Case-Based Journal Review: Inguinal Hernia 2025

Published: 2025-04-03

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Inside this episode

Kai, the Library's AI content creator, listened to this episode and mapped who's speaking, the chapters, key claims, and cases. Every item links to the exact moment in the recording.

AI-enriched

Who's speaking

Gody — host
Todd Ponsky — guest
Jose Campos — guest
Speaker 4

Chapters

0:00Introduction and Clinical Scenario — Hosts introduce the case-based journal review format and present the first clinical scenario: a 29-week preterm male infant in the NICU with uncomplicated unilateral inguinal hernia requiring oxygen via nasal cannula.
2:48Article 1: Early vs Late Repair in Preterm Infants — Discussion of JAMA randomized trial comparing early versus late inguinal hernia repair in preterm infants, including study design, outcomes showing higher adverse events with early repair, and clinical implications for practice change.
7:42Clinical Scenario: Distance and Visit Logistics — Presentation of second scenario involving an 8-month-old female with reducible hernia referred from 70 miles away, prompting discussion of pre-operative and post-operative visit practices across different institutions.
10:30Article 2: One-Stop Surgery Model — Review of Dutch prospective observational study on one-stop surgery for inguinal hernia, examining feasibility, safety, family satisfaction, and barriers to implementation including diagnostic uncertainty and cultural preferences.
14:10Article 3: Natural History of Patent Processus Vaginalis — Discussion of multi-institutional prospective study following infants with incidentally discovered patent processus vaginalis during pyloromyotomy, showing 1% hernia repair rate at one year and implications for contralateral exploration decisions.
17:41Summary and Closing — Recap of key clinical takeaways regarding timing of repair in preterm infants, streamlined care models, and management of incidental patent processus vaginalis, with acknowledgment that dogmatic teaching is being challenged by new evidence.

Key claims

1:17Preterm infants with inguinal hernia have a very high rate of incarceration — Todd Ponsky
1:43The younger the baby, the higher the risk of incarceration — Jose Campos
2:59The multi-center RCT included 308 patients: 159 in early repair group and 149 in late repair group, across 39 US hospitals between 2013 and 2021 — Gody
3:3644 patients in early repair group versus 27 in late repair group had at least one serious adverse event (28% vs 18%) — Gody
4:07Incarceration rate was around 4% in the late repair group — Gody
4:27In the early group 4% had spontaneous resolution, in the late group 11% had spontaneous resolution — Jose Campos
4:56One patient had a bowel injury during repair — Todd Ponsky
5:26There were more reintubations and more apnea in the early repair group — Todd Ponsky
5:56The study used 16 adverse events as a composite outcome including apnea, prolonged intubation, inguinal hernia complications like recurrence, incarceration, and re-operation — Gody
7:12The study was terminated early, had low recruitment rate, and ended up with less statistical power than initially calculated — Gody
10:32The one-stop surgery study from Netherlands included 91 patients: 54 one-stop surgery and 37 usual care, for children older than 3 months with inguinal hernia and ASA grade 1 or 2 — Gody
10:54All but one of the one-stop surgery patients were discharged home on the day of surgery — Gody
10:59Post-op complication and recurrence rates did not differ between intervention and control patients in the one-stop surgery study — Gody
11:05General satisfaction and inclusion of family were higher after one-stop surgery experience — Gody
11:35There was no diagnostic uncertainty in the one-stop surgery program — Jose Campos
12:26A surgery journal article found that routine follow-up for pediatric surgical conditions like circumcision, orchiopexy, and inguinal hernia altered management less than 1% of the time — Jose Campos
13:28When facing medical problems with low risk of complications, family satisfaction becomes a surrogate for quality — Jose Campos
15:34The patent processus vaginalis study enrolled infants under 4 months undergoing laparoscopic pyloromyotomy at 8 children's hospitals, with 246 eligible infants with PPV and 85% responding to at least one annual follow-up — Gody
15:49Of all patients with PPV, two had inguinal hernia repair for symptomatic hernia, one had orchiopexy and incidental inguinal hernia repair, for total of 3 hernia repairs — Gody
16:13The presence of patent processus vaginalis at time of pyloromyotomy was common, but need for hernia repair was around 1% in first year of follow-up — Gody
16:43A Mayo Clinic study by Ben Zendejas showed contralateral hernia occurrence after 50 year follow-up — Todd Ponsky

