To watch this episode on YouTube, click here.
Dr. Shirin Towfigh (00:00:10):
Well, Hi everyone, it’s Dr. Towfigh. Welcome to Hernia Talk Live, our weekly question answer session every Tuesday. We call it Hernia Talk Tuesdays. Thanks for those of you who are joining me on Facebook as a Facebook live at Dr. Towfigh, and those of you who are on Zoom, welcome. Thanks for everyone who’s been great at subscribing. We have a really growing YouTube channel at Hernia Doc, and as you know, we also have the podcast if you prefer podcasts. So let’s get today’s session started. I recently had a patient with a really huge inguinal scrotal hernia, and as you know, I like to pick my topics based on my experience for that week. So yeah, let’s talk about huge inguinal scrotal hernias, shall we? As you know, there’s had I think a previous talk about just scrotal hernias, but today’s will be on the huge ones.
(00:01:13):
So these are patients, usually male. I have, lemme try to think. I don’t think I’ve ever had a female who had a huge scrotal, well, not scrotal, theirs would be a labial hernia. But as you know with men, because they have a scrotum, the contents from their groin hernia can follow down the same path as the testicle and land on top of the testicle and the squirrel skin will just expand and the hernia can get larger and larger as years go by. So if you are delinquent in addressing your hernia for decades, you are at risk of having an inguinal scrotal hernia. And the scrotal part, which is the hernia part and the scrotum is really big, is the issue, right? That’s where all the contents end up. So in most people who have huge hernias, and by huge I mean not ones that you can see, but ones that you can see when you’re through your underwear, these are ones you can see through your pants, okay?
(00:02:21):
You can see ’em through jeans, through sweatpants, most of them who have it that are worried about how they look, tend to wear really loose sweatpants or really long shirts so that people don’t see it. It looks like an enormous growth between the legs. That is an inguinal squirrel, a huge one. So those are a very unique population. Fortunately in the United States, we don’t have that many of them. If you do any missions in third world countries where access to hernia surgery is low, there’s a lot of inguinal hernias. And actually fun fact, I guess people who have really huge inguinal hernias as a young adult, which are the ones that we see when we do missions in third world countries. Those patients tend to be people who had hernias as a child and then there was no good access to surgery as a child.
(00:03:28):
And then now they’re an adult and let’s say they’re construction worker or they work at the family farm and they need help because this hernia is in their way. So we don’t really see that as often in developed countries because access to care is usually better than in underdeveloped countries or what we call that kind of at-risk countries. And so people usually, or children and have hernias get access to care. It’s not as common to have a child have a hernia for a lot of their young life. Those get repaired. So let’s talk about it. If you guys are like me, you’re on TikTok, you’re on Instagram, social media, and you see there’s been a couple of posts that I’ve shared, but you can also see it of these enormous scrotums. So if someone has a huge scrotum, that doesn’t necessarily mean they have a hernia.
(00:04:40):
You can have a huge scrotum because you actually have large amount of contents within the scrotum. That could be a hydrocele, which is a fluid collection in the scrotum. It’s like a, think of it like a water balloon, just water in a sack in the scrotum. So everything is fine up in the groin area. The bulging and the abnormality is really at the scrotum itself. So that’s a hydrocele or varicocele seal. Varicocele seal is another reason for bulging is usually not that big, but what we call bag of worms because all the veins are dilated, enlarged in the scrotum. So that’s number one. Hydrocele is a pretty common reason to have a really huge sac like scrotum. And oftentimes you see a urologist. I do fix hydrocele seals if they’re involved with the hernia, but if it’s a pure hydrocele, a urologist would be a good option for that.
(00:05:42):
The next one is a more common one that I see, which are big hernias that extend down to the scrotum. And what kind of content is in that number one fat. So omentum, which is a big drape of fat that naturally occurs in the abdomen. It’s like a blanket of fat over your intestines that can fall into the scrotum and also colon. Your large intestine can fall into scrotum, small intestine can fall into the scrotum. There’s a lot of different contents in the area. I’ve seen bladder in the scrotum and some of those patients, they can feel it when their bladder filled. They can feel it in the scrotum or in the groin area. So it’s critical structures can actually fall into the scrotum. And so it’s really important that some type of imaging be done because you need to do a lot of planning for these hernia repairs.
