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Evaluation of the contralateral inguinal ring in clinically unilateral inguinal hernia: a systematic review and
P J Kokorowski1, H-H S Wang, J C Routh
1Division of Urology, Children's Hospital Los Angeles, Institute of Urology, University of Southern California, 4650 Sunset Blvd., #114, Los Angeles, CA, 90027, USA, pkokorowski@chla.usc.edu.
Insights
In pediatric inguinal hernia cases, a contralateral patent processus (CPP) found during laparoscopy doesn't reliably predict a future hernia. Expectant management is often safer than overtreatment for children with unilateral inguinal hernia.
Area of Science:
- Pediatric Surgery
- Surgical Outcomes
- Hernia Management
Background:
- Management of the contralateral inguinal canal in pediatric unilateral inguinal hernia is debated.
- Systematic review of literature is needed to clarify management strategies.
Purpose of the Study:
- To systematically review the literature on the management of the contralateral inguinal canal in children with clinical unilateral inguinal hernia.
Main Methods:
- Searched MEDLINE, EMBASE, and Cochrane databases (1940-2011) for pediatric inguinal hernia studies.
- Assessed contralateral patent processus (CPP) and metachronous contralateral hernia (MCH) incidence.
- Evaluated expectant management, laparoscopic evaluation, and pre-operative ultrasound for contralateral management.
Main Results:
- Pooled incidence of MCH after open unilateral repair was 7.3%.
- Laparoscopic examination identified CPP in 30% of cases; younger age correlated with higher CPP incidence.
- MCH incidence after negative laparoscopic evaluation was 0.9%.
Conclusions:
- Laparoscopically identified CPP is a poor predictor of future contralateral hernia.
- Nearly one-third of patients have CPP, but less than 10% develop MCH with expectant management.
- Contralateral hernia repair in patients with CPP leads to overtreatment in approximately two-thirds of cases.
Purpose:
The management of the contralateral inguinal canal in children with clinical unilateral inguinal hernia is controversial. Our objective was to systematically review the literature regarding management of the contralateral inguinal canal.
Methods:
We searched MEDLINE, EMBASE, and Cochrane databases (1940-2011) using 'hernia' and 'inguinal' and either 'pediatric,' 'infant,' or 'child,' to identify studies of pediatric (age ≤21 years) patients with inguinal hernia. Among clinical unilateral hernia patients, we assessed the number of cases with contralateral patent processus (CPP) and incidence of subsequent clinical metachronous contralateral hernia (MCH). We evaluated three strategies for contralateral management: expectant management, laparoscopic evaluation or pre-operative ultrasound. Pooled estimates of MCH or CPP were generated with random effects by study when heterogeneity was found (I(2) > 50 %, or Cochrane's Q p ≥ 0.10).
Results:
We identified 2,477 non-duplicated studies, 129 of which met our inclusion criteria and had sufficient information for quantitative analysis. The pooled incidence of MCH after open unilateral repair was 7.3 % (95 % CI 6.5-8.1 %). Laparoscopic examination identified CPP in 30 % (95 % CI 26-34 %). Lower age was associated with higher incidence of CPP (p < 0.01). The incidence of MCH after a negative laparoscopic evaluation was 0.9 % (95 % CI 0.5-1.3 %). Significant heterogeneity was found in studies and pooled estimates should be interpreted with caution.
Conclusions:
The literature suggests that laparoscopically identified CPP is a poor indicator of future contralateral hernia. Almost a third of patients will have a CPP, while less than one in 10 will develop MCH when managed expectantly. Performing contralateral hernia repair in patients with CPP results in overtreatment in roughly 2 out of 3 patients.
