Inguinal hernia repair in the perinatal period and early infancy: Clinical considerations

Contemporary neonatal intensive care has resulted in survival of many seriously ill preterm and older infants that frequently present with symptomatic inguinal hernia. Controversy exists concerning timing and safety of early repair in prematures or other neonates, especially those hospitalized with concurrent illness. This study examines this topic by evaluating predisposing factors, presentation, and postoperative complications in 100 recent consecutive hernia repairs in previously hospitalized infants less than 2 months of age. There were 85 boys and 15 girls. Thirty percent were premature (less than 36 wks gestation). Forty-two infants were hospitalized for RDS with assisted ventilation in 16 infants, hydrocephalus and ventriculoperitoneal (VP) shunt in 7 infants, and congenital heart disease (CHD) in 19 infants. Clinical presentation was on the right side in 44 infants, bilateral in 42, and on the left side in 14. Incarceration occurred in 31 cases with nine babies having overt intestinal obstruction. The incidence of cryptorchidism was 12.9%. All (VP) shunt, CHD patients, and incarcerated cases were treated with preoperative antibiotics. Following discharge, 49 preterm or previously ill infants developed a symptomatic hernia at home and were readmitted. Nine full-term infants were treated as outpatients. Bilateral inguinal exploration was performed in 92 cases with second hernia or patent processus found in 81. Seven of eight with unilateral exploration had acute incarceration with obstruction at the time of the procedure. Three subsequently required a second hernia repair. Two infants with incarceration and cryptorchid testis or ovarian slider had gonadal infarction. There were eight postoperative complications. Four prematures required postoperative ventilatory support, for apnea and bradycardia (2), Klebsiella sepsis (1), and digitalis toxicity (1). Scrotal hematoma occurred in two babies. A late wound infection was seen at 6 weeks (1) and a unilateral recurrence at 6 months in a VP shunt child. There were no deaths. These data indicate that inguinal hernia: (1) is common in preterm and other seriously ill babies hospitalized as newborns, (2) has a high (31%) incidence of incarceration (2 × that of the general childhood population), intestinal obstruction (9%), and gonadal infarction (2%), and (3) is potentially life threatening. Early elective hernia repair can be done safely in infants hospitalized for concurrent illness prior to their discharge. Prematures with hernias presenting at home should be managed as inpatients and carefully observed following anesthesia because of an increased risk of apnea and bradycardia. Full-term infants without previous respiratory illness or apneic episodes can be safely treated as outpatients. If precautions are followed, early repair should be associated with reduced morbidity and zero mortality.