What is the optimal timing and method for repairing bilateral inguinal hernias in a 27-week premature female infant, and what is the best screening test?

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 with adequate weight gain (typically >2 kg). The procedure of choice is a high ligation of the hernia sac via an open inguinal approach under general anesthesia, as this method has an established safety profile and lower recurrence rates in premature infants 1. Both sides should be repaired simultaneously during the same operation to minimize the risk of incarceration and reduce the need for additional surgeries. Preoperative ultrasound is the best screening test to confirm the diagnosis and evaluate for potential contralateral hernias, as it is a non-invasive and effective method for diagnosing inguinal hernias in infants 1. The procedure is typically performed as same-day surgery with careful attention to anesthesia risks in premature infants, including post-operative apnea monitoring for 12-24 hours, due to the high risk of postoperative apnea in this population 1. Some key points to consider when deciding on the optimal timing and method for repairing bilateral inguinal hernias in a premature infant include:

• The risk of incarceration, which can compromise ovarian blood supply and lead to serious complications
• The benefits of early repair, including reducing the risk of incarceration and minimizing the need for additional surgeries
• The importance of careful anesthesia management and post-operative monitoring to minimize the risks associated with surgery in premature infants
• The use of preoperative ultrasound to confirm the diagnosis and evaluate for potential contralateral hernias
• The choice of surgical approach, with open inguinal repair being the standard method for most premature infants due to its established safety profile and lower recurrence rates. It is also important to note that laparoscopic approaches are sometimes used, but traditional open repair remains the standard for most premature infants due to its established safety profile and lower recurrence rates in this population 1. Overall, the goal of surgical repair is to minimize the risk of complications and improve outcomes for the infant, while also taking into account the unique challenges and risks associated with surgery in premature infants.

From the Research

Optimal Timing for Repairing Bilateral Inguinal Hernias

• The optimal timing for repairing bilateral inguinal hernias in premature infants is a topic of debate, with some studies suggesting early repair to avoid complications such as incarceration and gonadal ischemia 2, while others recommend delaying surgery until the baby is ready for discharge from the neonatal unit 3, 4.
• A study published in 2021 found that delaying repair until after 55 weeks corrected gestational age resulted in safe clinical regression of hernias in approximately one third of premature infants, especially females 5.

Method for Repairing Bilateral Inguinal Hernias

• The method for repairing bilateral inguinal hernias in premature infants typically involves herniotomy, which can be performed through an open or laparoscopic approach 2, 6.
• Laparoscopic repair is considered a safe and effective alternative to conventional open herniorrhaphy, especially for incarcerated inguinal hernias 6.

Screening Test for Bilateral Inguinal Hernias

• Physical examination is the primary screening test for inguinal hernias in premature infants, with regular examinations and manual reduction of hernias recommended to detect incarcerations early 3, 4.
• There is no specific screening test mentioned in the studies for bilateral inguinal hernias, but physical examination and monitoring for signs of incarceration or other complications are essential for early detection and management 3, 5, 2, 4, 6.