(00:06:42):
There’s zero chance, 0.0, zero chance that any scrotal hernia will ever cure on its own. So don’t believe anyone that has trying to sell you certain herbal supplements or binders of any sort. There’s a hundred percent, this is a surgical problem. You cannot cure it by losing weight, changing your diet, et cetera, taking herbs, it just doesn’t work that it has to be a surgical problem. No amount of fitness will make that s hernia get smaller enough to matter, I should say. And then lastly, there is a phenomenon which I’ve seen multiple of, but Beverly Hills is right next to West Hollywood and there’s a group of men who like to get silicone injections into their scrotum and make their scrotum look larger as an aesthetic thing. So there’s a fraction of patients in the population that are seeking to have a large scrotum, kind of like breast implants where there’s a fraction of population that does breast implantation for cosmetic purposes.
(00:08:00):
You can do a similar kind of silicone based implant or an actual silicone injection into the scrotum. Now the issue that I’ve seen with that is it makes it very heavy. So not only does the scro suck become really huge, which is the purpose of it, and you can wear, let’s say Speedos, and it makes the look different than the typical male, but silicone is very heavy, so it weighs it down and then they get a thinning and stretching out of their natural skin. And it’s just a difficult surgical situation because it’s gravity. We live in a world with gravity. So if you have something that’s so heavy, it’s always going to get pulled down and it’ll continue to go down and down, down and then it doesn’t look pretty anymore because you want the scrotum to be somewhat elevated and not down to your knees basically. So you don’t want the scrotum to the mid thigh. Those are all aesthetically not pleasing. Upper thigh is fine. It’s the ones that start aging and pulling down with the silicone implants. So if any of you know anyone or have experience more about silicone implants in the scrotum, leave some comments for me because I want to hear about your take on it. But it’s definitely a thing at least in my part of the world.
(00:09:42):
So those are really the three main reasons to have a huge scrotal mess. There is a fourth one, which is a cancer. So there are cancers that grow. Usually if a cancer grows to be that big, it’s either not a bad cancer because otherwise it would’ve spread to the rest of your body by now, or it’s like a benign tumor. But usually it’s not a cancer. But if it is a cancer, it can be what’s called a sarcoma. I’ve had patients with a sarcoma and they were diagnosed with a hernia and they had the hernia fixed and it wasn’t the hernia that was causing the bulging, it was the tumor. So they had to go in there and the tumor had involved the testicle. So a lot of times the origin of the tumor is the testicle, and sometimes there’s other components of the and the spermatic cord that are involved in the tumor.
(00:10:43):
So that makes four diagnoses, right? Hydrocele tumor, silicone implant or large, huge inguinal scrotal hernia. And I would say the hydrocele and the scrotal hernia are the top two in the diagnosis, the other kind of ABER disease. So how do you treat this? It’s very different than a typical hernia. So I would suggest that most people who have these huge hernias, whether you ignored it for so many years or a lot of times we see it in patients that have conservators because they’re not deemed not capable to make their own independent decisions. And so their healthcare sometimes gets, it’s lower on the priority. So they’re like, this is cosmetic. We don’t need to fix your hernia because you’re a wheelchair bound or you’re not even that functional, so it doesn’t affect your function. And so you see sometimes that those hernias just get bigger and bigger and bigger and then it becomes very, very difficult. So even if you are, let’s say, conservator to a patient who’s not that functional, I would still get hernias fixed because waiting until it’s really humongous is not a good quality of life for the patient.
(00:12:14):
So how do you fix it? Well, it is still a hernia, so it still needs surgery. And of course there’s various ways of fixing groin hernias. The typical patient with just a straightforward hernia has multiple options. They have a open repair, a laparoscopic or robotic repair option, and then all of those can be performed with or without mesh. When you have a huge inguinal scrotal hernia, all the non mesh options are out the door. Not possible, not possible, not recommended. Don’t even try it. Don’t force a doctor to do it for you. Do not do a non mesh repair. Then the question is, do you do these open or laparoscopic robotic? I personally prefer the open repair for these patients.
(00:13:10):
I feel that is an opportunity for me to close the hole and not injure the nerves in the process and place a mesh. And so because of that, I think an open repair is great and the mesh can be placed in a variety of areas. Either the typical open Lichtenstein repair where the mesh is placed on top of the muscle as a keyhole or a retroperitoneal mesh like recreating a laparoscopic repair, but an open fashion. What’s important is what’s important is when you do the repair in these large inguinal scrotal hernias, you should not be putting mesh in until you recreate the groin. Now, in most people who have inguinal hernias, direct or indirect, well I take that back for indirect, the typical hernia, which is the early stage of what we’re talking about, most patients do not get their hernia closed, they just get it patched, they get it patched with mesh, and that’s fine because the size ratio between the mesh and the hole is pretty big.
