|Year : 2021 | Volume
| Issue : 4 | Page : 156-165
Surgical treatment for inguinoscrotal hernia with loss of dominion with preoperative progressive pneumoperitoneum and botulinum toxin: Case report and systematic review of the literature
José Ángel Ortiz Cubero, Marco Soto-Bigot, Marcelo Chaves-Sandí, Armando Méndez-Villalobos, Jesús Martínez-Hoed
Grupo Interdisciplinario de Trabajo para el Manejo de la Hernia Compleja, Servicio de Cirugía General, Hospital Dr. Rafael Ángel Calderón Guardia, San José, Costa Rica
|Date of Submission||07-Jun-2021|
|Date of Decision||13-Sep-2021|
|Date of Acceptance||29-Sep-2021|
|Date of Web Publication||31-Dec-2021|
Dr. José Ángel Ortiz Cubero
Grupo Interdisciplinario de Trabajo para el Manejo de la Hernia Compleja, Servicio de Cirugía General, Hospital Dr. Rafael Ángel Calderón Guardia, San José.
Source of Support: None, Conflict of Interest: None
PURPOSE: The aim of this article is to establish which is the best peri- and intraoperative approach for patients with giant inguinoscrotal hernia. METHODS: A systematic review of the literature was carried out according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria through a search in PubMed, Scielo, and other resources, from January 2011 to April 2020. Prospective, retrospective, case reports, and clinical series were included. Patients who underwent emergency procedures and studies involving children or pregnant women were excluded. RESULTS: A total of 24 publications related to giant inguinal hernia were identified, which together group a total of 81 patients. The average age of the patients was 62 years. Of the 81 patients, in 10 cases (12%), loss of domain was objectively established. In patients with loss of domain, preoperative pneumoperitoneum (PPP) + botulinum toxin type A (TBA) was used in 80% of the cases. In 10% only NPP was used and in the remaining 10% only TBA was used. Regarding the repair technique, 70% used the anterior route. The most frequent surgery was Lichtenstein’s procedure (38%), followed by Stoppa’s procedure (9%) and transabdominal preperitoneal procedure (9%). The most frequent complication was the development of seromas. The median postoperative follow-up was 15 months. CONCLUSIONS: Inguinoscrotal hernias with loss of domain are rare, and therefore their management is far from being clearly defined. In those cases, where the loss of domain is confirmed, both botulinum toxin and preoperative pneumoperitoneum have been used, without documenting major complications.To repair the defect, the most widely used technique is Lichtenstein’s procedure; however, the possibility of long-term recurrence should be assessed. The retrorectal repair could reduce the risk of recurrence as it is associated with greater mesh overlap.
Keywords: Giant inguinoscrotal hernia, inguinal hernia, inguinoscrotal hernia, lichtenstein’s repair, loss of domain, stoppa procedure
|How to cite this article:|
Ortiz Cubero JÁ, Soto-Bigot M, Chaves-Sandí M, Méndez-Villalobos A, Martínez-Hoed J. Surgical treatment for inguinoscrotal hernia with loss of dominion with preoperative progressive pneumoperitoneum and botulinum toxin: Case report and systematic review of the literature. Int J Abdom Wall Hernia Surg 2021;4:156-65
|How to cite this URL:|
Ortiz Cubero JÁ, Soto-Bigot M, Chaves-Sandí M, Méndez-Villalobos A, Martínez-Hoed J. Surgical treatment for inguinoscrotal hernia with loss of dominion with preoperative progressive pneumoperitoneum and botulinum toxin: Case report and systematic review of the literature. Int J Abdom Wall Hernia Surg [serial online] 2021 [cited 2022 Jan 20];4:156-65. Available from: http://www.herniasurgeryjournal.org/text.asp?2021/4/4/156/334560
| Key messages:|| |
- - Not all giant inguinoscrotal hernias have loss of domain. If the loss of domain is confirmed, both botulinum toxin and preoperative pneumoperitoneum have been used, without documenting major complications.
- - To repair the defect, the most widely used technique is the Lichtenstein procedure; however, the possibility of long-term recurrence should be assessed.
- - The retrorectal repair could reduce the risk of recurrence as it is associated with greater mesh overlap.
