Abstract
Background:
Most pediatric inguinal hernias (PIH) result from congenital patency of the processus vaginalis; however, a subset arises from acquired mechanisms involving posterior wall weakness. Representative examples include direct hernias and metachronous contralateral inguinal hernias (MCIH) that develop following negative laparoscopic exploration. In such cases, high ligation alone may be insufficient. This study aimed to evaluate the outcomes of laparoscopic iliopubic tract repair (IPTR) in acquired PIHs, focusing on recurrence, surgical outcomes, and safety.
Methods:
From January 2013 to December 2022, 12,792 pediatric patients younger than 10 years underwent laparoscopic inguinal hernia repair. Among them, 21 patients diagnosed with acquired PIHs were treated with laparoscopic IPTR. The repair involved suturing the iliopubic tract to the transversalis fascia using nonabsorbable suture to reinforce the posterior wall. We evaluated surgical outcomes, including recurrence and safety.
Results:
Of the 21 patients, 10 had direct hernias and 11 had indirect hernias of MCIH that were initially negative on laparoscopic evaluation but later developed into clinical PIHs. Compared with indirect PIH, direct PIH occurred in patients who were significantly older and heavier (P = .017 and P = .020, respectively). The omentum was the sole herniated organ in direct cases (P < .001). All surgeries were completed laparoscopically without conversion, and no intraoperative or postoperative complications occurred. At a median follow-up of 78 months, no recurrences were observed.
Conclusions:
Laparoscopic IPTR is a safe and effective surgical approach for acquired PIHs. It provides reliable posterior wall reinforcement and may reduce the risk of recurrence.
Keywords
Introduction
Inguinal hernia is one of the most common surgical conditions in the pediatric population. 1 Most pediatric inguinal hernias (PIHs) result from congenital patency of the processus vaginalis, a defect that has traditionally been considered the cornerstone of PIH pathogenesis. The standard treatment is high ligation, which closes the congenital processus vaginalis.
However, a subset of PIHs does not follow this classic pathogenesis. Acquired PIHs can occur, particularly in children with a history of prior hernia repair or with a delayed onset beyond infancy.2,3 Representative examples include direct hernias, which are thought to result from anatomical alterations distinct from patent processus vaginalis and metachronous contralateral inguinal hernias (MCIH) arising after negative laparoscopic evaluations (a contralateral closed processus vaginalis at the time of unilateral hernia repair). High ligation alone may not be sufficient for the treatment of acquired PIHs. Few studies have investigated the treatment of acquired PIHs.
Direct PIHs, although rare, have been documented in the pediatric population and may account for approximately 1%–4% of all PIH.3,4 Similarly, MCIH can occur in 0.8% of cases even after a confirmed negative laparoscopic evaluation, suggesting the potential for acquired development. 5 These cases are clinically significant due to posterior wall weakness and a potentially higher risk of recurrence following traditional high ligation. 6
High ligation at the internal inguinal ring remains the gold standard for most primary PIH repairs.7,8 However, in cases of acquired PIHs—especially those with a widened internal ring or weakened posterior wall—this technique may be insufficient. Prior studies have reported increased recurrence rates in such scenarios when high ligation alone is used.8,9 Reinforcement techniques, including iliopubic tract repair (IPTR)—which involves suturing the iliopubic tract to the transversalis fascia—have been proposed to enhance structural support and reduce the risk of recurrence in the treatment of direct and indirect inguinal hernias.2,10–12 Although IPTR has been well studied in open procedures for adult inguinal hernia treatment, 13 laparoscopic techniques have more recently gained attention.2,10,14 Some studies reference direct hernia repairs as simple fascial closures without defining a specific surgical approach,3,9,15 underscoring the need for clearer anatomical and procedural descriptions.
Laparoscopic IPTR has shown promising results in both primary and recurrent PIH.2,10,14 The pathophysiology of acquired PIHs—characterized by the absence of processus vaginalis and the formation of new defects through weakened fascia—parallels adult hernias, which typically require posterior wall reinforcement. This similarity raises the question of whether pediatric surgical strategies should evolve to reflect these anatomical and physiological differences.
This study aimed to assess the safety, feasibility, and recurrence outcomes of laparoscopic IPTR in acquired PIHs. By targeting this underrepresented subgroup, we seek to provide practical insights into optimizing surgical strategies for atypical PIHs.
