Inguinal hernia and hydrocele are common pediatric conditions arising from the persistence of a patent processus vaginalis (PPV). While clinical diagnosis and physical signs such as the contralateral silk sign are used for preoperative assessment, the decision to perform contralateral exploration remains controversial. This study aimed to evaluate the demographic and surgical characteristics of pediatric patients undergoing laparoscopic repair for inguinal hernia or hydrocele and assess the diagnostic accuracy of the contralateral silk sign in predicting contralateral PPV.

We conducted a retrospective cohort study from September 2017 to April 2024, including pediatric patients (≤18 years) who underwent laparoscopic repair of inguinal hernia or hydrocele performed by a single pediatric surgeon. Data collected included demographic variables, surgical findings, operative times, and the presence of contralateral silk signs and PPV. Analyses compared male patients with hernia versus hydrocele and males versus females with hernia. The accuracy of the silk sign in predicting contralateral PPV was calculated, and was evaluated through logistic regression. Statistical analyses were performed using SPSS 28.0, with p < 0.05 considered significant.

A total of 276 pediatric patients were analyzed (211 males and 65 females). Among male patients, 139 had inguinal hernia and 72 had hydrocele; all female patients presented with inguinal hernia. Males with hydrocele were significantly older than those with hernia (p < 0.01), while no differences were observed in gestational age, prematurity, or birth weight. Surgical complexity and operative time were comparable across hernia and hydrocele cases in males. However, females had a significantly shorter operation time than males (p < 0.01). Females preoperatively had a higher proportion of left-sided involvement and a lower proportion of right-sided involvement compared to males. Contralateral exploration revealed bilateral PPV in 49.2% of male and 55.4% of female hernia cases. Subgroup analysis of male patients ≥12 months showed no significant differences in baseline or surgical variables between hernia and hydrocele cases. The predictive value of the contralateral silk sign was limited, with no significant influence from patient age, sex, birth weight, or prematurity. Body weight percentiles also did not impact its accuracy.

Laparoscopic contralateral exploration revealed a high rate of occult PPV in pediatric patients with unilateral inguinal hernia or hydrocele. While the contralateral silk sign showed limited predictive value, it remains a useful but insufficient standalone tool. Surgical complexity did not significantly differ between hernia and hydrocele repair, though females experienced shorter operative times. These findings underscore the importance of intraoperative confirmation and suggest that demographic or clinical characteristics alone are inadequate predictors of contralateral PPV. Further prospective studies with larger, multi-institutional cohorts are warranted to optimize decision-making in pediatric hernia management.