- - It is necessary to develop studies to optimize and guarantee the best surgical outcome for these patients.
| Introduction|| |
Although treatment for inguinal hernia is fairly usual in a general surgeon’s daily practice, the management of giant inguinoscrotal hernia with loss of dominion (LODH) is not. This entity is defined as a hernia that reaches below the midpoint of the inner thigh of a patient in the upright position. The best treatment for LODH represents at least two surgical challenges: the first one, volume estimation, which is often calculated with the most accepted methods for LODH measurement: Tanaka’s and Sabbagh’s. Second, aiming for the best surgical treatment. Over time, several approaches have been described, such as posterior repairs as Nyhus, Stoppa, or Wantz, although the most familiar and most widely used technique is Lichtenstein’s repair.
To optimize the management of LODH, abdominal wall surgeons have gradually transferred their experience with ventral hernias toward management possibilities for inguinal hernias with loss of domain.
To avoid postoperative intra-abdominal hypertension syndrome, the use of botulinum toxin and preoperative progressive pneumoperitoneum has been offered as part of the therapeutical option for inguinoscrotal hernia (ISH); however, there are no recommendations in the literature for these therapies neither strong evidence.
In this scenario, we faced the question that led to performing this systematic review: Which is the best peri- and intraoperative approach for patients with a giant inguinoscrotal hernia?
| Case Presentation|| |
A 45-year-old male from a rural area in Costa Rica presented with a history of a right chronic inguinoscrotal hernia, first identified at the age of 17 years, his ISH was gradually growing until the taxis maneuver was no longer effective for hernia reduction due to its size [Figure 1]. The resting tomography revealed an inguinoscrotal hernia with a volume of 2,633 cc and an abdominal cavity volume of 6,744 cc (Tanaka’s Index of 39%). On the basis of these findings, treatment with type A botulinum toxin was initially applied, and after 3 weeks, progressive preoperative pneumoperitoneum (PPP) was started and lasted 10 days until final surgical management. To make this decision, we used the San José Classification (developed by our group), which is a practical tool to establish whether a patient requires adjuvant treatment or not. This classification [see [Table 1]] divides inguinoscrotal hernias into four groups: type I are hernias that barely insinuate into the scrotum; type II have a hernia sac that fills the entire scrotum; type III are those in which the sac reaches up to the middle third of the thigh, without exceeding it, and, finally, type IV reaches the lower third of the thigh. Type III hernias need to be studied to establish whether or not they require any preoperative intervention; however, type IVs must be initiated on pneumoperitoneum or botulinum toxin because they are very likely to present loss of domain.
|Figure 1: Tomography of the patient. Giant inguinoscrotal hernia con Tanaka of 29|
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|Table 1: San José’s Classification for the management of inguinoscrotal hernia|
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Botulinum toxin type A was infiltrated by ultrasound guidance, using Smoot’s technique, with the modification described by Ibarra (which consists in the injection of the toxin in each rectus abdominis) [Figure 2]. A bottle of botulin toxin type A (TBA) (Botox 100 units) diluted in 30 cc of saline was used, infiltrating 20 units in each site, for a total of 200 units of toxin.
|Figure 2: The "Xs" mark the infiltrations sites of the botulin toxin type A (TBA)|
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After 3 weeks, a central venipuncture catheter was placed for pneumoperitoneum insufflation, which was also done under ultrasound guidance.
The protocol used for the PPP was similar to the Hospital La Fe, in Valencia, Spain, in which the insufflated volume is calculated three times the volume of the hernia, distributed over a period of 10 days.
The patient was discharged 2 weeks after surgery. Thromboembolic prophylaxis and inspirometry continued for a month.
In this case, the PPP was not fully tolerated. During the first insufflation, the patient started with persistent vomits and pain upon the right inguinal hernia. Despite medical treatment, the patient remained symptomatic and the interval between insufflations had to be lengthened.
There was a progressive distention of the scrotum due to the PPP, but part of the insufflated gas remained in the abdomen. Despite several attempts, we only reached 73% of the proposed volume (5,800 cc vs. 7,899 cc).
An infraumbilical midline incision was made, reaching the retrorectal plane to perform a Stoppa procedure. The intestinal content reduction was difficult even with intraperitoneal traction, and there were no enterotomies during content dissection. Once hernia content was reduced, it was necessary to abandon the distal portion of the sac to avoid injuries to the testicles and his vessels. A 15 cm × 30 cm self-adhering mesh (Progrip ) was used for the repair. The mesh reached past the midline to prevent an incisional hernia.
