Hernia survey of the Section on Surgery of the American Academy of Pediatrics (original) (raw)
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Hernia Survey of the Section on Surgery of the American Academy of Pediatrics* 1
Journal of pediatric …, 1996
The members of the Section on Surgery of the American Academy of Pediatrics were surveyed to determine the practice of North American pediatric surgeons in infants with inguinal hernia (IH). Case-scenario multiple-choice-design questionnaires regarding hernias and hydroceles were sent to all members of the Surgical Section, and responses were received from 292 (50%). In healthy full-term infant boys with asymptomatic reducible IH, 82% of responders perform repair electively, no matter what the age or weight. In full-term girls with a reducible ovary, 59% perform surgery at the next available time; if the ovary is nonreducible but asymptomatic, 44% operate emergently or urgently and 42% at the next elective slot. In former preemies, the pattern of repair is as follows. (1] For those recently discharged after 2 months in the neonatal intensive care unit (NICU) with reducible IH, 65% perform the repair when convenient. (2) A general anesthetic is used in 70%; 15% use spinal anesthesia, and 11% use caudal block with sedation. (3) If the repair is done in the hospital outpatient (same-day) unit, 36% wait until 50 weeks postconception (PC) and 33% wait until 60 weeks PC. (4) If the baby's weight is at least 1,000 g, 71% perform the repair before discharge. The pain control choice after childhood IH repair is Tylenol for 30%, local infiltration biquivacaine for 30%, caudal block for 22%, regional block for 11%, and Tylenol/codeine combined for 7%. In 6-weekold full-term infants with communicating hydroceles without definite "hernia," two thirds treat as an IH with elective repair as soon as possible. With respect to contralateral exploration in infants with unilateral IH, 65% perform it in males if they are _<2 years of age and 84% use it in females of up to 4 years of age. This approach is not influenced by presenting side, presence of hydrocele, or history of prematurity. LaParoscopic evaluation of the contralateral IH is performed by only 6% of responders, 40% of whom use the open ipsilateral sac for laparoscope introduction.
Surgical Endoscopy, 2016
Background The role of laparoscopy in pediatric inguinal hernia (IH) is still controversial. The authors reported their twenty-year experience in laparoscopic IH repair in children. Methods In a twenty-year period (1995-2015), we operated 1300 infants and children (935 boys-365 girls) with IH using laparoscopy. The average age at surgery was 18 months (range 7 days-14 years). Body weight ranged between 1.9 and 50 kg (average 9.3). Preoperatively all patients presented a monolateral IH, right-sided in 781 cases (60.1 %) and left-sided in 519 (39.9 %). We excluded patients with bilateral IH and unstable patients in which laparoscopy was contraindicated. If the inguinal orifice diameter was C10 mm, we performed a modified purse string suture on peri-orificial peritoneum, in orifices B5 mm, we performed a N-shaped suture. Results No conversion to open surgery was reported. In 533 cases (41 %), we found a contralateral patency of internal inguinal ring that was always closed in laparoscopy. In 1273 cases (97.9 %), we found an oblique external hernia; in 21 cases (1.6 %), a direct hernia; and in 6 cases (0.5 %), a double hernia on the same side (hernia en pantaloon). We found an incarcerated hernia in 27 patients (2 %). Average operative time was 18 min (range 7-65). We recorded 5/1300 recurrences (0.3 %), but in the last 950 patients, we had no recurrence (0 %). We recorded 20 complications (1.5 %): 18 umbilical granulomas and two trocars scar infections, treated in outpatient setting. Conclusions On the basis of our twenty-year experience, we prefer to perform IH repair in children using laparoscopy rather than inguinal approach. Laparoscopy is as fast as inguinal approach, and it has the advantage to treat during the same anesthesia a contralateral patency occured in about 40 % of our cases and to treat also rare hernias in about 3 % of cases.
