Abstract
Pediatric inguinal hernias have long been understood as congenital defects arising from failure of processus vaginalis obliteration. This paradigm has guided decades of surgical practice, particularly the reliance on high ligation as the definitive treatment for nearly all hernias in children. The article presented by Lee and colleagues 1 challenges this traditional viewpoint by describing a cohort of patients younger than 10 years who developed either direct hernias or metachronous contralateral hernias despite a previously documented closed internal ring. Their dataset is uniquely powerful because routine laparoscopic repair and systematic intraoperative imaging allowed them to confirm the absence of a patent processus vaginalis at the index operation—something rarely available in most centers.
The concept of acquired pediatric hernias is not entirely new, but it remains controversial. Cases of metachronous hernia following a negative laparoscopic evaluation have been documented, with some authors suggesting these represent acquired defects rather than delayed congenital presentations. Watanabe et al. demonstrated that children can indeed present later with an inguinal hernia despite a clearly normal contralateral ring at the time of prior surgery, raising the possibility that a subset of hernias forms through a mechanism distinct from the classical congenital pathway. 1 Tam and colleagues similarly reported unexpected metachronous hernias following laparoscopic unilateral repair in children whose contralateral rings had appeared unequivocally closed. 2 These studies align closely with the findings presented in the current article, and together they highlight the existence of an uncommon but reproducible phenomenon.
What sets the present study apart is the sheer procedural volume—over 12,000 laparoscopic repairs in children, all performed by a single surgeon using consistent technique and documentation protocols. This level of standardization allowed the authors to identify a small but compelling group of 21 patients with later-appearing either direct (10) or indirect (11) hernias. It is difficult to overstate how rare it is to have video or photographic proof that a ring was normal at the initial operation; most centers simply do not maintain this level of detailed imaging. As a result, many similar cases in typical practice would never be detectable as “acquired”—they would simply be presumed congenital. This raises an important question: If these hernias are acquired, how many hernias that we see without having had laparoscopic evaluation are actually not congenital?
The operative question, then, becomes whether these etiologically distinct hernias require a different surgical approach. The authors advocate for laparoscopic iliopubic tract repair (IPTR) to reinforce the posterior wall, drawing parallels to adult hernia physiology. Their outcomes—no recurrences and no complications—are excellent. They also mirror the experience of other high-volume laparoscopic centers, where enhanced visualization of the inguinal region improves diagnostic accuracy and may allow for targeted repair of defects that could be overlooked during open surgery. Esposito and colleagues, in their 20-year laparoscopic series, emphasized the diagnostic advantage of laparoscopy in identifying subtle or atypical inguinal defects in children. 3
However, the essential issue remains: Is a tissue repair necessary for these lesions? The absence of a comparison group treated with high ligation alone limits the ability to determine whether IPTR meaningfully alters the natural history of these rare hernias. It also remains unclear how many of the more than 12,000 children in the authors’ series had non-congenital or “acquired” hernias but were nonetheless treated with high ligation alone, as if congenital, since they did not have previous laparoscopic confirmation that the ring was closed. Those patients underwent high ligatioon and experienced low recurrence. Alternatively, it is also possible that acquired hernias are truly separate entities that need tissue repair and that they represent all of the recurrences in the high ligation group.
We favor the idea that even if an indirect hernia is “acquired,” we surmise that they would enjoy the same low rate of recurrence as true congenital indirect hernias. Pediatric tissues possess far greater elasticity and healing capacity than adult tissues, and high ligation alone has successfully treated millions of pediatric hernias worldwide, including many that may have been anatomically similar to the cases described in this report. Underscoring this point, girls are able to heal their hernias without tissue repair and even without sutures using the Godoy Burnia technique.4,5And yet, without controlled data, it remains unclear whether reinforcement is essential or simply an elegant but nonessential addition.
Nonetheless, this study contributes significantly to an evolving understanding of pediatric inguinal hernias. The phenomenon of “acquired” hernias—whether due to true fascial change, mechanical stress, or developmental variation—deserves further investigation, ideally through multicenter prospective studies with standardized imaging and follow-up. The authors are to be commended for bringing attention to this unique subset of patients and for presenting a thoughtful and technically sound approach to their management with excellent outcomes.