Laparoscopic modified percutaneous internal ring suturing - a mesh-free alternative for indirect inguinal hernia repair in adults. a pilot prospective cohort study

What This Study Reports

A prospective cohort of 20 adults with indirect inguinal hernias underwent laparoscopic modified percutaneous internal ring suturing (PIRS) — a high-ligation technique traditionally reserved for pediatric patients 0:00 0:12. Published in the International Journal of Surgery, the study tested whether mesh-free repair could achieve durable results in adults 0:08 0:12.

Primary Outcomes

No patient experienced hernia recurrence over a median follow-up of 79 months 0:26 0:26. The cohort was predominantly male 0:25. Postoperatively, patients reported decreased pain and improved activity 0:31 0:31.

What This Means for Practice

This is a single-center study with 20 patients 0:35, so the evidence base remains narrow. But zero recurrences over six and a half years is a signal worth noting 0:26 0:26. The technique avoids mesh entirely, which eliminates mesh-related complications — chronic pain, infection, erosion — that drive a subset of adult hernia patients to seek alternatives.

The question is patient selection. Indirect hernias in adults are not uniform: some are small, reducible defects in young patients with intact tissue; others present in older patients with attenuated fascia and larger defects. The study does not stratify by defect size, patient age, or tissue quality, so we cannot yet define the ideal candidate. Younger patients with smaller indirect hernias may respond differently than older patients with larger defects and compromised tissue.

Unanswered Questions

The study demonstrates feasibility and durability in a selected cohort 0:35, but it does not compare modified PIRS to mesh repair in a randomized design. We do not know operative time, learning curve, or how recurrence risk scales with defect size. We also lack data on which patients were excluded and why.

For surgeons comfortable with laparoscopic technique, this offers a mesh-free option for indirect hernias in adults where tissue quality supports primary closure. Whether it should replace mesh repair in routine practice remains an open question, but the recurrence data at 79 months are strong enough to justify further study in a larger, comparative trial.

What This Study Tested

A single-center prospective cohort applied modified percutaneous internal ring suturing (PIRS) — a laparoscopic high-ligation technique traditionally reserved for pediatric hernias — to 20 adults with indirect inguinal hernias 0:12 0:23. The question: can you repair an adult indirect hernia without mesh and without recurrence?

What They Found

Over a median follow-up of 79 months, no patient experienced hernia recurrence 0:26 0:26. The majority of the cohort was male 0:25. Patients reported decreased postoperative pain and improved activity 0:31 0:31.

What This Means

High ligation is standard in children because the pathology is a patent processus vaginalis — close the neck, the hernia is fixed 0:00. In adults, the teaching has been that tissue is weaker, recurrence risk is higher, and mesh reinforcement is necessary. This small series challenges that assumption for a specific subset: young or middle-aged adults with indirect hernias and no significant floor weakness.

The appeal is clear. No mesh means no chronic foreign-body sensation, no risk of mesh erosion or infection, and potentially faster return to activity. The 79-month follow-up is long enough to capture most recurrences 0:26.

The Limitations

This is 20 patients from one center 0:35. There is no comparison arm, no data on hernia size or neck diameter, and no breakdown of which patients might be poor candidates. The technique requires laparoscopic skill and judgment to identify truly indirect hernias without posterior wall compromise. Applying this broadly without selection criteria would be a mistake.

For Your Practice

If you see adults with small indirect inguinal hernias — particularly younger patients asking about mesh-free options — this technique exists and has shown success in a limited series 0:35. It is not a replacement for mesh repair in direct hernias, large defects, or recurrent cases. It is a tool for a specific indication, and the evidence base is preliminary.