The quick recognition for the need to continue delivering surgical care to children during the pandemic led to the development of several guidelines for safely delivering elective services [1, 4,5,6]. Based on these guidelines, our institution formulated a dynamic local policy. Three aspects were considered: OPD activity, scheduling process, and operating theatre procedures.

We reinstituted “hot clinics” to see urgent patients which included inguinal hernia referrals in infants younger than 3 months old or any symptomatic child. We reduced the numbers of patients booked into these clinics to allow time to decontaminate the room between consultations and allow two-metre social distancing in the waiting area. We commenced virtual clinics (video and telephone clinics) to follow up new referrals and patients who were awaiting review or surgery and provide safety-netting advice on signs of hernia incarceration.

Details of the scheduling process and theatre procedures can be found in the supplemental document, New Pathway for Elective Admission of Children. This guidance relied on the COVID-19 local/regional/national prevalence rates which were monitored [10] and categorised as green 0.5%, amber 0.5–2% and red greater than 2% prevalence.

By adhering to this policy, although our operating turnaround time between cases increased, thus reducing capacity, we successfully delivered elective surgery to children with various conditions.

Inguinal herniotomy is one of the more common procedures performed in children. An incarcerated inguinal hernia can have significant morbidity including bowel necrosis that requires laparotomy and bowel resection. Incarceration has been reported to be more likely the longer children wait to have surgical correction of their hernia [11]; however, some other authors have not corroborated this finding [12].

We discovered that during the pandemic, children did not wait much longer to get assessed compared to a similar time period before the pandemic. A recent systematic review [11] reported a median (range) wait time to surgery of 46 days (1–552 days), which compares favourably to our wait times, before and during the pandemic.

Furthermore, children were not more likely to undergo emergency herniotomy for incarceration during the pandemic. Median (range) incarceration rates for children awaiting herniotomy surgery has been reported as 8% (0–56%) [11]. We report less incarceration rates, before and during the pandemic.

It was interesting to note that most children that required emergency herniotomy were previously undiagnosed; however, this needs verification in larger and longer-term studies. These first presentations as incarcerations may be due to parents not recognising the problem, recognising it too late, or unable to access primary care in a timely manner. This suggests that more public health education could be done to prevent this. This may also support the notion and proposal, as per our findings, that when parents are seen and shown how to reduce the hernia, the children are then less likely to develop an incarcerated hernia while awaiting surgery [12].

The Royal College of Surgeons of England’s guidelines recommending prioritisation of hernia surgery in infants 0–3 months old [4] thus remain appropriate, because we found this age group more likely to undergo emergency herniotomy. Neonates, particularly those that were premature, have been reported to be at more at risk for incarceration [11, 13], but not confirmed by other reports [12]. By prioritising surgery in this age group, we prevented a rise in the incidence of incarcerated hernias. Children over 12 months appeared to be the next more common age group to develop incarceration; this finding requires more robust investigation to determine if their prioritisation timeframe should be reviewed during recovery of services from the pandemic and in the upcoming updates of the prioritisation guidance [14].

The limitations of this study include the unknown impact of delayed primary care referrals during the pandemic. Additionally, we did not analyse elective work at our secondary sites, most of which were cancelled at the start of the pandemic, but later reintroduced with the same guidelines. Surgeons may have also had a lower threshold to get hernias that presented to the emergency department during the pandemic (but were reduced without significant difficulty) done as an emergency, due to limited elective lists. Furthermore, some children were not brought to their first clinic appointment causing longer delays to being seen and some patients had surgery cancelled due to non-COVID-19-related sickness and so prolonging time from OPD to surgery. Finally, the data on children and guardians who became COVID-19-positive after coming in for elective surgery was unavailable; this would have contributed useful insight to the effectiveness of our strategy. Importantly, as this study was a single-centre study, the sample size did not allow establishing statistical significance for several points such as the difference in wait times and incarceration rates. This might need larger pooling of data from several centres and/or similar national level studies.