Introduction and aim
The most frequent surgery in pediatric practice is inguinal hernia 1,2. Inguinal hernia is observed in 3.5–5% of full-term neonates 3. Inguinal hernia occurs predominantly in male patients 4. The recurrence was reported to be 0.68–4% in different studies 5–8.
Although the trend of laparoscopy in the treatment of inguinal hernia is increasing 9,10, because of some economic factors, open surgery remains the most commonly used approach. In the Khuzestan province, with a population of more than 4 000 000, the pediatric surgery ward was founded about 10 years ago. Hence, as the referral centers of pediatric surgery, we decided to perform this study to determine epidemiologic indexes and complications of inguinal hernia in pediatric patients who underwent inguinal hernia surgery.
The aim of this study was to evaluate pediatric clinical specifications and complications of inguinal hernia in the pediatric surgery ward in Ahvaz, Iran.
Patients and methods
All inpatients less than 12 years of age who were operated during 2003–2004 with a diagnosis of inguinal hernia were included in this study. The place of study was the Imam Khomeini hospital and the Abuzar children’s hospital: two referral centers for pediatric surgery. These hospitals have three pediatric surgeons and support the Khouzestan province with a population of more than four million. Their hospital records up to 2007 were reviewed for surgical complications and inguinal hernia recurrence. Patients with a history of kidney, liver, and heart failure were excluded from the study. Healthy neonates and children without evidence of medical conditions were included. Age, sex, and side of involvement were recorded for each case. Data were analyzed using SPSS software, version 13.0 (SPSS Inc., Chicago, Illinois, USA). A P value of less than 0.05 was considered to be significant. After surgery, patients were visited in the first week. Parents were requested to visit the hospital if there were complications such as pain, wound infection, and fever.
In this study, 269 cases were included. Of all patients, 296 were boys and 32 were girls (P<0.001). Of these patients, eight were less than 1-month old, 96 (35.7%) were 1-month to 1-year old, and 165 (61.3%) were greater than 1-year old. Clinical specifications and the demographic future are shown in Table 1.
Of all cases, 255 were without postoperative complications (P<0.001). Seven (2.6%) cases involved short-term complications of anesthesia. Most of them had cough and low-grade fever.
Hematoma and bleeding were observed in three cases. Wound infection was observed in one (0.4%) case. One (0.4%) case involved seroma, and two (1.4%) had local pain and parotid swelling.
Of all cases, 17 patients (19 inguinal hernias) were readmitted. Six events of recurrence were observed in 17 patients. There were 13 events of new contralateral inguinal hernia presentation. Of the 17 cases, there were two cases with simultaneous recurrent inguinal hernia and newly presented contralateral inguinal hernia.
Of the six recurrent inguinal hernia patients, four showed recurrence within the first year after surgery. Two patients with recurrent inguinal hernia were admitted after 1 year of surgery.
In the current study, 88.1% of the patients were boys. In Ghoroubi et al.’s study 11, 83.7% of the patients were male. In a study by Nassiri 12 on 521 infants and children, 89.4% of the patients were boys.
Omar and colleagues studied 827 children operated for inguinal hernia between 1998 and 2002 retrospectively. They performed 865 herniotomies. Of their cases, 497 patients (60.1%) had right-side involvement and 292 (35.3%) had left-side involvement. Of the 827 cases, 38 patients (4.6%) had bilateral involvement 13. In our study, 136 patients (50.55%) had right-side and 92 (34.20%) had left-side inguinal hernia. Bilateral inguinal hernia was observed in 41 (15.24%) cases. Our findings were similar to that of another study, but bilateral inguinal hernia was slightly higher than in Omar et al.’s study 13. In the study performed by De Lange et al. 14 in 90 Dutch hospitals, 72.6–77.4% of the patients were male. Right-side inguinal hernia was observed in 59.5–59.9% of the cases.
In our study, recurrence was more common in male than in female patients. Readmission for contralateral-side involvement was also more common in male patients.
Kalantari and colleagues studied 301 patients in the 1-year follow-up period. In their study, 213 (70.7%) patients had right-side inguinal hernia and 88 (29.3%) had left-side inguinal hernia. During this period, they encountered 33 new inguinal hernia cases that consisted of five (1.7%) recurrences and 28 (9.3%) contralateral inguinal hernia 15. In our study, of 269 cases, six events of recurrent inguinal hernia and 13 (4.8%) events of contralateral inguinal hernia were observed in the postoperative period. The follow-up period of our study was longer than that of the Kalantari et al.’s study 15.
In our study, bilateral involvement was observed in 12.2% of the male patients and 37.5% of the female patients. Most of the bilateral inguinal hernia was reported in infants less than 6 months old 16.
