Episode 114: InguinoScrotal Hernias | Hernia Talk Live Q&A

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Speaker 1 (00:00):

Hi everyone. It’s Dr. Towfigh. How are y’all doing? Welcome to Hernia Talk Live. It’s my weekly session with you all on Hernia Talk Tuesdays. My name is Dr. Shirin Towfigh. I am your hernia and laparoscopic surgery specialist. Thanks everyone for joining me on YouTube, I’m sorry, on Facebook Live as well as on Zoom. Those of you who follow me can spread the word, follow me on her Instagram and Twitter at hernia doc. And as always, this session in all previous sessions will be posted on my YouTube channel. So today’s going to be a fun day. I saw a patient in the office and I’d always tell you that some of my inspiration comes from my own patients, and it was a very simple, straightforward consultation. Though patient had a hernia, he saw the bulge and he felt that he should come in to have it considered for repair.

Speaker 1 (00:58):

And as most of you know, for men especially, there’s good evidence to show that if you have an inguinal hernia and the hernia is not bothering you, so asymptomatic or minimally bothering you, minimally symptomatic, then watchful waiting is considered safe. Most of those men who fall into a minimally asymptomatic or asymptomatic category for inguinal hernias can become worse over time. And on average or about 10 years, two-thirds of the patients will end up between five and 10 years. Two-thirds of the patients will end up having more symptoms and therefore wanting surgery. So the purpose of me bringing that up is that what actually happens is sometimes you wait and wait and wait and you’re hurting. It actually gets bigger. And so I often tell patients that choose watchful waiting, that it’s best if you not only wait for the hernia to become symptomatic, but also another indication for surgery if you want to delay it is come in once the hernia starts getting larger. And the reason why I explained that is as hernias become larger, and this is true for all hernias, the repair is more difficult. Your options for repair become more limited, and the outcomes for the repair such as hernia recurrence, chronic pain, et cetera, wound complications are much higher as you let the hernia get larger. So I do not recommend that you wait for your hernia to be larger.

Speaker 1 (02:38):

So even if you don’t have symptoms, you may want to get your hernia prepared if it’s getting larger, not that it’s unsafe to let it go, it’s just once you want to have the surgery, it’s a better outcome if you do it when the hernia is smaller. So these are all part of that whole tailored phenomenon that I talked to you about, how you tailor to the needs of the patient. If you’re 90 years old and you have minimum to no symptoms, maybe let’s not fix the hernia. If you’re young, consider fixing it because the chance of you requiring repair is close to a hundred percent. It’s at least it’s at 67% within 10 years or yeah, a little over six, 7%. So interestingly, I had a patient who came in, he’s like, I got this hernia. I saw my surgeon many years ago. We discussed watchful waiting.

Speaker 1 (03:34):

I kind of liked the watchful waiting idea and I had no symptoms, but it has been growing over time. And now he has what’s called an inguinoscrotal hernia. What is that? So inguinoscrotal means it’s an inguinal hernia, but it has a scrotal component. So all inguinal hernias have the propensity getting so big, the gravity pulls it down into the scrotum and specifically the indirect inguinal hernia, which we’ve talked about femoral direct and indirect. The indirect type of inguinal hernia is the most common type of scrotal hernia because what happens is the hole is actually at the level of the spermatic cord, which is what it feeds a testicle, and then the hernia kind of follows it down and eventually makes its way to the testicle and it starts growing there. And by growing, I mean the contents that are inside your abdomen start to now fill the scrotum and it can be very difficult and complicated.

Speaker 1 (04:42):

Now, let’s say you have an inguinoscrotal hernia. First of all, don’t wait until it gets inguinoscrotal if you can. In most western countries, we don’t see a lot of the really big inguinoscrotal hernias. And the reason for that is two twofold. One is access to care is much more available in western world or I would say a developed world. And secondly, most people that have jobs in the western world will tend to want to get that repaired and not let it go because it’s fairly easy to get a hernia repair, especially in the United States. Fairly, fairly easy to get that. However, in countries where there’s poor access to healthcare, and we have a lot of surgeons that have done a really great job of providing hernia surgery, free hernia surgery in Central America, in Africa, and I believe we have a group that goes to China in the rural areas of China, those surgeons see a lot of inguinoscrotal hernias.

Speaker 1 (06:04):

And interestingly, it’s a different type of hernia than you see in the us, though they’re both inguinoscrotal. The inguinoscrotal you see in the US are adult males that develop their hernia as adults and perhaps let it go for a while and it gets bigger and bigger and bigger in the reason why we’re seeing many more inguinoscrotal in Africa, central America areas that are not developed is many of these men have actually had a hernia since they were a child and they didn’t get their hernia repaired as a child. And then you see them now as adults, they’re in their twenties, their thirties, their forties, fifties, and now it’s this huge inguinoscrotal hernia. So it’s a very unique disease process. I put up a post a picture of a series of African men from a single tribe who all had these really enormous scrotums.

