Indirect Right Inguinal Hernia in a Six-Year-Old Girl: A Case Report and Literature Review
DOI:
https://doi.org/10.19166/med.v15i2.10968Keywords:
Direct inguinal hernia, Pediatric surgery, High ligation herniotomy, Groin herniaAbstract
Background:
Pediatric inguinal hernia is a common surgical problem, yet direct hernias in girls account for fewer than 1.5% of childhood groin defects. Although often painless and reducible, the cumulative risk of incarceration approaches 6%, warranting early repair.
Case Description:
A healthy six-year-old girl presented with a two-month history of an intermittent, painless right-groin bulge that appeared with crying or coughing. Physical examination revealed a 2.5 × 2 cm fully reducible mass; ultrasonography confirmed a fat-containing herniation medial to the inferior epigastric vessels, consistent with a reducible direct inguinal hernia. After optimization, she underwent an open high ligation herniotomy. The hernia sac was dissected to the internal ring and securely ligated without mesh. Operative time was 25 minutes and blood loss were negligible. The patient was discharged the same day, resumed unrestricted activity within one week, and remained asymptomatic at six-month follow-up with no evidence of recurrence.
Conclusions:
This case illustrates that open high ligation provides safe, durable closure for the exceedingly rare direct inguinal hernia in pediatric females, mirroring success rates above 98% reported for indirect defects. Early elective repair eliminates the risk of incarceration, avoids mesh-related morbidity, and allows rapid return to normal activity.
References
1. Pogorelić Z, Anand S, Križanac Z, Singh A. Comparison of Recurrence and Complication Rates Following Laparoscopic Inguinal Hernia Repair among Preterm versus Full-Term Newborns: A Systematic Review and Meta-Analysis. Children (Basel). 2021;8:853.
2. Watanabe T, Yokoyama S, Iwahashi M, Mori K, Yamade N, Yamaguchi K, et al. Asymptomatic patent processus vaginalis is a risk for developing external inguinal hernia in adults: A prospective cohort study. Annals of Medicine & Surgery [Internet]. 2021 [cited 2025 Jul 8];64. Available from: https://journals.lww.com/10.1016/j.amsu.2021.102258
3. HIP Trial Investigators, Blakely ML, Krzyzaniak A, Dassinger MS, Pedroza C, Weitkamp JH, et al. Effect of Early vs Late Inguinal Hernia Repair on Serious Adverse Event Rates in Preterm Infants: A Randomized Clinical Trial. JAMA. 2024;331:1035.
4. Beard JH, Ohene-Yeboah M, devries CR, Schecter WP. Hernia and Hydrocele. In: Debas HT, Donkor P, Gawande A, Jamison DT, Kruk ME, Mock CN, editors. Essential Surgery: Disease Control Priorities, Third Edition (Volume 1) [Internet]. Washington (DC): The International Bank for Reconstruction and Development / The World Bank; 2015 [cited 2025 Jul 8]. Available from: http://www.ncbi.nlm.nih.gov/books/NBK333501/
5. Rafiei MH, Jazini A. Is the ligation of hernial sac necessary in herniotomy for children? A randomized controlled trial of evaluating surgical complications and duration. Adv Biomed Res. 2015;4:97.
6. Memon AA, Khan A, Zafar H, Murtaza G, Zaidi M. Repair of large and giant incisional hernia with onlay mesh: perspective of a tertiary care hospital of a developing country. Int J Surg. 2013;11:41–5.
7. Dreuning K, Maat S, Twisk J, van Heurn E, Derikx J. Laparoscopic versus open pediatric inguinal hernia repair: state-of-the-art comparison and future perspectives from a meta-analysis. Surg Endosc. 2019;33:3177–91.
8. Harvard T.H. Chan School of Public Health, Boston, USA, Kerwan A, Al-Jabir A, Mathew G, Sohrabi C, Rashid R, et al. Revised Surgical CAse REport (SCARE) guideline: An update for the age of Artificial Intelligence. PJS [Internet]. 2025 [cited 2025 Jun 5]; Available from: https://premierscience.com/pjs-25-932/
9. Fischer KM, Zaontz M, Mittal S. Pediatric inguinal hernia repair and orchiopexy. Urology Video Journal. 2022;14:100151.
10. Chen YH, Wei CH, Wang KWK. Children With Inguinal Hernia Repairs: Age and Gender Characteristics. Glob Pediatr Health. 2018;5:2333794X18816909.
11. Pawlak M, East B, de Beaux AC. Algorithm for management of an incarcerated inguinal hernia in the emergency settings with manual reduction. Taxis, the technique and its safety. Hernia. 2021;25:1253–8.
12. Kafadar MT, Gök MA. Laparoscopic transabdominal preperitoneal repair of strangulated femoral hernia: Superiority of an unusual emergency surgical approach due to a case. Annals of Medicine and Surgery. 2018;36:110–2.
