Hernia recurrence following inguinal hernia repair in children

doi:10.1016/j.jpedsurg.2018.03.021

Journal of Pediatric Surgery

Volume 53, Issue 11, November 2018, Pages 2214-2218

https://doi.org/10.1016/j.jpedsurg.2018.03.021 Get rights and content

Abstract

Purpose

We aimed to describe the incidence, timing, and predictors of recurrence following inguinal hernia repair (IHR) in children.

Methods

We used the TRICARE claims database, a national cohort of > 3 million child dependents of members of the U.S. Armed Forces. We abstracted data on children < 12y who underwent IHR (2005–2014). Our primary outcome was recurrence (ICD9-CM diagnosis codes). We calculated incidence rates for the population and stratified by age, time from repair to recurrence, and multivariable logistic regression to determine predictors.

Results

Nine thousand nine hundred ninety-three children met inclusion criteria. Age at time of IHR was ≤ 1y in 37%, 2-3y in 23%, 4–5y in 16%, and 5–12y in 24%. Median follow-up time was 3.5y (IQR:1.6–6.1). 137 patients recurred (1.4%), with an incidence of 3.46 per 1000 person-years. Over half occurred in children 0-1y at repair (60%). The majority occurred within a year following repair (median 209 days [IQR:79–486]). Children 0-1y had 2.53 times greater odds of recurrence (compared to > 5y). Children with multiple comorbidities had 5.45 times greater odds compared to those with no comorbidities.

Conclusions

The incidence of recurrence following IHR is 3.46 per 1000 person-years. The majority occurred within a year of repair. Children ≤ 1y and those with multiple comorbidities were at increased risk.

Level of Evidence

Prognosis Study, Level II.

Section snippets

Study design and data source

We completed a retrospective cohort study utilizing the Department of Defense Military Health System Data Repository (MDR) and TRICARE insurance program, a previously well described database [14], [15], [16]. The MDR is a longitudinal claims database tracking care delivered to over 9 million members of the U.S. Armed Forces (inactive, active, retired) and their dependents. The MDR has been shown to be a nationally representative sample, and includes a cohort of > 3 million children [17].

Cohort characteristics

There were 3,033,305 children enrolled in TRICARE insurance and the MDR database between 2005 and 2014. We identified 10,025 children ≤ 12 years old who underwent inguinal hernia repair, of whom 9993 met inclusion criteria (Fig. 1). Patient characteristics are shown in Table 1. The greatest proportion of children undergoing initial hernia repair was between the ages of 0-1y (37%), with more than half of repairs performed in children < 3y of age (Table 1). Repairs were predominately performed in

Discussion

Using a large, national database of pediatric patients, we identified 9993 children who underwent inguinal hernia repair between 2005 and 2014. We analyzed this cohort to determine the incidence of recurrence, time from initial repair to recurrence, and risk factors associated with hernia recurrence. We found an overall incidence of 3.46 events per 1000 person-years. When we stratified by age, those < 1y at initial repair had the highest incidence of recurrence, with 5.88 events per 1000

Conclusions

We described the incidence, timing, and risk factors for inguinal hernia recurrence using a large nationally representative cohort of children. Incidence rates were highest among children who underwent initial primary repair at < 1y. The majority of hernia recurrences occurred within the first year of initial repair, but occurred as late as 6y following initial repair. In multivariable analysis, hernia recurrence was most likely in younger children and children with multiple comorbidities.

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Cited by (38)

