Pediatric Surgery International (2021) 37:587–595

https://doi.org/10.1007/s00383-020-04808-8

ORIGINAL ARTICLE

Epidemiology of abdominal wall and groin hernia repairs in children

Lindsey L. Wolf1,2,3 · Kristin A. Sonderman1,2,3,7   · Nicollette K. Kwon1,2 · Lindsey B. Armstrong4 · Brent R. Weil4 ·
Tracey P. Koehlmoos5 · Elena Losina6 · Robert L. Ricca5 · Christopher B. Weldon4 · Adil H. Haider1,2,3 ·
Samuel E. Rice‑Townsend4

Accepted: 5 December 2020 / Published online: 1 January 2021

© The Author(s), under exclusive licence to Springer-Verlag GmbH, DE part of Springer Nature 2021

Abstract
Purpose  We sought to estimate the prevalence, incidence, and timing of surgery for elective and non-elective hernia repairs.
Methods  We performed a retrospective cohort study, abstracting data on children < 18 years from the 2005–2014 DoD Mili-
tary Health System Data Repository, which includes > 3 million dependents of U.S. Armed Services members. Our primary
outcome was initial hernia repair (inguinal, umbilical, ventral, or femoral), stratified by elective versus non-elective repair
and by age. We calculated prevalence, incidence rate, and time from diagnosis to repair.
Results  19,398 children underwent hernia repair (12,220 inguinal, 5761 umbilical, 1373 ventral, 44 femoral). Prevalence
of non-elective repairs ranged from 6% (umbilical) to 22% (ventral). Incidence rates of elective repairs ranged from 0.03
[95% CI: 0.02–0.04] (femoral) to 8.92 [95% CI: 8.76–9.09] (inguinal) per 10,000 person-years, while incidence rates of
non-elective repairs ranged from 0.005 [95% CI: 0.002–0.01] (femoral) to 0.68 [95% CI: 0.64–0.73] (inguinal) per 10,000
person-years. Inguinal (median = 20, interquartile range [IQR] = 0–46 days), ventral (median = 23, IQR = 5–62 days), and
femoral hernias (median = 0, IQR = 0–12 days) were repaired more promptly and with less variation than umbilical hernias
(median = 66, IQR = 23–422 days).
Conclusions  These data describe the burden of hernia repair in the U.S. The large variation in time between diagnosis and
repair by hernia type identifies an important area of research to understand mechanisms underlying such heterogeneity and
determine the ideal timing for repair.
Level of evidence  Prognosis study II.

Keywords  Umbilical hernia · Inguinal hernia · Ventral hernia · Femoral hernia · Pediatric hernia

Introduction after diagnosis owing to concern about incarceration and

Repair of abdominal wall hernias comprises a substantial
portion of pediatric surgical practice and inguinal hernia
repairs are one of the most commonly performed pediatric
operations [1, 2]. Inguinal hernias are often repaired soon
potential for bowel injury. However, concerns about the risk
of exposure to anesthesia in infancy, including newly imple-
mented U.S. Food and Drug Administration warnings, has
spurred ongoing debate about the most appropriate timing
for repair [3–5]. There is similar uncertainty about the most

4
* Kristin A. Sonderman Department of Surgery, Boston Children’s Hospital, Boston,
kristin.sonderman@umm.edu MA, USA
5
1 Uniformed Services University of the Health Sciences,
Center for Surgery and Public Health, Brigham
Bethesda, MD, USA
and Women’s Hospital, Harvard Medical School, Boston,
6
MA, USA Orthopaedic and Arthritis Center for Outcomes Research
2 and Policy, Department of Orthopedic Surgery, Brigham
Harvard T.H. Chan School of Public Health, Boston, MA,
and Women’s Hospital, Innovation Evaluation in Orthopedic
USA
Treatments Research Center, Harvard Medical School,
3
Division of Trauma, Burns, and Surgical Critical Care, Boston, MA, USA
Department of Surgery, Brigham and Women’s Hospital, 7
22 S. Greene St., Baltimore, MD 21201, USA
Boston, MA, USA

