26 May 2025 Scrotal Hernias: Anatomical Characteristics, Diagnostic Nuances and Surgical Repair Challenges
In this blog post, I will discuss the anatomical features of scrotal hernias, the nuances in the diagnostic process, and the challenges we face in surgical repair. My goal is to provide both surgeons and patients seeking information on this topic with a clear understanding of the complex world of scrotal hernias and to share latest advancements in this field. Because we know that each hernia case is different, and scrotal hernias represent a special group that demands the highest level of surgical skill.
Not All Hernias Are the Same
Inguinal hernia repairs are common procedures in our surgical practice, but scrotal hernias break this routine. These hernias are characterised by large defects that pass through the inguinal canal and extend into the scrotum. Sometimes the inguinal floor becomes so lax, especially in what we call direct hernias, that the hernia sac and its contents can reach the scrotum.
Worldwide, more than 20 million patients undergo inguinal hernia repair annually. While scrotal hernias account for 6% of these cases in developed countries, this rate can reach up to 67% in underdeveloped countries. This disparity creates a significant disease burden, particularly on young men in their most productive years.
Many unanswered questions remain regarding the treatment of scrotal hernias. Scrotal hernias present significant challenges to surgeons not only because of their size and anatomical location but also due to the difficulties encountered during repair. Large hernia sacs, wide defects, and weakness of surrounding tissues make these cases more complex. Moreover, scrotal hernias have higher recurrence rates and can significantly impair patients’ quality of life. Therefore, proper technique selection, having an experienced surgeon, and adopting new innovative techniques and materials are of great importance in these cases.
Definition
Scrotal hernia is defined as an inguinal hernia that descends into the scrotum (testicular sac), causing noticeable deformity.
Classification
There is a practical classification guide for scrotal hernias, published in JAWS in March 2023. It is compatible with and essentially an extension of the EHS inguinal hernia classification.
The use of the letter ‘S’ is proposed for scrotal hernias, with the following subgroups:
– S1 (upper thigh level)
– S2 (mid-thigh level)
– S3 (lower thigh/knee level)
Measurements should be taken in a standing position, from the midpoint of the groin to the lowest point of the scrotum. Irreducible scrotal hernias are labeled as S(IR).
Diagnosis
Diagnosing scrotal hernias is very easy. The patient usually comes with the diagnosis himself. A swelling extending from the groin to the scrotum is visible. It’s important to ask whether this swelling reduces spontaneously when lying down or with manual pressure. This should be checked during examination, but forced and strenuous maneuvers should be avoided. The other groin must always be examined to check for accompanying hernias. Due to its size, a scrotal hernia may fill the scrotum and obscure the other groin. This is more pronounced in overweight patients.
Imaging
If reducible, radiological imaging is not necessary. Otherwise, cross-sectional imaging methods such as CT or MRI are useful to determine the contents of the hernia sac. Because herniated bowel or bladder increases the risk of visceral injury compared to herniated omentum. Especially in elderly patients, left-sided scrotal hernias are frequently associated with sliding-type herniation of the sigmoid colon. In these cases, one wall of the bowel forms part of the hernia sac wall. Right-sided scrotal hernias usually contain omentum or small intestine.
Repair Methods
Scrotal hernias are repaired using inguinal hernia repair techniques, but there are some special considerations.
Suture Repair
Open suture repair has no place here. In scrotal hernias, the anatomy of the inguinal floor is disrupted. Structures are displaced. The groin is weak. While suture tissue repairs in normal inguinal hernias already have problems like increased recurrence and chronic pain compared to mesh repairs, doing this in scrotal hernias is meaningless.
Open Mesh Repair
The problems with suture repair continue here as well. Since the anatomy is severely distorted, protecting important structures and performing reliable repairs presents difficulties. Risks of postoperative chronic pain, recurrence, hematoma, seroma, and wound site infections increase compared tot he minimally invasive techniques.
