Inguinal Hernia
Also covered as: incarcerated hernia · direct hernia · indirect hernia · femoral hernia · strangulated hernia · chronic pain · patent processus vaginalis · recurrent hernia
Educational content from recorded physician discussions — not medical advice. Always talk to your child's care team about your child's situation.
Content of this collection
Fundamentals
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Inguinal Hernias: Diagnosis and Management
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Inguinal hernia repair is the second most common surgery performed by pediatric surgeons. Here, we discuss the basics of diagnosis and management for inguinal hernias with Dr. Meera Kotagal. Special guests Rae Hanke and Gillian Goddard.Chec
podcast16:29 · Apr 2021
Pediatric Inguinal Hernia in Brief: Presentation, Workup, Diagnosis, Perioperative Considerations
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Inguinal hernia repair is the second most common surgery performed by pediatric surgeons so here, we cover the basics of presentation, diagnosis, surgical approach, and post operative management with Dr. Meera Kotagal and host Dr. Rod Gerar
video · Sep 2021
Surgical Management
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Laparoscopic Pediatric Hernia Repair: Online Course 2017
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This was a half-day course focused on teaching the fine points of a the laparoscopic pediatric hernia repair led by Drs Ian Mitchell, Todd Ponsky, Jeff Gander, Sophia Abdulhai, Abdulraouf Lamoshi, Louis Seya.We presented many of the differ
video102:10 · Sep 2018
Focus on Technique- Laparoscopic Pediatric Hernia Repair 2015
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Dr. Todd Ponsky introduces the event focusing on Laparoscopic Pediatric Hernia Repair. Recently, the non-mesh laparoscopic pediatric hernia repair in children and adolescents has gained immense popularity. This event, "Focus on Technique: L
video140:52 · Jan 2019
Female Neonatal Inguinal Hernia Repair Dr. Tamer Ashraf Wafa
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In this video, the surgical treatment of inguinal hernia in a 3 week old girl is demonstrated. The main focus of this video is to illustrate how to ligate and divide the hernial sac at the proper neck through a limited lower abdominal creas
video4:42 · Jul 2021
Pediatric Open Herniotomy in boys 15 Minutes Unedited Dr. Tamer Ashraf Wafa
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In this video, open inguinal hernia repair is demonstrated. The patient is a 3 month old boy. The right side is being operated on. The video shows the surgeon's point of view (POV). In this procedure, the operative steps are played in norma
video16:29 · Aug 2021
Herniotomy in a Neonate 1 month old boy By Dr. Tamer Ashraf Wafa
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In this video, open inguinal hernia repair is demonstrated. The patient is a 3 month old boy. The right side is being operated on. The video shows the surgeon's point of view (POV). In this procedure, the operative steps are played in norma
video9:59 · Aug 2021
Evidence & Research
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Pediatric inguinal hernias: should repair be open versus laparoscopic?
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Dr. Georgios Kampouroglou discusses the ideal approach for pediatric inguinal hernia repair, as he summarizes "Long-term Follow-Up of Pediatric Open and Laparoscopic Inguinal Hernia Repair " from the Journal of Pediatric Surgery. Link to th
video · Mar 2020
PAPS -Perioperative Opioid Use In Paediatric Inguinal Hernia Patients- A Systematic Review And Retrospective Audit Of Practice - Isabel Hageman
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Listen to Isabel Hageman gave her presentation of "Perioperative Opioid Use In Pediatric Inguinal Hernia Patients- A Systematic Review And Retrospective Audit Of Practice" at the first ever Best of the Best in Pediatric Surgery event.
video11:59 · May 2022
Best of the Best Gen Surg - Predictors of Low and High Opioid Tablet Consumption after Inguinal Hernia Repair – an ACHQC Opioid Reduction Task Force Analysis - Dr. Warren
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Listen to Jeremy Warren gave his presentation of "Predictors of Low and High Opioid Tablet Consumption after Inguinal Hernia Repair – an ACHQC Opioid Reduction Task Force Analysis" at the first ever Best of the Best in General Surgery event
video11:00 · Sep 2022
BOB Ped Surg 2023 - Wendy Song, CAPS - Presentation
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Watch Wendy Song, MD, present her presentation on "A comparison of operative and anesthetic techniques for inguinal hernia repair in infants."
