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36 Inguinal Hernia Recurrence
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Giant Hernia: Hug andTOP
Technique
GiampieroCampanelli, PieroGiovanniBruni,
FrancescaLombardo, andMartaCavalli
37
37.1 Introduction
Giant inguinoscrotal hernias have been dened as
those that extend below the midpoint of the inner
thigh with the patient in the standing position [1].
Giant inguinoscrotal hernias, with a signicant
secondary abdominal cavity, are infrequent in
developed countries; nevertheless, on rare occasions, patients visit their clinician after years of
neglect and refusing to admit their problem. Even
among underserved populations, the incidence of
giant inguinoscrotal hernias is less than that of
large inguinoscrotal hernias: indeed, this evidences the real distinction between giant and
large inguinoscrotal hernias. Giant inguinoscrotal hernias are not only those that extend below
the midpoint of the inner thigh when the patient
is standing but also those with an anteroposterior
diameter of at least 30 cm and a laterolateral
diameter of about 50cm and have been not reducible for more than 10years (Figs.37.1 and 37.2).
G. Campanelli (*) · P. G. Bruni · F. Lombardo
M. Cavalli
University of Insubria, Varese, Italy
General and Day Surgery Unit, Center of Research
and High Specialization for the Pathologies of
Abdominal Wall and Surgical Treatment and Repair
of Abdominal Hernia, Milano Hernia Center,
Istituto Clinico Sant’Ambrogio,
Milan, Italy
e-mail: giampiero.campanelli@grupposandonato.it
© Springer International Publishing AG, part of Springer Nature 2018
G. Campanelli (ed.), The Art of Hernia Surgery, https://doi.org/10.1007/978-3-319-72626-7_37
Fig. 37.1 Preoperative image (frontal view): the penis is
not visible
357
358
Fig. 37.2 Preoperative (lateral view)
37.2 Clinical Presentation
The size of the hernia often causes difculty in
walking, sitting, or lying down. The penis is frequently buried inside the scrotum, causing urine
to dribble over the already distended scrotal skin.
This can lead to ulceration and secondary infection. Patients may also complain of difculty in
voiding [2]. Peristaltic movement can be seen
through the enlarged scrotal sac. Testes are normally impalpable. Obviously other complications, such as intestinal obstruction and
strangulation, are also possible, though rare.
37.3 Literature Review
The surgical management of giant inguinoscrotal
hernias can lead to potentially fatal complications [2] as the surgeon is faced with the problem
of returning herniated viscera to the abdominal
cavity after years of scrotal displacement.
G. Campanelli et al.
Precipitous reduction of hernia contents into the
contracted peritoneal cavity may produce
changes in intra-abdominal and intrathoracic
pressure, potentially precipitating severe cardiac
and/or respiratory failure and a compartment
syndrome [2–7]. Moreover, reduction under
excessive tension places the patient at risk of
wound breakdown, with the incidence of wound
dehiscence and recurrence of the hernia reported
in up to 30% of patients [8].
The restoration of domain has been addressed
by various techniques, most of which have originally been reported for the treatment of massive
ventral hernias. The rst option involves debulking the abdominal contents, i.e., performing an
omentectomy, colectomy, or small-bowel resection [2, 5, 9]. Of course, this technique facilitates
visceral reduction but can be complicated by
peritoneal contamination with visceral and mesh
infection [10].
Another technique, described by Moss [6],
uses an elemental diet as a means of reducing visceral volume by minimizing intestinal secretions
and fecal volume. Although Moss described a
decrease in visceral volume of approximately 2L
over a period of 1month, the efcacy of this technique in extremely large hernias remains
questionable.
Induction of preoperative progressive pneumoperitoneum to treat very large hernias with
loss of domain was introduced in 1940 by Goňi
Moreno [11]. It is usually recommended for giant
ventral hernias but rarely for giant inguinal hernias [12–18]. Preoperative progressive pneumoperitoneum (PPP) was recommended for patients
with giant loss of domain hernias, including a
large amount of viscera in the hernia sac. PPP
increases the capacity of the retracted abdominal
cavity, achieves a pneumatic lysis of intestinal
adhesions, allows the reduction of the hernia contents, and improves diaphragmatic function. PPP
also facilitates dissection of the hernia sac and
can locate other hernias or weak zones that may
not have been evident in the initial examination.
Stretching of the hernia sac from PPP has been
found to be helpful in skin cleansing before the
operation and can potentially decrease the incidence of infections [14–16, 19]. Preoperative
37 Giant Hernia: Hug andTOP Technique
progressive pneumoperitoneum is contraindicated in patients suffering from cardiac and pulmonary insufciency and abdominal infections,
and it requires a prolonged preoperative hospital
stay that ranges from 7 to 18days [13, 14, 20, 21].
Some authors report technical failure of PPP,
with air spreading into the hernia sac and only succeeding in expanding the sac with minimal effect
on the contracted abdominal cavity [3, 4, 7, 22].
During our nearly 30-year experience, we
have designed an original technique [23] for the
reduction of viscera, avoiding the sac opening
and intestinal resection, with the placement of a
not absorbable mesh in the preperitoneal space.