(00:14:30):
A lot of mesh, a little bit of hole. It works great, you can patch it with a direct hernia, you tend to have wider holes. So we do like to close those and those can be safely closed, open or laparoscopic. But we never recommend closing the antal ring or the indirect hernia hole, laparoscopic or robotically. Why? Because the ileal inguinal nerve in particular, and sometimes the other nerves may be involved in that hernia. And so if you’re closing the hole, you may entra a nerve laparoscopically or robotically. Whereas if you go in open fashion, Lichtenstein typical, then you can safely identify those nerves, make sure you don’t injure them, and then close the hole without injuring those nerves. Now, why is it important to close the hole? The hole is closed to provide support for the mesh. You can’t just put mesh on air. That would be called bridging.
(00:15:46):
And you want the majority of the meh to be on healthy muscle in a small hernia. That’s not a problem. The majority of mesh is on muscle, and you’re bridging a small defect in these huge ones. They have what’s called, some people refer to it as a blowout of the pelvic floor or a blowout of the inguinal floor. So because it’s a blowout bridging it, there’s, there’s very little perimeter tissue compared to the size of mesh that you can place. So for an open repair, the technique is to gently close that hole, not in a fancy shouldice way, but just to close the hole enough to provide support onto which you can apply the mesh as a scaffold so the mesh can then be supported by the underlying muscle and you have a good repair.
(00:16:49):
So that’s the way that I like to do it, because I think it’s the best repair, and I’m not a fan of doing it purely laparoscopically or robotically. Some people argue, well, you’re doing open surgery, there’s only so big the mesh can be with an open surgery and you have to do a lot of suturing. That’s painful for the patient. So in order to put a larger piece of mesh to address this huge hernia and defect, maybe it’s better to do these laparoscopically or robotically because then you have a big space on the inside behind the muscle of the hernia, and therefore you have an opportunity to put a big mesh without the bladder in the way or the colon in the way, et cetera.
(00:17:38):
That argument is true. It is true that a laparoscopic approach, or what we call a posterior approach does provide you with an opportunity, put a much larger mesh, and therefore is a better hernia repair. So some people argue, why don’t you do what’s called a hybrid? So you want to be able to close the hole safely, so do that open, but you also want to put a very wide piece of mesh. You can do that part laparoscopically or robotically. That’s also totally legit way to do things. And then lastly, you can do them all open, but retroperitoneal knee or posteriorly, there’s a surgeon, French surgeon. Now that we got the Olympics in Paris, we can talk about some French S. So Renee Sopa is a famous French surgeon. He came up with a lot of different famous for the one that he’s most famous for, is the one where he recommends a giant piece of mesh to envelop the whole area where the pelvis is, the whole pelvic bowl to prevent these recurrence of these really humongous hernias, which is what they were seeing more often a decade, a century ago. So the oppa repair refers to placing a very large retroperitoneal match, many times larger than you can do in an open anterior approach like a Lichtenstein put. It’s a open posterior approach. So it’s the same area of operation as you would operate laparoscopically or robotically, but you do it through either a vertical or a horizontal scar depending on one side or two sides and the sides of the size of the patient. So that’s actually not a bad repair. That’s not a bad repair to do at all.
(00:19:55):
And in addition, you must suture in the mesh regardless of the type you do, although the oppa repair didn’t recommend sewing because the mesh is so huge, it’s like 10, 15 times larger than the hole that it doesn’t matter that you sew it in place. Just putting it in place should hold it in place. But in terms of suturing, usually you should suture the mesh to prevent the me from moving balling up and lastly, prevent the me from falling into this defect because you want to keep it very sturdy. When you have a patient with a huge inguinal hernia, you do not want them to have a recurrence. They already have so much trauma having lived with such a huge hernia, and then to commit to a big operation to fix the hernia, you just don’t want them to be susceptible to yet another problem, which would be a recurrence and then that would need another surgery and so on.
(00:21:04):
And usually people that have inguinal sal hernias already, they’re already probably someone who doesn’t like to see doctors or isn’t able to see doctors. So that’s the patient population you’re already dealing with. So you want to make sure they have a perfect repair and they don’t need to come back because they don’t like to come back to begin with. And if they do come back, then they’ll have the attitude of, well see, look, I didn’t want to have surgery. I was doing just fine and now I had surgery, now I have this complication. See, I told you so I should never have had this surgery. Now I have even more pain or whatever the situation.
(00:21:54):
So here’s a question. If you had your direct hernia, inguinal floor closed via an open repair, but now there is recurrence of bulging of the inguinal floor without a defect, what would be the best way to treat this? Can it be laparoscopic or open? Does the mesh need to be fixated in? Good question. That’s quite a dilemma. So I have seen direct hernias that are not closed, not tightened, that are repaired laparoscopically, and they’re not tightened usually because a surgeon is not aware that that would be a superior technique. And then the patient still has a bulge, and the bulge is because now they have this weak floppy thinned out, direct inal hernia, and the mesh is basically in it instead of securing it. So in those I do open, so they’ve had the surgery laparoscopically, I do those open and tighten the repair, tighten the muscle, the direct hernia, and then that’s all I need.
