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Objectives: The objective of this study was to describe use of the medial umbilical ligament (MUL) as a reinforcing flap to cover the internal ring (IR) during laparoscopic herniorrhaphy in children with indirect inguinal hernia. Methods: Laparoscopic high ligation of the IR was performed in a cohort (A) of 110 children with 140 indirect hernias between October 2001 and December 2004. We then developed 'recurrence risk criteria' to explain four recurrences (2.8%). These criteria include previous recurrence, an IR ≥1.5 cm in diameter (anterior-posterior), and older children in their teenage years (13-18 years). From January 2005 to February 2010, we carried out similar repairs in 226 consecutive children (cohort B) with 307 indirect hernias, except that we reinforced the IR with an MUL flap if one of the three recurrence risk criteria were met ( n=36). Of these children, 15 had an enlarged IR, 10 had recurrences, and 11 were teenagers. Results: The median patient age was 6.2 and 6.5 years in Groups A and B, respectively; there were four recurrences of 140 repairs (2.8%) in Group A, with a mean follow-up of 55 months (2-110 months). There were no recurrences in Group B including 36 MUL reinforcements with a mean follow-up of 32 months (5-74 months). Conclusion: Indirect hernias closed with our technique of laparoscopic high ligation of the IR will recur in 2.8% of children. Based on risk factors that we have developed, children prone to recurrence can be selected for MUL flap reinforcement of the IR, which may bring the recurrence rate close to zero. [ABSTRACT FROM AUTHOR]