Journal of Pediatric Surgery (2013) 48, 1972–1976

www.elsevier.com/locate/jpedsurg

Cardiorespiratory complications after laparoscopic hernia

repair in term and preterm babies
Christine Burgmeier a,⁎, Felix Schier b
a
Department of General and Pediatric Surgery, University Medical Center Ulm, 89081 Ulm, Germany
b
Department of Pediatric Surgery, University Medical Center Mainz, Mainz, Germany

Received 4 November 2012; revised 29 June 2013; accepted 30 June 2013

Key words:
Abstract
Laparoscopy;
Purpose: The aim of this study was to clarify the incidence of postoperative complications in infants
Hernia repair;
undergoing laparoscopic hernia repair within the first six months of life.
Preterm;
Methods: Retrospective, single-institution study comparing term and preterm babies undergoing surgery
Term infants;
between March 2005 and September 2012. The charts were reviewed for postoperative complications
Cardiorespiratory
and pre-existing diseases.
complications
Results: In the term group 188 of 199 babies (94.5%) had an uneventful postoperative course. Eleven
patients (5.5%) presented postoperative complications, three of them (1.5%) developed severe respiratory
complications. A relation between pre-existing diseases and postoperative complications could be
identified in two patients. Laparoscopy possibly induced cardiorespiratory instability in one infant.
In the preterm group 109 of 137 babies (79.6%) had an uneventful postoperative course. 28 preterm
infants (20.4%) developed postoperative complications, seven of them (5.1%) presented severe
respiratory complications. Pre-existing diseases were identified as an influencing factor in 22 preterm
infants. In one patient laparoscopy possibly caused minor instability of a pre-existing cardiac anomaly.
Conclusions: Postoperative complications are low in both groups, although the incidence is increased in
preterm infants. Pre-existing diseases are a major influencing factor for preterm infants. In very few infants
laparoscopy may have induced instability of cardiac anomalies.
© 2013 Elsevier Inc. All rights reserved.

Laparoscopic hernia repair has become a routine
procedure in children and is even feasible in small babies
including premature infants [1–5]. According to our
experience, age, size, and weight of the child are not limiting
factors for the laparoscopic approach in terms of the surgical
technique [4,5]. However, the laparoscopic approach has
⁎ Corresponding author. Tel.: + 49 731 500 53701; fax: + 49 731 500
53702.
E-mail address: burgmeierch@yahoo.de (C. Burgmeier).
been criticized for the need of general anesthesia including
relaxation and the risk of postoperative complications
induced by increased intra-abdominal pressure during
laparoscopy. Reports suggest that premature infants have
an increased risk of post-anesthetic cardiorespiratory com-
plications when compared with full-term infants undergoing
similar surgery [6]. Therefore, several authors advocate open
inguinal hernia repair during regional anesthesia, especially
in preterm infants [7–9]. The aim of this study was to
evaluate early postoperative complications after laparoscopic