(00:23:06):
But you are saying something else. You are saying that you had a direct hernia, sorry, an open angle hernia pair with mesh and well, I assume with mesh it doesn’t say that you had it with mesh. Please let me know if it was with mesh, but let’s assume you had a typical Lichtenstein repair. Oh, without mesh. Oh, that’s different situation. So if you had it with mesh and you have a bulge, then you need a laparoscopic repair. If you had the inal hernia without mesh and the Ingle floor was closed, which is all open without mesh hernias, close the defect, the internal ring and the direct defect, the inguinal, indirect and direct defect, regardless of whether you have those hernias or not, but now there’s a recurrence, then you need a laparoscopic or robotic with mesh. What you are talking about is a recurrence. You’re not talking what I’m talking about, which is a direct bulging.
(00:24:18):
That’s a primary problem. What you have is bulging because of a hernia recurrence. And so yes, you need to have a repair now with mesh, and that should be done laparoscopically or robotically and not open because you already failed the open repair and going in again, open has a higher risk of damaging nerves. So I would not do any open repair failure. I would not do it open again unless there are certain circumstances where you can have things done laparoscopically or robotically, but 99% of the time that’s not the case. You would have to do it laparoscopic or robotic and you would use mesh and yeah, I would fixate them. I would definitely fixate the mesh because by definition, if you had tissue repair, you had an opening of the entire AL floor and closing that, and now that that’s failed, you are at risk of the entire floor opening.
(00:25:26):
Well, a lot of people don’t understand is when they want a tissue repair, you’re actually causing an even higher larger tissue herniation if fails and you’re cutting through natural non hernia tissue to then sew it back together again. It’s one of the things I don’t like about tissue repairs is as they are Shouldice, McVay, Bassini, the Desarda, all of those, you are opening the hernia to close it, and I don’t like that idea in most patients. Okay, so we talked about the repair of the hernia, but there’s a but here, and this is why I think it’s so important that men who have huge, huge inguinal scrotal hernias, so mid thigh level, you can see it through your pants type inguinal hernias. It’s very important that those get repaired by a specialist because here’s what’s going to happen.
(00:26:38):
Number one, they need to have a plan of what to do with this really dilated, thinned out scrotal skin. I’ve seen patients that have calluses calluses on their scrotal skin because it’s been stretched out and injured so much from these hernias, calluses, not joking. If it’s really huge, that skin is so damaged that it won’t shrink back in again because see now the hernia is fixed. The scrotum only has your testicle in it, everything else is gone, gone, so it’s empty, and yet there’s all this space available because it used to be filled with colon fat, et cetera. Now that’s gone. You’re hoping, the hope is that the scrotal skin will shrink back to its normal position, and that will happen for most patients, except the ones that are at or below like the mid thigh, the ones that have skin changes, dryness, cracking, thickening, callousness of the skin, chronic skin changes of the scrotal skin, the ones that have hernias till below the level of the mid thigh, those patients, their scrotal skin is destroyed and will not have the opportunity to become back to normal again.
(00:28:21):
So that extreme, you should get a plastic surgeon involved and they or a urologist, usually plastic surgeon, and they will excise all the excess skin and sew everything together again, like a tummy tuck of the groin. If you want to think of a scrotum, if you want to think of it that way, take off all the extra flabby skin and sew everything tighter together. That’s how it’s usually done with a plastic surgeon or urologist if you’re in that. So that’s why it’s important to work with a hernia specialist because a hernia specialist will know which patient needs a plastic surgeon at the same time of the operation.
(00:29:06):
If you are smaller than that, then your skin will shrink back to normal, and the goal of the surgeon should be to do a perfect repair so there’s not much bleeding and it’s very delicate surgery. And then I have a whole protocol I use to help reduce bleeding, swelling and fluid collection. In the old scrotal sax area, it involves three things. It involves a scrotal support which holds testicles up and takes attention off the scrotal skin. It involves either gauze or sock placed underneath the scrotum and to the side of the scrotum within the scrotal support to add external pressure, mild external pressure over the space to prevent it from swelling and getting fluid collections including bleeding. And on top of that, wearing a compression underwear, wearing a compression underwear that provides external compression even more on top of all of that. Very important, do it for a good two weeks.