video · Feb 2023
Delayed versus early repair of inguinal hernia in preterm infants
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Another Article you should know by Dr. Cecilia Gigena
"Delayed versus early repair of inguinal hernia in preterm infants: A systematic review & meta-analysis"
Authors: Candy SC Choo, Yong Chen, Merrill McHoney
Full Article: https:
video0:43 · Nov 2023
Effect of Early vs Late Inguinal Hernia Repair on Serious Adverse Event Rates in Preterm Infants
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Martin L. Blakely, MD, MS; Andrea Krzyzaniak, MA; Melvin S. Dassinger, MD; Claudia Pedroza, PhD; Jorn-Hendrik Weitkamp, MD, PhD; Ankush Gosain, MD, PhD; Michael Cotten, MD; Susan R. Hintz, MD, MS; Henry Rice, MD; Sherry E. Courtney, MD; Kev
video1:35 · Nov 2024
The Use of Laryngeal Mask Airway Versus Endotracheal Intubation in Pediatric Laparoscopic Inguinal Hernia Repair: A Randomized Controlled Trial
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Emily L. Weisberg, Benjamin J. Pieters, Meredith S. Elman, Cory J. Nonnemacher, Janelle Noel-MacDonnell, Tolulope A. OyetunjiBackground
A laryngeal mask airway (LMA) is routinely used for many types of pediatric surgical procedures and as a
video0:49 · Sep 2025
Effect of a Pediatric Surgeon's Primarily Performed Technique on Inguinal Hernia Recurrence Rates: A Multicenter Retrospective Cohort Study
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Kathleen Heller, Brielle V Ochoa, Stephanie F Brierley, Benjamin E Padilla; Pediatric Inguinal Hernia Collaborative GroupPurpose: To investigate the effect of surgeons' preferred repair technique for pediatric inguinal hernia repair (IHR) -
video0:53 · Jan 2026
A Retrospective Nationwide Comparison of Laparoscopic vs Open Inguinal Hernia Repair in Children
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Michela Carter, Steven T Papastefan, Yao Tian, Stephen J Hartman, Meredith S Elman , Sara G Ungerleider , Aaron P Garrison , Tolulope A Oyetunji , Matthew P Landman, Mehul V Raval, Seth D Goldstein, Timothy B Lautz Background: Utilization o
video0:51 · Feb 2026
A Retrospective Nationwide Comparison of Laparoscopic vs Open Inguinal Hernia Repair in Children
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Michela Carter, Steven T Papastefan, Yao Tian, Stephen J Hartman, Meredith S Elman, Sara G Ungerleider, Aaron P Garrison, Tolulope A Oyetunji, Matthew P Landman, Mehul V Raval, Seth D Goldstein, Timothy B Lautz Background: Utilization of th
video0:51 · Feb 2026
Surgeon annual volume impacts recurrence rates of pediatric inguinal hernia repairs: A multi-institutional study
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Kathleen Heller, Brielle V Ochoa, Stephanie F Brierley, Benjamin E Padilla; Pediatric Inguinal Hernia Collaborative Group; Amir Alhajjat, Emily Byrd, Stephanie D Chao, Christopher Clinker, Jose Diaz-Miron, Goeto Dantes, R Scott Eldredge, El
video0:54 · Feb 2026
Laparoscopic modified percutaneous internal ring suturing - a mesh-free alternative for indirect inguinal hernia repair in adults. a pilot prospective cohort study
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Petter Fosse Gjessing, Todd Ponsky, Rolv-Ole LindsetmoBackgroundInguinal hernia surgery has undergone significant and extensive transformation, including the advent of tissue-based repairs and, later, tension-free repair with the acceptance
video0:43 · May 2026
Case-Based Learning
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Groin Controversies: Update Course 2016
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At the 4th Annual Stay Current in Pediatric Surgery Update Course in 2016, Dr. Todd Ponsky presents various cases involving groin hernia repairs. Topics discussed include reducible inguinal hernia, high ligation repair, mesh repair, hernia
video28:58 · Sep 2018
Groin Controversies - Todd Ponsky: Update Course 2014
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Dr. Todd Ponsky presents various cases involving groin hernia repairs. Topics discussed include reducible inguinal hernia, high ligation repair, mesh repair, hernia diagnostic exam, indirect versus direct hernia, open hernia repair, intraco
video28:58 · Nov 2018
Case-Based Journal Review: Inguinal Hernia 2025
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Dr. José Campos is back, this time helping us review some of the latest literature on the management of Inguinal Hernia in children. In this podcast, we're reviewing a hernia case with Dr. Todd Ponsky and incorporating literature from the l
podcast19:13 · Apr 2025
In-Depth Reviews
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Inguinal Hernia: Adult
