DOI: 10.1542/peds.2012-2008; originally published online September 24, 2012; 2012;130;768Pediatrics

SURGERYKasper S. Wang, COMMITTEE ON FETUS AND NEWBORN and SECTION ON

Assessment and Management of Inguinal Hernia in Infants  

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of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2012 by the American Academy published, and trademarked by the American Academy of Pediatrics, 141 Northwest Pointpublication, it has been published continuously since 1948. PEDIATRICS is owned, PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly

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CLINICAL REPORT

Assessment and Management of Inguinal Hernia inInfants

abstractInguinal hernia repair in infants is a routine surgical procedure. How-ever, numerous issues, including timing of the repair, the need to ex-plore the contralateral groin, use of laparoscopy, and anestheticapproach, remain unsettled. Given the lack of compelling data, consid-eration should be given to large, prospective, randomized controlledtrials to determine best practices for the management of inguinal her-nias in infants. Pediatrics 2012;130:768–773

INTRODUCTION

Inguinal hernia is a common condition requiring surgical repair in thepediatric age group. The incidence of inguinal hernias is approximately3% to 5% in term infants and 13% in infants born at less than 33 weeksof gestational age.1 Inguinal hernias in both term and preterm infantsare commonly repaired shortly after diagnosis to avoid incarcerationof the hernia. Given the lack of definitive data, optimal timing forrepair of inguinal hernias in infants remains debatable. This reportreviews the embryology and natural history of inguinal hernias aswell as published data regarding the timing and approach to inguinalhernia repair in infants.

EMBRYOLOGY AND NATURAL HISTORY OF THE PATENTPROCESSUS VAGINALIS

Complete understanding of the issues related to surgical repair of aninguinal hernia requires an understanding of the embryology of de-scent of the testes and the formation of the processus vaginalis.

Testicular descent involves 2 phases: intra-abdominal and extra-abdominal.2

During the intra-abdominal phase, the testis, which derives from thebipotential gonad originating at the urogenital ridge, is attached to thediaphragm by the craniosuspensory ligament. In the male fetus, re-gression of the craniosuspensory ligament results in transabdominalmigration of the testis between 8 and 15 weeks postconception. Simul-taneously, there is thickening of the gubernaculum, which attaches thetestis to the scrotum through the external and internal rings of theinguinal canal. As the male fetus grows and the abdomen elongates,the testis is essentially anchored by the thickened gubernaculum.3 In thefemale fetus, the craniosuspensory ligament is maintained; hence,the ovary retains its dorsal (retrocoelomic or retroperitoneal)

Kasper S. Wang, MD, and the COMMITTEE ON FETUS ANDNEWBORN AND SECTION ON SURGERY

KEY WORDSinguinal hernia, infants, surgery, anesthesia, laparoscopy

ABBREVIATIONPPV—patent processus vaginalis

This document is copyrighted and is property of the AmericanAcademy of Pediatrics and its Board of Directors. All authorshave filed conflict of interest statements with the AmericanAcademy of Pediatrics. Any conflicts have been resolved througha process approved by the Board of Directors. The AmericanAcademy of Pediatrics has neither solicited nor accepted anycommercial involvement in the development of the content ofthis publication.

The guidance in this report does not indicate an exclusivecourse of treatment or serve as a standard of medical care.Variations, taking into account individual circumstances, may beappropriate.

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intra-abdominal location. In addition,the gubernaculum does not thicken butpersists as the ovarian round ligament.

