The optimal approach for management of metachronous hernias in children: a decision analysis.
OBJECTIVE
Up to 30% of children undergoing unilateral hernia repair will later get a hernia on the contralateral side that requires repair. Three approaches have been used to address the potential for development of a metachronous hernia: (1) observation and repair of a contralateral hernia only if it later becomes apparent, (2) routine contralateral groin exploration, and (3) laparoscopy to evaluate the contralateral groin for a potential hernia. The purpose of this study was to use decision analysis to determine which approach resulted in the lowest morbidity, mortality, and cost.


METHODS
A decision tree was constructed for the management of metachronous hernias that accounted for the occurrence of both nonincarcerated and incarcerated metachronous hernias. Baseline values were estimated from recent reports in the literature. Total charges for each approach were obtained from available hospital records and were used to estimate cost.


RESULTS
Observation was favored over laparoscopy and laparoscopy over routine exploration with respect to preventing spermatic cord injury and preserving future fertility. Although a second operation may be required when observation is used, this approach was associated with only a small increase in anesthesia-related complications (1 in 17,847), cardiac arrests (1 in 62,500), and death (1 in 312,500). Although observation was the favored approach with respect to cost, laparoscopy was less expensive when the expected incidence of metachronous hernias was high.


CONCLUSIONS
Observation is the preferred approach to metachronous hernias because it results in the lowest incidence of injury and cost for most patients and is associated with a minimal increase in anesthesia-related morbidity and mortality. Laparoscopy may be advantageous for patients at high risk for development of a contralateral hernia. As a strategy for preventing metachronous hernias without consideration for injury or cost, routine exploration should be limited to situations in which laparoscopy cannot be performed because of small patient size or a preference for spinal anesthesia.
Burd
R S
RS
Division of General Surgery and Critical Care, Children's Hospital at University of Missouri Hospitals and Clinics, Columbia, MO, USA.
Heffington
S H
SH
Teague
J L
JL
D002648:Child; D002675:Child, Preschool; D003661:Decision Support Techniques; D005500:Follow-Up Studies; D006552:Hernia, Inguinal / Q000175:diagnosis* / Q000601:surgery*; D006801:Humans; D007223:Infant; D010535:Laparoscopy / Q000009:adverse effects / Q000379:methods*; D008297:Male; D012008:Recurrence; D018570:Risk Assessment; D013997:Time Factors; D016896:Treatment Outcome