Materials and Methods
This retrospective study was conducted at Damsoyu Hospital, Seoul, Republic of Korea. Between January 2013 and December 2022, 12,792 pediatric patients (<10 years) underwent laparoscopic inguinal hernia repair (Fig. 1). Among these, 21 patients diagnosed with acquired PIHs were treated with laparoscopic IPTR and included in the study. Acquired PIHs were defined as either a direct inguinal hernia or an MCIH without evidence of a congenital processus vaginalis at the time of initial exploration (Fig. 2). Patients with direct inguinal hernia were asymptomatic from birth and developed hernias as they grew, and patients with MCIH had intact processus vaginalis at the first surgery and developed hernias later, so they were classified as acquired PIH. Medical records were reviewed to collect patient demographics, operative details, and postoperative outcomes, including recurrence and complications. This study was approved by the Institutional Review Board of Damsoyu Hospital (DSY-2025-003).
Flowchart of patient.
Type of inguinal hernia.
Surgical procedure
All procedures were performed under general anesthesia with patients in the supine position. IPTR was performed using a three-port technique. The laparoscopic system contained a 2.9-mm camera and 2.7-mm instruments. A 3-mm transumbilical incision was used to establish pneumoperitoneum via a 3-mm trocar. Carbon dioxide (CO2) pneumoperitoneum was maintained at 7–8 mmHg. Two other 2.7-mm instruments were inserted through separate lateral abdominal incisions.
Peritoneal dissection revealed the hernia anatomy. The iliopubic tract suture technique was performed using nonabsorbable 3-0 silk, as previously reported.2,10,12 For indirect MCIH defects (Fig. 3), a continuous running suture was employed to join the iliopubic tract and transversus abdominis fascia. For direct hernia defects (Fig. 4), the iliopubic tract and transversus abdominis fascia were sutured. In males, the vas deferens and spermatic vessels were preserved; in females, the round ligament was preserved. Trocar sites were sealed with cyanoacrylate adhesive without the use of drains.
Surgical procedure of iliopubic tract repair in patient with indirect hernia of MCIH.
Surgical procedure of iliopubic tract repair in patient with direct inguinal hernia
Statistical methods
Statistical analyses were performed using R software (version 4.3.3; R Foundation for Statistical Computing, Vienna, Austria) and SPSS Statistics (version 27; IBM Corp., Armonk, NY, USA). Continuous variables were expressed as mean ± standard deviation and compared using Welch’s t test or the Mann–Whitney U test, as appropriate. Effect sizes for continuous variables were reported as mean differences with 95% confidence intervals. Categorical variables were analyzed using Fisher’s exact test or the chi-square test. For binary categorical outcomes, odds ratios with 95% confidence intervals were calculated, whereas for categorical variables with more than two categories, Cramer’s V with 95% confidence intervals was used to assess the strength of association. Because some groups had zero events, infinite odds ratios were occasionally obtained and reported as such. A post hoc power analysis was conducted to evaluate the achieved power for key comparisons, including age and body weight. All tests were two-sided, and a P value <.05 was considered statistically significant.
Results
Among 12,792 pediatric patients who underwent laparoscopic hernia repair, 21 cases (0.16%) of acquired PIHs were identified and treated with laparoscopic IPTR. These included 10 direct hernias and 11 MCIH.
Table 1 shows the comparison between indirect and direct PIHs. Patients with direct hernias were significantly older and heavier than those with indirect hernias (P = .017 and P = .020, respectively). The omentum was the only herniated organ in all direct cases, in contrast to bowel or ovary involvement in the indirect group (P < .001).
Patient Demographics
Values are presented as mean ± standard deviation or number (%).
Effect sizes are expressed as mean difference (MD) with 95% confidence intervals (CIs) for continuous variables, odds ratio (OR) with 95% CIs for binary categorical variables, and Cramer’s V with 95% CIs for categorical variables with more than two categories.
Categorical variables were analyzed using Fisher’s exact test or the chi-square test, as appropriate.
P-values for continuous variables were computed using Welch’s t-test (for unequal variances) and validated via non-parametric permutation tests (10,000 iterations).
Infinite odds ratios (Inf) indicate that no events were observed in one of the groups.
PIH, pediatric inguinal hernia; MCIH, metachronous contralateral inguinal hernia.
All procedures were completed laparoscopically without complications or conversions. No recurrences or postoperative complications occurred during a median follow-up of 78 months.