The second phase occurs between 25and 35 weeks of gestation.4 The testisdescends from its retroperitoneal,intra-abdominal location through theinguinal canal, drawing with it anextension of the peritoneal lining,which defines the processus vaginalis.Normally, the processus vaginalisobliterates and involutes, leaving nocommunication between the intra-abdominal peritoneal cavity and theextra-abdominal inguinal canal andscrotum. This enveloping involutedlayer is the tunica vaginalis. Bothhuman in vitro tissue culture and ro-dent model studies implicate genito-femoral nerve innervation as criticalfor regulation of gubernacular lengthas well as obliteration of the proc-essus vaginalis.5–7 Incomplete invo-lution results in a patent processusvaginalis (PPV), through which fluidcan travel and accumulate extra-abdominally as a hydrocele. If the com-munication is large, intra-abdominalstructures such as bowel may herni-ate, resulting in an indirect inguinalhernia. The relation of the processusvaginalis with testicular descent isthought to explain why more than 90%of pediatric inguinal hernias are di-agnosed in boys.1 Involution of the leftprocessus vaginalis precedes that ofright, which is consistent with the ob-servation that 60% of indirect inguinalhernias occur on the right side.8

The prevalence of PPV is highestduring infancy and declines with age.Congenital hydroceles, which are es-sentially clinically apparent PPV, usu-ally resolve spontaneously within 18 to24 months.9,10 The reported preva-lence of PPV is as high as 80% in termmale infants.11 However, this preva-lence is generally extrapolated fromfindings at time of exploration of thecontralateral internal ring during time

of inguinal hernia repair. Thus, mostreported rates of bilateral PPV arederived from observations in patientswith symptomatic unilateral inguinalhernias and likely overestimate thetrue prevalence of PPV in the generalpopulation. Rowe et al reported a 64%rate of contralateral PPV identified atthe time of inguinal hernia repair ininfants younger than 2 months. Repor-ted rates of contralateral PPV decreaseto between 33% and 50% in childrenyounger than 1 year of age and are aslow as 15% by 5 years of age.12–16 Notall cases of PPV result in inguinal her-nias. The estimated childhood risk ofdeveloping an inguinal hernia if thereis a PPV is between 25% and 50%.17,18

Even though the true prevalence ofa PPV in the general pediatric pop-ulation is likely lower than contralat-eral PPV reported at the time of herniarepair, it is clearly greatest at birthand declines with increasing age.

RATIONALE AND TIMING FORELECTIVE INGUINAL HERNIAREPAIR IN INFANTS

All inguinal hernias in infants arerepaired to avoid the risk of in-carceration of bowel and gonadal in-farction and atrophy.19–22 However, theserisks must be balanced against the riskof potential operative and anestheticcomplications. Unfortunately, data re-garding these risks are not definitive.

Many investigators have sought todefine the risk of inguinal hernia in-carceration in young children. How-ever, the physical features of hernia,such as the size of the abdominal walldefect, the amount of the herniatingintestine, and the ease with which itcan be reduced, do not consistentlypredict the risk of incarceration.Attempts have been made to correlatethe age at diagnosis, the durationbetween diagnosis and hernia repair,and infants’ gestational age with riskof inguinal hernia incarceration. Notably,

in an analysis of a Canadian adminis-trative database containing more than1000 children with inguinal hernia,Zamakshary et al showed that childrenyounger than 1 year had a twofoldgreater risk of inguinal hernia in-carceration when repair was performed≥14 days after diagnosis compared withchildren who had repair performed be-tween 1 and 2 years of age.23 Vaos et alreported a retrospective analysis ofpreterm infants undergoing inguinalhernia repair at 1 of 2 institutions.24 Theynoted that infants undergoing repairlater than 1 week after diagnosis wereat significantly greater risk of inguinalhernia incarceration, postoperative her-nia recurrence, and testicular atrophy,compared with infants undergoing ear-lier repair. Lautz et al analyzed the riskof inguinal hernia incarceration in ap-proximately 49 000 preterm infants us-ing the 2003 and 2006 Kids’ InpatientDatabases.25 They determined that theoverall rate of inguinal hernia incar-ceration was approximately 16% andthat the risk was greatest in infants inwhom surgery was delayed beyond 40weeks’ corrected gestational age (21%)compared with those repaired between36 and 39 weeks (9%) corrected age orless than 36 weeks corrected gesta-tional age (11%). Furthermore, 28% offormer preterm infants undergoingrepair during a subsequent hospitali-zation were noted to have inguinalhernia incarceration, suggesting aneven greater risk with further delay.Although fraught with limitations in-herent to administrative databases,the conclusions of this study arecompelling.

