- Intraoperative bleeding
Especially of the epigastric vessels or their branches at the lateral edge of the rectus sheath
Therapy: immediate suturing/bleeding control
- Bowel injury during adhesiolysis
Prophylaxis: careful, layer-by-layer dissection, if necessary, start dissection in an area free of defects, from there visualize the fascial defect and the hernia contents. Early opening of the hernia sac.
Deserosations must be recognized and immediately oversewn.
In the case of transmural lesions, the location (small intestine-large intestine) and the amount of bowel content leakage are crucial, possibly postponing the mesh implantation.
- Inability to close the anterior rectus sheath
Therapy: TAR (transversus abdominis release), abdominal wall component separation according to Ramirez or possibly bridging technique
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Intraoperative Complications
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Postoperative complications
- Rebleeding/Hematoma
Ultrasound monitoring, puncture if size progresses. Hemoglobin-relevant rebleeding and large symptomatic hematomas must be revised.
Rebleeding 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 musculature.
- Unnoticed secondary bowel perforation
Avoid interenteric bowel adhesiolysis, preferably only abdominal wall preparation possibly including the parietal peritoneum/transversalis fascia to ensure a safe distance from the firmly adherent bowel loop.
In case of deviation from the expected postoperative course and suspicion of an unrecognized bowel lesion (fever, peritonism, ileus, infection parameters), surgical exploration is necessary. Reoperation with detection of the bowel lesion and oversewing suture, possibly resection and abdominal lavage, antibiotic treatment, possibly mesh explantation. Mortality approximately 3%.
- Abdominal compartment syndrome
Reduced urine output, possibly bladder pressure measurement. Breakdown of the abdominal wall reconstruction, at least partially.
- Postoperative bowel paralysis/manifest ileus
Bowel paralysis after extensive adhesiolysis or bowel wall sutures is common. A slow dietary build-up is recommended, possibly with the administration of antiemetic medications to avoid retching and vomiting. Prophylaxis through epidural anesthesia and early mobilization. Attempt with conservative bowel stimulation, possibly administration of a prokinetic agent (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 in 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 due to suturing during mesh fixation, especially when using non-absorbable suture material.
Consistent postoperative analgesia. In case 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 of 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 a 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. If the size of the seroma leads to clinical symptoms, puncture (absolutely sterile!) can be performed in individual cases (possibly with microbiological examination). In case of recurrent seromas, repeated puncture should be avoided, and instead, a drainage should be inserted under ultrasound control and consistently drained for a few days. Caution: Each puncture increases the risk of 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 approximately 10 - 15%
Risk factors include a hernia diameter of > 5 cm, intra-abdominal obesity, and lateral defect location.
In clinically irrelevant recurrence with absence of symptoms, usually as an incidental finding during imaging for other reasons, there is only a limited indication for surgery. In case of size progression or symptoms, reoperation should be considered.
- Rebleeding/Hematoma