Hi, everyone. I'm Em Gootee from Cincinnati Children's. I'm Todd Ponsky. I'm a pediatric surgeon at Cincinnati Children's Hospital. And today, we're doing another episode of one of our most popular podcasts, Case -Based Journal Review. In this episode, we will talk about inguinal hernia by reviewing some recent literature brought by Dr. Jose Campos. Hi, I'm Jose Campos. I work in Santiago de Chile in Hospital Roberto del Rio, and I lead a group of volunteers under the wing of the Chilean Society
for Pediatric Surgery. We call ourselves Journal Hive, and we're trying to filter the best literature to make it easy for you to change your practice. Like always, we link the articles in the description below. So, Todd, you are asked to repair a unilateral uncomplicated inguinal hernia in the NICU. The patient is a male infant born at 29 weeks of gestation who currently depends on oxygen delivered via nasal cannula. He has no other significant comorbidities. Would you recommend repairing
the hernia before or after discharge? So these babies have a very high rate of incarceration. So I tend to repair these before they leave the hospital. Todd mentions that he would be willing to let them go home if he feels that the family could be trusted to evaluate and bring them to the hospital if there was an issue. And I even sometimes can teach them how to reduce it. But for the most part, I do it before they leave
the hospital. What do you do, Jose? So I learned to do the repair before discharge just because. What I've learned is that the younger the baby, the higher the risk of incarceration. So normally we just tell the NICU to wait for the best moment. The best moment would be just before discharge, when everything related to the prematurity of
the baby has just settled down. We would just ask them to let us know two weeks before, and then we would have enough time to organize a semi -elective surgery just before they go home. And this has been a longstanding question for pediatric surgeons. Because you're balancing medical complications of doing a surgery in a premature baby and actually making everything worse with your anesthesia. But if you let them go and bring them back another time, you're increasing
the possibility of emergency surgery. Because of complications like incarcerated hernia and other things. That's why we brought this article, which I think has the possibility to change our practice. Let's take a look at our first article. Effect of early versus late inguinal hernia repair on serious adverse events rates in preterm infants. A randomized clinical trial. This multicenter study included preterm infants with inguinal hernia diagnosed during their initial hospitalization
between 2013 and 2021 at 39 different U .S. hospitals. This is a really big... trial first published in JAMA. It's really really difficult to organize 39 centers to get enough recruitment for pediatric surgery and even harder for premature babies to for their parents to give consensus. In this paper they had 308 patients, 159 in the early repair group, when 149 in the late repair group.
44 patients in the early repair group versus 27 in the late repair group had at least one serious adverse event, which makes 28 % versus 18 % respectively. I read this article very carefully and I said, look, I could actually change my practice and actually sending the baby home, I could reduce the hospital stay and more importantly, reduce the chance of them having a serious adverse effect by 10%. I thought to myself that that
was really significant. When we look at the data, we see that one of the 16 adverse events that accounted for the composite outcome is recurrence, which is less than 1%, and incarceration, which is around 4 % for late repair. For me, the main takeaway is that The reason I was doing early repair might not be true. In the early group, they found only 4 % of spontaneous resolution. And in the late group, they found 11 % of spontaneous
resolution. So not only do they not have a higher rate of inguinal hernia complications, but waiting could also increase the likelihood of hernia
disappearing completely. Got it. Did they mention if any of those had... loss like dead bowel do they even talk about serious events or is it just that they had to come back to have it pushed back in again one had a bowel injury during repair but there's no mention yeah if you tell me that there was zero incidence of bowel loss which is really what you care about so if you're asking me if this would lead me to potentially change my practice it actually may I did not think at
the beginning you were going to convince me. I do have some caveats for this study, but I would like to listen to Todd's opinion before going into the second part of my argumentation. It seems like it's a well -done study with pretty clear evidence that there were more re -intubations, more apnea in the early repair, and the incidence
of what we all fear was very low. Todd also thinks that the reason these numbers might be so low is because these parents go home with education, as opposed to somebody who just happens to have a hernia at home. And they don't know how to push it back in if they're being taught to try to reduce it at home or to come back immediately
when they see it. In this paper, authors looked into 16 adverse events as a composite outcome, including apnea, prolonged intubation, inguinal hernia complications like recurrence, incarceration, and reoperation. I think just choosing something very serious like death or reoperation, given that the numbers in each group are so small, to have that as a primary outcome, I haven't done the math, but probably would have required more than a thousand of patients on each arm.
