Traditional inguinal hernia repairs are performed through a 1-4 cm inguinal incision. A few years after surgery the scar looks like this:
Below, I will discuss two ways to perform an inguinal hernia repair that leave virtually no scars.
High ligation of the hernia sac without cutting the external oblique
During the traditional inguinal hernia repair through the groin, the external oblique fascia is cut to expose the entire cord and be able to perform a high ligation of the inguinal sac.
At some point, surgeons realized that high ligation of the hernia sac during an orchiopexy could be achieved without having to open the external oblique. That saved time and decreased the pain associated with the procedure.
Not having to open the external oblique led to the development of the scrotal approach to orchiopexies, which requires a single incision for the entire procedure, instead of both an inguinal and a scrotal incision.
Scrotal orchiopexy –> Scrotal hernia repair
If one could repair an undescended testis through the scrotum, with minimal scarring, why not do the same for an isolated hernia? In the case of a simple inguinal hernia, I am not saving the patient from an extra incision if I go through the scrotum, but there are 2 advantages:
- Patient heals with virtually no scar
- The scrotal approach to hernias allows for the posterior approach to the hernia sac.
1. No scar
The scrotum is the most forgiving skin the body. No matter how good or bad you suture it, or what type of suture you use, it tends to heal with very little visible scarring — or the scars get camouflaged with all the scrotal rugae.
2. Posterior approach to hernias
The posterior approach to dissecting a hernia sac is the simplest and most teachable approach I have seen. I use it for hydroceles, orchiopexies, and hernias. In fact, I use the same procedure — the exact same steps — for hernias, hydroceles, and orchiopexies.
Scrotal hernia repair versus single-incision laparoscopic hernia repairs
For the past several years, I have been going back and forth in between repairing hernias through the scrotum versus laparoscopically. I have never regretted the scrotal approach but I have regretted the laparoscopic approach at least a couple times. On 2-3 cases, I have started laparoscopically and finished through the scrotum due to technical difficulties getting a good closure laparoscopically.
There are 2 infrequent but annoying issues with the laparoscopic approach:
- Persistent insuflattion after tying the suture. Although the hernia might appear totally closed, if there is still air getting to it, that means the closure was not perfect and the risk of recurrence will be higher.
- Bleeding while passing the needle. It is very difficult to see once this happens.
For the above reasons, I now prefer the scrotal approach for most cases.
That been said, I will definitely continue to do hernias laparoscopically for the following situations:
- Girls: no issues with bleeding, no danger of hurting vas or vessels
- Boys with severe hypospadias: who might need the tunica vaginalis in the future for a hypospadias repair.
The traditional hernia repair leaves a visible scar in the groin, which grows with the child. There are 2 other approaches to an inguinal hernia that leave no scars: scrotal and single incision laparoscopic. The scrotal approach is the most reliable and easy to do, but a laparoscopic approach is a great option for girls or boys with severe hypospadias.