Inguinal hernia (IH) repair is common in children and is usually performed by ... Vogels, H.D., C.J. Bruijnen, and S.W. Beasley, Predictors of recurrence after ...
Department of pediatric Surgery, Hamad Medical Corpora8on, Doha, Qatar Department of Surgery, Weill Cornell Medical College Qatar, Cornell University
Introduction: Inguinal hernia (IH) repair is common in children and is usually performed by pediatric and/or general surgeons with low complications rates [1]. There is a lack of evidence for early outcome in terms of hospital stay, reoperation rate, and morbidity as well as the choice of method for repair for inguinal hernia in children [2-4]. In our country, there is no national data on operative activity and surgical outcome after pediatric inguinal hernia repair. This study was conducted to study nationwide outcomes in terms of incidence, hospital stay, 30-day readmission, frequency of emergency repair and reoperations within the 12-months after primary inguinal hernia surgery in Qatar during the 2-year study period.
Materials & Methods: We collected retrospective data of children (0-14 years) operated for inguinal hernia across the country from January 2012 to November 2014. We studied, demography, complications and outcome. We used four indicators to identify unexpected outcome: frequency of emergency operation, hospital stay for > 2 days (2 nights in hospital or more) readmission within 30 days and reoperations within 12 months after repair including repair for recurrence. Emergency operation was defined as a procedure in patients coming to hospital without a beforehand planned inguinal hernia repair with obstructed or incarcerated hernia. The study was approved by the institutional ethical board.
Results: The study profile is shown in Table 1. Our study Cohort consisted of 558 patients of 38 nationalities. The procedures were performed by attending/consultants in 101 (18%), senior registrars in 245 (44%) and residents under supervision in 212 (38%) children. Ninety-nine (18%) children presented with an obstructed inguinal hernia (Table 2) and required emergency operation, which included 16 patients who had failed manual reduction and were explored immediately (Contents included bowel 13, ovary 3, appendix 1) where as other 83 patients had a successful manual reduction and were operated after 24-48 hrs. Prolonged hospital stay was observed in 118 (21%) of patients and the reasons included obstructed inguinal hernia (99), pain (8), fever (7), and scrotal hematoma (4). Complications were observed in 20 (3.6%) children (Table 3). The group of patients with unexpected outcome counted 129 patients (23%) which comprised of prolonged hospital stay in 21%, followed by readmission in 1.8%, reoperation in 1.8% children (Table 4). Table 1. Study Profile Study Cohort n= 558 Mean Age (mo.) Right Inguinal Hernia Repair
Male
Table 2. Frequency of Emergency OperaGon Female
6.63±2.64 5.92±2.11 226
93
Total 319
Le[ Inguinal Hernia Repair
147
39
186
Bilateral Inguinal Hernia Repair
40
13
53
Elec8ve
323
136
459
Emergency
90
9
99
Associated Procedures
139
8
147
Associated Malforma8ons
68
6
74
Study Cohort n= 99 with obstructed inguinal hernia
Male
Female
Total
Table 3. Post Op Morbidity, Table 4. Primary reasons for unexpected outcomes in 129 (23%) children aTer inguinal hernia repair n = 20 (3.6%) No
Morbidity
7
Recurrence
4
Scrotal Hematoma
Successful Reduc8on
76
7
83
Surgery Immediate
14
2
16
3
Wound Infec8on
Surgery > 24 Hr
29
5
34
3
Ascending Tes8s
Surgery >48 Hr
47
2
49
2
Tes8cular Atrophy
Morbidity
16
1
17
1
Fecal Fistula
Study Cohort, n = 558 Primary Reason for Prolonged hospital stay, n= 118 (21%)
Readmission, ReoperaGons, n = 11 (1.8%) n = 10 (1.8s%)
Obstructed hernia, n = 99
Recurrence, Recurrence, n = 7 n = 7
Pain, Ascending Tests, Ascending Tests, n = 8 n = 3 n = 3 Fever, Wound Infec8on, n = 7 n = 1 Hematoma, n = 4
