|Year : 2020 | Volume
| Issue : 4 | Page : 138-143
Large scrotal hernias: Totally extraperitoneal (TEP) or transabdominal preperitoneal (TAPP) repair?
Virinder Kumar Bansal1, Om Prakash1, Asuri Krishna1, Subodh Kumar1, Mayank Jain1, Mahesh Chandra Mishra2
1 Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India
2 Department of Surgery, Mahatma Gandhi University of Medical Sciences and Technology, Jaipur, Rajasthan, India
|Date of Submission||01-Jul-2020|
|Date of Decision||05-Jul-2020|
|Date of Acceptance||20-Aug-2020|
|Date of Web Publication||30-Nov-2020|
Prof. Virinder Kumar Bansal
Room Number 5021, 5th Floor, Teaching Block, Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi
Source of Support: None, Conflict of Interest: None
INTRODUCTION: Large scrotal hernias are rare, constituting <2% of all hernias repairs. Few of these large scrotal hernias become massive or giant due to neglect in treatment for many years. Conventionally, open surgery was advocated for these hernias, but with experience, laparoscopic repairs have been performed in the recent years for these hernias.
PATIENTS AND METHODS: We reviewed our experience of patients with large scrotal hernias (L3, M3, or R) undergoing either totally extraperitoneal (TEP) or transabdominal preperitoneal (TAPP). Demographic profile, clinical characteristics of hernia, and intra- and postoperative outcomes were recorded.
RESULTS: There were 144 patients with large hernias, of which 10 were massive hernias. TEP repair was attempted in 85 patients and TAPP repair in 59 patients. In 25 patients (7 in TEP and 18 in TAPP), laparoscopic-assisted approach was used. TEP repair successful in 64 patients (75.3%) and converted to TAPP in 15 patients (17.6%) and to open in 6 patients (7.1%). TAPP was successful in 53 patients (89.8%) and was converted to open repair in 6 patients (10.2%). Seroma was noted in 42 patients, spermatic cord edema in 26 patients, and scrotal hematoma in 14 patients at 1st week. The mean follow-up was 2 years. Two patients had recurrence and TAPP repair was done. None of the patients developed mesh infection or chronic groin pain.
CONCLUSION: We believe that TEP and TAPP repair are complementary and hernia surgeons should be adept at both techniques. TAPP repair has advantages in large irreducible hernias and should be preferred.
Keywords: Hybrid, large scrotal hernia, massive, totally extraperitoneal, transabdominal preperitoneal
|How to cite this article:|
Bansal VK, Prakash O, Krishna A, Kumar S, Jain M, Mishra MC. Large scrotal hernias: Totally extraperitoneal (TEP) or transabdominal preperitoneal (TAPP) repair?. Int J Abdom Wall Hernia Surg 2020;3:138-43
|How to cite this URL:|
Bansal VK, Prakash O, Krishna A, Kumar S, Jain M, Mishra MC. Large scrotal hernias: Totally extraperitoneal (TEP) or transabdominal preperitoneal (TAPP) repair?. Int J Abdom Wall Hernia Surg [serial online] 2020 [cited 2021 May 14];3:138-43. Available from: http://www.herniasurgeryjournal.org/text.asp?2020/3/4/138/302023
| Introduction|| |
Large scrotal hernias are rare and constitute <2% of all hernias repairs., They acquire large size often due to neglect of treatment for many years due to lack to access to health-care facility, illiteracy, fear of surgery, and impotence. Few of these large scrotal hernias go on to become massive or giant inguinal hernias.
These patients are a surgical challenges not only because of the size of the hernia but also due to more rigorous perioperative preparation for these patients, especially those with loss of domain. Conventionally, open surgery was advocated for these hernias in view of the irreducibility and space constraints., In the recent past with advances in laparoscopic skills, many of these hernias have been repaired by both totally extraperitoneal (TEP) or transabdominal preperitoneal (TAPP) repair with good results, and International End-hernia Society (IEHS) guidelines recommend that either TEP or TAPP can be possible therapeutic options for large scrotal hernias in the hands of experienced surgeons. We report our experience with laparoscopic repair of large and massive inguino scrotal hernias with both TEP and TAPP.
| Patients and Methods|| |
A retrospective analysis of a prospectively maintained database was done from January 2004 to December 2019. All patients undergoing laparoscopic repair for large scrotal hernias (L3, M3, or R) according to European Hernia Society (EHS) classification were analyzed [Figure 1]. Demographic profile, clinical characteristics of the hernia, and intraoperative and postoperative outcomes were recorded.