In this specific case, scrotoplasty was not needed because the scrotum, after reduction, retracted considerably by itself [Figure 3].
|Figure 3: A 45-year-old patient with a giant inguinoscrotal hernia type II (A), the same|
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After the procedure, the patient had an optimal recovery and was discharged on the third day without complications. During the outpatient follow-up, the presence of a seroma was diagnosed, but it did not require any intervention. After 8 months, the patient had an optimal evolution without recurrence nor persistent seroma.
| Materials and Methods|| |
A systematic review of the literature was performed in PubMed, Scielo, and other resources, from January 2011 to December 2020 using the terms giant inguinal hernia, giant inguinoscrotal hernia, and massive and huge inguinoscrotal hernia.
Prospective, retrospective, case reports, and clinical series were included. Patients who underwent emergency procedures and studies with children or pregnant women were excluded.
The search was carried out simultaneously and individually by the two main authors of the work, JAOC and JMH, and the articles obtained were compared by both. The article search period was between February 2021 and April 2021.
The information of selected investigations was compiled in a table designed for the purpose of the investigation. The table was completed with: author, year, number of patients included, classification of inguinoscrotal hernia, loss of domain, age, adjuvant therapy, type of repair, complications, follow-up time, and recurrence. In addition, the selected publications were evaluated with the MINORS criteria to assess the quality of the information. To the obtained data, frequencies and percentages were applied for the qualitative variables and measures of central tendency for the continuous variables.
| Results|| |
A total of 24 publications related to giant inguinal hernia were identified, which together group a total of 81 patients (see [Flowgram 1]). Four series were also found, the two largest with 25 cases each. A series of 134 cases was not included in the analysis because the definition of a giant hernia was not specific enough and it only required that there should be two viscera in the sac or a long segment of the intestine to be classified as a giant hernia. According to the MINORS criteria, the majority of these publications are not of good methodological quality, with an average score of 2.
Most of the patients were classified as having a giant inguinal hernia under Hodgkinson’s criteria. In the rest of the cases, the Trakarnsanga classification was used [Table 1].
The average age of the patients was 62 years [see [Table 2]]. Of the 81 patients, in 10 cases (12%), loss of domain was objectively established.
|Table 2: Studies about giant inguinoscrotal hernia published since 2010 until 2021|
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In patients with loss of domain, NPP + TBA was used in 80% of the cases. In 10% only NPP was used and in the remaining 10% only TBA.
Regarding the repair technique, 70% used the anterior route. The most frequent surgery was Lichtenstein’s procedure (38%), followed by Stoppa’s procedure (9%) and transabdominal preperitoneal procedure (9%). Other procedures such as enhanced view totally extraperitoneal technique, the combination of Lichtenstein and Stoppa, the Bassini technique, and others such as the anterior separation of components were also described. In 6% of the cases, it was necessary to perform concomitant orchidectomy.
Complications such as hematomas, seromas, hydrocele, and scrotal abscess occurred in 16% of the cases. The most frequent complication was the development of seromas. The median postoperative follow-up was 15 months, in which none reported recurrences.
| Discussion|| |
Inguinoscrotal hernia with loss of domain is not a frequent pathology; however, when diagnosed, it constitutes a challenge from a technical point of view. The size of the hernia is generally related to difficulty walking, sitting, or even lying down. There is chronic edema of the scrotum, leading to lymphatic congestion, abrasions, and ulceration, which can lead to severe infections.
In addition, there may be complications that even compromise the life of the patient, ranging from imprisonment and strangulation to bowel obstruction, but these complications are not limited to the gastrointestinal tract and can affect other organs.
The exact definition of a giant inguinoscrotal hernia, a huge or massive hernia, depends a lot on the training and experience of the surgeon dealing with the case. An ISH is defined as giant, using the Trakarnsanga Classification. It divides the giant inguinoscrotal hernia into three groups: those that reach down to the middle third of the medial edge of the thigh (group I), those that exceed the middle third of the thigh but do not exceed the height of the knees (group II) and those that descend below knees (group III). Group II and III hernias are considered giant. This classification has the disadvantage that classifies very large hernias, but it does not take into account the loss of domain or the specific treatment options. Besides, there are other definitions such as Hodgkinson’s, which describes a giant inguinoscrotal hernia as the one that reaches below the middle point of the thigh in standing position. Even so, there are other inguinoscrotal hernias that do not meet the Trakarnsanga criteria, but they have a considerable size that someone might consider giant. In some publications, inguinoscrotal hernias have also been described as huge or massive without a clear definition, depending on point of view, context, and training of the surgeon.
