Early Versus Late Inguinal Hernia Repair in Preterm Neonates: An Updated Systematic Review and Meta-Analysis with Trial Sequential Analysis

Background: The optimal timing of inguinal hernia repair in preterm neonates remains debated. Early repair may reduce incarceration risk but increases perioperative complications, while delayed repair lowers anesthetic risk but raises the risk of incarceration while awaiting repair. In the absence of consensus guidelines, practices vary widely. This systematic review and meta-analysis aimed to compare early (during birth hospitalization) versus delayed (post-discharge) inguinal hernia repair in preterm neonates. Methods: PubMed, Embase, Scopus, Web of Science, and CENTRAL were systematically searched from inception to May 2025. All original studies reporting data on early and delayed repair of inguinal hernia in preterm neonates were included. Meta-analyses were performed using random-effects models on RevMan version 5.4.1. Results: Eleven studies involving 5021 preterm infants were included, comprising one RCT and ten retrospective cohort studies. Early repair was associated with statistically significantly increased risks of hernia recurrence (RR: 2.52 [95 % CI: 1.16, 5.48], apnea requiring intervention (RR: 3.08 [95 % CI: 1.71, 5.55]), prolonged intubation (>48 h; RR: 4.97 [95 % CI: 2.40, 10.27]), metachronous hernia (RR: 6.32 [95 % CI: 2.44, 16.42]), and prolonged hospital stay (MD: 10.40 days [95 % CI: 1.63, 19.17]). No statistically significant differences were found in the risk of testicular atrophy, injury to adjacent structures, or operative time. Conclusions: Delayed hernia repair in preterm neonates may be associated with lower risks of recurrence and respiratory complications without a significant increase in risk of incarceration while awaiting repair. Further high-quality prospective studies are needed to optimize timing guidelines.