(00:30:31):
Let me tell you, the more compliant you are with this part of the operation absolutely makes a big difference. So important to do, and I just can’t stress how important it is that you have this much care given after surgery. Some people put drains in place. I’ve not had to do that Often, it’s another way of working it out. It doesn’t always work. These dressings works, I think, better. But yeah, you can put drains in place and then if you are kind of in the middle, so you may have overstretched the skin a little bit, but it’s not so diseased that you necessarily have to commit to a plastic surgeon. What you can do is have the surgeon do your hernia repair and put drains in place and do all this dressing stuff and give yourself a good three months and see what happens. If at the end of three months your scrotum is starting to shrink and look better, then you don’t need a plastic surgeon anymore.
(00:31:39):
If at three months you still have this very kind of diseased looking, kind of like a pregnant lady who gets all your stretch marks and thinned out skin, if that’s what your scrotum starts looking like, then after three months you can consider having another surgery with the plastic surgeon focused only on removing the excess skin and reconstructing the scrotum and the skin. So the same way a tummy tuck is called adominoplasty, a tuck of the scrotum is called the scrotal plasty. So you may need to scrotal plasty either at the time of surgery or later on three or more months later, depending on how big the hernia is to begin with. Now, one extreme, which I’d like to share with you, which is still a thing to do, but because of the patient populations that we have, we tend not to learn this much history because most of the surgeons that were doing this have died. They’re much older surgeons.
(00:32:47):
So one other thing in a patient with a really huge hernia or in a patient with a huge hernia that then recurred, right? So it was an inadequate repair and now it’s recurred is to do a oppa repair, which means put a humongous giant sac of mesh around the visceral sac and cut the testicles. You heard me? It’s the first time I’m advocating cut the testicles. It’s uncommon to do it for both side hernias because that really pushes the male into a hypo testosterone hypo androgen state, and they would need to get exogenous testosterone pellets of some sort. But at that extreme, the scrotum is so pulled apart from the hernia that the blood flow to the stretched out testicle, the stretched out spermatic cord, the blood flow to the testicle is somewhat compromised anyway. So yes, cutting the testicle. Now what do I mean by that? What I really mean is we are changing from a keyhole technique where we need to make space for the somatic cord and the blood flow to the testicle to go either through the mesh or underneath the mesh, which is a weakness of the hernia repair and a common area for hernia recurrences. If you can just get rid of that, like you do in a female, females don’t have testicles, so you can just cut the round ligament and just put a mesh with no holes in it, then that would be a better repair.
(00:34:57):
See, we have a question. Did one, does one-sided resection of the testicle increase the risk of hypogonadism? Not necessarily. If you need one testicle removed, let’s say for hernia repair, let’s say as a risk of hernia surgery where you destroy the blood flow to that testicle, whatever the reason, your other testicle will just grow bigger and it should take over the hormonal needs of your body. So most people who just have one testicle are still fine, as long as that other testicle is uninjured, it’ll just take over the role of making testosterone. Of course, I highly recommend you get your blood tests done and see a smart urologist who can handle the hormonal aspects and figure out what to do.
(00:35:58):
But no, usually it’s okay. It’s just that the one testicle that’s left behind will grow to be bigger. It needs to make more testosterone. So that’s an interesting thing. We don’t see these in women. I’ve certainly never seen it, and I have never seen a picture of a huge squirrel or a labial hernia in women that will reach down to the thigh because number one, women have a very small internal ring. Number two, women are less likely to get hernias anyway because our pelvic floor is different, not as pointy or narrow. And number three, if they do have a hernia repaired, it’s done with, we tend to cut the round ligament and in doing so, patch the inguinal floor with no hole. There’s no keyhole technique for women. I mean, there is, but we don’t recommend it necessarily. a lot of surgeons still do it because they’re just not used to doing surgery in women. They treat women just like men. I have a whole podcast on that issue. But yeah, so that’s how it happened in women less likely to have giant hernias in the groin and much less likely to have a giant hernia from a recurrence of a hernia because oftentimes we don’t use a keyhole technique or anything like that. That in a nutshell is a giant inguinal scrotal hernia and everything you need to know about it. Let me help answer some more questions.
(00:37:44):
Let’s see. Next question. Can all inal hernias become inguinal scrotal if left untreated for too long? I mean, theoretically, yes. Yes. So all indirect inal hernias have a risk of becoming inguinal scrotal if left untreated, and for too long, especially if you either have a propensity towards having hernias because of your collagen disorder or you’re obese or you have chronic constipation or other reasons for increased abdominal pressure. Direct hernias are less likely to be inguinal scrotal, though technically they can be, they just enter the scrotum in a different way. Is loss of domain often with giant inguinal scrotal hernias? Smart question. Okay, so loss of domain. Very good question. Loss of domain is a word that implies that the percent or more of your abdominal contents are not in the abdomen. And that’s one of the main problems with inguinal scrotal hernias is, okay, well there’s a lot of content in the scrotum.
