Complications - Femoral hernia repair, TIPP technique

Evidence-based risk factors for complications and reoperations in inguinal hernia surgery have been defined:

1. Age > 80 years: high mortality risk with existing comorbidities; more seromas, urinary retention, and readmissions; even at age > 60 years, more urinary retention and more complications.

2. ASA III and higher: more complications and reoperations, increased mortality risk

3. Female gender: increased risk for pain

4. Obesity: tendency for more complications

5. COPD: more complications, increased mortality in outpatient surgery

6. Diabetes mellitus: independent risk factor for postoperative complications

7. Anticoagulation/antiplatelet agents: 4-fold increased risk of postoperative bleeding. Even after discontinuation of anticoagulant medication, the risk of rebleeding is significantly increased.

8. Immunosuppression/corticosteroid medication: increased risk of recurrence

9. Liver cirrhosis: significant increase in complication rates

10. Nicotine abuse: significant increase in general and surgical complication risk

11. Bilateral inguinal hernia: increased perioperative risk, therefore no prophylactic surgery on a healthy side.

12. Increased complication rate in recurrent procedures and femoral hernias

13. Preoperative pain frequently leads to acute and then chronic groin pain postoperatively.

Irritation, constriction, or injury to inguinal nerves with postoperative persistent pain

The inguinal nerves should be preserved as much as possible.

During preparation and suturing at the inguinal ligament, there may be injury or transection of the nerves. Particularly at risk are:

• Lateral femoral cutaneous nerve, 
• Ilioinguinal nerve, 
• Iliohypogastric nerve, 
• Genital branch and femoral branch of the genitofemoral nerve.

In case of nerve damage or hindrance of mesh repair, neurectomy is preferred in case of doubt. Nerve mobilization for preservation represents a highly significant risk factor for chronic pain. Nerves damaged by the operation and removed from their natural embedding should be excised via proximal neurectomy. The nerve stump is infiltrated with a long-acting local anesthetic and embedded in the abdominal muscles to prevent scar adhesion with the mesh.

Injury to the vas deferens

If there is an injury to the vas deferens, the following aspects are crucial for further action: Was the vas deferens completely or only partially transected? How old is the patient? Does the patient have a desire for fertility?

In sexually inactive older patients, the vas deferens may be transected if necessary. In any case, the patient must be informed postoperatively about what happened and the implications for him.

Bowel injury

An intraoperative iatrogenic bowel lesion should be sutured immediately.

Vascular injury

Bleeding during suturing at the inguinal ligament (beware of the femoral vein). Locate the source of bleeding and possibly suture the femoral vein, consider consulting a vascular surgery colleague.

In the case of iatrogenic venous injury with subsequent thrombosis of the femoral vein in the operative area, it is a thrombosis of the pelvic level.

• Diagnostics: Duplex and Doppler sonography or phlebography
• Treatment of deep vein thrombosis: Compression, mobilization, full heparinization (beware of the risk of rebleeding!).
• For further information, please follow the link to the current guideline: Prophylaxis of venous thromboembolism (VTE).

Bladder injury

In the event of a bladder injury, the injured area must be sutured. Postoperatively, the bladder is decompressed for 7-10 days using a suprapubic fistula catheter (SPFK) or indwelling catheter.

Chronic postoperative pain (10-12%)

Definition: Chronic postoperative pain was defined by the "International Association for the Study of Pain" in 1986 as pain that persists for more than three months despite optimal conservative therapy.

The extent of preoperative and early postoperative pain is the decisive risk factor for postoperative pain. Open inguinal hernia surgery leads significantly more often to chronic pain than laparoscopic/endoscopic treatment.

According to international guidelines, large-pore meshes made of monofilament non-resorbable plastic (polypropylene, polyvinylidene fluoride, or polyester) are recommended. The pore size seems to be crucial for tissue integration and the avoidance of acute and chronic pain.

Indicators for a high risk of chronic postoperative pain after inguinal hernia surgery:

• young age,
• preoperative pain,
• open procedure.

Therapy: Blockade of the ilioinguinal and iliohypogastric nerves by infiltration with a long-acting local anesthetic 1-2 cm above and medial to the anterior superior iliac spine. The worst-case scenario is retroperitoneoscopic neurectomy of all three groin nerves.

Mesh removal is always associated with hernia recurrence and is therefore the last resort.

Recurrence (1-10%)

In recurrence operations, the same access route should not be chosen. Surgical treatment with a posterior approach (TAPP or TEP).

Hematoma/bleeding (requiring revision 1.1%; 3.9% in patients on anticoagulants)

• Bleeding or rebleeding in the wound area
• Clinic: tender and discolored swelling
• Diagnostics: ultrasound and exclusion of systemic causes (e.g., coagulation disorders)
• Therapy: Smaller hematomas should be observed and usually do not require further therapy.
• Larger hematomas should be punctured or evacuated. Severe rebleeding must be surgically revised.
• If the skin is under tension or causes neurological symptoms, the hematoma should be surgically relieved.

Seroma

• Small postoperative seromas are absorbed by the tissue and only require monitoring. If the size of the seroma leads to clinical symptoms, puncture (absolutely sterile!) can be performed in individual cases. Otherwise, monitoring and discussion of findings are sufficient. In recurrent seromas, multiple punctures should be avoided, and if necessary, a sonographically controlled drainage should be inserted and consistently drained for several days.

Wound infection/mesh infection (< 1%)

Superficial infection:Opening and spreading of the wound, extensive cleaning, and subsequent open wound treatment, systemic antibiotic therapy.

Deep infection involving the implanted mesh: Surgical revision in the operating room and open wound treatment, possibly vacuum treatment. Initially, an attempt should be made to preserve the mesh. In more severe cases, the mesh must be removed.

Disorders of testicular perfusion/ischemic orchitis/testicular atrophy(very rare)

Constriction or transection of the spermatic vessels can lead to postoperative testicular swelling due to reduced perfusion. This may result in damage to the testicle up to atrophy/loss of the testicle, and if necessary, open revision must be performed.

Unnoticed bowel lesion

• Clinic: Patient does not recover from the operation, abdominal pain, nausea, guarding, signs of peritonitis.
• Therapy: Reoperation with detection of the bowel lesion and suturing, possibly resection and abdominal lavage and antibiotic treatment for at least 1 week.