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appropriate timing for umbilical hernia repairs with attention
to the possibility of spontaneous closure.
Information from epidemiological studies adds to our
understanding of these conditions and may also be useful to
inform debates on best clinical practice. Large cohort stud-
ies from Taiwan have reported cumulative incidence esti-
mates for pediatric inguinal hernias, with 4.2% of children
undergoing inguinal hernia repair from birth to age 6 [6, 7].
However, large-scale studies are lacking in the literature for
umbilical, ventral, and femoral hernias. Furthermore, there
are no published reports of large-scale U.S.-based estimates
of incidence or timing of repair. We sought to estimate the
prevalence, incidence, and timing of surgery for elective and
non-elective hernia repairs from a large, national administra-
tive dataset of children in the U.S.
Material and methods
Study design and data source
We performed a retrospective cohort study, abstracting
data from the Department of Defense Military Health Sys-
tem Data Repository (MDR) over a 10-year period from
October 1, 2005 to September 30, 2014. The MDR tracks
healthcare delivered to a universally insured population of
active, reserve, and retired members of the United States
Armed Services and their dependents. These data repre-
sent > 9 million military personnel and their dependents,
including > 3 million children, and have been shown to be
a good representation of the national U.S. population [8].
The data are longitudinal in nature, and include all medical
care received while enrolled in the Department of Defense’s
TRICARE health insurance program, including outpatient
visits, hospitalizations, surgical procedures, imaging, and
medications. Additional details of the database have been
previously described [9–12]. The database has been exter-
nally validated by comparing the MDR to the previously
validated American College of Surgeons National Surgical
Quality Improvement Program- Pediatric (NSQIP-P), which
showed that patients included in the MDR were comparable
to those included in NSQIP-P, and that the MDR is espe-
cially valuable as a clinical outcomes research resource [13].
Study population and classification of outcomes
We included all children who underwent initial hernia repair
prior to age 18 years of one of the following four hernia
types: umbilical, inguinal (including unilateral and bilat-
eral), ventral, and femoral hernia. Ventral hernias included
those classified as epigastric, Spigelian, “other ventral her-
nia,” and “other hernia of the anterior abdominal wall.” A
hernia repair of each type was defined by ≥ 1 International
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Pediatric Surgery International (2021) 37:587–595
Classification of Diseases, 9th Revision, Clinical Modifi-
cation (ICD-9CM) diagnosis code and either an ICD-9CM
procedure code or Current Procedural Terminology (CPT)
code consistent with the given type of hernia repair [14]. The
coding classification is shown in the Appendix. We stratified
each type of hernia repair by those performed electively and
those performed urgently or semi-electively. We grouped
urgent and semi-elective repairs together as “non-elective”
repairs. “Non-elective” repairs were defined as those with
either: (1) an ICD-9CM diagnosis code indicating gangrene
or incarceration and any repair within 1 week or (2) a CPT
code indicating repair of an incarcerated or strangulated her-
nia. Within the population of non-elective repairs, we looked
at the distribution of time to surgery. We did not include
diagnosis codes for incisional hernias or recurrent hernias.
Patient characteristics
We collected demographic characteristics for all children
undergoing repair, including age, sex, race/ethnicity, pre-
term (defined by ICD-9 codes), and environment of care
(“direct” care at a military hospital versus “purchased” care
at a civilian hospital). We additionally described clinical
characteristics, including type of repair (laparoscopic ver-
sus open), urgency of repair (elective versus non-elective,
as described above), and specialty of the operating surgeon
(general surgeon, pediatric surgeon, urologist/pediatric
urologist, or others). A previously published and validated
pediatric surgical risk score for mortality was calculated at
the time of repair, based on other diagnoses recorded during
the same hospitalization, as a summary measure of patient
comorbidity [15].
Statistical analysis
We presented the distribution of surgical repair for each type
of hernia. We calculated overall and age-stratified incidence
rates. We considered the following age groups at the time of
diagnosis: < 2 years, 2–3 years, 4–5 years, 6–8 years, 9–12
years, and 13–17 years. We next calculated separate statistics
