Laparoscopic closure of the fascial defect combined with medial umbilical ligament reinforcement for incarcerated pediatric direct inguinal hernia: a case report with emergency management insights

Objective: Pediatric direct inguinal hernia (DIH) is an extremely rare congenital abdominal wall defect, accounting for less than 4% of all pediatric inguinal hernias. Its clinical manifestations overlap highly with indirect inguinal hernia (IIH), leading to frequent diagnostic dilemmas in emergency settings, especially for incarcerated cases. This single-case report aims to describe a case of incarcerated pediatric DIH and elaborate on the emergency diagnostic and therapeutic approach, to provide a detailed reference for managing similar cases. Methods: A 15-month-old male infant with left incarcerated DIH was admitted to the emergency department. Point-of-care ultrasound (POCUS) was performed to confirm the diagnosis by identifying the herniation pathway through Hesselbach's triangle. Laparoscopic closure of the fascial defect combined with medial umbilical ligament reinforcement was implemented without synthetic mesh implantation, in line with the physiological characteristics of pediatric abdominal wall development. Results: The infant was accurately diagnosed via POCUS within 2 h of admission, and emergency laparoscopic surgery was completed within 6 h (including time for diagnosis, preoperative optimization, and mandatory fasting). The operation duration was 15 min with an estimated blood loss of 1 mL. Postoperative recovery was uneventful, and the infant was discharged on postoperative day 1. Follow-up at 1, 2, 3 and 6 months showed no hernia recurrence, with normal abdominal wall development. Conclusion: In this case, POCUS was instrumental in the emergency differential diagnosis. Laparoscopic defect closure combined with medial umbilical ligament reinforcement, which avoids synthetic mesh, appeared to be safe and feasible with good short-term outcomes. This report highlights a diagnostic and therapeutic pathway for a rare condition. As a single-case report, these findings are hypothesis-generating and require validation in larger studies. Future prospective studies with longer follow-up are needed to confirm the efficacy and generalizability of this approach.