Costs and recurrence of inguinal hernia repair in premature infants during neonatal admission


      • What is currently known about this topic? Timing of inguinal hernia repair in premature infants is variable. Early repair, during admission in the neonatal intensive care unit (NICU) may be encouraged due to concerns about hernia incarceration, strangulation, or loss to follow up. On the other hand, delayed repair might be encouraged due to concerns about increased perioperative risk in premature infants.
      • What new information is contained in this article? In premature infants, inguinal hernia repair that is performed during initial hospitalization in the NICU is associated with lower cost, but higher recurrence rates, when compared to delayed repair.



      Timing of inguinal hernia repair (IHR) in premature infants remains variable, yet the impact of IHR timing on procedure costs and recurrence is unclear. We sought to compare cost and recurrence rates of IHR in premature infants based on timing of repair.


      We performed a retrospective cohort study using MarketScan insurance claims data from 2007-2018 to evaluate IHR occurring within 365 days of birth in preterm infants (gestational age [GA]<37 weeks at birth). Patients were stratified based on timing of IHR: those occurring during and after neonatal discharge. Hernia recurrences within one year following IHR were identified. Patient demographic characteristics and costs were compared between groups. Time to recurrence and cumulative recurrence hazards were estimated using Kaplan Meier analysis and Cox proportional hazards regression.


      We identified 3,662 preterm infants with IHR within 365 days of birth; 1,054(28.8%) occurred early. Infants with IHR during NICU stay were more likely to have GA at birth≤32 weeks (74.7% vs. 37.2%; p<0.01) and birthweight<1500g (83.0% vs. 40.3%; p<0.01) compared to post-NICU IHR. The hernia recurrence rate was higher and total procedure costs lower in early IHR. Early IHR (HR:1.86, 95% CI: 1.56-2.22), incarcerated/strangulated hernia (HR:1.86, 95% CI:1.49-2.32), GA≤32 weeks (HR: 1.40, 95% CI: 1.19-1.65), and congenital anomalies (HR: 1.32, 95% CI: 1.12-1.57) were predictors of hernia recurrence.


      Using insurance claims data, IHR performed during initial neonatal admission was associated with lower cost, but higher recurrence rate, when compared to delayed repairs in preterm infants.


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        • Khan FA
        • Zeidan N
        • Larson SD
        • Taylor JA
        • Islam S.
        Inguinal hernias in premature neonates: exploring optimal timing for repair.
        Pediatr Surg Int. 2018; 34: 1157-1161
        • Kumar VH
        • Clive J
        • Rosenkrantz TS
        • Bourque MD
        • Hussain N
        Inguinal hernia in preterm infants (≤32-Week Gestation).
        Pediatr Surg Int. 2002; 18: 147-152
        • Peevy KJ
        • Speed FA
        • Hoff CJ.
        Epidemiology of inguinal hernia in preterm neonates.
        Pediatrics. 1986; 77: 246-247
        • Fu YW
        • Pan ML
        • Hsu YJ
        • Chin TW.
        A nationwide survey of incidence rates and risk factors of inguinal hernia in preterm children.
        Pediatr Surg Int. 2018; 34: 91-95
        • Lautz TB
        • Raval MV
        • Reynolds M.
        Does timing matter? A national perspective on the risk of incarceration in premature neonates with inguinal hernia.
        J Pediatr. 2011; 158: 573-577
        • Olesen CS
        • Mortensen LQ
        • Oberg S
        • Rosenberg J.
        Risk of incarceration in children with inguinal hernia: a systematic review.
        Hernia. 2019; 23: 245-254
        • Vaos G
        • Gardikis S
        • Kambouri K
        • Sigalas I
        • Kourakis G
        • Petoussis G.
        Optimal timing for repair of an inguinal hernia in premature infants.
        Pediatr Surg Int. 2010; 26: 379-385
        • Sulkowski JP
        • Cooper JN
        • Duggan EM
        • Balci O
        • Anandalwar SP
        • Blakely ML
        • et al.
        Does timing of neonatal inguinal hernia repair affect outcomes?.
        J Pediatr Surg. 2015; 50: 171-176
        • Antonoff MB
        • Kreykes NS
        • Saltzman DA
        • Acton RD.
        American Academy of Pediatrics Section on Surgery hernia survey revisited.
        J Pediatr Surg. 2005; 40: 1009-1014
        • Mongelli F
        • Ferrario di Tor Vajana A
        • FitzGerald M
        • Cafarotti S
        • Lucchelli M
        • Proietti F
        • et al.
        Open and Laparoscopic Inguinal Hernia Surgery: A Cost Analysis.
        J Laparoendosc Adv Surg Tech A. 2019; 29: 608-613
        • Eklund A
        • Carlsson P
        • Rosenblad A
        • Montgomery A
        • Bergkvist L
        • Rudberg C
        • et al.
        Long-term cost-minimization analysis comparing laparoscopic with open (Lichtenstein) inguinal hernia repair.
        Br J Surg. 2010; 97: 765-771
        • Kelly Jr., RE
        • Wenger A
        • Horton Jr., C
        • Nuss D
        • Croitoru DP
        • Pestian JP
        The effects of a pediatric unilateral inguinal hernia clinical pathway on quality and cost.
        J Pediatr Surg. 2000; 35: 1045-1048
        • Lee SL
        • Sydorak RM
        • Lau ST.
        Laparoscopic contralateral groin exploration: is it cost effective?.
        J Pediatr Surg. 2010; 45: 793-795
        • Groff DB
        • Nagaraj HS
        • Pietsch JB.
        Inguinal hernias in premature infants operated on before discharge from the neonatal intensive care unit.
        Arch Surg. 1985; 120: 962-963
      1. IBM. IBM MarketScan Databases,; [accessed May 17.2022].

        • U.S Bureau of Labor Statistics
        Consumer Price Index for all Urban Consumers: Medicare Care Services.
        2021 ([accessed 24 Feb 2021.2021])
        • Brandt ML.
        Pediatric Hernias.
        Surg Clin North Am. 2008; 88 (-viii): 27
        • Verhelst J
        • de Goede B
        • van Kempen BJ
        • Langeveld HR
        • Poley MJ
        • Kazemier G
        • et al.
        Emergency repair of inguinal hernia in the premature infant is associated with high direct medical costs.
        Hernia. 2016; 20: 571-577
        • Taylor K
        • Sonderman KA
        • Wolf LL
        • Jiang W
        • Armstrong LB
        • Koehlmoos TP
        • et al.
        Hernia recurrence following inguinal hernia repair in children.
        J Pediatr Surg. 2018; 53: 2214-2218
        • Masoudian P
        • Sullivan KJ
        • Mohamed H
        • Nasr A.
        Optimal timing for inguinal hernia repair in premature infants: a systematic review and meta-analysis.
        J Pediatr Surg. 2019; 54: 1539-1545
        • Vogels HD
        • Bruijnen CJ
        • Beasley SW.
        Predictors of recurrence after inguinal herniotomy in boys.
        Pediatr Surg Int. 2009; 25: 235-238
        • Youn JK
        • Kim HY
        • Huh YJ
        • Han JW
        • Kim SH
        • Oh C
        • et al.
        Inguinal hernia in preterms in neonatal intensive care units: Optimal timing of herniorrhaphy and necessity of contralateral exploration in unilateral presentation.
        J Pediatr Surg. 2018; 53: 2155-2159
        • Baird R
        • Gholoum S
        • Laberge JM
        • Prematurity Puligandla P.
        not age at operation or incarceration, impacts complication rates of inguinal hernia repair.
        J Pediatr Surg. 2011; 46: 908-911