for elective and non-elective repairs. To calculate relevant
follow-up time, we included periods of continuous enroll-
ment for all children enrolled in TRICARE. For incidence
rate estimation, participants accumulated person-time at risk
for each endpoint until hernia repair, the end of enrollment
in the TRICARE health insurance program, or the age of 18
years. Incidence rates were calculated as number of events
over total person-time at risk for the overall rates and over
the relevant person-time at risk for the rates stratified by
age and urgency of repair. We constructed exact confidence
intervals for incidence rates under the assumption that the
observed event-rates followed the Poisson distribution.
Pediatric Surgery International (2021) 37:587–595 589
For each hernia type, we calculated the median time to
elective repair from the date of diagnosis across patients who
underwent each type of hernia repair. For the subgroup of
children who had a non-urgent diagnosis recorded in their
medical record and subsequently required a non-elective
repair, we calculated the median time to non-elective repair
from the first recorded date of diagnosis, a measure of time
between initial hernia diagnosis and presentation with an
incarcerated hernia. We performed all statistical analyses
using SAS 9.4 (Cary, NC) and R 3.5.2. The Partners Human
Research Committee approved this research.
Results
Patient characteristics
There were 3,033,305 children enrolled in the MDR over
2005–2014. We identified 19,398 children who underwent
hernia repair. Of these, 12,220 (63%) were inguinal, 5761
(30%) were umbilical, 1373 (7%) were ventral, and 44
(< 1%) were femoral (Fig. 1). Characteristics of the children
undergoing repair are shown in Table 1. The distribution of
hernia repairs among males versus females was similar for
umbilical, ventral, and femoral hernias. However, a predomi-
nance of inguinal hernia repairs occurred in males. Umbili-
cal hernia repairs were relatively more common among
black children, while femoral hernia repairs were relatively
more common among white children.
Most (96%) children had a pediatric surgical risk score
of 0, indicating extremely low risk of peri-operative mortal-
ity at the time of hernia repair. For hernia types other than
inguinal, 99% were performed by open technique. Inguinal
hernias were repaired laparoscopically 5% of the time. Non-
elective repairs were performed for 22% of ventral hernias,
16% of femoral hernias, 7% of inguinal hernias, and 6% of
umbilical hernias. Most cases defined as non-elective (95%)
Inguinal Hernia Repair Umbilical Hernia Repair
n= 12,220 n= 5761
Elective Non-elective Elective
n= 11,348 (93%) n= 872 (7%) n= 5417 (94%)
Fig. 1  Flowchart depicting hernia repair categories
were completed within 48 h of diagnosis. Combining all
hernias, repairs were most frequently performed by a gen-
eral surgeon (22%), followed by a pediatric surgeon (18%).
Nineteen percent of inguinal hernia repairs were performed
by a urologist or pediatric urologist. Children were more
frequently referred to as a “purchased care” setting for all
hernia types (Table 1).
Distribution of hernia repair by type
The greatest proportion of elective inguinal hernia repairs
(37%) and the majority of non-elective inguinal her-
nia repairs (54%) occurred before the age of 2 years. The
occurrence of both elective and non-elective inguinal hernia
repairs decreased with increasing age. Elective umbilical
hernia repairs were most commonly performed in children
aged 4–5 years (29%). Non-elective umbilical repairs were
most common in children < 2 years, with 43% of all non-
elective repairs recorded in children < 4 years. Similar to
inguinal hernia repairs, elective ventral hernia repairs were
most common in the first 3 years of life; however, non-
elective ventral hernia repairs were distributed more evenly
across all age groups. Both elective and non-elective repairs
for femoral hernia were seen more frequently among older
children (Table 2).
Incidence rates
Median follow-up time of children in the MDR was
6.1  years (IQR: 3.4–9.0).Overall incidence of elective
hernia repair per 10,000 person-years was 8.92 [95% CI:
8.76–9.09] for inguinal, 4.24 [95% CI: 4.13–4.36] for
umbilical, 0.85 [95% CI: 0.80–0.90] for ventral, and 0.03
[95% CI: 0.02- 0.04] for femoral hernias. Overall incidence
of non-elective hernia repair per 10,000 person-years was
0.68 [95% CI: 0.64–0.73] for inguinal, 0.27 [95% CI:
0.24–0.30] for umbilical, 0.23 [95% CI: 0.21–0.26] for
Children Enrolled in
TRICARE Insurance
2005-2014
n=3,033,305
Ventral Hernia Repair Femoral Hernia Repair
n= 1373 n= 44
Non-elective Elective Non-elective Elective Non-elective
n= 344 (6%) n= 1077 (78%) n= 296 (22%) n= 37 (84%) n= 7 (16%)
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590 Pediatric Surgery International (2021) 37:587–595

