Management of Giant Scrotal Hernia George Ferzli, MD, FACSChairman of Surgery, Lutheran Medical CenterProfessor of Surgery, SUNY HSCBrooklyn, New York, USA

Disclosure

Nothing to disclose.

General Douglas MacArthur developed bilateral hernias early in his military career but refused surgery until shortly before his death in his 80s. ("Old soldiers never die, they just fade away.")

Managing Inguinal Hernias, Albert B. Lowenfels, MD, FACS, 91st Annual Clinical Congress 2005   

Old Soldiers Never Die: The Life of Douglas MacArthur. by Geoffrey Perret Author(s) of Review: James I. Matray The Journal of Military History, Vol. 61, No. 3 (July 1997), pp. 634-635 doi:10.2307/2954062

Careful Patient Selection and Preop Education:

Preoperative discussion:

• Prostatism / constipation / abdominal straining colonoscopy recommended

• Pulmonary disease / fitness for general anesthesia

• Smoking cessation 2 weeks prior to operation (effect on wound healing, chronic cough, hernia recurrence)

• Previous incarceration, strangulation, hernia repair, abdominopelvic surgery or wound infection?

• Obesity?

Adrales, Gina L. MD, FACS, The Large Scrotal Hernia, SAGES 2008 Postgraduate Course: Challenging Hernias, Philadelphia PA April 9, 2008

Physical Exam:• Hernia reducibility?• Bilateral hernia?• Areas of nerve involvement (anesthesia /

hyperesthesia / contact dysesthesia)• Degree of testicle descent• Scrotal exam – note testicular or cord masses,

testicular lie and extent of scrotal sac• Skin exam – rule out rash, eczema or

candiadiasis (may increase the risk of wound and mesh infection - a full course of antifungal treatment for a week after the rash is visibly cleared to facilitate full resolution). Chronic open sores raises suspicion for Staph. infection, possibly methicillin-resistant. Should be addressed and if MRSA positive, eradication treatment may be beneficial. Adrales, Gina L. MD, FACS, The Large Scrotal Hernia, SAGES 2008 Postgraduate Course: Challenging Hernias, Philadelphia PA April 9, 2008

Potential Risks / Informed Consent:

• Ischemic orchitis - divide sac rather than reduce it

Adrales, Gina L. MD, FACS, The Large Scrotal Hernia, SAGES 2008 Postgraduate Course: Challenging Hernias, Philadelphia PA April 9, 2008

• Vas deferens injury due to obscure anatomy and inability to identify

• Nerve injury / entrapment and resulting chronic neuropathic pain

Femoral brs, genitofem.n.

Lateral femoral

cutaneous n.

Genital brs, genitofemoral n.

Potential Risks / Informed Consent:

• Bowel or bladder injury pitfall: thickened sac,– In sliding hernia, vessels are posterior, beware

of delayed injury

• Seroma

• Recurrence - can be related to lack of understanding of the difficult laparoscopic anatomy, or an incorrectly-sized prosthesis.

ABSOLUTE:• Prior groin irradiation• Prior pelvic lymph node resection• Massive scrotal hernia It appears that laparoscopy is notrecommended for the management of giant and massive inguino-scrotalhernias

RELATIVE:• Non-reducible, incarcerated inguino-scrotal hernia

• Prior laparoscopic herniorrhaphy

Contraindications to laparoscopic approach:

In TEP, the umbilicus-pubis distance and panniculus thickness are critical for trocar placement

TEP vs TAPP

• Supine position YES YES

• Foley catheter placement YES YES

• General anesthesia YES YES

• Reduce hernia sac manually

more operating space YES YES

• CO2 pressure 10 15

• Surgeon opposite hernia site YES YES

• Trocar placement 4 3

Trocar placement:

Transabdominal

Preperitoneal (TAPP)

Totally

Extraperitoneal (TEP)

Additional

trocar

Trocar placement considerations:

• Epigastric vessels

• Bladder

• Variable nerve distribution

Totally extraperitoneal (TEP) method:

