Four laparoscopic surgical strategies for pediatric direct inguinal hernia: a retrospective single-center case series of six male children

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Objective Pediatric direct inguinal hernia is a rare subtype of inguinal hernia, characterized by protrusion of abdominal viscera through the weak posterior wall of the inguinal canal without passing through the internal inguinal ring. This condition results from congenital hypoplasia of the transversalis fascia and focal structural defects in the inguinal region, with a lower incidence than pediatric indirect inguinal hernia. Multiple laparoscopic protocols for pediatric direct inguinal hernia have been reported, yet no unified surgical standard has been established, and relevant clinical data lack systematic collation. This retrospective single-center case series summarizes clinical experience of four laparoscopic repair techniques for pediatric direct inguinal hernia, with emphasis on surgical procedures, postoperative complications and long-term hernia recurrence. This study aims to report clinical outcomes of the four laparoscopic approaches and clarify the selection strategy of the four surgical modalities. Methods This is a retrospective, single-center, formal consecutive clinical case series. Inclusion criteria: 1) were intraoperatively confirmed as having primary direct inguinal hernia during laparoscopic surgery; 2) had complete electronic medical records, operative notes and outpatient follow-up data; 3) received laparoscopic repair techniques. Exclusion criteria: 1) combined indirect inguinal hernia, femoral hernia or other complicated inguinal region abnormalities; 2) recurrent hernia after prior inguinal surgery; 3) incomplete clinical or follow-up data. All patients underwent laparoscopic direct inguinal hernia repair at Shengli Oilfield Central Hospital between January 2019 and April 2026. Clinical data including age, gender, operation date, surgical technique and complications were retrospectively reviewed and analyzed. Results Six male pediatric patients met the inclusion criteria, and none satisfied any exclusion criterion. Among them, five presented with unilateral hernia and one with bilateral hernia. The median age was 3 years and 9 months (range: 2 years and 1 month to 7 years and 3 months). All children were preoperatively suspected to have indirect inguinal hernia by physical examination, while direct inguinal hernia was confirmed intraoperatively. All patients received laparoscopic repair adopting four distinct surgical techniques: laparoscopic eversion and lateral fixation of direct hernia sac, laparoscopic high ligation of direct hernia sac, laparoscopic reinforcement with medial umbilical ligament, and combined laparoscopic high ligation of hernia sac plus medial umbilical ligament reinforcement. All operations were completed successfully with minimal intraoperative blood loss. No intraoperative injuries to the vas deferens, spermatic vessels, testis, bowel, urinary bladder, external iliac vessels or nerves were identified. Oral liquid diet was resumed 6 to 8 h after surgery, and daily activities were restored within 24 h postoperatively. No short-term complications such as surgical site infection or hematoma occurred in any patient. The final follow-up was conducted in June 2026 before manuscript submission, with follow-up durations ranging from 5 months to 82 months. No long-term complications including hernia recurrence, testicular atrophy or chronic inguinal pain were documented in all subjects. Conclusion Laparoscopic surgery is safe, reliable and minimally invasive for pediatric direct inguinal hernia. Based on our single-center experience, surgical selection depends on whether the hernia sac is amenable to ligation and whether the medial umbilical ligament can sufficiently cover the Hesselbach's triangle. Large-cohort studies are required to further validate the clinical efficacy of each repair strategy.