Management of  Giant Scrotal Hernia   George Ferzli, MD, FACS Chairman of Surgery,  Lutheran Medical Center Professor of S...
Disclosure <ul><li>Nothing to disclose. </li></ul>
General Douglas MacArthur developed bilateral hernias early in his military career but refused surgery until shortly befor...
 
Careful Patient Selection and Preop Education: Preoperative discussion: <ul><li>Prostatism / constipation / abdominal stra...
Physical Exam: <ul><li>Hernia reducibility? </li></ul><ul><li>Bilateral hernia? </li></ul><ul><li>Areas of nerve involveme...
Potential Risks / Informed Consent: <ul><li>Ischemic orchitis - divide sac rather than reduce it </li></ul>Adrales, Gina L...
Potential Risks / Informed Consent: <ul><li>Bowel or bladder injury pitfall: thickened sac, </li></ul><ul><ul><li>In slidi...
<ul><li>ABSOLUTE: </li></ul><ul><li>Prior groin irradiation </li></ul><ul><li>Prior pelvic lymph node resection </li></ul>...
TEP vs TAPP •   Supine position YES YES •   Foley catheter placement YES YES •   General anesthesia YES YES •   Reduce her...
Trocar placement: <ul><li>Transabdominal </li></ul><ul><li>Preperitoneal (TAPP) </li></ul>Totally Extraperitoneal (TEP) Ad...
Trocar placement considerations: <ul><li>Epigastric vessels </li></ul><ul><li>Bladder </li></ul><ul><li>Variable nerve dis...
Totally extraperitoneal (TEP) method: <ul><li>Midline dissection to pubic symphysis, identify Cooper ligament </li></ul><u...
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...
Direct hernia Indirect hernia Note: releasing incision (division of transversalis sling) floor is opened to gain remote he...
4. SURGICAL MANAGEMENT Division of transversalis fascia sling •  Provides access to remote hernia sac •  Increases working...
5. SURGICAL MANAGEMENT Lipoma management Why supress a preperitoneal cordal lipoma? •  Delineates sac wall •  More room to...
6. SURGICAL MANAGEMENT Hernial sac reduction If testicle and tunica vaginalis present into space - divide sac rather than ...
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 discomf...
n or-time [median, min.] morbidity  reoperative rate  recurrence rate  conversion rate age [median] TEP  George Ferzli MD ...
Transabdominal preperitoneal (TAPP) method
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] ...
<ul><li>Patients with giant inguino-scrotal hernias and those with previous lower abdominal incisions or other complicatin...
the end
Giant (vs non-giant) scrotal hernia repair: <ul><li>Anesthesia: general (not epidural or local) </li></ul><ul><li>A Foley ...
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Management of Giant Scrotal Hernia

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Management of Giant Scrotal Hernia

