Inguinoscrotal hernias represent a complex type of inguinal hernia characterised by the extension of hernia contents into the scrotum. Their anatomical and technical particularities are associated with increased operative difficulty, a higher risk of complications, and substantial variability in surgical decision-making [1]. Despite these challenges, management strategies for inguinoscrotal hernias continue to rely on individual surgeon experience and limited scientific evidence, particularly under real-world clinical conditions.

Recently, specific recommendations for the management of inguinoscrotal hernias have been published with the aim of reducing recurrence, chronic pain, and postoperative infections [2]. However, the authors acknowledge that these recommendations are mainly based on retrospective series and low-level evidence, limiting their external validity. In addition, they highlight that laparoscopic repair of inguinoscrotal hernias may be technically demanding and associated with relevant conversion rates, emphasising that surgeons managing these cases should be proficient in both open and minimally invasive techniques [2]. Similarly, the updated HerniaSurge international guidelines provide broader recommendations regarding mesh repair, minimally invasive approaches, and prevention of recurrence and chronic postoperative pain [3]. Nevertheless, clinical guidelines do not always fully reflect the heterogeneity encountered in routine surgical practice, where patients present with varying comorbidities, surgical techniques, and follow-up strategies [4]. In this setting, registries offer a valuable source to evaluate outcomes under real-world conditions and assess the applicability of current recommendations across different clinical environments.

The present study analyses data from a national multicentre registry (EVEREG) of patients undergoing unilateral inguinoscrotal hernia repair. The primary aim is to describe the management and short-term outcomes of elective inguinoscrotal hernia repair and explore related factors associated with postoperative complications. Secondary outcomes are to describe recurrence during available follow-up and examine current surgical practice in relation to contemporary recommendations for scrotal hernia management.

Including data from more than 200 hospitals, the EVEREG database (http://www.evereg.es) is the national online hernia registry in Spain, whose characteristics have been described elsewhere [5]. The registry prospectively collects anonymised patient data and is maintained by surgeons with an interest in abdominal wall surgery (AWS). It is an audited register that gathers information on patient and hernia characteristics, surgical technical aspects, postoperative complications, and follow-up [6]. Participation in EVEREG is voluntary, and participating investigators commit to the consecutive registration of eligible cases. Therefore, the registry cannot be assumed to capture all inguinal hernia repairs performed in Spain.

Adult patients (≥18 years old) who underwent elective unilateral inguinoscrotal hernia repair between January 2021 and December 2024, as recorded in the EVEREG registry, were included. Scrotal hernia is defined as an inguinal hernia that has descended into the scrotum and causes any degree of scrotal distortion, according to current guidelines [2]. According to the registry, inguinoscrotal hernias were recorded in EVEREG as H3 or H4 according to the Kingsnorth classification: H3 corresponds to an inguinoscrotal hernia reducible with manual manipulation and H4 to an irreducible inguinoscrotal hernia [7]. Cases involving other types of groin hernia repairs or emergency surgeries were excluded. The final data extraction was performed in December 2025, allowing at least 1 year of potential follow-up for patients operated on through December 2024.

Patient demographic data (age, smoking status, body mass index (BMI)), comorbidities (diabetes status, hypertension (HTA), chronic obstructive pulmonary disease (COPD), liver disease, kidney disease, and other relevant medical conditions), and American Society of Anaesthesiologist (ASA) grade [8] were collected. Hernia characteristics, including if it was symptomatic, time since onset of hernia, loss of domain, recurrent hernia, and Kingsnorth hernia classification (type H3 and H4), were registered, as well as wound contamination according to the US Centres for Disease Control and Prevention (CDC) [9, 10]. Specifically, in EVEREG, the loss-of-domain field is conditionally displayed when the hernia is recorded as non-reducible, and the Tanaka index itself is not a mandatory registry field.

Abdominal wall prehabilitation with botulinum toxin and progressive preoperative pneumoperitoneum (PPP) was recorded. Data on surgeries (including ambulatory setting, antibiotic prophylaxis, type of anaesthesia, presence of a surgeon experienced in AWS, surgical approach, surgical technique, and intraoperative complications) were collected. Information about postoperative complications, Clavien-Dindo classification [11], surgical site infection (SSI), surgical site occurrences (SSO; including seroma, hematoma, SSI, and mesh infection), recurrence, length of follow-up, and hospital stay was collected.

This cohort study was conducted in accordance with the RECORD and STROBE statements [12, 13]. The primary outcome was the presence of postoperative complications. Secondary outcomes included recurrence at 30 days post-surgery and recurrence at latest available follow-up.

