Complications - Inguinal hernia repair, Rutkow Plug

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 of 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 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.

Irritation, constriction, or injury of inguinal nerves with post-operative 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: the lateral femoral cutaneous nerve, ilioinguinal nerve, iliohypogastric nerve, genital branch, and the femoral branch of the genitofemoral nerve.

In case of nerve damage or obstruction of the 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 removed by 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 post-operatively 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, possibly suture the femoral vein, and consider consulting a vascular surgery colleague.

Bladder injury

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

Chronic postoperative pain (10-12%)

Definition: Chronic postoperative pain was defined as early as 1986 by the "International Association for the Study of Pain" 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 repair.

In open inguinal hernia surgery, chronic pain is the most common complication. Nerve damage due to injuries or contact with alloplastic material are possible triggers. Scar formation with mesh shrinkage are other potential causes.

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 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 previous surgically treated inguinal hernia. It may also be a femoral hernia overlooked during surgery.

Clinic and diagnostics correspond to inguinal hernia.

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

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 require no further therapy.
• Larger hematomas should be punctured or evacuated. Severe rebleeding must be surgically revised.
• If the skin becomes tense or causes neurological symptoms, surgical revision is necessary.

Seroma formation

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!) may be performed in individual cases. Otherwise, monitoring and discussion of findings are sufficient. In the case of recurrent seromas, multiple punctures should be avoided, and if necessary, a sonographically controlled drainage should be placed and consistently drained for several days.

Plug migration/recurrence

• Prophylaxis: Fixation of the plug with multiple individual button sutures using a non-absorbable suture
• Therapy: preferably conventional revision and plug removal, followed by Lichtenstein repair. Laparoscopic procedure is very challenging due to existing adhesions, and the plug should not be removed.

Bacterial contamination of the mesh

• Prophylaxis: Glove change, single-shot antibiotic prophylaxis
• Therapy: Revision with swab collection, irrigation, and open wound treatment, accompanied by antibiotic therapy. If infection is not resolved or recurrent infections occur, plug and patch removal. In the usually subsequent "recurrence," TAPP or Lichtenstein operation (very challenging).

Deep vein thrombosis due to fibrosis at the tip of the plug

• Prophylaxis: Intraoperatively pay attention to the position relative to vessels!
• Diagnostics: Duplex and Doppler ultrasound or phlebography.
• Therapy of deep leg/pelvic vein thrombosis: Compression, mobilization, full heparinization (caution! Risk of bleeding!)
• For further information, please follow the link to the current guideline: Prophylaxis of venous thromboembolism (VTE)

Wound infection/mesh infection (<1%)

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

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, there is a risk of testicular damage up to atrophy/loss of the testicle, and open revision may be necessary.

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, as well as antibiotic treatment in case of existing peritonitis.

Mechanical ileus

• Clinic: Distended abdomen, radiological air-fluid levels, laboratory chemical lactate elevation with additional ischemia, possibly signs of transmural peritonitis.
• Therapy: Reoperation, detection of the cause, resolution of the cause.