Speaker 1 (07:09):

And I wanted us to explain that picture. For those of you that are surgeons or went to medical school, any medical doctors, you’ve seen this picture before. Most likely. It is a very classic picture important as part of medical history, there were some comments by non-physicians on my Instagram that felt the picture that was provided had some racial or colonial implications. Of course it does not. So their tribes in Africa that are prone to parasitic infections, certain parts of Africa, it has partly to do with some of their cultural practices. I read somewhere that they would drink uterine blood like menses menstrual blood from cows and as part of their rituals and they get a parasitic infection. This is called it’s a psoriasis, or it’s like you’ve heard of elephantiasis where you have these parasitic infections that then kind of evade the lymphatics and you can actually get scrotal scrotal elephantiasis or scrotal psoriasis.

Speaker 1 (08:32):

And it’s fascinating because the scrotum will become this huge enormous jug and it’s all just lymphatic drainage and parasitic infection in that scrotum. And the entire tribe would get it, for example. And so that was the picture that demonstrate that’s a very important picture from medical history. It has nothing to do with slavery or colonialization, it’s the interpretation of that picture by others was definitely not accurate and there was nothing nefarious in posting it. But what’s important is that specifically is not a hernia, it is a scrotal enlargement from a paras infection. However, the scrotum can get at least as large if not larger, with an inguinoscrotal hernia. The main difference in differentiating the two on physical exam is with the hernia, the contents come from the abdomen. So intestines, colon, small intestine and omentum or fat or inside the abdomen will go into this hole and fill the scrotum. So as opposed to parasitic infections where it’s limited to the scrotum and the neck of the scrotum is normal in patients that have inguinoscrotal hernias, the content is coming from the adamant. And so the hole or the neck of the scrotum is very wide as well. It’s like the entryway, the hallway entryway to the door to the scrotum. And so that’s the main difference in figuring out if something is a primary scrotal problem or it’s a hernia problem. Now we’re just way towards the scrotum.

Speaker 1 (10:23):

So that’s the explanation of that picture. It’s a fascinating picture. I was first exposed to it in medical school and that’s where they teach you parasitic infections and theoria. So I find it fascinating. So I didn’t mention that this can be not only that big, but even bigger. I have seen scrotal hernias that reach below the knee. So the scum is so enormous, it goes all the way down the knee. It’s huge and they’re very difficult to repair. The average general surgeon likely should not be repairing these because the outcomes are already poor in repairing them. The larger the hernia, the more difficult the repair and the more types of old school techniques need to be brought in. These are not the typical like, oh, I’ll do a Lichtenstein or laparoscopic repair. So here’s a question. How do you monitor yourself? How do you monitor yourself for an enlarging hernia if it is not easily seen?

Speaker 1 (11:31):

Good question. So these hernias are easily seen. So if your hernia is not easily seen, you are not at risk of having too large of a hernia. As a hernia gets bigger and it’s easily seen. If you’re noticing that it’s becoming bigger visibly, then that’s a good time to schedule your and not delay until you have more symptoms because of the fact that you can have these enormous hernias. And let me just show you some more pictures because I’m, I’m just fascinated by inguinoscrotal hernias. So our inguinoscrotal hernias, inguinal hernias, were the intestine protrudes from the inguinal canal and descend into the scum. Yes. And it’s not just intestine. I just did an operation I think two weeks ago where the bladder, the bladder was in the hernia. In women, you can have the bladder, you can have the ovary, the appendix can be in the hernia, anything in the pelvis can be in the hernia.

Speaker 1 (12:34):

I think there was one patient who had a gallbladder in his hernia that was a really big hernia without just a very, very abnormal one. And what is special about an Inguinal hernia with a scrotal component? So what’s special is first of all, it implies that there’s content in there that can be injured, intestine, bladder, et cetera. And it can cause side effects. So urinary frequency, incomplete bladder emptying, constipation or difficulty emptying your bowels. It can cause complications at the time of surgery. So for example, the skin of the scrotum can be very, very stretched out. You can have the abdomen not be used to having as much intestine in it. So now when you repair the hernia, you got to return all that hernia, hernia content from the scrotum into the abdomen and your abdomen maybe for years is not used to seeing that extra volume. And that can increase abdominal pressure and cause problems.

Speaker 1 (13:44):

And then you can bleed a lot. You can bleed a lot from these operations because of the space that was occupy occupying the area is no longer has any content. So you have a big wide sack of a scrotum with a little testicle in it and that’s it. And this big space is kind of loose and you can bleed into it without any compression. So there are techniques that I use and I’ll share some of those techniques with you. So if you need to have an inguinoscrotal hernia repair, you know what to do. So do scrotal hernias cause pain? Not necessarily. So the larger the hernia, the less pain. In general, the heaviness of the scrotum can be uncomfortable. It can show in your clothing and certain I’ve seen people like in the street, yeah, maybe you have too, where they’re walking, you’re like, maybe I should get that hernia fixed.