(00:39:06):
I need to return all of those back to where they came from, which is the abdomen, but that abdomen has not seen that much volume for years. It’s very possible that your belly is not going to stretch out enough to accommodate all this extra colon and large intestine, small intestine fat whatever’s in there, although it had before you had the hernias. And also by doing that and filling your belly again with new content within minutes of expansion, it may actually push the patient’s lungs up really high and in doing so cause you problems in breathing. So very difficult problem in patients. They must lose weight to increase space in their abdominal wall to decrease the fat there that’s competing with space. Some patients need extra Botox to loosen up the abdominal wall to allow for accommodation of this extra volume of contents. Some people need to be on a ventilator because they can’t breathe.
(00:40:23):
It’s so tight in there in the belly after the hernia has been closed. So yeah, loss of domain is an issue. It’s really end stage when you have loss of domain. Those patients are very, very difficult to treat. And oftentimes when a patient gets to that level, they are just not the best candidate for surgery anyway because they’re often bedbound and maybe not mentally capable and don’t really have much of a quality of life, even if that were repaired. Next question. Does using a large enough mesh prevent or reduce a recurrence through a keyhole? Yes. The key to a good keyhole is not to make the hole too tight or too small, and there are techniques that Dr. Parviz Amid came about to mitigate that and improve the Lichtenstein repair. It’s called the amid modification of the Lichtenstein repair. I use it all the time. And the larger the whole, sorry, the larger the mesh, the lower the re recurrence rate because it stabilizes the rest of the repair. Yeah, absolutely. Okay. Next question.
(00:41:47):
Are there anatomical modifications tied to the development of a giant inguinal hernia? I don’t know what that means. Are there anatomical modifications tie to the development of, I mean, no. I would say people who have giant inguinal hernias may have an underlying genetic predisposition to hernias to begin with and or maybe obese, but nothing else other than that, that I would say would predispose them to an inguinal scrotal hernia more than the average patient. Can giant inguinal scrotal hernias become life-threatening? Well, yes they can. So one of the things that most patients are worried about is, I don’t want to have emergency surgery. I don’t want to die of my hernia and so on. Here’s the thing. What we worry most about hernias before surgery is that you’ll end up in the emergency room because a hernia gets stuck. The hernia causes causes intestinal obstruction, you have intestine in the hernia, and that hernia will, there’ll be block of blood flow to that hernia. Those are all valid things to consider and consider in your decision of whether you should have a hernia or not, hernia repair or not. So I’m losing my train of thought here.
(00:43:19):
Okay, so when you then talk about life-threatening problems, it’s usually a bowel obstruction, intestinal obstruction or dead intestine or dead bowel that’s stuck in the hole. The wider the hole, the less chance of things getting stuck in it. That just makes sense from a phasix standpoint, the narrower the hole, but just wide enough to allow, let’s say intestine to go through. If you start because of gravity and time pushing intestine more and more in through this hole, now you get to a situation eventually where you’ll have more content through the hole than the hole can accommodate, and then the hole feels tighter and tighter around all this large volume of content because now you have a bouquet of flowers, sorry, bouquet of intestine beyond the whole, and then the blood flow starts to compromise. That’s called strangulation as opposed to incarceration, which is when the bowel is stuck in there because it’s just a lot of bowel.
(00:44:30):
But the blood flow to has not yet been affected. Most people go from hernia to incarceration to strangulation. It’s uncommon to move from hernia to strangulation outright, but it can happen. So I always tell my patients when they have these really huge hernias, let’s prevent incarceration because like I said earlier, the timeline is hernia, incarceration, strangulation. So you have to become incarcerated, which means a hernia gets stuck and can’t get pushed back in before it can strangulate. And if you could prevent incarceration, maybe you can prevent strangulation. So my recommendation to most patients is if you have a hernia that’s sticking out, always make sure you can always push it back in. Now, the smaller ones, you just take your hand, push it back in, not a big deal. The larger ones, you often have a live flat, take some full deep breaths and then gently massage the contents back inside.
(00:45:39):
And my recommendation is if you have a large hernia, especially one with intestine in it every single day, you should confirm that the contents easily go in and out, okay? Because what can happen is every time the contents are out and you just get a pulling, it’s hugging, gravity takes over. So when that happens, it’s just extra inflammation in the area and inflammation can cause scarring and scarring can cause an even more narrowing of that ring. And when that ring narrows, that’s a problem because then that’s a scarred ring. It’s not the muscle hole, it’s a scarring hole, and that does not stretch, and it’s impossible to then reduce hernias that way. And if you do reduce it, you do what’s called a reduction on mass where the whole thing falls in, but it’s still obstructed and then people can die that way. So not a good look, not a good look question.