It could be considered an evolution of TOP
technique (see Box 1).
359
We propose a modied open posterior
preperitoneal approach, called TOP (Total
Open Preperitoneal) technique, which we
usually use for the repair of giant and large
inguinoscrotal hernia [23], recurrent inguinal
hernia [28, 29], and femoral hernia or in the
treatment of postoperative chronic pain [30].
The TOP technique can be done under
local, spinal, or general anesthesia (the last
one is suggested during the learning curve
and obliged for giant inguinal hernia) and
requires a suprapubic transversal lateral
5–8 long-incision and 2cm below the superior-anterior iliac spin (ASIS) [26, 31]. See
also Chap. 42.
Box 1: The TOP technique
Stoppa proposed the open posterior preperitoneal repair for the rst time in 1965
[24, 25], under the name of “giant prosthetic reinforcement of the visceral sac”
(GPRVS). Later, in 1989, Wantz [26] proposed a similar procedure, differencing
from Stoppa technique for a monolateral
repair.
In both procedures, a large bilateral
Dacron mesh was placed in the preperitoneal space, covering Fruchaud’s myopectineal hole with extensive overlap in all
directions so that the peritoneal sheet cannot be extended.
The myopectineal hole is the weak spot
at which all hernias of the groin begin; it is
covered just by the transversalis fascia and
includes the Hesselbach triangle, the deep
inguinal ring, and the Scarpa triangle of the
femoral region [27]. A mesh placed in this
space is compressed by the internal abdominal pressure and xed against the internal
abdominal wall, according with the hydrostatic principle by Pascal: when there is an
increase in pressure at any point in a conned uid, there is an equal increase at
every other point in the container.
37.4 Surgical Technique
Before surgery, we require, in addition to standard tests (complete blood count, chest X-ray,
ECG), a spirometry, arterial blood gases, and a
CT scan of the abdomen.
We usually prepare the patients as we will
have for a bowel operation with a colon
preparation.
We normally administer double antibiotic
therapy (cephalosporins plus metronidazole) as
antibiotic prophylaxis at anesthesia induction.
Prior to surgery, patients sign an informed
consent, in which orchiectomy and bowel resection were included, in addition to standard surgical risks.
Surgical technique includes the following
steps:
1. Single pararectus incision extending from the
level of the umbilicus to the groin region and
extending down the proximal half of
scrotum.
2. Isolation of the entire large sac from the scro-
tal cavity, taking care not to open the sac
(Figs.37.3, 37.4 and 37.5). Testis is normally
hypotrophic and covered with scar tissue, and
cord route is not clearly evident (Fig.37.6), so
an orchiectomy is advised.
360
G. Campanelli et al.
Isolated sac
Scrotal cavity
Fig. 37.3 Isolation of the entire large sac from the scrotal
cavity
Fig. 37.4 Scrotal cavity after isolation of the entire sac
3. Opening of the inguinal channel and component separation. Incision of the lateral margin
of the anterior rectus sheet, starting at the level
of the umbilicus until to the level of the external inguinal ring (anterior component separation). This pararectus incision includes the
medial insertions of the internal oblique muscle fascia to the rectus muscle fascia and,
behind these, the deep portion of the transversalis fascia (transversus abdominis release,
TAR). This separation of the lateral margin of
the rectus muscle from the internal oblique
muscle at the level of the umbilicus (Fig.37.7)
Fig. 37.5 Drawing of isolated sac from the scrotal
cavity
Fig. 37.6 Identication of the testis
is continued distally to the internal inguinal
ring and below it. At this level the bers of the
internal oblique muscle are completely cut,
and the epigastric vessels are separated and
ligated (Figs.37.8 and 37.9). In this way the
entire internal ring is cleared, and a complete
opening and communication between the posterior and anterior inguinal region are
achieved, allowing the preperitoneal space to
be approached widely. Practically speaking,
the approach to the preperitoneum is achieved
through a classical pararectus incision, completed with the section of the epigastric vessels and the internal ring. Just to remind,
normally the internal ring is bounded, above
37 Giant Hernia: Hug andTOP Technique
Fig. 37.7 Drawing of
the preperitoneal space
achieved by pararectus
umbilicus
incision. The pararectus
incision extending from
the umbilicus to the
groin region and to the
Preperitoneal
space
mid-scrotum with the
separation between
rectus muscle and
oblique muscles. The
internal oblique at the
level of the internal ring
and the epigastric
Int.
obl. m.
vessels in this drawing
are not yet separated
361
Lateral edge of
rectus muscle
Internal ring and
epigastric vessels
Fig. 37.8 Opening of
the posterior wall of the
inguinal canal with the
clamp below the upper
and lower portion of the
internal inguinal ring
and behind the epigastric
vessels. They will be
separated in order to
achieve a complete
communication between
the anterior and
posterior space
Lateral edge of
rectus muscle
Preperitoneal
space
Int
obl.m.
