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Inguinal hernia in premature boys: should we systematically explore the contralateral side?
Olivier Pierre Maillet1, Sarah Garnier1, Christophe Dadure2
1Unité de Chirurgie Viscérale et Urologique Pédiatrique, Département de Chirurgie Pédiatrique CHU Lapeyronie, Montpellier Université Montpellier I, Montpellier, France.
Insights
Bilateral surgery for unilateral inguinal hernia in premature boys is often unnecessary, with only 11% developing a contralateral hernia. Treating only the symptomatic side reduces surgical morbidity and the risk of secondary cryptorchidism.
Area of Science:
- Pediatric Surgery
- Neonatal Urology
- Surgical Outcomes Research
Background:
- Unilateral inguinal hernia in premature boys traditionally leads to bilateral surgery due to high rates of contralateral patent processus vaginalis.
- Recent advancements in pediatric anesthesia and concerns about morbidity in low birth-weight infants necessitate re-evaluation of this surgical approach.
Purpose of the Study:
- To determine the incidence of contralateral metachronous hernia in premature boys after unilateral inguinal hernia repair.
- To compare the postoperative morbidity between preventive bilateral surgery and elective unilateral surgery for inguinal hernias in premature infants.
Main Methods:
- A retrospective multicenter analysis was conducted on 964 premature boys who underwent surgery for unilateral inguinal hernia between 1998 and 2012.
- The study compared outcomes for 557 infants who had unilateral herniotomy versus 407 who had bilateral herniotomy, with a median follow-up of 12 months.
Main Results:
- Contralateral metachronous hernias occurred in 11% of infants following unilateral surgery, with no significant difference based on the initial side.
- Preventive bilateral surgery was associated with higher contralateral postoperative morbidity (2.45%) compared to elective surgery for metachronous hernias (0.9%), particularly secondary cryptorchidism (1% vs 0%).
- Elective surgery did not increase the risk of testicular hypotrophy (0.7%) despite the risk of metachronous incarcerated hernias.
Conclusions:
- Systematic bilateral herniotomy is not indicated in most premature boys with unilateral inguinal hernias, as it carries significant morbidity.
- Secondary surgery for metachronous hernias is safe, does not elevate the risk of testicular lesions, and may reduce the incidence of secondary cryptorchidism.
- These findings, coupled with potential risks of hypofertility after bilateral procedures, support treating only the symptomatic side in this patient population.
Objective:
Bilateral surgery has been largely advocated in premature boys with unilateral inguinal hernia owing to the high incidence of contralateral patent processus vaginalis. Recently, the potential morbidity of herniotomy in low birth-weight babies and the progress in pediatric anesthesia questioned this attitude. This study aims to evaluate the incidence of contralateral metachronous hernia in a large series of premature boys and to compare the morbidity of preventive versus elective surgery.
Methods:
This retrospective multicenter analysis of 964 premature boys presenting with unilateral inguinal hernia operated from 1998 to 2012 included 557 infants who benefited from a unilateral herniotomy and 407 from a bilateral herniotomy (median follow-up 12months).
Results:
Contralateral metachronous hernia after unilateral surgery occurred in 11% (n=60) without significant difference according to the initial symptomatic side (9.5% on right vs 13% on left, p>0.05). Postoperative morbidity on the contralateral side was higher after preventive surgery than elective surgery with metachronous hernia (2.45% versus 0.9%, p=0.05) especially for secondary cryptorchidism (1% vs 0%, p=0.03). Despite the risk of metachronous incarcerated hernia, elective surgery did not increase the rate of testicular hypotrophy on the opposite side (0.7%, vs 0.7%, p>0.05).
Conclusion:
Systematic bilateral herniotomy is unnecessary in almost 90% of patients and has a significant morbidity. Secondary surgery for metachronous hernia does not increase the risk of testicular lesion and even reduces the risk of secondary cryptorchidism. These results, along with the risk of hypofertility reported after bilateral surgery, may justify treating only the symptomatic side in premature boys.
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