Abstract
Purpose
To propose a new clinical classification for pediatric inguinal hernias modified from a similar classification system for adult inguinal hernia and to propose a tailored repair for each type. The impact of this approach on hernia recurrence will be assessed.
Methods
This prospective and retrospective cross-sectional study was conducted in two tertiary teaching university hospitals in Egypt (Alexandria and Tanta University Children’s Hospitals) from January 2013 to December 2014 on children below 12 years of age with indirect inguinal hernias who were divided into two groups: (a) prospective group I, classified according to our proposed pediatric hernia classification and tailored treatment (PHCTT) into types: pediatric Nyhus 1 (PNI) assigned for herniotomy alone, pediatric Nyhus II (PNII) assigned for herniotomy plus deep ring narrowing, and type pediatric Nyhus III (PNIII) assigned for herniotomy plus posterior wall repair. (b) Retrospective unclassified group II where all cases were assigned to herniotomy alone (open). Data about patient characteristics, assigned hernia type, operative findings, procedures done, and postoperative complications were documented and analyzed by comparing the outcomes of the two groups.
Results
A total of 371 patients were included in this study with 401 hernias (30 bilateral); group I included of 217 patients, while group II included 154 patients. There was a male preponderance in group I (173/217 = 80%) and in group II (130/154 = 85%); the majority in both groups were less than 12 months of age, in group I (132/217 = 66%) and in group II (120/154 = 85%). The median age was 4 months and the median duration of symptoms was 2 months. For group I, PNII hernias formed the predominant cluster making 40% (94/235) followed by PNI hernias making 34.8% (82/235), while PNIII hernias were the least group being 25% (59/235) only. The mean follow-up period was 9.2 months ± 4.8 SD (and 9.1 months ± 2 SD in group II). The pooled recurrence rate was 1.9% (8/401) of the whole series, a weighted mean of the individual recurrence rates of 0% (0/235) of group I and 4.8% (8/166) of group II patients, all males. This difference in the recurrence rates between the two groups was statistically significant (P = 0.004).
Conclusions
Pediatric inguinal hernias are not the same and there is extreme variation in the presentation regarding the size of the defect. We proposed a nouvelle pediatric hernia classification modified from the original Nyhus classification for adult inguinal hernia with tailored surgical approach to each type (PHCTT). Applying this (PHCTT), it has the benefit of a significant reduction of recurrence rate.
![](http://media.springernature.com/m312/springer-static/image/art%3A10.1007%2Fs10029-018-1816-y/MediaObjects/10029_2018_1816_Fig1_HTML.png)
![](http://media.springernature.com/m312/springer-static/image/art%3A10.1007%2Fs10029-018-1816-y/MediaObjects/10029_2018_1816_Fig2_HTML.png)
![](http://media.springernature.com/m312/springer-static/image/art%3A10.1007%2Fs10029-018-1816-y/MediaObjects/10029_2018_1816_Fig3_HTML.jpg)
![](http://media.springernature.com/m312/springer-static/image/art%3A10.1007%2Fs10029-018-1816-y/MediaObjects/10029_2018_1816_Fig4_HTML.jpg)
Similar content being viewed by others
References
Lau ST, Lee YH, Caty MG (2007) Current management of hernias and hydroceles. Semin Pediatr Surg. https://doi.org/10.1053/j.sempedsurg.2006.10.007
Wang KS (2012) Assessment and management of inguinal hernia in infants abstract. Off J Am Acad Pediatr 130:767–774. https://doi.org/10.1542/peds.2012-2008
Lugo-Vicente H (2003) PSU, 2003. In: Pediatric Surgery Update, vol 21. http://home.coqui.net/titolugo/PSU21.html#2161. Accessed 23 Feb 2018
Agrawal CS, Pratap A (2007) Pediatric inguinal hernia: controversies and decision making. Nepal Med Coll J 9:199–203
Suvera M, Damor P, Patel S (2013) Surgery for inguinal hernia in pediatric age. Int J Res Med Sci 1:112. https://doi.org/10.5455/2320-6012.ijrms20130515
Brandt MLDM (2008) Pediatric hernias. Surg Clin N Am 88:27–43. https://doi.org/10.1016/j.suc.2007.11.006
Shah JNSN (2010) Paediatric day care inguinal hernia surgery in a general hospital: a prospective study on change in practice. J Nepal Paediatr Soc 30:128–131
Gilbert AI, Graham MF, Voigt WJ (2018) Inguinal hernia: anatomy and management. In: Medscape C. https://www.medscape.org/viewarticle/420354_5. Accessed 23 Feb 2018
Borenstein SH, To T, Wajja A, Langer JC (2005) Effect of subspecialty training and volume on outcome after pediatric inguinal hernia repair. J Pediatr Surg. https://doi.org/10.1016/j.jpedsurg.2004.09.002
Dorairajan N (2004) Inguinal hernia-yesterday, today and tomorrow. Indian J Surg 66:137–139
Kassab P, Franciulli EF, Wroclawski CKIECO (2013) Meshless treatment of open inguinal hernia repair: a prospective study. Einstein 11:186–189
Renzulli P, Frei E, Schafer MS, Wegmuller H L (1997) Preoperative Nyhus classification of inguinal hernias and type-related individual hernia repair. A case for diagnostic laparoscopy. Surg Laparosc 7:373–377 (Abstract Citations BioEntities Related Articles External Links Renzulli P, Frei E, Schäfer M, Werlen S, Wegmüller H)
Taylor K, Sonderman KA, Wolf LL et al (2018) Hernia recurrence following inguinal hernia repair in children. J Pediatr Surg. https://doi.org/10.1016/j.jpedsurg.2018.03.021
Zollinger R Jr (2003) Classification systems for groin hernias. Surg Clin N Am 83:1053–1063. https://doi.org/10.1016/S0039-6109(03)00126-9
Nyhus LM, Lloyd M, Condon RE, Robert E (1995) Hernia. J.B. Lippincott, Philadelphia
McDonnell D, Wakefield C (2018) Adult groin hernias: acute and elective. Surg Oxford Int Ed 36:238–244. https://doi.org/10.1016/j.mpsur.2018.03.003
Hebra A (2017) Pediatric hernias. In: Medscape. https://emedicine.medscape.com/article/932680-overview. Accessed 23 Feb 2018
Toki A, Watanabe Y, Sasaki K et al (2003) Ultrasonographic diagnosis for potential contralateral inguinal hernia in children. J Pediatr Surg 38:224–226. https://doi.org/10.1053/jpsu.2003.50048
Shehata SM, El Attar A, Attia M et al (2013) Laparoscopic herniotomy in children: prospective assessment of tertiary center experience in a developing country. Hernia 17:229–234. https://doi.org/10.1007/s10029-012-1031-1
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of interest
SS declares no conflict of interest. SS declares no conflict of interest. HW declares no conflict of interest. MA declares no conflict of interest. AE declares no conflict of interest.
Ethical approval
Ethical approval and human rights forms were approved by IRB of Alexandria University.
Human and animal rights
The study conducted on human participants has been performed according to the ethical standards of the Helsinki declaration and its later amendments. The study was approved by the IRB of Alexandria University, a detailed informed consent was obtained from each of the patients' guardians.
Informed consent
A detailed informed consent was obtained from each patient’s guardian.
Rights and permissions
About this article
Cite this article
Shehata, S., Shehata, S., Wella, H.L. et al. Pediatric inguinal hernias, are they all the same? A proposed pediatric hernia classification and tailored treatment. Hernia 22, 941–946 (2018). https://doi.org/10.1007/s10029-018-1816-y
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s10029-018-1816-y