Discussion: This nationwide study has demonstrated a satisfactory early outcome following pediatric inguinal hernia repair. Hospital stay was in most patients no more than a day, and only a few children were readmitted to hospital, and recurrence rate was 1.3%., which is comparable with other reported series [2, 5, 6] Inguinal hernia repair in an elective setting carries a low risk and has good results, however, while waiting for elective repair, the child is at risk of developing incarceration, transforming a safe, and elective procedure into a more emergent one, requiring manual reduction and urgent repair [7, 8]. In our series, we observed 18% children with incarcerated inguinal hernia during 2-year study period and less than half of these children were booked for elective surgical repair. Among 99children with incarcerated inguinal hernia, 16% children had failed reduction and required immediate surgery whereas others were operated in next 24-48 hrs., but yet the complications such as testicular atrophy, ascending testis requiring surgery, wound infection and recurrences were higher as compared to the electively operated group of children. Prolonged wait time for inguinal hernia repair in children has been reported to be associated with a higher rate of incarceration as well as greater usage of emergency department resources [7]. A wait time for surgery of more than 14 days was associated with a doubling of the risk of hernia incarceration among infants and young children with inguinal hernia [9]. Although our waiting period is not long (average 2-months), yet we received a large number of children with incarcerated hernia and this needs a further in-depth analysis to look into the possible causes and possibly further reduce the waiting time. The present study has also given us the opportunity to analyze possible needs for surgical quality improvement as suggested by Borenstein et al. [10]. They found, in a cohort of 20,545 pediatric hernia repairs with a maximum of 8 years follow up that pediatric surgeon specialization and high-volume general surgeons reduced the risk of recurrence but not complications. The risk of recurrences and complications for repairs performed by pediatric surgeons and high-volume general surgeons were at the same level as in our study and in other large-scale national reports [5, 6, 11, 12] In conclusion, our national results after pediatric inguinal hernia repair has shown acceptable outcomes and have encouraged us to conduct such studies at regular intervals to evaluate possible needs for surgical quality improvement.
References:
1. Hall, N.J., et al., Age-‐related probability of contralateral processus vaginalis patency in children with unilateral inguinal hernia. Pediatr Surg Int, 2012. 28(11): p. 1085-‐8. 2. Rosenberg, J., Pediatric inguinal hernia repair-‐a cri8cal appraisal. Hernia, 2008. 12(2): p. 113-‐5. 3. Lau, S.T., Y.H. Lee, and M.G. Caty, Current management of hernias and hydroceles. Semin Pediatr Surg, 2007. 16(1): p. 50-‐7. 4. Chinnaswamy, P., et al., Laparoscopic inguinal hernia repair in children. JSLS, 2005. 9(4): p. 393-‐8. 5. Bisgaard, T., et al., Acceptable na8onwide outcome a[er paediatric inguinal hernia repair. Hernia, 2014. 18(3): p. 325-‐31. 6. Vogels, H.D., C.J. Bruijnen, and S.W. Beasley, Predictors of recurrence a[er inguinal herniotomy in boys. Pediatr Surg Int, 2009. 25(3): p. 235-‐8. 7. Chen, L.E., et al., Impact of wait 8me on outcome for inguinal hernia repair in infants. Pediatr Surg Int, 2009. 25(3): p. 223-‐7. 8. Stylianos, S., N.N. Jacir, and B.H. Harris, Incarcera8on of inguinal hernia in infants prior to elec8ve repair. J Pediatr Surg, 1993. 28(4): p. 582-‐3. 9. Zamakhshary, M., et al., Risk of incarcera8on of inguinal hernia among infants and young children awai8ng elec8ve surgery. CMAJ, 2008. 179(10): p. 1001-‐5. 10. Borenstein, S.H., et al., Effect of subspecialty training and volume on outcome a[er pediatric inguinal hernia repair. J Pediatr Surg, 2005. 40(1): p. 75-‐80. 11. Erdogan, D., et al., Analysis of 3,776 pediatric inguinal hernia and hydrocele cases in a ter8ary center. J Pediatr Surg, 2013. 48(8): p. 1767-‐72. 12. Vogels, H.D., C.J. Bruijnen, and S.W. Beasley, Establishing benchmarks for the outcome of herniotomy in children. Br J Surg, 2010. 97(7): p. 1135-‐9.
Acknowledgments: Supported by the Medical Research Center, Hamad Medical Corporation, Qatar