The San José Classification allows the elimination of adjectives and divides the hernia into objective types, providing a management to follow.
Forced reduction of this type of hernias can cause a compartment syndrome, in which the diaphragm is pushed into the thoracic cavity, generating respiratory distress and compromised venous return. In addition, forced reintroduction of the intestine into the abdomen can lead to intestinal obstruction, wound dehiscence, and recurrence. Up to 30% of cases in which a forced reduction is made would have wound dehiscence and recurrence. The fact that the hernia cannot be reduced spontaneously speaks clinically of a hernia with loss of domain, although, in some cases, the adhesions to the hernial sac or narrow hernia orifice can limit the possibility of returning viscera to the abdominal cavity. Besides that, the fact that a hernia is classified as giant does not imply that it will have a loss of domain, so, in some cases, tomography can be useful to objectify that suspicion. Only in 10% of the cases, the diagnosis of loss of domain was made; however, it is to be expected that in hernias whose sac extends below the knee the incidence will be higher.
The Tanaka Index describes a way to obtain approximate volumetric calculations from the three spatial diameters, applying ellipsoid volume formulas, as this is the geometric figure that most closely resembles hernial sacs or even the abdominal cavity. Another form of volumetric calculation would be Sabbagh’s Index, which relates the herniated volume with the total peritoneal volume (cavity plus hernia) being a rate, rather than a percentage. For some, this method is more significant, as it relates the herniated volume to the total volume of the cavity. In our case, we use the Tanaka because we do not have the program to calculate the Sabbagh Index. We consider a loss of domain when the Tanaka exceeds 20%.
In the vast majority of cases with documented loss of domain, preoperative pneumoperitoneum and TBA was used. Pneumoperitoneum is a technique that allows us to increase the volume of the cavity by means of the mechanical distension of the muscles of the wall, which favors the lysis of adhesions. Also, the distension of the sac allows to “clean” the skin, thus potentially reducing the incidence of infections. In addition, the establishment of the pneumoperitoneum allows a diagnostic test to be carried out, to establish whether the patient will tolerate the reintroduction of the contents of the sac to the abdominal cavity. Despite the above, its usefulness in inguinoscrotal hernia has been questioned, because in many cases the pneumoperitoneum will distend the scrotal bag, which offers less resistance,, without achieving a significant effect in the abdominal cavity. In the reviewed publications, no complications associated with the procedure were recorded. However, the pneumoperitoneum itself generates discomfort and is difficult for patients, especially during the last days of its onset. Abdominal pain, nausea, and mild dyspnea are common, and some discomfort must be tolerated to achieve the desired effect. Tolerance is also related to a socio-cultural aspect as in some countries the procedure can be performed on an outpatient basis;, however, in others, patients require hospitalization as they cannot adequately follow the indications required for the management of insufflation.
One of the main problems is that there is no method that defines how much is the volume of air necessary to guarantee the desired effect. However, in our case, we use what is proposed by Bueno-Lledó, three times the volume of the incisional hernia, divided between the 10 and 12 days of the abbreviated pneumoperitoneum period, without exceeding 500–1,000 cc per day.
It should be mentioned that access to botulinum toxin for the surgeon is not generalized, which is why in many cases PPP is used as the only therapy.
Botulinum toxin type A has gained relevance as a tool to perform a chemical relaxation of the components of the abdominal wall, and thereby increase its volume. Ibarra described the procedure in 2014 for giant inguinal hernias, demonstrating a significant decrease in the thickness of the wall muscles and an increase in the length of the lateral muscles. Almost no adverse effects or complications related to its application have been described if the recommended doses are used., Ibarra’s technique is generally used; however, in the case of inguinoscrotal hernias it is also necessary to infiltrate the rectus abdominis for the placement of the toxin to improve the possibility of increasing the volume of the cavity.
Once the infiltration is carried out, the peak of the toxin effect occurs around 4 weeks, so it is at that time that the repair should be scheduled. There are few studies that support this therapy for giant inguinoscrotal hernia.
