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Early versus delayed repair of reduced incarcerated inguinal hernias in the pediatric population
Early Versus Delayed Repair of Reduced Incarcerated Hernias in the Pediatric Population
Inguinal
By D.B. Gahukamble and A.S. Khamage Benghazi, 1 ibya l This study concerns 183 pediatric patients (age range, 14 days to 10 years) who initially presented with incarcerated inguinal hernias. In all of them, initial conservative management to reduce the hernia was successful. This consisted of elevation of the lower half of body and sedation and/or gentle manual pressure. Thereafter, 75 of them had “early” operation (within 72 hours). Early surgery was not possible for the other 108 patients because of various reasons. These patients were discharged from the ward and were scheduled for “delayed” repair within 1 to 3 months. The complication rates were similar for the two groups, but 17 (15.7%) of the 108 patients in the delayed group had repeat incarceration, some of them more than once during the waiting period. Reincarceration occurred as early as 5 days and as late as 120 days after the initial discharge. The authors conclude that the results of delayed repair were unfavorably affected by the recurrent incarceration, and therefore all pediatric patients should have hernia repair within 5 days after the reduction of incarceration. Copyri9ht o 7996 by W. 8. Saunders Company INDEX
WORDS:
Hernia,
inguinal,
incarcerated.
M
OST SURGEONS who deal with hernias in children agree that once the incarcerated inguinal hernias are reduced under sedation and/or manual reduction, “early” repair (within 72 hours) should be undertaken.1-3 Although ideal, this plan is not always easy to implement in practice. In our hospital, efforts have been made to perform hernia repair within 72 hours after reduction of incarceration. But this is not always possible because of a variety of reasons. Therefore, some operations are performed later. The present study compares the results of early operation with those of “delayed” operation (1 to 3 months after reduction). In this study, incarceration denotes hernia in which the sac contents cannot be easily reduced into the abdominal cavity.’
From the Department of Pediatric Surgery, Faculty of Medicine, Al Arab Medical Universi@ Benghazi; Libya. Address reprint requests to D.B. Gahukamble, MS, MCh, FIGS, Head, Department of Pediatric Surgery, P.O. Box 7199, Benghazi, Libya. Copyright o I996 by W B. Saunders Company 0022-3468/96/3109-0005$03.00/O
1218
MATERIALS
AND METHODS
From September 1982 to August 1992, 214 children were admitted to the Children’s Surgical Ward of Al Jala Hospital with clinical features of irreducucibility of inguinal hernia as the initial presentation. A record was maintained for each patient in which details of history, treatment, repeat admission, and follow-up were recorded. Thirty-one patients required emergency surgery. Three of them had unequivocal signs of strangulation; in the other 28, although there were no physical signs of vascular compromise, reduction’ under sedation and gentle manual pressure had failed. These 31 were not included in further analyses and discussions. Ours is the only institution to which patients with surgical problems are referred from other clinics and hospitals. The medical services are entirely free and easily accessible. With our setup, outpatient or day surgery is not possible; we follow a “short-stay regimen” of 3 days in the hospital4 For the remaining 183 patients, conservative management was successful. It consisted of elevation of the lower half of the body and sedation and/or gentle manual pressure. Thereafter, 75 of the patients had early surgery (within 72 hours of the reduction). Early elective operation was not possible for the other 108 patients because of various reasons beyond our control. The main reason for the delay was lack of operating time. However, two patients were anemic, so it was decided to treat this condition before the procedure. In one patient, recurrent attacks of respiratory infections resulted in the delay. Two patients came from towns far away from our center and were not prepared for the extended stay required for early operation. These 108 patients were discharged from the ward and were scheduled for surgery within 1 to 3 months. When the dates for surgery were given, no differentiation was made between easily reducible hernias and those that were difficult to reduce.
