We should note that 99% of inguinal hernias in childhood are indirect hernias and their treatment is surgery [9]. It has been reported that Mitchell-Banks herniotomy and modified Ferguson methods can be safely used in patients younger than two years of age [10]. In addition, it has been reported that Mitchell-Banks herniotomy reduces the recurrence rate in patients older than two years of age [11]. The fact that indirect hernia was detected in all of our patients in our study supports that inguinal hernia in children develops when the processus vaginalis remains open towards the inguinal canal [12].
The male/female ratio (2.44:1) and right/left ratio (2.45:1) that we mentioned in the article were compatible with the literature [13, 14]. The inguinal hernia was seen on the right in 59% of male patients and 57.7% of female patients. There was no statistically significant difference between the genders regarding the percentage of sides (p > 0.05).
The rate of incarcerated inguinal hernia has been reported as 3–16% [15, 16]. In our study, this rate was 1.7% lower than in published studies. The risk of incarceration increases with low gestational age. It increases up to 16% in term infants and up to 39% in premature infants [9, 17, 18]. The rate of our premature patients who were operated on for incarcerated inguinal hernia was 14.4%. Our results showed that the rate of incarceration increases with lower gestational age.
Sliding hernia was seen with a rate of 19.5% (n = 67) in females, and 3.2% (n = 27) in male. The most common sliding hernia component in women was the ovary, while it was the bladder in men. Our findings regarding sliding hernia were consistent with the literature [15].
The appendix is very rarely found in the inguinal hernia sac (Amyand's hernia) at a rate of 0.13-1% [19]. It was detected in 0.33% (n = 4) of our patients and appendectomy was required in one patient.
Metachronous contralateral hernia development was observed in some patients who were operated unilaterally. Due to the possibility of PPV on the contralateral side in patients presenting with a unilateral hernia, there are different approaches for exploration of the contralateral side. In the literature, bilateral surgical exploration has been recommended for all unilateral male patients under two months of age [20, 21]. In some publications, the necessity of contralateral exploration has been reported in all female patients [22, 23]. The incidence of contralateral hernia has been reported as 2–29% [15, 21, 24]. It was reported that 38% of contralateral exploration was negative [25], and routine contralateral exploration was not recommended [9]. Contralateral exploration was not applied to the patients unless the parents gave a suspicious history of contralateral hernia or there were sufficient clinical findings. In our study, we concluded that routine contralateral inguinal exploration is not indicated in line with the literature.
Complication rate is higher in patients with multiple comorbidities in hernia patients [26]. In our study, four of the patients who developed recurrent hernia had a history of frequent lung infections. It can be thought that this situation develops due to increased intra-abdominal pressure due to frequent coughing attacks.
Complications after inguinal hernia repair are usually related to the incision site. Suture abscesses may require additional postoperative wound care and lead to poor cosmetic results. While suture abscess was more common in a study [9], it was reported that scrotal edema and hematoma were common in another study [27, 35]. In another series, wound infection was the most common complication [15]. Consistent with the literature, the most common complication in our series was wound infection, with a rate of 3.12%. All of our patients who developed inguinoscrotal hematoma recovered uneventfully with spontaneous resorption. Iatrogenic injury of the spermatic cord causing testicular atrophy is a rare complication reported in 0.1–1.2% of inguinal hernia cases [9, 15, 28, 29]. Being premature, being < 2 years old, and having been operated on for an incarcerated inguinal hernia are also factors that increase the risk of this complication [30–33]. Two patients in our series had iatrogenic testicular atrophy. Both patients had no known risk factors.
The rate of recurrent hernia varies between 0.2–3.8%. The recurrence rate is higher in infants younger than one year of age, and most of the recurrences develop in the first six months [26, 34]. Recurrence was seen in 62.5% of our patients in the first six months. Our results were consistent with the literature; and 0.6% had recurrent hernias and 62.5% were younger than one year old.
The strength of this study is that it is one of the large series evaluating the preoperative and postoperative period in children who underwent single-center inguinal hernia repair.