Massive or giant hernias were defined as an inguinal hernia that extends below the mid-point of the inner thigh in standing position or anterior and posterior diameter of at least 30 cm, a latero-lateral diameter of about 50 cm, and have been nonreducible for more than 10 years, [Figure 2].
Details of preoperative workup included biochemical investigations; cardio-pulmonary evaluation and ultrasound/computed tomography scan of abdomen and scrotum were recorded. Patients above the age of 60 years underwent uroflowmetry analysis and postvoid residual urine for evaluation of benign prostatic hypertrophy. If significant bladder outflow obstruction was found, the patients were started on medical therapy for at least 4 weeks prior to surgery. Written informed consent was taken from all the patients and included consent for orchiectomy and possible postoperative elective ventilation, if required especially in patients with massive/giant scrotal hernias. A vigorous chest physiotherapy with incentive spirometer was started a week before surgery. All procedures were performed under general anesthesia. The patients underwent either TEP or TAPP, depending on patient factors as well as surgeon preference. A single dose of prophylactic antibiotic (amoxicillin + clavulanic acid) was given at the time of induction, and preoperative catheterization was done to decompress the bladder in all patients. TEP and TAPP were performed by the standard technique and either an appropriate sized 3D Bard mesh or flat polypropylene mesh was used. Tacker fixation was done in all patients. Irreducible hernias were reduced after general anesthesia with or without external manipulation. Where hernial contents (bowel, omentum, bladder, and sigmoid colon) could not be reduced, a laparoscopic-assisted (hybrid) approach was used, where in a 3–4 cm incision was made over the hernial sac, adhesiolysis of the contents with the sac was done, and the contents were reduced. The sac was then sutured, and skin and subcutaneous tissue were closed. After this, the procedure was completed laparoscopically. A suction drain was placed in cases where there was bleeding or some collection. Intraoperative details including operating time, creation of space, delineation of anatomy, and complications were recorded in a prestructured pro forma.
Foleys catheter was removed on the next day morning in majority of the patients. Patients were discharged from the hospital once they started accepting oral feeds; there was no fever or abdominal signs and voiding urine adequately. The patients were followed up in follow-up clinic at 1 week, 6 weeks, 3 months, 6 months, and yearly thereafter. The patients underwent clinical examination at each visit and any scrotal hematoma, cord edema, pain, recurrence, seroma, port site/mesh infection, and other symptoms were recorded. If a seroma was detected, it was observed for 4–6 weeks. Intervention was done only if the seroma persisted or became symptomatic after the period of observation.
Quantitative data waweres analyzed by application of Student's t-test/Mann–Whitney test. The qualitative data were analyzed by Chi-square test/Fisher's test, whichever applicable. P < 0.05 was considered statistically significant. Other appropriate statistical analysis was done wherever required.
| Results|| |
One hundred and forty-four male patients had large scrotal hernias out of 1,994 patients operated during this period [Figure 3]. Of these, ten were massive hernias. TEP repair was attempted in 85 patients (97 hernias) and TAPP repair was attempted in 59 patients (73 hernias). All patients with massive hernia underwent TAPP repair [Figure 1].
The mean age of the patients in the TEP group was 57.7 years (range: 43–86 years) and in TAPP group, it was 55.3 years (range: 42–78 years). There was no significant difference in body mass index (24.9 ± 3.9 vs. 25.1 ± 3.2), and majority of the hernias were unilateral and indirect in the TEP group [Table 1].
The hernial contents could be reduced with manipulation from inside or outside in 57 patients undergoing TEP and 35 patients in TAPP groups [Figure 4] and [Figure 5]. In 25 patients (7 in TEP and 18 in TAPP), the contents could not to be reduced so a laparoscopic-assisted approach was used in these patients. Of the 18 laparoscopic assisted procedures in TAPP group, 8 patients had massive hernias [Table 2].
|Figure 4: Transabdominal preperitoneal view of hernial contents in large scrotal hernia|
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|Figure 5: Intraoperatively bilateral direct defect in transabdominal preperitoneal repair|
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TEP repair was successful in 64 patients (75.3%) and was converted to TAPP in 15 patients (17.6%) and to open in 6 patients (7.1%). The reasons for conversion was inadequate space in 8 patients and bleeding leading to poor vision with unsatisfactory dissection in 13 patients. One patient had small sigmoid colon perforation without contamination, which was repaired primarily after open conversion and open tissue repair was done. Peritoneal breach occurred in 23 (27%) patients. The sac was opened at the deep ring deliberately in 21 patients due to difficulty in the reduction of contents. Moderate bleeding during dissection was seen in ten patients and IEV were injured in four patients. However, hemostasis was achieved with monopolar diathermy or harmonic. A close suction drain was placed in all the 14 patients and removed after 48 h.
