Can One-port Laparoscopic Percutaneous Internal Ring Suturing Technique be an Alternative to Conventional Laparoscopic Repair for Female Inguinal Hernia? – A Nonrandomized Comparative Cohort Study

ABSTRACT

Background:

The optimal laparoscopic technique for pediatric female inguinal hernia remains debated. While intracorporeal Incision, Dissection, Excision, and Suturing (IDES) closely emulates open herniotomy, Percutaneous Internal Ring Suturing (PIRS) offers a simpler, one-port alternative. This study compares the feasibility, safety, and long-term efficacy of PIRS versus conventional IDES in female children.

Materials and Methods:

In this single-center case–control study conducted over 10 years, 178 female children (1–12 years) undergoing elective laparoscopic inguinal hernia repair were included. Ninety-three patients underwent IDES repair, and 85 underwent one-port PIRS. Perioperative parameters, intraoperative events, postoperative recovery, and long-term recurrence were analyzed. Patients were followed up at regular intervals for a mean duration of approximately 9 years. Statistical analysis included fragility index assessment for significant outcomes.

Results:

Baseline characteristics were comparable between groups. The mean operative time was significantly shorter in the PIRS group (P < 0.001). Detection and repair rates of contralateral patent processus vaginalis were similar (~15%). Postoperative pain scores, analgesic requirements, time to oral feeds, hospital stay, and early complications were comparable. One recurrence occurred in each group during long-term follow-up, with no statistically significant difference. Suture breakage and minor subperitoneal hematoma were infrequent and statistically fragile findings without clinical consequence. No major vascular injuries or long-term morbidity were observed.

Conclusion:

One-port PIRS provides outcomes equivalent to conventional laparoscopic IDES repair in female pediatric inguinal hernia, with the advantage of reduced operative time and technical simplicity. In experienced hands, PIRS represents a safe, durable, and cosmetically superior alternative suitable for routine use in girls.

INTRODUCTION

Inguinal hernia remains one of the most frequent clinical challenges encountered by pediatric surgeons, with an estimated incidence ranging from 0.8% to 4.4% in the pediatric population.[1] The laparoscopic approach offers several distinct advantages, including superior visualization of the internal inguinal ring, the unique ability to detect and treat a contralateral patent processus vaginalis (CPPV), and improved patient outcomes such as reduced postoperative pain, better cosmesis, and faster recovery times.[2] Despite these benefits, open herniotomy is still widely practiced in many centers due to concerns regarding the definite learning curve and reported recurrence rates that can reach up to 3%.[3,4] The ongoing debate regarding the best technique is further fueled by a lack of Level 1 evidence in current literature, with many systematic reviews failing to address an expected near-zero recurrence rate.[2,5,6,7,8,9]

Two commonly used techniques across the world include – Incision, Dissection, Excision, and Suturing (IDES), which emulates open herniotomy and has a near-zero recurrence rate, and the Percutaneous Internal Ring Suturing (PIRS) technique which is more popular in the Western world and has not gained so much momentum in India.[10,11] The PIRS technique has proven particularly effective as a daycare procedure and is increasingly utilized. Excellent cosmetic results and reduced recurrence rates are associated with this method. This procedure is particularly suitable for girls because they lack a spermatic cord and vascular structures that can cause complications with this technique in boys.[12,13,14] We analyzed its feasibility, safety, and long-term clinical efficacy over conventional IDES repair in female children in a tertiary center in Central India.

MATERIALS AND METHODS

This case–control study was conducted at a tertiary care pediatric surgery center in Central India over 10 years to evaluate and compare outcomes one-port laparoscopic PIRS against conventional laparoscopic IDES repair as control for inguinal hernia in female children. A total of 178 consecutive female patients diagnosed with unilateral or bilateral inguinal hernia and planned for elective laparoscopic repair were included. The operative technique was selected based on the surgeon’s preference and expertise after discussion with parents/guardians during informed consent. Informed consent regarding laparoscopic evaluation and repair of CPPV, if detected intraoperatively, was routinely obtained from parents/guardians. Based on the operative technique employed, patients were divided into two groups: 93 patients underwent laparoscopic IDES repair, and 85 patients underwent the PIRS technique. The technique was chosen randomly while no randomization could be performed, with informed consent obtained from parents or guardians in all cases, along with IEC approval.

Female children from 1 to 12 years with an uncomplicated inguinal hernia were included, while patients with recurrent hernia, complicated hernia (irreducible, obstructed, or strangulated), prior lower abdominal surgery, and associated simultaneous abdominal procedures were excluded. In the IDES group, standard three-port laparoscopy was used to inspect both internal inguinal rings, followed by circumferential peritoneal incision around the internal ring, dissection and excision of the hernial sac, and intracorporeal closure of the internal ring using absorbable sutures, closely replicating the principles of open herniotomy.