  1. 1. Management of Giant Scrotal Hernia George Ferzli, MD, FACS Chairman of Surgery, Lutheran Medical Center Professor of Surgery, SUNY HSC Brooklyn, New York, USA
  2. 2. Disclosure <ul><li>Nothing to disclose. </li></ul>
  3. 3. General Douglas MacArthur developed bilateral hernias early in his military career but refused surgery until shortly before his death in his 80s. (&quot;Old soldiers never die, they just fade away.&quot;) 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
  4. 5. Careful Patient Selection and Preop Education: Preoperative discussion: <ul><li>Prostatism / constipation / abdominal straining  colonoscopy recommended </li></ul><ul><li>Pulmonary disease / fitness for general anesthesia </li></ul><ul><li>Smoking cessation 2 weeks prior to operation (effect on wound healing, chronic cough, hernia recurrence) </li></ul><ul><li>Previous incarceration, strangulation, hernia repair, abdominopelvic surgery or wound infection? </li></ul><ul><li>Obesity? </li></ul>Adrales, Gina L. MD, FACS, The Large Scrotal Hernia, SAGES 2008 Postgraduate Course: Challenging Hernias, Philadelphia PA April 9, 2008
  5. 6. Physical Exam: <ul><li>Hernia reducibility? </li></ul><ul><li>Bilateral hernia? </li></ul><ul><li>Areas of nerve involvement (anesthesia / hyperesthesia / contact dysesthesia) </li></ul><ul><li>Degree of testicle descent </li></ul><ul><li>Scrotal exam – note testicular or cord masses, testicular lie and extent of scrotal sac </li></ul><ul><li>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. </li></ul>Adrales, Gina L. MD, FACS, The Large Scrotal Hernia, SAGES 2008 Postgraduate Course: Challenging Hernias, Philadelphia PA April 9, 2008
  6. 7. Potential Risks / Informed Consent: <ul><li>Ischemic orchitis - divide sac rather than reduce it </li></ul>Adrales, Gina L. MD, FACS, The Large Scrotal Hernia, SAGES 2008 Postgraduate Course: Challenging Hernias, Philadelphia PA April 9, 2008 <ul><li>Vas deferens injury due to obscure </li></ul><ul><li>anatomy and inability to identify </li></ul><ul><li>Nerve injury / entrapment and </li></ul><ul><li>resulting chronic neuropathic pain </li></ul>Femoral brs, genitofem.n. Lateral femoral cutaneous n. Genital brs, genitofemoral n.
  7. 8. Potential Risks / Informed Consent: <ul><li>Bowel or bladder injury pitfall: thickened sac, </li></ul><ul><ul><li>In sliding hernia, vessels are posterior, beware of delayed injury </li></ul></ul><ul><li>Seroma </li></ul><ul><li>Recurrence - can be related to lack of understanding of the difficult laparoscopic anatomy, or an incorrectly-sized prosthesis. </li></ul>
  8. 9. <ul><li>ABSOLUTE: </li></ul><ul><li>Prior groin irradiation </li></ul><ul><li>Prior pelvic lymph node resection </li></ul><ul><li>Massive scrotal hernia </li></ul><ul><li>It appears that laparoscopy is not </li></ul><ul><li>recommended for the management </li></ul><ul><li>of giant and massive inguino-scrotal </li></ul><ul><li>hernias </li></ul><ul><li>RELATIVE: </li></ul><ul><li>Non-reducible, incarcerated inguino-scrotal hernia </li></ul><ul><li>Prior laparoscopic herniorrhaphy </li></ul>Contraindications to laparoscopic approach: In TEP, the umbilicus-pubis distance and panniculus thickness are critical for trocar placement
  9. 10. 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 • CO 2 pressure 10 15 • Surgeon opposite hernia site YES YES • Trocar placement 4 3
  10. 11. Trocar placement: <ul><li>Transabdominal </li></ul><ul><li>Preperitoneal (TAPP) </li></ul>Totally Extraperitoneal (TEP) Additional trocar
  11. 12. Trocar placement considerations: <ul><li>Epigastric vessels </li></ul><ul><li>Bladder </li></ul><ul><li>Variable nerve distribution </li></ul>
  12. 13. Totally extraperitoneal (TEP) method: <ul><li>Midline dissection to pubic symphysis, identify Cooper ligament </li></ul><ul><li>Medial dissection of Retzius’ space followed by lateral dissection of Bogros space </li></ul><ul><li>Division of epigastric vessels </li></ul><ul><li>Lipoma management </li></ul><ul><li>Division of transversalis sling </li></ul><ul><li>Dissection of hernia sac </li></ul><ul><li>Reduction of hernia sac </li></ul><ul><li>Closure of hernia sac </li></ul><ul><li>Mesh placement </li></ul><ul><li>Secure sac to mesh </li></ul><ul><li>JP drain placed </li></ul>
  13. 14. 1. SURGICAL MANAGEMENT: Identify Cooper ligament
  14. 15. 2. SURGICAL MANAGEMENT Dissection of Bogros space
  15. 16. 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
  16. 17. Direct hernia Indirect hernia Note: releasing incision (division of transversalis sling) floor is opened to gain remote hernial access
  17. 18. 4. SURGICAL MANAGEMENT Division of transversalis fascia sling • Provides access to remote hernia sac • Increases working space
  18. 19. 5. SURGICAL MANAGEMENT Lipoma management Why supress a preperitoneal cordal lipoma? • Delineates sac wall • More room to work
  19. 20. 6. SURGICAL MANAGEMENT Hernial sac reduction If testicle and tunica vaginalis present into space - divide sac rather than reduce it to minimize de-vascularisation
  20. 21. 7. SURGICAL MANAGEMENT Hernia sac division Be careful not to injure bowel or bladder
  21. 22. 8. SURGICAL MANAGEMENT Hernial sac closure Beware of not catching bowel
  22. 23. 9. SURGICAL MANAGEMENT Sac secured to mesh Oversized polypropylene mesh for adequate coverage
  23. 24. To tack, or not to tack “ that is the question” Increase in hernia recurrence? Increase in post-operative pain and cost.
  24. 25. 10. SURGICAL MANAGEMENT Drain placement • Drain in lateral port • Icepack and NSAIDs help reduce postoperative discomfort
  25. 26. 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
  26. 27. Transabdominal preperitoneal (TAPP) method
  27. 28. 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
  28. 29. <ul><li>Patients with giant inguino-scrotal hernias and those with previous lower abdominal incisions or other complicating situation usually undergo TAPP herniorrhaphy </li></ul><ul><li>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) </li></ul><ul><li>TEP is more demanding than TAPP initially because of the limited working space </li></ul><ul><li>Surgeons should be comfortable with TAPP herniorrhaphy for giant inguino-scrotal hernias before progressing to TEP </li></ul>Conclusion:
  29. 30. the end
  30. 31. Giant (vs non-giant) scrotal hernia repair: <ul><li>Anesthesia: general (not epidural or local) </li></ul><ul><li>A Foley catheter is always placed </li></ul><ul><li>Hernia reduced manually after the patient is asleep </li></ul><ul><li>3 trocars placed (may need additional 4th) </li></ul><ul><li>Epigastric vessels are always divided: </li></ul><ul><ul><li>allows access to the deep internal ring without injury </li></ul></ul><ul><ul><li>mesh lies smoothly without warping </li></ul></ul><ul><li>Transversalis fascia sling divided to gain access to the distal sac </li></ul><ul><li>A preperitoneal cordal lipoma must first be suppressed: </li></ul><ul><ul><li>Increases working space and better visualization of sac </li></ul></ul><ul><ul><li>margins </li></ul></ul>

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