From January 2021 to December 2024, 748 male patients undergoing elective unilateral inguinoscrotal hernia repair were included. The extent of missingness varied between variables and was particularly relevant for some registry fields. Mean age was 66.31 years (SD 14.24) and mean BMI was 27.46 (SD 8.38). According to available data, 20.4% of patients were active smokers (N = 152/743), 138 had diabetes (18.4%), 351 suffered HTA (46.9%), 123 had COPD (16.4%), 25 had liver disease (3.3%) and 44 had adrenal disease (5.9%). Other comorbidities were reported in 20.5% of patients (N = 153). Overall, 28.18% of patients (N = 177/628) were classified as ASA III-V. Most inguinoscrotal hernias were symptomatic at presentation (98%, N = 687/701), and 44.3% of patients (N = 321/725) reported a hernia duration of less than 1 year. According to the Kingsnorth classification, most hernias were classified as H3-type (78.3%, N = 586). Among the 162 irreducible hernias (H4-type), information on loss of domain was available in 108 (66.7%), of which 17 (15.7%) were recorded as loss of domain. Additionally, 11.5% of hernias (N = 86/746) represented recurrences after previous repair.

PPP was performed in 0.8% of cases (N = 6/741) and three patients received botulinum toxin (0.4%). Ambulatory surgery was carried out in 51.3% of cases (N = 384/740), and most of them were type H3 hernias (84.6%, N = 325). In 56.8% of cases, the repair was performed by a surgeon with experience in AWS (N = 420/740). Most of the procedures were conducted under general anaesthesia (63.6%,N = 466/733) and 36.4% under locoregional anaesthesia; 83.2% of patients (N = 616/740) received antibiotic prophylaxis.

Most patients (83.4%, N = 605/725) underwent open repair, and 16.6% received minimally invasive surgery. A total of seven cases (5.5%) required conversion to open surgery. The preferred mesh position was anterior in 70.8% of cases (N = 505/713) and posterior in 29.2% (N = 208/713). Permanent synthetic mesh was used in 99.4% of cases (N = 699/703), while only four cases involved an absorbable synthetic mesh. Among permanent synthetic meshes, polypropylene was the most frequently used material (99.4%). Mesh fixation methods were recorded in 87.43% of patients (N = 657/748; N = 548 for the open approach and N = 109 for the laparoscopic approach). In the open group, mesh fixation methods included absorbable suture in 61.1% of cases (N = 335/548), non-absorbable sutures in 30.1%, tackers in 1.3%, and glue in 1.5%, whereas in 6% of cases no mesh fixation was applied. In the laparoscopic group, the most frequently used mesh fixation methods were tackers in 43.1% of cases (N = 43/109), followed by glue (38.5%), absorbable sutures (8.3%), and non-absorbable suture (0.9%), while no mesh fixation was used in 9.2% of cases.

In 9.6% of cases (N = 38/397), an associated procedure was required, including intestinal resection (N = 2), orchiectomy (N = 1) and other hernia repairs (N = 26), among others. Intraoperative complications occurred in 18/693 cases (2.6%). According to the CDC classification, surgical field was classified as clean or clean-contaminated in 99.9% of cases (N = 739/740 (clean N = 710, clean-contaminated N = 29)) and contaminated or dirty in one case. The mean surgical time was 63.07 min (SD 27.19). The mean length of hospital stay was 5.28 days (SD 75.85).

The analysis of the EVEREG registry showed high rates of postoperative complications and SSO in inguinoscrotal repairs, which appear to exceed those generally reported in the literature for conventional inguinal hernia repairs [14–18]. Comorbidities, H4-type hernias, and longer operative time were identified as adverse prognostic factors for complications, whereas ambulatory surgery and the involvement of an AWS-experienced surgeon were associated with improved outcomes. Recurrence was infrequently reported, and the only factor linked to better results was the participation of an AWS-experienced surgeon.

Our study shows results consistent with those reported in registries [17], although most of the available literature is based on case reports and cohort studies [2, 19, 20] which include heterogeneous techniques and results. The heterogeneity in surgical management observed in the EVEREG registry reflects variation in current practice but also limits direct comparison between techniques (e.g., patient selection for open or minimally invasive repair).

Interestingly, impaired outcomes related to patient comorbidities such as age and ASA grade are also in line with current evidence [17, 21, 22]. Although these factors are largely non-modifiable and mainly reflect patient comorbidity rather than specific characteristics of the inguinoscrotal hernia, they may be useful for preoperative risk assessment.