Optimal Timing of Inguinal Hernia Repair in Premature Infants: An NSQIP-P Study
2023, Journal of Surgical Research
Among premature infants, the incidence of inguinal hernias is reported to be as high as 30%. Despite being one of the most commonly performed procedures, the optimal setting of inguinal hernia repair (IHR) that is inpatient versus outpatient remains debatable. We sought to compare the 30-day outcomes of each approach by querying the National Surgical Quality Improvement Program-Pediatric database.
A retrospective cohort study comparing inpatient versus outpatient IHR using the National Surgical Quality Improvement Program-Pediatric database from 2013 to 2019 was performed. Demographic and clinical data were initially compared using univariate analysis. Continuous variables are presented as median and interquartile range and categorical variables are presented as n (%). Subsequently, cohorts were propensity matched using clinically and statistically significant patient characteristics.
928 patients underwent IHR, 634 (68.3%) while inpatient, 294 (31.7%) following hospital discharge. Inpatient IHR was associated with lower age at the time of surgery (120 versus 147 d; P < 0.0001), younger gestational age (27 versus 33 wk; P < 0.0001), decreased probability of repair in elective setting (87.2% versus 97.3%; P < 0.0001), and increased preoperative supplemental oxygen need (42% versus 4.4%; P < 0.0001). Comparison of propensity matched cohorts revealed that inpatient IHR was associated with increased procedure time (82 versus 51 min; P < 0.0001) and anesthetic duration (146 versus 102 min; P < 0.0001), wound infection rates (3.8% versus 0%; P = 0.007), blood transfusions (4.2% versus 0.5%; P = 0.036), unplanned intubations (2.8% versus 0%; P = 0.03), ventilator days (0 versus 0; range [0,30 versus 0,2]; P = 0.002), reoperation rate (5.6% versus 0%; P < 0.001), postoperative hospital length of stay (4 versus 1 d; P < 0.0001), and unplanned readmissions (8.9% versus 0.9%; P = 0.002).
Inpatient IHR in premature neonates were associated with different postoperative outcomes than outpatient IHR. At least in the elective setting among premature infants, outpatient IHR can be considered safe in select patients while we await higher quality prospective data.
Costs and recurrence of inguinal hernia repair in premature infants during neonatal admission
2023, Journal of Pediatric Surgery
Citation Excerpt :
Our results therefore suggest that hernias repaired in the post-NICU setting are generally more expensive, however, the follow up costs we suspect are associated with recurrences seen more frequently in early NICU repairs may offset the cost initially conserved with a NICU repair. In regard to hernia recurrence, our study demonstrates hernia recurrence rates in premature infants that are higher than reported in other studies that include older children [19]. Moreover, our data reinforces findings from a recent meta-analysis by Masoudian et al. [20], which showed that recurrences were more frequent in infants who had early IHR during initial NICU admission.
Timing of inguinal hernia repair (IHR) in premature infants remains variable, yet the impact of IHR timing on procedure costs and recurrence is unclear. We sought to compare cost and recurrence rates of IHR in premature infants based on timing of repair.
We performed a retrospective cohort study using MarketScan insurance claims data from 2007 to 2018 to evaluate IHR occurring within 365 days of birth in preterm infants (gestational age [GA]<37 weeks at birth). Patients were stratified based on timing of IHR: those occurring during and after neonatal discharge. Hernia recurrences within one year following IHR were identified. Patient demographic characteristics and costs were compared between groups. Time to recurrence and cumulative recurrence hazards were estimated using Kaplan Meier analysis and Cox proportional hazards regression.
We identified 3,662 preterm infants with IHR within 365 days of birth; 1,054(28.8%) occurred early. Infants with IHR during NICU stay were more likely to have GA at birth≤32 weeks (74.7% vs. 37.2%; p<0.01) and birthweight<1500 g (83.0% vs. 40.3%; p<0.01) compared to post-NICU IHR. The hernia recurrence rate was higher and total procedure costs lower in early IHR. Early IHR (HR:1.86, 95% CI: 1.56–2.22), incarcerated/strangulated hernia (HR:1.86, 95% CI:1.49–2.32), GA≤32 weeks (HR: 1.40, 95% CI: 1.19–1.65), and congenital anomalies (HR: 1.32, 95% CI: 1.12–1.57) were predictors of hernia recurrence.
Using insurance claims data, IHR performed during initial neonatal admission was associated with lower cost, but higher recurrence rate, when compared to delayed repairs in preterm infants.
Retrospective study
Level III
Open and laparoscopic inguinal hernia repair in children: A regional experience
2023, Journal of Pediatric Surgery
The optimal approach for pediatric inguinal hernia repair continues to be debated. We conducted a regional retrospective study to assess rates of recurrence and metachronous hernias after open repair (OPEN) and laparoscopic repair (LAP)
A retrospective cohort study was conducted at two children's hospitals that serve a region of approximately 4 million people. All patients < 14 years old undergoing OPEN or LAP by pediatric surgeons during a 5-year period (2011 – 2015) were analyzed after a minimum follow up of 4 years. Cox proportional regression was used to compare the effect of surgical approach on hernia recurrence and metachronous contralateral hernias.
A total of 1,952 patients, 587 female (30%) and 1365 male (70%), had 2305 hernias repaired. Median post operative follow up time was 6.6 years (range 4–9 years). OPEN and LAP were performed for 1827 (79%) and 478 (21%) hernias, respectively. There were no significant differences in rate of prematurity, age at repair, or frequency of emergent repair. LAP was associated with a lower incidence of metachronous contralateral hernias compared to OPEN (1.4% vs 3.8%, p = 0.047), and a higher incidence of recurrence (9% vs 0.9%, p < 0.001). After adjusting for confounders, LAP had a higher rate of recurrence than OPEN (hazard ratio 10.4, 95% CI 6–18.1).The recurrence rate did not decrease over the study period (p = 0.731).