Conversely, other data indicate thatdelay in inguinal hernia repair is as-sociated with low rates of inguinalhernia incarceration. Lee et al reporteda 4.6% rate of hernia incarceration in172 former preterm infants withina single Kaiser system hospital. Of the127 infants who were discharged from

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the hospital with known inguinal her-nias and scheduled for a plannedelective outpatient repair, there wereno episodes of inguinal hernia in-carceration while awaiting repair.26

Uemura et al reported comparable in-guinal hernia incarceration rates in 19preterm infants (birth weight range492–2401 g) who underwent repair atmore than 2 weeks after diagnosis,compared with 21 preterm infants whounderwent more urgent repair.27 Al-though these studies suggest that in-guinal hernia repair can be delayed,the data are not as compelling asthose suggesting repair on a moreurgent basis.

Inguinal hernia repair is associated withoperative complications, including her-nia recurrence, vas deferens injury, andtesticular atrophy, the rates of whichvary from 1% to 8%.28–31 Long-termcomplications include chronic pain andinfertility in adulthood.32 In a single-institution, retrospective analysis, Mosset al observed low recurrence andcomplication rates up to 5 years aftersurgical repair in infants younger than 2months of age.33 Conversely, a retrospec-tive analysis by Baird et al revealeda higher rate of complications in infantswho were 43 weeks’ corrected gesta-tional age or younger, compared withthose who underwent repair at an olderage.34 They speculated that the greaterfriability of the hernia sac in formerpreterm infants predisposes to repairfailure.

Early repair of inguinal hernias inpreterm infants must be further bal-anced against the risk of postoperativeapnea after general anesthesia. His-torically, the rate of postoperativeapnea in preterm infants has beenreported to be as high as 49%.35,36 Therisk of postoperative apnea is asso-ciated with perioperative anemia anda history of preoperative apnea aswell as associated comorbidities.35,37

Vaos et al noted that preterm infants

undergoing inguinal hernia repairwithin 1 week of diagnosis experienceda significantly greater rate of apneacompared with those undergoing repairlater.24 Melone et al reported on a co-hort of 127 former preterm infants(mean gestational age, 32.7 weeks) whounderwent outpatient inguinal herniarepair at a mean corrected gestationalage of 45.3 weeks. The authors identi-fied only 2 infants who experiencedepisodes of apnea: 1 in the operatingroom, the other postdischarge. Theyconcluded that because the apnea rateis so low, elective outpatient inguinalhernia repair is a feasible option forpreterm infants. Lee et al reported noepisodes of apnea in a cohort of pre-term infants (30.7 weeks’ gestation atbirth) undergoing outpatient electivehernia repair.26 However, the authorsnoted that 13 of 45 former preterminfants who underwent elective inguinalhernia repair before discharge fromthe NICU remained intubated for longerthan 2 days postoperatively.

Younger corrected gestational age isassociated with a greater risk of ap-nea.38 Allen et al noted a nearly 9% rateof postoperative apnea in their cohortof 57 preterm infants undergoing in-guinal hernia repair.39 In a subsetanalysis, infants who experienced ap-nea episodes tended to be younger (41weeks’ corrected gestational age com-pared with 47 weeks’ corrected gesta-tional age); had significantly higherperioperative risk, as measured byAmerican Society of Anesthesia scores(2.6 compared with 1.8); and weremore likely to have received intra-operative narcotic and muscle re-laxation compared with infants whowere not apneic. A recent meta-analysisconcluded that former preterm infantsundergoing general anesthesia whoare less than 46 weeks’ correctedgestational age should be observed forat least 12 hours postoperatively andthat those who are between 46 and 60

weeks’ corrected gestational age shouldreceive more individualized care on thebasis of the presence or absence ofassociated comorbidities.40