0022-3468/$ – see front matter © 2013 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.jpedsurg.2013.06.031
Cardiorespiratory complications after hernia repair
hernia repair in term and preterm infants. The influence of
the past medical history and pre-existing diseases was
investigated. Additionally, the association of increased intra-
abdominal pressure during the laparoscopic procedure as a
potential risk factor for the development of early postoper-
ative complications was evaluated.
1. Patients and methods
In this retrospective study, 336 children (249 male and 87
female) underwent laparoscopic hernia repair under general
anesthesia within the first six months of life. Between March
2005 and September 2012 199 term (term group, 152 male and
47 female) and 137 preterm infants (preterm group, 97 male
and 40 female) were identified. The charts were reviewed for
early postoperative complications, pre-existing diseases and
the past medical history. Prematurity was defined as less than
37 weeks of gestational age. Median gestational age at birth
was 32 weeks (range 24 to 36 weeks) in the preterm and
39 weeks (range 37 to 42 weeks) in the term group. In the
preterm group the birth weight varied from 0.45 kg to 4.0 kg
(median 2.0 kg) and the median weight at the time of surgery
was 3.4 kg (range 1.6 kg to 6.6 kg). In the term group birth
weight ranged from 1.8 kg to 5.0 kg (median 3.5 kg) and
median weight at the time of surgery was 4.7 kg with a range
from 2.6 kg to 8.3 kg. On average, the operation was
performed on the 69th postnatal day in the preterm group
and on the 45th postnatal day in the term group.
1.1. Operative procedure
During the study period, the practice at our institution was
to perform laparoscopic hernia repair in term and preterm
babies using general anesthesia and tracheal intubation. The
infants were placed in a supine position. A Veress needle was
inserted at the umbilicus and carbon dioxide was insufflated
to intra-abdominal pressures between 8 and 15 mm Hg, on
average 12 mmHg. The Veress needle was then exchanged
for a 2- or 5- mm laparoscope. Two additional 2 mm trocars
were advanced through the right and left anterior abdominal
wall. The clinically diagnosed open inguinal ring was closed
using a 4-0 monofilament, non-resorbable purse-string or Z-
type suture and 2 mm instruments. Incarcerated hernias were
first reduced by combined external pressure and internal
laparoscopic pulling. If an open processus vaginalis was
identified contralaterally, it was closed in the same way. All
infants were monitored for postoperative complications for a
minimum of one overnight stay.
1.2. Statistical analysis
Univariate, multivariable logistic regression was used to
identify risk factors for the development of early postoper-
ative complications. Data were analyzed with SPSS (Version
1973
13.0, Chicago, IL) statistical software. Variables were term
and preterm group, postnatal operative day, weight at the
time of surgery, birth weight and gestational age at birth. P
values less than 0.05 were considered significant.
2. Results
All operations were successfully performed using lapa-
roscopic technique. There were no immediate surgical
complications in either group.
2.1. Group I (term infants, n = 199)
One hundred eighty-eight of 199 term infants (94.5%) had
an uneventful postoperative course on normal ward and 168
(84.4%) could be discharged from the hospital on the first
postoperative day. Postoperative complications after laparo-
scopic hernia repair were noted in 11 term infants (5.5%): six
babies (3.0%) presented minor respiratory distress in the
postoperative course, including bronchial obstruction, apnea
and short-duration decreases of oxygen saturation. Three
term babies (1.5%) developed severe respiratory problems in
the postoperative course: in one infant re-intubation and in
two babies prolonged ventilator support were necessary. One
of these three babies required high frequency oscillation
ventilation (HFOV) due to an acute respiratory distress
syndrome. Overall, three term infants developed non-
respiratory complications in the postoperative course: three
term babies (1.5%) developed signs of infection and one of
them additionally had bradycardia. Table 1 summarizes the
postoperative complications after laparoscopic hernia repair
in term infants. The total number of complications exceeds
11 because several babies developed more than one
complication in the postoperative course.
The required interventions in the postoperative course
of these 11 babies included prolonged ventilator support
(n = 1), re-intubation (n = 1), high frequency oscillation
ventilation (n = 1) and administration of oxygen (n = 5).
All three babies presenting signs of infections were treated
with intravenous antibiotics (n = 3).
In the entire group of term infants 175 babies (87.9%) had
neither pre-existing diseases nor a complicated past medical
history. Only seven infants with postnatal respiratory distress
(3.5%) were identified. One of them required postnatal
intubation (0.5%). Table 2 demonstrates the pre-existing
diseases in the group of term infants. The total number of
pre-existing diseases exceeds the number of patients because
several babies presented a combination of postnatal diseases.
In the next step, we tried to identify a relation between
early postoperative complications and pre-existing diseases,
and the laparoscopic procedure or general anesthesia. In the
group of term infants, one baby with postnatal respiratory
distress in the past medical history required prolonged
ventilator support after laparoscopic hernia repair. One
1974
Table 1 Postoperative complications after laparoscopic hernia