Speaker 1 (14:47):

That’s like a really large hernia. And I have a story to tell you about that one day. I don’t know if it’ll come out well on the video, but my point is that just because you have a large looking hernia doesn’t mean that necessarily it’s painful. But many do have discomfort from everything being so out and hanging out. And so yes, it can cause usually a dull pain, usually not a sharp pain. What are the growing injuries? What other groin injuries can cause scrotal pain? That’s a really good question because the pain in the scrotum may or may not be due to a hernia. Now let’s talk about less obvious hernias. So let’s not talk about the big ones where you can just see it and you go to your doctor and say, I have scrotal pain. So now they have to figure out why you have this pain. Of course hernias can cause it. So let’s first differentiate the anatomy. So there’s the scrotum, which is the sac. It contains the testicle, which is where the male sperm is stored, and there are vessels and nerves that feed the testicle. That’s pretty much all there is within the scrotum. Now there’s scrotal pain where it’s actually the skin and that could be very sensitive. That’s usually a nerve problem. And it could be the nerve damage or nerve pressure on it from let’s say a hernia. Let’s say.

Speaker 1 (16:27):

The other thing that you can have is testicular pain. So the scrotum skin is fine, but there’s testicular pain. There’s a slew of reasons for getting testicular pain. Anglo hernia is one of them. Some of the other ones include actual testicular problems that you can get cyst, you can have sperm. Sperm leaks are called, which are called spermatocele. You can have blood flow issues to the testicle. You’ve heard of the word torsion. Testicular torsion. You can have various infections of the testicle called osteitis of gonorrhea, syphilis. And let’s see, you can have, tumors don’t usually hurt in most places, tumors don’t hurt including of the testicle or the scrotum, but you can have enlarged in enlarged areas that are abnormal.

Speaker 1 (17:23):

Next question. By the way, you got a lot of questions on this one, so I’m glad that I’m talking about specifically inguinoscrotal hernias. So can an inguinal hernia become giant and are they at risk for intestinal incarceration or obstruction? Yes. So the larger the hernia, the more the risk of incarceration, which means the contents get stuck in the hernia and they can’t go back in the abdomen or of obstruction. And the reason for that is just think of trying to stuff a bunch of things into a bag. The neck or the top of the bag is what restricts how much stuff you can stick in there. So once the bag is filled, you can still, and you still want to fill some stuff in the neck may be too tight now for all the content that’s going through it. And that’s what causes bowel obstructions and or worse than that strangulation.

Speaker 1 (18:30):

So yes, the larger the hernia, the higher the risk of strangulation and incarceration. However, and in most men, as the hernia gets large than the neck also stretches out and accommodates over time. So it becomes less of a bottleneck. It’s the early ones that co have the bottleneck that can be the problem. Next question. At what site in the inguinal canal can a hernia cause pressure on a nerve and which nerve? So hernias tend to cause pressure on the nerves at the internal ring. At the early stages of the hernia, it’s usually the ilioinguinal nerve and it can also be the genital branch of the genital femoral nerve. And the ilioinguinal nerve can cause inner like inner thigh radiating pain, the inner thigh or base of the penis and the general femoral nerve can cause sensitivity and pain along the scrotum. You could also have some of the nerves on the vast deference, which is what carries sperm from the testicle to the prostate that has little nerves on it that can also be squashed by the hernia. And in doing so, give testicular pain. So almost all of those hernia pains are at the level of the internal ring or the early parts of the groin of the groin hernia. I see another, here’s another question. I have pain where my belt buckle sits after a keyhole hernia pair. Still don’t know why. So the belt buckle depends on the belt buckle where you have it, but if it’s at the belly button or just below the belly button, then that is maybe an incisional problem.

Speaker 1 (20:20):

Maybe incisional problem at the belly button. Maybe you have a belly button hernia or a scar or a non-healing wound at the belly button. But keyhole surgery is usually a term we use for laparoscopic surgery and it should not give any pain in the midline where a hernia is. Next question, is there loss of domain? Is loss of domain frequent and morbid and treatment high in such cases? Yes. So loss of domain is a very unique medical term. Specifically it implies that more than half of your abdominal contents are no longer in your abdomen because you have a hernia. It’s most commonly seen for hernias of the abdominal wall.

Speaker 1 (21:16):

And with that what happens is the abdominal wall kind of opens up and then over time the path of least resistance is for it to stay outside the belly. And if the hole is large enough, we can’t, you going to have more and more of your hernia outside your abdomen. That’s called loss of domain. The same thing can happen for groin hernias. It’s not as common because there’s a little bit smaller hole and it can’t get that big. But I have seen patients with loss of domain in their scrotum. Those are really, really, really difficult hernias to repair and need often a multiple teams involved. We sometimes even have plastic surgeons involved and so on. It’s, it’s really a difficult situation if it’s that bad. But what happens is if you have loss of domain, then your belly is used to not having much content because it’s all out outside the belly.