Minimally Invasive Techniques
These include laparoscopic and robotically assisted techniques. These techniques can be broadly divided into two:
– TEP
– TAPP
In the TEP technique, the procedure is performed by entering behind the muscles without entering the abdominal cavity. However, TEP presents difficulties in scrotal hernias. Because this technique involves working in a narrow space. Reducing the hernia sac is challenging, and peritoneal tears may cause CO2 gas leakage into the abdomen and narrowing of the surgical field. Placing a large mesh (an important point I’ll mention later) may not be possible.
In the TAPP technique, a wide working area is obtained by entering the abdominal cavity. A high peritoneal incision (above the ASIS) creates a large flap, making manipulation of the hernia sac easier. It allows placement of a large mesh. It enables completing the dissection without fully reducing the hernia sac, which can be partially reduced. This is difficult with TEP. Attempting to fully reduce the hernia sac can be traumatic and sometimes bloody. The spermatic vessels and vas deferens may be damaged. Instead, when sufficient peritoneal flap is obtained, it’s enough to circumferentially divide the hernia sac and separate it from the scrotal side. If it’s a sliding hernia, it’s essential to reach the distal part of the bowel and perform this separation. Otherwise, the anatomical plane may be lost, and organ injury may occur.
Hernia Sac Abandonment Technique
The way to simplify scrotal hernia surgery is to reduce the indirect hernia contents and then divide the hernia sac with a 360-degree incision at the level of the internal ring. Of course, this is done with the TAPP technique. The approach is different in direct hernias, which I’ll explain in the next paragraph. After separating the indirect hernia sac, the surgery is performed with a high peritoneal incision as in classical TAPP technique. After mesh placement, preferably the peritoneal flap defect formed by the 360-degree incision is closed with an absorbable suture using continuous suture technique. Then the peritoneal flap is sutured to complete the operation. This technique is called ‘Abandon the sac.’ Seroma formation will naturally come to mind. However, there is no increase in seroma rates as might be expected. Both the hematoma and seroma that may occur with complete reduction of the hernia sac, as well as the risk of injury to the spermatic vessels, are avoided. Technically, Complete sac reduction is also difficult and requires experience. It prolongs operation time. Will you take these risks or accept possible seroma formation? This is a good question in my opinion, and I prefer this innovative technique, i.e., abandoning the hernia sac, in most cases. In my experience, I haven’t observed increased seroma formation.
Approach to Direct Hernias
Direct hernias, although not very common, can extend into the scrotum. In this case, what we call EHS M3 type, where the entire inguinal floor bulges outward widely, is usually present. Here, instead of a hernia sac, there is loosened and sac-like transversalis fascia. Usually, preperitoneal fatty tissues, bladder, and intestines are seen in the defect. Both TEP and TAPP can be applied to these hernias. However, both have some common important details and differ from standard laparoscopic inguinal hernia repair. One of these is what to do with the loose transversalis fascia after reducing the hernia contents. It can be left as is and the operation can be completed by placing a mesh. However, in addition to increased seroma risk, the mesh may migrate into the defect or stretch despite being fixed with staples. Recurrence or pseudo-recurrence may occur. To reduce these risks, I recommend the following:
– Pulling and fixing the transversalis fascia to the preperitoneal space
– Using a larger mesh
– Extending the mesh beyond the contralateral Cooper’s ligament
– Using a heavier mesh
– Performing fixation (with staples or adhesive)
Fixing the transversalis fascia to Cooper’s, not to the pubic symphysis but to the Adminiculum lineae albae above it, to the rectus muscle on the same side with a staple (easier) or suture. The intention here is both to reduce dead space in the groin and thus seroma risk, and to ensure the mesh contacts a wider surface. However, laparoscopic suture repair of the posterior wall should not be performed. This increases your risk of injuring the genital branch of the genitofemoral nerve and the iliohypogastric nerve at the upper edge. This should be avoided. Recently, in robotic inguinal hernia repair; with the superior maneuvering capabilities of the robot, suturing has become easier and I see those who do it. But having a robot doesn’t give you a green light to do this.
