WEBVTT 00:00:00.000 --> 00:00:02.980 Hi, everyone. I'm Em Gootee from Cincinnati Children's. 00:00:02.980 --> 00:00:06.599 I'm Todd Ponsky. I'm a pediatric surgeon at Cincinnati 00:00:06.599 --> 00:00:08.960 Children's Hospital. And today, we're doing another 00:00:08.960 --> 00:00:11.720 episode of one of our most popular podcasts, 00:00:12.240 --> 00:00:15.039 Case -Based Journal Review. In this episode, 00:00:15.140 --> 00:00:17.559 we will talk about inguinal hernia by reviewing 00:00:17.559 --> 00:00:21.019 some recent literature brought by Dr. Jose Campos. 00:00:21.660 --> 00:00:24.800 Hi, I'm Jose Campos. I work in Santiago de Chile 00:00:24.800 --> 00:00:28.120 in Hospital Roberto del Rio, and I lead a group 00:00:28.120 --> 00:00:31.399 of volunteers under the wing of the Chilean Society 00:00:31.399 --> 00:00:34.340 for Pediatric Surgery. We call ourselves Journal 00:00:34.340 --> 00:00:37.299 Hive, and we're trying to filter the best literature 00:00:37.299 --> 00:00:40.320 to make it easy for you to change your practice. 00:00:40.740 --> 00:00:43.700 Like always, we link the articles in the description 00:00:43.700 --> 00:00:47.420 below. So, Todd, you are asked to repair a unilateral 00:00:47.420 --> 00:00:51.039 uncomplicated inguinal hernia in the NICU. The 00:00:51.039 --> 00:00:54.380 patient is a male infant born at 29 weeks of 00:00:54.380 --> 00:00:57.600 gestation who currently depends on oxygen delivered 00:00:57.600 --> 00:01:00.759 via nasal cannula. He has no other significant 00:01:00.759 --> 00:01:03.420 comorbidities. Would you recommend repairing 00:01:03.420 --> 00:01:07.079 the hernia before or after discharge? So these 00:01:07.079 --> 00:01:10.420 babies have a very high rate of incarceration. 00:01:11.500 --> 00:01:15.299 So I tend to repair these before they leave the 00:01:15.299 --> 00:01:18.159 hospital. Todd mentions that he would be willing 00:01:18.159 --> 00:01:20.840 to let them go home if he feels that the family 00:01:20.840 --> 00:01:23.379 could be trusted to evaluate and bring them to 00:01:23.379 --> 00:01:26.900 the hospital if there was an issue. And I even 00:01:26.900 --> 00:01:29.040 sometimes can teach them how to reduce it. But 00:01:29.040 --> 00:01:30.840 for the most part, I do it before they leave 00:01:30.840 --> 00:01:34.159 the hospital. What do you do, Jose? So I learned 00:01:34.159 --> 00:01:37.560 to do the repair before discharge just because. 00:01:38.189 --> 00:01:40.209 What I've learned is that the younger the baby, 00:01:40.349 --> 00:01:43.469 the higher the risk of incarceration. So normally 00:01:43.469 --> 00:01:47.469 we just tell the NICU to wait for the best moment. 00:01:47.609 --> 00:01:50.250 The best moment would be just before discharge, 00:01:50.609 --> 00:01:53.209 when everything related to the prematurity of 00:01:53.209 --> 00:01:56.030 the baby has just settled down. We would just 00:01:56.030 --> 00:01:58.090 ask them to let us know two weeks before, and 00:01:58.090 --> 00:02:00.689 then we would have enough time to organize a 00:02:00.689 --> 00:02:03.450 semi -elective surgery just before they go home. 00:02:03.670 --> 00:02:05.969 And this has been a longstanding question for 00:02:05.969 --> 00:02:08.719 pediatric surgeons. Because you're balancing 00:02:08.719 --> 00:02:13.039 medical complications of doing a surgery in a 00:02:13.039 --> 00:02:15.620 premature baby and actually making everything 00:02:15.620 --> 00:02:18.699 worse with your anesthesia. But if you let them 00:02:18.699 --> 00:02:21.620 go and bring them back another time, you're increasing 00:02:21.620 --> 00:02:24.400 the possibility of emergency surgery. Because 00:02:24.400 --> 00:02:27.520 of complications like incarcerated hernia and 00:02:27.520 --> 00:02:30.479 other things. That's why we brought this article, 00:02:30.539 --> 00:02:33.180 which I think has the possibility to change our 00:02:33.180 --> 00:02:35.699 practice. Let's take a look at our first article. 