To reduce the incidence of postoperativeapnea, spinal, rather than general, an-esthesia has been used for inguinalhernia repair in preterm infants.41–43

Although some studies have been en-couraging, none have been adequatelypowered. Indeed, Craven et al pub-lished a Cochrane Collaboration analy-sis in which only 108 patients from 4small randomized or quasi-randomizedstudies comparing spinal and generalanesthesia were identified.44 The authorsconcluded that there was no evidencethat spinal anesthesia was associatedwith a reduction in postoperative apnea,bradycardia, or oxygen desaturation.Furthermore, the authors concludedthat a large, randomized controlledtrial was necessary to determinewhether spinal anesthesia reducespostoperative cardiorespiratory com-plications; to date, no such study hasbeen reported.

Over the past decade, studies per-formed in rodents and nonhuman pri-mates have shown a dose-dependentassociation of neuronal apoptosis withgeneral anesthetic agents, includingketamine, propofol, and isoflurane.45–47

Importantly, there is emerging evidencethat the use of general anesthesiain infancy may be associated withlong-term neurocognitive and de-velopmental problems, specificallyafter multiple exposures to generalanesthesia before 3 years of age.48

DiMaggio et al, using a New York StateMedicaid database, showed that chil-dren younger than 3 years who weregiven general anesthesia for inguinalhernia repair had a greater thantwofold risk of developmental or be-havioral disorders than did age-matched control children.49 A poten-tial bias of this study is that childrenundergoing surgery at a young age may

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also be predisposed to learning orcognitive disorders. Bartels et al at-tempted to address this issue by usingthe Netherlands Twin Registry to evalu-ate monozygotic concordant-discordanttwins. In a study of 1143 monozygotictwin pairs, exposure to anesthesia be-fore 3 years of age was associated withreduced educational achievement.50 How-ever, there was no difference in out-come between twin pairs when onetwin had undergone anesthesia and theother had not. The authors concludedthat there is no causal relationship be-tween anesthesia exposure and learn-ing disabilities. Hansen et al recentlycompared ninth-grade test scores ofnearly 2700 Swedish children who hadundergone inguinal hernia repair asinfants with those of randomly selectedage-matched controls and found nodifference in test performance.51 Clearly,the issue of whether anesthetic expo-sure as an infant affects long-termneurodevelopment is unsettled. Twolarge clinical studies are under way toaddress this issue.52

Ultimately, the timing of preterm infantinguinal hernia repair varies widely inpractice. In a 2005 survey of membersof the American Academy of PediatricsSection on Surgery, 63% reportedroutinely performing hernia repairsjust before discharge from the NICU,18% performed repairs at a specificcorrected gestational age, and 5%performed repairs when it was con-venient.53 If a hernia was discoveredafter discharge, 53% of respondentswould repair the hernia when it wasconvenient, and 27% of respondentswould wait to repair until the infantwas between 38 and 60 weeks’ cor-rected gestational age (mean, 53.1weeks’ corrected gestational age). Ina previous survey performed in 1993,surgeons were more likely to repair aninguinal hernia when convenient.54

Timing of inguinal hernia repair inpreterm and term infants represents

a balance of the risks of inguinal herniaincarceration and of postoperative re-spiratory complications. At present, theliterature does not clearly define whatthese risks are and how they should bebalanced.

CONTRALATERAL INGUINALEXPLORATION

The utility of contralateral inguinalexploration in children is an areaof active debate. The rationale forattempting to diagnose a contralateralPPV is that repair can be performed toprevent any potential contralateralincarceration with no additive anes-thetic risk. Historically, surgeons per-formed routine open contralateralinguinal explorations to identify PPV ineither all children or in selected pop-ulations (ie, former preterm infantsor children younger than 2 years).Marulaiah et al suggested that routinecontralateral exploration is not in-dicated, given the risks associated withsuch exploration, such as spermaticcord injury.55 Alternatively, given thehigh incidence of subsequent hernias ifa contralateral PPV is encountered,others support routine exploration.13,56,57

