Blair GK. Children are waiting for care and answers. Can Med Assoc J
2008;179:983-4.
[9] Chen LE, Zamakhshary M, Langer JC, et al. Impact of wait time on
outcome for inguinal hernia repair in infants. Pediatr Surg Int 2009;25:
223-7.
[10] Misra D, Hewitt G, Potts SR, et al. Inguinal herniotomy in young
infants, with emphasis on premature neonates. J Pediatr Surg 1994;29:
1496-8.
[11] Uemura S, Woodward AA, Amerena R, et al. Early repair of inguinal
hernia in premature babies. Pediatr Surg Int 1999;15:36-9.