00:02:36.250 --> 00:02:39.150 Effect of early versus late inguinal hernia repair 00:02:39.150 --> 00:02:42.289 on serious adverse events rates in preterm infants. 00:02:42.590 --> 00:02:46.090 A randomized clinical trial. This multicenter 00:02:46.090 --> 00:02:48.789 study included preterm infants with inguinal 00:02:48.789 --> 00:02:52.009 hernia diagnosed during their initial hospitalization 00:02:52.009 --> 00:02:57.990 between 2013 and 2021 at 39 different U .S. hospitals. 00:02:58.430 --> 00:03:01.210 This is a really big... trial first published 00:03:01.210 --> 00:03:04.370 in JAMA. It's really really difficult to organize 00:03:04.370 --> 00:03:08.449 39 centers to get enough recruitment for pediatric 00:03:08.449 --> 00:03:11.229 surgery and even harder for premature babies 00:03:11.229 --> 00:03:13.870 to for their parents to give consensus. In this 00:03:13.870 --> 00:03:18.889 paper they had 308 patients, 159 in the early 00:03:18.889 --> 00:03:22.400 repair group, when 149 in the late repair group. 00:03:22.539 --> 00:03:25.240 44 patients in the early repair group versus 00:03:25.240 --> 00:03:28.780 27 in the late repair group had at least one 00:03:28.780 --> 00:03:33.060 serious adverse event, which makes 28 % versus 00:03:33.060 --> 00:03:37.340 18 % respectively. I read this article very carefully 00:03:37.340 --> 00:03:39.789 and I said, look, I could actually change my 00:03:39.789 --> 00:03:41.969 practice and actually sending the baby home, 00:03:42.030 --> 00:03:45.050 I could reduce the hospital stay and more importantly, 00:03:45.090 --> 00:03:48.069 reduce the chance of them having a serious adverse 00:03:48.069 --> 00:03:51.449 effect by 10%. I thought to myself that that 00:03:51.449 --> 00:03:54.030 was really significant. When we look at the data, 00:03:54.150 --> 00:03:57.229 we see that one of the 16 adverse events that 00:03:57.229 --> 00:04:00.509 accounted for the composite outcome is recurrence, 00:04:00.550 --> 00:04:03.990 which is less than 1%, and incarceration, which 00:04:03.990 --> 00:04:07.030 is around 4 % for late repair. For me, the main 00:04:07.030 --> 00:04:11.599 takeaway is that The reason I was doing early 00:04:11.599 --> 00:04:14.599 repair might not be true. In the early group, 00:04:14.680 --> 00:04:17.620 they found only 4 % of spontaneous resolution. 00:04:18.040 --> 00:04:21.579 And in the late group, they found 11 % of spontaneous 00:04:21.579 --> 00:04:24.740 resolution. So not only do they not have a higher 00:04:24.740 --> 00:04:27.779 rate of inguinal hernia complications, but waiting 00:04:27.779 --> 00:04:30.379 could also increase the likelihood of hernia 00:04:30.379 --> 00:04:33.819 disappearing completely. Got it. Did they mention 00:04:33.819 --> 00:04:37.540 if any of those had... loss like dead bowel do 00:04:37.540 --> 00:04:39.860 they even talk about serious events or is it 00:04:39.860 --> 00:04:41.959 just that they had to come back to have it pushed 00:04:41.959 --> 00:04:45.720 back in again one had a bowel injury during repair 00:04:45.720 --> 00:04:48.660 but there's no mention yeah if you tell me that 00:04:48.660 --> 00:04:51.959 there was zero incidence of bowel loss which 00:04:51.959 --> 00:04:55.000 is really what you care about so if you're asking 00:04:55.000 --> 00:04:57.160 me if this would lead me to potentially change 00:04:57.160 --> 00:05:01.459 my practice it actually may I did not think at 00:05:01.459 --> 00:05:02.980 the beginning you were going to convince me. 00:05:03.040 --> 00:05:05.720 I do have some caveats for this study, but I 00:05:05.720 --> 00:05:07.839 would like to listen to Todd's opinion before 00:05:07.839 --> 00:05:11.500 going into the second part of my argumentation. 