Brian P. Jacob, David C. Chen, Bruce Ramshaw, Shirin Towfigh (eds.) - The SAGES Manual of Groin Pain-Springer International Publishing (2016)

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pain.” The use of fine, low-voltage instruments and bipolar cautery helps
to avoid damage to sensitive structures and to prevent residual hematoma
, which is one of the most commonly cited causes of postoperative
pain.
One rarely mentioned cause of pain after hernia surgery is grasping
and traction of the cord structures, which is common during open surgery.
This pain may be caused by injury to the vasa nervorum. In
laparoscopic repair, traction may occur during separation of an indirect
sac from the cord structures, as some surgeons grasp the cord structures
to dissect them from the sac. We advise pulling the sac medially while
dissecting the fibrous and fatty tissues next to the cord structures, using
fine Maryland forceps without directly touching the cord structures. As
dissection progresses, the sac can be grasped more laterally and rotated
medially. This process is continued until the hernia sac is separated from
the vas deferens and the spermatic vessels by a bluish transparency.
Videos of these maneuvers are available online [ 8 , 9 ]. It is then possible
to deal with the sac in two ways. If the sac does not extend deeply into
the scrotum, it can be reduced completely. In cases of large inguinoscrotal
hernias, attempting to completely reduce the sac risks damage to the
cord structures and the development of orchitis. Failure to deal with the
distal sac, however , carries the risk of formation of large and sometimes
cumbersome hematomas, seromas, or pseudohydroceles. Repeated
drainage and occasionally surgery may be necessary in such cases.
We previously described a technique for managing the distal sac in
large inguinoscrotal hernias [ 10 ]. After ligating the sac and dividing it
distally, at the level of the internal ring, we reduce the distal sac by pulling
it out of the scrotum and fixing it high and laterally to the posterior
inguinal wall with tacks or sutures. Using this maneuver, we were able
to reduce the incidence and severity of seromas, with no cases of postoperative
orchitis, testicular pain, or neuralgia [ 10 ]. A video showing
this maneuver is available online [ 11 ].
The next step is parietalization of structures, which consists of proximal
dissection of the sac and peritoneum to allow proper placement of
the mesh over the cord structures. Extensive proximal dissection helps to
prevent recurrence by rolling of the mesh or a sac sliding under the
mesh. Parietalization is complete when upward traction of the sac does
not move the cord structures. A video showing parietalization is available
online [ 12 ].