Speaker 1 (22:13):

It’s usually in the scrotum or in the hernia. And so to repair the hernia, to put all the intestines back where they belong, and now that means your belly is going to feel fuller and it’s not used to be so pooched out. And it also can push on your diaphragm, which is the muscle underneath your lungs, which is what helps you breathe. So you are going to feel like your diaphragm’s really high up and you can’t take deep breaths. And some people actually have difficulty breathing because you’re feeling their belly full of intestine that they’re not used to and it pushes their lungs up and they can’t breathe very well. It’s a very, very important aspect of hernia repairs to make sure your patient can breathe after surgery. So that loss of domain treatment of loss of domain is very complicated and therefore, as implied in the question, high morbidity and risk for mortality, which means you can actually die because if you’re not breathing or if you’re, you’re, you have breathing problems, you can get pneumonias or you can have respiratory arrest because of it.

Speaker 1 (23:21):

These are all really great questions. The next question that was submitted has to do with the treatment of it. So how are Alcock’s hernias treated and what happens to the enlarged scrotum when you treat them? Great question. So the main concept is returning all the contents back inside the abdomen, number one and number two, somehow patching or closing that hole so that things don’t return. Again, the problem is in the pelvis. So in the abdominal wall you can treat 19, 20, 25 centimeter hernias and still be able to close everything and put really wide meshes. The issue with inguinoscrotal hernias is if they’re really big, and I’m talking really, really, really big, then you’re getting close to the bladder and the vessels and a lot of very important structures that you can’t just patch over and therefore it, it’s tricky what you have to do. So in general, the concept behind successful treatment of inguinal hernias is number one, carefully return every content back inside the belly. Number two, assess that hole and see how much of it you can actually close. The point of closure is not to actually be part of the hernia repair of cell itself, but to allow maximum exposure of muscle to Mesh and the least amount of bridging where you manage to just dangling in the air in between within the hernia defect, you must use Mesh for these large inguinoscrotal hernias. Now can it be done with a tissue repair? Yes.

Speaker 1 (25:10):

Is it a good repair? No. Is it going to recur or cause chronic pain? Very likely. So most inguinal hernias, especially the really big ones, are best done with Mesh and you can do an open repair or you can do a posterior exposure repair. Before we had laparoscopic surgery, before we had robotic surgery, professor Renee Stoppa from France came up with a unique way of what’s called repair of a giant visceral sac. And what he would do is he would go be, he was like, let’s not put Mesh in front of the muscle. Let’s put Mesh behind the muscle as a big sack kind of covering it all. And that’s called a Stoppa repair and Renee Stoppa came up with it. I’ve done Stoppa repairs before. It’s a fasting very satisfying operation. We can now do Stoppa repairs robotically in many ways, and I really think it’s a great repair.

Speaker 1 (26:15):

I just did one again two weeks ago, a robotic Stoppa type repair worked really, really well. The patient is completely symmetric now his left and right side look exactly the same, which is awesome, whereas before he had his big bulge. So with the Stoppa repair or the robotic kind of Stoppa repair, what you’re doing is you’re putting an extra wide amount of Mesh to completely cover the hole and prevent intestine and other contents, bladder, et cetera, from going into back into the hole. The Mesh is much, much larger than typical groin Mesh. So your typical groin Mesh is 10 by 15 centimeters. The next step up is 12 by 16 centimeters. And depending on how big the hernia is, you can keep stepping it up to be even larger.

Speaker 1 (27:07):

Now you’re left with just the scrotal skin and the testicle and the spermatic cord, but they’re all stretched out. So one option is to allow your own natural skin to basically spring back into place. And for the small, medium and large inguinoscrotal, that works really well. So after surgery I have patients wear what’s called scrotal support. It’s kind of like a jock strap. In addition to that, I have them roll like a tube sock or I give them gauze rolls, but you don’t really need a gauze roll, like a tube soft tube sock would work. You just kind of roll it up and put it in the jock strap. The purpose is to manually compress and pull in all the contents because as upright human beings, you don’t want everything to sag down. And by externally compressing, you’re reducing that space that used to be so stretched out and you’re reducing the risk of bleeding hematoma, fluid collection seroma, and therefore really improving their recovery.

Speaker 1 (28:27):

And that skin will just start stretching back in or springing back into place in some really, really extreme situations. The skin has been so stretched out, it’s actually callous. I’ve seen it. It’s really fascinating that the scrotal skin can become a callous, almost like a cast. Have you seen people who have these heels? The heel of their foot is callous and then it’s like there’s cracks in it. So the scrotum can become like that because it’s being chronically pulled on and there’s swelling in the area because it’s like having your foot being down all the time. You can get ankle swelling, so you get scrotal skin swelling and then calluses and then it can crack and that skin is totally unhealthy. That skin will never go back. That’s when the plastic surgeon comes into place and they do what’s called scrotalplasty, kind of like abdominalplasty where they tighten up the belly.

