Loss Of Domain In Giant

Inguinal Hernia
Dr. Srinivas
Definition Of Scrotal Hernia
KQ1: Is there a Definition and System of Classification for Scrotal Hernia?

• Recommendation: Scrotal hernia is defined as an inguinal hernia which has descended into and
causes any distortion of the scrotum. It is suggested to denote Scrotal Hernia with an S and this can
be subdivided into S1 (upper third thigh), S2 (middle third thigh) and S3 (lower third
thigh/patellar). Measurements should be taken from the mid inguinal point to the lowest part of
the scrotum in upright position. S(IR) is used to denote irreducible scrotal hernia.

• EHS Classification of Scrotal Hernia- L3/M3
• Sanders et al- 10, 20, 30cm
• Trakarnsagna et al
• Ertem et al- Volumetric system of grading scrotal sac using CT scan during valsava ( 0-500, 500-
999, 1000-1999, 2000-2999, >3000 )
Risks of Complications

KQ2: Is there a Greater Risk of Complications Associated With Scrotal Hernia Repair?

• Statement: Repair of scrotal hernia using whatever method has a higher risk of complications
than non-scrotal inguinal hernia.

• Köckerling et al- 98321 patients from HerniaMed Registry, 2710 scrotal hernias (2.7%)

Scrotal hernia patients had increased age, BMI, higher ASA score, larger defects, more risk factors,
BUT lesser preoperative pain
Patients had higher post operative complications, complications related reoperations, general
complications- increased risk of bleeding, seroma formation, prolonged ileus, bowel injury,
anastomotic insufficiency, decreased wound healing, infection, BUT less chronic post operative
pain.
Specialization

KQ3: In View of Increased Risks of Complications in Repairing Scrotal

Hernias (Open or Endoscopic)—Should these be Performed by “Dedicated”
Specialist Hernia Surgeons?

• Recommendation: Management of scrotal hernias (especially for example S2 and S3/

Irreducible/Loss of Domain/ASA 4) can be associated with a high degree of complexity and
thereby a high risk of complications. It is suggested that repairs in these patients be performed by
teams that include dedicated Abdominal Wall Hernia surgeons.
• Köckerling et al 2710, Matthews et al 2614, Leibl et al 191, Bittner et al 440 (Single center), Bansal
et al 144 
    Even in recurrence.
Watchful Waiting

KQ4: Is there a Role for Watchful Waiting in Scrotal Hernias?

• Recommendation: Despite the higher rate of complications, scrotal hernias are suggested to be
repaired since quality of life improvements and decreased post-operative chronic pain scores
have been demonstrated.
• In high resource countries, in consideration of comorbidities in this patient cohort, watchful
waiting can be considered after shared decision between surgeon and patient.
• In low resource countries, with limited access to acute care surgery, watchful waiting is not
suggested. Sanders et al, Osifo et al – Inguinal hernias in Ghana
Diagnostics

KQ5: Should Preoperative Diagnostic Imaging be Requested for Scrotal

Hernias?

• Recommendation: Reducible scrotal hernias do not require any pre-op imaging while irreducible
scrotal hernias are suggested to undergo pre-op cross-sectional imaging or ultrasound if
available. 
• As per HerniaSurge guidelines, CT or MRI is beneficial in irreducible hernias as risk of visceral
injury is increased.
Anesthesia

KQ6: What is the Role of Local Versus Regional Versus General Anesthesia in
Scrotal Hernia Repair?

• Statement: General anesthesia must be used for endoscopic approaches for scrotal hernias. For
anterior approaches, local anesthesia can be used in large reducible scrotal hernias in selected
cases, especially in low-resource countries, although the risks of requiring intra-venous sedation
or conversion to regional or general anesthesia should be considered.
• Recommendation: General or regional anesthesia is recommended for irreducible scrotal hernias.
• Regional anesthesia is not generally recommended due to a higher risk of urine retention and
necessity of a Urinary Catheter. However, in low resource settings it is often the only option.
• Transversus abdominis block 30 minutes prior to local anaesthesia. 
• Osifo et al – 134 patients under local anaesthesia only 10 patients required IV sedation.
Suture Repair

KQ7: Is there a Role for Suture Repair in the Management of Scrotal Hernia?

