What are the management options for a post-operative adult male patient with a history of indirect inguinal hernia repair who still has a palpable sac in the scrotum?

Post-Operative Scrotal Sac After Indirect Inguinal Hernia Repair

A palpable sac in the scrotum after indirect inguinal hernia repair is abnormal and requires evaluation to distinguish between a residual/incompletely reduced hernia sac (which may contain fluid forming a seroma/pseudohydrocele), retained omental tissue ("omentaloma"), or true hernia recurrence.

Understanding the Post-Operative Scrotal Mass

The presence of a palpable scrotal mass after indirect inguinal hernia repair represents one of several distinct pathologies:

Residual Distal Sac with Seroma Formation

• When large inguinoscrotal hernias are repaired, complete dissection of the distal sac extending deep into the scrotum is often not performed due to risk of orchitis and cord structure damage 1
• Failure to adequately manage the distal sac commonly results in formation of a large seroma or pseudohydrocele in the remaining peritoneal sac 1
• Transection of the hernia sac during laparoscopic TEP repair (rather than complete reduction) significantly increases seroma formation (24 of 275 cases versus 6 of 245 cases with complete reduction, P = .002) 2

Retained Omental Tissue

• Incomplete removal of hernial sac contents during laparoscopic repair can result in retained omentum forming an encapsulated mass termed "omentaloma of the scrotum" 3
• This presents as persistent scrotal swelling with new onset scrotal pain post-operatively 3
• Imaging reveals a well-defined fat-containing mass that is hypointense on T2 fat-saturated MRI sequences 3

True Hernia Recurrence

• Actual recurrence with herniated contents extending into the scrotum is less common but must be excluded 4

Diagnostic Approach

Clinical Examination

• Palpate for a reducible mass versus a fixed, non-reducible structure 4
• Assess for tenderness, which suggests retained omentum or complications 3
• Examine for a palpable impulse on coughing (silk sign), which indicates patent processus vaginalis with active herniation 4
• Ensure the testis is palpable and separate from the mass 4

Imaging Studies

• Ultrasound is the initial imaging modality to characterize the scrotal mass and differentiate fluid collections from solid masses 3
• MRI provides definitive characterization when ultrasound is inconclusive, particularly for identifying fat-containing masses (retained omentum) versus fluid collections 3
• CT scanning is reserved for suspected complications like bowel obstruction or strangulation 4

Management Algorithm

Asymptomatic Seroma/Pseudohydrocele

• Small, asymptomatic fluid collections can be observed, as many resolve spontaneously over 3 months 1
• Symptomatic seromas identified at 8 days post-operatively can be drained with low recurrence risk 1

Retained Omentum (Omentaloma)

• Requires surgical excision via scrotal exploration when causing persistent swelling or pain 3
• Histopathology confirms lobules of fibroadipose tissue with chronic inflammation and foamy histiocytes 3
• Complete excision resolves symptoms 3

True Recurrence

• Requires repeat hernia repair using appropriate technique based on previous approach 5
• Laparoscopic approaches (TEP or TAPP) are particularly beneficial for recurrent hernias, offering comparable outcomes with reduced chronic pain 5

Prevention Strategies for Future Cases

Optimal Distal Sac Management

• For large inguinoscrotal hernias, the distal sac should be pulled out of the scrotum and fixed high and laterally to the posterior inguinal wall rather than left in situ 1
• This technique significantly reduces clinically significant seroma formation 1

Complete Sac Reduction

• When technically feasible, complete reduction of the hernia sac is preferable to transection, as it reduces seroma formation from 8.7% to 2.4% 2
• In cases with completely patent processus vaginalis, systematic division of the sac with proximal closure using pre-tied Endoloop is safe and effective without cord structure injury 6

Ensuring Complete Content Removal

• Meticulous inspection and complete removal of all hernial sac contents (particularly omentum) is crucial during laparoscopic repair 3

Common Pitfalls to Avoid

• Assuming all post-operative scrotal masses are benign seromas without imaging confirmation can miss retained omentum or recurrence 3
• Leaving the distal sac in situ without fixation in large inguinoscrotal hernias predictably leads to symptomatic seroma formation 1
• Transecting the hernia sac unnecessarily during TEP repair increases seroma risk when complete reduction is technically achievable 2