Behind the knife

Scrotal extension of inguinal hernias is usually through the deep ring. This video reviews a less common circumstance: scrotal extension through a direct hernia. We share the unedited dissection on the right side and highlight elements of the entire case. Important aspects of these repairs include using larger, heavy weight mesh (to avoid eventration) and prioritizing fixation centrally. Though anecdotal experiences will recommend posterior plication of the pseudo sac, this maneuver may risk complications such as cord injury or nerve entrapment. When desiring tissue reapproximation, I will typically perform anterior plication to thoroughly identify structures and avoid integration of surrounding structures in the suture line.