13. Cullis PS, Fouad D, Goldstein AM, Wong KKY, Boonthai A, Lobos P, et al. Major surgical conditions of childhood and their lifelong implications: comprehensive review. BJS Open. 2024;8:zrae028.
14. DeMatteo C, Bednar ED, Randall S, Falla K. Effectiveness of return to activity and return to school protocols for children postconcussion: a systematic review. BMJ Open Sport Exerc Med. 2020;6:e000667.
15. Dreuning KMA, Van Nassau F, Anema JR, Van Heurn LWE, Derikx JPM. Implementing Contralateral Surgical Exploration during Hernia Repair in Children with Unilateral Inguinal Hernia: A Dutch Qualitative Study. Children (Basel). 2023;10:1631.
16. Simons MP, Aufenacker T, Bay-Nielsen M, Bouillot JL, Campanelli G, Conze J, et al. European Hernia Society guidelines on the treatment of inguinal hernia in adult patients. Hernia. 2009;13:343–403.
17. Stabilini C, van Veenendaal N, Aasvang E, Agresta F, Aufenacker T, Berrevoet F, et al. Update of the international HerniaSurge guidelines for groin hernia management. BJS Open. 2023;7:zrad080.
18. Postoperative Stomach and Duodenum. In: Textbook of Gastrointestinal Radiology, 2-Volume Set [Internet]. Elsevier; 2015 [cited 2025 Jul 8]. p. 630–56. Available from: https://linkinghub.elsevier.com/retrieve/pii/B9781455751174000350
19. Tran HM, MacQueen I, Chen D, Simons M. Systematic Review and Guidelines for Management of Scrotal Inguinal Hernias. J Abdom Wall Surg [Internet]. 2023 [cited 2025 Jul 8];2. Available from: https://www.frontierspartnerships.org/articles/10.3389/jaws.2023.11195/full
20. Taverner F, Krishnan P, Baird R, von Ungern-Sternberg BS. Perioperative management of infant inguinal hernia surgery; a review of the recent literature. Paediatr Anaesth. 2023;33:793–9.
21. Khan FA, Jancelewicz T, Kieran K, Islam S, COMMITTEE ON FETUS AND NEWBORN, Eichenwald E, et al. Assessment and Management of Inguinal Hernias in Children. Pediatrics [Internet]. 2023 [cited 2025 Jul 8];152. Available from: https://publications.aap.org/pediatrics/article/152/1/e2023062510/192151/Assessment-and-Management-of-Inguinal-Hernias-in
22. Wang K, Tan SS, Xiao Y, Wang Z, Peng C, Pang W, et al. Characteristics and treatments for pediatric ordinary and incarcerated inguinal hernia based on gender: 12-year experiences from a single center. BMC Surg [Internet]. 2021 [cited 2025 Jul 8];21. Available from: https://bmcsurg.biomedcentral.com/articles/10.1186/s12893-020-01039-5
23. Inguinal Hernia in Children: A Literature Review. In: Pediatric Surgical Procedures - An Updated Guide - Volume I [Internet]. IntechOpen; 2025 [cited 2025 Jul 8]. Available from: https://www.intechopen.com/chapters/89745
24. Loscalzo J, Fauci AS, Kasper DL, Hauser SL, Longo DL, Jameson JL, editors. Harrison’s principles of internal medicine. 21st edition. New York: McGraw Hill; 2022. 1 p.
25. Pediatric Surgery [Internet]. Elsevier; 2012 [cited 2025 Jul 8]. Available from: https://linkinghub.elsevier.com/retrieve/pii/C2009041746X
26. Children’s problems in the emergency department. In: RCEM Lecture Notes [Internet]. 1st ed. Wiley; 2023 [cited 2025 Jul 8]. p. 326–40. Available from: https://onlinelibrary.wiley.com/doi/10.1002/9781394323289.ch18
27. Ridha H, de Vries RPH, Nijholt IM, Abbes S, Boomsma MF, Nijveldt RJ. Positive predictive value of ultrasound in correctly identifying an inguinal hernia: a single-centered retrospective pilot study. Insights Imaging. 2022;13:133.
28. Ghafoor S, Tognella A, Stocker D, Hötker AM, Kaniewska M, Sartoretti T, et al. Diagnostic performance of CT with Valsalva maneuver for the diagnosis and characterization of inguinal hernias. Hernia. 2023;27:1253–61.
29. Djekidel M, Govindarajan KK. Nuclear Medicine Pediatric Assessment, Protocols, and Interpretation. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 [cited 2025 Jul 8]. Available from: http://www.ncbi.nlm.nih.gov/books/NBK572132/
30. Singh Y, Tissot C, Fraga MV, Yousef N, Cortes RG, Lopez J, et al. International evidence-based guidelines on Point of Care Ultrasound (POCUS) for critically ill neonates and children issued by the POCUS Working Group of the European Society of Paediatric and Neonatal Intensive Care (ESPNIC). Crit Care. 2020;24:65.
