Pediatric inguinal hernias, are they all the same? A proposed pediatric hernia classification and tailored treatment.

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.