repair in term and preterm infants.
Term group Preterm
(n = 199) group
(n = 137)
Postoperative complications n = 11 n = 28
Minor postoperative respiratory n=6 n = 18
complications (including short-term
oxygen desaturation, bronchial
obstruction and apnea)
Severe postoperative respiratory n=3 n=7
complications (including
re-intubation and prolonged
ventilator support)
Postoperative seizure n=0 n=3
Postoperative bradycardia n=1 n=3
Postoperative signs of infection n=3 n=1
The total number of complications exceeds the number of patients
with complications because several patients developed more than
one complication.
patient with Arnold–Chiari syndrome presented with apnea
and oxygen desaturation during the postoperative course. It
should be noted that this patient showed central apnea and
repeated oxygen desaturations preoperatively. According to
these similar clinical presentations in their past medical
history, a relationship between early postoperative compli-
cations and pre-existing diseases was assumed in these two
patients (18.2%).
Another term baby (9.0%) with a preoperatively hemo-
dynamic stable persistent foramen ovale (PFO) developed
acute respiratory distress and required high frequency
oscillation ventilation (HFOV) in the postoperative course.
Echocardiography showed hemodynamically relevant shunt-
ing of a PFO and reduced right-ventricular function
postoperatively. The influence of laparoscopic surgery
remains unclear, but the development of shunt-inversion
after increased intra-abdominal pressure during laparoscopic
surgery is conceivable.
Six term infants (54.5%) showed decreased oxygen
saturation and required short-term administration of oxygen
in the postoperative course. None of these infants was known
to have pre-existing diseases or showed similar clinical signs
in their past medical history. A relation to general anesthesia
was assumed in these six patients.
Two patients (18.2%) showed signs of infection in the
postoperative course, but no relation to anesthesia, laparos-
copy or pre-existing diseases could be identified.
Table 3 demonstrates the assumed relations between early
postoperative complications in the group of term infants.
2.2. Group II (premature infants, n = 137)
In the preterm group 109 of 137 babies (79.6%) had an
uneventful postoperative course and 59 infants (43.1%)
could be discharged from the hospital on the first
C. Burgmeier, F. Schier
postoperative day. In 28 preterm infants (20.4%) postoper-
ative complications were noted after laparoscopic hernia
repair. Eighteen of these patients (13.1%) developed minor
respiratory distress postoperatively, including short-term
oxygen desaturations, bronchial obstruction and apnea.
Seven infants (5.1%) had severe respiratory complications
in the postoperative course after laparoscopic hernia repair:
three babies required prolonged ventilator support and in
four patients re-intubation became necessary. Three infants
(2.2%) presented seizures in the postoperative course, two of
these patients required re-intubation. Both infants were
neurologically impaired and presented with seizures preop-
eratively. Bradycardia was recorded in three babies (2.2%)
and was combined with minor respiratory distress in two
cases. One preterm patient (0.7%) showed signs of infection
in the postoperative course. Table 1 compares the postop-
erative complications in preterm and term infants. The total
number of complications exceeds 28 because several infants
developed more than one complication in the postoperative
course.
The required interventions in the postoperative course of
these 28 patients included prolonged ventilator support (n = 3),
re-intubation (n = 4), inhalation (n = 3) and administration of
oxygen (n = 11). In other patients the administration of
antiepileptic drugs (n = 2), diuretics (n = 1), naloxone (n = 1)
or intravenous antibiotics (n = 1) was necessary. Six preterm
infants required no interventions (n = 6). In several patients
combinations of treatments were necessary, so the total number
exceeds 28.
On chart review, 111 of 137 preterm babies (81.0%)
undergoing laparoscopic hernia repair under general anes-
thesia had pre-existing diseases or a complicated past
medical history. 103 infants (75.2%) presented postpartum
respiratory distress and 28 of them (20.4%) had severe
respiratory problems including postnatal intubation, pneu-
mothorax or bronchopulmonary dysplasia (BPD) in their
past medical history. Table 2 summarizes the pre-existing
diseases of preterm infants in comparison with term infants.
The total number of pre-existing diseases exceeds the
number of patients because several patients presented more
than one disease in their past medical history.
Similar to the term patients we tried to relate early
postoperative complications to pre-existing diseases, laparo-
scopic surgery and general anesthesia. 28 preterm babies
developed early postoperative complications, 22 of them
(78.6%) showed similar clinical presentations in their past
medical history. 20 patients had postnatal respiratory distress
and developed oxygen desaturation and apnea in the
postoperative course. One preterm infant was known to have
repeated episodes of apnea and bradycardia preoperatively and
showed bradycardia postoperatively. Another patient with
posthemorrhagic hydrocephalus presented with a seizure after
laparoscopic hernia repair. According to these similar clinical
presentations in their past medical history, we assumed a
relation between early postoperative complications and pre-
existing diseases in these 22 preterm infants (78.6%).
Cardiorespiratory complications after hernia repair 1975

