Evaluation of the contralateral inguinal ring in clinically unilateral inguinal hernia: a systematic review and meta-analysis

Abstract

Purpose The management of the contralateral inguinal canal in children with clinical unilateral inguinal hernia is controversial. Our objective was to systematically review the literature regarding management of the contralateral inguinal canal. Methods We searched MEDLINE, EMBASE, and Cochrane databases (1940–2011) using ‘hernia’ and ‘inguinal’ and either ‘pediatric,’ ‘infant,’ or ‘child,’ to identify studies of pediatric (age≤21 yrs) patients with inguinal hernia. Among clinical unilateral hernia patients, we assessed the number of cases with contralateral patent processus (CPP) and incidence of subsequent clinical metachronous contralateral hernia (MCH). We evaluated three strategies for contralateral management: expectant management, laparoscopic evaluation or pre-operative ultrasound. Pooled estimates of MCH or CPP were generated with random effects by study when heterogeneity was found (I2>50%, or Cochrane’s Q p≥0.10). Results We identified 2,477 non-duplicated studies, 129 of which met our inclusion criteria and had sufficient information for quantitative analysis. The pooled incidence of MCH after open unilateral repair was 7.3% (95% CI 6.5%–8.1%). Laparoscopic examination identified CPP in 30% (95% CI 26%–34%). Lower age was associated with higher incidence of CPP (p<0.01). The incidence of MCH after a negative laparoscopic evaluation was 0.9% (95% CI 0.5%–1.3%). Significant heterogeneity was found in studies and pooled estimates should be interpreted with caution. Conclusions The literature suggests that laparoscopically identified CPP is a poor indicator of future contralateral hernia. Almost a third of patients will have a CPP, while less than one in 10 will develop MCH when managed expectantly. Performing contralateral hernia repair in patients with CPP results in overtreatment in roughly 2 out of 3 patients.

Management of inguinal hernia in children: a single center experience of 490 patients

“…Performing contralateral hernia repair in patients with CPP results in overtreatment in roughly 2 out of 3 patients. 8,11 Our reported hernia recurrence rates are comparable to those associated with open repair. 1,9,11 However, data regarding the risk of testicular atrophy are not available as it needs long term follow up.…”

“…Although contralateral repair in patients with CPP may reduce the incidence of MCH, such a strategy will result in significant overtreatment since a majority of these patients will not develop clinical MCH. 6,8 The literature suggests that laparoscopically identified CPP is a poor indicator of future contralateral hernia. Almost a third of patients will have a CPP, while less than one in 10 will develop MCH when managed expectantly.…”

Comparison of percutaneous extraperitoneal closure (LPEC) and open repair for pediatric inguinal hernia: experience of a single institution with over 1000 cases

“…Previous reports stated that laparoscopic contralateral internal inguinal ring observation was attempted from the early 1990s [25]. A contralateral PPV was seen in 6-66 % of cases [16,[25][26][27][28][29][30][31][32]; the range is very wide. This seems to be because the way of observing the contralateral internal ring varied in each study.…”

Common urological problems in children: inguinoscrotal pathologies

“…25,29 Yet, a meta-analysis revealed that only 6% of all patients returned with MCH after unilateral inguinal hernia repair. 26 Thus, the presence of CPPV does not necessarily equate to subsequent clinical inguinal hernia.…”

“…26 Thus, the presence of CPPV does not necessarily equate to subsequent clinical inguinal hernia. Kokorowski et al 29 concluded that patent processus vaginalis might be over-treated. Repair of the patent processus vaginalis will definitely decrease the risk of MCH, the costs, and the risk of future hernia incarceration.…”