(00:46:45):
Do you also use keyhole in laparoscopic hernia repair? And if not, how do you manage the spermatic cord so it exits into the inguinal floor? I do not use a laparoscopic keyhole technique. I believe also the European Hernia Society guidelines or maybe the hernia surge guidelines also recommend laparoscopically not to perform the keyhole technique. The reason for it is in the retroperitoneum, we don’t really have a lot of protection of this spermatic cord. There’s no cremasteric muscle, for example, and so when you’re placing mesh around the spermatic cord like a collar, it can erode into the spermatic. If you make it too tight, it can obstruct blood flow. If you make it too loose, you’re going to have a keyhole that will allow for hernia recurrence. It’s just not a good repair. So we don’t really have a choice for the, well, we do have a choice, but we choose not to do the keyhole in a way that the amid modification of a lichtenstein has been described.
(00:48:04):
However, laparoscopically we just, what we do is the mesh runs under the floor up and into the hole, and the mesh covers that trajectory so that it goes under the mesh instead of through the mesh and into the woods they go. Okay, next question. What are the strategies that can be used for giant anal hernias associated with loss of domain to reintegrate hernia content inside the abdominal cavity, and how can you overcome the lack of space and the problems related to a sudden increase of interabdominal pressure? And that’s a problem. So like I mentioned earlier, people who have a loss of domain or have just a very large amount of content in their scrotum will need all of that return into the belly, and in doing so, you’re causing the belly to be stressed by all this extra volume. So Botox works to loosen up the abdominal wall. Some people inject air to artificially expand the abdominal wall over time, that doesn’t really work well for these huge hernias because the air just goes in the hernias and then the patient must lose weight to make extra space for the hernia and the herniation. So that’s how it works.
(00:50:01):
But if it fails and you do a perfect hernia pair and the patient cannot tolerate all the extra pressure, then they can’t breathe on their own. So you can’t actually finish the surgery and wake them up from anesthesia. They need to be kept in the intensive care unit under anesthesia until their abdominal wall gets used to, so to speak, this extra pressure and they can start breathing again. It’s a problem. It’s definitely a problem. Considering all the different surgical techniques such as multi-stage surgery, component separation, and abdominal wall reconstruction, is there a limit to the size of inguinal scrotal hernias that can be successfully treated? That’s a great question. So like I said, the ones that are really, really huge below the knee, those are often in patients that are medically not appropriate to have surgery. They’re already bedbound. They have a perceived low risk of quality of life, regardless of whether they have the surgery or not, and or they have a low kind of expected life left in them, so it’s just not appropriate to fix a hernia in those patients. What happens, which is a problem, is when that type of patient now has a bowel obstruction, intestinal obstruction, dead bowel, whatever, that’s a life-threatening problem that how do you address the hernia? In a lot of patients, we just address the bowel obstruction and we still leave the hernia in place because it’s not the hernia, but the bowel obstruction that needs to be addressed, and that’s just a difficult situation. Fortunately, it doesn’t happen very often, but you need to get ethics involved and family involved or conservers involved in those situations.
(00:52:02):
Apologies because I think you are the Mozart of hernia surgery. Okay, I’ll take that as a compliment. Thank you. Mozart’s great, but it was really hard for me to visualize what you were saying about the spermatic cord management without the keyhole. Does the spermatic cord bypass the mesh by going along its side to enter the anterior space? Kind of. It’s not going along. Its side’s going underneath. It’s like, how should I say it? That’s a good analogy. Okay, here’s an analogy. Let’s think about not the hernia, but a hole in the ground. So if you have a hole in the ground and you want to cover it with a big tarp, you can do so, but what if there’s a drain involved? So you need to cover this ground with a big tarp so people can walk on it, let’s say, but you also need to allow this drain, this pipe to drain into the ground.
(00:53:14):
There’s two ways of doing it. You can put the tarp so that the tarp is under the pipe when cut a circle where the drain hole is, so the pipe can go into the hole, and then there’s the tarp covers the rest of the ground. So if you look at it, you see tarp on the ground, a drain pipe, a pipe on the ground, and then going through a hole in the middle of the tarp into a drain. The other option is leave the pipe on the ground entering the drain and just put the tarp on top of everything. So it’s on the ground, it’s on the hole, it’s on the pipe onto the drain hole. That’s the on method which we use for laparoscopic repair versus the first one, which I explained, which is the keyhole method, which we use usually for open surgery. Not as much for laparoscopic surgery, although there are patients who do do it. Yeah. Okay. Next question. Can a minimally invasive approach be feasible for giant inguinal scrotal hernias? Yeah. Feasible? Yes. Recommended sometimes absolutely necessary. No, significantly better. No.
