A comparison of operative and anesthetic techniques for inguinal hernia repair in infants.

BACKGROUND: Pediatric inguinal hernia repair (IHR) is increasingly performed using minimally invasive surgery (MIS) but has only recently been described using caudal block without endotracheal intubation. We evaluated the surgical outcomes and resource utilization of infants undergoing hernia repair, comparing both the operative approach (open/MIS) and anesthetic technique (general anesthesia [GA]/caudal). METHODS: All infants <1 year-of-age undergoing elective IHR without concomitant procedures from July 2016 to July 2021 at a single tertiary care teaching center were retrospectively reviewed. Eight surgeons and 25 anesthesiologists contributed patients, with approach dictated by practitioner preference. Data collected included patient demographics, surgical and anesthetic details, and operating room (OR) utilization metrics. Post-operative complications were evaluated and aggregated, including recurrent hernia, metachronous hernia, hematoma, hydrocele, testicular atrophy, and acquired cryptorchidism. Descriptive statistics were performed with R Studios (p < 0.05). RESULTS: Of the 338 patients included for analysis, most underwent an open procedure (n = 275) while anesthetic technique was evenly split between GA (n = 185) and caudal (n = 153). Most patients were male (87.6%) and born premature: mean gestational age of 31.4 ± 4.1 weeks. MIS-to-Open conversion was noted once (3.3%) in the GA MIS group, but none in caudal. Median follow up was 2.5 (1.4-3.8) years. No differences were noted in aggregate surgical complication rates (p = 0.4). The Caudal Open group had the shortest total OR time (p < 0.01); caudal anesthesia shortened post-procedure times (p < 0.01). CONCLUSION: MIS IHR performed under caudal block and sedation yields comparable complication rates compared to the open approach or GA. Open IHR with caudal blockade was the most efficient operative room utilization. TYPE OF STUDY: Original Article, Clinical Research. LEVELS OF EVIDENCE: Level III.

Safety of administering cefazolin versus other antibiotics in penicillin-allergic patients for surgical prophylaxis at a major Canadian teaching hospital.

BACKGROUND: Cefazolin surgical prophylaxis is associated with better patient outcomes; however, its use in penicillin-allergic patients is controversial. We evaluated the safety of cefazolin as surgical prophylaxis in penicillin-allergic patients, including those with anaphylaxis histories. METHODS: We conducted a pre and postintervention quality improvement evaluation of an institution-wide policy change at a tertiary-care hospital, before (October 2017-January 2018), during (February 2018-September 2018), and after (October 2018-October 2019) transition to routine cefazolin prophylaxis for penicillin-allergic patients, including those with anaphylaxis histories but excluding severe delayed reactions (eg, Stevens-Johnson syndrome). Retrospective data was collected on all surgical prophylaxis patients with penicillin-anaphylactic histories between October 2017 and September 2018. From October 2018, we prospectively reviewed adverse events with cefazolin. Primary outcome was adverse events in penicillin-allergic patients receiving cefazolin perioperatively. RESULTS: From October 2017 to October 2019, 27,467 operations were performed. Of 220 patients with penicillin-anaphylactic histories reviewed prior to the full policy change, no statistically significant differences were reported in allergic reactions (P = .70), surgical site infections (P = 1.00), or adverse events (P = .32) with cefazolin compared to other antibiotics. Postpolicy implementation, cefazolin usage increased 18.2%, while vancomycin and clindamycin decreased by 11.4% and 62.0%, respectively. No anaphylaxis was documented in penicillin-allergic patients receiving cefazolin in either the review or quality assurance follow-up after the change. Of 3 patients developing reactions to cefazolin, none had histories of penicillin allergy. Surgical site infection rates were similar between pre and postpolicy time periods (P = .842). CONCLUSION: Administration of cefazolin in penicillin-anaphylactic patients for surgical prophylaxis appears to be safe.