Table 1  Characteristics of Variable Inguinal Umbilical Ventral Femoral

children undergoing hernia n (%) n (%) n (%) n (%)
repair
Overall (n = 19,398) 12,220 (63) 5761 (30) 1373 (7) 44 (0.2)
Age at diagnosis (years)
 0–1 6456 (53) 2874 (50) 666 (49) 16 (36)
 2–3 1657 (14) 853 (15) 207 (15) 3 (7)
 4–5 1188 (10) 881 (15) 149 (11) 3 (7)
 6–8 1089 (9) 571 (10) 106 (8) 10 (23)
 9–12 805 (7) 314 (5) 97 (7) 3 (7)
 13–17 1025 (8) 268 (5) 148 (11) 9 (20)
Sex
 Female 1757 (14) 2780 (48) 679 (49) 20 (45)
 Male 10,462 (86) 2981 (52) 694 (51) 24 (55)
Race/ethnicity
 White 7428 (61) 2051 (36) 830 (60) 37 (84)
 Black 1836 (15) 2722 (47) 252 (18) 2 (5)
 Hispanic 795 (7) 215 (4) 86 (6) 0 (0)
 Asian 451 (4) 81 (1) 24 (2) 0 (0)
 Native 82 (1) 18 (0.3) 8 (0.6) 1 (2)
 Other 1266 (10) 537(9) 140 (10) 3 (7)
 Missing 362 (3) 137 (2) 33 (2) 1 (2)
Pediatric surgical risk score
 0 11,660 (95) 5531 (96) 1322 (96) 44 (100)
 1 350 (3) 158 (3) 29 (2) 0 (0)
 ≥ 2 210 (2) 72 (1) 22 (2) 0 (0)
Preterm
 Yes 1741 (14) 362 (6) 125 (9) 1 (2)
 No 10,479 (86) 5399 (94) 1248 (91) 43 (98)
Laparoscopic repair
 Yes 604 (5) 95 (2) 10 (1) 0 (0)
 No 11,616 (95) 5666 (98) 1363 (99) 44 (100)
Non-elective repair
 Yes 872 (7) 344 (6) 296 (22) 7 (16)
 No 11,348 (93) 5417 (94) 1077 (78) 37 (84)
Surgeon specialty
 General surgeon 2186 (18) 1743 (30) 336 (24) 14 (32)
 Pediatric surgeon 1788 (15) 1379 (24) 314 (23) 7 (16)
 Urologist/pediatric urologist 2352 (19) 67 (1) 8 (1) 0 (0)
 Other listed provider 5833 (48) 2491 (43) 700 (51) 23 (52)
 Missing 61 (1) 81 (1) 15 (1) 0 (0)
Environment of care
 Direct 3009 (25) 2105 (37) 295 (21) 11 (25)
 Purchased 9211 (75) 3656 (63) 1078 (79) 33 (75)

ventral, and 0.005 [95% CI: 0.002–0.011] for femoral
hernias. When stratified by age group, incidence gener-
ally decreased with increasing age (Fig. 2). This was most
pronounced for inguinal hernias, where the incidence of
elective hernia repair per 10,000 person-years ranged from
38.3 [95% CI: 37.4–39.3] in children < 2 years to 2.8 [95%
CI: 2.6–3.0] in children 9–12 years, while the incidence
of non-elective inguinal hernia repair per 10,000 person-
years ranged from 3.9 [95% CI: 3.6–4.2] in children < 2
years to 0.15 [95% CI: 0.11–0.21] in children 9–12 years.
Incidence of ventral hernia repair also decreased with
increasing age, with incidence of elective ventral hernia
repair per 10,000 person-years ranging from 3.6 [95% CI:
3.3–3.9] in children < 2 years to 0.26 [95% CI: 0.21–0.33]

