When a groin hernia grows large enough to descend into the scrotum, the operation that follows is unlike an ordinary hernia repair. Surgeons face distorted anatomy, a larger dissection field, and a higher chance of bleeding, fluid collections, and recurrence. Yet the evidence base guiding these operations has long rested on small retrospective series and individual experience rather than large, real-world datasets. A new analysis of Spain’s national EVEREG registry, published in the Journal of Abdominal Wall Surgery, now offers one of the clearest pictures to date of how inguinoscrotal hernias are actually repaired and which factors determine whether patients recover smoothly or run into trouble.
The research team, led by surgeons at Hospital Universitari Vall d’Hebron and the Universitat Autònoma de Barcelona, examined 748 adult male patients who underwent elective unilateral inguinoscrotal hernia repair between January 2021 and December 2024. EVEREG is an audited, voluntary national registry drawing data from more than 200 hospitals across Spain, prospectively collecting anonymised information on patient characteristics, surgical technique, complications, and follow-up. Because participation is voluntary, the registry cannot be assumed to capture every hernia repair performed in the country, but it provides a rare window into routine practice rather than the carefully controlled conditions of a clinical trial.
The patients in the cohort were typical of a complex surgical population. Mean age was 66.3 years and mean body mass index 27.5. Nearly one in five had diabetes, almost half had hypertension, and roughly one in six suffered from chronic obstructive pulmonary disease. More than a quarter of patients with recorded anaesthetic fitness were classified as ASA grade III to V, indicating severe systemic disease. Almost all hernias were symptomatic at presentation, and according to the Kingsnorth classification, 78.3 percent were H3-type hernias, reducible with manual manipulation, while 21.7 percent were H4-type, meaning the hernia was irreducible. A small but notable proportion, 11.5 percent, were recurrences after previous repair.
Technically, the operations followed a clear pattern. Open repair dominated, accounting for 83.4 percent of cases, with minimally invasive surgery used in 16.6 percent. The preferred mesh position was anterior in 70.8 percent of cases and posterior in the remainder. Permanent synthetic mesh, overwhelmingly polypropylene, was used in 99.4 percent of recorded cases. Just over half of all procedures, 51.3 percent, were performed as ambulatory or day surgery, and in 56.8 percent of cases the operating surgeon had recognised experience in abdominal wall surgery. General anaesthesia was used in 63.6 percent of operations, and antibiotic prophylaxis was administered to 83.2 percent of patients. Preoperative progressive pneumoperitoneum, a technique for gradually expanding the abdominal cavity before repairing giant hernias, was used in only 0.8 percent of cases, and botulinum toxin prehabilitation in 0.4 percent.
The headline safety finding was reassuring: postoperative complications occurred in 6.95 percent of patients, and the overwhelming majority were low-grade events, classified as Clavien-Dindo grade I or II in 84.6 percent of affected patients. Among patients with complications and available event-level data, hematoma was the most frequently recorded occurrence, followed by seroma; surgical site infection was uncommon, and no mesh infections were reported. Early recurrence within 30 days of surgery was documented in 1.63 percent of patients with available data. At the latest available follow-up, which averaged only 3.36 months, recurrence was reported in 7.5 percent of the small subgroup with follow-up data, a figure the authors treat with caution given how quickly follow-up completion fell away over time.
The statistical analysis identified a consistent set of risk factors. In bivariate comparisons, advanced age, diabetes, chronic obstructive pulmonary disease, higher ASA grade, H4-type hernias, an open surgical approach, intraoperative complications, and longer operative times were all significantly associated with postoperative complications. Conversely, ambulatory surgery and the involvement of a surgeon experienced in abdominal wall repair were associated with better outcomes. When the team moved to multivariable binary logistic regression, adjusting for age, diabetes, COPD, ASA grade, recurrence status, hernia type, intraoperative complications, and operative time, the protective signals held firm. Ambulatory surgery cut the odds of complications by roughly 64 percent, with an adjusted odds ratio of 0.359, and an experienced abdominal wall surgeon nearly halved them, with an odds ratio of 0.49. The laparoscopic approach also appeared protective, with an odds ratio of 0.127, but the authors stress this finding rests on very few events and a borderline p value of 0.046, so it must be interpreted with great caution. Longer operative time remained independently associated with higher odds of complications, each additional minute carrying a small but measurable increase in risk.