American Academy of Pediatrics Section on Surgery hernia survey revisited
Journal of Pediatric Surgery, 2005
Background: The aim of the study was to describe current treatment and trends in surgical management of pediatric inguinal hernias (IHs), specifically contralateral exploration. Methods: Surveys were sent to 599 Surgical Section members. Questions paralleled the 1993 American Academy of Pediatrics survey and addressed recent controversial topics. Statistical analysis by v 2 was performed. Results: Three hundred ninety-five (66%) surveys returned. For full-term boys with reducible IH, 79% (82%) repair electively, regardless of age or weight. For full-term girls with reducible ovary, 49% (27%) repair electively, 36% (59%) next available slot, 5% (10%) emergently (P b .01). In former premature infants, 53% (65%) repair reducible IH when convenient, regardless of age. For unilaterally presenting IH, 44% (65%) routinely explore contralateral groins in boys 2 years or younger (P b .01); 47% (84%) routinely explore girls 4 years or younger (P b .01). No significant association between routine exploration patterns and years in practice, region of country, or training program affiliation was found. Laparoscopic evaluation for contralateral IH was reported by 37% (6%), (P b .01) 1993 results italicized. Conclusion: Reports of routine contralateral inguinal exploration had absolute decreases of 21% for boys 2 years or younger, 37% for girls 4 years or younger. There has been a shift toward elective repair for girls with reducible ovaries. Use of laparoscopy for diagnostic contralateral evaluation has increased dramatically. D
Large Inguinal Hernia in Infants: Is Laparoscopic Repair The Answer?
Journal of Laparoendoscopic & Advanced Surgical Techniques, 2007
Purpose: Infants with large hernias present a challenge to the pediatric surgeon. We present our experience of laparoscopic repair of large hernias in 16 infants, the youngest aged 40 days. Fifteen of the infants were younger than 18 months and one was 2 years old. Materials and Methods: Sixteen male infants with large inguinal hernias (hernia extending to the bottom of the scrotum and the diameter of the open internal ring Ͼ2 cm on laparoscopy) underwent laparoscopic hernia repair. Diagnostic laparoscopy was performed under general anesthesia with a telescopic port at the umbilicus. If the internal ring was open, two working ports were introduced pararectally on either side. An open internal ring was considered an indication for hernia repair. The needle, carrying 3-0 nylon nonabsorbable sutures, was introduced through the groin skin at the internal inguinal ring and the internal ring was closed by taking continuous sutures to approximate the edges of the ring. The needle was then taken out through the entry point and the knot was tied extracorporeally and buried in the subcutaneous tissue. In 4 patients in the initial part of the study, intracorporeal (knot tied internally) suturing was done to close the internal ring. A contralateral repair was done if the internal ring was open. Results: A total of 18 repairs were performed in 16 patients: 10 had a right sided hernia, 4 had a left sided hernia, and 2 had an open contralateral ring (suggestive of contralateral patent processus vaginalis). The contents of the hernia were bowel (1 patient), omentum (3 patients), and bowel adhesions at the internal ring (1 patient). There was 1 conversion. The mean operative time was 23 minutes for unilateral repair and 29 minutes for bilateral repair. The mean follow-up was 19 months (range, 3 months to 3 years). There are no recurrences to date. There was no morbidity or mortality. Conclusion: Laparoscopy is safe and feasible for repair of large inguinal hernias in infants Յ2 years and provides treatment of contralateral patent processus vaginalis in the same setting with no significant increase in operating time. Extracorporeal knot tying has made the procedure feasible in the limited working space available in these babies. Though there were no recurrences or postoperative hydrocele, the number of patients in the study is too small to comment on rates of recurrence or hydrocele.
