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The contralateral inguinal hernia in children
Journal of Pediatric Surgery (2005) 40, 1058 – 1060
www.elsevier.com/locate/jpedsurg
Correspondence
The contralateral inguinal hernia in children To the Editor, We read with interest the article by Hata et al [1] in the September issue of the Journal of Pediatric Surgery. In this study, 22.4% of 348 pediatric patients with inguinal hernia (IH) had a contralateral patent processus vaginalis (CPPV) diagnosed with ultrasound (US) preoperatively and underwent bilateral open IH repair; 94.9% of all CPPVs were confirmed intraoperatively. Although no sex or side difference was noted, a difference in the incidence of CPPV was seen between infants younger than 2 years (26%) and older children (18%) — although this was not statistically significant ( P = .075). Although they conclude that patency of the PV alone cannot be considered a sufficient condition for IH development, for (Rowe et al [2]) CPPV detected in children younger than 2 years has the potential to obliterate spontaneously, we were startled to read that the authors operated on every detected CPPV— at whatever age? The evergreen pediatric surgical problem of bthe contralateral IHQ seems to be a never-ending discussion. A quick PubMed review reveals more than 100 recent publications on the subject. It is interesting that ever since the first reports on the subject, we do not seem to come to a consensus about the management of one of the most common daily practice problems [2,3]. Interest in the subject was renewed recently with bnovelQ minimal invasive techniques such as improved US and laparoscopy [1,4,5]. However, in an era of cost containment and managed health care, we would like to express a certain feeling of drifting away from the core of the matter. To keep the pediatric IH as common and simple as it is and should be, let us not forget some general basic assumptions: Fig. 1. First, the objective finding of a CPPV does not equal IH. Whether a CPPV will develop into an IH and whether this IH will become symptomatic remains rather unpredictable. 0022-3468/$ – see front matter D 2005 Elsevier Inc. All rights reserved.
Chances may depend on certain risk factors [6]. Taking for granted that every symptomatic IH in a child needs to be operated on for its risk of incarceration, the contrary is true for the PPV: 60% of PPVs close within 2 years after birth, and less than 50% of the remainder may develop clinical hernia [2]. Adult autopsy studies even showed more than 15% to have a PPV without demonstrable symptomatic hernia [6]. The preoperative detection of a CPPV therefore may cause a potentially false overestimation: 5.1% of the US-positive patients operated on by Hata et al were not found to have a CPPV intraoperatively [1]. Could the authors comment on this? A retrospective, only locally published study performed in our own department on 1757 pediatric IH patients with a mean follow-up of more than 5 years showed more than 30% of the patients to be younger than 3 months, more than 40% younger than 1 year, and more than 50% younger than 2 years [7]. The risk for IH incarceration was found to be age-dependent: 25% for those younger than 1 month, 17% between 1 and 6 months, 8% between 6 and 12 months, and 4.2% between 1 and 5 years. No sex difference but a striking side predominance was noted for IH: a significant majority occurred on the right side (62%) whereas 129 (8%) were bilateral. The chances of developing a left IH after initially being operated on for a right IH were 1 in 20, but 8% developed a bright after left IH.Q The time interval for presentation of a contralateral symptomatic IH was at a mean of 25% within a month, 45%
Fig. 1
General pediatric IH observations.
