Background

Very few surgical entities have fascinated surgeons over centuries than the complexity of inguinal hernia repair. Despite being one of the commonest procedures performed, the surgical fraternity all over the world is still in the quest for the final word on the best type of repair. Similarly, treatment of complex groin hernia remains the same [1]. Complex groin hernia can be defined as those with large size, e.g., inguinoscrotal hernia, sliding hernia, multiple recurrences, infected mesh and strangulation, etc. The approach to these hernias involves a great deal of preoperative preparations and decision-making that is carried through the operation and postoperative period. The laparoscopic approach in these cases is feasible and with good outcomes provided that the surgeon adheres to three M’s; mastery of the anatomy, meticulous dissection, and modus operandi [2]. No wonder hundreds of procedures have been described for the treatment of complex groin hernia. There has been always a concern about whether complex groin hernia can be treated with laparoscopy or not but more favorable outcomes have been found with laparoscopy than in open surgery [1].

The laparoscopic exploration allows for the treatment of incarcerated/strangulated hernias and the intraoperative diagnosis of occult hernias.

TAPP appeared to be superior in terms of learning curve, diagnosis of occult hernia, and the feasibility for incarcerated or strangulated hernia [3].

Complex Inguinoscrotal Hernias

Any hernia that passes beyond the inguinal ligament and extends to the scrotum is termed as inguinoscrotal hernia [4, 5]. Scrotal hernia has been defined subjectively in the past as scrotal, big scrotal, giant scrotal hernia, etc. Decision to choose the best approach to treat such a hernia is not unanimous and is different to treating surgeons. This may be attributed to absence of uniformity in classification of such type of hernias. In this scenario, Ertem M et al. have proposed a volumetric classification and based on this, the surgical procedure [4] (Table 1 and Fig. 1).

Table 1 Choice of surgery in relation to scrotal volume
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Fig. 1
Two images of a scrotal hernia. The first is a contrast-enhanced computed tomography image, the second is a photo with indicated measurements of 40 and 25 centimeters.

Measurement of scrotum volume in giant hernia

Scrotal volume can be calculated with the following formula [4]

Scrotal volume = length * width * depth * 0.52

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The clinical external measurement will provide almost exact volume. Normally the CECT for decision-making for scrotal hernia is not required, except in giant hernias and hernia with loss of domain.

Those inguinoscrotal hernias that are hanging below the midpoint of the inner thigh when the patient is standing is called as giant inguinal hernias [6] (Fig. 2). The term giant scrotal hernia should be used if the hernia volume is greater than 1000 ml [4].

Fig. 2
Three photographs of Types one, two, and three of giant scrotal hernias. These are hernias whose volume is greater than 1000 milliliters and hang below the midpoint of the inner thigh.

Showing giant scrotal hernias Type I, II, and III

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Challenges with Complex Inguinoscrotal Hernia

  1. 1.

    Large abdominal wall defects [EHS:M/L ≥ 3].

  2. 2.

    Difficulty in dissecting large hernia sac.

  3. 3.

    Increased risk of injury to inferior epigastric artery, testicular vessels, urinary bladder, sigmoid colon, etc.

  4. 4.

    Chronic bacterial and fungal skin infections.

  5. 5.

    Loss of domain.

  6. 6.

    Scrotal reconstruction.

Laparoscopy vs. Open

  1. 1.

    Comparison of laparoscopic and Lichtenstein repair in recurrent hernia by Z. Demetreshavili showed similar operative time (p = 0.068) and postoperative outcomes (infection, seroma, hematoma) (p = 0.19), less postoperative pain (p = 0.002) and few sicker days leave in TAPP (p < 0.001) [7].

  2. 2.

    Laparoscopic repair in cases of sliding hernia is safe and feasible with safe outcome. TAPP is the preferable method [1].

We will here be discussing about the laparoscopic management of the same. Complex groin hernia is much more difficult to repair through the anterior approach, not only because of the large volume to be reduced but also due to the retroperitoneal sliding component that usually occurs [8].

Indications for Laparoscopic Approach

All complex groin hernia cases are fit for surgery.

Contraindications for Laparoscopic Approach

  1. 1.

    Prior groin irradiation.

  2. 2.

    Prior pelvic lymph node.

  3. 3.

    Poor candidate for general anesthesia.

  4. 4.

    Giant inguinal hernia type II and III.

Relative Contraindications

  1. 1.

    Prior laparoscopic herniorrhaphies [9].

Preoperative Assessment

  1. 1.

    Select those patients who give consent for laparoscopic surgery.

  2. 2.

    Conditions predisposing hernia such as constipation, prostatism, pulmonary conditions asthma, COPD) should be addressed.

  3. 3.

    Adoption of lifestyle modifications such as cessation of smoking, exercise, and weight loss should be encouraged.

