Modified Mitchell-Banks technique in pediatric inguinal hernia repair: a personalized surgical approach

The classical Mitchell-Banks herniotomy (MBH) is widely employed in infants; however, its applicability in older pediatric populations remains incompletely defined. To address this limitation, we describe an external-oblique-sparing modification of MBH incorporating controlled aponeurotic stretching and the Axis-Directed Inguinal Alignment Maneuver (ADIAM), referred to in this study as the Büyükbeşe technique.

To evaluate the feasibility, short-term clinical outcomes, and early complication profile of the Büyükbeşe technique across different pediatric age groups and to descriptively examine relationships between internal inguinal ring (IIR) diameter, anatomical characteristics, and postoperative outcomes.

This single-center retrospective study included 110 pediatric patients aged 0-18 years who underwent hernia repair between October 1, 2024, and April 21, 2025. Patients were analyzed according to predefined age groups (0-2, 2-5, 5-10, and 10-18 years), ethnicity, and local surgical complication status.

The mean age was 4.79 ± 4.02 years, and 82.7% of patients were male. The mean IIR diameter was 8.59 ± 4.86 mm. Overall perioperative adverse events occurred in 20.0% of patients, including local surgical complications in 19.1%, predominantly scrotal edema (11.8%) and hematoma (4.5%). One systemic perioperative adverse event, postoperative respiratory failure, occurred in 0.9% of patients and was included in the overall perioperative adverse event count. Patients with local surgical complications were significantly younger (1.31 ± 1.05 vs. 5.61 ± 4.02 years), shorter (71.2 ± 14.2 vs. 98.6 ± 29.8 cm), and had larger IIR diameters than those without local surgical complications (10.88 ± 7.03 vs. 8.05 ± 4.06 mm; p = 0.034). Local surgical complication rates decreased with age (0-2 years: 45.7%; 10-18 years: 0.0%; p < 0.001). No early recurrence, surgical site infection, or clinically evident testicular complications were observed during the 30-day follow-up period, and all procedures were mesh-free.

In this preliminary technical case series, the Büyükbeşe technique, an external-oblique-sparing modification of Mitchell-Banks herniotomy, was technically feasible in clinical practice, with short-term findings that should be interpreted cautiously because of the observed early local postoperative morbidity. Exploratory observations suggested that younger age, smaller body size, and relatively larger IIR diameters were more frequently observed among patients with local surgical complications; however, these findings remain hypothesis-generating and require prospective validation. The technique may offer preservation of the anterior inguinal wall, but this potential advantage should be considered alongside the technical challenges associated with limited operative exposure, increased traction, and deep tissue manipulation within a confined operative corridor, particularly in the youngest age group. Further evaluation in diverse clinical settings may help clarify the reproducibility and generalizability of this technique.