Points of disagreement

1:17Timing of hernia repair in preterm infants before versus after NICU discharge
- Todd Ponsky: Tends to repair before hospital discharge due to high incarceration risk, but willing to let patients go home if family can be trusted to evaluate and reduce hernias
- Jose Campos: Initially practiced early repair before discharge, but after reviewing the JAMA trial showing 10% reduction in serious adverse events with delayed repair, is willing to change practice and send babies home
14:24Management of incidentally discovered contralateral patent processus vaginalis
- Todd Ponsky: Recommends repairing contralateral PPV found during hernia repair after discussion with parents, citing concern for lifetime risk based on 50-year Mayo Clinic follow-up data
- Jose Campos: Does not repair incidentally found PPV and advises parents against repair based on 1% hernia development rate at one year, though acknowledges temptation to repair

Open questions

What is the long-term (beyond 1 year) rate of hernia development in infants with incidentally discovered patent processus vaginalis?
Does the size or appearance of patent processus vaginalis on laparoscopy predict progression to clinical hernia?
What is the actual incidence of bowel loss or necrosis from incarcerated hernias in preterm infants managed with delayed repair?
How do cultural differences affect family preferences for in-person versus remote post-operative follow-up?
What is the optimal timing window for hernia repair in preterm infants balancing anesthesia risks against incarceration risk?

This episode was analyzed and enriched by Kai, the Library's AI content creator. Every item links to the moment it comes from — click a timestamp to listen in context.

Written for:

Inguinal Hernia Repair in Infants: When Timing, Visits, and Contralateral Findings Matter

The episode's main topic retold as a plain-language walkthrough — what it is, why it matters, and what the speakers concluded. Written by Kai from the episode transcript and reviewed before publishing.

For the care team · Explainer · AI-written, human-reviewed

Why This Exists as a Distinct Problem

Inguinal hernia repair is the most common elective operation in pediatric surgery, but three clinical scenarios generate persistent uncertainty: whether to repair preterm infants before NICU discharge or after they go home, whether families need multiple preoperative and postoperative visits for a straightforward operation, and what to do when you find a patent processus vaginalis on the opposite side during an unrelated procedure. Each question touches on risk tolerance, resource use, and the gap between traditional teaching and emerging evidence.

The Core Clinical Problem

The traditional approach to preterm inguinal hernia has been repair before discharge, driven by teaching that younger infants face higher incarceration risk [c1, c2]. For term infants, the standard has been a preoperative visit to confirm the diagnosis, surgery, and a postoperative visit to check the wound. When a patent processus vaginalis is discovered incidentally during laparoscopy for another indication, many surgeons repair it prophylactically to prevent future hernia. All three practices rest on avoiding a bad outcome — incarceration with bowel loss, missed diagnosis, or a second operation years later — but the actual frequency of these outcomes has been poorly quantified.

How the Approach Works

Timing in Preterm Infants

A multicenter randomized trial across 39 US hospitals enrolled 308 preterm infants with inguinal hernia diagnosed during their initial hospitalization between 2013 and 2021 2:59. The study compared early repair (before discharge) against late repair (after discharge, when the infant was physiologically stable). The composite outcome included 16 adverse events: apnea, prolonged intubation, recurrence, incarceration, and reoperation 5:56.

Early repair produced more harm: 44 patients (28%) in the early group versus 27 (18%) in the late group experienced at least one serious adverse event 3:36. The feared outcome — incarceration — occurred in approximately 4% of the late repair group 4:07. One patient sustained a bowel injury during repair 4:56. The early group had more reintubations and more apnea 5:26. Spontaneous resolution occurred in 4% of the early group but 11% of the late group 4:27, suggesting that waiting not only avoids perioperative complications but may eliminate the need for surgery entirely in some cases.

The trial was terminated early and had lower statistical power than initially planned 7:12, but the signal is clear enough to support a practice change for many surgeons. The key is that families going home are educated about what to watch for and when to return, which likely explains why incarceration rates remained low despite delayed repair.