Correspondence
1059
within 3 months, and 56% within the year. It is therefore our strong belief and message to every parent presenting with a child with a unilateral symptomatic IH that the presentation of a contralateral symptomatic IH is slightly side-dependent but may approximately occur in 1 (5.8%) of 18 patients [7]. This would mean 17/18 unnecessary contralateral groin explorations with possible morbidity [6,8,9] and also no need for further technical investigations for a CPPV, neither pre- nor intraoperatively in the absence of symptoms and in a patient in good general condition [1,4-9]. Whatever the predictive values of all technical investigations may be, do they actually warrant surgical treatment in the absence of symptoms—not without any complications or costs [6,8,9]? The diagnosis of symptomatic IH still is a clinical one and remains in our opinion the only correct indication for surgical intervention. For healthy children without augmented anesthesia risks, the finding of a simple CPPV, whether detected by US or even when presenting as a typical bluish and translucent hydrocoele, will be noted and observed for at least a year, as spontaneous obliteration mostly will occur [2,6]. The parents are sensitized and the risk of incarceration is small. The active investigation for a CPPV may lead to overestimation (up to 48% or more) and also potential overtreatment—which in our opinion seems a waste of time, means and money, with possible iatrogenic comorbidity [1,4,5,8]. bCome what may, in 1 in 18 it eventually will, the parents are warned, and we’ll be there.Q Perhaps that, in this new century of outpatient surgery and minimal anesthesia risks, a consensus of conservative but more cost-effective bwatchful waiting Q for the contralateral side in pediatric IH soon may see the light, after more than 50 years of debate? Surely we are not alone with this opinion.
References [1] Hata S, Takahashi Y, Nakamura T, et al. Preoperative sonographic evaluation is a useful method of detecting contralateral patent processus vaginalis in pediatric patients with unilateral inguinal hernia. J Pediatr Surg 2004;39:1396 - 9. [2] Rowe MI, Copelson LW, Clathworthy HW. The patent processus vaginalis and the inguinal hernia. J Pediatr Surg 1969;4:102 - 7. [3] Rothenberg RE, Barnett T. Bilateral herniotomy in infants and children. Surgery 1955;37:947 - 50. [4] Bhatia AM, Gow KW, Heiss KF, et al. Is the use of laparoscopy to determine presence of contralateral patent processus vaginalis justified in children greater than 2 years of age? J Pediatr Surg 2004;39: 778 - 81. [5] Miltenburg DM, Nuchtern JG, Jaksic T, et al. Laparoscopic evaluation of the pediatric inguinal hernia—a meta-analysis. J Pediatr Surg 1998;33:874 - 9. [6] Tackett LD, Breuer CK, Luks FI, et al. Incidence of contralateral inguinal hernia: a prospective trial. J Pediatr Surg 1999;34:684 - 7. [7] Verhelst A, Schwagten K. Liespathologie bij kinderen. Overzicht resultaten van aangepaste kinderchirurgische techniek: morbiditeitslimieten bereikt? Acta Antwerp 1991;8(1):5 - 10 [in Dutch]. [8] McGregor DB, Halverson K, McVay CB. The unilateral pediatric inguinal hernia: should the contralateral side be explored? J Pediatr Surg 1980;15:313 - 7. [9] Surana R, Puri P. Is contralateral exploration necessary in infants with unilateral inguinal hernia? J Pediatr Surg 1993;28:1026 - 7.
Lucas E. Matthyssens Koenraad J. Schwagten Dirk Vervloessem Arnold A. Verhelst Department of Pediatric Surgery Queen Paola Children’s Hospital, ZNA B-2020 Antwerp, Belgium E-mail address: [email protected] doi:10.1016/j.jpedsurg.2005.03.038
Reply To the Editor, The purpose of our paper is to identify the accuracy of preoperative diagnosis of PPV by ultrasound (US). Therefore, every patients with CPPV detected by US underwent contralateral operation. The cause of false positive in 4 patients may be a technical problem. These false-positive cases are observed in early stage and no false-positive cases were found in the latter half. The incidence of contralateral hernia after unilateral herniorrhaphy is 7% in meta-analysis study [1]. Is this percentage too small? Preoperative US examination costs $35 and takes only about 5 minutes, whereas the medical expenses of herniorrhaphy in day surgery is about $1800. Preoperative examination by US can prevent second
operation in 7% of patients, consequently save money and time, and avoid anesthesia risk. Off course we should reduce overestimation and overtreatment to prevent the unnecessary contralateral explosion. Therefore, we have followed up patients with CPPV without explosion from January 2003 and investigated the CPPV appearance detected by US to clarify which type or size of CPPV will develop to inguinal hernia and to restrict the criteria for explosion.