RESULTS
Among the 183 patients (180 boys, 3 girls) admitted with incarcerated inguinal hernias, 75 (41%) were infants and the rest 108 (59%) were between 1 and 10 years of age. The youngest patient was 14 days old. Three of the 75 in whom reduction was successful had persistent inguinal swelling despite the fact that symptoms had subsided completely. At the time of surgery, it was proven that these swellings were attributable to omentum adherent to the hernia sac. Four other patients in this group had transient scrotal hematomas during the immediate postoperative period. Seventeen (15.7%) of the 108 patients who had successful manual reduction and were awaiting de-
JournalofPediatricSorgery,
Vol31,
No 9 (September),
1998:
pp 1218-1220
INCARCERATED
INGUINAL
HERNIA
1219
layed hernia repair had repeat incarceration, some of them more than once. Of these 17, nine were infants in whom the second episode of incarceration occurred between 5 and 120 days (mean, 47.8 days) from initial discharge. The other eight were over 1 year of age; their repeat attacks of incarceration occurred between 5 and 48 days (mean, 22.3 days). The patient whose incarceration developed 120 days later was not brought back to the hospital before the scheduled date. In two of the 17 patients, attempts at hernia reduction failed at the time of the second episode, and they were operated on immediately. Six others could be accommodated for early elective operation after the second reduction procedure. The remaining nine patients were again rescheduled for hernia repair, but repeat attacks of incarceration ensued (Table 1). There were 34 new episodes of incarceration among the delayed group. The average duration of hospitalization stay for those with early repair was 4.6 days; for those with delayed repair it was 5 days. The age groups, gender distribution, and laterality of the cases are shown in Table 2. Complications are listed in Table 3. A comparison of the groups showed that apart from the recurrence of incarceration in 15.7% of the patients in the delayed group, the complication rates associated with the operations were similar. All the patients had follow-up in the outpatient clinic for a minimum of 2 years. There were no late complications in any patient.
DISCUSSION
Our data show that the postoperative complications associated with early and delayed repair are similar except for the occurrence of repeat incarceration in the later group. The complications in the early group were not clinically significant, but the hospital stay was longer because of the short waiting period before the operation could be performed. Nevertheless, early hernia repair sometimes is technically difficult because of an edematous and friable sac.’ However, when the definitive operation is delayed until after reduction of incarceration, edema and
Table
1. Repeat
Incarceration
Incarcerations
Distribution,
Fourth Total
8 34
Leterality
Age < 1 yr > 1 yr Gender Males Females Laterality Right side
of Reduced
Hernias
Early Repair
Category
Delayed
Repair
32 43
43 65
72
108
3
0
75
Left side
104
0
4
friability are not a problem, and the involved tissue returns to its normal texture. This creates an ideal setting for the repair of hernia, but it is evident from our study that patients with delayed repair can experience serious new attacks of incarceration. In the present study, only 17 (15.7%) patients in the delayed group had repeat attacks of incarceration, and those operated on at the time of reincarceration had no serious complications. Based on this information on our delayed group, it could be argued that a modest delay (of 1 to 3 months) while awaiting the scheduled date or the resolution of the intercurrent illness will not increase the risk of serious complications. However, in our small group there were problems. Repeated hospitalizations and reductions were necessary. Two cases required immediate operation and thus were subjected to additional risks. We believe that this is not acceptable in the presentday management of inguinal hernias. Recurrence of incarceration of reduced inguinal hernias is not a new experience.3,5 However, the interval between the initial reduction of incarceration and the repeat episode is variable. It is evident from the present study that the repeat event can occur as early as 5 days after the initial hospital discharge. The implication of this finding is that there is no “safe” waiting period for patients discharged from the hospital after reduction. Therefore, if good results are to be achieved in patients who had successful reduction of incarceration, definitive hernia repair should be performed within 5 days of the initial reduction. This is true for infants as well as older children. 3. Complications
Related
to Early
and
Delayed
Early Repair (n = 75) Complication
No. of Attacks 17 9
and
lnguinal
in 17 Patients
Second time Third time time
Gender Incarcerated
Table Table
2. Age Group,
Postoperative Postoperative Reincarceration Total
scrotal edema abdominal distension
Infants
Children
Hernia
Repair
Delayed Repair In = 108) Infants
Children
3
1
1
1 0
0 0
1 4 13 19 (17.6%)
5 (6.6%)
0
GAHUKAMBLE
1220
AND
KHAMAGE
REFERENCES 1. Rowe MI, Lloyd DL: Inguinal hernia, in Welch KJ, Randolph KJ, Rawitch MW, et al (eds): Pediatric Surgery (ed 4), chap 78. Chicago, IL, Year Book Medical, 1986, pp 770-793 2. Tan PKH: Inguinal hernia, Lister J, Irwing IM (eds): Neonatal Surgery (ed 3) chap 26. London, England, Butterworth, 1990, pp 367-375 3. Stylianos S, Jacir NN, Harris BH: Incarceration of inguinal
hernia in infants prior to elective repair. J Pediatr Surg 28582-583, 1993 4. Gahukamble DB, Rakas FS: Safety of short stay regimen for repair of inguinal hernias in children. Indian Pediatr 26:1248-1250, 1988 5. Rowe MI, Clatworthy HW: Incarcerated and strangulated hernias in children. Arch Surg 101:136-139,197O
Inguinal
By D.B. Gahukamble and A.S. Khamage Benghazi, 1 ibya l This study concerns 183 pediatric patients (age range, 14 days to 10 years) who initially presented with incarcerated inguinal hernias. In all of them, initial conservative management to reduce the hernia was successful. This consisted of elevation of the lower half of body and sedation and/or gentle manual pressure. Thereafter, 75 of them had “early” operation (within 72 hours). Early surgery was not possible for the other 108 patients because of various reasons. These patients were discharged from the ward and were scheduled for “delayed” repair within 1 to 3 months. The complication rates were similar for the two groups, but 17 (15.7%) of the 108 patients in the delayed group had repeat incarceration, some of them more than once during the waiting period. Reincarceration occurred as early as 5 days and as late as 120 days after the initial discharge. The authors conclude that the results of delayed repair were unfavorably affected by the recurrent incarceration, and therefore all pediatric patients should have hernia repair within 5 days after the reduction of incarceration. Copyri9ht o 7996 by W. 8. Saunders Company INDEX
WORDS:
Hernia,
inguinal,
incarcerated.
