P1.050: Timing of Inguinal Hernia Repair in Premature Infants: Weighing Determinants of the Wait

Background: Inguinal hernia repair timing in premature neonates remains controversial. The surgeon must balance risk and benefit of surgery while considering individual patient characteristics, potential perioperative cardiorespiratory issues, return ED visits, and technical complications. However, the extent to which demographics, insurance status, and neighborhood-level social determinants of health affect timing of surgery is poorly understood. Premature infants who present to the emergency department with a non-incarcerated or reducible inguinal hernia may be admitted for semi-elective repair (SER) or scheduled as an outpatient elective repair (OER). This single center study examines the relationship between patient characteristics, demographics, insurance payor group, distance to the hospital, and neighborhood opportunity on whether premature neonates undergo SER versus OER.

Methods: Retrospective study of premature (gestational age (GA) < 37 weeks) infants diagnosed with an inguinal hernia in the ED or outpatient clinic and underwent surgical repair before one year of age between January 2013 and December 2022 at an urban children’s hospital were included. Patients with major medical comorbidities and/or those who underwent simultaneous major abdominal surgeries were excluded. Those who underwent hernia repair within 24 hours of presentation were also excluded. The remaining 727 patients were included in this analysis and were categorized based on whether they were admitted following inguinal hernia diagnosis and underwent SER >24 hours after admission versus scheduled for OER. Patient characteristics, demographics, insurance payor group, hospital distance, and national COI scores were compared between groups. High risk class was defined by a documented incarcerated hernia that was reduced by surgery. Exact Chi-square tests were performed to compare categorical variables and independent-samples t-tests were performed to compare means. Surgeons’ decision to admit for SER was modeled using Firth’s penalized logistic regression. Statistical significance was set at an alpha level of 0.05.

Results: Significant differences between OER (n=557) and SER (n=170) cohorts included GA at birth (32.6 vs. 29.4 weeks, p < 0.001), preoperative corrected GA (44.4 vs 41 weeks, p < 0.001), preoperative weight (4.6 vs. 3.5kg, p < 0.001), and high risk class (7.7% vs. 27.1%, p < 0.001). Sex, race, ethnicity, payor group, and distance to the hospital were not significant predictors of surgeon’s decision. Following adjustments based on probability of undergoing SER, there were no significant differences in COI scores between OER and SER.

Conclusion: Individual patient characteristics – and not demographic, geographic, or neighborhood opportunity factors – primarily drive the decision to manage premature neonatal hernia repairs semi-electively or electively at our institution. Propsective, multi-center studies are needed to further evaluate these findings.