Abstract
ObjectivesThe incidence of children developing metachronous contralateral inguinal hernia (MCIH) is 7–15%. Contralateral groin exploration during unilateral hernia repair can prevent MCIH development and subsequent second surgery and anaesthesia. Preoperative ultrasonography is a less invasive strategy and potentially able to detect contralateral patent processus vaginalis (CPPV) prior to MCIH development.MethodsWe queried MEDLINE, Embase and Cochrane library to identify studies regarding children aged < 18 years diagnosed with unilateral inguinal hernia without clinical signs of contralateral hernia, who underwent preoperative ultrasonography of the contralateral groin. We assessed heterogeneity and used a random-effects model to obtain pooled estimates of sensitivity, specificity and area under the receiver operating characteristic curve (AUC).ResultsFourteen studies (2120 patients) were included, seven (1013 patients) in the meta-analysis. In studies using surgical exploration as reference test (n = 4, 494 patients), pooled sensitivity and specificity were 93% and 88% respectively. In studies using contralateral exploration as reference test following positive and clinical follow-up after negative ultrasonographic test results (n = 3, 519 patients), pooled sensitivity was 86% and specificity 98%. The AUC (0.984) shows high diagnostic accuracy of preoperative ultrasonography for detecting CPPV, although diagnostic ultrasonographic criteria largely differ and large heterogeneity exists. Reported inguinal canal diameters in children with CPPV were 2.70 ± 1.17 mm, 6.8 ± 1.3 mm and 9.0 ± 1.9 mm.ConclusionDiagnostic accuracy of preoperative ultrasonography to detect CPPV seems promising, though may result in an overestimation of MCIH prevalence, since CPPV does not invariably lead to MCIH. Unequivocal ultrasonographic criteria are mandatory for proper diagnosis of CPPV and subsequent prediction of MCIH.Key Points• Diagnostic accuracy of preoperative ultrasonography for detection of CPPV in children with unilateral inguinal hernia is high.• Preoperative ultrasonographic evaluation of the contralateral groin assumedly results in an overestimation of MCIH prevalence.• Unequivocal ultrasonographic criteria are mandatory for proper diagnosis of CPPV and risk factor identification is needed to predict whether CPPV develops into clinically apparent MCIH.
Highlights
Inguinal hernia is the most common surgical condition in childhood and presents in approximately 0.8–5% of term children and more than 30% in premature born children [1, 2]
Unequivocal ultrasonographic criteria are mandatory for proper diagnosis of contralateral patent processus vaginalis (CPPV) and risk factor identification is needed to predict whether CPPV develops into clinically apparent metachronous contralateral inguinal hernia (MCIH)
7–15% of children develop a hernia on the opposite side after unilateral hernia repair, a metachronous contralateral inguinal hernia (MCIH), with the highest risk in children under the age of 6 months or with initial left-sided hernia [3, 4]
Summary
Inguinal hernia is the most common surgical condition in childhood and presents in approximately 0.8–5% of term children and more than 30% in premature born children [1, 2]. 7–15% of children develop a hernia on the opposite side after unilateral hernia repair, a metachronous contralateral inguinal hernia (MCIH), with the highest risk in children under the age of 6 months or with initial left-sided hernia [3, 4]. Medical history and physical examination of the groin are not adequate to detect a hidden (or asymptomatic) patent processus vaginalis (PV) [5–7], which is likely to develop into an MCIH. Preventive strategies have been proposed since the 1950s and exploration of the contralateral groin during unilateral hernia repair is frequently used to detect contralateral patent processus vaginalis (CPPV). Contralateral exploration carries risks of operative complications (e.g. wound infection, haematoma or testicular atrophy) and is unnecessary if the processus vaginalis is closed [9, 10].
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