Reference [1] Miltenburg DM, Nuchtern JG, Jaksic T, et al. Meta-analysis of the risk of metachronous hernia in infants and children. Am J Surg 1997; 174:741 - 4.
www.elsevier.com/locate/jpedsurg
Correspondence
The contralateral inguinal hernia in children To the Editor, We read with interest the article by Hata et al [1] in the September issue of the Journal of Pediatric Surgery. In this study, 22.4% of 348 pediatric patients with inguinal hernia (IH) had a contralateral patent processus vaginalis (CPPV) diagnosed with ultrasound (US) preoperatively and underwent bilateral open IH repair; 94.9% of all CPPVs were confirmed intraoperatively. Although no sex or side difference was noted, a difference in the incidence of CPPV was seen between infants younger than 2 years (26%) and older children (18%) — although this was not statistically significant ( P = .075). Although they conclude that patency of the PV alone cannot be considered a sufficient condition for IH development, for (Rowe et al [2]) CPPV detected in children younger than 2 years has the potential to obliterate spontaneously, we were startled to read that the authors operated on every detected CPPV— at whatever age? The evergreen pediatric surgical problem of bthe contralateral IHQ seems to be a never-ending discussion. A quick PubMed review reveals more than 100 recent publications on the subject. It is interesting that ever since the first reports on the subject, we do not seem to come to a consensus about the management of one of the most common daily practice problems [2,3]. Interest in the subject was renewed recently with bnovelQ minimal invasive techniques such as improved US and laparoscopy [1,4,5]. However, in an era of cost containment and managed health care, we would like to express a certain feeling of drifting away from the core of the matter. To keep the pediatric IH as common and simple as it is and should be, let us not forget some general basic assumptions: Fig. 1. First, the objective finding of a CPPV does not equal IH. Whether a CPPV will develop into an IH and whether this IH will become symptomatic remains rather unpredictable. 0022-3468/$ – see front matter D 2005 Elsevier Inc. All rights reserved.
Chances may depend on certain risk factors [6]. Taking for granted that every symptomatic IH in a child needs to be operated on for its risk of incarceration, the contrary is true for the PPV: 60% of PPVs close within 2 years after birth, and less than 50% of the remainder may develop clinical hernia [2]. Adult autopsy studies even showed more than 15% to have a PPV without demonstrable symptomatic hernia [6]. The preoperative detection of a CPPV therefore may cause a potentially false overestimation: 5.1% of the US-positive patients operated on by Hata et al were not found to have a CPPV intraoperatively [1]. Could the authors comment on this? A retrospective, only locally published study performed in our own department on 1757 pediatric IH patients with a mean follow-up of more than 5 years showed more than 30% of the patients to be younger than 3 months, more than 40% younger than 1 year, and more than 50% younger than 2 years [7]. The risk for IH incarceration was found to be age-dependent: 25% for those younger than 1 month, 17% between 1 and 6 months, 8% between 6 and 12 months, and 4.2% between 1 and 5 years. No sex difference but a striking side predominance was noted for IH: a significant majority occurred on the right side (62%) whereas 129 (8%) were bilateral. The chances of developing a left IH after initially being operated on for a right IH were 1 in 20, but 8% developed a bright after left IH.Q The time interval for presentation of a contralateral symptomatic IH was at a mean of 25% within a month, 45%
Fig. 1
General pediatric IH observations.
Correspondence
1059
within 3 months, and 56% within the year. It is therefore our strong belief and message to every parent presenting with a child with a unilateral symptomatic IH that the presentation of a contralateral symptomatic IH is slightly side-dependent but may approximately occur in 1 (5.8%) of 18 patients [7]. This would mean 17/18 unnecessary contralateral groin explorations with possible morbidity [6,8,9] and also no need for further technical investigations for a CPPV, neither pre- nor intraoperatively in the absence of symptoms and in a patient in good general condition [1,4-9]. Whatever the predictive values of all technical investigations may be, do they actually warrant surgical treatment in the absence of symptoms—not without any complications or costs [6,8,9]? The diagnosis of symptomatic IH still is a clinical one and remains in our opinion the only correct indication for surgical intervention. For healthy children without augmented anesthesia risks, the finding of a simple CPPV, whether detected by US or even when presenting as a typical bluish and translucent hydrocoele, will be noted and observed for at least a year, as spontaneous obliteration mostly will occur [2,6]. The parents are sensitized and the risk of incarceration is small. The active investigation for a CPPV may lead to overestimation (up to 48% or more) and also potential overtreatment—which in our opinion seems a waste of time, means and money, with possible iatrogenic comorbidity [1,4,5,8]. bCome what may, in 1 in 18 it eventually will, the parents are warned, and we’ll be there.Q Perhaps that, in this new century of outpatient surgery and minimal anesthesia risks, a consensus of conservative but more cost-effective bwatchful waiting Q for the contralateral side in pediatric IH soon may see the light, after more than 50 years of debate? Surely we are not alone with this opinion.
