Management of Giant Scrotal Hernia
-
Upload
george-s-ferzli -
Category
Health & Medicine
-
view
5.627 -
download
1
Transcript of Management of Giant Scrotal Hernia
![Page 1: Management of Giant Scrotal Hernia](https://reader035.fdocuments.us/reader035/viewer/2022062404/554b42f6b4c905b5378b4d62/html5/thumbnails/1.jpg)
Management of Giant Scrotal Hernia George Ferzli, MD, FACSChairman of Surgery, Lutheran Medical CenterProfessor of Surgery, SUNY HSCBrooklyn, New York, USA
![Page 2: Management of Giant Scrotal Hernia](https://reader035.fdocuments.us/reader035/viewer/2022062404/554b42f6b4c905b5378b4d62/html5/thumbnails/2.jpg)
Disclosure
Nothing to disclose.
![Page 3: Management of Giant Scrotal Hernia](https://reader035.fdocuments.us/reader035/viewer/2022062404/554b42f6b4c905b5378b4d62/html5/thumbnails/3.jpg)
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
![Page 4: Management of Giant Scrotal Hernia](https://reader035.fdocuments.us/reader035/viewer/2022062404/554b42f6b4c905b5378b4d62/html5/thumbnails/4.jpg)
![Page 5: Management of Giant Scrotal Hernia](https://reader035.fdocuments.us/reader035/viewer/2022062404/554b42f6b4c905b5378b4d62/html5/thumbnails/5.jpg)
Careful Patient Selection and Preop Education:
Preoperative discussion:
• Prostatism / constipation / abdominal straining colonoscopy recommended
• Pulmonary disease / fitness for general anesthesia
• Smoking cessation 2 weeks prior to operation (effect on wound healing, chronic cough, hernia recurrence)
• Previous incarceration, strangulation, hernia repair, abdominopelvic surgery or wound infection?
• Obesity?
Adrales, Gina L. MD, FACS, The Large Scrotal Hernia, SAGES 2008 Postgraduate Course: Challenging Hernias, Philadelphia PA April 9, 2008
![Page 6: Management of Giant Scrotal Hernia](https://reader035.fdocuments.us/reader035/viewer/2022062404/554b42f6b4c905b5378b4d62/html5/thumbnails/6.jpg)
Physical Exam:• Hernia reducibility?• Bilateral hernia?• Areas of nerve involvement (anesthesia /
hyperesthesia / contact dysesthesia)• Degree of testicle descent• Scrotal exam – note testicular or cord masses,
testicular lie and extent of scrotal sac• 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. Adrales, Gina L. MD, FACS, The Large Scrotal Hernia, SAGES 2008 Postgraduate Course: Challenging Hernias, Philadelphia PA April 9, 2008
![Page 7: Management of Giant Scrotal Hernia](https://reader035.fdocuments.us/reader035/viewer/2022062404/554b42f6b4c905b5378b4d62/html5/thumbnails/7.jpg)
Potential Risks / Informed Consent:
• Ischemic orchitis - divide sac rather than reduce it
Adrales, Gina L. MD, FACS, The Large Scrotal Hernia, SAGES 2008 Postgraduate Course: Challenging Hernias, Philadelphia PA April 9, 2008
• Vas deferens injury due to obscure anatomy and inability to identify
• Nerve injury / entrapment and resulting chronic neuropathic pain
Femoral brs, genitofem.n.
Lateral femoral
cutaneous n.
Genital brs, genitofemoral n.
![Page 8: Management of Giant Scrotal Hernia](https://reader035.fdocuments.us/reader035/viewer/2022062404/554b42f6b4c905b5378b4d62/html5/thumbnails/8.jpg)
Potential Risks / Informed Consent:
• Bowel or bladder injury pitfall: thickened sac,– In sliding hernia, vessels are posterior, beware
of delayed injury
• Seroma
• Recurrence - can be related to lack of understanding of the difficult laparoscopic anatomy, or an incorrectly-sized prosthesis.