Streamlining Visits

A Dutch prospective observational study tested a one-stop surgery model for children older than 3 months with inguinal hernia and ASA grade 1 or 2 10:32. The intervention group (54 patients) had diagnosis, surgery, and discharge on the same day; the control group (37 patients) followed the usual three-visit pathway. All but one of the one-stop patients went home the day of surgery 10:54. Postoperative complication and recurrence rates did not differ between groups 10:59, but general satisfaction and family inclusion were higher in the one-stop group 11:05.

The model requires diagnostic certainty — the hernia must be palpable or clearly documented 11:35. A separate study found that routine postoperative visits for uncomplicated pediatric surgical conditions altered management less than 1% of the time 12:26, suggesting that the traditional visit structure serves social rather than clinical needs. When complications are rare, family satisfaction becomes a valid surrogate for quality 13:28.

Incidental Patent Processus Vaginalis

A multi-institutional prospective study followed 246 infants under 4 months who had a patent processus vaginalis discovered during laparoscopic pyloromyotomy at 8 children's hospitals 15:34. At one year, 85% had responded to follow-up. Three patients required hernia repair: two for symptomatic hernia and one incidentally during orchiopexy 15:49. The hernia repair rate was approximately 1% in the first year 16:13.

This low rate challenges the practice of prophylactic contralateral repair, though one-year follow-up may be insufficient. A Mayo Clinic study documented contralateral hernia occurrence after 50 years 16:43, raising the question of whether preventing a lifetime risk justifies immediate intervention. The appearance of a patent processus vaginalis during laparoscopy is unreliable — it changes with scope angle and intra-abdominal pressure — making size-based decisions problematic.

Where Practice Remains Contested

The preterm hernia trial supports delayed repair, but surgeons must still individualize decisions based on distance from the hospital, family confidence, and ability to recognize complications. The one-stop surgery model works when the diagnosis is certain, but many referrals come with ambiguous histories. The patent processus vaginalis data suggest a conservative approach, but the follow-up period is short and the lifetime risk unknown. All three scenarios require shared decision-making rather than protocol-driven care.

When to Involve This Team

Refer preterm infants with inguinal hernia to pediatric surgery before NICU discharge for counseling, but repair can often be deferred until after discharge if the family is comfortable and has access to emergency care. For term infants with a clearly palpable hernia, same-day surgery is feasible and may be preferable for families traveling long distances. When a patent processus vaginalis is discovered incidentally, inform the family of the low short-term risk and offer observation rather than immediate repair, but document the finding and ensure follow-up.

Takeaways from this story

Delaying hernia repair until after NICU discharge reduces serious adverse events by 10% in preterm infants, with only 4% incarceration risk
One-stop surgery for inguinal hernia (diagnosis, repair, discharge same day) is safe and increases family satisfaction when diagnosis is certain
Patent processus vaginalis found during pyloromyotomy requires hernia repair in only 1% of infants at one year, supporting observation over prophylactic repair
Routine postoperative visits for uncomplicated hernia repair alter management less than 1% of the time; phone follow-up may be sufficient

Inguinal Hernia Management in Preterm Infants: When Waiting Is Safer

The episode's teaching points arranged as a structured lesson, building from the basics up to the finer points. Written by Kai from the episode transcript and reviewed before publishing.

For trainees · Teaching arc · AI-written, human-reviewed

Reframing the Incarceration Risk

The traditional teaching holds that preterm infants with inguinal hernia have a very high rate of incarceration 1:17, with risk increasing as gestational age decreases 1:43. This drove a generation of surgeons to repair hernias before NICU discharge, accepting the respiratory complications of early surgery to avoid the catastrophe of incarcerated bowel. A multi-center randomized trial across 39 US hospitals challenges that calculus 2:59. Among 308 preterm infants, those randomized to late repair (after discharge) had fewer serious adverse events than those repaired early: 18% versus 28% 3:36. The feared outcome—incarceration—occurred in only 4% of the late repair group 4:07. One patient sustained a bowel injury during repair 4:56, but no cases of bowel loss from incarceration were reported. The early repair group experienced more reintubations and more apnea 5:26, complications that carry their own morbidity in fragile preterm infants.