Analysis of 3776 pediatric inguinal hernia and hydrocele cases in a tertiary center
Journal of Pediatric Surgery, 2013
Background/Purpose: This study describes the pediatric inguinal hernia and hydrocele experience of a tertiary care training hospital. Methods: A total of 3776 patients who had been operated between January 2005 and June 2009 for inguinal hernia, cord hydrocele, and hydrocele were included. The surgeries and patient follow-up were performed by 6 pediatric surgery specialists and 8 pediatric surgery residents. Results: The patient age varied from 6 days to 17 years. There were 2959 (78.4%) males and 817 (21.6%) females (ratio: 3.6:1). The hernia was on the right in 2306 (61.1%) patients, on the left in 1111 (29.4%) patients, and bilateral in 359 (9.5%) patients. Age at presentation was younger in males (pb.001). Contralateral hernia repair was required later on during follow-up in 2% of the patients. Postoperative complications developed in 1.2% of the patients. Reoperation was needed because of wound infection in 0.6%, recurrence in 0.4%, hematoma in 0.1%, testicular atrophy in 1 patient, and acquired undescended testis in 1 patient. Conclusions: The age of first hernia symptoms was younger in males compared to females and in premature babies compared to term babies (pb.05). The recurrent hernia rate was higher in infancy. The complication rate was higher in hernia surgery in the newborn period and in cases of incarcerated hernia compared to the overall rate (pb.05). There was no indication for contralateral routine exploration.
ABC of General Paediatric Surgery: INGUINAL HERNIA, HYDROCELE, AND THE UNDESCENDED TESTIS
BMJ, 1996
Clinical embryology and anatomy of the inguinal region dutomna '~The testis is formed from coelomic epithelium and primordial germ cells in a longitudinal fold high on the posterior abdominal wall at a similar level to the developing kidneys. As gestation proceeds, the testis migrates down the posterior wall towards the deep inguinal ring, probably under the control of the hormone mullerian duct inhibitory factor. The gubernaculum, a condensation of mesenchyme, forms _ within the future inguinal canal and guides the testis through the layers i_______ of the body wall towards the scrotum. Two factors seem to be important in this second stage-the release of testosterone from the fetal testis itself and an intact genitofemoral nerve, which probably-\ l <; releases substances causing gubernacular contraction. A tongue of the peritoneal cavity also precedes the migrating testis through the canal-the processus vaginalis. After birth this peritoneal communication should obliterate and disappear, but failure to do this may lead to two of the commonest problems of this region, hernias and .....%'..%-. hydroceles. Anatomy of the processus vaginalis. Inguinal hernias Anatomically these are virtually all indirect and often complete (that is, the sac comes all the way to the scrotum). Infantile hernias occur in about 1-2% of births and are much more common in premature babies than in full term infants. They appear as an intermittent, usually reducible, lump in the groin. The correct management is a surgical herniotomy when the child's condition allows. In most uncomplicated cases this should be within two or three weeks of diagnosis. Infant
Recommendations for treatment of contralateral inguinal hernias in children
Hernia, 1999
It is impossible to determine whether or not a child will develop a contralateral hernia after inguinal hernia repair. There exists no risk score for the occurrence of a contralateral hernia. This well-known fact prompted us to perform the underlying study. In a retrospective trial, we reviewed the files of all children operated on for inguinal hernias in our department from January 1986 until December z994. During this period, we performed 1721 hernia repairs on a7o8 children aged o-16 years. In 96 (5.6%) of these patients, the indication to operate was a contralateral hernia following previous unilateral repair. Comparison of the ages at the time of primary inguinal repair of those children who developed a contralateral hernia (n=96) and those who did not (n=1612) showed a significantly increased incidence of contralateral hernias if the primary operation was performed before the age of two months (p<o.ool). Diseases predisposing to hernias were found in 38% of all children (prematurity, dystrophia, ventriculo-peritoneal shunt, ascites, asthma). The authors recommend a contralateral exploration for children under the age of two months if they have any predisposing disease.
Assessment and Management of Inguinal Hernia in Infants
Pediatrics, 2012
Inguinal hernia repair in infants is a routine surgical procedure. However, numerous issues, including timing of the repair, the need to explore the contralateral groin, use of laparoscopy, and anesthetic approach, remain unsettled. Given the lack of compelling data, consideration should be given to large, prospective, randomized controlled trials to determine best practices for the management of inguinal hernias in infants.