M
OST SURGEONS who deal with hernias in children agree that once the incarcerated inguinal hernias are reduced under sedation and/or manual reduction, “early” repair (within 72 hours) should be undertaken.1-3 Although ideal, this plan is not always easy to implement in practice. In our hospital, efforts have been made to perform hernia repair within 72 hours after reduction of incarceration. But this is not always possible because of a variety of reasons. Therefore, some operations are performed later. The present study compares the results of early operation with those of “delayed” operation (1 to 3 months after reduction). In this study, incarceration denotes hernia in which the sac contents cannot be easily reduced into the abdominal cavity.’
From the Department of Pediatric Surgery, Faculty of Medicine, Al Arab Medical Universi@ Benghazi; Libya. Address reprint requests to D.B. Gahukamble, MS, MCh, FIGS, Head, Department of Pediatric Surgery, P.O. Box 7199, Benghazi, Libya. Copyright o I996 by W B. Saunders Company 0022-3468/96/3109-0005$03.00/O
1218
MATERIALS
AND METHODS
From September 1982 to August 1992, 214 children were admitted to the Children’s Surgical Ward of Al Jala Hospital with clinical features of irreducucibility of inguinal hernia as the initial presentation. A record was maintained for each patient in which details of history, treatment, repeat admission, and follow-up were recorded. Thirty-one patients required emergency surgery. Three of them had unequivocal signs of strangulation; in the other 28, although there were no physical signs of vascular compromise, reduction’ under sedation and gentle manual pressure had failed. These 31 were not included in further analyses and discussions. Ours is the only institution to which patients with surgical problems are referred from other clinics and hospitals. The medical services are entirely free and easily accessible. With our setup, outpatient or day surgery is not possible; we follow a “short-stay regimen” of 3 days in the hospital4 For the remaining 183 patients, conservative management was successful. It consisted of elevation of the lower half of the body and sedation and/or gentle manual pressure. Thereafter, 75 of the patients had early surgery (within 72 hours of the reduction). Early elective operation was not possible for the other 108 patients because of various reasons beyond our control. The main reason for the delay was lack of operating time. However, two patients were anemic, so it was decided to treat this condition before the procedure. In one patient, recurrent attacks of respiratory infections resulted in the delay. Two patients came from towns far away from our center and were not prepared for the extended stay required for early operation. These 108 patients were discharged from the ward and were scheduled for surgery within 1 to 3 months. When the dates for surgery were given, no differentiation was made between easily reducible hernias and those that were difficult to reduce.