• Recommendation: In general, and consistent with the inguinal hernia guidelines, the use of mesh
is recommended in the repair of scrotal hernias. However, in low resource settings and in cases of
contamination, a suture repair may be considered.
• Shouldice repair is preferred in such settings.
Operative Techniques (Excluding Suture Repair)

KQ8: What is the Recommended Technique for Repair of a Scrotal Hernia?

• Recommendation: Depending on expertise, minimally invasive techniques can safely be

employed. Although laparoscopic options are feasible, open repair remains the default operation
for irreducible scrotal hernias. It is suggested that surgeons treating scrotal hernias are proficient
in both anterior and posterior approaches.
• Bansal et al - 144 patients, 85 TEP & 59 TAPP ( 7 & 18 required a hybrid Lap assisted
approach ). TEP repair successful in 64 patients (75.3%) and converted to TAPP in 15 patients
(17.6%) and to open in 6 patients (7.1%). TAPP was successful in 53 patients (89.8%) and was
converted to open repair in 6 patients (10.2%). Seroma was noted in 42 patients, spermatic cord
edema in 26 patients, and scrotal hematoma in 14 patients at 1st week. The mean follow-up was 2
years. Two patients had recurrence and TAPP repair was done. None of the patients developed
mesh infection or chronic groin pain.
TEP or TAPP

KQ9: For Patients Considered Suitable for Endoscopic Repair Which

Method, TEP or TAPP, is More Suitable?

• Statement: In expert hands, it seems safe to use either the TEP (25% conversion rate) or TAPP
techniques for scrotal hernia repair. TAPP is the safest minimally invasive approach for irreducible
scrotal hernias. Conversion and complication rates are high and depend on the size and
complexity of the hernia.
• Leibl et al – 191 patients TAPP with 1% recurrence
• Ferzli et al - 17 patients TEP ( Divided Inferior Epigastric vessels to allow access to Deep inguinal
ring, also permitted the release of the transversalis fascial sling which allowed division of the floor
towards the external ring.
Prophylactic Antibiotics

KQ10: Is routine preoperative antibiotic prophylaxis necessary in scrotal

hernia repair?

• Recommendation: While there is generally no indication for antibiotic prophylaxis for primary
inguinal hernia repair (whether anterior or endoscopic), scrotal hernias represent a higher risk
cohort often with prolonged operative duration, increased dead space and tissue manipulation,
and potential bowel involvement as well as urinary catheterization. Pre-operative IV antibiotic
prophylaxis is recommended irrespective of the hospital setting (high or low resource countries).
• Strength of recommendation: Upgrade to Strong.
Urinary Catheterization

KQ11: Should Urinary Catheterization be Routinely Recommended in Scrotal

Hernia Repair?

• Recommendation: Bladder catheterization is not routinely recommended in scrotal hernia repair.

In complex scrotal hernia, (irreducibility, recurrence, loss of domain, S2 and S3, ASA 4, frail
patients), TEP/TAPP approach, and in situations with anticipated long operative time,
catheterization is suggested.
• Strength of recommendation: Upgrade to Strong.
• Anterior approach - Risk of bladder injury.
• TEP > TAPP - Safer insertion of trocar, decreased risk while Space of Retzius dissection, improve
mesh placement.
• 15% developed urinary difficulties after catheter removal.
Reducible Versus Irreducible Scrotal Hernia

KQ12: Does the Management Differ for Reducible Versus Irreducible Scrotal
Hernia?

• Statement: It is important to note that many irreducible scrotal hernias can be reduced after
induction of general anesthesia and muscle relaxation as well as placing the patient in
Trendelenburg position. Consequently, the decision as to whether the surgeon decides on an
anterior or laparoscopic approach may not be made until attempted reduction of herniated
content has been initiated. Even for experienced laparoscopic surgeon’s irreducibility may sway
them toward an open anterior approach if they are only experienced in the TEP approach.
Sac Management

KQ13: What is the Ideal Management of the Sac?