Spontaneous resolution favors waiting. In the early repair group, 4% of hernias resolved spontaneously; in the late group, 11% resolved without intervention 4:27. Waiting not only reduces perioperative respiratory complications but also spares a subset of infants from unnecessary surgery entirely.

Composite outcomes make rare events measurable. The trial used 16 adverse events as a composite outcome, including apnea, prolonged intubation, recurrence, incarceration, and re-operation 5:56. When the outcome you most fear—bowel loss from incarceration—is rare enough that detecting a difference would require over 1000 patients per arm, composite outcomes allow feasible trials while still capturing clinically meaningful safety signals. The trade-off is interpretability: a 10% absolute reduction in serious adverse events matters, but the weight you assign it depends on which events drove the difference.

Individualize based on family and access. The evidence supports late repair as generally safer, but individual decisions should account for distance from the hospital, family confidence in recognizing complications, and ability to return emergently. Parents in this trial went home with education on hernia reduction and red flags for incarceration—a different context than a hernia discovered incidentally at home.

When Family Satisfaction Becomes the Outcome

A Dutch one-stop surgery program enrolled 91 children over 3 months old with inguinal hernia and ASA 1-2 status 10:32. Fifty-four underwent one-stop surgery (diagnosis and repair in a single visit); 37 received usual care with multiple preoperative visits. All but one one-stop patient went home the same day 10:54. Complication and recurrence rates did not differ between groups 10:59, but general satisfaction and family inclusion were higher in the one-stop group 11:05.

Low complication rates shift the quality metric. When facing medical problems with very low risk of complications, family satisfaction becomes a surrogate for quality 13:28. If outcomes are uniformly excellent regardless of approach, then convenience, shared decision-making, and family preference become the differentiators. A study in *Surgery* found that routine follow-up for pediatric conditions like inguinal hernia altered management less than 1% of the time 12:26—at that threshold, requiring families to return for a postoperative visit serves the system more than the patient.

The Lifetime Question of Contralateral Repair

A multi-center study followed 246 infants under 4 months who underwent laparoscopic pyloromyotomy and were found to have patent processus vaginalis 15:34. Of these, only three required hernia repair in the first year: two for symptomatic hernia, one incidentally during orchiopexy 15:49. The need for repair was around 1% 16:13. But one year is not a lifetime. A Mayo Clinic study documented contralateral hernia occurrence after 50 years of follow-up 16:43. The question is not whether some patent processus vaginalis will eventually become hernias—some will—but whether repairing all of them now to prevent a subset from becoming symptomatic later justifies the immediate surgical risk. The answer depends on how you weight a 1% annual risk compounded over decades against the certainty of a second anesthetic and operation today.

Takeaways from this story

Late hernia repair in preterm infants reduced serious adverse events from 28% to 18%, with only 4% incarceration rate in the delayed group.
Waiting increased spontaneous hernia resolution from 4% to 11%, sparing some infants from surgery entirely.
When complication rates are under 1%, family satisfaction becomes a valid quality metric—routine follow-up rarely changes management.
Patent processus vaginalis at pyloromyotomy led to only 1% hernia repair rate in first year, but lifetime risk extends beyond short follow-up.

Delayed Repair, Selective Follow-up, and Contralateral PPV in Pediatric Inguinal Hernia

The essential version of this episode — what it covers, the points that matter most, and what it changes for you. Written by Kai from the episode transcript and reviewed before publishing.

For specialists · Core brief · AI-written, human-reviewed

Timing of Repair in Preterm Infants

A multi-center RCT across 39 US hospitals enrolled 308 preterm infants with inguinal hernia diagnosed during initial hospitalization: 159 underwent early repair before discharge, 149 had delayed repair after discharge 2:59. The delayed group had fewer serious adverse events—18% versus 28% in the early group 3:36. Incarceration occurred in approximately 4% of delayed repairs 4:07, with no documented bowel loss. The early repair group experienced more reintubations and apnea episodes 5:26. Spontaneous resolution occurred in 11% of the delayed group versus 4% of the early group 4:27. One bowel injury occurred during repair 4:56.