Table 2 presents the outcomes of patients with MCIHs following indirect PIH surgery. All patients had a negative contralateral finding at the first surgery but subsequently developed MCIH. The duration from the first surgery to the development of a metachronous hernia was 31 months. All were treated with IPTR, and no recurrences occurred.
Characteristics of Metachronous Contralateral Inguinal Hernia
Discussion
This study evaluated the feasibility and outcomes of laparoscopic IPTR in acquired PIHs. All procedures were successfully completed without conversion to open surgery, and no recurrences or testicular atrophy were observed during the follow-up. The absence of intraoperative complications and the favorable postoperative outcomes support the safety and effectiveness of IPTR in this select group of patients with acquired PIHs. Laparoscopic IPTR successfully treated all cases of acquired PIHs.
These findings align with previous reports highlighting the benefits of IPTR in both primary and recurrent PIHs. Lee et al. reported no recurrences among 1650 pediatric patients undergoing IPTR, 2 while Nayak et al. observed no recurrence in 238 repairs among 190 children, particularly emphasizing its use in older children or those with a wide internal ring. 14 Their approach—suturing the iliopubic tract—closely resembles the technique employed in our study. Furthermore, Lee and Park demonstrated a significantly lower re-recurrence rate (0% versus 8.6%) when IPTR was added to high ligation in recurrent cases. Collectively, these studies support the notion that reinforcing the posterior inguinal wall enhances the durability of hernia repair, especially in non-congenital or high-risk situations.
Acquired inguinal hernias differ anatomically from typical congenital cases. In acquired PIHs, there is no patent processus vaginalis; instead, a new fascial defect develops through a weakened abdominal wall. This pathophysiology closely resembles adult-type hernias, for which posterior wall reinforcement is a standard component of surgical repair. High ligation alone may be insufficient in such cases.16,17 The iliopubic tract provides a stable anatomical anchor for reinforcing the weakened posterior abdominal wall, which may explain the low recurrence rates observed in this and other studies. Moreover, IPTR is technically straightforward because the iliopubic tract is readily identifiable during laparoscopy, and its complication profile does not differ significantly from that of high ligation alone. 2
Laparoscopic repair offers several inherent advantages over open surgery, including enhanced visualization of both inguinal rings and the opportunity to detect occult contralateral hernias intraoperatively.6,15 In this study, 6 patients with direct PIH had contralateral defects that were repaired simultaneously. This diagnostic capability contributes to overall surgical thoroughness and safety. In congenital cases, reported rates of contralateral patent processus vaginalis range from 20% to 40%, further underscoring the diagnostic value of laparoscopy.5,18
This study has several strengths. It is among the few to focus exclusively on acquired PIHs in children, a subgroup underrepresented in the literature. All procedures were performed using a standardized laparoscopic IPTR technique, minimizing variability. The follow-up period was sufficient to capture early- and intermediate-term outcomes, including recurrence and postoperative complications. Given the anatomical similarity to adult-type hernias and the favorable outcomes observed, laparoscopic IPTR should be strongly considered as a first-line approach for acquired PIHs.
Nevertheless, several limitations warrant consideration. The sample size was small, reflecting both the rarity of acquired PIHs and the strict inclusion criteria. Although no recurrences were observed, larger studies are needed to validate these findings. Additionally, the absence of a control group treated with high ligation alone limits comparative interpretation. Finally, while follow-up was adequate for the assessment of short-term outcomes, longer-term data are needed to evaluate potential late complications, including chronic pain or fertility issues.
Future studies should pursue multicenter prospective trials comparing IPTR with conventional high ligation in acquired and high-risk primary hernia cases. In addition, the development of standardized preoperative criteria for identifying acquired PIHs could support more consistent surgical decision-making.
In conclusion, laparoscopic iliopubic tract repair was safe and effective in children with acquired PIH, showing no recurrences and favorable short-term outcomes.
Footnotes
Acknowledgments
The authors thank Hyejin Park for conducting the primary English grammar correction of this article and Beom Seok Oh from the Research Center of Damsoyu Hospital and Young Hyun Lee from the Ewha Womans University Graduate School of Engineering for their assistance with statistical analysis and data organization.
Author Disclosure Statement
No competing financial interests exist.
Funding Information
The authors have no financial ties to disclose.
Ethical Approval
This study was approved by the Institutional Review Board of Damsoyu Hospital (DSY-2025-003).
Human and Animal Rights
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.
Informed Consent
Informed consent was obtained from all individual participants included in the study.