In the PIRS group, repair was performed using a single 5-mm umbilical port for laparoscopic visualization after establishing pneumoperitoneum. A 5-mm telescope was introduced to inspect the affected and contralateral internal inguinal rings. Under direct laparoscopic guidance, a 16-gauge intravenous cannula preloaded with a nonabsorbable suture loop (Nylon 4-0) was inserted percutaneously at the level of the internal inguinal ring and advanced extraperitoneally along one semicircle of the ring, carefully hugging the peritoneum to avoid injury to the iliac vessels. The looped suture was deployed into the peritoneal cavity, and the cannula was withdrawn. The cannula was then reintroduced through the same skin puncture site and passed extraperitoneally around the remaining semicircle of the internal ring. A second nonabsorbable suture (Nylon 4-0, without loop) was passed through the cannula so that its intraperitoneal end traversed the previously placed loop. Gentle traction on the loop retrieved the free suture end extracorporeally, thereby completing circumferential encirclement of the internal ring. An extracorporeal knot was then tied to achieve complete closure of the ring. No sac dissection or excision was performed. Any CPPV identified during laparoscopy was repaired in the same sitting [Figure 1a–f].

Figure 1.

Steps of Percutaneous Internal Ring Suturing (PIRS) for Pediatric Female Inguinal Hernia. (a) Introduction of a 16-G intravenous cannula percutaneously in the sub-peritoneal space along the semicircle of the internal inguinal ring under laparoscopic visualization. (b) Deployment of the preloaded non-absorbable suture loop (Nylon 4-0) into the peritoneal cavity after completing the first semicircular encirclement. (c) Reintroduction of the cannula through the same skin puncture site to pass a second non-absorbable suture (Nylon 4-0) extraperitoneally around the remaining semicircle of the internal ring. (d) The free end of the second suture is passed through the previously placed loop. (e) The free end of the second suture is retrieved extracorporeally by pulling the loop, achieving complete circumferential encirclement of the internal ring. (f) Extracorporeal knot tying resulting in secure closure of the internal inguinal ring without sac dissection or excision

All procedures were performed by experienced pediatric surgeons proficient in both techniques to minimize operator-related bias. Primary outcomes included perioperative measures and recurrence. Perioperative data, including operative time, intraoperative events, detection of CPPV, time to oral feeds, duration of hospital stay, and early postoperative complications, were prospectively recorded. Patients were followed up at one week, one month, and annually thereafter for 3 years to assess late complications, particularly recurrence. Data were analyzed using appropriate statistical methods, with continuous variables expressed as mean ± standard deviation and categorical variables as proportions; a P < 0.05 was considered statistically significant.

RESULTS

A total of 178 female children underwent laparoscopic repair for inguinal hernia, including 93 patients in the IDES group and 85 patients in the PIRS group. The two groups were well matched in baseline characteristics [Table 1]. The mean age at surgery was approximately 48 months in both groups, and the distribution of unilateral and bilateral hernias was comparable, with bilateral hernias observed in 8%–9% of cases.

Table 1.

Demographic profile and surgical outcomes comparing incision, dissection, excision, suturing, and percutaneous internal ring suturing techniques

Parameter	IDES Group (n=93), n (%)	PIRS Group (n=85), n (%)	Effect estimate (95% CI)	P
Mean age (months)	49.2±18.6	47.8±17.9	Mean difference 1.4 months (−4.0 to 6.8)	0.64
Age range (months)	12–144	12–144	-	-
Unilateral hernia	85 (91.4)	77 (90.6)	Risk difference 0.8% (−7.8 to 9.4)	0.86
Bilateral hernia	8 (8.6)	8 (9.4)	Risk difference−0.8% (−9.4 to 7.8)	0.86
CPPV detected	14 (15.1)	13 (15.3)	Risk difference−0.2% (−10.7 to 10.3)	0.97
Mean operative time (min)	37.2±6.1	22.1±4.6	Mean difference 15.1 min (13.5 to 16.7)	<0.001*
Breaking of the suture	5 (5.4)	0	Risk difference 5.4% (0.8 to 10.0)	0.03*
Intraoperative subperitoneal hematoma	1 (1.1)	6 (7.1)	Risk difference−6.0% (−11.6 to−0.4)	0.048*
Time to oral feeds (h)	5.0±1.1	4.8±1.0	Mean difference 0.2 h (−0.1 to 0.5)	0.21
Hospital stay (h)	18.9±5.2	18.1±4.9	Mean difference 0.8 h (−0.7 to 2.3)	0.33
Recurrence	1 (1.1)	1 (1.2)	Risk difference−0.1% (−3.3 to 3.1)	0.97
Mean follow-up (years)	9.1±1.8	8.9±1.6	Mean difference 0.2 years (−0.3 to 0.7)	0.58

