An updated AAP clinical report on pediatric inguinal hernias examines the embryology, pathophysiology and natural progression of patent processus vaginalis (PPV), as well as current evaluation and treatment approaches.
Special attention is given to the risks associated with general anesthesia in very young children. Additionally, the report reviews best practices for managing inguinal hernias, including the optimal timing of repair in preterm infants, the appropriate health care professionals to perform these repairs, the preferred surgical approach, the need for contralateral evaluation, the management of recurrent hernias and the handling of asymptomatic PPV discovered during nonhernia-related abdominal explorations.
The report Assessment and Management of Inguinal Hernias in Children, from the Committee on Fetus and Newborn, Section on Surgery and Section on Urology, is available at https://doi.org/10.1542/peds.2023-062510 and will be published in the July issue of Pediatrics.
Optimal timing of surgery, expertise of surgeon
Clinicians should consider the urgency of repair, as approximately 4% of inguinal hernias will become incarcerated. For preterm infants with low birth weight, timing continues to be debated, and data from the Timing of Inguinal Hernia Repair in Premature Infants trial are awaited. Available retrospective data, however, suggest that repair can be safely considered after discharge from the neonatal intensive care unit.
The report highlights that optimal outcomes in pediatric inguinal hernia repair are associated with subspecialty training and high surgical volume. Ideally, pediatric general surgeons, pediatric urologists or general surgeons with significant yearly case volumes should perform herniorrhaphy.
The laparoscopic approach as an alternative to the traditional open high ligation has become increasingly popular. Available data suggest that the laparoscopic approach is at least as effective, if not superior, to traditional open repair.
The need for routine contralateral exploration in patients with unilateral inguinal hernias also is addressed. Proponents of routine exploration typically emphasize a 10% to 15% risk of developing a metachronous hernia, while opponents argue that not all PPVs progress to clinically significant hernias. In the absence of strong evidence for or against repair of incidentally discovered contralateral PPV, surgeons should consider family values and engage in a nuanced preoperative discussion about the risks and benefits of each approach.
Recurrent inguinal hernias occur after about 1% of elective repairs, though recurrence rates can be as high as 24% in patients with risk factors such as incarceration, ascites or a ventriculoperitoneal shunt.
Based on retrospective data and the potential advantages of laparoscopy (including access to anatomic areas unexplored in an open approach, improved identification of the root cause of recurrence and ability to identify rare defects like femoral hernias), the report suggests that recurrent hernias can be addressed laparoscopically.
General anesthesia concern
In recent years, concern about the impact of general anesthesia on pediatric neurodevelopment has been increasing, prompted by a Food and Drug Administration drug safety communication. The report reviewed data from the two most comprehensive studies available on the effects of general anesthesia on neurodevelopment: the General Anesthesia Compared to Spinal Anesthesia study and the Pediatric Anesthesia NeuroDevelopment Assessment study.
Based on these studies, the report concluded that there is no definitive evidence that exposure to a single, short duration of general anesthesia adversely affects neurodevelopmental outcomes in otherwise healthy children.
Dr. Khan is a lead author of the clinical report.