Lee et al indicated that it is cost-effective to perform routine contralat-eral groin explorations.58 Results fromthe aforementioned 2005 survey ofAmerican Academy of Pediatrics Sec-tion on Surgery members revealed avariety of practices; 15% of respon-dents indicated that they never explorethe contralateral side in a male pa-tient, 12% responded that they alwaysdo, and 73% responded that they hadan age cutoff beyond which they wouldnot explore.53 Respondents also hada wide variation of practices whencaring for a girl with a unilateral her-nia. For both male and female patientswith hernias, however, results of thesurvey revealed that there were sig-nificant reductions in the routineexplorations of the contralateral side

compared with results from the samesurvey performed in 1996.54 Variousdiagnostic modalities, such as thephysical examination, herniography, orultrasonographic examination are notparticularly sensitive or specific, thusmaking these efforts unreliable.56,59

With the advent of laparoscopic tech-niques, inspection of the contralateralinternal ring has become increasinglypopular as the method of choice forevaluating for a PPV. According tosurvey responses, use of laparoscopyas the modality with which to explorethe contralateral ring has increasedfrom 6% in 1996 to 37% in 2005.53,54

Use of laparoscopy to explore thecontralateral groin has likely increasedsince then.

LAPAROSCOPIC APPROACH TOINGUINAL HERNIA REPAIR ININFANTS

Laparoscopic repair has been used ef-fectively in preterm infants. Varioustechniques have been described, but allroutinely use a port placed in the um-bilicus to visualize the internal ring.Reported hernia recurrence rates arecomparable to those associated withopen repair.60,61 However, data regardingthe risk of testicular atrophy are notavailable.62,63 A prospective, randomized,single-blinded trial comparing laparo-scopic to open repair of inguinal her-nias showed that children who wereolder than 3 months of age when lap-aroscopic repair was performed re-quired significantly fewer doses of painmedication.64 The utility of laparoscopicrepair of inguinal hernias in youngerinfants remains undetermined to date.

CONCLUSIONS

� Inguinal hernias are common in theinfant population. The risk of herniaincarceration drives the preferenceto pursue surgical repair.

� Data regarding optimal timing of re-pair are conflicting and inadequate.

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� There is no consensus on when orif contralateral inguinal explora-tion is necessary.

� Data regarding a laparoscopic ap-proach to inguinal hernia repairssuggest that it is comparable tothe standard open technique.

� Given the lack of data supportingevidence-based approaches to ingui-nal hernias in infants, considerationshould be given to large, prospective,randomized, controlled trials to an-swer these important questions.

LEAD AUTHORKasper S. Wang, MD

COMMITTEE ON FETUS ANDNEWBORN, 2011–2012Lu-Ann Papile, MD, ChairpersonJill E. Baley, MDWilliam Benitz, MDJames Cummings, MDWaldemar A. Carlo, MDPraveen Kumar, MDRichard A. Polin, MDRosemarie C. Tan, MD, PhDKristi L. Watterberg, MD

LIAISONSCAPT Wanda Denise Barfield, MD, MPH—Centersfor Disease Control and PreventionGeorge Macones, MD—American College ofObstetricians and GynecologistsAnn L. Jefferies, MD—Canadian Pediatric SocietyRosalie O. Mainous, PhD, RNC, NNP—NationalAssociation of Neonatal Nurses

Tonse N. K. Raju, MD, DCH—National Institutesof Health

STAFFJim Couto, MA

SECTION ON SURGERY EXECUTIVECOMMITTEE, 2011–2012Mary L. Brandt, MD, ChairpersonRobert C. Shamberger MD, Immediate PastChairpersonMichael G. Caty, MDKurt F. Heiss, MDGeorge W. Holcomb, III, MDRebecka L. Meyers, MDR. Lawrence Moss, MDFrederick J. Rescorla, MD

STAFFVivan Thorne

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