Speaker 1 (29:39):

A scrotalplasty is where tighten up or rhinoplasty where they kind of tighten up the nose. A scrotalplasty is when they tighten up the skin of the scrum. So they will take off 40, 60% of the scrotal skin and get it to a more healthy skin. And it’s a difficult recovery, but very useful, especially for people that have chronic, chronic large scrotal hernias that’s been ignored, ignored for years, and they need to have a good recovery after the hernia repair because you don’t want to do a perfectly good hernia repair and the patient’s completely uncomfortable and disabled because they have the scrotum full of fluid or blood. As you know, if I give you water balloon full of water or water, it’s going to be very heavy. So imagine carrying that with you around. So that’s kind of what happens with these testicular or scrotal kind of skins.

Speaker 1 (30:45):

I hope you guys are entertained by all this by the way, because I don’t know, I feel like sometimes this is a difficult topic to discuss. We’re talking about testicles and maybe the women aren’t relating, and I know I have a lot of female followers in addition to lovely male followers. So you let me know if you have any questions about what I’m saying. I hope the anatomy I’m talking about is about too complicated. I think most people know what scone sac is and what a testicle is, and I just want to, oh, you know what? Yeah, let’s talk about this. So again, going back to the treatment. So usually when I talk to patients for inguinal hernia repairs, I’m like, oh, you got all these options. You can do a tissue repair. There’s a Shouldice, but McVay, we can do laparoscopic repair with Mesh, robotic hernia repair with Mesh, we can do a open Mesh based repair. The Lichtenstein, if it’s really small hernia, we can do robotic ilio pubic tract repair, which is a tissue based repair. We can do an open pre peritoneal repair with Mesh. There’s a lot of options out there. I have books and books and books that are written like a century ago almost that describes all these different hernia repair options that were invented back in the day.

Speaker 1 (32:17):

So what happens is the larger your hernia, the shorter the list of surgical options that are appropriate for you. So for example, tissue based repair out the door, the larger the hernia, the worse. A tissue repair is as an option. Now it’s possible to do it, it’s just not as good of an option because you’re relying on thinned out tissue that’s even less healthy than it was before and a much wider gap to close with that thinned out tissue. So just not a good option. So this gentleman actually very educated, very knowledgeable, I think has seen almost every video I put out maybe is on today, I’m not even sure, has read everything, understands every part of hernia care and how to be an excellent patient.

Speaker 1 (33:25):

So his option was I would love a Shouldice repair. I can’t offer him a Shouldice repair. The Shouldice repair is not a good option for the large inguinoscrotal hernias. It’s definitely not an option for the giant ones like the ones down to the knee. But an option for a medium to large one still not the best option. And what if you have a career that maybe you’re a singer, definitely not a good option. Or if you play wind instrument or if are, let’s say you’re auctioneer, you’re constantly, you got to kind of talk a lot. So not a good option to have a tissue repair. So if you do want a tissue repair, and I know there’s many of you that follow me that are keen on Shouldice tissue repairs, no Mesh, et cetera, do not wait for your hernias to get too large because the larger the hernia, the less likely that a tissue repair would be an option for you. So if you want to keep within that tissue repair, then get your hernia repaired earlier.

Speaker 1 (34:42):

All right, next question. I had bilateral hernia repairs open and a volleyball size scrotum from hematoma. Yes, yes. My scrotal skin never seemed to return to normal size and may test these hang lower. I am elderly. Okay, thank you for saying that. That’s what I’m trying to say. When you have hernia surgery, you are at risk of bleeding and that and the larger the hernia to begin with, the larger the risk of bleeding. And then that’s called the hematoma. And this patient seems that he had a volleyball size scrotum, which is huge. I used to play volleyball so I know exactly how big that would be. And his scrotal skin never seemed to return a normal size. So he is his, what happens, you kind of stretch out the scrotum and then it scars down with all that blood that was in there. Now what it could have been done was at the time of the hematoma or to prevent the hematoma, which is what I do, is to bind the scrotum similar to how you would bind a belly or bind a kid, you bind it and we usually use a jock strap with, it’s a jock strap with a tube to socks rolled in the space where your scrotum goes.

Speaker 1 (36:10):

And then on top of that you can wear a compression underwear. I’ve talked about this before. Under Armour has really good compression underwear for men.