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Table 2  Comparison of patient characteristics stratified by elective

and non-elective repairs
Variable Overall Elective Non-elective
n (%) n (%) n (%)

Inguinal
Overall 12,220 (63) 11,348 (93) 872 (7)
Age at repair (years)
 0–1 4704 (38) 4232 (37) 472 (54)
 2–3 2129 (17) 2014 (18) 115 (13)
 4–5 1498 (12) 1423 (13) 75 (9)
 6–8 1422 (12) 1365 (12) 57 (7)
 9–12 1043 (9) 980 (9) 63 (7)
 13–17 1424 (12) 1334 (12) 90 (10)
Umbilical
Overall 5761 (30) 5417 (94) 344 (6)
Age at repair (years)
 0–1 1042 (18) 964 (18) 78 (23)
 2–3 1264 (22) 1195 (22) 69 (20)
 4–5 1609 (28) 1555 (29) 54 (16)
 6–8 992 (17) 937 (17) 55 (16)
 9–12 460 (8) 423 (8) 37 (11)
 13–17 394 (7) 343 (6) 51 (15)
Ventral
Overall 1373 (7) 1077 (78) 296 (22)
Age at repair (years)
Fig. 2  Incidence of each hernia type stratified by age group
 0–1 359 (26) 303 (28) 56 (19)
 2–3 306 (22) 240 (22) 66 (22)
 4–5 206 (15) 166 (15) 40 (14)
[95% CI: 0.06–0.13] in children 9–12 years. Incidence of
 6–8 172 (13) 128 (12) 44 (15)
femoral hernias was so low that no clear trends by age
 9–12 129 (9) 97 (9) 32 (11)
 13–17 201 (15) 143 (13) 58 (20)
were apparent.
Femoral
Overall 44 (0.2) 37 (84) 7 (16)
Timing of hernia repairs
Age at repair (years)
 0–1 4 (9) 4 (11) 0 (0)
The time between first diagnosis and elective hernia repair
 2–3 5 (11) 4 (11) 1 (14)
varied substantially by type of hernia and age at diagno-
 4–5 7 (16) 6 (16) 1 (14)
sis. Median time from first diagnosis to elective repair was
 6–8 14 (32) 12 (32) 2 (29)
20 days (IQR: 0–46) for inguinal hernia, 66 days (IQR:
 9–12 4 (9) 3 (8) 1 (14)
23–422) for umbilical hernia, 23 days (IQR: 5–62) for ven-
 13–17 10 (23) 8 (22) 2 (29)
tral hernia, and 0 days (IQR: 0–12) for femoral hernia. For
elective umbilical hernia repair, there was pronounced varia-
tion in time to surgery by age at diagnosis, with median time
to repair of 425 days (46–1159) in children < 2 years ranging
in children 9–12 years and incidence of non-elective ven- to median time to repair of 25 days (1–61) in children 13–17
tral hernia repair per 10,000 person-years ranging from years. No clear trends by age were observed for the other
0.76 [95% CI: 0.63–0.91] in children < 2 years to 0.09 hernia types (Table 3).
[95% CI: 0.06–0.13] in children 9–12 years. The incidence Of children who underwent a non-elective hernia repair,
of elective umbilical hernias per 10,000 person-years was many had a prior non-urgent hernia diagnosis recorded
17.6 [95% CI: 17.0–18.3] in children aged < 2 years to in their medical record, with 43% of non-elective ingui-
0.73 [95% CI: 0.64–0.83] in children 13–17 years. The nal repairs, 64% of non-elective umbilical hernia repairs,
incidence of non-elective umbilical hernia repairs per and 68% of non-elective ventral hernia repairs previously
10,000 person-years decreased with increasing age from diagnosed. Of the 7 who underwent non-elective femoral
1.15 [95% CI: 0.98–1.33] in children < 2 years to 0.09 hernia repair, 5 were diagnosed and underwent repair the