*P<0.05 statistically significant. Risk difference calculated as IDES minus PIRS. Confidence intervals interpreted cautiously due to low event rates for some categorical outcomes. CI: Confidence interval, IDES: Incision, dissection, excision, and suturing, PIRS: Percutaneous internal ring suturing, CPPV: Contralateral patent processus vaginalis

The mean operative duration was significantly shorter in the PIRS group compared with the IDES group (P < 0.001). The incidence of CPPV detected intraoperatively was similar in both groups, and all detected CPPVs were repaired in the same sitting. No major intraoperative complications were encountered in either group. Postoperative outcomes, including time to initiation of oral feeds, duration of hospital stay, and early postoperative complications, were comparable between the two groups. Intraoperative breaking of suture during knotting was noted in 5 cases of IDES as compared to none in the PIRS group, as Vicryl 4-0 was used in the IDES group and involved intracorporeal suturing, which was duly replaced with a new suture without any consequence. Contralateral patent processus vaginal was seen in around 15% cases in both groups and was duly repaired after confirming the bubble test (Referred to as an External Squeeze Test, which is a diagnostic maneuver used to confirm the presence of a patent processus vaginalis, considered positive if bubbles are visualized at the internal ring). Postoperative analgesia dose requirement was similar in the two groups.

Patients were followed up at 1 week, 1 month, 6 months, and annually thereafter, with a mean follow-up duration of 9.1 ± 1.8 years in the IDES group and 8.9 ± 1.6 years in the PIRS group. During the follow-up period, one recurrence was observed in each group, with no statistically significant difference. Both recurrences were managed with open repair. No cases of external iliac vessel puncture/injury, wound infection, or long-term procedure-related morbidity were noted.

Fragility index analysis was performed for outcomes showing statistical differences to assess the robustness of the results. The outcomes of suture breakage (P = 0.03) and intraoperative subperitoneal hematoma (P = 0.048) were found to have a fragility index of 1, indicating that a change in the outcome status of a single patient would render these results statistically non-significant. This reflects the low event rates and suggests that, although these findings reached statistical significance, they are statistically fragile and should be interpreted with caution as technique-related intraoperative observations rather than clinically meaningful differences. Operative duration and recurrence rates showed a fragility index of 0, highlighting the strength of the findings. Overall, fragility analysis supports the conclusion that both procedures demonstrate equivalent clinical reliability, lower operative duration for PIRS, with observed differences limited to minor, technique-specific intraoperative events.

Therefore, with comparable long-term outcomes over a mean follow-up of nearly 9 years, one-port laparoscopic PIRS offers results equivalent to conventional laparoscopic IDES repair in female pediatric inguinal hernia, with the advantage of significantly reduced operative time and fewer technical issues of fragile statistical significance.

DISCUSSION

Over the last two decades, laparoscopic repair has progressively challenged open herniotomy as the preferred approach for pediatric inguinal hernia. Contemporary guidelines and systematic reviews consistently highlight several advantages of laparoscopy, including superior visualization of the internal inguinal ring, the ability to identify and simultaneously repair a CPPV, reduced postoperative pain, faster recovery, and improved cosmetic outcomes.[2,3,4,5,6,15,16] Large series and meta-analyses have demonstrated comparable, and in experienced hands even lower, recurrence rates when laparoscopic principles are meticulously followed. In addition, laparoscopy provides a unique diagnostic advantage by allowing inspection of pelvic organs in girls and assessment of gonadal structures, which is not feasible with open repair. These cumulative benefits have led many centers worldwide to increasingly favor laparoscopic techniques, particularly for bilateral or suspected contralateral disease.[2,16]

After its innovation by Patkowski, despite its widespread adoption in Europe and parts of the Western world, PIRS has not gained equivalent momentum in India.[11,17,18] Several factors may explain this discrepancy. First, there is a strong legacy of open herniotomy and, more recently, intracorporeal laparoscopic techniques such as IDES, which closely emulate open surgery and are perceived to offer near-zero recurrence.[10] Most of the initial workshops on laparoscopic hernia repair were done by Dr Felix Schier and further propagated by Dr Rasik Shah, who were proponents of intracorporeal repairs which had excellent results. Second, early reports of higher recurrence rates with PIRS, particularly from single-center studies and during the learning curve phase, have created caution among Indian surgeons who often operate in high-volume, resource-constrained settings.[12,19,20] Third, variability in technique, instrumentation, and suture materials across reports has contributed to inconsistent outcomes, further limiting confidence.[11,13,14,17,21,22,23,24] Finally, academic publications, structured training, and mentorship in PIRS have been less widespread in India compared to Europe, where the technique originated and evolved.[25,26,27,28,29,30]

