What is the recommended management for pediatric patients at high risk for contralateral inguinal hernia?

Management of Pediatric Patients at High Risk for Contralateral Inguinal Hernia

For pediatric patients at high risk for contralateral inguinal hernia, laparoscopic evaluation with prophylactic closure of patent processus vaginalis is recommended, particularly in children under 4 years of age and those with left-sided initial hernias. 1, 2, 3

High-Risk Groups for Metachronous Contralateral Inguinal Hernia (MCIH)

• Children younger than 6 months at initial herniorrhaphy have significantly higher risk of developing MCIH (7.5% in 12-23 month age group vs. 2.9% in patients ≥60 months) 4
• Patients with initial left-sided hernias have higher risk of developing right-sided MCIH (7.1%) compared to right-sided initial hernias developing left-sided MCIH (4.3%) 4, 5
• Female patients may require special consideration, as some studies identify them as having increased risk for MCIH 3

Evaluation Approaches

• Laparoscopic evaluation during initial hernia repair allows direct visualization of the contralateral internal ring to identify occult contralateral patent processus vaginalis (CPPV) 6, 7
• Studies show that 31-38.5% of pediatric patients with unilateral inguinal hernia have a contralateral patent processus vaginalis that can be identified during laparoscopic evaluation 6, 7
• Traditional open exploration carries risks of spermatic cord injury and testicular atrophy, making laparoscopic evaluation preferable 2

Management Algorithm

1. For high-risk patients (age <4 years, left-sided initial hernia):

   • Perform laparoscopic evaluation of the contralateral side during initial hernia repair 5, 3
   • If CPPV is identified, proceed with prophylactic closure 6

2. For lower-risk patients:

   • Consider "wait and see" approach with close follow-up for at least 2 years 4, 5
   • Most MCIHs (77%) occur within 1 year and 94% within 2 years after initial repair 4

Benefits of Prophylactic Closure

• Reduces the risk of developing MCIH by 5.7% compared to open repair without contralateral exploration 6
• Eliminates need for second anesthesia exposure and surgery if MCIH develops 1, 6
• Minimal additional risk of complications from laparoscopic exploration (infection rate 1.0% vs. 0.6% without laparoscopy, statistically insignificant difference) 7

Considerations and Caveats

• Number needed to treat (NNT) is approximately 18 procedures to prevent one MCIH, suggesting individualized decision-making is important 6
• For patients with specific risk factors (age <6 months, left-sided initial hernia), the NNT improves to 9 5
• Long-term follow-up data (17 years) shows overall MCIH rate of 12.3%, with 91.7% occurring within 5 years of initial surgery 3
• Current practice patterns vary widely among pediatric surgeons, with 15% never exploring the contralateral side in male patients, 12% always exploring, and 73% having an age cutoff for exploration 1, 2

Timing of Repair

• If contralateral exploration is not performed, close follow-up for at least 2 years is essential, as most MCIHs develop within this timeframe 4, 3
• For preterm infants with inguinal hernias, timing of repair should balance the risks of incarceration against postoperative respiratory complications 1