00:05:11.740 --> 00:05:14.819 It seems like it's a well -done study with pretty 00:05:14.819 --> 00:05:18.100 clear evidence that there were more re -intubations, 00:05:18.139 --> 00:05:22.300 more apnea in the early repair, and the incidence 00:05:22.300 --> 00:05:25.680 of what we all fear was very low. Todd also thinks 00:05:25.680 --> 00:05:28.399 that the reason these numbers might be so low 00:05:28.399 --> 00:05:30.740 is because these parents go home with education, 00:05:31.100 --> 00:05:33.600 as opposed to somebody who just happens to have 00:05:33.600 --> 00:05:35.860 a hernia at home. And they don't know how to 00:05:35.860 --> 00:05:38.279 push it back in if they're being taught to try 00:05:38.279 --> 00:05:41.199 to reduce it at home or to come back immediately 00:05:41.199 --> 00:05:44.100 when they see it. In this paper, authors looked 00:05:44.100 --> 00:05:47.459 into 16 adverse events as a composite outcome, 00:05:47.680 --> 00:05:51.180 including apnea, prolonged intubation, inguinal 00:05:51.180 --> 00:05:53.779 hernia complications like recurrence, incarceration, 00:05:54.279 --> 00:05:57.420 and reoperation. I think just choosing something 00:05:57.420 --> 00:06:00.699 very serious like death or reoperation, given 00:06:00.699 --> 00:06:04.220 that the numbers in each group are so small, 00:06:04.379 --> 00:06:08.279 to have that as a primary outcome, I haven't 00:06:08.279 --> 00:06:09.959 done the math, but probably would have required 00:06:09.959 --> 00:06:12.420 more than a thousand of patients on each arm. 00:06:12.540 --> 00:06:15.620 So I think that's why they came out with this 00:06:15.620 --> 00:06:19.089 composite outcome. Jose, I would just say the 00:06:19.089 --> 00:06:21.129 same thing, that it would change my practice 00:06:21.129 --> 00:06:23.610 and I'd be more willing to send patients home, 00:06:23.670 --> 00:06:28.069 where before I rarely did. But I would individualize 00:06:28.069 --> 00:06:30.850 it based on how far away they live, discussing 00:06:30.850 --> 00:06:33.170 it with the parents and their confidence level 00:06:33.170 --> 00:06:36.529 and comfort level in having them be at home. 00:06:36.709 --> 00:06:39.649 So you look at the home -going situation. You 00:06:39.649 --> 00:06:42.310 talk to the parents, you look at all the factors 00:06:42.310 --> 00:06:45.490 of the patient. But what this paper does is it 00:06:45.490 --> 00:06:48.649 tells pediatric surgeons that sending them home 00:06:48.649 --> 00:06:52.310 is generally safe and maybe safer, and it is 00:06:52.310 --> 00:06:55.430 an option if in the past it was not an option 00:06:55.430 --> 00:06:59.449 for them. Yeah, I agree with that. And just to 00:06:59.449 --> 00:07:02.230 be fair, we need to say to our audience that 00:07:02.230 --> 00:07:05.009 this article is quite powerful, but it does have 00:07:05.009 --> 00:07:08.209 some... Downside to it. Here, Jose is talking 00:07:08.209 --> 00:07:11.350 about how the study was terminated early, had 00:07:11.350 --> 00:07:13.889 a low recruitment rate, and ended up having less 00:07:13.889 --> 00:07:16.470 statistical power than initially calculated. 00:07:16.889 --> 00:07:19.709 I guess this would change my practice, but I 00:07:19.709 --> 00:07:22.769 don't think everything is said in this particular 00:07:22.769 --> 00:07:25.930 topic or question. Let's move to the second question. 00:07:26.290 --> 00:07:29.470 You receive a referral from a nearby town located 00:07:29.470 --> 00:07:33.060 70 miles from your hospital. A pediatrician is 00:07:33.060 --> 00:07:35.319 referring an eight -month -old female with a 00:07:35.319 --> 00:07:38.920 reducible inguinal hernia. Todd, how would you 00:07:38.920 --> 00:07:41.480 organize the surgery regarding pre -op and post 00:07:41.480 --> 00:07:45.620 -op visits? It depends on where I'm operating. 00:07:45.839 --> 00:07:49.879 When I operate in Akron, we would get to see 00:07:49.879 --> 00:07:52.779 the patient, evaluate the patient, and schedule 00:07:52.779 --> 00:07:56.779 them for surgery. So two different cases. If 00:07:56.779 --> 00:08:00.629 Todd examines the hernia and he feels it, or 00:08:00.629 --> 00:08:03.750 if he has a strong confidence in the way it was 00:08:03.750 --> 00:08:06.870 described to him that there truly was a hernia. 