![Page 9: Management of Giant Scrotal Hernia](https://reader035.fdocuments.us/reader035/viewer/2022062404/554b42f6b4c905b5378b4d62/html5/thumbnails/9.jpg)
ABSOLUTE:• Prior groin irradiation• Prior pelvic lymph node resection• Massive scrotal hernia It appears that laparoscopy is notrecommended for the management of giant and massive inguino-scrotalhernias
RELATIVE:• Non-reducible, incarcerated inguino-scrotal hernia
• Prior laparoscopic herniorrhaphy
Contraindications to laparoscopic approach:
In TEP, the umbilicus-pubis distance and panniculus thickness are critical for trocar placement
![Page 10: Management of Giant Scrotal Hernia](https://reader035.fdocuments.us/reader035/viewer/2022062404/554b42f6b4c905b5378b4d62/html5/thumbnails/10.jpg)
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
• CO2 pressure 10 15
• Surgeon opposite hernia site YES YES
• Trocar placement 4 3
![Page 11: Management of Giant Scrotal Hernia](https://reader035.fdocuments.us/reader035/viewer/2022062404/554b42f6b4c905b5378b4d62/html5/thumbnails/11.jpg)
Trocar placement:
Transabdominal
Preperitoneal (TAPP)
Totally
Extraperitoneal (TEP)
Additional
trocar
![Page 12: Management of Giant Scrotal Hernia](https://reader035.fdocuments.us/reader035/viewer/2022062404/554b42f6b4c905b5378b4d62/html5/thumbnails/12.jpg)
Trocar placement considerations:
• Epigastric vessels
• Bladder
• Variable nerve distribution
![Page 13: Management of Giant Scrotal Hernia](https://reader035.fdocuments.us/reader035/viewer/2022062404/554b42f6b4c905b5378b4d62/html5/thumbnails/13.jpg)
Totally extraperitoneal (TEP) method:
• Midline dissection to pubic symphysis, identify Cooper ligament
• Medial dissection of Retzius’ space followed by lateral dissection of Bogros space
• Division of epigastric vessels
• Lipoma management
• Division of transversalis sling
• Dissection of hernia sac
• Reduction of hernia sac
• Closure of hernia sac
• Mesh placement
• Secure sac to mesh
• JP drain placed
![Page 14: Management of Giant Scrotal Hernia](https://reader035.fdocuments.us/reader035/viewer/2022062404/554b42f6b4c905b5378b4d62/html5/thumbnails/14.jpg)
1. SURGICAL MANAGEMENT:
Identify Cooper ligament
![Page 15: Management of Giant Scrotal Hernia](https://reader035.fdocuments.us/reader035/viewer/2022062404/554b42f6b4c905b5378b4d62/html5/thumbnails/15.jpg)
2. SURGICAL MANAGEMENT
Dissection of Bogros space
![Page 16: Management of Giant Scrotal Hernia](https://reader035.fdocuments.us/reader035/viewer/2022062404/554b42f6b4c905b5378b4d62/html5/thumbnails/16.jpg)
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
![Page 17: Management of Giant Scrotal Hernia](https://reader035.fdocuments.us/reader035/viewer/2022062404/554b42f6b4c905b5378b4d62/html5/thumbnails/17.jpg)
Direct hernia Indirect hernia
Note: releasing incision (division of transversalis sling)floor is opened to gain remote hernial access
![Page 18: Management of Giant Scrotal Hernia](https://reader035.fdocuments.us/reader035/viewer/2022062404/554b42f6b4c905b5378b4d62/html5/thumbnails/18.jpg)
4. SURGICAL MANAGEMENT
Division of transversalis fascia sling
• Provides access to remote hernia sac
• Increases working space
![Page 19: Management of Giant Scrotal Hernia](https://reader035.fdocuments.us/reader035/viewer/2022062404/554b42f6b4c905b5378b4d62/html5/thumbnails/19.jpg)
5. SURGICAL MANAGEMENT
Lipoma management
Why supress a preperitoneal cordal lipoma?
