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Complications - Open incisional hernia repair with retromuscular mesh augmentation

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Anatomy Perioperative management Technique Complications Evidence Total Video

  1. Intraoperative complications

    Injury to hernia sac content

    • e.g., bowel
    • Treatment: Immediate suture
    • Prevention: Careful dissection in layers, perhaps even starting dissection in an area without defect and then continuing from there to expose the fascial defect and hernia sac content.

    Vascular injury

    • particularly the epigastric vessels and their branches at the lateral margin of the rectus sheath
    • Treatment: Immediate suture/hemostasis

    Failed closure of the anterior rectus sheath

    • Treatment: Ramirez procedure with separation of components or possibly bridging technique

  2. Postoperative complications

    Depending on the extent of the hernia repair the following complications are possible:

    Intestinal paralysis

    • Treatment: Fasting, possibly gastric tube, moist heat, enemas
    • Prevention: Peridural catheter, ambulation

    Hematoma

    • Treatment: Depending on the extent, possibly revision surgery with evacuation of hematoma
    • Prevention: Diligent hemostasis

    Wound infection - superficial

    • Treatment: Non-surgical with open wound management
    • Prevention: Preoperative antibiotic protocol (e.g., cephalosporin)

    Wound infection - subfascial involving the mesh

    • Treatment: Depending on the type of mesh (large-pore) open wound management, possibly NPWT
    • Prevention: Only open the package with the mesh just before implantation

    Seroma

    • Definition: Spaces in the surgical field filled with secretions and lymph.
    • Clinical symptoms: Swelling without tenderness and discoloration.
    • Diagnostic work-up: Ultrasonography
    • Treatment: If the size of the seroma results in clinical symptoms, in rare cases this may require paracentesis (under absolutely sterile conditions!). Usually, after informing the patient the seroma only needs to be followed up. In case of recurrent seroma repeat paracentesis is not recommended, but rather insert a drain under sonographic guidance and leave in place for several days. This also applies to those rare cases where the seroma results in an infection. Surgical excision is reserved for those rare cases with formation of a seroma capsule.
    • Prevention: Sparing epifascial dissection

    Chronic pain

    Treatment: Depending on the underlying cause, e.g., excision in case of suture granuloma.