Internal ring and
epigastric vessels
362
Fig. 37.9 Drawing of
complete division of the
muscles bers of the
internal oblique and the
epigastric vessels
Fig. 37.10 The hug technique
Preperitoneal
space
Int.
obl. m.
and laterally, by the arched lower margin of
the transversalis fascia and the inferior portion
of the internal oblique muscle and, below and
medially, by the inferior epigastric vessels. It
is important to understand that in the giant
inguinal scrotal hernia, the anatomy and the
anatomical structures of the internal ring are
subverted as the bers of the internal oblique
muscle are pushed upward and the anatomical
separation between anterior and posterior
inguinal region does not exist anymore.
4. Reduction of viscera in abdominal cavity. The
hug technique (Figs.37.10 and 37.11) permits
a progressive reduction of the viscera without
G. Campanelli et al.
Lateral edge of
rectus muscle
Internal ring and
epigastric vessels
opening the sac. The surgeon gently embraces
the entire sac with his arms inducing a slow,
progressive, and continuous emptying of
bowel content into the distal portion. In this
way, the “volume” of the content inside the
jejunal-colonic loops becomes slowly little by
little, and all the contents of the sac can be
gradually and completely reduced into the
cavity. The sac reduction normally requires
about 1h; during this time surgeon should feel
abdominal cavity resistance being slowly
overcome. The opening of the sac would make
the reduction more difcult because the huge
amount of free jejunal-colonic bowel would
spread across the operating eld with constant
escape of the other loops once some have been
reduced. This situation normally forces then
to intestinal resection.
5. Preparation of the space and placement of the
mesh. The space behind the rectus muscle,
from the pubic symphysis and the contralateral
Cooper ligament until the umbilicus, is prepared. The Retzius space, the ipsilateral
Cooper ligament, the iliac vein and artery in
the Bogros space, the obturator region, and the
psoas region are dissected. In this space, an
approximately 30×30cm heavyweight polypropylene mesh (Figs. 37.12 and 37.13) is
37 Giant Hernia: Hug andTOP Technique
363
placed and xed with nonabsorbable sutures to
the brous tissue of the internal pubic symphysis and to Cooper ligament (ipsilateral and
contralateral). In addition, one absorbable
suture is placed in the psoas muscle, and a
nonabsorbable transmuscular suture is placed
in the rectus muscle. The choice of a heavy-
Fig. 37.11 Drawing of the hug technique
weight mesh is justied by the totally destroyed
posterior wall and the wide component separation needed to achieve a sufciently large preperitoneal space. Once placed, the mesh covers
the area from the contralateral retropubic space
to the ipsilateral psoas muscle region, from
below the umbilicus to the prevesical Retzius
space (3–4cm below the inferior edge of the
pubic bone), and it is folded toward the retroperitoneal space in order to achieve a complete
reinforcement of the visceral sac. Fibrin glue
can be sprayed on the entire mesh surface to
better x it to the wall and to reduce the risk of
seroma after the wide dissection.
A drain is normally placed.
6. Abdominal wall closure. First the internal
oblique fascia is reapproximated to the inguinal
ligament to restore the posterior wall of the
inguinal channel. Then the lateral edge of the
rectus muscle is reapproximated to the medial
edge of the internal oblique muscle. Next is the
closure from up to down of the anterior rectus
sheath to the internal oblique fascia and nally
the closure of the external oblique aponeurosis.
7. Scrotal skin reductive plastic surgery. Starting
from the proximal scrotum, two longitudinal
incisions are made continuing distally removing from each side 25% of the excess skin,
paying careful attention to hemostasis of the
subcutaneous Dartos fascia. A running suture
Fig. 37.12 Two
polypropylene meshes
are sutured together and
placed in the
preperitoneal space for a
total surface of
spread in the prepared
space toward the
contralateral retropubic
space from one side and
covering all of the psoas
muscle on the other side
(anterior view)
Lateral edge of
rectus muscle
Internal obl m.
Mesh placed in the
preperitoneal space
Upper portion
of scrotal cavity
Medial part of
scrotal skin
364
IIeopsoas m.
foramen
G. Campanelli et al.
Fig. 37.13 Drawing of
the nal position of the
mesh (posterior view)
Right rectus m.
Pubis symphysis
Left rectus m.
Vas
Obturator
Mesh
External iliac
vessles
Fig. 37.14 Scrotal size after reductive plastic surgery:
the penis is now visible
of all the subcutaneous tissue planes is performed from the distal to proximal scrotum
achieving a complete closure of all the cavity
and dead spaces. The skin is then closed with
interrupted sutures or staples (Fig.37.14).
Fig. 37.15 Long-term follow-up
Patients are normally admitted to the intensive
care unit for 24–48h, for prolonged mechanical
ventilation and monitoring of their respiratory
function. Respiratory physiotherapy must start as
soon as possible, after extubation. Liquid diet can
be admitted in the second day. Antibiotic prophylaxis is administered for the entire hospitalization. Normally patient is discharged after
6–7days after surgery.
Figure 37.15 shows one of our patients at
long-term follow-up.
37 Giant Hernia: Hug andTOP Technique
365
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