Complications - Inguinal hernia repair using TEP technique

Bleeding/Vascular Injury

In case of bleeding, it is advisable to initially use suction and irrigation to maintain a clearer surgical field 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 tacks in the "triangle of doom" (vessels), an anatomical triangle defined by the vas deferens medially, the spermatic vessels laterally, and the peritoneal fold inferiorly.
• 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 vein injury and subsequent thrombosis of the femoral vein in the surgical area, it is a thrombosis of the pelvic floor.
  • Diagnosis: 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 this link to the current guideline: Prophylaxis of venous thromboembolism (VTE).

Pneumopneumoperitoneum

Gas insufflation of the peritoneal cavity often occurs, slightly constricting the preperitoneal working space. Generally, this does not significantly interfere with further preparation. If necessary, sufficient surgical field can be ensured by venting the abdomen using an inserted Veress needle. If it is still not possible to obtain enough working space, conversion to TAPP can be easily performed.

Larger Defect of the Peritoneum

Large defects (> 1-2cm) in the peritoneum should be closed with sutures or clips to prevent the mesh from contacting intra-abdominal organs and to avoid internal hernias with potential bowel entrapment.

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

• The lateral femoral cutaneous nerve and genitofemoral nerve are particularly at risk in the "triangle of pain" (an inverted V, with the apex corresponding to the internal inguinal ring, 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 entrapment of nerves in tacks during mesh fixation
• Fixation of the mesh with glue reduces the frequency of pain compared to fixation with tacks.

Injury to the Vas Deferens

If there is an injury to the vas deferens, the following aspects are crucial for further management: 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 the implications for them.

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 sutured. Postoperatively, the bladder is decompressed for 1 week using a suprapubic fistula catheter (SPFK) 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 tacks, 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 leads to chronic pain significantly more often than laparoscopic/endoscopic repair.

According to international guidelines, large-pore meshes made of monofilament non-resorbable 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 the 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
• Nicotinism
• 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.

With mesh-based surgical techniques, recurrences tend to occur at an early postoperative stage; once meshes are ingrown, 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 probably represent the natural course in the inguinal region.

Therapy: In recurrence operations, the same access route should not be chosen. Surgical repair with anterior procedure (Lichtenstein).

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

• Drop in hemoglobin, low blood pressure, larger bloody drainage amounts, visible hematomas
• Diagnostics: Sonography 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; instead, a sonographically controlled drainage should be inserted 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 to distinguish the recurrence from the fluid collection!

Wound infection/mesh infection (<1%)

Opening and spreading of the wound, extensive cleaning, and subsequent open wound treatment, systemic antibiotic therapy. Worst-case scenario mesh explantation.

Postoperative bladder leakage:

Small injuries to the bladder occasionally occur. An unusually large, clear secretion over the drainage or a correspondingly large seroma is then observed. Determination of urea and creatinine in the secretion helps to confirm the diagnosis. A bladder fistula can almost always be treated sufficiently by placing an indwelling 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. Subsequently, damage to the testicle up to atrophy/loss of the testicle may occur, and open revision may be necessary.

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, antibiotic treatment.

Postoperative ileus

Internal hernia due to a larger peritoneal defect.

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 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 risk.

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.