RESULTS
Among the 183 patients (180 boys, 3 girls) admitted with incarcerated inguinal hernias, 75 (41%) were infants and the rest 108 (59%) were between 1 and 10 years of age. The youngest patient was 14 days old. Three of the 75 in whom reduction was successful had persistent inguinal swelling despite the fact that symptoms had subsided completely. At the time of surgery, it was proven that these swellings were attributable to omentum adherent to the hernia sac. Four other patients in this group had transient scrotal hematomas during the immediate postoperative period. Seventeen (15.7%) of the 108 patients who had successful manual reduction and were awaiting de-
JournalofPediatricSorgery,
Vol31,
No 9 (September),
1998:
pp 1218-1220
INCARCERATED
INGUINAL
HERNIA
1219
layed hernia repair had repeat incarceration, some of them more than once. Of these 17, nine were infants in whom the second episode of incarceration occurred between 5 and 120 days (mean, 47.8 days) from initial discharge. The other eight were over 1 year of age; their repeat attacks of incarceration occurred between 5 and 48 days (mean, 22.3 days). The patient whose incarceration developed 120 days later was not brought back to the hospital before the scheduled date. In two of the 17 patients, attempts at hernia reduction failed at the time of the second episode, and they were operated on immediately. Six others could be accommodated for early elective operation after the second reduction procedure. The remaining nine patients were again rescheduled for hernia repair, but repeat attacks of incarceration ensued (Table 1). There were 34 new episodes of incarceration among the delayed group. The average duration of hospitalization stay for those with early repair was 4.6 days; for those with delayed repair it was 5 days. The age groups, gender distribution, and laterality of the cases are shown in Table 2. Complications are listed in Table 3. A comparison of the groups showed that apart from the recurrence of incarceration in 15.7% of the patients in the delayed group, the complication rates associated with the operations were similar. All the patients had follow-up in the outpatient clinic for a minimum of 2 years. There were no late complications in any patient.
DISCUSSION
Our data show that the postoperative complications associated with early and delayed repair are similar except for the occurrence of repeat incarceration in the later group. The complications in the early group were not clinically significant, but the hospital stay was longer because of the short waiting period before the operation could be performed. Nevertheless, early hernia repair sometimes is technically difficult because of an edematous and friable sac.’ However, when the definitive operation is delayed until after reduction of incarceration, edema and
Table
1. Repeat
Incarceration
Incarcerations
Distribution,
Fourth Total
8 34
Leterality
Age < 1 yr > 1 yr Gender Males Females Laterality Right side
of Reduced
Hernias
Early Repair
Category
Delayed
Repair
32 43
43 65
72
108
3
0
75
Left side
104
0
4
friability are not a problem, and the involved tissue returns to its normal texture. This creates an ideal setting for the repair of hernia, but it is evident from our study that patients with delayed repair can experience serious new attacks of incarceration. In the present study, only 17 (15.7%) patients in the delayed group had repeat attacks of incarceration, and those operated on at the time of reincarceration had no serious complications. Based on this information on our delayed group, it could be argued that a modest delay (of 1 to 3 months) while awaiting the scheduled date or the resolution of the intercurrent illness will not increase the risk of serious complications. However, in our small group there were problems. Repeated hospitalizations and reductions were necessary. Two cases required immediate operation and thus were subjected to additional risks. We believe that this is not acceptable in the presentday management of inguinal hernias. Recurrence of incarceration of reduced inguinal hernias is not a new experience.3,5 However, the interval between the initial reduction of incarceration and the repeat episode is variable. It is evident from the present study that the repeat event can occur as early as 5 days after the initial hospital discharge. The implication of this finding is that there is no “safe” waiting period for patients discharged from the hospital after reduction. Therefore, if good results are to be achieved in patients who had successful reduction of incarceration, definitive hernia repair should be performed within 5 days of the initial reduction. This is true for infants as well as older children. 3. Complications
Related
to Early
and
Delayed
Early Repair (n = 75) Complication
No. of Attacks 17 9
and
lnguinal
in 17 Patients
Second time Third time time
Gender Incarcerated
Table Table
2. Age Group,
Postoperative Postoperative Reincarceration Total
scrotal edema abdominal distension
Infants
Children
Hernia
Repair
Delayed Repair In = 108) Infants
Children
3
1
1
1 0
0 0
1 4 13 19 (17.6%)
5 (6.6%)
0
GAHUKAMBLE
1220
AND
KHAMAGE
REFERENCES 1. Rowe MI, Lloyd DL: Inguinal hernia, in Welch KJ, Randolph KJ, Rawitch MW, et al (eds): Pediatric Surgery (ed 4), chap 78. Chicago, IL, Year Book Medical, 1986, pp 770-793 2. Tan PKH: Inguinal hernia, Lister J, Irwing IM (eds): Neonatal Surgery (ed 3) chap 26. London, England, Butterworth, 1990, pp 367-375 3. Stylianos S, Jacir NN, Harris BH: Incarceration of inguinal
hernia in infants prior to elective repair. J Pediatr Surg 28582-583, 1993 4. Gahukamble DB, Rakas FS: Safety of short stay regimen for repair of inguinal hernias in children. Indian Pediatr 26:1248-1250, 1988 5. Rowe MI, Clatworthy HW: Incarcerated and strangulated hernias in children. Arch Surg 101:136-139,197O