(00:54:57):
The key to these huge inguinal hernia is to be able to close the hole instead of patch it because the hole is very wide and patching. It implies bridging and bridging is never good, especially in the pelvis where we are upright beings, and so all of the pressure will be on this bridged area. We got away with bridging hernias in the abdominal wall because there’s actually less pressure on it, but in the pelvis, there’s a lot of pressure because of gravity, and so bridging is not easy to do in those patients. So with the laparoscopic repair, you can’t bridge as well, whereas with the, I’m sorry, you can’t really only bridge because sewing is not as safe to do as it is with open repair. You can’t sew the muscle together safely. I know people do it. I’ve seen videos of people doing it. I highly do not recommend it.
(00:55:59):
It implies that they don’t understand the anatomy, which is there are nerves on the other side of the muscle, such as the ileal nerve that are at risk of being caught in your suture when you’re trying to do that. So an open oppa repair, an open giant retroperitoneal, visceral S sock repair or an open Lichtenstein repair, all of these with mesh will be my recommendation. Next question. Does the laparoscopic technique with the whole pipe and tarp analogy described cause a lot of mesh and cord to be in contact with each other? Yeah, either way, there’s mesh contact, so you have to minimize that contact the tarp on everything as opposed to the keyhole. The only repair with a tarp on everything has a similar amount of mesh contact with these matic cord, as does the keyhole. The keyhole has the additional problem of having mesh contact around this matic cord, like a collar that can potentially erode into the contents, whereas the onlay mesh technique actually is flat mesh that’s sitting on top of the cord. So as long as you reduce the amount of mesh that’s in contact with the cord and yet not compromise the repair, the repair, I personally like to add sometimes an anti-adhesive limited only to the area where the mesh and this spermatic cord touch to reduce how much interaction there is between the mesh and this spermatic cord without affecting the adhesion of the mesh to the rest of the area, which is the muscles and the bone. That’s my technique that I like to use. I hope that more people follow that technique themselves.
(00:58:11):
I think we have one more question is extensive use of mesh, both required and high risk for giant English squirrel hernias? I would say it’s low risk. The type of mesh that we use is a flat mesh, and in this situation, it’s the lowest risk procedure, right? So yes, it does involve mesh. There are people that can react to mesh, mesh erod into organs, but if placed correctly in most patients, even though it’s going to be a much larger mesh than usual, that mesh for inguinal scrotal hernias will be great. It would be a horrible, horrible problem. If you both have a huge inguinal scrotal hernia and you’re of the type where you will react adversely to mesh, that would be horrible. You have very, very, very little options available for repair, and that would be, man, that will really suck. Another question, what happens with when you have a giant inguinal hernia and how do you reconstruct the scrotum after repairing the hernia?
(00:59:27):
We already went over that, so I’m not going to belabor the point again. What are the intraoperative and postsurgical complications of giant inguinal hernia treatment that you fear the most? So is always on our mind. It’s not the worst thing I fear. The worst thing I fear is any bleeding into the sack because it’s such a large surface and you’re basically taking, excuse me, you’re basically taking tons of tissue and hernia off of it in the area. All that space can bleed, and so it’s so important to prevent. We all have our own ways of doing it, but if you bleed into the space, why is it that bad? You don’t bleed to death. That’s not why I’m worried. What I’m worried about is you bleed into this huge sack and then the blood clots, and now you have a sack of blood clot that takes months, months to eventually absorb, and during that month, it’s like you’re carrying a sack of water or a sack of sand around it.
(01:00:58):
It’s very heavy, very uncomfortable. Patient hates you. Don’t want that to be on your conscience all the time. So that’s what I worry about the most. All right. It is time, ladies and gentlemen. We are done with our Hernia Talk episode. Today is July 30th. We’re almost August of 2024. Thanks for joining me. Thanks for joining me. Join me next week. I have got a great guest. We have several guests coming up. I’m really excited about that. Last week was really fun. I’ll post that episode. It’s already up on YouTube. Join me online Instagram. I’m having a lot of fun with it at Hernia Doc. I’m on Twitter at Hernia doc as well. And don’t forget to subscribe and like and comment and enjoy our Hernia Talk Live episodes on YouTube and as a podcast wherever you like to listen to your podcast. See you all next week. Bye.
