Early versus Delayed Inguinal Hernia Repair in Preterm Neonates: An Updated Systematic Review and Meta-Analysis

Inguinal hernias are common among preterm neonates in the neonatal intensive care unit (NICU), affecting up to 30% of all preterms. The timing of surgical repair remains controversial due to concerns about respiratory immaturity and the risk of hernia incarceration with delayed intervention. Previous meta-analyses were limited by methodological weaknesses, including heterogeneous populations and lack of randomized data. We aimed to provide an updated meta-analysis comparing outcomes associated with early versus late hernia repair in premature neonates based on more recent and rigorous evidence.A systematic review was conducted using PubMed, EMBASE, and Cochrane databases to identify studies comparing inguinal hernia repair (IHR) outcomes in preterm neonates during their initial NICU hospitalization (early repair) or after discharge (late repair). The review followed PRISMA guidelines, and statistical significance was defined as p < 0.05.Of 1,860 studies screened, 8 met inclusion criteria (one randomized controlled trial and seven retrospective cohort studies), encompassing 1,624 patients. Among them, 881 neonates (54.2%) underwent early herniorrhaphy. Mean gestational age ranged from 26 to 29 weeks in the early repair group and from 26 to 33 weeks in the late repair group. There was no significant difference in the odds of incarceration between groups (odds ratios [OR]: 1.16; 95% confidence interval [CI]: 0.76-1.79; p = 0.49; I ² = 16%). Early repair was associated with a significantly higher risk of respiratory complications (OR: 3.73; 95% CI: 2.02-6.9; p < 0.0001; I ² = 0%) and hernia recurrence (OR: 3.59; 95% CI: 1.22-10.5; p = 0.02; I ² = 0%). No significant differences were observed in wound infections, testicular complications, readmissions, mortality, procedure duration, or reoperation rates.Early IHR during initial NICU hospitalization in preterm neonates significantly increases the risk of respiratory complications and hernia recurrence without reducing the risk of incarceration or other major surgical complications. These findings suggest that delaying herniorrhaphy until after NICU discharge, when clinically feasible, may optimize outcomes and minimize perioperative risks for this vulnerable population.