Laparoscopic inguinal hernia repair in children resulted in a modest decrease in the incidence of metachronous hernias, at the cost of a significant increase in recurrence.
Retrospective Comparative Study.
Level III.
Delayed versus early repair of inguinal hernia in preterm infants: A systematic review and meta-analysis
2022, Journal of Pediatric Surgery
To evaluate the clinical outcomes of herniotomy in preterm infants undergoing early versus delayed repair, the risk factors for complications, and to identify best timing of surgery.
Medline, Embase and Central databases were searched from inception until 25 Jan 2021 to identify publications comparing the timing of neonatal inguinal hernia repair between early intervention (before discharge from first hospitalization) and delayed (after first hospitalisation discharge) intervention. Inclusion criteria was preterm infants diagnosed with inguinal hernia during neonatal intensive care unit admission. Results were analyzed using fixed and random effects meta-analysis (RevManv5.4).
Out of 721 articles found, six studies were included in the meta-analysis. Patients in the early group had lower odds of developing incarceration [odds ratio (OR) 0.43, 95% confidence interval (CI) 0.34–0.55, I² = 0%, p < 0.001]; but higher risk of post-operative respiratory complications (OR 4.36, 95% CI 2.13–8.94, I² = 40%, p < 0.001). No significant differences were reported in recurrence rate (OR 3.10, 95% CI 0.90–10.64, I² = 0%, p = 0.07) and surgical complication rate (OR 0.94, 95% CI 0.18–4.83, I² = 0%, p = 0.94) between early and delayed groups.
While early inguinal hernia repair in preterm infants reduces the risk of incarceration, it increases the risk of post-operative respiratory complications compared to delayed repair. Surgeons should discuss the risks and benefits of delaying inguinal hernia repair with the caregivers to make an informed decision best suited to the patient physiology and circumstances.
Treatment study, level 3.
Spigelian-like hernia with cryptorchidism and tibial hemimelia
2022, Journal of Pediatric Surgery Case Reports
We describe a case of an unusual lateral congenital abdominal wall hernia. This male patient was born with a constellation of anomalies including a Spigelian-like left lower quadrant abdominal wall hernia, right tibial hemimelia, left hip dysplasia with dislocation, cleft palate and cryptorchidism. At three months of age, the patient underwent a diagnostic laparoscopy, right inguinal hernia repair, left lower quadrant abdominal wall hernia repair, and bilateral orchiopexy to manage these defects.
Follow-up of children who undergo an uncomplicated surgical procedure: A caregiver survey to determine satisfaction, family impact, and preferences for alternate follow-up
2022, Journal of Pediatric Surgery
Citation Excerpt :
Post-operative surgical follow-up has traditionally been carried out in-person to assess surgical sites and recovery. However, the rates of short-term hernia recurrence and wound infections are rare [1,2] and recovery is often straightforward. The Canadian healthcare system has been centralized since the 1990s to improve outcomes and to decrease costs to the healthcare system [3].
Historically most surgical patients returned to clinic for an in-person postoperative follow-up. However, returning to hospital impacts the family in many ways. We hypothesized that in-person follow-up is not necessary after an uncomplicated procedure, and that caregivers would prefer an alternate follow-up.
We surveyed caregivers of children less than 17 years of age who underwent a simple appendectomy, pyloromyotomy, cholecystectomy, or repair of an inguinal or umbilical hernia. With REB approval and caregiver consent, surveys were completed in-person during clinic visits and by telephone for alternate follow-up plans.
Despite interruptions due to COVID-19, 24 surveys were completed (clinic visit group N = 7, alternate plan group N = 17). Thirteen families resided in Winnipeg. The majority rated their overall satisfaction with follow-up as good-excellent (6/7 clinic group, 17/17 alternate group). The most frequent impacts to attend clinic were time off work (18/24), parking (17/24), gas costs (17/24), time from school (13/24) and childcare arrangements (12/24). The median estimated cost to attend clinic was 142 CAD$. Most families preferred an alternate plan (18/24) (i.e. call surgeon only if concerned, follow-up with their primary care provider or attend virtually). Only 4 children having an alternate follow-up plan required medical treatment for minor issues.
We conclude there is significant impact on families to attend a post-operative in-person clinic visit. Although all respondents rated their satisfaction highly, the majority preferred the option of an alternate plan. Surgeons should consider offering families alternate follow-up after an uncomplicated procedure.

View all citing articles on Scopus

^☆: Funding: This project was funded in part by the Henry M. Jackson Foundation for the Advancement of Military Medicine through a grant from the Department of Defense (DoD). WJ and AHH receive partial salary support.

^☆☆: Role of the Funding Source: The funding source did not have a role in the collection, analysis, and interpretation of data; writing of the report; or decision to submit the article for publication.

^★: 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.

¹: Indicates co-first authors.

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Inguino-ScrotalHernia recurrence following inguinal hernia repair in children☆,☆☆,★

Abstract

Purpose

Methods

Results

Conclusions

Level of Evidence

Section snippets

Study design and data source

Cohort characteristics

Discussion

Conclusions

Surg Clin North Am

J Pediatr Surg

Semin Pediatr Surg

J Pediatr Surg

J Pediatr Surg

J Pediatr Surg

J Pediatr Surg

Am J Surg

J Pediatr Surg

J Pediatr Surg

J Pediatr Surg

Inguino-Scrotal
Hernia recurrence following inguinal hernia repair in children☆,☆☆,★