Internal Ring Closure in Pediatric Indirect Inguinal Hernia Repair

Rationale for Closing the Internal (Deep) Inguinal Ring

Closing the internal (deep) inguinal ring is the fundamental principle of pediatric inguinal hernia repair, aiming to eliminate the patent processus vaginalis (PPV) and prevent recurrence in a 5‑year‑old child. 1
All indirect inguinal hernias in children arise from a patent processus vaginalis, a persistent communication between the peritoneal cavity and the inguinal canal that fails to obliterate after testicular descent. 1
By age 5 years, approximately 15 % of children retain a PPV; when present, the PPV confers a 25–50 % risk of progressing to a clinically apparent hernia. 3
The primary surgical goal is to close the PPV at the internal ring, thereby removing the anatomical defect that causes the hernia. 1

Traditional open repair employs high ligation of the hernia sac at the internal ring, effectively closing the PPV. 1
In children, the internal ring itself does not require narrowing or reinforcement because the defect is the PPV rather than a structural weakness of the ring. 1

Laparoscopic repair provides outcomes comparable to or better than open repair and allows simultaneous inspection and treatment of a contralateral PPV, which is present in about 15 % of 5‑year‑old patients. 3
When a laparoscopic approach is chosen, the surgeon should evaluate the opposite side for a PPV and close any identified PPV to prevent a metachronous hernia. 3

Perform hernia repair—either open or laparoscopic—with closure of the internal ring as the primary objective. 1
If using laparoscopy, assess the contralateral inguinal region because a PPV persists in roughly 15 % of children at this age. 3
Ensure that the internal ring closure is adequate but avoids excessive narrowing that could compromise spermatic cord structures. [1][2]