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

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 retentions and readmissions. Already at an age > 60 years more urinary retentions 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 toward more complications.

5. COPD: More complications, increased mortality in outpatient surgery.

6. Diabetes mellitus: Independent risk factor for postoperative complications.

7. Anticoagulation/platelet aggregation inhibitors: 4-fold increased postoperative bleeding risk. Even after discontinuation of anticoagulant medication, the risk of rebleeding is significantly increased.

8. Immunosuppression/corticosteroid medication: Increased recurrence risk.

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 surgery 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 case of bleeding, it is recommended to first use suction and irrigation to keep the site clear and to securely identify the source of bleeding. If clips are required, a 5 mm trocar can be replaced by a 10 mm one. In case of poor visibility, open conversion must be performed.

• No staplers in the “triangle of doom” (vessels), anatomical triangle defined by the vas deferens medially, the gonadal 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 of bleeding oversewn, if necessary conversion and involvement of a vascular surgeon.
• Injury to the epigastric vessels during balloon dissection, suturing of the peritoneum or parietalization, if necessary these vessels must be clipped.
• In case of iatrogenic vein damage and subsequent thrombosis of the femoral vein in the surgical area, it is a thrombosis of the pelvic floor.
  • Diagnostics: Duplex and Doppler sonography or phlebography
  • Treatment of deep vein thrombosis: Compression, mobilization, full heparinization (caution 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 Postoperatively Persistent Pain

• Particularly at risk are the lateral femoral cutaneous nerve and genitofemoral nerve in the “triangle of pain” (inverted V whose tip corresponds to the internal inguinal ring, the upper anterior thigh is formed by the iliopubic tract or the inguinal ligament, the medial posterior by the spermatic vessels).
• Significantly lower with minimally invasive procedures
• Traumatic damage to nerves during preparation, suturing or entrapment of nerves in tacks during mesh fixation.
• Fixation of meshes with glue reduces the pain frequency compared to fixation with staplers.

Injury to the Vas Deferens

If an injury to the vas deferens occurs, the following aspects are decisive for further procedure: Was the vas deferens completely or only partially severed? How old is the patient? Does the patient have a desire to father children?

In sexually inactive older patients, the vas deferens may be severed if necessary. In any case, the patient must be informed postoperatively about what happened and what consequences this has for him.

Intestinal Injury (< 1 %)

Recognized intestinal lesions or coagulation damages are oversewn laparoscopically.

Urinary Bladder Injury (< 1 %)

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

In case of urinary bladder injury, the injured site must be oversewn. Postoperatively, the bladder is decompressed for 1 week via a suprapubic fistula catheter (SPFC) or indwelling catheter.