Introduction Inguinal herniotomy is one of the most common operations performed in paediatric surgical practice. Isolation and high ligation of the indirect hernia sac is well recognised as an essential part of the operation and may be combined with narrowing of the deep ring and/or repair of the inguinal canal floor [1]. To gain access to the hernia sac at the deep ring, the transin- guinal approach is commonly used; the superficial ring is opened and the hernia sac separated from the sper- matic cord. In the preterm, neonate or young infant this step can be technically demanding and carries the risk of damaging the vas deferens, testicular vessels or creating a tear in the sac, which may lead to hernia recurrence. The preperitoneal approach is an alternative open technique for inguinal hernias that was introduced by Annandale in 1886. Access to the deep ring is achieved through the preperitoneal space with no dissection required in the inguinal canal. In early reports, the approach was not considered suitable for boys younger than 7 or 8, or for routine hernia repairs in infants and children [2, 3]. However, in later reports it was successfully used in infants with incar- cerated hernias using a transverse suprainguinal muscle-splitting incision [4–6]. We have been using the preperitoneal approach on all infants with routine and incarcerated ingui- nal hernias for the past 9 years. The purpose of the current study was to evaluate our experience, in particular to examine efficacy, outcome and complications. Patients and methods The medical records of all infants who consecutively underwent preperitoneal inguinal herniotomy be- tween January 1995 to March 2004 were retrospec- tively reviewed. All infants had primary hernias that were operated upon by one Consultant Paediatric Surgeon (AM) at the Norfolk & Norwich University Hospital. Data retrieved from each record included: patient demographics, operative details, post-operative com- plications (particularly hernia recurrence and testicular atrophy) and follow-up interval. For this study, pre- term was defined as less than 37 weeks’ gestational age at operation. Operative time reflected actual operating time i.e. excluded anaesthetic time. Both elective and emergency cases were included. The latter was defined as those presenting with incar- ceration or recent history of suchlike. Manual reduc- tion under sedation was attempted first for those presenting with incarceration and if successful, herni- otomy performed on the next available operating list. If manual reduction was unsuccessful, herniotomy was performed the same day. Early in the series contralateral exploration was routinely performed in both elective and emergency cases. This was subsequently discontinued with the advent of hernioscopy and growing evidence to suggest possible morbidity with this practice. V. Karri (&) Æ D. Klass Æ S. Alshryda Æ A. Mathur Department of Paediatric Surgery, Norfolk & Norwich University Hospital, Colney Lane, Colney, Norwich, Norfolk NR4 7UY, UK e-mail: vasu_karri@hotmail.com Pediatr Surg Int (2006) 22:785–789 DOI 10.1007/s00383-006-1775-8 123 ORIGINAL ARTICLE Preperitoneal approach for herniotomy in infants: a 9-year review Vasu Karri Æ Darren Klass Æ Sattar Alshryda Æ Azad Mathur Accepted: 8 August 2006 / Published online: 30 August 2006 Ó Springer-Verlag 2006