The composite outcome included 16 events: apnea, prolonged intubation, recurrence, incarceration, and re-operation 5:56. The study terminated early with lower statistical power than calculated 7:12. Despite these limitations, the data support delayed repair as generally safe and potentially safer, though decisions should be individualized based on family proximity to hospital, ability to recognize complications, and comfort level.

Streamlined Follow-up

A Dutch observational study of 91 children (age >3 months, ASA 1-2) compared one-stop surgery (diagnosis and repair same day, 54 patients) with usual care (37 patients) 10:32. All but one one-stop patient went home same day 10:54. Complication and recurrence rates were equivalent 10:59, while family satisfaction and sense of inclusion were higher in the one-stop group 11:05. A separate analysis found routine follow-up altered management in less than 1% of pediatric hernia cases 12:26.

Contralateral Patent Processus Vaginalis

A multi-center study enrolled 246 infants under 4 months undergoing laparoscopic pyloromyotomy with identified PPV, with 85% completing at least one annual follow-up 15:34. Three required hernia repair: two for symptomatic hernias, one incidental during orchiopexy 15:49. The one-year hernia repair rate was approximately 1% 16:13. However, Mayo Clinic data demonstrate contralateral hernia occurrence extends beyond 50 years 16:43, raising questions about the adequacy of short-term follow-up for guiding intraoperative decisions about incidental PPV.

Takeaways from this story

Delayed hernia repair in preterm infants reduced serious adverse events from 28% to 18% with only 4% incarceration rate
Spontaneous hernia resolution occurred in 11% of delayed repairs versus 4% of early repairs in preterm infants
One-stop surgery (same-day diagnosis and repair) achieved equivalent outcomes with higher family satisfaction
Incidental PPV at pyloromyotomy required repair in only 1% at one year, but lifetime risk extends beyond 50 years

Topic overview

Three pediatric surgeons discuss recent evidence on inguinal hernia management in children, focusing on timing of repair in preterm infants, streamlining pre- and post-operative visits, and management of incidentally discovered contralateral patent processus vaginalis. A randomized trial showed that delaying hernia repair until after NICU discharge in preterm infants resulted in fewer serious adverse events (18% vs 28%) and higher spontaneous resolution rates (11% vs 4%) compared to early repair, with incarceration rates around 4% in the delayed group. A Dutch observational study demonstrated feasibility of one-stop surgery models with single-visit care, and a multi-center prospective study found only 1% of infants with patent processus vaginalis discovered during pyloromyotomy required hernia repair within one year of follow-up.

Key takeaways

Delaying hernia repair until after NICU discharge in preterm infants reduced serious adverse events from 28% to 18%. (3:36)
Late repair in preterm infants had 11% spontaneous resolution vs 4% in early repair, with ~4% incarceration risk. (4:07)
One-stop surgery for inguinal hernia (age >3mo, ASA 1-2) achieved same-day discharge in 98% with higher family satisfaction. (10:32)
Patent processus vaginalis found during pyloromyotomy required hernia repair in only 1% of infants at 1-year follow-up. (15:34)

Keywords

inguinal hernia patent processus vaginalis prematurity incarceration apnea pyloric stenosis inguinal hernia repair laparoscopic hernia repair pyloromyotomy orchiopexy circumcision contralateral exploration Cincinnati Children's Hospital Hospital Roberto El Rio Chilean Society for Pediatric Surgery