• Midline dissection to pubic symphysis, identify Cooper ligament

• Medial dissection of Retzius’ space followed by lateral dissection of Bogros space

• Division of epigastric vessels

• Lipoma management

• Division of transversalis sling

• Dissection of hernia sac

• Reduction of hernia sac

• Closure of hernia sac

• Mesh placement

• Secure sac to mesh

• JP drain placed

1. SURGICAL MANAGEMENT:

Identify Cooper ligament

2. SURGICAL MANAGEMENT

Dissection of Bogros space

3. SURGICAL MANAGEMENT

Division of epigastric vessels

Why divide the epigastric vessels?

To allow easier dissection of the sac and to avoid warping of mesh

Direct hernia Indirect hernia

Note: releasing incision (division of transversalis sling)floor is opened to gain remote hernial access

4. SURGICAL MANAGEMENT

Division of transversalis fascia sling

• Provides access to remote hernia sac

• Increases working space

5. SURGICAL MANAGEMENT

Lipoma management

Why supress a preperitoneal cordal lipoma?

• Delineates sac wall

• More room to work

6. SURGICAL MANAGEMENT

Hernial sac reduction

If testicle and tunica vaginalis present into space - divide sac rather than reduce it to minimize de-vascularisation

7. SURGICAL MANAGEMENT

Hernia sac division

Be careful not to injure bowel or bladder

8. SURGICAL MANAGEMENT

Hernial sac closure

Beware of not catching bowel

9. SURGICAL MANAGEMENT

Sac secured to mesh

Oversized polypropylene mesh for adequate coverage

To tack, or not to tack

“that is the question”

Increase in hernia recurrence?

Increase in post-operative pain and cost.

10. SURGICAL MANAGEMENT

Drain placement

• Drain in lateral port• Icepack and NSAIDs help reduce postoperative discomfort

n

or-time [median, min.]

morbidity

reoperative rate

recurrence rate

conversion rate

age [median]

TEP George Ferzli MD FACS, 1990 –2007

Results

Total number of TEP -1706

1 cecum, 12 seromas

2 hydrocelectomies

n = 82

69

15.8%

2.4%

2.4%

9.7%

age [Median] 64

Transabdominal preperitoneal (TAPP) method

results results

*eigene Rezidive: n=92 extern vorop: n=70

PH (without preop.)

last 2000

40

1,7%

0,3%

0,1%

10

50 [17-100]

25

PH

n=13136

40

2,8%

0,4%

0,7%

14

60 [17-97]

25

scrotal hernia

n=807

60

4,4%

0,85%

2,3%

17

61(18-97)

25

post. repair

n=162*

75

7,0%

3,8%

0,6%

17

59 [29-90]

25

n

op-time [med.,min.]

morbidity

reop.-rate

rec.-rate out of work [med.,days

age [Median]

BMI [Median]

TAPP Marienhospital Stuttgart, 3/93-12/07

• Patients with giant inguino-scrotal hernias and those with previous lower abdominal incisions or other complicating situation usually undergo TAPP herniorrhaphy

• The challenge of TAPP procedure for giant inguino-scrotal hernias is peritoneal closure (peritoneum can be thin and easily torn once dissected – difficult to obtain complete coverage of the prosthesis)

• TEP is more demanding than TAPP initially because of the limited working space

• Surgeons should be comfortable with TAPP herniorrhaphy for giant inguino-scrotal hernias before progressing to TEP

Conclusion:

the

end

Giant (vs non-giant) scrotal hernia repair:

• Anesthesia: general (not epidural or local)

• A Foley catheter is always placed

• Hernia reduced manually after the patient is asleep

• 3 trocars placed (may need additional 4th)

• Epigastric vessels are always divided:

allows access to the deep internal ring without injury

mesh lies smoothly without warping

• Transversalis fascia sling divided to gain access to the distal sac

• A preperitoneal cordal lipoma must first be suppressed:

Increases working space and better visualization of sac

margins