Management of inguinal hernias in children
Myron Yaster MD and Lynne G. Maxwell MD
Original article
Faraz A. Khan, Tim Jancelewicz, Kathleen Kieran, Saleem Islam, COMMITTEE ON FETUS AND NEWBORN, SECTION ON SURGERY, SECTION ON UROLOGY; Assessment and Management of Inguinal Hernias in Children. Pediatrics July 2023; 152 (1): e2023062510. 10.1542/peds.2023-062510
One of the most common conditions requiring surgery in pediatrics is the repair of inguinal hernias. Today’s PAAD is a wonderful review by Khan et al.1 and is a must read for all pediatric anesthesiologists. It provides not only a wonderful description of the anatomy, embryology, pathophysiology, and methods and timing of surgical repair of the patent processus vaginalis (PPV) but also a wonderful review of the anesthetic issues involved in management of these mostly very young patients.
For the sake of brevity in today’s PAAD we will concentrate on the methods and timing of surgery and some of the anesthetic issues discussed in this article.
“Despite being one of the most commonly performed operations in preterm neonates, the optimal timing of inguinal hernia repair remains controversial, as suggested by the significant variability in practice among pediatric surgical specialists.”1 Because many of these babies are hospitalized in the NICU or “growing” nurseries, should they undergo repair before discharge or be allowed to go home and return when convenient on an outpatient basis? Those favoring early surgery are concerned with the risk of bowel incarceration, strangulation, and testicular atrophy.2, 3 “Possible motivations for delaying inguinal hernia repair in preterm neonates include technical challenges, higher rate of recurrence, comorbid conditions associated with prematurity, and anesthesia-related concerns including risk of postoperative apnea and prolonged postoperative ventilator dependence.”1, 4
Although the gold standard surgical approach is an open, high ligation of the hernia sac, increasingly many surgeons are repairing these defects laparoscopically.5 Recent meta-analysis of studies comparing the complication and recurrence rates between these 2 techniques show no real differences. The gain in popularity of the laparoscopic technique is “because of the reduced rate of postoperative complications, shorter operative time in patients needing bilateral repair, and similar rates of recurrence.”6 Finally, “contralateral exploration has been a subject of considerable debate.”1 The laparoscopic technique allows for inspection of the contralateral side without any additional open surgical intervention, although some surgeons repair the visible hernia in an open fashion, followed by a brief laparoscopic look at the contralateral side to assess the presence of a PPV, followed by open repair if PPV is present. Low insufflation pressure is used for this assessment and it may be performed in infants having spinal anesthesia with a natural airway as easily as in those under general endotracheal anesthesia.
Because these surgical repairs are performed in very young infants, is anesthesia safe? We’ve discussed the risks of general anesthesia on neurodevelopment in many previous PAADs. This article provides a very concise and measured discussion. The 2 most robust clinical human studies, the GAS7, 8 and PANDA9 studies, have concluded that “there is no evidence that exposure to a single brief general anesthetic poses any significant risk to neurodevelopment, academic performance, or risk of attention-deficit/hyperactivity disorder or autism spectrum disorder.”1 Finally, infants born prematurely undergoing either general anesthesia or spinal anesthesia are at an increased risk of developing post anesthesia apnea. Known contributors include gestational age, postconceptional age, and anemia.10 Who requires overnight observation and monitoring remains institutionally parochial, as there is no general consensus as to the post-conceptual age (PCA) at which the risk of post anesthesia apnea declines to the level of a full term newborn >44 weeks PCA. You can pick a number 52, 54, 56, or 60 post conceptual weeks (and while you’re at it you may want to buy a powerball or megamillions lottery ticket).
This clinical report is a fine example of a common process in which subspecialty committees and sections of The American Academy of Pediatrics (in this case Committee on Fetus and Newborn and Sections on Surgery and Urology) identify a topic which merits review and discussion to educate the membership of the AAP and the general pediatric community. I (LGM) had the honor and pleasure of serving on the AAP Committee on Drugs for many years and collaborating with other pediatric subspecialists on clinical reports on topics of general pediatric interest.
References
1. Khan FA, Jancelewicz T, Kieran K, et al. Assessment and Management of Inguinal Hernias in Children. Pediatrics. 2023;152(1)doi:10.1542/peds.2023-062510
2. Lautz TB, Raval MV, Reynolds M. Does timing matter? A national perspective on the risk of incarceration in premature neonates with inguinal hernia. The Journal of pediatrics. Apr 2011;158(4):573-7. doi:10.1016/j.jpeds.2010.09.047
3. Puri P, Guiney EJ, O'Donnell B. Inguinal hernia in infants: the fate of the testis following incarceration. J Pediatr Surg. Feb 1984;19(1):44-6. doi:10.1016/s0022-3468(84)80013-5
4. Morini F, Dreuning KMA, Janssen Lok MJH, et al. Surgical Management of Pediatric Inguinal Hernia: A Systematic Review and Guideline from the European Pediatric Surgeons' Association Evidence and Guideline Committee. Eur J Pediatr Surg. Jun 2022;32(3):219-232. doi:10.1055/s-0040-1721420
5. Shaughnessy MP, Maassel NL, Yung N, Solomon DG, Cowles RA. Laparoscopy is increasingly used for pediatric inguinal hernia repair. J Pediatr Surg. Nov 2021;56(11):2016-2021. doi:10.1016/j.jpedsurg.2021.01.032
6. Davies DA, Rideout DA, Clarke SA. The International Pediatric Endosurgery Group Evidence-Based Guideline on Minimal Access Approaches to the Operative Management of Inguinal Hernia in Children. J Laparoendosc Adv Surg Tech A. Feb 2020;30(2):221-227. doi:10.1089/lap.2016.0453
7. Davidson AJ, Disma N, de Graaff JC, et al. Neurodevelopmental outcome at 2 years of age after general anaesthesia and awake-regional anaesthesia in infancy (GAS): an international multicentre, randomised controlled trial. Lancet (London, England). Jan 16 2016;387(10015):239-50. doi:10.1016/s0140-6736(15)00608-x
8. McCann ME, de Graaff JC, Dorris L, et al. Neurodevelopmental outcome at 5 years of age after general anaesthesia or awake-regional anaesthesia in infancy (GAS): an international, multicentre, randomised, controlled equivalence trial. Lancet (London, England). Feb 16 2019;393(10172):664-677. doi:10.1016/s0140-6736(18)32485-1
9. Sun LS, Li G, Miller TLK, et al. Association Between a Single General Anesthesia Exposure Before Age 36 Months and Neurocognitive Outcomes in Later Childhood. Jama. 2016;315(21):2312-2320. doi:10.1001/jama.2016.6967
10. Cote CJ, Zaslavsky A, Downes JJ, et al. Postoperative apnea in former preterm infants after inguinal herniorrhaphy. A combined analysis. Anesthesiology. 4/1995 1995;82(4):809-822. Not in File.