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Dr Michael Rosen discusses Adult Inguinal Hernias with Dr Jeffrey Ponsky Edited by Harveen LambaIntroductions:Dr. Ponsky, professor of surgery at the Cleveland Clinic Lerner College of Medicine and Department of Surgery and Dr. Michael Rose
podcast31:02 · Dec 2020
2026 Laparoscopic Pediatric Hernia Repair
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Dr. Todd Ponsky from Cincinnati Children's Hospital leads an interactive course discussing controversies and various techniques for inguinal hernia repair, particularly focusing on the laparoscopic approach. He presents patient scenarios an
video123:40 · Jun 2026
Inguinal Hernia With M. Rosen
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An interactive discussion about inguinal hernia between Jeffrey Ponsky, MD and Michael Rosen, MD. Dr. Rosen is professor of surgery at Cleveland Clinic Lerner
podcast31:05 · Jul 2026
Inguinal Hernia With M. Rosen
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An interactive discussion about inguinal hernia between Jeffrey Ponsky, MD and Michael Rosen, MD. Dr. Rosen is professor of surgery at Cleveland Clinic Lerner
podcast31:05 · Jul 2026
Inguinal Hernia With M. Rosen
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An interactive discussion about inguinal hernia between Jeffrey Ponsky, MD and Michael Rosen, MD. Dr. Rosen is professor of surgery at Cleveland Clinic Lerner College of Medicine. Table of Contents 1:00:44 1 Introductions 2:02:45Work up for
podcast31:05 · Jul 2026
Common questions
What are the types of hernia repair?
Three primary repair approaches exist for inguinal hernia: tissue repair, open mesh repair, and laparoscopic mesh repair. Within open repair, surgeons can perform repairs without mesh or with mesh using techniques such as Lichtenstein. Laparoscopic approaches include preperitoneal or extraperitoneal repairs. Literature supports all three approaches for unilateral primary hernias, with approach selection based on patient factors rather than one technique being substantially superior to others.
What is Inguinal Hernia?
An inguinal hernia is a defect in the groin region resulting from failure of the processus vaginalis to fuse. Indirect inguinal hernias—the most common type—occur above the inguinal ligament and lateral to the epigastric vessels and represent a congenital anomaly present at birth. Inguinal hernias are very common, particularly in preterm infants, and inguinal hernia repair is the second most common surgery performed by pediatric surgeons. Risk factors include prematurity, male sex, family history, undescended testicle, hydrocele, and connective tissue disorders.
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Inguinal hernia repair in children centers on high ligation of the patent processus vaginalis, with ongoing debate between open and laparoscopic approaches. Laparoscopic repair carries a 3-fold higher ipsilateral recurrence risk than open repair in large registry studies, driven primarily by surgeon volume—low-volume laparoscopic surgeons show 3.3-fold increased recurrence versus high-volume peers, while open repair outcomes remain volume-independent [e11460-c5, e11554-c4, e11554-c3]. Contralateral patent processus vaginalis exists in 30–40% of unilateral cases, yet metachronous hernia risk is only 3–11%, and 50% of patent processus may never herniate [e12251-c1, e12251-c2, e12251-c3]. In preterm infants, timing remains contentious: late repair (post-NICU discharge) reduces serious adverse events from 28% to 18% and shortens length of stay by 3 days, though incarceration risk in the interim is ~4% [e9088-c3, e9088-c4, e10168-c5]. Most recurrences after indirect repair are direct hernias, not missed indirect defects . Technical nuances matter: parietalization of the cord and inferior dissection are critical in laparoscopic repair, mesh size must cover the entire myopectineal orifice, and braided non-absorbable suture outperforms monofilament in experimental models [e3441-c9, e3441-c10, e3441-c17, e12251-c9]. Chronic pain after mesh repair in adults can reach 30%, underscoring the appeal of tissue-only repair in children .
- Laparoscopic repair has 3× higher ipsilateral recurrence than open repair; low-volume laparoscopic surgeons show 3.3× higher recurrence, while open outcomes are volume-independent.
- Late repair in preterm infants reduces serious adverse events (18% vs 28%) and shortens stay by 3 days, with ~4% interim incarceration risk.
- Contralateral patent processus exists in 30–40% of unilateral hernias, but metachronous hernia risk is only 3–11%; 50% may never herniate.
