Bilateral giant inguinoscrotal hernia. Presentation of a novel combined two-stage repair approach

Management strategy of giant inguinoscrotal hernia-a case series of 24 consecutive patients surgically treated over 17 years period

PURPOSE

Management of giant inguinoscrotal hernia (GIH) is still a challenging procedure associated with a higher risk of intraabdominal hypertension and abdominal compartment syndrome as a life-threatening condition. The aim of the study was to present our management strategy for GIH.

METHODS

This is a retrospective review of a case series including 24 consecutive patients with 25 GIH who underwent reconstructive surgery from January 2006 to June 2023, at the University Clinic for Digestive Surgery and Hernia Center Zuvela. A combined surgical strategy was applied: the modified Rives repair for groin hernias alone, Rives combined with organ resection to reduce hernia contents, and Rives combined with procedures for abdominal cavity enlargement. A surgical approach was defined based on the patient's general health, the volume of the hernia sac, and perioperative parameters.

RESULTS

All patients were male aged between 43 and 82 years. Rives was the only procedure in 12 patients. In addition to Rives, omentectomy was performed in four patients and intestinal resection in one. Abdominal cavity enlargement was performed following Rives hernioplasty in 9 patients. The median operative time was 215 min (range, 70-720). Surgical complications occurred in seven patients. In-hospital mortality was 12.5%. There was no groin hernia recurrence.

CONCLUSION

Our strategy is a single-stage treatment including modified Rives repair with or without additional procedures for abdominal cavity enlargement or hernia volume reduction, tailored to the individual patient characteristics. The procedure is associated with a higher risk of major morbidity requiring a well-trained intensive care unit team.

Botulinum Toxin A as an Adjunct for the Repair Giant Inguinal Hernias: Case Reports and a Review of the Literature

The management of giant inguinoscrotal hernias remains a challenge as a result of the loss of the intra-abdominal domain from long-standing hernia contents within the scrotum. Multiple techniques have been described for abdominal wall relaxation and augmentation to allow the safe return of viscera from the scrotum to the intraperitoneal cavity without adversely affecting cardiorespiratory physiology. Preoperative progressive pneumoperitoneum, phrenectomy, and component separation are but a few common techniques previously described as adjuncts to the management of these massively large hernias. However, these strategies require an additional invasive stage, and reproducibility remains challenging. Botulinum toxin A (BTA) has been successfully used for the management of complex ventral hernias. Its use for these hernias has shown reproducibility and a low side effect profile. In the present report, we describe our institutional experience with BTA for giant inguinal hernias in two patients and present a review of the literature. In one case, a 77-year-old man with a substantial cardiac history presented with a giant left inguinal hernia that was interfering with his activities of daily living. He had BTA six weeks prior to inguinal hernia repair. Repair was performed via an inguinal incision with a favorable return of the viscera into the peritoneum. He was discharged on the same day of the operation. A second patient, 78 years of age, had a giant right inguinoscrotal hernia. He had a significant cardiac history and was treated with BTA six weeks prior to inguinal hernia repair via a groin incision. Neither patient had complaints nor recurrence at 7- and 3-month follow-ups. While the literature on this topic is scarce, we found 13 cases of inguinal hernias treated with BTA as an adjunct. BTA might be a promising adjunct for the management of giant inguinoscrotal hernias in addition to or in place of current strategies.

Bilateral giant inguinoscrotal hernia: A case report

Introduction

Bilateral giant inguinoscrotal hernia (GIH) is rare and creates significant challenge in surgical management. The main concern of hernia reduction to abdominal cavity is development of abdominal compartment syndrome (ACS). Different approaches for prevention of ACS after surgery have been suggested.

Case presentation

We report a case of 68-year-old male with bilateral inguinoscrotal hernia for 20 years reaching just below midpoint of thigh. He presented with difficulty in micturition and mobility. Preoperative investigations were normal. He underwent bilateral mesh repair without any preoperative or intraoperative adjunct measures. No significant complication occurred in postoperative period.

Case discussion

Bilateral GIH is rare and the patients usually present late. GIH has been classified into three types on the basis of extension. Type I GIH can be managed with simple hernioplasty, in both unilateral and bilateral cases. Measures like resection of hernia contents and measures to enlarge intraabdominal space are warranted in type II and III GIH. Abdominal volume can be increased by utilising techniques like Pre-operative Progressive Pneumoperitoneum (PPP), injection of Botulinum toxin A (BTA) in the anterior abdominal wall, and rotation of viable tissue. The measures can be used either alone or in combination.

Conclusion

Type I GIH can be treated with simple hernioplasty with safety with monitoring for features of ACS and respiratory complications postoperatively. However, additional measures like resection of hernia contents or procedures to enlarge intra-abdominal space are warranted for type II and III GIH.

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Surgical management of bilateral giant inguinoscrotal hernia is challenging as reduction of hernia contents to abdominal cavity may lead to development of abdominal compartment syndrome (ACS) and cardiorespiratory complications.

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We report a case of bilateral GIH managed with bilateral mesh repair with postoperative monitoring for features of ACS and cardiorespiratory complications.

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There was no significant complication in the postoperative period and no recurrence in six month follow-up period.

The Use of Botulinum Toxin in Complex Hernia Surgery: Achieving a Sense of Closure

Abdominal wall surgeons have developed a host of tools to help facilitate fascial closure. Botulinum toxin A is one of the most recently identified treatments and has grown in popularity over recent years; showing great promise in a number of case series and cohort studies. The toxin paralyses lateral abdominal wall muscles in order to increase laxity of the tissues—facilitating medialisation of the rectus muscles. Several research groups around the world are developing expertise with its use-uncovering its potential. We present a review of the relevant literature over the last two decades, summarising the key evidence behind its indications, dosing and effects.

Successful outcome of a giant inguinoscrotal hernia: a novel two-staged repair using preoperative progressive pneumoperitoneum and transversus abdominis release

Giant inguinoscrotal hernias, defined as the extension beyond the midpoint of the inner thigh, continue to require multi-step approaches due to their complexity. Although rare in developed countries, they are commonly present in rural areas after years of neglect. This consequently allows the abdomen to maladapt to lower volumes, creating a loss of domain. Here, we present a giant left inguinoscrotal hernia managed with a unique multi-stage approach, aimed to minimize commonly encountered perioperative complications associated with abdominal hypertension. The combined two-staged approach used begins with preoperative progressive pneumoperitoneum, followed by the combined procedures of laparotomy hernia repair (Stoppa technique) and transversus abdominis release, thereby promoting a tension-free closure that is able to accommodate the reduced contents. Various modalities used in treating these hernias have been previously described; however, to our knowledge, the combined use of techniques described here has not been reported.