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592 Pediatric Surgery International (2021) 37:587–595

Table 3  Timing of elective Variable Inguinal Umbilical Ventral Femoral

hernia repair
n Median (IQR) n Median (IQR) n Median (IQR) n median (IQR)
days days days days

Overall 11,348 20 (0–46) 5417 66 (23–422) 1077 23 (5–62) 37 0 (0–12)

Age at
diagnosis
(years)
 0–1 5858 14 (0–45) 2698 425 (46–1159) 551 29 (7–95) 15 0 (0–0)
 2–3 1583 19 (0–43) 817 74 (25–500) 159 21 (5–58) 2 0 (0–0)
 4–5 1131 24 (0–49) 844 49 (23–117) 115 28 (7–65) 2 6 (0–12)
 6–8 1042 22 (0–48) 539 41 (20–95) 81 22 (5–44) 8 0 (0–21)
 9–12 763 20 (0–43) 290 43 (15–85) 72 27 (8–89) 3 6 (0–83)
 13–17 971 24 (9–48) 229 25 (1–61) 99 15 (1–41) 7 0 (0–0)

same day. Like the trend seen with elective repairs, median
time to non-elective repair was longer for umbilical her-
nias (67, IQR 25–412 days) compared to inguinal (21, IQR
6–54 days), ventral (36, IQR 18–76 days), and femoral (16,
IQR 15–16 days) hernias. Seventy-three children < 2 years
and 31 children aged 2–3 years with a previously diagnosed
umbilical hernia required a non-elective repair; median time
to repair was 318 days (IQR: 39–696) in the children < 2
years and 67 days (IQR: 34–560) in the children aged 2–3
years. While median time to non-elective repair was longer
than median time to elective repair for ventral hernias,
this time was shorter for inguinal and umbilical hernias
(Table 4).
Discussion
We analyzed a large, national database, including > 3 million
children in our cohort. Of these, we identified > 19,000 chil-
dren who underwent a hernia repair between 2005 and 2014.
Inguinal hernia repairs were the most common, compris-
ing 63% of all repairs, followed by umbilical (30%), ventral
(7%), and femoral (< 1%) repairs. The prevalence of non-
elective repairs ranged from 6% of all repairs for umbilical
hernias to 22% of all repairs for ventral hernias. Incidence of
elective hernia repairs per 10,000 person-years ranged from
8.9 for inguinal repairs to 0.03 for femoral repairs, while the
incidence of non-elective repairs per 10,000 person-years
ranged from 0.68 for inguinal repairs to 0.005 for femo-
ral repairs, with incidence rates generally decreasing with
increasing age. Inguinal and ventral hernias were typically
repaired electively soon after diagnosis. There was, however,
substantial variation in the time from diagnosis to elective
repair of umbilical hernias.
These findings are consistent with and expand upon those
from prior reports. Of all hernia types, pediatric inguinal
hernias have been best described. Two retrospective, longi-
tudinal studies from the Taiwanese national health insurance
database reported a cumulative incidence of 6.6% in males
and 0.74% in females by age 15 years, with 63% of children

Table 4  Timing of non-elective Variable Inguinal Umbilical Ventral Femoral

repair
n Median (IQR) n Median (IQR) n Median (IQR) n median (IQR)
days days days days

Overall 374 21 (6–54) 219 67 (25–412) 200 36 (18–76) 2 16 (15–16)