Hashtags

#PediatricSurgery #NICUCare #InguinalHernia #PretermInfants

Transcript

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Hi everyone, I'm I'm Gody from Cincinnati Children's. I'm Todd Ponsky. I'm a pediatric surgeon at Cincinnati Children's Hospital. And today we're doing another episode of one of our most popular podcasts, Case-based Journal Review. In this episode, we will talk about inguinal hernia by reviewing some recent literature brought by Dr. Jose Campos. Hi, I'm Jose Campos. I work in Santiago de Chile in Hospital Roberto El Rio, and I lead a group of volunteers under the wing of the Chilean Society for Pediatric Surgery. We call ourselves Journal Hive, and we're trying to filter the best literature to make it easy for you to change your practice. Like always, we'll link the articles in the description below. So Todd, you are asked to repair a unilateral uncomplicated inguinal hernia in the NICU. The patient is a male infant born at 29 weeks of gestation who currently depends on oxygen delivered via nasal cannula. He has no other significant comorbidities. Would you recommend repairing the hernia before or after discharge? So these babies have a very high rate of incarceration. So I tend to repair these before they leave the hospital. Todd mentions that he would be willing to let them go home if he feels that the family could be trusted to evaluate and bring them to the hospital if there was an issue. And I even sometimes can teach them how to reduce it, but for the most part I do it before they leave the hospital. What do you do, Jose? So I learned to do the repair before discharge just because what I've learned is that the younger the baby, the higher the risk of incarceration. So normally we just tell the NICU to wait for the best moment. The best moment would be just before discharge. Then everything related to the prematurity of the baby has just settled down. We would just ask them to let us know 2 weeks before and then we would have enough time to organize a. Semi-elective surgery just before they go home, and this has been a long standing question for pediatric surgeons because you're balancing medical complications of doing a surgery in a premature baby and actually making everything worse with your anesthesia. But if you let them go and bring them back another time, you're increasing the possibility of emergency surgery because of complications like incarcerated hernia and other things. That's why we brought this article which I think has the possibility to change our practice. Let's take a look at our first article. Effect of early versus late inguinal hernia repair on serious adverse events rates in preterm infants. A randomized clinical trial. This multi-center study included preterm infants with inguinal hernia diagnosed during their initial hospitalization between 2013 and 2021 at 39 different US hospitals. This is a really big trial first published in JAMA. It's really, really difficult to organize 39 centers to get enough recruitment for pediatric surgery and even harder for premature babies for their parents to give consent. In this paper, they had 308 patients, 159 in the early repair group when 149 in the late repair group. 44 patients in the early repair group versus 27 in the late repair group had at least one serious adverse event. Which makes 28% versus 18% respectively. I read this article very carefully and I said, look, I could actually change my practice and actually sending the baby home. I could reduce the hospital stay and, more importantly, reduce the chance of them having a serious adverse effect by 10%. I thought to myself that there was really significant. When we look at the data, we see that one of the 16 adverse events that accounted for the composite outcome is recurrence, which is less than 1%, and incarceration, which is around 4% for late repair. For me, the main takeaway is that The reason I was doing early repair might not be true. In the early group they found only 4% of spontaneous resolution, and in the late group they found 11% of spontaneous resolution. So not only do they not have a higher rate of inguinal hernia complications, but weeding could also increase the likelihood of hernia disappearing completely. Got it. Did they mention if any of those had lost like dead bowel? Did they even talk about serious events, or is it just that they had to come back to have it pushed back in again? One had a bowel injury during repair, but there's no mention if you tell me that there was 0 incidence of bowel loss, which is really what you care about, so if you're asking me if this would lead me to potentially change my practice. It actually may. I did not think at the beginning you were going to convince me. I do have some caveats for this study, but I would like to listen to Todd's opinion before going into the second part of my argumentation. It seems like it's a well done study with pretty clear evidence that there were more. More reintubations, more apnea in the early repair, and the incidence of what we all fear was very low. Todd also thinks that the reason these numbers might be so low is because these parents go home with education as opposed to somebody who just happens to have a hernia at home, and they don't know to push it back in if they're being taught to try to reduce it at home. Or to come back immediately when they see it. In this paper, authors looked into 16 adverse events as a composite outcome, including apnea, prolonged intubation, inguinal hernia complications like recurrence, incarceration, and re-operation. I think just choosing something very serious like death or re-operation, given that the numbers in each group are so small. To have that as a primary outcome, I, I haven't done the math, but probably would have required more than 1000 patients on each arm. So I think that's why they came out with this