1. Evidence Based Medicine 指導醫師：駱至誠 教授 Clerk ：林旻暭、洪俊宇、黃冠慈

2. Clinical Scenario  A four month-old boy with left side inguinal hernia receives inguinal herniotomy by the open technique Question: Does it benefits from routine contralateral exploration at the time of the primary inguinal herniotomy?

3. Introduction of Inguinal Hernia

4. Inguinal Hernia  An inguinal hernia develops when the processus vaginalis fails to obliterate during late gestation, allowing communication between the abdominal cavity and the inguinal canal to persist. Abdominal contents can then herniate into the inguinal canal.

5. Inguinal Hernia  The vast majority of hernias in children are indirect, with contents protruding through the internal inguinal ring into the inguinal canal.

7. 5 A’s AskAcquireAppraisalApply Audi t

8. AskAcquireAppraisalApply Audi t

9. Outcome: Incidence of metachronous contralateral inguinal hernia Comparison: Unilateral exploration Intervention: Contralateral exploration Patient/Problem: A 4 month-old child with left side inguinal hernia

10. AskAcquireAppraisalApply Audi t

11. Acquire Database: PubMed Keywords: Metachronous contralateral inguinal hernia

13. Metachronous contralateral inguinal hernia

15. The evidence pyramid

16. Level of evidence

17. AskAcquireAppraisalApply Audi t

18. Critical Appraisal of systemic review paper 10 question for Critical Appraisal of Systemic review  Is the trial valid?  (Q1~Q5)  What are the results?  (Q6~Q7)  Will the results help locally?  (Q8~Q10)

19. Q1.Did the review ask a clearly- focused question?

20. Q2. Did the review include the right type of studies?

21. Q3.Did the reviewers try to identify all relevant studies?

22. Q4. Did the reviewers assess the quality of the included studies?

23. Q5.If the results of the studies have been combined, was it reasonable to do so?  These review article included study with evidence level II-a and II-b so there were no heterogeneity(I 2 ) and Westley score for evaluation

24. Q6. How are the results presented and what is the main result?

25. Q7. How precise are the result?  Same as Q5

26. AskAcquireAppraisalApply Audi t

27. Q8. Can the result be applied to the local population?  Patient 的 data 來自 61 個 studies  Patients 的年齡從 GA 31 wks 到 18 y/o 並沒有特別 提起 patients 的種族 不知道

28. Q9. Were all important outcomes considered?  Develop MCIH following a unilateral inguinal herniotomy: (49568 patients)  5.76%(95%CI:5.55-5.97%)  NNT(number need to treat):18 (95%CI:16.8-18%)  Gender incidenceNNT male6.13% (95%CI:5.74-6.52%)17 (95%CI:15.3-17.4) female6.37% (95%CI:5.63-7.11%)16 (95%CI:14.1-17.8)

29.  Age  <6 month: 183/1470  >6month: 144/2044  p<0.0001  NNT for age<6 month:9 (95%CI:7.1-9.3) Q9. Were all important outcomes considered?

30.  Laterality of initial hernia(22104 patients)  P<0.0001 Initial siteLeftRight Incidence34%66% MCIH incidence 12.1%6.9% NNT915 yes

31. Q9. Should policy of practice change as a result of the evidence contained in this review?

32. AskAcquireAppraisalApply Audi t

33. A four month-old boy with left side inguinal hernia receives inguinal herniotomy by the open technique Risk factor: left side 、 four-month 並不作 routine 的 explore, 告知 risk factor 並和家長討 論治療計畫