Adolescent Surgery Session: They Look Like Adults, but Aren't the Same-Hernia Repair
With Dr. Joe Dodd & Dr. Harrod Patel · hosted by Dr. Todd Ponsky
Chapter 1 of 5 · Fundamentals
PPV vs muscle defect
Conceptual framework: patent processus vaginalis versus muscle defect
Expert statements on this page
No expert statements were drawn from this page.
Host summaries · secondary, not cited in answers
Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
More about this diagnosis
Indirect inguinal herniaVideo
2026 Laparoscopic Pediatric Hernia Repair
123 min · Published Jun 2026
Video
Groin Controversies: Update Course 2016
Dr. Todd Ponsky · 28 min · Published Jul 2017
Video
Laparoscopic Pediatric Hernia Repair: Online Course 2017
Dr. Todd Ponsky · 102 min · Published Aug 2017
Video
Pediatric Hernia: Update Course 2013
52 min · Published Jul 2017
Video
Laparoscopic modified percutaneous internal ring suturing - a mesh-free alternative for indirect inguinal hernia repair in adults. a pilot prospective cohort study
43 s · Published May 2026
Podcast
Inguinal Hernia: Adult
31 min · Published Jan 2017
Only a few other public items share this expert — go deeper there →
What the experts said
In Europe, surgeons treat pediatric inguinal hernias by dividing the sac without ligating it, and this approach works.
The European technique works because of a shutter mechanism: the muscle wants to come together but the peritoneum holds it open; cutting the peritoneum allows it to retract and the muscle closes.
After 50-year follow-up of pediatric hernia repairs, the true indirect recurrence rate is probably about 2 to 4%.
Most adults who have mesh repairs are done having children, so the true infertility rate of putting mesh over the vas is unknown.
The key component of the Bassini operation is probably the high ligation.
A multi-center retrospective review of 150 adolescent patients (ages 13-18) with 2-year follow-up showed 2 recurrences among 53 respondents after high ligation.
Laparoscopic high ligation does not require touching the cord structures, avoiding potential vas injury.
High ligation is an adequate operation for indirect hernias in small children.
With a 1.2 to 3% recurrence rate for high ligation in children, it must not be a muscle problem.
Indirect inguinal hernias are probably not a muscle problem in adolescents either.
Not every single adult needs mesh for indirect inguinal hernia repair.
Putting mesh in someone under age 18 who may still be growing risks creating problems because mesh does not grow and actually shrinks.
At University of Michigan during training, out of hundreds of pediatric hernias, only one or two cases received a ring plasty (a few stitches), and no one was putting in mesh.
A recurrence is a recurrence regardless of whether it is direct or indirect; mesh is placed in adults to prevent another hernia of any type.
The cutoff for placing mesh should be when the patient has finished growing.
In adolescents where the external and internal rings do not overlie each other, something more than high ligation should be done.
After laparoscopic high ligation, the speaker allows return to sports almost immediately, waiting only a couple of weeks before tackle football, because the operation does not significantly involve muscle.
Ziggy Iron's study of 6000 patients showed a 1.2% recurrence rate after high ligation in babies.
Zendejas published a study in Journal of American College of Surgeons with 332 patients and 213 survey respondents after 50-year follow-up of pediatric hernia repairs.
In the Zendejas 50-year follow-up study, 8.4% of patients had a groin operation on the same side, but only 4 of 12 operative cases were indirect hernias; the rest were direct hernias.
Mesh repairs have an 11 to 30% incidence of chronic pain according to multiple articles.
Beetz in 1997 compared high ligation to Bassini and Shouldice repairs in adults; Shouldice had the lowest recurrence rate, but Bassini and high ligation had the same recurrence rate.
In rabbits, squeezing the vas once with pickups obliterates it.
Mesh shrinks over time based on available data.
According to the NYHUS classification system, a class 1 hernia just gets high ligation in many practices.
The physiological basis for high ligation is that the external ring and internal ring are right on top of each other in young children; as they grow, the internal ring separates from the external ring.
In Hong Kong, over 1000 laparoscopic high ligations in adolescents have been performed with no reported recurrences.