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Inguinal hernia repair in premature infants: more questions than answers
  1. Eileen M Duggan1,
  2. Vikram P Patel2,
  3. Martin L Blakely3
  1. 1Department of General Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
  2. 2Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
  3. 3Department of Pediatric Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
  1. Correspondence to Dr Martin L Blakely, Department of Pediatric Surgery, Vanderbilt University Medical Center, 7100 Doctors’ Office Tower, 2200 Children's Way, Nashville, Tennessee 37232, USA; martin.blakely{at}vanderbilt.edu

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Inguinal hernia (IH) repair in term infants and older children is associated with very low morbidity and little controversy. However, this procedure has a different risk profile in premature infants. It is the most common major operative procedure in this population and has much higher morbidity than in term infants and older children.1–3 The morbidity (and some mortality) is not appreciated by many outside the paediatric surgery and neonatology fields.4

The incidence of IH is reported to be 13%–15% in premature infants—though the true incidence may be higher—and is inversely related to gestational age.5 ,6 Despite the frequency of IH, there is no consensus regarding many aspects of its management. The controversial aspects of IH repair in premature infants that we will address include timing of repair, anaesthetic mode, and the potential of long-term neurocognitive impairment related to anaesthetic agents.

Cardiopulmonary concerns

Many premature infants have cardiac or respiratory comorbidities and remain on oxygen at the time of IH repair. Severe apnoea and the need for ventilator support after operation are major concerns.7 Postoperative apnoea is known to be associated with a prior history of apnoea, prematurity and low postmenstrual age (PMA) at operation.3 ,8 ,9 In a case series with 47 premature infants, all of whom had IH repair prior to neonatal intensive care unit (NICU) discharge, 34% needed postoperative assisted ventilation, 23% had apneas/bradycardia and 4% required postoperative reintubation.10 Another review of 57 preterm infants showed that 8.8% either failed extubation or were unable to be extubated immediately postoperatively.11 Another case series of 126 preterm infants with IH repair reported a 5% apnoea rate; all of these infants had a prior history of apnoea.12 A fairly recent study showed that 13% of 45 premature infants who had IH repair …

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