Complications - Incisional hernia repair, open sublay

• Intraoperative Bleeding
  
  Especially of the epigastric vessels or their branches at the lateral edge of the rectus sheath
  
  Therapy: immediate ligation/hemostasis
   
• Intestinal injury during adhesiolysis
  
  Prophylaxis: Careful, layer-by-layer preparation, if necessary start preparation in the defect-free area, from there display the fascial defect and the hernia content. Early opening of the hernia sac.
  
  Deserosalizations must be recognized and immediately oversewn.
  
  In transmural lesions, the location (small intestine-colon) and the amount of intestinal content leakage are decisive, if necessary postpone mesh implantation.
   
• Inability to close the anterior rectus sheath
  
  Therapy: TAR (transversus abdominis release), abdominal wall component separation according to Ramirez or if necessary bridging technique

• Postoperative Bleeding/Hematoma
  
  Ultrasound control, in case of size progression possibly puncture. Hb-relevant postoperative bleedings and large symptomatic hematomas must be revised.
  
  Postoperative bleedings after removal of Redon drainages: Erosion by Redon drainage. The suction must be removed before pulling to prevent the suctioned drainage from causing bleedings in the drainage channel or on the musculature.
   
• Unnoticed secondary intestinal perforation
  
  Avoid interenteric intestinal adhesiolysis, if possible only abdominal wall-near preparation possibly including the parietal peritoneum/transversalis fascia to ensure a safe distance to the firmly adhered intestinal loop.
  
  In case of deviation from the expected postoperative course and suspicion of an unrecognized intestinal lesion (fever, peritonism, ileus, infection parameters), surgical exploration must be performed. Reoperation with detection of the intestinal lesion and oversewing, possibly resection and abdominal lavage, antibiotic treatment, possibly mesh explantation. Lethality approx. 3 %.
   
• Abdominal compartment situation
  
  Reduced urine output possibly bladder pressure measurement. Dissolve the abdominal wall reconstruction, at least partially.
   
• Postoperative intestinal paralysis/manifest ileus
  
  An intestinal paralysis after extensive adhesiolysis or intestinal wall oversewing is common. A slow dietary buildup is recommended possibly administration of antiemetic medications to avoid retching and vomiting. Prophylaxis through PDC and early mobilization. Attempt with conservative intestinal stimulation possibly administration of a prokinetic (e.g. Neostigmine). In case of a manifest ileus reoperation with detection and elimination of the cause.
   
• Chronic postoperative pain

Chronic postoperative pain 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 are traumatic damage to the nerves by suturing during mesh fixation especially when using non-resorbable suture material.

Consistent postoperative analgesia. In case of therapy-refractory pain that is punctually localized to a transfascial thread/knot, this should be removed via a circumscribed access. Identification of a segmental spread and attempt at a segmental blockade possibly neurectomy of the affected intercostal nerve. Mesh removal ultima ratio.

Risk factors are preexisting or poorly controlled early postoperative pain, female gender and width of the hernia gap > 10 cm
 

• Seroma
  
  A seroma is regularly present depending on the size of the hernia sac and without therapeutic consequence, possibly ultrasound follow-up control. If the size of the seroma leads to clinical symptoms, a puncture (absolutely sterile!) can be performed in individual cases (possibly with microbiological examination). In case of recurrent seromas, do not puncture multiple times, but then insert a drainage under ultrasound control and drain consistently for a few days. Caution: Every puncture increases the risk of a mesh infection.
   
•  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 approx. 10 - 15 %
  
  Risk factors are a hernia diameter of > 5 cm, intra-abdominal adiposity and a lateral defect localization.
  
  In case of clinically irrelevant recurrence with absence of symptoms, usually as an incidental finding in the context of imaging for other reasons, there is only a limited indication for surgery. In case of size progression or symptoms, a reoperation should be considered.