Objective <p>To evaluate the clinical outcomes of laparoscopic internal ring reinforcement combined with high ligation and double-loop high ligation in the treatment of pediatric giant inguinal hernia.</p> Methods <p>This retrospective cohort study included 381 children with giant inguinal hernia who underwent laparoscopic repair at the Children’s Hospital Affiliated to Shandong University between February 2021 and April 2025. Patients were categorized into three groups according to the surgical technique employed. Group A (<i>n</i> = 155) underwent laparoscopic internal ring reinforcement by suturing the iliopubic tract to the lower margin of the transversus abdominis arch combined with high ligation of the hernia sac. Group B (<i>n</i> = 130) underwent laparoscopic double-loop high ligation, whereas the control group (<i>n</i> = 96) underwent conventional single high ligation. Perioperative outcomes, including operative time, intraoperative subperitoneal hematoma, 24-hour postoperative pain score, and recurrence within 12 months, were compared among the groups. Given the retrospective nature of the study and the potential for treatment-selection bias, an exploratory subgroup analysis was additionally performed in patients with an internal ring diameter of 1.5–2.0&#xa0;cm.</p> Results <p>No significant differences were observed among the three groups with respect to age, sex, laterality, or history of incarceration (all <i>P</i> &gt; 0.05). Using a 2.0-cm threshold derived from institutional experience, patients with an internal ring diameter ≥ 2.0&#xa0;cm preferentially underwent reinforcement-based procedures. Operative time was significantly longer in Groups A and B than in the control group (<i>P</i> &lt; 0.001). During the 12-month follow-up period, no recurrence was observed in either reinforcement group, whereas three recurrences occurred in the control group, resulting in a significant difference among the groups (<i>P</i> = 0.015). No significant differences were identified in the incidence of intraoperative subperitoneal hematoma or 24-hour postoperative pain scores (<i>P</i> = 0.946 and <i>P</i> = 0.589, respectively). In the exploratory subgroup analysis of patients with an internal ring diameter of 1.5–2.0&#xa0;cm, recurrence remained less frequent in the reinforcement groups, while postoperative pain scores and hematoma rates were comparable among the three groups. Exploratory odds ratio analysis also suggested a potential association between reinforcement-based procedures and a lower observed recurrence rate.</p> Conclusions <p>In children with giant inguinal hernia, reinforcement-based laparoscopic procedures may be associated with a lower observed recurrence rate than conventional single high ligation, without an apparent increase in operative morbidity. Double-loop high ligation may represent a feasible reinforcement option when excessive tension is encountered after single high ligation. These findings suggest a potential benefit of an internal ring diameter-oriented surgical strategy in selected patients. However, the 2.0-cm threshold used in this study was based on institutional experience rather than formal cutoff validation, and the results should be interpreted cautiously given the retrospective design, potential treatment-selection bias, and the limited number of recurrence events. Further prospective multicenter studies are required to validate these findings.</p>