So I think that's why they came out with this composite outcome. Jose, I would just say the same thing, that it would change my practice and I'd be more willing to send patients home, where before I rarely did. But I would individualize it based on how far away they live, discussing it with the parents and their confidence level and comfort level in having them be at home. So you look at the home -going situation. You talk to the parents, you look at all the factors
of the patient. But what this paper does is it tells pediatric surgeons that sending them home is generally safe and maybe safer, and it is an option if in the past it was not an option for them. Yeah, I agree with that. And just to be fair, we need to say to our audience that this article is quite powerful, but it does have
some... Downside to it. Here, Jose is talking about how the study was terminated early, had a low recruitment rate, and ended up having less statistical power than initially calculated. I guess this would change my practice, but I don't think everything is said in this particular topic or question. Let's move to the second question. You receive a referral from a nearby town located 70 miles from your hospital. A pediatrician is referring an eight -month -old female with a
reducible inguinal hernia. Todd, how would you organize the surgery regarding pre -op and post -op visits? It depends on where I'm operating. When I operate in Akron, we would get to see the patient, evaluate the patient, and schedule them for surgery. So two different cases. If Todd examines the hernia and he feels it, or if he has a strong confidence in the way it was described to him that there truly was a hernia. Either of those, I'll schedule the patient, don't
get an ultrasound. If I am in Cincinnati, they do have a same -day -same -day, they call it. This same -day -same -day system is available at Cincinnati Children's two days a week. Patients are evaluated in the morning and the OR is set up in the afternoon. And then they get a phone follow -up after two weeks if that is the preferred method as opposed to coming in. So basically, they only have one total visit. But it's not every single patient. It's just offered as an
option. How does post -op follow -up work? In Akron, I don't have physical follow -up. We do phone follow -up for most of our post -ops. In Akron, they have a very deliberate form. Advanced practice providers like nurses, nurse practitioners, or physician assistants call the patients' families, go through the questions, and if the answer to any of them are concerning, they ask families to come into the office, or they can go see a pediatrician. That's how we do almost all of
our follow -ups. However, if they want to come see us, absolutely they can come see us. Was this always like that, or did... this change after COVID? It was always like that since probably 2015. So what's your situation, Jose? So after COVID, we do have like video conference for a limited amount of patients. But what we normally would do, I would say most centers in Chile is just bring the patient in, like physically check
for the hernia. send them home, schedule the surgery for another day, and then bring them back for a physical follow -up visit. The only ones that don't get these treatments are the ones that live really, really far away. But if you really live that far away, usually you get to a different hospital. For inguinal hernia, the case you mentioned, we would do three visits. And that's why I wanted to highlight this point.
And that's why I find this article that you're about to talk to us so interesting and so potentially practice changing. And let's look at our article. One -stop surgery, an innovation to limit hospital visits in children. This is an article from the Netherlands. It is a prospective observational study of children older than three months with inguinal hernia and ASA grade 1 or 2. There were 91 patients, 54 of them were one -stop surgery,
and 37 was usual care. All but one of the one -stop surgery patients were discharged home on the day of the surgery. Post -op complication and recurrence rates did not differ between the intervention and control patients. General satisfaction and inclusion of family were higher after one stop surgery experience. Look, I don't know. I would be very happy to embrace this change. So far, it has changed my mind, but not my practice. Whenever we talk to the surgeons, they state
two obstacles for this. First one is diagnostic uncertainty. The more rigid. teaching at least for me in Chile has been that if you don't feel the hernia for yourself you do not operate on that child you know and that's why I was so glad to read this because there was no diagnostic uncertainty in this program. And the second one
is family satisfaction. What we're actually learning from this study although I'm not sure it's going to be applicable to our cultural environment in Chile, people actually enjoying their time and they're very happy with a phone consult and not necessarily they need to come in. We learned from Jose that he was taught that patients' families prefer to see the person responsible for their operation, aka the surgeon, in an in -person follow -up setting. Todd's practice is already
halfway. They were able to do it in two visits instead of we in three, but I'm... very open to do it in just one visit. Jose wanted to add that last month there was an article published in the Surgery Journal. They were asking themselves, how many times do you find something that would alter your management for routine pediatric surgical conditions like circumcision or ketopexy, inguinal hernia, and so on? And the answer was less than
