The critical steps of hernia sac neck transaction at the IIR were not achieved in many laparoscopic procedures unlike during OH. Thus, transient or persistent hydrocele was unavoidable after these laparoscopic techniques. Tsai et al. and others dissected and transected the neck of the sac at IIR to be followed by a suture closure, moreover with this being a faithful reproduction of the inguinal approach [24�C26]. They claimed that leaving the hernial sac in continuity without disconnection at IIR may be the cause of subsequent recurrence and hydrocele formation. Ozgediz et al. and Bharathi et al. stated that avoiding the vas deferens and gonadal vessels during subcutaneous endoscopically assisted ligation repair in males may leave a small gap at IIR as well as leaving the hernia sac in situ, which has the potential to contribute to a higher incidence of recurrence in male patients [15, 21].

Technical modifications including injection of saline to lift up the peritoneum, the placement of single suture with complete encirclement of the sac, and disconnection of the hernial sac at IIR have been proposed to reduce the recurrence rates [27]. Yang et al. [22] in their meta-analysis stated that the recurrence rate of laparoscopic hernia repair was higher than OH in 2 studies [9, 28], lower in 3 studies [8, 29, 30], and equal (zero) in 2 studies [3, 10]. In the present study, recurrence rate was 0.8% in group A at one-year followup, while in group B the recurrence rate was 2.4%.

The recurrence rate in the group A is lower than that reported in the literature that is because we started laparoscopic hernia repair in our unit after gaining good experiences in different laparoscopic procedures. Complete encirclement of the neck of the sac at the IIR with piercing of the peritoneum twice by RN may add fixation of the suture at this level which prevents migration of the suture distally preventing recurrence. It also, may result in creation of adhesions of the sac minimizing hydrocele formation. Laparoscopic approach was conducted for all recurrent hernias in this study as recommended by others [13, 31]. The natural history of the PPV in infants remains a controversial topic. Prior studies indicate that 40% of PPVs close spontaneously by two months of age and 60% by 2 years of age; however, the risk of incarceration is highest during infancy [32].

While in some other series PPVs less than 2mm were not closed [6]. Our approach has been to ligate all PPVs to avoid the development of metachronous hernia. However, more studies are needed to clarify Dacomitinib this point. For many years, the possible risks of testicular atrophy (0.7�C13%), spermatic vessel injury (1.6%), and nerve injury (5�C15%) with routine contralateral exploration and repair of PPV in children who have primary unilateral inguinal hernia have been debated [33].