Age at
diagnosis
(years)
 0–1 169 15 (3–49) 73 318 (39–696) 42 38 (21–96) 0 –
 2–3 52 13 (3–29) 31 67 (34–560) 40 44 (23–60) 1 16 (16–16)
 4–5 40 25 (10–64) 36 54 (33–221) 31 39 (17–105) 0 –
 6–8 35 41 (16–73) 29 57 (34–105) 24 49 (27–141) 0 –
 9–12 33 28 (8–64) 22 41 (23–99) 20 22 (13–62) 0 –
 13–17 45 34 (15–59) 28 21 (9–59) 43 27 (15–67) 1 15 (15–15)
*
 Sum of observations from Tables 3 and 4 does not equal the total number of observations due to missing
date of diagnosis in 5123 children

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undergoing repair < 4 years [6, 7]. A large, cross-sectional
study on inguinal hernia repairs at U.S. academic medical
centers included > 26,000 initial inguinal hernia repairs,
with 76% of children undergoing repair < 4 years [16]. These
compare to 67% of children undergoing repair < 4 years in
the current study. In addition, two large, single-institution,
retrospective analyses have described children undergoing
inguinal hernia repair, with mean age at diagnosis reported
to be 2.7–3.3 years [17, 18]. Incarceration has been reported
in 4–12% of pediatric inguinal hernia presentations, which
may increase to 30% in infants [2, 6, 16, 18, 19]. In our
study, 7% of inguinal hernias were repaired non-electively
for incarceration, with over half of these non-elective opera-
tions occurring in children < 2 years.
The largest published study on umbilical hernia repairs
followed 377 children treated at 3 U.S. teaching hospitals
from 1964 to 1974, with 61% of repairs occurring < 4 years
and 7% occurring urgently [20]. A second long-term ret-
rospective review also reported a 7% prevalence of incar-
ceration [21]. In the current study, we found a prevalence
of non-elective umbilical hernia repair of 6%. It is standard
practice to observe asymptomatic umbilical hernias until the
age of 4 years, given that many will close spontaneously,
obviating the need for surgery [22]. Umbilical hernia repair
occurred most commonly at age 4–5 years in the current
study; however, 43% of all non-elective umbilical hernia
repairs occurred in children < 4 years.
There are few published reports on ventral or epigastric
hernias in children. One single-institution, retrospective
review over 14 years described 38 epigastric hernia repairs
in children < 18 years, with mean age at presentation of 4.3
years. Of these, 7 presented with an asymptomatic, nonre-
ducible epigastric mass, and 6 presented with a tender epi-
gastric mass [23]. Taken together, this prevalence of 34%
is similar to the prevalence of incarceration observed in the
current study. The group of ventral hernias includes more
heterogeneity than the other groups of hernias in this study.
It is important to note that epigastric hernias are most likely
to contain preperitoneal fat, rather than intraperitoneal con-
tents, making incarceration much less clinically relevant for
this hernia type. The group of ventral hernias also includes
incisional hernias, which are at risk of presenting with bowel
incarceration and obstruction. We found femoral hernias to
be exceedingly rare in children, comprising approximately
0.2% of all groin hernias in our cohort. Other reports in the
literature have found femoral hernias account for 0.4–2.8%
of all groin hernias [24–26]. The overall low proportion of
laparoscopic cases may be related to a temporal effect. While
there are no reports on the prevalence of laparoscopic hernia
repairs in the pediatric literature, a study of inguinal hernia
repairs in adults showed an increase in the use of laparos-
copy over time, ranging from 27% of cases in 2008 to 40%
in 2014 [19]. This same trend may present in the pediatric
population, with current rates of laparoscopy use expected
to be higher than those demonstrated by these data.
Timing of hernia repair has been previously studied in
the case of inguinal hernias. The Taiwanese national health
insurance database studies on pediatric inguinal hernia
reported a mean time from first diagnosis to surgery of
59 days, which did not differ between elective and urgent
repairs [6]. Similarly, in the current work, the time from
diagnosis to surgery was similar between children under-
going elective and non-elective inguinal hernia repairs—
there did not appear to be a substantial delay to explain the
non-elective presentations. In contrast, a retrospective study
using administrative data from Canada on children < 2 years
found a median time to surgery of 35 days, with an increased
risk of incarceration observed with wait times > 14 days
[19].
This study is susceptible to the limitations of administra-
tive data, including the lack of clinical variables such as
specific neonatal age in days or weight at the time of surgery
[27]. In the MDR, specific procedure dates are unavailable
for procedures performed in the inpatient setting; instead,
the first date of the admission was applied as the proce-
dure date. We were unable to reliably capture any history
of hernia repair that may have occurred outside the MDR,
during any period when a child was not covered in the TRI-
CARE program. These children would have contributed
follow-up time to the denominator without truly being at
risk for the event of interest; therefore, the incidence rates
presented may underestimate the incidence of abdominal
wall hernia repairs. The classification of elective versus non-
elective repairs was made on the basis of CPT and ICD-9
codes; there is the potential that a hernia found to be stuck
at the time of an elective repair was therefore classified as a
non-elective repair. As most repairs of incarcerated hernias
were performed within 48 h of diagnosis, we were unable to
investigate outcomes of children undergoing delayed repair
after an incarceration event, which may be a topic for future
study. This study uses data through 2014, which were the
most recent data available during the study period. Despite
this, our study covered a 10-year period, which provided us
with valuable information about the prevalence, incidence,
and timing of surgery for elective and non-elective hernia
repairs in children in MHS.
Despite these limitations, there are several advantages to
the MDR, including availability of inpatient and outpatient
information (both diagnoses and procedures), its national
scope, and its longitudinal nature over an extended period
of time. MDR has been compared to the validated National
Surgical Quality Improvement Program-Pediatric database
and was found to be comparable in regard to demographics
and clinical outcomes, with the added advantage of offering
longer follow-up beyond the 30 day peri-operative period
[13].
13

