This retrospective two-center audit was conducted at two high-volume tertiary pediatric surgery centers between 2016 and 2021. All children who underwent laparoscopic inguinal hernia repair during the study period were included in serial order. Patients who underwent primary open inguinal hernia repair, those with previous inguinal surgery, and cases with known associated congenital or systemic conditions were excluded from the analysis. Patients with unusual intraoperative findings identified during laparoscopy constituted the study focus. The study was conducted in accordance with the Declaration of Helsinki and approved by the local ethics committee. Data were collected from the Departments of Pediatric Surgery and Pediatric Urology at Ankara University Faculty of Medicine (Türkiye) and Wroclaw University Faculty of Medicine (Poland).

All procedures were performed or directly supervised by consultant pediatric surgeons with near-equal experience in laparoscopic inguinal hernia repair, ensuring standardization of surgical expertise across both centers.

The study focused on intraoperative findings that deviated from typical IIH presentations, excluding cases with known associated conditions. Prior to data extraction, an “unusual finding” was predefined as any intraoperative laparoscopic diagnosis other than a typical indirect inguinal hernia associated with a patent processus vaginalis (PPV). Unusual findings were categorized as: (i) non-indirect hernia types (e.g., direct inguinal hernia, femoral hernia); (ii) rare hernia variants (e.g., pantaloon hernia, Spigelian hernia); (iii) unexpected hernia sac contents or incarceration (e.g., Amyand's hernia, omental incarceration, ovarian/uterine incarceration); (iv) other unexpected intraabdominal/inguinal pathology relevant to the presentation or operative management (e.g., intraabdominal spermatic cord cyst, suspicious gonadal structure); and (v) laparoscopic hernia nonvizualization, defined as a closed internal ring with no PPV and no peritoneal sac/defect.

In most cases, the diagnosis of inguinal hernia was based on clinical symptoms and physical examination. Preoperative diagnosis was not based solely on a positive silk-glove sign. Surgery was indicated when a visible or palpable intermittent groin swelling was reported by the family and/or demonstrated on examination, typically accentuated during crying, coughing, or straining, and consistent with a reducible inguinal hernia. Patients were selected for laparoscopic repair based on a preoperative clinical diagnosis of inguinal hernia and institutional practice during the study period. Laparoscopic PIRS repair was the preferred approach in both centers in patients who were candidates for laparoscopic surgery and pneumoperitoneum induction. Patients with contraindications to laparoscopy who underwent primary open inguinal hernia repair were excluded from this study. Procedures were routinely recorded, and all available recordings were retrospectively reviewed by two consultant pediatric surgeons to confirm and categorize unusual intraoperative findings. A standardized data-extraction approach was used to document the type of finding, laterality, need for additional trocars, and intraoperative management. Discrepancies were resolved by discussion and consensus. A 5-mm camera trocar was inserted into the peritoneal cavity via an umbilical incision created using the open (Hasson) technique. Pneumoperitoneum was established with CO₂ insufflation according to the patient's age and body habitus. A 30-degree laparoscope was used to inspect both internal inguinal rings and assess for contralateral pathology. When a patent processus vaginalis (PPV)/open internal ring was identified, the patient was positioned in Trendelenburg with contralateral tilt to facilitate exposure by allowing the bowel to fall away from the operative field. Percutaneous access was then obtained using an 18-G needle. For PIRS repair, a 2/0 non-absorbable suture was placed circumferentially around the internal ring under direct laparoscopic visualization, and an extracorporeal knot was tied to achieve complete ring closure while avoiding entrapment of the vas deferens and gonadal vessels. Modified percutaneous repair for DIH (modified PIRS): When a direct inguinal hernia was identified intraoperatively (medial to the inferior epigastric vessels), a modified percutaneous suturing approach was performed under laparoscopic visualization. An 18-G needle loaded with a 2/0 non-absorbable suture was introduced percutaneously, and the medial defect was closed by two sequential needle passes—one from the lateral margin and one from the medial margin—so that the suture encompassed the defect and approximated the tissues overlying the medial weakness without entrapping the vas deferens or gonadal vessels. The knot was tied extracorporeally under direct vision to achieve defect closure. When deemed necessary, the medial umbilical ligament was mobilized and advanced over the defect and secured as reinforcement during closure (Figure 1). The contralateral side was assessed routinely and repaired when indicated. Contralateral findings were classified intraoperatively as either contralateral “open canal/true hernia” or contralateral PPV. To minimize subjective interpretation, contralateral findings were categorized using predefined visual criteria under standard pneumoperitoneum and 30° inspection. A contralateral “open canal/true hernia” was recorded when a well-formed hernia-type peritoneal sac was seen extending beyond the internal ring into the inguinal canal, typically appearing as a deep funnel-shaped sac configuration with a clearly gaping canal (i.e., a configuration consistent with a hernia sac rather than a simple patency). In contrast, contralateral PPV only was defined as patency of the internal ring/processus vaginalis without a formed hernia sac configuration, characterized by a shallow peritoneal dimple or slit-like opening at the ring without a funnel-shaped sac descending into the canal and without herniated contents. When available, the classification was corroborated on retrospective video review by two consultant pediatric surgeons and any discrepancies were resolved by consensus. Contralateral “open canal/true hernia” was identified and was repaired during the same anesthesia using PIRS. Contralateral PPV was defined as a patent processus vaginalis/patent internal ring without a clear hernia configuration, and these cases were managed by observation. For the purpose of this study, contralateral pathology was recorded as an asymptomatic contralateral PPV/open internal ring identified via laparoscopy (i.e., visible patency of the internal ring with a peritoneal sac/communication). Because these findings may represent an occult predisposition rather than a clinically apparent hernia, they are referred to as contralateral PPV/open internal ring throughout the manuscript. Additional working trocars were inserted selectively when required, for safe reduction and assessment of incarcerated contents (e.g., Amyand's hernia, omental incarceration, or ovarian incarceration), after which PIRS closure was completed. The same operative workflow was followed in both centers. DIH was defined intraoperatively as a medial defect relative to the inferior epigastric vessels. During the early phase of the study period, when DIH was unexpectedly encountered during laparoscopy, three patients were managed with classical open repair in accordance with the institutional practice at that time. After completion of the learning curve, subsequent DIH cases were managed laparoscopically using a modified percutaneous suturing technique to close the medial defect under direct visualization, with extracorporeal knot tying. In this study, “no hernia” refers to patients with preoperative clinical findings suggestive of inguinal hernia, but with no hernia identified during laparoscopy, defined as the absence of a patent processus vaginalis (PPV) with a closed internal inguinal ring and no peritoneal sac/defect on inspection.