Speaker 1 (36:20):

I recommend the ones with leggings that kind of cri the crisscross pattern that they have and his testis testes hang lower. So they hang lower because they are connected to the base of your scrotum. So wherever the scrotum goes, the testicle will go with it. Also, they may hang lower because of the type of operation that was done. So sometimes what happens is the operation, they cut what’s called the cremasteric muscle and that cremasteric muscle is the muscle that holds onto this spermatic cord, lifts the testicle up and down with it. If that muscle is cut, you’re at risk of having the testicle not be able to be lifted up and therefore it plunges down lower and longer than you would want.

Speaker 1 (37:21):

Is treatment of large inguinal hernias a challenge even for experiencing specialized surgeons and what are the difficulties? Yes. So one of the difficulties is actual operative planning to find the right operation. So for example, for these large ones, not the giant ones, but for the large ones, I like to do those robotically. As many of you know, I do offer laparoscopic and robotic surgery and open surgery. I prefer laparoscopic surgery for most straightforward inguinal hernias. However, with the larger hernias, I prefer robotic surgery because there’s more room to, it’s a tapp procedure T A P P, whereas the laparoscopic procedure I prefer is a tep TEP. And so that’s one reason. The second reason is with the robotic surgery, I can sew better and close the whole to allow for a better Mesh placement. I can secure the Mesh with sutures better than by tacking with laparoscopic and I can make wider have a wider work working space than any other type of operation approach. So that’s what I would offer most patients that come with Alcock’s, if they’re healthy, if they’re not healthy, then I would do an open repair. And there’s all these maneuvers to do to help reduce the risk of hematoma, seroma and what’s called the hydrocele, basically fluid collections in the scrotum because that’s a very kind of, it really messes up your recovery if you’re having problems with a heavy fluid-filled scrotum because that’s going to take months and months and months for it to get back to normal and it really affects your quality of life.

Speaker 1 (39:14):

And then there’s the question of do I need a plastic surgeon to do the scrotalplasty all the steps that I take to reduce the risk of bleeding hematoma, seroma, hydrocele after surgery, doing the right operations so that the patient doesn’t recur because recurring from a hernia can occur, but recurring after inguinoscrotal hernia is even more difficult to address. So there are all these different factors. Do they have good healthy lungs where they can tolerate return of all of this, the content inside. So the next question is how much time does it take for an inguinal hernia to grow in size? And are there cases where immediate treatment is not recommended? Yeah, there’s no need for immediate treatment. These are not urgent or emergent. It’s just watchful waiting is not something I recommend once the hernia is growing in size. So going back to the question I already forgot the question.

Speaker 1 (40:17):

Oh, how much time does it take for these to grow? Highly variable. Some people come in my office literally and say, I just got this last week and it’s a humongous scrotal hernia. I’m like, there’s no way. Then you went from normal to scrotal in one week. There’s just no way. I think some men just didn’t know they had a hernia. And once it made that extra leap forward into the scrotum, then they knew they had a hernia. But were otherwise oblivious to it because it doesn’t happen within a week. Doesn’t happen within a month. It happens over year’s time. But it could be in some people one year, it could be in some people 15 years or 20 years. It’s very, it’s hard to know.

Speaker 1 (41:05):

And let’s see, what are the factors that lead to delay treatment of inguinoscrotal hernias are socioeconomic aspects and difficulties accessing healthcare among them? Yes, yes and no. So I feel in the United States about half the patients who have inguinoscrotal hernias have it because they had no symptoms. It was just a bulge, it wasn’t bothering them. They felt, I don’t need to fix it. Someone said, yeah, you got a hernia. And then now it’s gone to the point where you can’t wear a bathing suit, their partner is complaining about it. Some hernia can gets so large you can’t see the penis anymore. So it becomes more of a quality of life issue and or they’re start getting symptoms now that it’s, it’s so large and then they’re like, okay, maybe I should get this addressed.

Speaker 1 (42:09):

But I feel that half of the patients in the US are like that. And the other half truly are patients that have ignored it. The story I was going to tell you, this is a funny story. I still remember this patient. I was a chief resident and at that time the chief resident is king of the hill. So you run the show you’re attending obviously makes the final decisions. But we were at the VA, we have a really great VA here in Los Angeles. And the way the VA was run, at least at that time is the attendings were the boss, but really the chief resident was the boss boss.

Speaker 1 (42:56):

So on a daily basis, the chief resident would, I was a really good chief resident and I had what’s called of would do weekly and teaching rounds kind of how the attendings went. And we would go to different patients. And one patient was, this patient was an elderly patient. I think he was in the Korean War and he slept on his gun and the gun blew off through his pillow. His pillow was, his gun was under the pillow and then I guess it was loaded, so it shot his cheek off. So he had this huge hole in his cheek and the different head and neck surgery teams were taking care of it, et cetera. Plastic surgery was taking care of it. And as general surgery we were involved in just making sure that all the teams were coordinated. We went to see this patient, the nicest guy.