composite outcome. Jose, I, I would just say the same thing that they would change my practice and I'd be more willing to send patients home, where before I rarely did. But I would individualize it based on how far away they live, discussing it with the parents and their confidence level and comfort level and having them be at home. So you look at the homegoing situation. You talk to the parents, you look at all the factors of the patient. But what this paper does is it tells pediatric surgeons that sending them home is generally safe and maybe safer, and it is an option if in the past it was not an option for them. Yeah, I, I agree with that. And just to be fair, we, we need to say to our audience that this article is quite powerful, but it does have some downsides to it. Here, Jose's talking about how the study was terminated early, had a low recruitment rate, and ended up having less statistical power than initially calculated. I guess this would change my practice, but I don't think everything is said in this particular topic or question. Let's move to the second question. You receive a referral from a nearby town located 70 miles from your hospital. A pediatrician is referring an 8-month-old female with a reducible inguinal hernia. Todd, how would you organize the surgery regarding pre-op and post-op visits? It depends on where I'm operating. When I operate in Akron, we would get to see the patient. Evaluate the patient and schedule them for surgery. So two different cases. If Todd examines the hernia and he feels it. Or if he has a strong confidence in the way it was described to him that there truly was a hernia. Either of those, I'll schedule the patient. Don't get an ultrasound. If I am in Cincinnati, they do have a same day, same day they call it. The same day, same day system is available at Cincinnati Children's two days a week. Patients are evaluated in the morning and the OR is set up in the afternoon. And then they get a phone follow up after 2 weeks if that is the preferred method as opposed to coming in. So basically they only have 1 total visit, but it's not every single patient. It's just offered as an option. How does post-op follow-up work in Akron? I don't have physical follow-up. We do phone follow up for most of our post-ops in Akron. They have a very deliberate form. Advanced practice providers like nurses, nurse practitioners, or physician assistants call the patients' families, go through the questions, and if the answers to any of them are concerning, they ask families to come into the office, or they can go see a pediatrician. That's how. We do almost all of our follow-ups. However, if they want to come see us, absolutely they can come see us. Was this always like that, or did this change after COVID? It was always like that since probably 2015. So what's your situation, Jose? So after COVID, we do have like video conference for a limited amount of patients, but what we normally would do, I would say most centers in Chile is just bring the patient in. Like physically check for the hernia, send them home, schedule the surgery for another day, and then bring them back for a physical follow-up visit. The only ones that don't get these treatments are the ones that live really, really far away. But if you really live that far away, Usually you get to a different hospital for inguinal hernia, the case you mentioned, we would do 3 visits, and that's why I wanted to highlight this point and that's why I find this article that you're about to talk to us so interesting and so potentially practice changing. And let's look at our article. One Stop Surgery, an innovation to Limit Hospital visits in Children. This is an article from the Netherlands. It is a prospective observational study of children older than 3 months with inguinal hernia and ASA grade 1 or 2. There were 91 patients, 54 of them were one-stop surgery, and 37 was usual care. All but 1 of the one-stop surgery patients were discharged home on the day of the surgery. Post-op complication and recurrence rates did not differ between the intervention and control patients. General satisfaction and inclusion of family were higher after one-stop surgery experience. Look, I don't know. I would be very happy to embrace this change. So far it has changed my mind. But not my practice. Whenever we talk to the surgeons, they stay two obstacles for this. First one is diagnostic uncertainty. The more rigid teaching, at least for me in Chile, has been that if you don't feel the hernia for yourself, you do not operate on that child, you know. And that's why I was so glad to read this because there was no diagnostic uncertainty in this program. And the second one is family satisfaction. What we're actually learning from this study, although I'm not sure it's going to be applicable to our cultural environment. Environment in Chile, people actually enjoying their time and they're very happy with a phone console and not necessarily they need to come in. We learned from Jose that he was taught that patients' families prefer to see the person responsible for their operation, AKA the surgeon. In an in-person follow-up setting, Todd's practice is already halfway. They were able to do it in 2 visits instead of we in 3, but I'm very open to do it in just 1 visit. Jose wanted to add that last month there was an article published in the surgery journal. They were asking themselves, how many times do you find something that would alter your management for routine pediatric surgical conditions like circumcision. In orchiopexy, inguinal hernia, and so on. And the answer was less than 1%. Of course, we've added this article in the description below if you'd like to read and learn more. Actually, there might be a benefit of leaving the family, I wouldn't say alone, but just give them a phone call or just give them really, really good