The optimal procedure for GISH has not been established due to its rarity [2]; and two major problems, including recurrence and seroma, remain. For normal inguinal hernia, there was no difference in the recurrence rate between laparoscopic TAPP and the anterior approach [8]. Moreover, Cavalli et al. have documented the recurrence rate via anterior approach after GISH as high as 30% [9]; however, there have been no reports focused on recurrence of laparoscopic TAPP after GISH. We considered that laparoscopic TAPP had a great advantage in directly inspecting the hernia orifice followed by properly covering it with a prosthetic mesh (depending on the size of hernia orifice) over anterior approach [2, 6]. Hence, we regarded laparoscopic TAPP as an optimal procedure for GISH and usual inguinal hernia at our institution. In fact, we could successfully repair a large sized-hernia orifice by directly inspecting it and properly covering it with reinforcement mesh in the patient, and as a result, no recurrence was observed for 3 years after surgery. Therefore, in the present case, laparoscopic TAPP greatly contributed to successful repair for GISH.
The other major problem to be resolved is seroma following the hernia repair procedure, especially in laparoscopic TAPP. [10] Regarding normal inguinal hernia, several meta-analyses demonstrated that laparoscopic TAPP had a significantly higher incidence of seroma formation than that in open hernia repair [8, 11,12,13,14]. For GISH, Staubitz et al. have reported that only 1 out of 71 (1.4%) patients who underwent a herniorrhaphy with an anterior approach for GISH had a delayed scrotal hematocele, necessitating reoperation 6 months after the surgery, and 15 of 71 (21%) patients had postoperative scrotal fluid collections (seroma/hematocele) [15]. In contrast, there have only been four reports so far since 2011 [2, 5,6,7]. According to these reports, 7 out of 13 (53.8%) patients developed postoperative scrotal fluid collections after laparoscopic TAPP for GISHs. However, all patients except for one who required a puncture three times, recovered without an invasive procedure [2, 5,6,7]. These findings suggest that scrotal fluid collection was a recoverable complication, whereas an anterior approach is superior in preventing scrotal fluid collection to laparoscopic TAPP. However, in the present case, delayed refractory hematocele occurred, leading to reoperation after laparoscopic TAPP for a GISH. To the best of our knowledge, there have been no reports on the incidence of delayed scrotal fluid collection after laparoscopic TAPP for GISHs, and this is the first report about a severe complication leading to hemi-orchiectomy after laparoscopic TAPP for a GISH.
Three points are mainly considered as the causes of scrotal fluid collection after laparoscopic TAPP for GISH. The first is to leave plenty of empty space even after repair; second is to require a larger dissected area to lay the prosthetic mesh properly; and third is to have difficulty in fully removing the hernia sac due to technical limitations of the laparoscopic surgery. We believe that the main cause of such repercussions in laparoscopic TAPP for GISH was due to the presence of the residual hernia sac [16, 17]. Thus, the complete resection of the hernia sac plays an important role in reducing the incidence of postoperative scrotal fluid collection. On the other hand, it is controversial to remove the hernia sac in GISH. According to the EHS and IEHS guidelines, hernia sac transection and leaving the distal hernia sac undisturbed in GISHs are weakly recommended for preventing ischemic orchitis [3, 4]. Most patients with a GISH have a long disease history; therefore, there is often firm adhesion between the hernia sac and the testicle or the spermatic cord. In addition, a long-standing GISH can sometimes elongate the spermatic cord or the spermatic cord is twisted, causing testicular atrophy [18]. Therefore, total removal of a hernia sac has a potential risk of injury to the spermatic cord or orchitis [15]. Staubitz et al. reported that 14 of 71 (20%) patients who underwent herniorrhaphy with complete resection of the hernia sac via an anterior approach for GISH required intraoperative orchiectomy [15]. In the present case, the distal hernia sac was not completely resected to avoid spermatic cord injury. However, the remnant sac induced refractory hematocele and severe inflammation around the spermatic cord leading to firm adhesion. Further, dissection of the remnant hernia sac including the hematocele induced spermatic cord injury, leading to hemi-orchiectomy. Had we considered completely removing the giant hernia sac in the primary operation, orchiectomy might have been avoided in this case. Alternatively, had we carefully assessed the testis blood perfusion after dissecting the remnant sac from the spermatic cord in the secondary operation, at least the third operation could have been avoided.
To avoid this serious complication, we believe that it is important to perform total or subtotal hernia sac resection and that robotic procedures can contribute to this. Although there has been no established evidence that robotic surgery prevents the incidence of seroma after surgery when compared to laparoscopic surgery [19], we have previously demonstrated that the robotic system would be clinically more advantageous for more technically demanding procedures such as laparoscopic total gastrectomy [20]. Therefore, we hope to develop and establish a more feasible procedure to resect hernia sacs in GISHs using robotic systems in future. Until then, we consider it safer to perform the hernia repair via the anterior approach for GISH, despite its high recurrence rate.