What are the benefits, alternatives, and risks of surgical repair for inguinal scrotal hernias?

Benefits, Alternatives, and Risks of Surgical Repair for Inguinal Scrotal Hernias

Surgical repair is the only definitive treatment for inguinal scrotal hernias, with benefits including prevention of complications such as incarceration and strangulation, while risks include wound infection, seroma formation, and recurrence. 1

Benefits of Surgical Repair

• Prevention of complications: Surgery prevents potentially life-threatening complications such as:

  • Incarceration (trapped hernia contents)
  • Strangulation (compromised blood supply to hernia contents)
  • Intestinal obstruction
  • Skin complications (ulceration or necrosis) 1

• Improved quality of life: Repair resolves symptoms including:

  • Pain and discomfort
  • Cosmetic concerns from scrotal distortion
  • Functional limitations in daily activities 2

• Long-term resolution: Surgical repair offers a definitive solution to prevent progression of the hernia, which is particularly important as scrotal hernias represent a heavy disease burden on relatively young men during their most productive period of life 2

Surgical Approaches

1. Open Anterior Approach:

   • Most commonly used technique worldwide 2
   • Preferred for hemodynamically unstable patients 1
   • Uses midline incision over the hernia with identification and isolation of the hernia sac
   • Primary repair with non-absorbable sutures when possible
   • Mesh reinforcement for defects >3 cm 1

2. Laparoscopic Approaches:

   • TAPP (Transabdominal Preperitoneal):

     • Lower conversion rates to open surgery compared to TEP 2
     • Benefits include shorter hospital stays and fewer wound infections 1
     • Uses triangular or diamond configuration of 3-4 trocars 1

   • TEP (Totally Extraperitoneal):

     • Alternative minimally invasive approach 2
     • May have higher conversion rates to open surgery for scrotal hernias 2

3. Robotic-Assisted Repair:

   • Emerging technique with favorable outcomes
   • Average case duration: 100 minutes for unilateral hernias 3
   • Low recurrence rates reported 3

4. Combined Approaches:

   • Open + TAPP/TEP methods for complex scrotal hernias
   • May minimize surgical trauma and reduce procedure time 4

Alternatives to Surgery

• Watchful waiting: Not recommended for symptomatic scrotal hernias due to high risk of complications 1, 2
• Truss or supportive devices: May temporarily relieve symptoms but do not treat the underlying condition and are not considered definitive treatment 2

Risks and Complications

1. Immediate Complications:

   • Bleeding and hematoma formation (including massive penoscrotal hematoma in rare cases) 5
   • Serosal bowel injury during dissection 4
   • Urinary retention (especially in complex cases) 2

2. Early Postoperative Complications:

   • Seroma formation (collection of fluid) 4, 3
   • Surgical site infections
   • Pain requiring analgesic management 1
   • Abdominal compartment syndrome in unstable patients 1

3. Late Complications:

   • Chronic pain (2-3% of cases) 4
   • Recurrence of hernia
   • Testicular atrophy (rare)
   • Cosmetic disfigurement 5

Special Considerations

• Size Classification: Scrotal hernias are classified based on size:

  • SI: Upper third thigh
  • SII: Middle thigh
  • SIII: Lower third thigh or below
  • IR: Irreducible 2

• Giant Inguinoscrotal Hernias: Extremely large hernias extending below the knee require special management approaches:

  • May require staged repair
  • Preoperative pneumoperitoneum may be needed
  • Higher risk of respiratory complications after contents are returned to abdominal cavity 6

• Antibiotic Prophylaxis: Recommended despite weak evidence 2

  • 1st generation cephalosporin (e.g., cefazolin 2g) 1

• Mesh Selection:

  • Synthetic non-absorbable mesh for clean fields
  • Biologic or biosynthetic meshes for contaminated/dirty fields 1

Postoperative Management

• Pain Control: Multimodal analgesic regimen to minimize opioid use:

  • Acetaminophen and NSAIDs as first-line treatment
  • Dexamethasone useful for reducing postoperative nausea and vomiting 1

• Activity Restrictions:

  • Bed rest for 48-72 hours after repair of large scrotal defects 1
  • Early mobilization for smaller defects

• Drain Management:

  • Remove drains when drainage is less than 30-50 mL/day (usually 3-17 days postoperatively) 1

• Monitoring:

  • Watch for signs of recurrence, infection, or seroma formation
  • Consider suppressive dose of oral cephalosporin for several weeks postoperatively to decrease wound-related complications in complex cases 1

Key Pitfalls to Avoid

• Inadequate bleeding control: Essential to achieve adequate hemostasis during and at the end of operation to avoid scrotal hematoma 5

• Delayed treatment: Strangulated hernias require immediate surgical intervention, as delayed treatment beyond 24 hours significantly increases mortality 1

• Inadequate mesh overlap: Ensure 1.5-2.5 cm mesh overlap to prevent recurrence 1

• Failure to address modifiable risk factors: Patients should be evaluated for smoking cessation, diabetes control (HbA1C <7%), and weight management (BMI <40 kg/m²) before elective surgery 1