Introduction: Inguinal hernia repair represents a major component of paediatric surgical workload, yet outcome reporting from resource-limited settings is often limited by incomplete case-mix characterization and inadequate follow-up. We evaluated clinical outcomes and service implications using a practical coding method in a large tertiary cohort. Objectives: To characterize outcomes and case-mix in paediatric inguinal hernia repair. Methods: We conducted a retrospective cohort study of children (0–16 years) undergoing inguinal hernia repair between January 2019 and December 2025 at a highvolume tertiary paediatric centre (n = 515). Recurrent presentations were identified using asterisk notation in operative laterality records. Demographics, operative approach, recurrence, metachronous hernia, and emergency presentation were analysed. Results: Median age at repair was 24 months, 65.6% of patients were male, and 47 .6% had rightsided hernias. Fourteen patients (2.7%) presented with recurrent hernias, most managed laparoscopically (64% vs 36%, p > 0.05). Overall post-repair recurrence was 1.9% and was higher following laparoscopic repair (4.9% vs 1.0%, p = 0.014). Emergency surgery occurred in 9.5% of cases and was most frequent in infants under 12 months, with similar use of open and laparoscopic approaches. Metachronous hernia developed in 9.2% of unilateral repairs. Conclusion: Systematic case-mix characterization using a low-cost coding method improvesoutcome interpretation in resource-limited settings. The opposing effects of laparoscopic repair on recurrence and metachronous hernia highlight the need for careful case selection and technical standardization. Prioritizing early infant repair and strengthening pragmatic data systems may improve surgical quality and service delivery in comparable environments.