00:08:07.029 --> 00:08:09.629 Either of those, I'll schedule the patient, don't 00:08:09.629 --> 00:08:12.970 get an ultrasound. If I am in Cincinnati, they 00:08:12.970 --> 00:08:17.269 do have a same -day -same -day, they call it. 00:08:17.389 --> 00:08:19.569 This same -day -same -day system is available 00:08:19.569 --> 00:08:22.829 at Cincinnati Children's two days a week. Patients 00:08:22.829 --> 00:08:25.250 are evaluated in the morning and the OR is set 00:08:25.250 --> 00:08:28.079 up in the afternoon. And then they get a phone 00:08:28.079 --> 00:08:30.620 follow -up after two weeks if that is the preferred 00:08:30.620 --> 00:08:33.980 method as opposed to coming in. So basically, 00:08:34.000 --> 00:08:37.120 they only have one total visit. But it's not 00:08:37.120 --> 00:08:40.179 every single patient. It's just offered as an 00:08:40.179 --> 00:08:44.600 option. How does post -op follow -up work? In 00:08:44.600 --> 00:08:47.539 Akron, I don't have physical follow -up. We do 00:08:47.539 --> 00:08:50.360 phone follow -up for most of our post -ops. In 00:08:50.360 --> 00:08:53.200 Akron, they have a very deliberate form. Advanced 00:08:53.200 --> 00:08:55.899 practice providers like nurses, nurse practitioners, 00:08:56.019 --> 00:08:58.679 or physician assistants call the patients' families, 00:08:59.039 --> 00:09:01.340 go through the questions, and if the answer to 00:09:01.340 --> 00:09:03.740 any of them are concerning, they ask families 00:09:03.740 --> 00:09:06.399 to come into the office, or they can go see a 00:09:06.399 --> 00:09:08.700 pediatrician. That's how we do almost all of 00:09:08.700 --> 00:09:10.539 our follow -ups. However, if they want to come 00:09:10.539 --> 00:09:13.240 see us, absolutely they can come see us. Was 00:09:13.240 --> 00:09:16.240 this always like that, or did... this change 00:09:16.240 --> 00:09:20.019 after COVID? It was always like that since probably 00:09:20.019 --> 00:09:23.620 2015. So what's your situation, Jose? So after 00:09:23.620 --> 00:09:26.120 COVID, we do have like video conference for a 00:09:26.120 --> 00:09:28.759 limited amount of patients. But what we normally 00:09:28.759 --> 00:09:32.440 would do, I would say most centers in Chile is 00:09:32.440 --> 00:09:36.100 just bring the patient in, like physically check 00:09:36.100 --> 00:09:39.480 for the hernia. send them home, schedule the 00:09:39.480 --> 00:09:41.620 surgery for another day, and then bring them 00:09:41.620 --> 00:09:44.259 back for a physical follow -up visit. The only 00:09:44.259 --> 00:09:46.700 ones that don't get these treatments are the 00:09:46.700 --> 00:09:49.659 ones that live really, really far away. But if 00:09:49.659 --> 00:09:52.759 you really live that far away, usually you get 00:09:52.759 --> 00:09:55.870 to a different hospital. For inguinal hernia, 00:09:56.029 --> 00:09:58.690 the case you mentioned, we would do three visits. 00:09:58.889 --> 00:10:01.730 And that's why I wanted to highlight this point. 00:10:01.809 --> 00:10:03.850 And that's why I find this article that you're 00:10:03.850 --> 00:10:07.210 about to talk to us so interesting and so potentially 00:10:07.210 --> 00:10:10.289 practice changing. And let's look at our article. 