Aim:Debatable issues in the management of inguinal hernia in premature infants remain unresolved. This study reviews our experience in the management of inguinal hernia in premature infants.Materials and Methods:Retrospective chart review of premature infants with inguinal hernia from 1999 to 2009. Infants were grouped into 2: Group 1 had repair (HR) just before discharge from the neonatal intensive care unit (NICU) and Group 2 after discharge.Results:Eighty four premature infants were identified. None of 23 infants in Group 1 developed incarcerated hernia while waiting for repair. Of the 61 infants in Group 2, 47 (77%) underwent day surgery repair and 14 were admitted for repair. At repair mean postconceptional age (PCA) in Group1 was 39.5 ± 3.05 weeks. Mean PCA in Group 2 was 66.5 ± 42.73 weeks for day surgery infants and 47.03 ± 8.87 weeks for admitted infants. None of the 84 infants had an episode of postoperative apnea. Five (5.9%) infants presented subsequently with metachronous contralateral hernia and the same number of infants had hernia recurrence.Conclusions:Delaying HR in premature infants until ready for discharge from the NICU allows for repair closer to term without increasing the risk of incarceration. Because of low occurrence of metachronous hernia contralateral inguinal exploration is not justified. Day surgery HR can be performed in former premature infant if PCA is >47 weeks without increasing postoperative complications.

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stay in surgical patients in numerous meta-analyses of randomised clinical trials (Drovers et al 2011;Cerantola et al 2011). Its impact on hospital costs has already been assessed in gastrointestinal (GI) cancer surgery based on Swiss, US, Italian and German hospital costs (Mauskopf et al 2011; Chevrou-Séverac et al 2011; Braga et al 2005; and Senkal et al 1999). The objective of this study is to assess whether IN is a cost-effective option in hospitals of the British National Health System (NHS) for upper GI cancer patients undergoing surgery. Methods Based on the Cerantola et al (2011) meta-analysis, the RR of complications of IN vs control were computed. Hospital cost and length of hospital stay (LOS) of upper GI cancer patients undergoing major surgery were retrieved from the HRG (healthcare resource group) database of 2010. Then an average cost per stay for patients presenting with post-surgical complications and without were computed. Two approaches to compute the difference in costs per patient were performed: one based on cost of stay related to the LOS of patients of each group (IN vs control); and another based on a weighted cost of stay link to the rate of patients with and without complications of each group. Results The RR of complications was 0.69 (95% CI 0.58 to 0.83) for pre-operative use of IN, demonstrating a decrease in post-operative risk of complications due to the use of IN. When running costeffectiveness analysis, the NHS recommends using the average cost per day of £675. This value was used into the LOS approach. The HRG costs of stay were calculated for different upper GI cancers (oesophagus, small intestine, stomach, duodenum, liver and pancreas) and different level of complications, ranging from £968 to £2395 per hospital stay. When considering the LOS approach, £1585 were saved per patient-stay. When considering the complication approach, savings reached £176 per patient for patients with oesophagus cancers, £201 for stomach and duodenum cancers, £394 for small intestine cancers, and £608 for pancreas cancer. Conclusion Costs of IN are more than offset by the savings linked to decrease in LOS and to avoided costs of treatment for complications. Thus, as in the USA, Switzerland, Italy and Germany, in the NHS hospital setting, IN is a cost-effective and cost-saving nutritional intervention.

Correspondence Laparoscopic inguinal hernia repair SirWe read the interesting Review by Messrs Liem and Vroonhoven on laparoscopic inguinal hernia repair (Br J Surg 1996; 83: 1197-204), and agree with the authors that it is premature to advocate a transition from conventional to laparoscopic techniques on a large scale. We were surprised that no comment was made on the risk of mesh infection and pubic osteitis after laparoscopic herniorrhaphy. Several cases of such a complication have been rep~rtedl-~. In theory, infection should not be encountered after a laparoscopic approach for several reasons: the prosthesis introduced through the port has no contact with the skin, it is placed deep and the operation site is away from the port wound'. Laparoscopic experience shows that this is a definite risk and was reported in 0.1 to 0.5 per cent in large series'.2; this is close to the rate reported after conventional prosthetic repair. The mechanism of this complication is unclear; it could be an unrecognized injury of the bladder or the bowel, or even a postoperative haematoma secondarily infected. In the majority of patients the prosthesis had to be removed. As osteitis can be a tragedy for any patient, extra care must be taken when performing laparoscopic hernia repair and patients should be informed about this risk before operation.