- Intraoperative Bleeding
Especially of the epigastric vessels or their branches at the lateral edge of the rectus sheath
Therapy: immediate suturing/hemostasis
- Bowel 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 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 decisive; if necessary, postpone the mesh implantation.
- Inability to Close the Anterior Rectus Sheath
Bridging Technique: In the event that the anterior fascial layers cannot be completely united, fixation of the fascial edges on the mesh already placed in the sublay position with a continuous non-absorbable suture in the sense of partial anterior bridging is permissible. If a large hernia is treated with a dorsal fascial closure, a sublay mesh in a retromuscular position, and a small residual bridging of the anterior fascia, and a primary skin closure is achieved over it, a satisfactory result can be assumed.
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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 muscle.
- 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 tightly adherent bowel loops.
If the expected postoperative course deviates and there is suspicion of an unrecognized bowel lesion (fever, peritonism, 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. Partial reopening of the abdominal wall reconstruction.
- 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 with conservative bowel stimulation, possibly 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 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 from suturing during mesh fixation, especially when using non-absorbable suture material.
Consistent postoperative analgesia. In the 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 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 sonographic follow-up.
- Therapy: Wait at least 4-6 weeks, then possibly sterile puncture. In very large seromas with discomfort or suspicion of superinfection, sonographically 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 found incidentally during imaging for other reasons, an indication for surgery should be considered very cautiously. In the case of size progression or symptoms, reoperation should be considered.
- Rebleeding/Hematoma