Except anesthetic complications, recurrence is the most frequent (2.2% of all cases) complication of herniotomy.
Other studies reported recurrence as the most frequent complication and is reported to occur in 0.5–3.8% of the cases 8,17–19. The concurrence rate of recurrent inguinal hernia after uncomplicated inguinal hernia repairs is generally reported at 0.5–1 20. In the study by De Lange and colleagues, there was a relatively high incidence of recurrence within 1 year after the surgery (2001 1.8%, 2005 1.3%) compared with the Bonnard and Aigrain’s study 20. However, there is a report of recurrence of inguinal hernia between 1 and 9% in different reports involving different age groups 21–23. The study by Vogels and colleagues comprised 2471 herniotomies in 1786 boys, of which 685 were bilateral, 713 unilateral on the right side, and 388 unilateral on the left side. There were 17 recurrences, with an overall incidence of 0.69% 24. In our study, six (2.5%) patients showed recurrence and all of them were boys. The inguinal hernia recurrence rate in our study was higher than in other studies.
In our study, there was no report of testicular atrophy. In the study by Nah and colleagues on incarcerated inguinal hernia, 35 patients underwent open surgery. Of the 35 patients, five showed the following complications: vas transaction (1); testicular atrophy (2); inguinal hernia recurrence (1), and acquired undesended testis (1) 25.
In our study, three patients had hematoma and bleeding and one (0.4%) patient had seroma. In the De Lange et al.’s study 14, hematoma or seroma was found in 12 (1.6%) cases in 2001 and in seven (0.9%) cases in 2005. In the study by Yeung et al. 26 on 262 outpatients who underwent inguinal herniotomy, postoperative complications include wound hematoma (2, 0.8%), wound infection (2, 0.8%), hernia recurrence (8, 3.1%), and contralateral inguinal hernia (3, 1.1%). However, our patients underwent surgery as inpatient cases, and surgical complications were similar to that of inpatients who underwent surgery in the Yeung et al.’s study 26.
Among all cases, one patient (0.4%) showed wound infection. In the study by Tiryaki and colleagues 1000 children underwent surgery for indirect inguinal hernia from 1987 to 1993. There were 849 boys and 151 girls (M/F ratio: 8.5/1.5). Tiryaki et al. 27 reported wound infection in 1.9% of their cases. Ein and colleagues reported 1.2% of wound infection in their study. The duration of the Ein et al.’s study 28 was 35 years, from 1969 to 2004. In two periods of the De Lange et al.’s study 14, 0.3% of the patients were reported to have developed wound infection. There is evidence that the frequency of surgical site infection for outpatient (1%) cases is lower than that for inpatients (4%) 29. However, all of our cases were inpatients, and the rate of surgical site infection was lower than that in the Audry et al.’s study 29. This low rate of infection may be because of the small sample size in our study as compared with other studies or the use of improved techniques of sterilization and prevention of infection in the surgical ward.
There was no mortality among our cases. In our previous study, there was no mortality among cases with inguinal hernia in the newborn period 30.
Most of our patients were greater than 1-year old followed by those in the age group of 1 month to 1 year. In the Nassiri study 12, 127 (24.3%) patients were up to 12 months old and 394 (75.7%) patients were greater than 12 months old. In the Kalantari et al.’s study 15, 123 (40.9%) patients were up to 6 months old and 196 (65.0%) patients were up to 2 years old.
We found that all of the ipsi-lateral recurrences were in male patients. The incidence of wound infection in our inpatients who underwent inguinal hernia surgery was similar or lesser than that in another study. The male/female ratio in our study was similar to that in another study.
There were no reliable data to indicate that the cases included in this study were emergent or elective.
This paper is issued from the general practitioner thesis of Fatemeh Mehdianzadeh.
Conflicts of interest
There are no conflicts of interest.
