From the Guidelines
For a 27-week premature female with bilateral inguinal hernias, surgical repair should be performed before discharge from the NICU, once the infant is clinically stable, as this approach balances the risks of hernia incarceration and postoperative respiratory complications, as noted in studies such as 1 and 1.
Key Considerations
- The procedure of choice is a bilateral inguinal herniorrhaphy, which should be done as an elective procedure rather than emergently, considering the high incidence of bilateral hernias in premature infants, up to 60% as mentioned in 1.
- The infant should weigh at least 2 kg and be medically stable with no active respiratory issues before undergoing surgery, as anesthesia considerations are critical, with general anesthesia typically used along with regional blocks for pain control, as discussed in 1.
- Postoperatively, the infant should be monitored closely for apnea, bradycardia, and pain, given the potential risks associated with anesthesia and the surgical procedure itself, as highlighted in 1.
Rationale for Early Repair
- Early repair is recommended because premature females have a higher risk of incarceration (10-30%) which can compromise ovarian blood supply, as implied by the need for timely intervention in cases of inguinal hernias in infants, as seen in 1 and 1.
- The procedure is typically well-tolerated with low recurrence rates (1-2%) and minimal complications when performed by experienced pediatric surgeons, suggesting that the benefits of early repair outweigh the risks, as noted in 1 and 1.
Approach to Surgery
- The surgery involves high ligation of the hernia sac through a small inguinal incision, a technique that has been effectively used in preterm infants, as described in 1.
- Laparoscopic repair has also been used effectively in preterm infants, with reported hernia recurrence rates comparable to those associated with open repair, as mentioned in 1, but the choice between open and laparoscopic approaches should be based on the individual case and the surgeon's expertise.
From the Research
Timing of Bilateral Inguinal Hernia Repair
- The optimal timing for bilateral inguinal hernia repair in a 27-week premature female infant is not clearly established, but studies suggest that delaying repair until after 55 weeks corrected gestational age may be safe and effective 2, 3.
- A study published in 2021 found that one third of premature infants with inguinal hernias, especially females, experienced clinical regression of their hernias when repair was delayed until after 55 weeks corrected gestational age 2.
- Another study published in 2024 found that delaying inguinal hernia repair until after discharge from the neonatal intensive care unit resulted in fewer serious adverse events compared to early repair 3.
Surgical Approach
- A single transverse supra-pubic incision may be a safe and effective approach for bilateral inguinal hernia repair in female infants, including premature infants 4.
- This approach has been shown to have excellent postoperative results, with no hernia recurrences and minimal complications 4.
Special Considerations
- Premature female infants with bilateral inguinal hernias may be at risk for rare complications, such as irreducible indirect inguinal hernia containing uterus and bilateral adnexa 5.
- The surgical repair of such cases may be more challenging due to adhesions between the organs and the wall of the sac, and requires careful consideration and planning 5.
Outpatient vs. Inpatient Repair
- Studies have shown that inguinal hernia repair can be safely performed as an outpatient procedure following hospital discharge in appropriate patients, with no significant differences in rates of incarceration or recurrence compared to inpatient repair 6.
- However, the optimal timing of inguinal hernia repair in premature infants remains unclear and may require additional multicenter investigation 6.