00:10:10.669 --> 00:10:13.830 One -stop surgery, an innovation to limit hospital 00:10:13.830 --> 00:10:16.289 visits in children. This is an article from the 00:10:16.289 --> 00:10:18.759 Netherlands. It is a prospective observational 00:10:18.759 --> 00:10:21.799 study of children older than three months with 00:10:21.799 --> 00:10:26.059 inguinal hernia and ASA grade 1 or 2. There were 00:10:26.059 --> 00:10:30.039 91 patients, 54 of them were one -stop surgery, 00:10:30.240 --> 00:10:34.399 and 37 was usual care. All but one of the one 00:10:34.399 --> 00:10:36.740 -stop surgery patients were discharged home on 00:10:36.740 --> 00:10:39.379 the day of the surgery. Post -op complication 00:10:39.379 --> 00:10:42.200 and recurrence rates did not differ between the 00:10:42.200 --> 00:10:45.000 intervention and control patients. General satisfaction 00:10:45.000 --> 00:10:47.879 and inclusion of family were higher after one 00:10:47.879 --> 00:10:50.399 stop surgery experience. Look, I don't know. 00:10:50.539 --> 00:10:53.899 I would be very happy to embrace this change. 00:10:54.039 --> 00:10:57.519 So far, it has changed my mind, but not my practice. 00:10:57.779 --> 00:11:00.940 Whenever we talk to the surgeons, they state 00:11:00.940 --> 00:11:03.759 two obstacles for this. First one is diagnostic 00:11:03.759 --> 00:11:07.360 uncertainty. The more rigid. teaching at least 00:11:07.360 --> 00:11:09.919 for me in Chile has been that if you don't feel 00:11:09.919 --> 00:11:12.919 the hernia for yourself you do not operate on 00:11:12.919 --> 00:11:15.799 that child you know and that's why I was so glad 00:11:15.799 --> 00:11:19.080 to read this because there was no diagnostic 00:11:19.080 --> 00:11:21.379 uncertainty in this program. And the second one 00:11:21.379 --> 00:11:24.179 is family satisfaction. What we're actually learning 00:11:24.179 --> 00:11:26.320 from this study although I'm not sure it's going 00:11:26.320 --> 00:11:30.059 to be applicable to our cultural environment 00:11:30.059 --> 00:11:33.200 in Chile, people actually enjoying their time 00:11:33.200 --> 00:11:36.100 and they're very happy with a phone consult and 00:11:36.100 --> 00:11:38.919 not necessarily they need to come in. We learned 00:11:38.919 --> 00:11:41.740 from Jose that he was taught that patients' families 00:11:41.740 --> 00:11:44.460 prefer to see the person responsible for their 00:11:44.460 --> 00:11:48.539 operation, aka the surgeon, in an in -person 00:11:48.539 --> 00:11:51.019 follow -up setting. Todd's practice is already 00:11:51.019 --> 00:11:53.580 halfway. They were able to do it in two visits 00:11:53.580 --> 00:11:57.549 instead of we in three, but I'm... very open 00:11:57.549 --> 00:12:00.909 to do it in just one visit. Jose wanted to add 00:12:00.909 --> 00:12:03.230 that last month there was an article published 00:12:03.230 --> 00:12:05.929 in the Surgery Journal. They were asking themselves, 00:12:06.289 --> 00:12:08.309 how many times do you find something that would 00:12:08.309 --> 00:12:11.450 alter your management for routine pediatric surgical 00:12:11.450 --> 00:12:15.070 conditions like circumcision or ketopexy, inguinal 00:12:15.070 --> 00:12:18.190 hernia, and so on? And the answer was less than 00:12:18.190 --> 00:12:21.450 1%. Of course, we've added this article in the 00:12:21.450 --> 00:12:23.669 description below if you'd like to read and learn 00:12:23.669 --> 00:12:26.289 more. Actually, there might be a benefit of... 00:12:26.539 --> 00:12:28.980 Leaving the family, I wouldn't say alone, but 00:12:28.980 --> 00:12:32.379 just give them a phone call or just give them 00:12:32.379 --> 00:12:35.000 really, really good instructions to get in touch 00:12:35.000 --> 00:12:37.519 if there's a problem. I would assume this is 00:12:37.519 --> 00:12:40.100 independent of the physician, but the hospital 00:12:40.100 --> 00:12:42.519 also needs to provide resources to make it a 00:12:42.519 --> 00:12:45.539 one -stop solution, right? Yes, it is. It has 00:12:45.539 --> 00:12:49.240 to be done in a high resource setting, I think. 