References [1] Hata S, Takahashi Y, Nakamura T, et al. Preoperative sonographic evaluation is a useful method of detecting contralateral patent processus vaginalis in pediatric patients with unilateral inguinal hernia. J Pediatr Surg 2004;39:1396 - 9. [2] Rowe MI, Copelson LW, Clathworthy HW. The patent processus vaginalis and the inguinal hernia. J Pediatr Surg 1969;4:102 - 7. [3] Rothenberg RE, Barnett T. Bilateral herniotomy in infants and children. Surgery 1955;37:947 - 50. [4] Bhatia AM, Gow KW, Heiss KF, et al. Is the use of laparoscopy to determine presence of contralateral patent processus vaginalis justified in children greater than 2 years of age? J Pediatr Surg 2004;39: 778 - 81. [5] Miltenburg DM, Nuchtern JG, Jaksic T, et al. Laparoscopic evaluation of the pediatric inguinal hernia—a meta-analysis. J Pediatr Surg 1998;33:874 - 9. [6] Tackett LD, Breuer CK, Luks FI, et al. Incidence of contralateral inguinal hernia: a prospective trial. J Pediatr Surg 1999;34:684 - 7. [7] Verhelst A, Schwagten K. Liespathologie bij kinderen. Overzicht resultaten van aangepaste kinderchirurgische techniek: morbiditeitslimieten bereikt? Acta Antwerp 1991;8(1):5 - 10 [in Dutch]. [8] McGregor DB, Halverson K, McVay CB. The unilateral pediatric inguinal hernia: should the contralateral side be explored? J Pediatr Surg 1980;15:313 - 7. [9] Surana R, Puri P. Is contralateral exploration necessary in infants with unilateral inguinal hernia? J Pediatr Surg 1993;28:1026 - 7.
Lucas E. Matthyssens Koenraad J. Schwagten Dirk Vervloessem Arnold A. Verhelst Department of Pediatric Surgery Queen Paola Children’s Hospital, ZNA B-2020 Antwerp, Belgium E-mail address: [email protected] doi:10.1016/j.jpedsurg.2005.03.038
Reply To the Editor, The purpose of our paper is to identify the accuracy of preoperative diagnosis of PPV by ultrasound (US). Therefore, every patients with CPPV detected by US underwent contralateral operation. The cause of false positive in 4 patients may be a technical problem. These false-positive cases are observed in early stage and no false-positive cases were found in the latter half. The incidence of contralateral hernia after unilateral herniorrhaphy is 7% in meta-analysis study [1]. Is this percentage too small? Preoperative US examination costs $35 and takes only about 5 minutes, whereas the medical expenses of herniorrhaphy in day surgery is about $1800. Preoperative examination by US can prevent second
operation in 7% of patients, consequently save money and time, and avoid anesthesia risk. Off course we should reduce overestimation and overtreatment to prevent the unnecessary contralateral explosion. Therefore, we have followed up patients with CPPV without explosion from January 2003 and investigated the CPPV appearance detected by US to clarify which type or size of CPPV will develop to inguinal hernia and to restrict the criteria for explosion.
Reference [1] Miltenburg DM, Nuchtern JG, Jaksic T, et al. Meta-analysis of the risk of metachronous hernia in infants and children. Am J Surg 1997; 174:741 - 4.