Background: Adult inguinal hernia repair has progressively moved from sac-centered gestures toward parietal reinforcement. Yet the peritoneal sac continues to generate uncertainty, especially in advanced inguinoscrotal disease, where redundancy, fibrosis, persistent dead space, and loss-of-domain physiology complicate any simple rule of sac preservation or excision (Lichtenstein et al., 1989; Amid, 2004; Simons et al., 2009; HerniaSurge Group, 2018; Bencini, 2026).
Methods: This paper is a narrative review with concept-building intent. It integrates guideline documents, registry analyses, comparative studies on sac handling and postoperative morbidity, literature on scrotal and giant inguinoscrotal hernias, literature on loss of domain, and a small but historically relevant body of original surgical experience by the present author and collaborators in large abdominal wall defects and unusual inguinoscrotal masses (Simons et al., 2009; HerniaSurge Group, 2018; Bencini, 2026; Tran et al., 2023; Köckerling et al., 2021; Chaouch et al., 2023; Delikoukos et al., 2007; Daes, 2014; Savoie et al., 2014; Lodha et al., 2023; Supsamutchai et al., 2025; Bencini et al., 1986; Bencini et al., 1986; Biondi & Bencini, 1988).
Results: A severity-based framework is proposed in which the sac may be: (1) functionally secondary and suitable for non-ligation; (2) present but not the dominant operative target because the main problem is parietal reconstruction and control of residual cavity; (3) absent despite a clinically hernia-like mass; or (4) transformed into a pathological space-forming compartment that requires active management. In Class I–II hernias, non-ligation may be rational when reduction is feasible and parietal reinforcement is robust (Bencini, 2026; Chaouch et al., 2023; Delikoukos et al., 2007). In Class III–IV hernias, sac redundancy, fibrosis, pseudocavity formation, and loss-of-domain physiology may support sac-directed strategies such as fenestration, partial management, distal-sac preservation, or resection depending on anatomy and operative goals (Tran et al., 2023; Chaouch et al., 2023; Delikoukos et al., 2007; Daes, 2014; Savoie et al., 2014; Lodha et al., 2023; Supsamutchai et al., 2025). Historical case material is consistent with the proposition that size alone does not mandate sac excision, but neither does it justify dogmatic sac preservation (Bencini et al., 1986; Bencini et al., 1986; Biondi & Bencini, 1988).
Conclusion: The correct question is not whether the hernia sac should always be removed or always preserved. The correct question is what role the sac is actually playing in the individual case. Severity-based sac management may provide a more coherent framework than any binary doctrine and helps define the rational limits of pure non-ligation techniques, including Parietal Inguinal Box Repair (PIBR) (Bencini, 2026).
Keywords: Inguinal Hernia; Scrotal Hernia; Hernia Sac; Non-Ligation; Seroma; Loss Of Domain; PIBR; Dead Space; Mesh Fixation.
Citation: Bencini, C., & Fralleone, L. (2026). Severity-Based Management of the Hernia Sac in Inguinal and Inguinoscrotal Hernias and the Limits of Non-Ligation Techniques (Including PIBR). J Sur & Surgic Proce.,4(2):1-11. DOI : https://doi.org/10.47485/3069-8154.1032