TAPP repair was successful in 53 patients (89.8%) and was converted to open repair in 6 patients (10.2%). Out of these six conversions, two patients had massive hernias. The reason for conversion was inadequate space and sigmoid colon perforation without contamination in one patient, which was repaired primarily after open conversion and open tissue repair was done. In nine patients, there was moderate bleeding during dissection; hemostasis was achieved with monopolar diathermy or harmonic. A close suction drain was placed in these patients and removed after 48 h [Table 2].
The mean operating time was 74 min (range, 68–184 min) in TEP repair and 86 min (range, 76–210 min) in TAPP repair. The mean operating time for massive scrotal hernia was 140 min (range, 92–240 min) [Table 2]. Six patients had serosal injuries (four in TEP, and two in TAPP) to the small bowel, and were repaired laparoscopically. Urinary bladder injuries were noted intraoperative in four patients (one in TEP, and three in TAPP), which were repaired laparoscopically with 2-0 polyglactin suture, and the catheter was removed after 2 weeks of surgery after a check cystogram [Table 3]. Preshaped bard 3 D max large size mesh was used in 106 (67%), extra-large in 39 (24.7%), and flat polypropylene mesh (12 cm × 15 cm) was used in 8.3% of hernias repair. Absorbable or nonabsorbable tacker was used in majority with 2-point tacker fixation and in few patients with large hernias, multiple tackers were used to prevent mesh protrusion through the defect [Table 2].
Two patients required elective postoperative ventilation for 48 h following TAPP repair of massive scrotal hernia. However, none of these patients developed abdominal compartment syndrome. The length of the postoperative hospital stay ranged from 2 to 5 days, and majority (70%) could be discharged from the hospital with-in 48 h.
Seroma was noted in 42 patients (28 in TEP and 16 in TAPP), spermatic cord edema in 26 patients (14 in TEP and 12 in TAPP), scrotal hematoma in 14 patients (9 in TEP and 5 in TAPP), and ecchymosis in 30 patients (18 in TEP and 12 in TAPP) at 1st week. Port-site infection was noted in five patients (three in TEP and two in TAPP), and managed with normal saline dressing and oral antibiotics [Table 3].
The mean follow-up was 2 years (range, 9 months to 10 years). Spermatic cord edema resolved spontaneously in all the 26 patients, scrotal hematoma resolved spontaneously in 10 patients, and 4 patients required aspiration at 3 weeks. Postoperative seroma resolved spontaneously in 26 patients at 6-week follow-up and in the remaining 17 patient's needle aspiration done. Second aspiration was needed in 14 patients after an interval of 3 weeks. Three patients required placement of a drain for persistent seroma for a period ranging from 2 to 4 weeks. Seroma still persisted in two patients and were explored surgically wherein the clotted blood was removed. One patient in each group developed recurrence of hernia during follow-up of 6 month and were repaired with TAPP. None of the patients developed mesh infection or chronic groin pain [Table 3].
| Discussion|| |
Large scrotal hernias are rare and represent a unique challenge for even the experienced surgeon regardless of the approach used. Patients often have multiple comorbidities that increase the risk of perioperative morbidity and mortality. Large scrotal hernias appears when patients neglect the treatment for many years due to lack of access to health care, inhibition to express medical concern, illiteracy or fear of impotence and operation, and generally are much more commonly seen in underdeveloped countries. Many of these go on to develop massive or giant hernias.
With the advances in laparoscopic equipment, techniques, and experience, more and more difficult cases are being attempted laparoscopically. The EHS recommended Lichtenstein repair as the preferred technique for large scrotal hernias, but as per the recent IEHS recommendations, both TAPP and TEP are possible therapeutic options by experienced surgeons. Misra et al. in their experience of TEP repairs for large scrotal hernia reported that operative time, complication rates, and frequency of recurrences are higher in large scrotal hernia repair as compared to normal laparoscopic hernia repair.