• Statement: While it is preferrable to attempt to reduce the sac en bloc, there are occasions when
this is not possible or even necessary. The decision of whether to abandon the sac depends on
difficulties encountered during attempted sac reduction and surgeon’s preference. Transecting
the neck and leaving the distal sac in situ probably increases the risk of seroma formation.
• Morrell et al – Primary Abandon of the Sac, neck incised circumferentially and peritoneal
flaps sutured, 2 out of 26 patients had seroma.
• Ferzli et al - Enlargement of internal ring after ligation of Inferior epigastric vessels and reduction
of complete sac.
• Daes et al - eTEP done and distal part of sac sutured to posterior inguinal canal.
• Savoie et al - 25 Bassini's repair done with sac in situ, 3 patients developed seromas with 2
requiring aspiration.
Drains Use
KQ14: Does the Use of Drains Decrease the Incidence of Seroma Formation
in the Repair of Scrotal Hernia, Open or Endoscopic?

• Statement: For standard inguinal hernia repair, either open or laparoscopic, HerniaSurge does not
recommend the use of drains. However, for scrotal hernias the use of drains may be justified
depending on surgeon’s preference and patient factors such as large size or S2/3 (outside the
focus of this guideline) hernias.
• With or without drains, risk of seroma 29%.
• Agresta et al - 10 B/L scrotal hernias TAPP with drain placement developed no seromas.
• Most seromas are asymptomatic and resolve with 3 months.
• Large & symptomatic seromas require surgical intervention.
Orchidectomy

KQ15: Should Orchidectomy be Considered in the Operative Management of

Scrotal Hernias?

• Statement: Orchidectomy may be considered for complex or longstanding scrotal hernia but is
not routinely recommended. The possible necessity should be considered in the informed
consent process.
• Leibel et al – 1 out of 193 TAPP patients.
• Bansal et al – 5 out of 144 patients.
• Osifo et al – 0 out of 134 patients.
• Maybe required even in the post operative period.
Cremaster Resection

KQ16: What is the Ideal Management of the Cremaster and Nerves in Scrotal
Hernia Repair?

• Statement: In open anterior repair, nerve identifying surgery and pragmatic resection are
recommended. In longstanding scrotal hernias with enlargement of the cord, hypertrophic
cremaster and an enlarged internal ring a cremaster resection and pragmatic neurectomy can be
necessary to reconstruct the internal ring.
Scrotal Skin Management

KQ17: What is the Role of Scrotoplasty in the Management of Scrotal

Hernias?

• Statement: The scrotal skin has an unusual ability to stretch and shrink and it is rarely necessary
to excise the excess skin during open or endoscopic scrotal hernia repair unless the skin is
compromised.
• A case series of 134 patients with Bassini's repair with no scrotoplasty had 18 patients with
scrotal haematoma.
• Bansal et al – No scrotoplasty in 144 patients.
• Delayed scrotoplasty can be done in persistent redundancy and troublesome scrotal haematoma.
Mesh Fixation

KQ18: Should Mesh Fixation be Recommended for all Endoscopic Scrotal

Hernia Repairs?

• Statement: As per HerniaSurge guidelines, in endoscopic repair direct inguinal and hence scrotal
hernias with large defects should have adequate overlap across the midline and the mesh should
in M3 defects be fixed with traumatic fixation in the midline and/or pubic ramus to minimize the
risks of a direct recurrence. A larger and “heavier” weight mesh should be considered for very
large defects.
• Reduction of a large direct sac & decreasing the dead space either with tack inversion to Cooper's
ligament or Rectus abdominis –Minimizes the risk of medial aspect of mesh eventrating into the
defect.
• Large indirect sacs are inverted and tacked superolaterally, well above the inguinal nerves to
prevent risk recurrence and seroma.
• NOT recommended to narrow the defect due to the risk of nerve entrapment.
Management of Hydrocele and Scrotal Hernia

KQ19: What is the Management of a Coexistent Hydrocele at Scrotal Hernia

Repair?

• Recommendation: In view of increased rate of complications including infection, concomitant

treatment of hydrocele with scrotal hernia repair is not suggested.
What is Giant Inguinal Hernia ?