Speaker 1 (44:02):

He was so nice and he just had a thin sheet over him and I saw a stump, which I assume was his amputated leg at the VA. Unfortunately there’s a lot of amputees. So I thought this is what was called a blown knee or above knee, above knee amputation. That’s how big it was. It looked like it was a wide big. And I assumed through the sheet that he had, he had an amputation. And oftentimes the amputation is from the war that they served in. And I always like to hear people’s stories as I like stories. So through the sheet, and by the way, my team didn’t tell me anything through the sheet. I grabbed this stump and I said, so tell me your story. Which war did this happen in? How’d this happen? Something like that. And I saw that my team members were lying or saying like, no, don’t, don’t look.

Speaker 1 (45:10):

And I pulled down the sheet and it was a hernia and it was the largest hernia I’d seen ever. It literally looked like an amputated thigh down to the knee. He had two legs, he had two normal legs. I just didn’t see the second leg because his hernia was so enormous and was bulging the sheet and the skin was completely dried and calloused, like firm like the heel of a person. I was explaining some heels, get all firm and cracked and old and just this thick rind of dead skin over it. And I was like, oh, well this is a hernia. How long have you had this? It’s like, oh, forever. And I said, well, do you want this fixed? And he says, no. And this gentleman was probably in his eighties, seventies, maybe seventies. No, the girls love it. And I was like, the girls love it.

Speaker 1 (46:20):

Oh my god, I couldn’t stop laughing. And he was a funny guy and he literally did not want me to fix it. I offered to put him on a schedule to fix it. He was like, no, I like it this way. They like it this way. So that’s another reason why these things are not addressed. And then in the second, third, mostly third world countries, there’s poor access. And often these are hernias that are not repaired as children because we tend to repair hernias for children and don’t let it kind of go. And then because it’s not repair as a child, it’s now complete loss of domain are really large as an adult. So very fascinating socioeconomic impact that hernias can have.

Speaker 1 (47:13):

Okay, I hope you like that story. I haven’t told that story a long time, but that was back a long, long time ago when I was a resident at the Veterans Affairs hospital. Next one, can inguinoscrotal hernias be repaired without Mesh? Yeah, we discussed that it can be, but they should not be. That’s my answer. There are patients who, especially in second third world countries that are getting these done as tissue repair because Mesh repair is not common. I know of many surgeons in the United States that offer tissue-based repair for scrotal hernias, not the really, really giant ones. Actually, let me give you this other story. So if it’s really big, like huge and they failed prior repairs, one of the techniques we use actually is called orchiectomy. So as part of the hernia repair, you actually cut out the testicle. And what that does is it then you don’t need to make space for that testicle anymore as one less risk factor or area for the hernia to recurrent.

Speaker 1 (48:37):

Now that’s an extreme situation, but it’s something that’s taught as an option for patients who have recurrent hernias and they have loss of domain and the hole is too big and you need to be able to close the hole, but you can’t close it completely because they have a testicle running through it. And so one option is just to cut out that testicle. But yeah, the Bassini repair, maybe a Shouldice can be performed in patients with inguinoscrotal hernias if they do want to have a tissue repair. Or if you do want to have a tissue repair, you must must get your hernia repaired earlier rather than later. So going back to this gentleman who I saw in the office. So he has an inguinoscrotal hernia I operate, I offered him robotic repair with Mesh tap repair, T A P P. He also has a hernia on the other side and a smaller also not giving him pain.

Speaker 1 (49:42):

And I know that he really does prefer he came to me actually because I do offer the Shouldice hernia repair. So what I told him is, I understand you prefer not to have Mesh and U, so let’s deal with this first, this English hernias the main problem. And in the future if you see that you’re starting to get symptoms or you’re right, the opposite of hernia side is getting bigger, come in early and I can do a Shouldice on that side because then that would be a legit option. But oh, and he had some risk factors for recurrence, so I didn’t want to mess up his hernia repair on the left side because of his different risk factors or risk factors can include things like the type of job you have, the type of hobby that you have if you’re a singer, a wind instrument player, opera. I’ve done opera singers, they generate a lot of abdominal pressure and so you don’t want to give them a repair where it’s just going to pop the minute they start singing again or using some wind instrument. I had a what? I have one sack saxophone player last week. So those people tend to need better repairs than the average patient. Alright, let’s see what else we can talk about.

Speaker 1 (51:21):

And then the timing of the surgery is completely up to the patient. And again, anal hernias, if they have no symptoms, technically don’t need to be repaired, like you don’t have to get it repaired. We recommend it once it gets that big because as a surgeon I prefer to operate on smaller hernias basically because it’s easier, better outcomes, better for the patient. But if you have an anal scrotal hernia, is it absolutely necessary that you have it repaired? No. Is there higher risk than the average hernia that you will have of intestinal obstruction or strangulation? Yes. And so that’s one of the other reasons why we don’t recommend watchful waiting for a lot of these patients. But again, if you are educated and understand the risks and benefits of what needs to be done and are here to make your a educated, informed decision, then what we do know is that patients who don’t have too much symptoms can keep delaying their ankle hernias. Let me tell you this. I saw again another patient this past week.

