Complications - Inguinal hernia repair, transabdominal preperitoneal hernioplasty (TAPP)

Evidence-based risk factors for complications and reoperations in inguinal hernia surgery have been defined:
1. Age >80 years: With existing comorbidities, high mortality risk; 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 of pain.
4. Obesity: Tendency towards 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 risks.
11. Bilateral inguinal hernia: Increased perioperative risk, therefore no prophylactic operation 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.

Bleeding/Vascular Injury

In the event of bleeding, it is advisable to initially use suction and irrigation to maintain a clearer view of the site and to reliably identify the source of bleeding. If clips are necessary, a 5mm trocar can be replaced with a 10mm one. If visibility is poor, conversion to open surgery is required.

• No staples in the "triangle of doom" (vessels), an anatomical triangle defined by the vas deferens medially, the spermatic vessels laterally, and the peritoneal fold below.
• Bleeding from the femoral vessels leads to massive blood loss with clinical hypovolemic shock in a short time. The bleeding must be detected and the source sutured, possibly requiring conversion and the involvement of a vascular surgeon.
• Injury to the epigastric vessels during balloon dissection, suturing of the peritoneum, or parietalization may require these vessels to be clipped.
• In the case of iatrogenic venous injury and 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).

Irritation, Constriction, or Injury of Inguinal Nerves with Postoperative Persistent Pain

• Particularly at risk are the lateral femoral cutaneous nerve and genitofemoral nerve in the "triangle of pain" (an inverted V whose apex corresponds to the internal inguinal ring, with the upper anterior limb formed by the iliopubic tract or inguinal ligament, and the medial posterior by the spermatic vessels).
• Significantly lower in minimally invasive procedures
• Traumatic nerve damage during preparation, suturing, or pinching of nerves in staples during mesh fixation.
• Fixation of the mesh with glue reduces the frequency of pain compared to fixation with staples.

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 children?

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 what the consequences are for him.

Bowel Injury (< 1%)

Recognized bowel lesions or coagulation damage are oversewn laparoscopically.

Bladder Injury (< 1%)

Bleeding from the retropubic plexus increases the risk of bladder injury.

In the event of a bladder injury, the injured site must be oversewn. Postoperatively, the bladder is decompressed for 1 week using a suprapubic fistula catheter (SPC) or Foley catheter.

Chronic postoperative pain (10-12%)

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

Risk factors for the development of chronic pain include open procedures, young patient age, small-pore meshes, mesh fixation with sutures or staples, pre-existing or poorly controlled early postoperative pain.

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

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

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 inguinal nerves.

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

Recurrence (1-10%)

Risk factors:

• Female gender
• Direct hernia
• Sliding hernia in men
• Nicotine abuse
• Presence of a recurrent hernia

Definition: Newly developed inguinal hernia after previously surgically treated inguinal hernia.

Clinic and diagnostics correspond to the inguinal hernia. DD pseudo-recurrence: Certain protrusion of the mesh through a large defect without an actual hernia.

In the absence of symptoms, only a relative indication for surgery.

Tendency for higher recurrence rates with TEP and TAPP compared to the Lichtenstein procedure.

In mesh-based surgical techniques, recurrences tend to occur at an early postoperative stage; once meshes are integrated, they seem to maintain their stability over time. In later recurrences, the distinction between complication and natural course is fluid. Recurrences after more than 5 years likely represent the natural course in the inguinal region.

Therapy: In recurrence surgeries, the same approach should not be chosen. Surgical repair with the anterior approach (Lichtenstein).

Hematoma/Bleeding (1.1%; 3.9% in patients with anticoagulant therapy)

• Drop in hemoglobin, low blood pressure, larger bloody drainage volumes, visible hematomas
• Diagnostics: Ultrasound and exclusion of systemic causes (e.g., coagulation disorders)
• Depending on the size, resorption can be awaited, otherwise early minimally invasive revision, aspiration of the hematoma, and possibly hemostasis.

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, repeated puncture should be avoided, and if necessary, a sonographically controlled drainage should be placed and consistently drained for several days.

Tip: Since the defect is only covered and not actually closed, a seroma/hematoma can appear like a recurrence to the inexperienced. An ultrasound examination helps distinguish the recurrence from the fluid collection!

Wound infection

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

Postoperative bladder leakage:

Small intraoperatively unrecognized bladder injuries occasionally occur. This is indicated by an unusually large, clear secretion volume through the indwelling drain or a correspondingly large seroma. Determination of urea and creatinine in the secretion helps confirm the diagnosis. A bladder fistula can almost always be sufficiently treated by placing a urinary catheter, which is then left in place for about 1 week.

Disturbances 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 can 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 surgery, abdominal pain, nausea, guarding, signs of peritonitis.

Therapy: Reoperation with detection of the bowel lesion and suturing, if necessary, resection and abdominal lavage, antibiotic treatment.

Postoperative ileus

Internal hernia due to insufficient peritoneal closure of a larger peritoneal defect.