The model performed reasonably well as a risk-prediction tool, achieving an area under the receiver operating characteristic curve of 0.797, and a sensitivity analysis produced consistent estimates. Recurrence analysis was more limited. Within the first postoperative month, seven recurrences were detected, and none of the demographic or surgical variables, including surgeon experience, were significantly associated with early recurrence, although patients with early recurrence did stay longer in hospital. At the latest available follow-up, recurrence was documented in three of 40 patients, and the only factor linked to lower recurrence risk was the participation of an abdominal-wall-experienced surgeon, with zero recurrences in that group compared with 21.4 percent otherwise. Because so few recurrence events were recorded, these analyses were explicitly exploratory and were not subjected to multivariable modelling.
The discussion section places these findings in context. The complication and surgical site occurrence rates exceeded those generally reported for conventional inguinal hernia repairs, which is consistent with the known technical difficulty of scrotal hernias, where the hernia sac descends into the scrotum and distorts the anatomy. The authors note that comorbidity-related factors such as age and ASA grade, although largely non-modifiable, may be useful for preoperative risk assessment. The apparent advantage of ambulatory surgery likely reflects case selection, since day-surgery patients were predominantly those with simpler H3-type hernias. The benefit associated with experienced surgeons, however, aligns with international guideline recommendations and with prior registry-based work showing that abdominal wall specialists improve outcomes in complex hernia care, supporting individualised management and referral of difficult cases to experienced teams.
The study also raises questions about the future direction of scrotal hernia surgery. Conversion from minimally invasive to open surgery occurred in 5.5 percent of laparoscopic cases, higher than in conventional groin hernia series, and the authors suggest that robotic platforms deserve evaluation for complex groin hernias. They also point to open preperitoneal approaches, which accounted for only 16 percent of open procedures in this cohort but have shown strong results in experienced centres and may offer an economical alternative to both the Lichtenstein technique and laparoscopy. The limitations are candidly acknowledged: incomplete registry data, particularly for recurrence and loss of domain; short and fading follow-up; voluntary participation that may skew the sample toward abdominal-wall-interested centres; and the absence of information on sac management, chronic pain, testicular atrophy, and costs. The registry’s Kingsnorth-based classification also predates the classification recommended in current guidelines. The authors conclude that open repair with anterior mesh placement remains the dominant approach in Spain, that complications cluster in patients with greater comorbidity and hernia complexity, and that while the data cannot establish the superiority of any single technique, they make a strong case for entrusting complex inguinoscrotal hernias to surgeons who repair abdominal walls for a living.
Subject of Research: Risk factors for complications and recurrence after elective inguinoscrotal hernia repair in the Spanish EVEREG national registry
Article Title: Inguinoscrotal hernia repair: analysis of the national EVEREG registry
Article References: Verdaguer-Tremolosa, M., Rodrigues-Gonçalves, V., MartÃnez-López, M. P., López-Cano, M., & in representation of EVEREG group (2026). Inguinoscrotal hernia repair: analysis of the national EVEREG registry. Journal of Abdominal Wall Surgery, 5, Article 17525. https://doi.org/10.3389/jaws.2026.17525
Image Credits: AI Generated
Keywords: inguinoscrotal hernia, hernia repair, EVEREG registry, abdominal wall surgery, mesh repair, Clavien-Dindo complications, laparoscopic surgery, ambulatory surgery, surgical recurrence, Kingsnorth classification, HerniaSurge guidelines, surgical outcomes
News Source: Ophelia Keating. (October 16, 2026). Experienced Abdominal Wall Surgeons Cut Complications in Scrotal Hernia Repair, Spanish Registry Shows. Scienmag.