Speaker 1 (52:45):

This patient had a femoral hernia. The imaging did not say femoral hernia that said possible hernia and they called it inguinal femoral hernia. First of all, there’s no such thing as inguinal femoral hernia. It’s either an inguinal hernia or a femoral hernia or an inguinal and a femoral hernia. But there’s no such thing as inguinal femoral hernia. Just that means their radiologist didn’t know what they’re talking about. So this patient saw two other surgeons before coming to me. Those surgeons I assume examined the patient but didn’t understand that what they were examining was a femoral hernia. There are very slight details as to what’s a femoral, what’s the inguinal on examination. They did not look at the imaging and just read the radiology report that said inguinal femoral hernia. And they said, oh yeah, watchful waiting. Meanwhile, this patient has a femoral hernia. I looked at the imaging, clearly it’s a femoral hernia.

Speaker 1 (53:52):

I examined her clearly she has a femoral hernia. And what do we know? Everybody say it with me. The only hernia that is considered inappropriate for watchful waiting is what? femoral hernia. Why? Because it has the highest risk of death than any other hernia. 5%. Why? Because the way the location is, you can get intestines stuck and not, and you can’t unstick it, you can’t reduce it because it gets stuck. Most hernias are through muscle or fascia. Muscle and fascist stretches. I think we did a whole session on femoral hernias, did we not? I think we did. We did do a whole session on femoral hernias. This was almost two years ago maybe. And just to kind of finish this thought, femoral hernias are not through muscle or fascia, it’s through a bone. It’s between. It’s through a space between bone and ligament. So two non stretching firm structures.

Speaker 1 (55:08):

If you pop in through that hole, you can potentially not pop it back because it won’t stretch and allow for that to be reduced. And so you can get intestine stock, they ended up in the hospital, then bowel intestinal surgery, if they got to you too late, you have sepsis and there’s a risk of death. And therefore watchful winning is not considered a valid option for patients that have femoral hernias. The other thing you should know is this patient was told, eh, watchful waiting come back completely incorrect. Two surgeons. If you look at the European Hernia Society guidelines, it’s very, very, very clear. Watchful waiting is not an option for femoral hernias because you can die from it. And therefore when you see a patient with a femoral hernia, you must offer surgery. And she’s a smart lady. I said, come in when you want to get it repaired but don’t delay it.

Speaker 1 (56:12):

You know, should do it in the next several months, less than a year I prefer. So those are two situations where you should not wait. Large inguinoscrotal hernias or enlarging hernias, I should say enlarging hernias because they can become inguinoscrotal and it just completely complicates the situation. And secondly, femoral hernias. One last thing I want to talk to you about is the idea of wearing a truss for these scrotal hernias. So a truss as a hernia belt. I think we did, we do. Do you guys remember if we did a truss hernia? I think we did a hernia binder one. I’m not sure if we did a session on Hernia Talk Live on trusses. But I do know on my Instagram I did a full video, a full reel on Inguinal hernia trusses. I highly recommend you go to it, but if you do have scrotal component or an enlarged component to your hernia in the groin and it’s causing you symptoms, so basically you feel like this dull achy heaviness, then a truss will help you not feel that.

Speaker 1 (57:29):

Let’s say you’re a security guard, you have to stay on your feet all day. You have this hernia, you don’t have time off yet to take to get it repaired. Wear a hernia truss. And then what the hernia trust does is it holds the hernia back in place and prevents you from having these symptoms. The way to wear it is you have to be able to completely reduce the hernia in place, then you put it on. So I usually tell patients to lay flat in bed, push the hernia contents back in and then wear the hernia on top of it. However, if you can’t reduce it, you shouldn’t be wearing a truss, it can cause damage. Or if you don’t have symptoms, you can argue that it’s really not helpful to wear the truss cause it’s uncomfortable to begin with. And the only purpose of the truss is to reduce your symptoms and not to make your hernia any better or your outcomes any better.

Speaker 1 (58:21):

So that’s what I have for you all. Here’s another question. Can trust further damage muscles and floor? No, it does not. It doesn’t cause any damage unless you’re wearing it in incorrectly. It could chafe you or cause some skin, skin issues. But other than that, it does not actually make your hernia worse or at all. And that is the conclusion of you. Another successful Hernia Talk Live session. Thanks to all of you for joining me and you guys sent me so many questions. I love answering them. I told you a story I haven’t told you really I haven’t told anyone in a really long time back for my residency time and I hope you enjoyed it. So thank you everyone. Please follow me on Twitter and Instagram at Hernia doc on Facebook at Dr. Towfigh Dr. Towfigh and do subscribe to my YouTube channel and you’ll be able to watch this and share it with all your friends. Bye everyone.