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
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