The collected data included demographics, hernia laterality, surgical technique, unusual findings, intraoperative and postoperative complications, and patient outcomes. Internal ring diameter was intraoperatively assessed via laparoscopic inspection; however, ring diameter was not recorded as a standardized quantitative variable in this retrospective dataset.

Postoperative follow-up was performed according to routine institutional practice in both centers. All patients were assessed clinically before discharge and were routinely scheduled for an early outpatient visit (typically within 7–10 days). Longer-term follow-up beyond the early postoperative period was not standardized in this retrospective dataset and depended on local referral pathways and family preference; therefore, recurrence could not be evaluated reliably, and age-stratified follow-up analyses were not performed.

This study was designed as a descriptive retrospective case series focusing on rare intraoperative findings. Accordingly, the data were presented as counts and proportions for categorical variables and mean (range) for continuous variables. Given the very low frequency of individual unusual findings (several entities occurred only once), subgroup or comparative inferential analyses were not pre-specified and would be underpowered; therefore, no hypothesis-testing subgroup analyses were performed.

Unusual findings included DIH in seven children, an incarcerated appendix within the hernia sac in four (one requiring appendectomy), omental incarceration in three, and hernia nonvisualization in two cases (Figure 2). In both patients, surgery had been indicated based on a history of intermittent groin swelling reported by the family and/or demonstrated on examination during crying/coughing/straining; however, laparoscopy showed a closed internal ring with no PPV, consistent with the absence of an inguinal hernia at the time of surgery. Additionally, one case each of femoral hernia, Spigelian hernia, hernia en pantaloon, intraabdominal spermatic cord cyst, incarcerated uterus with ovary, and suspicious gonadal structures were identified (Table 1). The pantaloon hernia was confirmed laparoscopically by the presence of combined medial and lateral components and was repaired using the PIRS technique with internal ring closure under direct vision. For the Spigelian hernia, a pre-repair laparoscopic image was available and included, however, a post-repair image could not be obtained due to technical failure of the video recording system (Figure 3).

Direct inguinal hernia (DIH) was identified in seven children; four were managed laparoscopically using modified PIRS, whereas three underwent classical open repair. All patients were discharged on the day of surgery, and no intraoperative or postoperative complications were reported. No age- or ring-diameter–specific activity restrictions were prescribed postoperatively; children were allowed to return to normal activities as tolerated, with routine advice to avoid strenuous exertion during the early postoperative period.