Table 2 Preexisting diseases and past medical history of term Table 4 Logistic regression analysis to identify risk factors for
and preterm infants undergoing laparoscopic hernia repair. early postoperative complications after laparoscopic hernia repair.
Term Preterm P OR CI
group group Group [term; preterm] 0.300 0.527 0.157 to 1.770
Pre-existing diseases n = 24 n = 111 Postnatal operative 0.038 0.979 0.959 to 0.999
Postnatal respiratory distress n=7 n = 103 day [days]
Severe postnatal respiratory distress n=1 n = 28 Weight at the time 0.586 1.000 1.000 to 1.001
(including intubation, pneumothorax of surgery [kg]
and bronchopulmonary dysplasia) Birth weight [kg] 0.105 1.001 1.000 to 1.001
Episodes of apnea and bradycardia n=1 n = 43 Gestational age at 0.001 0.736 0.619 to 0.880
Cardiac anomalies n = 12 n = 34 birth [weeks]
Neurological anomalies n=7 n=9 P = p value lower, OR = odds ratio, CI = 95% confidence range.
The total number of pre-existing diseases exceeds the number of patients
because several patients presented more than one disease in their past
medical history.

In one preterm infant (3.6%) with prior hemodynamically
non-relevant persistent ductus arteriosus (PDA) and PFO,
postoperative administration of diuretics was necessary due
to a hemodynamically relevant PDA without cardiorespira-
tory instability. In this case we assumed a possible influence
of increased intra-abdominal pressure during laparoscopy to
be decisive for the development of a hemodynamically
relevant PDA.
Three preterm infants developed oxygen desaturations
postoperatively without similar clinical presentations in their
past medical history. Two of them required prolonged
ventilator support and in one of them administration of
naloxone was necessary. A relation to general anesthesia was
assumed in these three patients (10.7%). In two patients
(7.1%) no relation to general anesthesia, laparoscopy or pre-
existing diseases could be identified. One baby developed
signs of infection and another presented with a seizure
without prior history of epilepsy. Table 3 demonstrates the
assumed relations between early postoperative complications
in the group of preterm infants.
2.3. Statistical analysis
Statistical significance was found for gestational age at
birth (p = 0.001) and postnatal operative day (p = 0.038).
Logistic regression showed that there was no statistically
significant difference between the two groups (p = 0.300).
Table 4 demonstrates logistic regression analysis including p
values (P), odds ratio (OR) and 95% confidence range.
3. Discussion
Until recently, laparoscopic hernia repair was avoided in
term and preterm babies because of the need for general
anesthesia with relaxation and the risk of postoperative
complications in this fragile group of patients. In this
retrospective study postoperative complications after lapa-
roscopic hernia repair in term and preterm babies were
evaluated. Additionally, we tried to identify a relation
between pre-existing diseases, the laparoscopic procedure
and anesthesia. Limiting our investigations to infants
younger than six months inherently selects patients at higher
risk of complications. Lung-related diseases, such as apnea
and BPD are well-known in premature infants. Besides,
medical problems associated with prematurity are frequently
complex. Pre-existing diseases have been described to be a
risk factor for the development of postoperative complica-
tions, especially in preterm infants [10]. As expected, in this
study more infants in the preterm group than in the term
group had pre-existing diseases and a complicated past
medical history (12.1% vs. 81.0%). A possible relation
between pre-existing diseases and early postoperative
complications after laparoscopic hernia repair was found in
18.2% of term and 78.6% of preterm infants. Regarding the
incidence of early postoperative complications probably
being associated with the laparoscopic procedure, we
identified one term and one preterm infant. Both were
known to have hemodynamically stable cardiac anomalies
preoperatively. During the study period, the practice at our
institution was the performance of laparoscopic hernia repair

Table 3 Assumed relation of postoperative complications after laparoscopic hernia repair to pre-existing diseases, the laparoscopic
procedure and general anesthesia.
Relation to Relation to Relation to Unrelated
pre-existing laparoscopic anesthesia postoperative
disease procedure complications
Term group (n = 11) n=2 n =1 n=6 n=2
Preterm group (n = 28) n = 22 n=1 n=3 n=2
1976
under general anesthesia in stable infants without hemody-
namically relevant cardiac anomalies. Only in a very small
number of patients open herniotomy during regional
anesthesia was performed.
In the literature there is a lack of reports about early
postoperative complications, especially for preterm babies
and little is known about the influence of increased intra-
abdominal pressure during the laparoscopic procedure,
especially in patients with cardiac anomalies. In preterm
infants immaturity of organs implicates an increased risk for
post-anesthetic cardiorespiratory complications compared
with term infants [6]. Several studies suggest that regional
anesthesia reduces the risk of postoperative complications
[7–9]. But it has also been reported that there is no clinically
meaningful benefit of spinal anesthesia over general
anesthesia for preterm infants undergoing inguinal hernior-
rhaphy [11]. Weiss et al. stated in 2003 that modern
combined general anesthesia is equally safe and effective in
most preterm infants as regional anesthesia [12]. Currently,
there is an international study going on comparing spinal
versus general anesthesia.
The present study lacks comparison to a group of patients
undergoing open hernia repair using regional anesthesia.
During the study period, the practice at our institution was
the performance of laparoscopic hernia repair under general
anesthesia with relaxation in every stable term and preterm
infant without hemodynamically relevant cardiac anomalies.
Only in a very small number of patients with complex heart
defects open hernia repair under regional anesthesia was
performed. Other limitations of this study are the retrospec-
tive study design and the lack of information about the
intraoperative anesthetic charts. In the future, further
prospective studies comparing intra- and postoperative
complications after laparoscopic and open hernia repair
under general, epidural or spinal anesthesia are necessary to
clarify the influence of pre-existing diseases, increased intra-
abdominal pressure during laparoscopy and the effects of
general or regional anesthesia for the development of early
postoperative complications in this special group of patients.
Cardiorespiratory complications after laparoscopic hernia
repair under general anesthesia are low in both term and
C. Burgmeier, F. Schier
preterm babies, although the incidence is increased in
preterm infants. Pre-existing diseases and a complicated
past medical history are a risk factor for the development of
early postoperative complications, especially in preterm
babies. The laparoscopic approach provides a low risk of
shunt-inversion and cardiorespiratory instability in term and
preterm infants with stable cardiac anomalies.
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