00:12:49.419 --> 00:12:51.919 The last article, we were okay sending patients 00:12:51.919 --> 00:12:53.980 home because the incidence of a problem is very 00:12:53.980 --> 00:12:56.090 low. You have to apply the same thing here. That 00:12:56.090 --> 00:12:59.409 if you look at how often you find a problem when 00:12:59.409 --> 00:13:02.269 someone comes back to you for a post -op hernia 00:13:02.269 --> 00:13:06.789 is probably in the hundredths of a decimal. There's 00:13:06.789 --> 00:13:09.230 one thing that this article says that I was touched 00:13:09.230 --> 00:13:12.549 by this phrase. When you were facing medical 00:13:12.549 --> 00:13:16.690 problems with a low risk of complications, then 00:13:16.690 --> 00:13:20.200 family satisfaction becomes... A surrogate for 00:13:20.200 --> 00:13:23.159 quality. Think about how many unnecessary times 00:13:23.159 --> 00:13:25.080 people are coming back to the hospital for a 00:13:25.080 --> 00:13:27.120 visit for social reasons. Leave it up to the 00:13:27.120 --> 00:13:30.720 parents. Some want to come. Let them come. But 00:13:30.720 --> 00:13:33.500 some don't. So you give them the choice. I really 00:13:33.500 --> 00:13:35.899 like your approach of offering this to the family 00:13:35.899 --> 00:13:37.580 instead of saying, no, we're not going to see 00:13:37.580 --> 00:13:39.740 you. We're going to call you. But this opens 00:13:39.740 --> 00:13:42.639 the possibility of offering both and just adapt 00:13:42.639 --> 00:13:45.740 to what's better for this. family in particular. 00:13:45.980 --> 00:13:48.679 So, Todd, you perform a laparoscopic inguinal 00:13:48.679 --> 00:13:52.980 hernia repair on this patient and find a contralateral 00:13:52.980 --> 00:13:56.419 patent processus vaginalis. Would you proceed 00:13:56.419 --> 00:13:59.700 to repair the contralateral side as well? What 00:13:59.700 --> 00:14:02.200 is the risk of this patent processus vaginalis 00:14:02.200 --> 00:14:05.259 progressing into a clinically evident inguinal 00:14:05.259 --> 00:14:09.320 hernia? If I go in and I do a pyloric stenosis 00:14:09.320 --> 00:14:13.120 and I see an incidental patent processes, I leave 00:14:13.120 --> 00:14:16.139 it alone. If I am going in to do an inguinal 00:14:16.139 --> 00:14:19.320 hernia repair, before the operation, I have the 00:14:19.320 --> 00:14:21.779 conversation with the parents. What do you want 00:14:21.779 --> 00:14:24.259 me to do if I find a hernia on the other side? 00:14:24.559 --> 00:14:27.220 Todd mentions that he recommends repairing it 00:14:27.220 --> 00:14:29.980 after having a detailed conversation about hernias 00:14:29.980 --> 00:14:32.740 with the family, allowing them to make an informed 00:14:32.740 --> 00:14:36.059 choice. What do you do, Jose? So if I find it 00:14:36.059 --> 00:14:38.120 incidentally in another operation, I do nothing. 00:14:38.440 --> 00:14:41.379 And if the baby has a symptomatic unilateral 00:14:41.379 --> 00:14:44.500 inguinal hair repair, I only that one side. And 00:14:44.500 --> 00:14:47.519 it's very difficult to resist to a temptation 00:14:47.519 --> 00:14:50.080 of repairing the other one. That's usually my 00:14:50.080 --> 00:14:52.500 advice to the parents, but I also have the discussion 00:14:52.500 --> 00:14:55.419 beforehand. Last article of the day is Natural 00:14:55.419 --> 00:14:59.879 History and Consequence of Patent Processes Vaginalis, 00:14:59.940 --> 00:15:02.639 an interim analysis from a multi -institutional 00:15:02.639 --> 00:15:05.799 prospective observational study. Infants under 00:15:05.799 --> 00:15:08.100 four months undergoing laparoscopic pulmonary 00:15:08.100 --> 00:15:11.039 myotomy were enrolled at eight children's hospitals. 00:15:11.299 --> 00:15:15.840 There were 246 eligible infants with PPV, and 00:15:15.840 --> 00:15:20.220 85 % responded to at least one annual follow 00:15:20.220 --> 00:15:23.679 -up. Of all, two patients had an inguinal hernia 00:15:23.679 --> 00:15:27.419 repair for a symptomatic hernia, one had an orchopexy 00:15:27.419 --> 00:15:30.500 and incidental inguinal hernia repair, for a 00:15:30.500 --> 00:15:33.340 total of three hernia repairs. The reason I brought 00:15:33.340 --> 00:15:35.940 this article is that it has a homogeneous cohort. 