  4. 4.

    Hernia characteristics such as size, recurrent, bilateral, incarcerated, and strangulation should be assessed.

  5. 5.

    Consent should be taken and should be explained about the increased risk of complications such as seroma, SSI, vascular injury, injury to vas deferens, injury to bowel and urinary bladder, chronic groin pain, and recurrence.

As techniques of TEP and TAPP has been already discussed in the previous chapter, in this chapter an overview of special consideration that must be kept in mind while approaching laparoscopically will be discussed.

Special Considerations in Dealing Inguinoscrotal Hernias

  1. 1.

    Insertion of an additional fourth 5 mm trocar may be needed to facilitate the exposure (Fig. 3).

  2. 2.

    Wider preperitoneal space creation is required.

  3. 3.

    In the case of large and incarcerated hernias, releasing incision on transversalis sling is given with hook cautery at the 10 o’clock position (if necessary division of the epigastric vessels may be done) to allow remote hernial access and increases working space and complete reduction of the sac (Fig. 4).

  4. 4.

    Inferior epigastric vessels may be divided which allow access to the deep internal ring without injury and also allows the smooth placement of mesh without wrapping.

  5. 5.

    If hernia is not reducible, ring can be enlarged with anteromedial incision in case of direct hernia whereas antero-lateral incision in case of indirect hernia.

  6. 6.

    As sac is quite large in these patients, if complete reduction is not possible, it can be divided as distal as possible.

  7. 7.

    In order to check the viability of bowel in case of TEP, umbilical port is transferred from preperitoneal position to intraperitoneal position. If there is a need for resection of nonviable segment it can be done intraperitoneally once the repair of hernia is completed preperitoneally.

  8. 8.

    Hybrid approach: Combined laparoscopic approaches and open extraperitoneal approach when the content of the sac cannot be reduced (Fig. 5).

  9. 9.

    As defect is large, a standard weight mesh with wider covering (at least 4–5 cm) is preferable. The fixation must be favored in such cases.

  10. 10.

    A closed suction drain is inserted to prevent the inevitable incidence of postoperative seroma (optional).

  11. 11.

    In patients with loss of domain: various adjuncts to increase intra-abdominal space is required (i.e., preoperative progressive pneumoperitoneum, Botulinum toxins, component separation, musculocutaneous flaps, etc.) [6].

Fig. 3
An illustration of an exposed area for a surgical procedure with four dots exhibited. These dots serve as port placements, including the extra port in T E P P.

Creation of extra port in TEPP

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Fig. 4
An illustration of the division of the epigastric vessels in a transverse sling is depicted.

Showing division of transverse sling

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Fig. 5
Two photographs of the hybrid approach in inguinoscrotal hernia surgeries. The photo on the left is the combined laparoscopy approach, and the one on the right is the open extraperitoneal approach.

Hybrid approach: combined laparoscopy and open

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Sliding Inguinal Hernia

Sliding hernia is very uncommon of all hernia and contributes 6–8% of all hernia cases [10, 11]. It is a type of hernia in which the posterior wall of the sac is not only formed by the parietal peritoneum but also formed by the sigmoid colon with its mesentery on its left side, caecum on the right side, and often with the portion of bladder in both sides [10, 12]. Sliding hernia is also called as “longstanding hernia” and usually developed in old age patients with a history of long duration [10, 11].

Bendavid defines a sliding hernia as a “protrusion through an abdominal wall opening of a retroperitoneal organ, with or without its mesentery, with or without an adjacent peritoneal sac” [1, 10].

He describes three types of sliding hernia [1, 10, 11] (Fig. 5).

  1. 1.

    Type 1: most common and contributes 95% of sliding hernias

    : when a part of the peritoneal sac is made up by the wall of a viscus,

  2. 2.

    Type 2: contributes 5% of sliding hernias

    : when the mesentery of a retroperitoneal viscus forms part of the wall of the peritoneal sac

  3. 3.

    Type 3: very rare

    : when the viscus itself protrudes without a peritoneal sac.

Challenges with Sliding Hernia

  1. 1.

    Diagnosis of this hernia is not possible preoperatively and is usually an intraoperative finding [11] (Figs. 6 and 7).

  2. 2.

    This hernia continues to test the surgeon’s understanding of the inguinal canal’s anatomy and technical expertise with a significant rate of complications and a higher rate of recurrence [1, 10].

Fig. 6
A photograph of a probe on a sliding hernia.

Transabdominal view of sliding hernia

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Fig. 7
A photograph depicts the extraperitoneal view of a sliding hernia.

