Purpose <p>The aim of this study was to compare the clinical efficacy, diagnostic concordance, and recurrence rates of open high ligation versus laparoscopic percutaneous internal ring suturing (PIRS) in adolescent inguinal hernia repair.</p> Methods <p>A retrospective review was conducted of 87 adolescent patients who underwent inguinal hernia repair via open high ligation (<i>n</i> = 44) or laparoscopic PIRS (<i>n</i> = 43) between 2012 and 2024 at a single tertiary care center. Demographic data, postoperative complications, recurrence, diagnostic concordance (kappa), and follow-up duration were analyzed.</p> Results <p>The median age in both groups was 12 years (range 10–17). Intraoperative diagnostic laparoscopy was performed in 44 patients in the open surgery group to evaluate the contralateral inguinal region, and contralateral hernia was detected and repaired simultaneously in one patient. Diagnostic concordance was perfect in the open group (κ = 0.945) and near-perfect in the PIRS group (κ = 0.885), both statistically significant (<i>p</i> &lt; 0.001). No recurrences were observed in the open group, whereas recurrence occurred in one patient in the laparoscopic group (<i>p</i> = 0.99). The mean follow-up duration was 103.8 months (range 11–150) and 31.7 months (range 4–137) in the open and laparoscopic group, respectively.</p> Conclusion <p>Laparoscopic PIRS repair in adolescents demonstrated outcomes comparable to open high ligation in terms of recurrence and complication rates.</p>