On the other hand, scrotal hernias have been associated with higher rates of complications and SSO, such as bleeding and seroma [23, 24], as well as recurrence [2, 25]. Those results are consistent with our findings. The lower risk of complications associated with ambulatory surgery and H3-type hernias may be related to a lower complexity of these cases and patient selection. The involvement of a surgeon with experience in AWS, as suggested by the guidelines [2], was associated with significantly lower risk of complications and, despite the scarcity of data, it also appeared to have an impact on recurrence at the latest available follow-up, as previously reported [26, 27].

CDC grade and mesh type were not associated with complications, but the limited number of patients in some groups may have influenced this outcome. In contrast, operative time was related to worse outcomes and could be linked to additional procedures, repair complexity, need for conversion, or team experience and materials. Although the open approach is recommended [2] and accounted for the majority of cases, it was associated with a higher complication rate, while only a small proportion of laparoscopic procedures was performed. This finding should be interpreted very cautiously given the bordering P value (P = 0.046), the confidence interval, and the very limited number of postoperative events among patients undergoing laparoscopy and a possible selection bias (e.g., preferential use of open surgery for more complex or irreducible hernias).

However, higher conversion rates from minimally invasive to open surgery were observed compared with conventional groin hernia repairs from other series [28, 29]. Future investigations should address the role of robotic platforms in complex groin hernias and evaluate if they can improve minimally invasive surgery rates [30–32]. Similarly, open preperitoneal approaches have shown remarkable results and, although they accounted for only a small proportion (16%) of the open procedures in our study, they may represent an economical and valid alternative to minimally invasive approaches and the Lichtenstein technique [33–35]. In fact, centres with experience in this technique have reported good short- and long-term outcomes in groin hernia repair, including patients with inguinoscrotal hernias [36].

In contrast to the literature [17], postoperative complications did not appear to influence recurrence rates at the latest available follow-up; however, the limited number of recurrence cases reported may have affected this outcome and should be carefully interpreted. Additionally, recurrences during the first postoperative month may be related to technical defects or hernia persistency and should be more appropriately interpreted as an early technical failure. Nonetheless, recurrence rate at the latest available follow-up was higher than in conventional repairs [2], and the influence of an experienced surgeon might suggest that, in line with current recommendations, referral to or management in collaboration with an experienced abdominal wall surgeon should be considered in complex cases.

Limitations of our study include those inherent to registries [37, 38] and their retrospective nature, especially in terms of data incompleteness (relevant in variables such as recurrence or loss of domain) and loss to follow-up, which could strongly influence outcomes such as seroma rate or recurrence at the latest available follow-up. In fact, follow-up completion decreased markedly over time, preventing reliable estimates of recurrence at fixed 1- and 2-year intervals and limiting interpretation beyond the early postoperative period. Furthermore, participation in EVEREG is voluntary. Participating centres and surgeons may have a particular interest in AWS, and registered patients may therefore not fully represent all inguinoscrotal hernia repairs performed in Spain, so selection and reporting bias cannot be excluded. Additionally, the small proportion of H4-type hernias and cases with loss of domain makes it difficult to generalise our results to giant scrotal hernias. Moreover, the classification used was not the one recommended in the guideline [2], as the registry was initiated prior to its publication. Intraoperative complications were rarely recorded, and additional procedures such as intestinal resections or orchiectomies associated with the repair may be underreported. In addition, although postoperative complications and their Clavien-Dindo grade were recorded, the specific treatment of each complication was not systematically available in the registry. Similarly, no information was reported on the management of the sac, incidence of testicular atrophy, scrotoplasty, drainage placement, preoperative symptoms, or chronic pain, or costs. It is unknown whether patients received prehabilitation strategies to optimise baseline comorbidities or if a shared decision-making model was used, and the definition of “surgeon with experience” in AWS within the registry does not imply a formal certification. We could also not directly compare outcomes from different surgical techniques or patient selection for each. Patients who opted for watch-and-wait strategies [2, 39] were not evaluated. Finally, it is not possible to generalise our findings to other healthcare systems, emergency settings, or low-income countries.

To conclude, this multicentre registry analysis describes the management and short-term outcomes of elective inguinoscrotal hernia repair in participating EVEREG centres. Open repair with anterior mesh placement was the most frequently used approach, while postoperative complications occurred in approximately 7% of patients and were mostly low-grade. Patient comorbidity and greater hernia complexity were associated with worse outcomes, while surgery performed by an AWS-experienced surgeon was independently associated with fewer postoperative complications. These findings support individualized surgical planning and consideration of referral of complex cases to experienced abdominal wall teams. The available data do not allow conclusions regarding the superiority of a specific technique or long-term recurrence.