laparoscopic inguinal hernia repair is now used as an alternative to conventional open herniotomy in children . although there is ongoing debate regarding the preferred method of inguinal hernia repair , the laparoscopic approach is gaining popularity because of the potential advantages of faster recovery , attenuated pain , improved cosmetics , and low recurrence rates ( 1,2 ) . among various laparoscopic techniques , laparoscopic percutaneous extraperitoneal closure ( lpec ) of the hernia is a recently well - developed technique ( 3 ) . a previous study evaluated the safety , efficacy , and reliability of lpec in children ( 4 ) . however , because this technique involves percutaneous closure of inguinal hernias , the inclusion of tissues between the skin and hernial sac , including nerves and muscles , may cause injury and increase the postoperative morbidity in the long - term ( 5 ) . the present study described a novel and effective technique to close inguinal hernias with transumbilical endoscopic surgery in girls . the surgical technique was modified according to our previous study ( 5 ) . under general anesthesia , patients were laid supine in the trendelenburg position at a 15 tilt . the surgeon performed the operation standing on the patient 's left side , and the camera assistant stood on the right side . a veress needle was inserted into the abdomen , and pneumoperitoneum was established at 8 to 12 mmhg . one 3-mm trocar and one 5-mm trocar were inserted through the umbilicus , and a 4.5-mm 0 laparoscope ( karl storz gmbh & co. , tuttlingen , germany ) and a 3-mm needle holder were placed through the umbilical incision ( fig . the needle holder was placed on the identical side for the convenience of suturing . under laparoscopic monitoring , a round needle with 20 non - absorbable suture material was introduced into the peritoneal cavity through the anterior abdominal wall near the internal inguinal ring . the suture inside the peritoneal cavity was 5 to 8 cm long , and the end of the suture was left outside the peritoneal cavity in favor of ligation . the needle was passed through the peritoneum to place an extraperitoneal purse - string suture around the internal inguinal ring ( fig . the needle was then passed back into the peritoneal cavity and out through the abdominal wall , and the needle ends of the stitch were cut . the operating assistant maintained tension on the end of the suture outside the abdominal cavity , and a 3- or 5-mm needle holder was used to manipulate the end of the suture inside the peritoneal cavity ( fig . 3 ) . before the knot of the purse - string stitch was tied , the hernia sac was compressed to expel the gas and liquid within the sac . airtightness was confirmed by the absence of hernial sac enlargement when the intraperitoneal pressure was increased . the same procedure was performed on the contralateral side if the processus vaginalis was patent . a total of 96 female pediatric patients ( age range , 8 months to 8 years ; median , 3.4 years ) with inguinal hernias ( 25 left - sided , 53 right - sided and 18 bilateral ) were included in this study . from december , 2009 to august , 2015 , 114 procedures were performed in 96 female pediatric patients using the transumbilical laparoscopic intraperitoneal closure technique . the mean operating time was 15 min ( range , 1020 min ) for the unilateral and 24 min ( range , 1828 min ) for the bilateral lesions . the findings showed less operative bleeding , no major complications , and no secondary injury for all the groups . the postoperative course was uneventful for all the patients , and no severe perioperative complications were observed . the mean follow - up period was 28 months ( range , 674 months ) . there were no cases of recurrence or postoperative hydrocele . laparoscopic inguinal hernia repair in children has recently become an alternative to conventional open herniotomy . various single - incision laparoscopic surgeries have been reported ( 57 ) . however , given the fact that laparoscopic inguinal hernia repair technique involves percutaneous closure of inguinal hernias , tissues between the skin and hernial sac , including nerves and muscles , may be injured by their inclusion in the suture line , which potentially increases postoperative morbidity in the long - term . to preserve the advantages and overcome the limitations of the single - port technique , we designed a novel technique with which to close inguinal hernias with transumbilical laparoscopic intraperitoneal closure in female pediatric patients . this technique involves transumbilical laparoscopic closure of inguinal hernias without the use of special instruments . it