A larger mesh; since it will adhere to a wider surface in the groin, remains stable by distributing the weakness and pressure arising from the direct hernia defect over a larger area. Also, the mesh should extend beyond the pubic symphysis to the contralateral Cooper’s by at least 2 cm. Otherwise, in a large direct hernia, the mesh remains right at the edge of the defect and the recurrence risk from that edge increases significantly, just like extending the mesh 2 cm beyond the pubis in Lichtenstein repair.
Normally we use light and medium-weight meshes. If the posterior wall is weak and we leave the direct hernia defect as is, heavier meshes adhere better. They don’t stretch and have less risk of migrating into the defect.
Normally, according to EHS guidelines, fixation is unnecessary and we have sufficient evidence. But in EHS M3, i.e., large direct hernias, fixation is preferred. This can be done with staples, adhesive, or sutures. It doesn’t matter if the staples are metal or absorbable. However, applying them to the right places and in small amounts is recommended to avoid chronic pain risk. 1-2 to Cooper’s (of course to the other Cooper’s as well), 1-2 to the medial upper edge is enough. It’s good not to do invasive fixation lateral to the epigastric vessels. However, you can safely fixate on every point with tissue adhesive solutions. Suturing is difficult in TEP technique because the working area is small. It’s easier to place sutures in TAPP.
Fourth Trocar
Laparoscopic/robotic inguinal hernia repair is usually performed with 3 trocar entries. In laparoscopy, one 10 mm and two 5 mm trocars are used, while in robotics, three 8 mm trocars are used. However, in scrotal hernia, a fourth trocar entry is often needed to better expose the surgical field, control tissues better, and reduce organs when necessary, which is often the case.
Urinary Catheter and Drain Use
I also want to say something about preoperative bladder catheterisation and postoperative drain placement. In my daily practice, I never place a bladder catheter. There’s no need. I just tell the patient to urinate before the operation. When the bladder is empty, it doesn’t bother you during the operation. I also tell anesthesia not to give too much fluid. I don’t see postoperative urinary retention. In fact, I haven’t placed a catheter for years because of this. Sugammadex, the drug that reverses the muscle relaxant used by anesthesia, has made this problem history. I routinely place the catheter selectively when I will remove the mesh laparoscopically; under sterile conditions and with a 3-way Foley. If bladder injury is suspected during dissection, I inflate the bladder with methylene blue-stained serum and check for extravasation.
I also don’t use drains routinely. They may be needed in very special situations. In that case, I don’t keep it for more than 24 hours.
If the hernia is S3 – meaning its lower edge extends to the knee – this is a serious problem. In these patients, since organ volume loss will accompany, when you return the hernia contents into the abdomen, intra-abdominal pressure will increase and intra-abdominal hypertension may occur. This may even lead to abdominal compartment syndrome. In these patients, CT volumetry must be performed prior to the surgery; measures to increase intra-abdominal volume should be taken. Such as Botox application, Progressive PneumoPeritoneum, and component separation techniques. Each of these is a separate blog post.
Scrotal Hernia in Women
Scrotal hernia is quite rare in women. There is only a soft ligament called round ligament suspending the uterus in the inguinal canal. But it still follows the same approach principles as in men. With one difference; there’s no need to preserve the ligament and it should be divided so that the mesh is placed well.
Complications
Complications seen in inguinal hernia repair are also seen after scrotal hernia repair. Bleeding, hematoma, seroma, pain, long-term pain and of course, recurrence. There’s nothing specific to scrotal hernia among these, but in scrotal hernia repair, there’s an increased risk of organ injury. Therefore, it’s necessary to be aware of these when they occur and to address the injury according to its characteristics. Other than that, other problems are generally known complications.
Final Word
Scrotal hernias should be managed by specialised surgeons/centers on abdominal wall hernia surgery. Their complexity demands expertise to minimize complications and optimise outcomes.
