From the Guidelines
Patients with hernia inguinoescrotal should undergo emergency hernia repair immediately when intestinal strangulation is suspected, as recommended by the 2017 update of the WSES guidelines for emergency repair of complicated abdominal wall hernias 1.
Diagnosis and Treatment
The diagnosis of hernia inguinoescrotal involves identifying the protrusion of abdominal contents through the inguinal canal and into the scrotum. Treatment typically requires surgical repair, as hernia inguinoescrotal does not resolve on its own and can lead to complications if left untreated.
- The recommended approach is a hernioplasty procedure, which can be performed using either open or laparoscopic techniques, with mesh reinforcement being the standard of care for most adult patients 1.
- The use of mesh in clean surgical fields (CDC wound class I) is associated with a lower recurrence rate, if compared to tissue repair, without an increase in the wound infection rate, as stated in the 2017 update of the WSES guidelines 1.
Preoperative Care
While awaiting surgery, patients should:
- Avoid heavy lifting (nothing over 10-15 pounds)
- Maintain healthy bowel habits to prevent constipation
- Seek immediate medical attention if they experience severe pain, nausea, vomiting, or inability to reduce the hernia, as these may indicate incarceration or strangulation requiring emergency intervention
Pain Management
Pain management can include acetaminophen or NSAIDs like ibuprofen (400-600mg every 6-8 hours) if not contraindicated.
Laparoscopic Approach
- Diagnostic laparoscopy may be a useful tool with the target of assessing bowel viability after spontaneous reduction of strangulated groin hernias, as stated in the 2017 update of the WSES guidelines 1.
- Repair of incarcerated hernias—both ventral and groin—may be performed with a laparoscopic approach in the absence of strangulation and suspicion of the need of bowel resection, where an open pre-peritoneal approach is preferable 1.
From the Research
Definition and Classification of Hernia Inguinoescrotal
- A hernia inguinoescrotal is defined as an inguinal hernia that has descended into and causes any scrotal distortion 2.
- A new classification for scrotal hernias was proposed based on hernia size, with SI for upper third thigh, SII for middle thigh, and SIII for lower third thigh or below, and irreducibility denoted with IR 2.
- The EHS classification system is suggested to stratify inguinal hernia patients for tailored treatment, research, and audit 3, 4.
Surgical Treatment Strategies
- Mesh repair is recommended as the first choice for inguinal hernia repair, either by an open procedure or a laparo-endoscopic repair technique 3, 4.
- The Lichtenstein technique is the standard in open inguinal hernia repair, and transabdominal preperitoneal and totally extraperitoneal approaches have comparable outcomes 3, 4.
- Open anterior repair for inguinal hernia offers several distinct advantages over endoscopic repair, including a shorter learning curve and lower costs 5.
- Laparoscopic approaches, such as TAPP and TEP, are recommended for minimally invasive repairs, with TAPP resulting in less conversion to open approach compared to TEP 2.
Management of Scrotal Hernias
- Scrotal hernia repairs have higher associated morbidity and mortality compared to non-complex groin hernia repairs, irrespective of surgical experience 2.
- Antibiotic prophylaxis is recommended for scrotal hernia repairs, despite weak evidence 2.
- Urinary catheterization is recommended in complex cases due to prolonged operative time 2.
- A combined open transabdominal and inguinal approach may be used to treat giant inguinoscrotal hernias, with meshes placed in a premuscular position and in a preperitoneal position 6.