requires one 3-mm trocar and one 5-mm trocar with a 4.5-mm 0 laparoscope and a 3-mm needle holder . the direction of the purse - string suture is circular , counterclockwise on the left and clockwise on the right to avoid injury to the inferior epigastric artery . purse - string suturing is easier to perform in female patients because there is no vas deferens or spermatic cord ; thus , the operator is less concerned about causing injury . after purse - string suturing , the needle is passed out through the abdominal wall and knots are tied intraperitoneally with a one - hand tie to avoid injury . transumbilical laparoscopic intraperitoneal closure in female patients provides a true high ligation analogous to that performed in the open technique . we observed no recurrence in the patients of the present study during our limited follow - up period . scarless endoscopic abdominal surgery has become an important concern in recent years with the development of minimally invasive surgery . a new concept known as natural orifice transluminal endoscopic surgery appeared with the publication of the first experimental study by kalloo et al ( 8) ; however , few clinical studies explaining this method exist in the literature . the major limiting barriers for its clinical application include access , closure , infection , suturing technology , and orientation ( 9 ) . compared to natural orifice transluminal endoscopic surgery , transumbilical endoscopic surgery is a less complicated and safer method . transumbilical endoscopic surgery produce scarless outcome and theoretically has the same advantage of rapid recovery . compared to the current single - incision laparoscopic extraperitoneal closure techniques , our method is easy to perform and the instruments are readily available . our preliminary experience showed satisfactory outcomes with the transumbilical laparoscopic intraperitoneal closure technique for complete endoscopic closure of inguinal hernias in female pediatric patients . cosmetic result and the ability to simultaneously detect and repair contralateral patent processus vaginalis are the two main advantages of laparoscopic surgery over open surgery . our results suggest that transumbilical endoscopic surgery for inguinal hernias in female pediatric patients is safe , effective , and reliable . two - port transumbilical laparoscopic intraperitoneal closure of inguinal hernias is an effective technique in minimal - access surgery for pediatric patients . the cosmetic results of transumbilical laparoscopic intraperitoneal closure in the present study were excellent because of the presence of only two umbilical wounds for the unilateral and bilateral hernias . the wound scar associated with the laparoscopic port was hidden in the umbilicus , and the puncture wounds made by the devices were minimal . 4 ) . in the present study , because the hernia sac was closed intracorporeally , the risk of intra - abdominal complications was not totally eliminated . although serious complications such as unintentional puncturing of the iliac vein and intra - abdominal viscus did not occur , future studies with greater numbers of patients and long - term follow - ups should be conducted .
laparoscopic percutaneous extraperitoneal closure of inguinal hernia with variable devices as an effective technique in minimal - access surgery for pediatric inguinal hernias in children was investigated in the present study . 
 a veress needle was inserted into the abdomen . 
 trocars , laparoscope and needle holder were placed through the umbilical incision . under laparoscopic monitoring , 
 a round needle was introduced into the peritoneal cavity through the anterior abdominal wall . 
 the end of the suture inside the peritoneal cavity was left outside the peritoneal cavity in favor of ligation . 
 the needle was passed through the peritoneum to place an extraperitoneal purse - string suture around the internal inguinal ring , counterclockwise on the left and clockwise on the right . 
 the needle was then passed back into the peritoneal cavity and out through the abdominal wall , and the needle ends of the stitch were cut . 
 the ends of the suture were tied . 
 we described a technique used for transumbilical endoscopic closure of pediatric inguinal hernias in girls . 
 this technique is simple and can be performed quickly . 
 the cosmetic result is excellent because the two umbilical incisions are only 5-mm long , which make it possible to perform surgery without a visible scar . 
 we performed this procedure in over 96 patients and have had no recurrences . 
 thus , this method may become the laparoscopic repair of choice for females with inguinal hernias .