There are many technical challenges in dealing with large scrotal hernias laparoscopically. The first and foremost is that majority of these hernias are irreducible for a long time and when the large scrotal contents are reduced intra-abdominally, there is loss of domain which leads to increased intra-abdominal and intra-thoracic pressure, which can lead to acute abdominal compartment syndrome, which may predispose the patient to postoperative respiratory problems and other complications., Various techniques have been used including the use of pre-operative progressive pneumoperitoneum, botulin toxin injection, component separation, and intra-operative bowel and omentum dissection to increase the intra-abdominal space. These problems are more common in giant inguinal hernias rather than large scrotal hernias. In our experience of laparoscopic repair of giant inguinal hernia in ten patients, only two patients were put on elective ventilation for 24–48 h and in two patients omentum resection was done because omentum was adherent to the sac and was bulky.
The other intra-operative problems encountered in these patients are reduction of chronically irreducible contents. Generally, in majority of the patients, the contents can be reduced by gentle manipulation from both inside and outside along with taxis maneuver and division of few adhesions with monopolar cautery or harmonic. In difficult cases, the laparoscopic-assisted approach was found to be useful, which has been described previously by Palanivelu et al. We also recommend early recourse to this technique when encountering difficult adhesions as it makes the procedure much more faster and avoids the potential bowel and bladder injuries and patients get the benefits of laparoscopic surgery. We used this approach in 25 patients and found no superficial surgical-site infection or mesh infection in these patients. Palanivelu et al. in their publication have recommended TAPP repair in all patients with irreducible large hernias, whereas TEP repair if the hernia is reducible.
The question of whether to do a TEP or TAPP would depend on the surgeon's expertise. Generally, the problems of loss of space because of peritoneal breach in much more common in TEP repair, especially in large scrotal hernias because of the difficulties in reduction of the contents, possibility of bowel injuries because of excessive traction without vision and bleeding from the testicular vessels. The incidence of peritoneal breach has been reported to be very high in these patients leading on to loss of space and conversions to TAPP or open repair. Misra et al. reported >35% incidence of peritoneal breach. The TAPP repair has advantages where the hernial contents can be clearly visualized and reduced under vision and working space is much more.
The incidence of testicular vessels and cord structure injury is also very high in these patients because of excessive traction and adhesions. Generally, these can be controlled by local compression, but sometimes, in massive groin hernias or recurrent hernias, we prefer to take a preoperative consent for orchiectomy.
The incidence of postoperative seroma has been reported to be higher following TAPP repair for large scrotal hernia. Most large scrotal hernia repairs either open or laparoscopic have a higher risk of seroma formation. Bierca et al. reported 20% seroma following Lichtenstein repair in 15 patients of giant inguinal hernia. Fujinaka et al. and Leibl et al. reported 75% and 10.5% seroma following TAPP repair, respectively, whereas Misra et al. reported 75% seroma following TEP repair in twenty patients. The seroma formation rate in our study was 30.5% (32.9% in TEP and 21.1% in TAPP). In large scrotal hernia, laparoscopic complete dissection of hernial sac is not possible, it might lead on to increased risk of orchitis and hematoma. Leible et al. also found there was no difference in the postoperative formation of a seroma between complete and incomplete sac dissection and even seroma develops after the placement of closed suction drain. Köckerling et al. also have reported higher postoperative complication (1.7 vs. 3.9%, P < 0.001) and higher seroma formation (TEP 0.51% vs. TAPP 3.06, P < 0.001) following TAPP repair. They recommended a tailored approach depending on surgeon's experience in deciding the procedure and have reported good results with Lichtenstein repair. Drain should be used more liberally in these patients, but whether drain decrease the incidence of seroma or not is not clear.
We recommend that TAPP repair should be attempted for all large irreducible hernias and TEP can be attempted in large reducible hernias with sufficient surgeon experience. Both procedures have similar outcomes in terms of success of surgery and long-term outcomes such as seroma, wound infection and recurrence rates with TAPP having higher incidence of seroma and TEP having higher conversion to TAPP or open repair.
In large scrotal hernias, both TEP and TAPP repair are feasible with slightly increased incidence of intraoperative complications such as longer operative time, scrotal edema and seroma, and bowel injury. Laparoscopic-assisted approach should be resorted to early if there are difficult adhesions in a large hernia, which helps in the prevention of complications of bowel–bladder injury.
We believe that TEP and TAPP repair are complementary and hernia surgeons should be adept at both techniques. Definitely, TAPP repair has advantages in large irreducible hernias and should be preferred in such circumstances.
This is a retrospective review of cases for which Ethical clearance is not required. No patient related confidential information has been revealed in this manuscript.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2], [Table 3]