1%. Of course, we've added this article in the description below if you'd like to read and learn more. Actually, there might be a benefit of... Leaving the family, I wouldn't say alone, but just give them a phone call or just give them really, really good instructions to get in touch if there's a problem. I would assume this is independent of the physician, but the hospital also needs to provide resources to make it a
one -stop solution, right? Yes, it is. It has to be done in a high resource setting, I think. The last article, we were okay sending patients home because the incidence of a problem is very low. You have to apply the same thing here. That if you look at how often you find a problem when someone comes back to you for a post -op hernia is probably in the hundredths of a decimal. There's one thing that this article says that I was touched
by this phrase. When you were facing medical problems with a low risk of complications, then family satisfaction becomes... A surrogate for quality. Think about how many unnecessary times people are coming back to the hospital for a visit for social reasons. Leave it up to the parents. Some want to come. Let them come. But some don't. So you give them the choice. I really like your approach of offering this to the family instead of saying, no, we're not going to see
you. We're going to call you. But this opens the possibility of offering both and just adapt to what's better for this. family in particular. So, Todd, you perform a laparoscopic inguinal hernia repair on this patient and find a contralateral patent processus vaginalis. Would you proceed to repair the contralateral side as well? What is the risk of this patent processus vaginalis progressing into a clinically evident inguinal
hernia? If I go in and I do a pyloric stenosis and I see an incidental patent processes, I leave it alone. If I am going in to do an inguinal hernia repair, before the operation, I have the conversation with the parents. What do you want me to do if I find a hernia on the other side? Todd mentions that he recommends repairing it after having a detailed conversation about hernias with the family, allowing them to make an informed
choice. What do you do, Jose? So if I find it incidentally in another operation, I do nothing. And if the baby has a symptomatic unilateral inguinal hair repair, I only that one side. And it's very difficult to resist to a temptation of repairing the other one. That's usually my advice to the parents, but I also have the discussion beforehand. Last article of the day is Natural History and Consequence of Patent Processes Vaginalis, an interim analysis from a multi -institutional
prospective observational study. Infants under four months undergoing laparoscopic pulmonary myotomy were enrolled at eight children's hospitals. There were 246 eligible infants with PPV, and 85 % responded to at least one annual follow -up. Of all, two patients had an inguinal hernia repair for a symptomatic hernia, one had an orchopexy and incidental inguinal hernia repair, for a total of three hernia repairs. The reason I brought this article is that it has a homogeneous cohort.
It has standardized follow -up. It's multicentric. I think it's better quality research than everything we've known previously. According to this study, the presence of a patent -processed vaginalis at the time of palromyotomy was common, but the need for hernia repair was around 1 % in the first year of follow -up. So that is... To me, it's really low. I don't think this is definite evidence, and I'll keep my eyes and my ears open for the final closure of this follow -up study.
But if this number is as low as 1%, I would not repair the other side. The problem is one year is not enough. If you look at the study at a Mayo Clinic that Benzendejas wrote when he was a resident there, there was a contralateral hernia occurrence after a 50 -year follow -up. And again, we've added this article in the description below if you'd like to read and learn more. Another discussion, no, I don't take that into account.
I think the diagnosis of a hernia changes so quickly after you've given different angle of your scope or different pressures. To wrap up today's discussion, let's review what we learned. The first article highlighted that delaying inguinal hernia repair in preterm infants does not result in more complications, suggesting that surgical
timing should be tailored to each case. We also explored the benefits of one -stop surgery models, which streamlined the process, reduced hospital visits, and increased patient satisfaction without raising complications. Finally, we examined the likelihood of a patent processus vaginalis progressing into asymptomatic hernia, which found to be low. Therefore, if found incidentally during surgery for unilateral hernia, repairing the contralateral
side may not always be necessary. Though discussions with parents are crucial before making this decision. Final comment I want to make is we've been dealing with this pathology for a hundred years and we still don't know the natural history of PPVs and inguinal hernias. And I'm just happy that these three articles that we brought are bringing freshness or novelty or curiosity for some things that have been taught very dogmatically, like
the discussions we've had. Yeah. No, I think these are great papers and glad you brought them forward. It's good discussion. Thank you for listening to this episode. Don't forget to follow us on social media, subscribe to our YouTube channel, and download the Stay Current app for tons of pediatric surgery content.