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

3. General Douglas MacArthur developed bilateral hernias early in his military career but refused surgery until shortly before his death in his 80s. ("Old soldiers never die, they just fade away.") 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

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

14. 1. SURGICAL MANAGEMENT: Identify Cooper ligament

15. 2. SURGICAL MANAGEMENT Dissection of Bogros space

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

17. Direct hernia Indirect hernia Note: releasing incision (division of transversalis sling) floor is opened to gain remote hernial access

18. 4. SURGICAL MANAGEMENT Division of transversalis fascia sling • Provides access to remote hernia sac • Increases working space

19. 5. SURGICAL MANAGEMENT Lipoma management Why supress a preperitoneal cordal lipoma? • Delineates sac wall • More room to work

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

21. 7. SURGICAL MANAGEMENT Hernia sac division Be careful not to injure bowel or bladder

22. 8. SURGICAL MANAGEMENT Hernial sac closure Beware of not catching bowel

23. 9. SURGICAL MANAGEMENT Sac secured to mesh Oversized polypropylene mesh for adequate coverage

24. To tack, or not to tack “ that is the question” Increase in hernia recurrence? Increase in post-operative pain and cost.

25. 10. SURGICAL MANAGEMENT Drain placement • Drain in lateral port • Icepack and NSAIDs help reduce postoperative discomfort

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

27. Transabdominal preperitoneal (TAPP) method

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

30. the end