The commonly reported concerns with PIRS include recurrence due to incomplete encirclement of the internal ring, loosening or breakage of sutures, and inadvertent inclusion or injury of adjacent structures.[12,19,20] Subperitoneal hematoma, as seen in the present study, is another recognized intraoperative event related to blind or semi-blind passage of the needle in the extraperitoneal plane. Importantly, most of these issues are technique-related, occur predominantly during the learning curve, and are infrequent in experienced hands, as reflected by their low absolute event rates and fragile statistical significance in the current analysis.

A notable limitation of PIRS literature is the lack of technical uniformity.[11,13,14,17,21,22,23,24] Various authors have described the use of hypodermic needles, spinal needles, epidural needles, specially designed PIRS needles, and intravenous cannulas, with suture materials ranging from absorbable to non-absorbable monofilament and braided sutures. Differences also exist in whether a single or double pass is used, how the knot is buried, and whether hydrodissection is employed. We use pneumodissection in males where vas and vessels are closely related to the peritoneum, while it is not usually needed in females. Such heterogeneity likely explains the wide variation in reported recurrence rates. In the present study, a 16-gauge intravenous cannula with non-absorbable nylon was used, which provided adequate strength and knot security, and may have contributed to the excellent long-term outcomes.

PIRS is especially attractive in female children because of the absence of a spermatic cord and testicular vessels at the internal ring. This anatomical simplicity minimizes the risk of critical structure entrapment and allows safe circumferential closure of the ring. In boys, the risk of entrapment or injury to the vas deferens and testicular vessels has been a major deterrent.[13] In addition, laparoscopy facilitates direct visualization of the uterus, ovaries, and fallopian tubes, enabling detection of ovarian herniation or associated anomalies. Several studies have therefore suggested that PIRS may be ideally suited, if not the preferred technique, for inguinal hernia repair in girls. The present study reinforces this concept by demonstrating equivalent long-term recurrence rates between PIRS and IDES with significantly shorter operative times.

The findings of this study suggest that one-port PIRS can effectively replace conventional laparoscopic IDES repair for female inguinal hernia. Both techniques demonstrated comparable safety profiles, postoperative recovery, and long-term recurrence rates over a mean follow-up of nearly 9 years. The only consistent advantage of PIRS was a significantly shorter operative duration. Importantly, the differences in intraoperative events were minor, statistically fragile, and clinically insignificant. From a pragmatic perspective, PIRS offers a simpler, faster, and cosmetically superior alternative without compromising durability, making it a strong candidate to become the procedure of choice for female pediatric inguinal hernia in experienced centers.

The role of PIRS in boys remains more contentious. While some contemporary studies and randomized trials suggest acceptable safety and recurrence rates, concerns regarding vas deferens and testicular vessel entrapment persist. It is likely that with improved needle design, refined technique, and adequate training, PIRS may find a broader role in selected male patients. However, until long-term, high-quality data consistently demonstrate equivalence or superiority, many surgeons may continue to prefer intracorporeal techniques such as IDES for boys.[14,18]

This study has several limitations. Its cohort design without randomization introduces the potential for selection bias and limited generalizability despite comparable baseline characteristics. The choice of surgical technique was not blinded and depended on the surgeon’s preference, which may influence outcomes. Although the follow-up duration was long, the absolute number of adverse events was low, resulting in statistically fragile significance for some comparisons. The procedure was primarily performed by experienced pediatric surgeons while residents participated under supervision after adequate laparoscopic training. A prospective study is desired to assess the learning curve for residents. Finally, being a single-center experience, the results may not be universally generalizable, particularly to centers with limited laparoscopic expertise. Nonetheless, the strength of this study lies in its large cohort, uniform surgical expertise, and detailed analysis including fragility and effect size assessment, and exceptionally long follow-up.

CONCLUSION

One-port laparoscopic PIRS provides outcomes equivalent to conventional laparoscopic IDES repair in female pediatric inguinal hernia, with comparable recurrence, safety, and long-term durability. Its significant advantage lies in shorter operative time and technical simplicity. In experienced hands, PIRS represents a safe and efficient alternative for intracorporeal repair in girls.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.