- Most recurrences after indirect repair are direct hernias. Parietalization and inferior dissection are critical laparoscopic steps; mesh must cover the entire myopectineal orifice.
- Braided non-absorbable suture (10% failure) outperforms prolene (75%) and vicryl (80%) in experimental high-ligation models after suture removal.
For patients & families
An inguinal hernia happens when tissue pushes through a weak spot in the groin area. Doctors have learned that in very premature babies, waiting to repair the hernia until after they leave the NICU may be safer than operating right away—one large study found fewer breathing problems and shorter hospital stays when surgery was delayed, though about 4% of babies did develop a trapped hernia while waiting [e9088-c3, e9088-c4, e9088-c6, e9401-c8, e9401-c9, e10168-c4, e10168-c5]. For older infants and children, hernias can be repaired using either an open incision or laparoscopy (small cameras and instruments). Physicians discussed that laparoscopic repair may have a higher chance of the hernia coming back—more than three times higher in some studies—but it might reduce the need for surgery on the other side later [e11460-c5, e11460-c6, e11527-c5, e11527-c6]. The surgeon's experience matters: doctors who do laparoscopic repairs regularly have much lower recurrence rates than those who only do them occasionally [e11386-c2, e11386-c3, e11554-c4]. Most hernias in children are repaired without mesh, and follow-up visits after uncomplicated repairs rarely change the treatment plan .
An inguinal hernia happens when tissue pushes through a weak spot in the groin area. Doctors have learned that in very premature babies, waiting to repair the hernia until after they leave the NICU may be safer than operating right away—one large study found fewer breathing problems and shorter hospital stays when surgery was delayed, though about 4% of babies did develop a trapped hernia while waiting [e9088-c3, e9088-c4, e9088-c6, e9401-c8, e9401-c9, e10168-c4, e10168-c5]. For older infants and children, hernias can be repaired using either an open incision or laparoscopy (small cameras and instruments). Physicians discussed that laparoscopic repair may have a higher chance of the hernia coming back—more than three times higher in some studies—but it might reduce the need for surgery on the other side later [e11460-c5, e11460-c6, e11527-c5, e11527-c6]. The surgeon's experience matters: doctors who do laparoscopic repairs regularly have much lower recurrence rates than those who only do them occasionally [e11386-c2, e11386-c3, e11554-c4]. Most hernias in children are repaired without mesh, and follow-up visits after uncomplicated repairs rarely change the treatment plan .
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Every expert statement below comes from the recorded discussions, with its speaker and moment.
Laparoscopic Pediatric Hernia Repair: Online Course 2017
Contralateral patent processus vaginalis presents in 30-40% of children with unilateral hernia (Holcomb 1994), with 4× greater risk of developing symptomatic hernia and 3-11% metachronous hernia rate.
host_summaryTodd Ponsky11:05 ↗
In a rabbit model, grabbing the vas deferens once with pickups obliterates it.
clinicalTodd Ponsky17:03 ↗
Zendejas 50-year follow-up (Journal of American College of Surgeons) found 5% infertility rate after hernia repair, matching general population—no evidence of infertility problem from hernia surgery.
host_summaryTodd Ponsky18:00 ↗
Andrologia study of 8500 fertility clinic patients showed markedly reduced semen quality and morphology problems in men with prior hernia repair compared to fertile controls.
host_summaryTodd Ponsky18:23 ↗
The most common cause of recurrence after open pediatric hernia repair is development of a direct hernia, not indirect recurrence.
clinicalTodd Ponsky24:51 ↗
Direct hernias after initial indirect repair may be iatrogenic: pulling up the cord during open dissection in premature infants with see-through thin floors may take fibers of the floor and cause a direct defect.
opinionTodd Ponsky25:35 ↗
Adult general surgeons performing Lichtenstein mesh repairs argue that pulling up the cord disrupts the floor even in indirect hernias, so they always reinforce with mesh or fascia repair.
host_summaryJeff Gander25:55 ↗
Current large studies from multiple countries (mostly China) report laparoscopic pediatric hernia recurrence rates of approximately 1% or less.
host_summaryTodd Ponsky27:39 ↗
Early laparoscopic hernia repairs using Z-stitch technique (Felix Shear era) had 6% or higher recurrence rates; modern techniques with modifications have reduced this substantially.
host_summaryTodd Ponsky27:28 ↗
Postoperative hydrocele after laparoscopic hernia repair is extremely rare; in 10+ years Ponsky has never required intervention for one.