• Delineates sac wall
• More room to work
![Page 20: Management of Giant Scrotal Hernia](https://reader035.fdocuments.us/reader035/viewer/2022062404/554b42f6b4c905b5378b4d62/html5/thumbnails/20.jpg)
6. SURGICAL MANAGEMENT
Hernial sac reduction
If testicle and tunica vaginalis present into space - divide sac rather than reduce it to minimize de-vascularisation
![Page 21: Management of Giant Scrotal Hernia](https://reader035.fdocuments.us/reader035/viewer/2022062404/554b42f6b4c905b5378b4d62/html5/thumbnails/21.jpg)
7. SURGICAL MANAGEMENT
Hernia sac division
Be careful not to injure bowel or bladder
![Page 22: Management of Giant Scrotal Hernia](https://reader035.fdocuments.us/reader035/viewer/2022062404/554b42f6b4c905b5378b4d62/html5/thumbnails/22.jpg)
8. SURGICAL MANAGEMENT
Hernial sac closure
Beware of not catching bowel
![Page 23: Management of Giant Scrotal Hernia](https://reader035.fdocuments.us/reader035/viewer/2022062404/554b42f6b4c905b5378b4d62/html5/thumbnails/23.jpg)
9. SURGICAL MANAGEMENT
Sac secured to mesh
Oversized polypropylene mesh for adequate coverage
![Page 24: Management of Giant Scrotal Hernia](https://reader035.fdocuments.us/reader035/viewer/2022062404/554b42f6b4c905b5378b4d62/html5/thumbnails/24.jpg)
To tack, or not to tack
“that is the question”
Increase in hernia recurrence?
Increase in post-operative pain and cost.
![Page 25: Management of Giant Scrotal Hernia](https://reader035.fdocuments.us/reader035/viewer/2022062404/554b42f6b4c905b5378b4d62/html5/thumbnails/25.jpg)
10. SURGICAL MANAGEMENT
Drain placement
• Drain in lateral port• Icepack and NSAIDs help reduce postoperative discomfort
![Page 26: Management of Giant Scrotal Hernia](https://reader035.fdocuments.us/reader035/viewer/2022062404/554b42f6b4c905b5378b4d62/html5/thumbnails/26.jpg)
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
![Page 27: Management of Giant Scrotal Hernia](https://reader035.fdocuments.us/reader035/viewer/2022062404/554b42f6b4c905b5378b4d62/html5/thumbnails/27.jpg)
Transabdominal preperitoneal (TAPP) method
![Page 28: Management of Giant Scrotal Hernia](https://reader035.fdocuments.us/reader035/viewer/2022062404/554b42f6b4c905b5378b4d62/html5/thumbnails/28.jpg)
results 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
![Page 29: Management of Giant Scrotal Hernia](https://reader035.fdocuments.us/reader035/viewer/2022062404/554b42f6b4c905b5378b4d62/html5/thumbnails/29.jpg)
• Patients with giant inguino-scrotal hernias and those with previous lower abdominal incisions or other complicating situation usually undergo TAPP herniorrhaphy
• 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)
• TEP is more demanding than TAPP initially because of the limited working space
• Surgeons should be comfortable with TAPP herniorrhaphy for giant inguino-scrotal hernias before progressing to TEP
Conclusion:
![Page 30: Management of Giant Scrotal Hernia](https://reader035.fdocuments.us/reader035/viewer/2022062404/554b42f6b4c905b5378b4d62/html5/thumbnails/30.jpg)
the
end
![Page 31: Management of Giant Scrotal Hernia](https://reader035.fdocuments.us/reader035/viewer/2022062404/554b42f6b4c905b5378b4d62/html5/thumbnails/31.jpg)
Giant (vs non-giant) scrotal hernia repair:
• Anesthesia: general (not epidural or local)
• A Foley catheter is always placed
• Hernia reduced manually after the patient is asleep
• 3 trocars placed (may need additional 4th)
• Epigastric vessels are always divided:
allows access to the deep internal ring without injury
mesh lies smoothly without warping
• Transversalis fascia sling divided to gain access to the distal sac
• A preperitoneal cordal lipoma must first be suppressed:
Increases working space and better visualization of sac
margins