Surgical techniques to increase the volume of the abdominal cavity have been described too; however, they are barely mentioned in the actual literature. One of the described techniques was performed making a midline incision and then closing it with a mesh bridge covered with peritoneum or with viable tissue from the hernial sac. This allows us to increase the volume of the cavity but adds the risk of a midline incisional hernia.
More recently, endoscopic component separation has been used, with the placement of an extraperitoneal mesh with a midline incision. Procedures involving the rotation of myocutaneous flaps, as described by Berrevoet, have also been described, dissecting a fasciocutaneous flap from the anterolateral region of the thigh, which is then interposed in an umbilicopubic incision.
Another option is the resection of the abdominal viscera with the aim of reducing the content of the cavity. It is a technique with a higher risk of complications and, above all, infection of the mesh. Right hemicolectomy, total colectomy, splenectomy, omentum resection, and even intestinal resection are usually performed.
It is very important to be clear that the fact that the hernia is giant does not imply that it has a loss of domain and if there is no loss of domain, it is not indicated to perform any type of adjuvancy. Even if it is decided to use an adjuvant technique, its use is not adequately documented and there are still several questions that must be elucidated.
| Surgical Technique|| |
Initially, it must be taken into account that the surgeon is facing a very compromised inguinal floor, so the decision of the surgical procedure is fundamental. The literature review is clear that the most widely used technique is the Lichtenstein procedure. However, will it be the best option? As mentioned, the inguinal region is generally destroyed, so it would be intuitive to think that a better mesh overlap would reduce the risk of recurrence. On the basis of this principle, it would be appropriate to use the posterior techniques, both open and laparoscopic, although the latter tend to be extremely demanding in the context of this type of patient.
Posterior open approaches are not as popular as the Lichtenstein technique. Although he was not the first to use this type of approach, it was Nyhus who developed and popularized it from 1954 onwards. This is an approach in which a lateral transverse suprainguinal McEvedy incision is made to access the Bogros and Fruchaud spaces and repair the defect. Another option is to perform a Stoppa procedure, where a subperitoneal, prevesical, and retrorectal approach is performed through an umbilico-pubic incision, which extends below Cooper’s ligaments. Then, a 24 cm × 18 cm mesh is used to bilaterally reinforce the entire posterior bilateral inguinal region. At the end of the eighties, it was Wantz who, using a wide transverse Nyhus-type musculoaponeurotic incision followed by an extensive unilateral dissection, was able to place a large prosthesis (15 cm × 15 cm) in the entire unilateral inguinal area, taking advantage of the proximal portion of it to spread it over the peritoneal sac as a «hemi-stoppa».,
The posterior approach also shows the advantage of accessing the abdominal cavity and manipulating the intestine if necessary without the need for another wound, in addition, so that other nonobvious defects can be identified through the incision to do a Lichtenstein. It has also been mentioned that this type of approach avoids the risk of neuralgia related to an ilioinguinal or genitofemoral injury.
The vast majority of surgeries performed were Lichtenstein procedures with almost no complications; however, long-term recurrence studies are necessary. In most of the patients reviewed, the follow-up time was insufficient.
After completing the repair, a decision must be made whether or not to place drains. As far as possible, it is tried not to place drains, as they increase the risk of infection of the mesh. The performance of a concomitant scrotoplasty has been the subject of debate, with some arguing that it increases morbidity and much of the excess skin tends to retract over time. However, there are several publications with different reconstruction techniques with good results.
| Conclusions|| |
Inguinoscrotal hernias with loss of domain are uncommon, and therefore their management is far from being clearly defined. Most of the publications are case reports and small series. Certain procedures have been adopted from the experience with ventral hernias; however, few publications support these strategies in a giant inguinoscrotal hernia.
It is very important to emphasize that not all giant inguinoscrotal hernias have loss of domain. In those cases, where the loss of domain is confirmed, both botulinum toxin and preoperative pneumoperitoneum have been used, without documenting major complications.
To repair the defect, the most widely used technique is the Lichtenstein procedure; however, the possibility of long-term recurrence should be assessed. The retrorectal repairs could reduce the risk of recurrence as it is associated with greater mesh overlap.
It is necessary to develop studies that allow establishing clear guidelines, based on evidence, to optimize and guarantee the best surgical outcome for these patients.
The authors thanks Kenneth Ceciliano Moreira for the review of 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]
[Table 1], [Table 2]