clinicalTodd Ponsky67:18 ↗
In rabbit hernia model, suture ligation alone without peritoneal injury resulted in 75% failure at 2 weeks and 83% failure at 4 weeks when suture was removed.
clinicalTodd Ponsky44:16 ↗
In rabbit model, anterior peritoneal injury plus suture resulted in 87% closure at 2 weeks and 100% reperitonealisation at 4 weeks even after suture removal.
clinicalTodd Ponsky44:33 ↗
Braided non-absorbable suture (Ethibond) performed best in rabbit hernia repair studies compared to absorbable (Vicryl) or monofilament non-absorbable (Prolene).
clinicalTodd Ponsky44:58 ↗
Repeat study comparing absorbable vs. non-absorbable suture with peritoneal injury showed equal failure rates on both sides, suggesting technical error rather than suture type determined outcome.
clinicalTodd Ponsky45:49 ↗
Patent processus vaginalis may close spontaneously even years after initial identification; one case showed complete closure 3 years after documented patent processus on prior laparoscopy.
host_summaryTodd Ponsky10:18 ↗
Direct inguinal hernias begin appearing around age 29 in adults, suggesting a floor pathophysiology change at that age that may distinguish pediatric-type indirect hernias from adult-type requiring floor reinforcement.
opinionTodd Ponsky83:38 ↗
Two-center retrospective study (Kansas City and Rainbow) of adolescents receiving open high ligation showed 1.9% recurrence rate.
epidemiologicalTodd Ponsky85:45 ↗
NIH study reported 30% chronic groin pain rate after adult mesh hernia repairs, though expert hernia surgeons argue their rates are lower.
host_summaryTodd Ponsky80:28 ↗
Felix Shear ultrasound study showed no deficiency in testicular blood flow after laparoscopic hernia repair in infants.
host_summaryTodd Ponsky93:39 ↗
When performing laparoscopic hernia repair, if cord structures are visible between peritoneum and needle, the needle has passed under the cord—safe passage shows only peritoneum over the needle.
clinicalTodd Ponsky38:14 ↗
In babies, single knot ligation is preferred over double ligation to reduce suture granuloma risk from thin subcutaneous tissue; older children tolerate double ligation without granuloma formation.
clinicalTodd Ponsky52:04 ↗
With laparoscopic approach, waiting 24-48 hours after reducing an incarcerated hernia may be unnecessary since inflammation does not complicate the laparoscopic repair as it does open surgery.
opinionTodd Ponsky22:28 ↗
The 'ocean argument': laparoscopic hernia repair difficulty remains constant regardless of external complexity (incarceration, prematurity, inflammation), unlike open repair where external factors significantly increase difficulty.
opinionTodd Ponsky19:20 ↗
Munther Haddad (Leeds, UK) published series on open hernia repair with sac division but no ligation, achieving same recurrence rate as traditional ligation; argues ligation creates a smaller hernia sac rather than eliminating it.
host_summaryTodd Ponsky42:14 ↗
Mario Raquelme performs complete laparoscopic sac excision without suture closure, relying on muscle layer apposition after sac removal; reports minimal recurrences.
host_summaryTodd Ponsky49:56 ↗
Bernia technique (Godoy/Varela/Guelfand, Chile): in girls, grasp and invert the patent processus sac, then cauterize extensively to obliterate it without suture; two-center study (with Navotny) reported no recurrences.
host_summaryTodd Ponsky40:00 ↗
SEAL technique (Harrison/Albanese/Novahara, Stanford) uses large CT needle to capture substantial tissue in single pass; very fast (<1 minute) but Ponsky found high postoperative pain, possibly from capturing nerves or excessive tissue.
clinicalTodd Ponsky34:20 ↗
Survey of pediatric vs. adult surgeons on same adolescent hernia case: 86% of pediatric surgeons chose high ligation, while adult surgeons predominantly chose muscle/mesh repair—same anatomy, different training.
epidemiologicalTodd Ponsky80:55 ↗
At IPEG Hawaii ~10 years ago, ~90% of audience favored open hernia repair; at BAPS London recently, ~70-80% favored laparoscopic—represents major practice shift.
epidemiologicalTodd Ponsky91:48 ↗
Choi (Seoul, Korea) published comparison of totally laparoscopic hydrocelectomy vs. scrotal incision for pediatric cord hydrocele, demonstrating feasibility of laparoscopic approach.
host_summaryTodd Ponsky72:41 ↗
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