A hernia sac that extends into the scrotum may:a. Require extensive dissection and reduction
In cases where the viability of sac contents is in question, the sac should be incised, and hernia contents should be evaluated for signs of ischemia. The defect should be enlarged to augment blood flow to the sac contents. Viable contents may be reduced into the peritoneal cavity, while nonviable contents should be resected, and synthetic prostheses should be avoided in the repair. In elective cases, the sac may be amputated at the internal inguinal ring or inverted into the preperitoneum. Both methods are effective; however, patients undergoing sac excision had significantly increased postoperative pain in a prospective trial. Dissection of a densely adherent sac may result in injury to cord structures and should be avoided; however, sac ligation at the internal inguinal ring is necessary in these cases. A hernia sac that extends into the scrotum may require division within the inguinal canal, as extensive dissection and reduction risks injury to the pampiniform plexus, resulting in testicular atrophy and orchitis. At this point, the inguinal canal is reconstructed, either with native tissue or with prostheses. The following sections describe the most commonly performed types of tissue-based and prosthetic-based reconstructions.