instructions to get in touch if there's a problem. I would assume this is independent of the physician. But the hospital also needs to provide resources to make it a one-stop solution, right? Yes, it is. It has to be done in a high resource setting, I think. The last article, we were OK sending patients home because the incidence of a problem is very low. You have to apply the same thing here, that if you look at how often you find a problem when someone comes back to you for a post-op hernia is probably in the Hundreds of a decimal. There's one thing that this article says that I was touched by this phrase. When you were facing medical problems with a low risk of complications, then family satisfaction becomes a surrogate for quality. Think about how many unnecessary times people are coming back to the hospital for a visit for social reasons. Leave it up to the parents. Some want to come. Let them come. But some don't, so you give them the choice. I, I really like your approach of offering this to the family instead of saying, no, we're not going to see you, we're going to call you, but this opens the possibility of offering both and just adapt to what's better for this family in particular. So Todd, you perform a laparoscopic inguinal hernia repair on this patient and find a contralateral patent processes vaginalis. Would you proceed to repair the contralateral site as well? What is the risk of this patent processes vaginalis progressing into a clinically evident inguinal hernia? If I go in and I do a pyloric stenosis and I see an incidental patent prosthesis, I leave it alone. If I am going in to do an inguinal hernia repair before the operation, I have the conversation with the parents. What do you want me to do if I find a hernia on the other side? Todd mentions that he recommends repairing it after having a detailed conversation about hernias with the family, allowing them to make an informed choice. What do you do, Jose? So if I find it incidentally in another operation, I do nothing, and if the baby has a symptomatic unilateral inguinal hernia repair, I only that one side, and it's very difficult to resist. To a temptation of repairing the other one. That's usually my advice to the parents, but I also have the discussion beforehand. Last article of the day is Natural History and Consequence of patent Prossesses vaginalis, an interim analysis from a multi-institutional perspective observational study. Infants under 4 months undergoing laparoscopic poromyotomy were enrolled at 8 children's hospitals. There were 246 eligible infants with PPV. And 85% responded to at least one annual follow-up. Of all, two patients had an inguinal hernia repair for a symptomatic hernia. One had an orchiopexy, and incidental inguinal hernia repair, for a total of 3 hernia repairs. The reason I brought this article is that it has a homogeneous cohort. It has standardized follow-up. It's multicentric. I think it's better quality research than everything we've known previously. According to this study, the presence of a patentsis vaginalis at the time of palomyotomy was common, but the need for hernia repair was around 1% in the first year of follow-up. So that is, to me, is really low. I don't think this is definite evidence, and I'll keep my eyes and my ears open for the final closure of this follow-up study. But if this number is as low as 1%, I would not repair the other side. The problem is 1 year is not enough. If you look at the study out of Mayo Clinic that Ben Zendejas wrote when he was a resident there. There was a contralateral hernia occurrence after a 50 year follow up. And again, we've added this article in the description below if you'd like to read and learn more. The reason I would do it is not for the immediate year, it's for their lifetime, but it's an interesting paper. Jose, do you give the parents a choice, or do you always just say, if I find another one, I'm not touching it? I do give the parents a choice, but I make a statement on my advice on not repairing, and they usually follow that advice. And the size of it doesn't matter to you if it's a big hole or a small hole. Oh, that's a, a big another discussion. No, I don't take that into account. I think the diagnosis of a hernia changes so quickly after you've given different angle of your scope or different pressures. To wrap up today's discussion, let's review what we learned. The first article highlighted that delaying inguinal hernia repair in preterm infants does not result in more complications, suggesting that surgical timing should be tailored to each case. We also explored the benefits of one-stop surgery models which streamline the process, reduce hospital visits, and increase patient satisfaction without raising complications. Finally, we examined the likelihood of a patent processes. Vaginalis progressing into asymptomatic hernia which is found to be low. Therefore, if found incidentally during surgery for unilateral hernia, repairing the contralateral side may not always be necessary, though discussions with parents are crucial before making this decision. The Final comment I want to make is we've been dealing with this pathologies like for 100 years, and we still don't know the natural history of PPVs and inguinal hernias, and I'm just happy. That these 3 articles that we brought are bringing freshness or novelty or curiosity for some things that have been taught very dogmatically like the discussions we've had. Yeah, no, I think these are great papers and glad you brought them forward. It's a good discussion. Thank you for listening to this episode. Don't forget to follow us on social media, subscribe to our YouTube channel, and download the Stay Current app for tons of pediatric surgery content. Global Cat MD along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe.

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