Round Ligament Management in Percutaneous Inguinal Hernia Repair: Comparative Outcomes Using the FLAIR Technique in Girls

Abstract

Background

Fenestrated laparoscopic-assisted internal ring-rrhaphy (FLAIR) is a refined percutaneous technique for pediatric inguinal hernia repair. Although its outcomes have been reported in boys, its application in girls, particularly in relation to round ligament management, remains underexplored. Whether to include or exclude the ligament during internal ring closure is still debated.

Aim and Methods

This study evaluated the impact of round ligament management on surgical outcomes in girls undergoing FLAIR. A retrospective cohort of 69 hernias, operated on between July 2016 and December 2023, was reviewed. Patients were divided into two groups: those in whom the round ligament was included in the closure (Inclusion group) and those in whom it was deliberately spared (Exclusion group). Recurrence rates and postoperative complications were compared.

Results

All four recurrences (11%) occurred in the Inclusion group, while no recurrences were observed in the Exclusion group (p = 0.048). All recurrences occurred within 3 months postoperatively and were successfully reoperated using the exclusion technique, with no further recurrence during follow-up. No significant differences in other postoperative complications were identified between groups.

Conclusion

FLAIR appears to be a safe and effective approach in girls, particularly when the round ligament is excluded from the closure. Exclusion was associated with zero recurrences and no increase in complications. These findings, observed over intermediate-term follow-up, suggest that sparing the round ligament may enhance repair integrity and potentially protect the ligament from entrapment, thereby preserving its anatomical function. Larger, multicenter studies with extended follow-up are needed to validate these results and guide pediatric hernia repair strategies.

Keywords

percutaneous hernia repair - FLAIR - round ligament - laparoscopic hernia repair

Ethics Approval

This study was conducted in accordance with the Council for International Organizations of Medical Sciences (CIOMS) Ethical Guidelines. Full approval was granted by the Brunei Biomedical Research and Ethics Unit (BREU) on November 6, 2024 (Reference ID: 792024).

Publication History

Received: 17 June 2025

Accepted: 29 June 2025

Article published online:
15 July 2025

• References

• 1 Ramanathan S, Palaniappan Y, Sheikh A, Ryan J, Kielar A. Crossing the canal: looking beyond hernias—spectrum of common, uncommon and atypical pathologies in the inguinal canal. Clin Imaging 2017; 42: 7-18
• 2 Abdulhai S, Glenn IC, Ponsky TA. Inguinal hernia. Clin Perinatol 2017; 44 (04) 865-877
• 3 Shikha A, Han WSP, Wong J. The technique and results of fenestrated laparoscopic-assisted internal ring-rrhaphy (FLAIR) for boys with a high risk of recurrence inguinal hernia. J Pediatr Endosc Surg. 2022; 4: 99-111
• 4 Frýbová B, Trčka J, Dotlačil V, Poš L, Patkowski D, Rygl M. Laparoscopic inguinal hernia repair in children via PIRS (percutaneous internal ring suturing). Rozhl Chir 2020; 99 (06) 277-281
• 5 Patkowski D, Czernik J, Chrzan R, Jaworski W, Apoznański W. Percutaneous internal ring suturing: a simple minimally invasive technique for inguinal hernia repair in children. J Laparoendosc Adv Surg Tech A 2006; 16 (05) 513-517
• 6 Morini F, Dreuning KMA, Janssen Lok MJH. et al. Surgical management of pediatric inguinal hernia: a systematic review and guideline from the European Pediatric Surgeons' Association Evidence and Guideline Committee. Eur J Pediatr Surg 2022; 32 (03) 219-232
• 7 Sheth S, Sonkawde R. Surgical importance of the round ligament. J Gynecol Surg 1999; 15: 163-167
• 8 Zhong W, Zhang L, Zhong JQ. et al. Comparison of outcomes between preservation or division of the uterine round ligament in laparoscopic groin hernia repair in females: a meta-analysis and trial sequential analysis. Hernia 2024; 28 (02) 343-354
• 9 Mollaeian M, Mollaeian A, Ghavami-Adel M, Abdullahi A, Torabi B. Preserving the continuity of round ligament along with hernia sac in indirect inguinal hernia repair in female children does not increase the recurrence rate of hernia. Experience with 217 cases. Pediatr Surg Int 2012; 28 (04) 363-366
• 10 Schmidt L, Andresen K, Öberg S, Rosenberg J. Dealing with the round ligament of uterus in laparoscopic groin hernia repair: a nationwide survey among experienced surgeons. Hernia 2018; 22 (05) 849-855
• 11 Ulman H, Aubert O, Wiernik A. et al. Analysis of techniques in laparoscopic inguinal hernia repairs across pediatric age groups: EUPSA trainees of European pediatric surgery survey. Eur J Pediatr Surg 2025; 35 (01) 22-27