conventional inguinal hernia repair in children involves ligation of the hernial sac at the internal inguinal ring .
laparoscopic surgery has been applied in children , and the repair is based on the same principle .
this study aimed to document the authors ' experience with laparoscopic inguinal hernia repair in children .
patients were admitted in the evening 1 day before surgery and discharged within 24 hours following surgery .
two lateral ports of 3-mm were made through the right and left pararectal region to maintain a triangular orientation . in cases with small defects , laparoscopic ring closure ( lrc )
was done with 4  0 absorbable purse - string suture ( figures 1 , 2 , and 3 ) .
in early cases and when difficulty was noted , saline was injected to separate the peritoneum from cord structures .
the procedure was modified in 24% of children with a dilated internal ring ( figure 4 ) .
ligature of the hernial sac at the internal ring is inadequate in such cases . here
the sac was identified and dissected from the cord structures and then divided ( figure 5 ) . in patients with a large hernial sac ,
the landmarks identified included the iliopubic tract ( ipt ) , arching of fascia transversalis , cord structures , and the peritoneal reflection ( figure 6 ) .
the ipt was identified as a shiny white band running under the cord structures at the inferior border of the internal ring .
the tranversus arch was identified as the arching of the transversalis fascia immediately above and lateral to the internal ring .
the ipt was approximated to the transversus arch by using nonabsorbable 2 0 interrupted suture to narrow the internal ring ( figure 7 ) .
all patients were evaluated after 5 days , 4 weeks , 6 months , 1 year , and then annually , when possible .
laparoscopic ring closure : continuation of the purse string on the inferior aspect of the internal ring .
laparoscopic ring closure : completion of the purse string suture and occlusion of the internal ring .
laparoscopic iliopubic tract repair : completion of the dissection and landmarks identified : ( a ) dilated internal ring , ( b ) iliopubic tract , ( c ) cord structures , ( d ) transversalis fascial arch .
ninety - three indirect inguinal hernial sacs were closed ( 28 right , 7 left , 58 bilateral ) in 64 children ( 56 boys and 8 girls ) , ranging in age from 3 years to 13 years ( median , 5.1 years ) .
the mean operating time for lrc was 25 minutes ( range , unilateral 21 to 35 ; bilateral 28 to 50 ) .
the contralateral processus vaginalis was patent in 20% of children . in 24% of children ,
of the 29 bilateral hernias , 20 underwent lrc , 7 underwent liptr , and 2 underwent lrc on one side and liptr on the other side .
the median follow - up was 30 months ( range , 2 to 84 ) .
the first recurrence was in a 3-year - old female child after 8 months , following a right lrc .
the second one was in a 4-year - old boy after 5 months , following a left lrc .
the essential step in the conventional method for inguinal hernia repair in children is simple ligation of the hernial sac without narrowing the open ring . from our point of view
first and the most obvious is the confirmation of the hernia and looking for the contralateral side .
first championed by ger , ring closure is essentially a high ligation of the indirect hernia sac , which is the preferred technique in pediatric patients .
this technique re - establishes the usual anatomic relations of the medial aspect of the internal ring and cord structures , giving them a flush union with the transversus abdominis muscle and eliminating the lead point that allows the intestine to enter the inguinal canal .
ligature of the hernial sac at the internal ring alone is inadequate in patients with dilated internal ring ( 24% of children ) , as it does not take care of the component of the dilated ring .
reports exist in the literature of methods to tighten this dilated ring . in hernias exceeding 4 mm to 5 mm in diameter , the external hemicircumference of the neck was opened to bring the conjoined tendon closer to the crural arch with a nonresorbable suture without the use of a prosthesis .
ipt repair has been described as ringplasty , wherein the deep structures of the lateral iliopubic tract were approximated to the proximal arching musculotendinous fibers of the transversus abdominis muscle gazayerli described a laparoscopic preperitoneal ipt repair by approximating the transversus abdominis to the ipt , similar to the anterior preperitoneal approach described by nyhus and associates .
we believe that in children with a dilated internal ring , a routine lrc would be inadequate .
this is also observed in our 2 recurrences with one of them occurring within 5 months of lrc .
the recurrence rate of inguinal hernias is slightly higher with laparoscopic herniorrhaphy than with the conventional technique .
following liptr , there have been no recurrences . in children with recurrences after lrc , the surgeon has an undisturbed anatomy for the groin incision ; the risk of an injury to the vas deferens , subsequent testicular atrophy , and the risk of superior displacement of the testicle seem less likely .
the problems we faced during liptr were trivial and related to the little scar tissue at the internal ring .
this could be explained by some peritoneal fluid passing in between the knots placed during ring closure .
our series shows that both techniques are safe , reproducible , and technically easy for experienced laparoscopic surgeons .
the long - term follow - up of liptr would help assess any technical modifications .
laparoscopic inguinal hernia repair in children can be offered , as it is safe , reproducible , and technically easy for experienced laparoscopic surgeons .
 background : this study aimed to document the authors ' experience with laparoscopic inguinal hernia repair in children.methods:ninety-three hernia repairs were performed in 64 children . 
 the neck was closed with a purse string suture by using 4 - 0 absorbable suture.results:ninety-three indirect inguinal hernial sacs were closed in 64 children . 
 nine percent of children had an ectopic testis . 
 the mean operating time for laparoscopic ring closure was 25 minutes ( range , unilateral 21 to 35 ; bilateral , 28 to 50 ) . 
 the contralateral processus vaginalis was patent in 20% of children . in 24% of children , 
 the final procedure was modified based on the findings of a dilated internal ring . 
 a laparoscopic ilio - pubic tract repair was done in these cases . 
 laparoscopic mobilization , orchiopexy followed by ilio - pubic tract repair was done in 9% of children . 
 scrotal swelling occurred in one child . 
 hydrocoele occurred in one patient . 
 recurrence rate was 3.1%.conclusion : laparoscopic inguinal hernia repair in children can be offered , as it is safe , reproducible , and technically easy for experienced laparoscopic surgeons . 
 iliopubic tract repair may be added in cases with dilated internal ring . 
 recurrence following laparoscopic ring closure can be managed with laparoscopic ilio - pubic tract repair . 
 the long - term follow - up of laparoscopic ilio - pubic tract repair is awaited . 