• Why – Neglect, lack of facilities, embarassment, fear of surgery

• Contents – Udwadia et al : GIH + Haemetemesis – Strangulated stomach in GIH
Paul Sayad et al : Gastric perforation – 2 stage repair
Fitz et al : Gastric perforation in GIH
Kenjiro et al : Duodenal rupture ( DJ + Right Hemicolectomy )
Weitzenfeld et al : HUN due to herniation of kidney & ureter
• Problems – Penis is buried with urethra distortion : Voiding difficulty & urinary retention,
UTIs, urine dribbling with skin excoriation, ulceration and secondary infection, decreased
mobility, back pain & posture change, atrophy of testis, psychological impact.
• Physiological changes
Akpo's classification of bilateral giant inguinoscrotal hernia
Grades Description

Grade 0 The phallus is incompletely engulfed in its detumescence state

Grade 1 The phallus is completely engulfed in its detumescence state

1a. The complete phallic length is exposed following erection with the hernia reduced

1b. Part of the phallus is exposed in its tumescence state

Grade 2 The phallus is completely engulfed in its tumescence state

Grade 3 Presence of complications e.g. skin necrosis/ulceration, urine retention, acute abdomen

3a: Skin necrosis/ulceration

3b: Urinary retention
3c: Acute abdomen from intestinal obstruction
Operative Problems:
• Loss of Domain & IAH/ACS
• Cardiorespiratory problems
• Need for elective post operative
ventilation 
• Wound breakdown & recurrence
• Scrotal skin is left redundant
• Loss of Domain : Simple reduction in its contents & primary fascial closure either can't be
achieved without additional reconstruction techniques or can't be achieved without significant
risk of complications due to raised IAP.
• Volumetric definition : 
Sabbagh index : LOD >20% = HSV/ACV+HSV
                                                       HSV/TPV
Tanaka index : LOD >0.25 = HSV/ACV
                              0.52*l*b*h 
Certain considerations
• Lateral extension of internal ring or dividing the lower end of rectus
• ?Role of colon evaluation, 0.4% malignancy
 Intrasaccular
 Saccular
 Extrasaccular
• Bowel preparation
• Spermatic cord and testis
• Closed drainage system – Chronicity and scrotal haematoma
Gnas et al 2014
Coetze et al
• Debulking procedures : Omentectomy, Right hemicolectomy, Total colectomy, Small bowel
resection
• Ziffren & Womack 1950
• Direct forced closure 30- 60% recurrence
• Hamer et al : 10 patients with PPP – No recurrence 
                            20 patients with direct closure – 3 recurrence
• Astudillo et al : 12 vs 12
    Decreased hospital stay ( 3.5 +/-  1 vs 12.5 +/-  1.5 days ), Duration of ileus, Dosing of narcotics,    
      Operative time, Recurrence in 2 years
• Savoie et al : 1 Spontaneous reduction in decubitus position with No trophic changes 
Touroff et al 1954 - Phrenectomy
Serpell et al 1988
Hug Technique Cavalli et al
Pre operative Progressive Pneumoperitoneum

• Goni Moreno 1950

• Site of creation under Local anaesthesia
• Technique, Conze et al 
    Martinez Munise – Double lumen catheter ; Peritoneal dialysis catheter, Silicone Foley's
• Initial insufflation and End point ( Goni Moreno )
• Volume, duration & Pressure 
• Limitations
• Adverse effects : Clexane, Herzage et al; No to N2O
• Contra-indications
• Advantages :
o Allows fascial repair under decreased tension
o Pneumatic lysis of the intestinal adhesions
o Reduction of hernial contents
o Locates occult hernias or areas of weakness
o Stretching of hernial sac and skin cleansing
o Improves diaphragm function
o Decreases chronic oedema of mesentery
o Therapeutic vs Diagnostic
Botulinum Toxin

• ACh release inhibitor ; Ibarra et al

• Clinical effects within 2-3 days, Maximum effects in 2 weeks, Duration 3-6 months
• Contra-indications : MG , AG
• Cakmak et al – BTA & AWR
• 300 Units in 150ml ( 2U/ml ) - 25ml in each site, 3 points, Inject Inside out
• 500 Units in 50ml ( 10U/ml ) - 5ml in each site, 5 points, Beuno Lledo et al