BOB Ped Surg 2023 - Jason Fraser, APSA - Presentation

Good morning. Thank you for allowing us the opportunity to present our consortium's work here today for this event. The natural history of the patent process vaginalis or PPV in the absence of symptomatic hernia is relatively unknown. And this has led to inconclusive recommendations on managing PPVs when they're found incidentally at the time of another operation, or when they're found on the contralateral side during inguinal hernia repair. Acknowledging the natural history and timing of obliteration of the process of vaginalis is indistinct, we launched a multi-center study to follow a large cohort of patients prospectively up to age 18 years. Our aim was to better understand the frequency and timing of the appearance of an inguinal hernia in a group of infants who had an incidental finding of a PPV at the time of another procedure. Here, we report our initial four years of recruitment and available follow-up data. This is a prospective observational study of eight centers in the Midwest Pediatric Surgery Consortium of infants less than four months of age who were undergoing a laparoscopic pyloromyotomy and at the time had their inguinal canals examined. Patients who had a PPV were included and were followed yearly via phone survey, and they will be continued to follow yearly up to age 18 years. Those without a PPV were not included, and they will not be followed. PPV location, size, depth, scrotal or labial insufflation, and patient demographics were recorded. Patients were contacted yearly to determine the presence of a hernia or hernia repair. PPV was measured using the pyloric grasper, whose length of the metal portion is 2 centimeters and the width when opened is 1.5 centimeters. There were a total of 610 patients enrolled, 84 were excluded, leaving 526 for analysis. Of the 526 patients, there were a total of 283 patients with the PPV, or nearly 54%. 35 on the left, 132 bilateral, and 116 on the right. Patients with the PPV were significantly younger, weighed less, were more commonly male, and had a significantly lower estimated gestational age at birth than those where a PPV was not found at laparoscopy. There were a total of 414 PPV dimensional measurements recorded where bilateral PPVs are not separated. The scrotum and labia most frequently did not insufflate. A right-sided PPV is more common, but there is a similar depth and width of right and left PPVs as determined by ability to visualize the bottom. There were a total of 246 patients eligible for at least one annual follow-up, and of these 85% responded to at least one of the yearly follow-up calls. There were three patients who presented in the first year with an inguinal hernia. No hernias were seen any of the patients who reached two, three, or four-year follow-up milestone. Stated differently, there were three inguinal hernias of the 246 patients with a PPV who had follow-up with a 1.2% hernia rate. All of these hernias occurred in the first year. The three patients who had inguinal hernia repair are detailed here. Patient one, who had bilateral PPVs noted on laparoscopy, presented with symptoms of an incarcerated right inguinal hernia, necessitating an urgent bilateral inguinal hernia repair 49 days post laparoscopic pyloromyotomy. Patient two had bilateral PPVs and was found to have a right undescended testicle and underwent a right orchiopexy and incidentally had a right inguinal hernia repair 120 days post laparoscopic pyloromyotomy. Now this patient was included in this analysis as the patient had a hernia repaired. Patient three had a right PPV, presented with a right inguinal hernia, and underwent a right inguinal hernia. In conclusion, there's a high incidence of PPV seen in this patient population, and the need for inguinal hernia repair thus far has been low to date. However, long-term follow-up into adulthood will delineate the subsequent natural history. Thank you all very much and I appreciate the opportunity to present our work here today.