What are the steps and considerations for a right inguinal scrotal repair open procedure?

Open Right Inguinal Scrotal Hernia Repair Technique

The standard open surgical approach remains the preferred technique for right inguinal scrotal hernia repair due to its reliability, reproducibility, and excellent outcomes with lower recurrence rates when performed correctly.

Preoperative Considerations

• Evaluate patient for modifiable risk factors:
  • Smoking cessation
  • Diabetes control (HbA1C <7%)
  • Weight management (BMI <40 kg/m²) 1
• Obtain appropriate imaging if needed to assess hernia extent
• Consider antibiotic prophylaxis with 1st generation cephalosporin (e.g., cefazolin 2g) 2
• Ensure proper anesthesia (local anesthesia with sedation is preferred for open repair) 3

Surgical Technique

Step 1: Incision and Exposure

• Make an oblique incision approximately 2 cm above the inguinal ligament, starting at the pubic tubercle and extending laterally 5-7 cm
• Divide subcutaneous tissue and Scarpa's fascia to expose the external oblique aponeurosis
• Identify the external ring and open the external oblique aponeurosis along its fibers to expose the inguinal canal

Step 2: Sac Identification and Dissection

• Identify and isolate the hernia sac from the spermatic cord structures
• For large inguinoscrotal hernias:
  • Carefully dissect the sac from cord structures up to the deep ring
  • For very large scrotal components, consider pulling the distal sac out of the scrotum and fixing it high and laterally to the posterior inguinal wall to prevent seroma formation 4
  • Avoid complete dissection of distal sac extending deep into scrotum to prevent orchitis and damage to cord structures 4

Step 3: Sac Management

• Open the sac and inspect contents
• Reduce contents back into peritoneal cavity
• High ligation of the sac at the internal ring
• For large scrotal hernias, consider partial excision of the sac with fixation of the remainder to prevent seroma formation 5

Step 4: Repair Technique

• For primary repair of small defects (<3 cm):

  • Use non-absorbable sutures to approximate the transversalis fascia
  • Reinforce the posterior wall of the inguinal canal

• For larger defects (>3 cm) or recurrent hernias:

  • Perform tension-free repair using mesh (Lichtenstein technique) 1, 3
  • Use synthetic non-absorbable mesh for clean fields 1
  • Ensure mesh overlaps the defect by 1.5-2.5 cm in all directions 1
  • Secure mesh with non-absorbable sutures to the pubic tubercle, inguinal ligament, and conjoined tendon

Step 5: Closure

• Close the external oblique aponeurosis with absorbable sutures
• Close Scarpa's fascia and subcutaneous tissue with absorbable sutures
• Close skin with subcuticular sutures or skin staples

Special Considerations for Scrotal Hernias

• For giant inguinoscrotal hernias:

  • Consider creating a midline anterior wall defect to increase intra-abdominal capacity
  • Cover defect with mesh and then with a rotation flap of inguinoscrotal skin 5
  • This technique helps prevent respiratory compromise in patients with chronic airflow limitation

• For scrotal component management:

  • Avoid aggressive dissection of distal sac to prevent damage to cord structures
  • Consider partial excision with fixation of the remainder to prevent seroma formation 4
  • Keep patient on bed rest for 48-72 hours after repair of large scrotal defects 2

Postoperative Care

• Monitor for complications including seroma, surgical site infection, and recurrence 1
• Use multimodal pain management:
  • Acetaminophen and NSAIDs as first-line treatment
  • Minimize opioid use 1
• Early mobilization as tolerated
• Remove drains when drainage is less than 30-50 mL/day (usually 3-17 days postoperatively) 2
• Consider suppressive dose of oral cephalosporin for several weeks postoperatively to decrease wound-related complications 2

Potential Complications

• Seroma formation (particularly with large scrotal hernias)
• Hematoma
• Wound infection
• Testicular atrophy or ischemia
• Chronic pain
• Recurrence

The open approach for inguinal scrotal hernia repair remains the standard of care, especially for large scrotal hernias, due to its reliability and reproducibility. While laparoscopic and robotic approaches are emerging options with potential benefits of shorter hospital stays and fewer wound infections 1, 6, the open technique offers advantages of lower recurrence rates, ability to be performed under local anesthesia, and better management of the scrotal component of the hernia.