Totally extraperitoneal view of sliding hernia

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The surgeon’s experience and comfort level should dictate the choice of the safest repair for the patient. The common techniques and consideration of laparoscopic approach [TEP/TAPP] to inguinoscrotal hernias is already discussed in earlier chapter. We will here be discussing about the common pitfalls and the techniques/precautions to deal with it. Laparoscopic repair of sliding inguinal hernias is feasible and safe with impressive results. TAPP approach is preferred over TEP approach as it allows better identification of these hernias and offers easier method of sac reduction [1].

Special Considerations [1]

  1. 1.

    Foleys’s catheter needs to be inserted after induction of anesthesia-risk of urinary bladder injury is minimized by doing this.

  2. 2.

    After induction of general anesthesia attempt to reduce hernia content should be made. For irreducible hernias, TAPP should be done whereas reducible hernia needs to be operated by TEP.

  3. 3.

    Insertion of an additional fourth 5 mm trocar may be needed to facilitate the exposure.

  4. 4.

    As diagnosis of sliding hernia is intraoperative we should see whether the content of the sac is forming the wall of the sac or adhered to it. moreover sliding hernia may be missed during TEP repair as diagnosis is made only after opening of peritoneal sac which is not routinely opened in TEP repair.

  5. 5.

    Usually sliding hernia presents with irreducibility and also poses difficulty in reduction of sac, most surgeons prefer TAPP repair. Moreover, due to the high incidence of recurrence, retroperitonealization of the organ is also recommended which is possible with TAPP repair.

  6. 6.

    Attempt to separate the sac from the sliding component should never be made. In case of difficulty in reduction of sac, it may be divided beyond the level of the content. The deep inguinal ring may be cut on superolateral aspect to facilitate reduction of hernia contents.

  7. 7.

    The technique of a combined approach to these difficult cases can simply be another useful tool in the hernia surgeons’ armamentarium.

  8. 8.

    Do not hesitate to convert laparoscopic approach to open approach in cases where there is difficulty in reduction of sac and high risk of injuries to hernia contents. Stoppa or Lichtenstein repair may be preferable in some situations.

To ensure the proper safe landing of both patients and surgeons while approaching complex inguinoscrotal hernias laparoscopically, we strongly advised to follow the 10 golden rules for a safe MIS inguinal hernia repair [3] (summarized below) along with the abovementioned special considerations.

Summary of the Ten Golden Rules [3]

  1. 1.

    Beginning of surgery.

    Creation of peritoneal flaps in TAPP.

    Dissection of preperitoneal space in TEP.

  2. 2.

    Dissection should always follow the peritoneal plane.

  3. 3.

    Dissection must be creating enough space to accommodate an adequately sized mesh.

  4. 4.

    External iliac vein must be visible so that there is no chance of missed femoral hernias.

  5. 5.

    Parietalization of the elements of the cord must be sufficient.

  6. 6.

    If needed the distal hernia sac can be transected or abandoned in case of complex inguinoscrotal hernias.

  7. 7.

    The deep inguinal canal should be explored in search of lipoma of cord.

  8. 8.

    Mesh should properly cover the myopectineal orifice with overlap of atleast 3–4 cm.

  9. 9.

    Surgeon can decide intraoperatively if the mesh needs fixation.

  10. 10.

    Deflation should be done under direct visualization.

Complications

Intraoperative

  1. 1.

    Pneumoperitoneum.

  2. 2.

    Injury to inferior epigastric artery.

  3. 3.

    Injury to major vessels.

  4. 4.

    Bowel/Urinary bladder injury.

  5. 5.

    Inability to reduce hernia contents.

Postoperative

  1. 1.

    Acute urinary retention.

  2. 2.

    Seroma: The risk of seroma formation is higher for endoscopic techniques than for open repairs [9].

  3. 3.

    Hematoma: The incidence of hematomas is lower for endoscopic (4.2–13.1%) techniques than for open repair (5.6–16%) [9].

  4. 4.

    Chronic pain.

  5. 5.

    Ischemic orchitis.

  6. 6.

    Testicular atrophy.

  7. 7.

    Early recurrence.

Postoperative Care

  1. 1.

    Acute urinary retention: single shot rubber catheter drainage/Foley’s catheterization.

  2. 2.

    Day care surgery: can be discharged on the same day.

  3. 3.

    Analgesics: injectables/orals,

    To improve postoperative pain, infiltration of trocar site with local anesthesia is recommended.

  4. 4.

    Thromboprophylaxis: It is recommended that thromboembolic prophylaxis is given according to usual routines in patients with risk factors [9].

Conclusion

There has been little evidence about laparoscopic approach to complex inguinoscrotal hernias and sliding inguinal hernias. Before making a bold claim which technique is the best, more research should be conducted on this. Laparoscopic approach to these hernias is possible with a meticulous selection of patients and taking special considerations into account. The choice of techniques whether TAPP/TEPP depends upon the surgeon’s choice with which he/she is comfortable.