594
This work has several implications. We characterize
the age distributions of the different types of abdominal
wall hernias and provide incidence rates within a large,
U.S.-based population. We report a high prevalence of
non-elective repair (22%) in children with ventral hernias,
which has not been previously reported. In addition, the
high prevalence of incarceration in children < 2 years for
inguinal (54%), umbilical (23%), and ventral (19%) her-
nias has important implications regarding the timing of
surgery; this higher risk of incarceration must be balanced
with the concerns related to undergoing anesthesia at
younger ages [3, 5, 28]. Umbilical hernia repair occurred
most commonly at age 4–5 years, matching the accepted
standard of care [22, 29]; however, there were a sizable
number of non-elective repairs—nearly half of all non-
elective umbilical hernia repairs—in children < 4 years.
Conclusions
We characterized the practice patterns for pediatric
abdominal wall hernia repair in a large national cohort
generalizable to the pediatric population in the U.S. Inci-
dence of pediatric hernia repairs was highest in the young-
est children and decreased with age. Non-elective repairs
accounted for 8% of all repairs and were most common in
the youngest children. The findings on substantial varia-
tion in time from the first diagnosis to repair, as well as
the rates of non-elective repairs in very young children,
may raise interesting questions for future research about
the ideal timing for each type of hernia repair.
Funding  Funding for this project was provided in part by the Ameri-
can College of Surgeons Resident Research Scholarship to LLW. The
Center for Surgery and Public Health and the Uniformed Services Uni-
versity of Health Sciences are jointly supported by the Henry M. Jack-
son Foundation for the Advancement of Military Medicine to provide
protected research efforts involving the analysis and study of military
TRICARE data; AHH received partial salary support. Neither fund-
ing source had any role in the collection, analysis, and interpretation
of data; writing of the report; or decision to submit the article for
publication.
Compliance with ethical standards  data repository and American College of Surgeons National Surgi-
Conflict of interest  All authors have no conflicts of interest.
Ethical approval  This article does not contain any studies with human
participants or animals performed by any of the authors.
Disclaimer  The opinions and assertions expressed herein are those
of the author(s) and do not necessarily reflect the official policy or
position of the Uniformed Services University or the Department of
Defense.
13
Pediatric Surgery International (2021) 37:587–595
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