31. Amerson JR. Inguinal Canal and Hernia Examination. In: Walker HK, Hall WD, Hurst JW, editors. Clinical Methods: The History, Physical, and Laboratory Examinations [Internet]. 3rd ed. Boston: Butterworths; 1990 [cited 2025 Jul 8]. Available from: http://www.ncbi.nlm.nih.gov/books/NBK423/
32. Marin JR, Abo AM, Arroyo AC, Doniger SJ, Fischer JW, Rempell R, et al. Pediatric emergency medicine point-of-care ultrasound: summary of the evidence. Crit Ultrasound J [Internet]. 2016 [cited 2025 Jul 8];8. Available from: https://theultrasoundjournal.springeropen.com/articles/10.1186/s13089-016-0049-5
33. Kopscik M, Crisman JL, Lomasney L, Smith S, Jadidi S. Sports Hernias: A Comprehensive Review for Clinicians. Cureus. 2023;15:e43283.
34. HerniaSurge Group. International guidelines for groin hernia management. Hernia. 2018;22:1–165.
35. Tarasconi A, Perrone G, Davies J, Coimbra R, Moore E, Azzaroli F, et al. Anorectal emergencies: WSES-AAST guidelines. World J Emerg Surg. 2021;16:48.
36. Reistrup H, Fonnes S, Rosenberg J. No Reason to Use Mesh in Groin Hernia Repair in Adolescents. J Abdom Wall Surg. 2023;2:12336.
37. Ma Q, Liu X, Zou Z, Liang C, Chen J, Yang H, et al. Surgical methods and outcomes of inguinal hernia repair in children, adolescents and young adults in a retrospective cohort study. Sci Rep. 2025;15:9220.
38. Niedzielski JK, Oszukowska E, Słowikowska-Hilczer J. Undescended testis - current trends and guidelines: a review of the literature. Arch Med Sci. 2016;12:667–77.
39. Abd-Alrazek M, Alsherbiny H, Mahfouz M, Alsamahy O, Shalaby R, Shams A, et al. Laparoscopic pediatric inguinal hernia repair: a controlled randomized study. Journal of Pediatric Surgery. 2017;52:1539–44.
40. Carter M, Papastefan ST, Tian Y, Hartman SJ, Elman MS, Ungerleider SG, et al. A Retrospective Nationwide Comparison of Laparoscopic vs Open Inguinal Hernia Repair in Children. J Pediatr Surg. 2025;60:162056.
41. Brunicardi FC, Andersen DK, Billiar TR, Dunn DL, Kao LS, Hunter JG, et al. Schwartz’s Principles of Surgery. In: Schwartz’s Principles of Surgery, 11e [Internet]. 11th ed. New York, NY: McGraw-Hill Education; 2019 [cited 2025 Jul 8]. Available from: accessmedicine.mhmedical.com/content.aspx?aid=1175835034
42. Gause CD, Casamassima MGS, Yang J, Hsiung G, Rhee D, Salazar JH, et al. Laparoscopic versus open inguinal hernia repair in children ≤3: a randomized controlled trial. Pediatr Surg Int. 2017;33:367–76.
43. Criss CN, Gish N, Gish J, Carr B, McLeod JS, Church JT, et al. Outcomes of Adolescent and Young Adults Receiving High Ligation and Mesh Repairs: A 16-Year Experience. Journal of Laparoendoscopic & Advanced Surgical Techniques. 2018;28:223–8.
44. Kim EJ, Oh C, Um JW. Laparoscopic surgery: an effective and safe surgical method of pediatric inguinal hernia repair. J Minim Invasive Surg. 2021;24:200–7.
45. Carter M, Papastefan ST, Tian Y, Hartman SJ, Elman MS, Ungerleider SG, et al. A Retrospective Nationwide Comparison of Laparoscopic vs Open Inguinal Hernia Repair in Children. Journal of Pediatric Surgery. 2025;60:162056.
46. Gasior AC, Knott EM, Ranters A, Peter SD, Ponsky TA. Two-center Analysis of Long-term Outcomes after High Ligation Inguinal Hernia Repair in Adolescents. The American SurgeonTM. 2015;81:1260–2.
47. Gibbons AT, Hanke RE, Casar Berazaluce AM, Abdulhai S, Glenn IC, McNinch NL, et al. Recurrence after laparoscopic high ligation in adolescents: A multicenter international retrospective study of ten hospitals. Journal of Pediatric Surgery. 2021;56:126–9.
48. Fan G, Yao G. Analysis of the efficacy of laparoscopic high hernia sac ligation in adolescent indirect hernia. BMC Surg [Internet]. 2023 [cited 2025 Jul 8];23. Available from: https://bmcsurg.biomedcentral.com/articles/10.1186/s12893-023-02048-w
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