Methodical endoscopic repair of congenital indirect inguinoscrotal hernia in adult male patients with completely patent processus vaginalis.

PURPOSE: Indirect inguinal hernia related to the presence of a patent processus vaginalis (PPV) in adult is estimated to be around 15%. Most surgeons would favor a standard anterior hernioplasty to minimize the potential risk of damaging the spermatic cord structures that are always intimately fused to the congenital peritoneal sac. This also means overlooking the potential benefit of alternative posterior techniques such as endoscopic totally extraperitoneal (TEP) repair that is known to offer faster recovery with reduced risk of developing chronic groin pain. The aim of this study was to evaluate the safety of TEP approach for repair of adult inguinoscrotal hernias associated with completely PPV and to compare those results with a corresponding group of male patients undergoing an identical procedure, but with no demonstrated PPV.
METHODS: This is a prospective study of consecutive male patients diagnosed with inguinal hernia during a 10-year period and eligible for endoscopic TEP repair. Every recognized completely PPV were systematically divided taking care not to damage the attached cord structures and the proximal end closed with a pre-tied Endoloop of PDS. In both groups, all meshes were secured with fibrin sealant only. Patients were reviewed in clinic 2 and 6 weeks after the operation. Further follow-up was scheduled if deemed necessary. The primary post-operative outcome parameter was spermatic cord injury; secondary outcome parameters included groin pain, surgical complications, and recurrence.
RESULTS: Nine hundred and thirty-nine hernia repairs were prospectively recorded during this period. All procedures were carried out endoscopically. A total of 41 patients with a median age of 27 years presented with 43 inguinoscrotal hernias (two bilateral) related to the presence of a congenital completely PPV. 72% of them were right-sided. No injury to the cord structures was recorded and only one complication (2.4%) occurred at 1 week post-operatively that was unrelated to the PPV. There was no report of chronic groin or testicular pain, symptomatic seroma formation, or hernia recurrence. By comparison, out of the 608 patients representing the no PPV group, there were 35 complications out of 33 patients (5.4%), one of those requiring subsequent laparoscopic revision. Only one early post-operative recurrence was recorded in this group (0.15%).
CONCLUSIONS: In the presence of a completely PPV, the recognized benefit of a posterior approach, such as endoscopic TEP inguinal hernia repair, outweighs the theoretical risk of damaging the spermatic cord structures when dissecting and dividing the congenital hernia sac. This technique should be the preferred option among expert laparoscopic surgeons.