1. Gupta DK, Rohatgi M. Inguinal hernia in children: an Indian experience. Pediat Surg Int. 1993;8:466–468
2. Ul Hasan N. Management of inguinal hernia of childhood as practiced in Karachi, Pakistan. Pediat Surg Int. 1993;8:462–463
3. Grosfeld JL. Current concepts in inguinal hernia in infants and children. World J Surg. 1989;13:506–515
4. Patkowski D, Rysiakiewicz K, Rysiakiewicz J, Koziełł A, Apoznański W, Czernik J. Minimally invasive surgery in newborns and infants – own experience. Polish J Surg. 2009;81:81–86
5. Vibits H, Pahle E. Recurrences after inguinal herniotomy in children. Long time follow-up. Ann Chir Gynaecol. 1992;81:300–302
6. Fung A, Barsoum G, Bentley TM, Wild K, Klikjian AM. Inguinal herniotomy in young infants. Br J Surg. 1992;79:1071–1072
7. Wright JE. Recurrent inguinal hernia in infancy and childhood. Pediat Surg Int. 1994;9:164–166
8. Steinau G, Treutner KH, Feeken G, Schumpelick V, Arensman RM. Recurrent inguinal hernias in infants and children. World J Surg. 1995;19:303–306
9. Laberge J-M. What’s new in pediatric surgery. J Am Coll Surg. 2002;195:208–218
10. Chan KL, Hui WC, Tam PKH. Prospective randomized single-center, single-blind comparison of laparoscopic versus open repair of pediatric inguinal hernia. Surg Endosc. 2005;19:927–932
11. Ghoroubi J, Imanzadeh F, Askarpour S, Sayyari AA, Ahadi MMS, Javaherizadeh H. Ten years study of inguinal hernia in children. J Surg Pak. 2008;13:173–174
12. Nassiri SJ. Contralateral exploration is not mandatory in unilateral inguinal hernia in children: a prospective 6-year study. Pediat Surg Int. 2002;18(5–6):470–471
13. Omar AR, Omar AM, Shaheen AN, Geryani MH. Treatment strategy of inguinal hernia in infants and children in eastern Libya. Saudi Med J. 2004;25:753–755
14. De Lange DH, Kreeft M, Van Ramshorst GH, Aufenacker TJ, Rauwerda JA, Simons MP. Inguinal hernia surgery in the Netherlands: are patients treated according to the guidelines? Hernia. 2010;14:143–148
15. Kalantari M, Shirgir S, Ahmadi J, Zanjani A, Soltani AE. Inguinal hernia and occurrence on the other side: a prospective analysis in Iran. Hernia. 2009;13:41–43
16. Tackett LD, Breuer CK, Luks FI, Caldamone AA, Breuer JG, DeLuca FG, et al. Incidence of contralateral inguinal hernia: a prospective analysis. J Pediatr Surg. 1999;34:684–688
17. Morecroft JA, Stringer MD, Higgins M, Holmes SJK, Capps SNJ. Follow-up after inguinal herniotomy or surgery for hydrocele in boys. Br J Surg. 1993;80:1613–1614
18. Kvist E, Gyrtrup HJ, Mejdahl S, Ronnebech J. Outpatient orchiopexy and herniotomy in children. Acta Paediatr Scand. 1989;78:754–758
19. Nagraj S, Sinha S, Grant H, Lakhoo K, Hitchcock R, Johnson P. The incidence of complications following primary inguinal herniotomy in babies weighing 5 kg or less. Pediat Surg Int. 2006;22:500–502
20. Bonnard A, Aigrain Y. Inguinal hernias in children. Rev Prat. 2003;53:1667–1670
21. Rescorla FJ, Grosfeld JL. Inguinal hernia repair in the perinatal period and early infancy: clinical considerations. J Pediatr Surg. 1984;19:832–837
22. Fette AM, Höllwarth ME. Special aspects of neonatal inguinal hernia and herniotomy. Hernia. 2001;5:92–96
23. Grosfeld JL, Minnick K, Shedd F, West KW, Rescorla FJ, Vane DW. Inguinal hernia in children: factors affecting recurrence in 62 cases. J Pediatr Surg. 1991;26:283–287
24. Vogels HDE, Bruijnen CJP, Beasley SW. Predictors of recurrence after inguinal herniotomy in boys. Pediat Surg Int. 2009;25:235–238
25. Nah SA, Giacomello L, Eaton S, De Coppi P, Curry JI, Drake DP, et al. Surgical repair of incarcerated inguinal hernia in children: laparoscopic or open? Eur J Pediatr Surg. 2011;21:8–11
26. Yeung YP, Cheng MS, Ho KL, Yip AW. Day-case inguinal herniotomy in Chinese children: retrospective study. Hong Kong Med J. 2002;8:245–248
27. Tiryaki T, Baskin D, Bulut M. Operative complications of hernia repair in childhood. Pediat Surg Int. 1998;13(2–3):160–161
28. Ein SH, Njere I, Ein A. Six thousand three hundred sixty-one pediatric inguinal hernias: a 35-year review. J Pediatr Surg. 2006;41:980–986
29. Audry G, Johanet S, Achrafi H, Lupold M, Gruner M. The risk of wound infection after inguineal incision in pediatric outpatient surgery. Eur J Pediatr Surg. 1994;4:87–89
30. Peyvasteh M, Askarpour S, Javaherizadeh H, Fatahian T. Evaluation of epidemiologic indices of neonate’s diseases in the Pediatric Surgery Ward of the Ahvaz Jundishapur University hospitals during the period 1993–1996 and 2002–2005. Ann Pediatr Surg. 2011;7:7–9