00:15:36.120 --> 00:15:39.299 It has standardized follow -up. It's multicentric. 00:15:39.559 --> 00:15:42.899 I think it's better quality research than everything 00:15:42.899 --> 00:15:45.259 we've known previously. According to this study, 00:15:45.399 --> 00:15:47.960 the presence of a patent -processed vaginalis 00:15:47.960 --> 00:15:51.440 at the time of palromyotomy was common, but the 00:15:51.440 --> 00:15:54.200 need for hernia repair was around 1 % in the 00:15:54.200 --> 00:15:57.799 first year of follow -up. So that is... To me, 00:15:57.820 --> 00:16:00.200 it's really low. I don't think this is definite 00:16:00.200 --> 00:16:03.720 evidence, and I'll keep my eyes and my ears open 00:16:03.720 --> 00:16:06.179 for the final closure of this follow -up study. 00:16:06.700 --> 00:16:10.899 But if this number is as low as 1%, I would not 00:16:10.899 --> 00:16:14.059 repair the other side. The problem is one year 00:16:14.059 --> 00:16:16.799 is not enough. If you look at the study at a 00:16:16.799 --> 00:16:19.879 Mayo Clinic that Benzendejas wrote when he was 00:16:19.879 --> 00:16:23.740 a resident there, there was a contralateral hernia 00:16:23.740 --> 00:16:26.529 occurrence after a 50 -year follow -up. And again, 00:16:26.629 --> 00:16:28.669 we've added this article in the description below 00:16:28.669 --> 00:16:56.309 if you'd like to read and learn more. Another 00:16:56.309 --> 00:16:58.889 discussion, no, I don't take that into account. 00:16:59.210 --> 00:17:02.870 I think the diagnosis of a hernia changes so 00:17:02.870 --> 00:17:06.170 quickly after you've given different angle of 00:17:06.170 --> 00:17:09.009 your scope or different pressures. To wrap up 00:17:09.009 --> 00:17:11.430 today's discussion, let's review what we learned. 00:17:11.690 --> 00:17:14.349 The first article highlighted that delaying inguinal 00:17:14.349 --> 00:17:17.509 hernia repair in preterm infants does not result 00:17:17.509 --> 00:17:20.730 in more complications, suggesting that surgical 00:17:20.730 --> 00:17:23.819 timing should be tailored to each case. We also 00:17:23.819 --> 00:17:26.480 explored the benefits of one -stop surgery models, 00:17:26.759 --> 00:17:29.960 which streamlined the process, reduced hospital 00:17:29.960 --> 00:17:33.059 visits, and increased patient satisfaction without 00:17:33.059 --> 00:17:36.200 raising complications. Finally, we examined the 00:17:36.200 --> 00:17:39.960 likelihood of a patent processus vaginalis progressing 00:17:39.960 --> 00:17:42.940 into asymptomatic hernia, which found to be low. 00:17:43.180 --> 00:17:46.160 Therefore, if found incidentally during surgery 00:17:46.160 --> 00:17:49.279 for unilateral hernia, repairing the contralateral 00:17:49.279 --> 00:17:52.720 side may not always be necessary. Though discussions 00:17:52.720 --> 00:17:55.539 with parents are crucial before making this decision. 00:17:55.819 --> 00:17:58.079 Final comment I want to make is we've been dealing 00:17:58.079 --> 00:18:01.079 with this pathology for a hundred years and we 00:18:01.079 --> 00:18:03.640 still don't know the natural history of PPVs 00:18:03.640 --> 00:18:06.079 and inguinal hernias. And I'm just happy that 00:18:06.079 --> 00:18:08.420 these three articles that we brought are bringing 00:18:08.420 --> 00:18:13.539 freshness or novelty or curiosity for some things 00:18:13.539 --> 00:18:16.019 that have been taught very dogmatically, like 00:18:16.019 --> 00:18:18.930 the discussions we've had. Yeah. No, I think 00:18:18.930 --> 00:18:21.509 these are great papers and glad you brought them 00:18:21.509 --> 00:18:23.509 forward. It's good discussion. Thank you for 00:18:23.509 --> 00:18:25.869 listening to this episode. Don't forget to follow 00:18:25.869 --> 00:18:28.009 us on social media, subscribe to our YouTube 00:18:28.009 --> 00:18:30.289 channel, and download the Stay Current app for 00:18:30.289 --> 00:18:32.009 tons of pediatric surgery content.