Surgical treatment for inguinoscrotal hernia with loss of dominion with preoperative progressive pneumoperitoneum and botulinum toxin: Case report and systematic review of the literature

PURPOSE: The aim of this article is to establish which is the best peri- and intraoperative approach for patients with giant inguinoscrotal hernia. METHODS: A systematic review of the literature was carried out according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria through a search in PubMed, Scielo, and other resources, from January 2011 to April 2020. Prospective, retrospective, case reports, and clinical series were included. Patients who underwent emergency procedures and studies involving children or pregnant women were excluded. RESULTS: A total of 24 publications related to giant inguinal hernia were identified, which together group a total of 81 patients. The average age of the patients was 62 years. Of the 81 patients, in 10 cases (12%), loss of domain was objectively established. In patients with loss of domain, preoperative pneumoperitoneum (PPP) + botulinum toxin type A (TBA) was used in 80% of the cases. In 10% only NPP was used and in the remaining 10% only TBA was used. Regarding the repair technique, 70% used the anterior route. The most frequent surgery was Lichtenstein’s procedure (38%), followed by Stoppa’s procedure (9%) and transabdominal preperitoneal procedure (9%). The most frequent complication was the development of seromas. The median postoperative follow-up was 15 months. CONCLUSIONS: Inguinoscrotal hernias with loss of domain are rare, and therefore their management is far from being clearly defined. In those cases, where the loss of domain is confirmed, both botulinum toxin and preoperative pneumoperitoneum have been used, without documenting major complications.To repair the defect, the most widely used technique is Lichtenstein’s procedure; however, the possibility of long-term recurrence should be assessed. The retrorectal repair could reduce the risk of recurrence as it is associated with greater mesh overlap.