- Bleeding/Hematoma
Ultrasound monitoring, puncture if size progresses. Hemoglobin-relevant bleeding and large symptomatic hematomas must be revised.
Bleeding after removal of Redon drains: Erosion by Redon drain. The suction must be removed before pulling to prevent the aspirated drain from causing bleeding in the drainage channel or on the muscle.
- Unnoticed secondary bowel perforation
Avoid interenteric bowel adhesiolysis, preferably only perform abdominal wall preparation, possibly including the parietal peritoneum/transversalis fascia, to ensure a safe distance from the firmly adherent bowel loops.
If the expected postoperative course deviates and there is suspicion of an unrecognized bowel lesion (fever, peritonitis, ileus, infection parameters), surgical exploration is necessary. Reoperation with detection of the bowel lesion and suturing, possibly resection and abdominal lavage, antibiotic treatment, possibly mesh explantation. Mortality approximately 3%.
- Abdominal compartment syndrome
Reduced urine output, possibly bladder pressure measurement. Dissolution of the abdominal wall reconstruction, at least partially.
- Postoperative bowel paralysis/manifest ileus
Bowel paralysis after extensive adhesiolysis or bowel wall suturing is common. A slow dietary build-up is recommended, possibly with the administration of antiemetic medications to avoid retching and vomiting, which could endanger the fresh reconstruction. Prophylaxis through epidural anesthesia and early mobilization. Attempt conservative bowel stimulation, possibly with the administration of a prokinetic (e.g., neostigmine). In the case of a manifest ileus, reoperation with detection and correction of the cause.
- Chronic postoperative pain
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. Possible causes include traumatic nerve damage from suturing during mesh fixation, especially when using non-absorbable suture material.
Consistent postoperative analgesia. In cases of therapy-resistant pain localized to a trans-fascial suture/knot, it should be removed through a circumscribed approach. Identification of segmental spread and attempt at segmental blockade, possibly neurectomy of the affected intercostal nerve. Mesh removal as a last resort.
Risk factors include pre-existing or poorly controlled early postoperative pain, female gender, and defect width > 10 cm.
- Seroma
- A seroma is regularly present depending on the size of the hernia sac and without therapeutic consequence, possibly ultrasound follow-up.
- Therapy: Wait at least 4-6 weeks, then possibly sterile puncture. In very large seromas with discomfort or suspicion of superinfection, ultrasound or CT-guided placement of a suction drain. In rare cases, if persistent and forming a seroma capsule, surgical excision.
Prophylaxis: Insertion of Redon drains and removal only after secretion has ceased.
- Wound healing disorder/skin necrosis
In extensive subcutaneous mobilizations, attention must be paid to the perforating vessels as much as possible to avoid skin necrosis.
- Wound infection/mesh infection
Superficial wound infection: Conservative approach with open wound treatment
Subfascial wound infection with mesh involvement: open wound treatment, possibly VAC
- Recurrence
In clinically irrelevant recurrence with no symptoms, usually an incidental finding during imaging for other reasons, surgical indication should be very cautious. In case of size progression or symptoms, reoperation should be considered.
