Application of the NICE Knot in Laparoscopic High Ligation of Pediatric Indirect Inguinal Hernia: A 21-Patient Case Series in Obese Older Children

Yalong Ma¹Luyu Ren¹Zixuan Li²Tixue Wang²Yanying Li²Jinsong Sun²Chongfang Zhang²Baohua Yu²Ping Li^2*

• ¹Jining Medical University Clinical Medical College, Jining, China
• ²Affiliated Hospital of Jining Medical University, Jining, China

Rationale: Indirect inguinal hernia is the most common type of abdominal external hernia in clinical practice. During Laparoscopic percutaneous extraperitoneal ligation of the internal ring, extracorporeal suture knotting is required. If excessive tension is applied during knotting or for obese older children with thick abdominal walls and large internal inguinal rings, conventional extracorporeal knotting in laparoscopic hernia repair often fails to achieve sufficient tightness, leading to a high risk of recurrence—this clinical challenge calls for a practical technical optimization. Patient concerns: Twenty-one pediatric patients with indirect inguinal hernia were enrolled, their BMI percentiles ranged from P95.1 to P99.9 (mean: P97.5), BMI z-scores from 2.03 to 3.91 (mean: 2.83), and corresponding BMI values from 29.0 to 38.0 kg/m² (mean: 32.1 kg/m²). Diagnoses: Indirect Inguinal Hernia. Interventions: Laparoscopic high ligation of the hernia sac for indirect inguinal hernia was performed immediately. The pediatric patients in this group were older children with obesity, characterized by a thick abdominal wall and abundant subcutaneous fat, and a larger diameter of the internal ring. Conventional extracorporeal knotting proved inadequate to achieve sufficient tightness, preventing complete closure of the internal ring. Consequently, a ligation technique for improvement was adopted: strong braided sutures were employed using the Nice knot technique, followed by three alternating single knots to achieve firm fixation. Examination confirmed stable ligation of the hernia ring. Outcomes: All cases in this group were successfully operated laparoscopically without conversion to open surgery. Follow-up was conducted over a period of 6 - 24 months (mean: 12 months), during which no recurrence of the hernia was observed. After recovery, no significant scars were visible in the inguinal region or around the umbilicus. Lesson: This study optimized the application of the Nice knot (a mature suture technique) to address the clinical difficulty of extracorporeal knotting in 21 obese older children with indirect inguinal hernias. The value of this technical adaptation lies in its practicality—effectively improving knot stability and reducing recurrence risk in this specific pediatric subgroup, rather than a new discovery of the knot itself. The postoperative treatment was excellent, with no scarring and no recurrences observed.