Complications - Transabdominal preperitoneal patch (TAPP) repair of inguinal hernia

  1. Risikofaktoren

    Evidenzbasierte Risikofaktoren für Komplikationen und Reoperationen bei der Leistenhernien OP wurden definiert:
    1. Alter >80 Jahre : Bei bestehenden Komorbiditäten hohes Letalitätsrisiko; mehr Serome, Harnverhalte und Wiederaufnahmen. Schon bei einem Alter > 60 Jahre mehr Harnverhalte und mehr Komplikationen.
    2. ASA III und höher: Mehr Komplikationen und Reoperationen, erhöhtes Letalitätsrisiko.
    3. Weibliches Geschlecht: Erhöhtes Risiko für Schmerzen.
    4. Adipositas: Tendenz zu mehr Komplikationen.
    5. COPD: Mehr Komplikationen, erhöhte Letalität in der ambulanten Chirurgie.
    6. Diabetes mellitus: Unabhängiger Risikofaktor für postoperative Komplikationen.
    7. Antikoagulation/Thrombozytenaggregationshemmer: 4-fach erhöhtes postoperatives Blutungsrisiko. Auch nach Absetzen der gerinnungshemmenden Medikation ist das Nachblutungsrisiko deutlich erhöht.
    8. Immunsuppression/Kortisonmedikation: Erhöhtes Rezidivrisiko.
    9. Leberzirrhose: Erhebliche Zunahme der Komplikationsraten.
    10. Nikotinabusus: Deutliche Steigerung des allgemeinen und chirurgischen Komplikationsrisikos.
    11. Beidseitige Leistenhernie: Erhöhtes perioperatives Risiko, deshalb keine prophylaktische Operation einer gesunden Seite.
    12. Erhöhte Komplikationsrate bei Rezidiveingriffen und Schenkelhernien.
    13. Präoperative Schmerzen führen gehäuft zu akuten und dann chronischen Leistenschmerzen postoperativ.

     

  2. Intraoperative complications

    Irritation, entrapment and injury of the inguinal nerves with persistent postoperative pain (ilioinguinal syndrome, genital nerve syndrome)

    • The nerves were injured or divided during dissection. These are the particular nerves at danger: Lateral femoral cutaneous; ilioinguinal; iliohypogastric; genital and femoral branches of the genitofemoral nerve.
    • Imprudent stapling may injure, irritate and even snag nerves.
    • If the nerves are not divided but only irritated or touched, this may result in postoperative paresthesia which often is amenable to local anesthetics.

    Injury to the spermatic duct

    • How to proceed in any injury of the spermatic duct depends on the following aspects: Has the spermatic duct been divided completely or only partially? How old is the patient? Does the patient want to preserve his fertility?
    • In elderly patients no longer sexually active. the spermatic duct may be transected, otherwise this requires microsurgical suture.
    • After the operation the patient must always be informed of what had happened and the consequences for him.

    Bladder injury

    • If the bladder has been injured the lesion must be oversewn. If not amenable to laparoscopic repair, convert to open procedure, Relieve the bladder for seven to ten days with a suprapubic catheter. In order to minimize the risk of bladder injury do not carry the peritoneal incision beyond the medial umbilical fold.

    Bowel injury

    • In case of accidental iatrogenic bowel injury during the procedure the lesion should immediately be closed by laparoscopic suture. If there is no clear view or the sutured closure of the intestinal lesion appears questionable, convert to open surgery and suture the lesion under direct visual control or resect it with anastomosis. In bowel injury with limited intra-abdominal contamination, the prosthetic may still be implanted following thorough lavage of the abdominal cavity.

    Injury to the femoral artery and arterial hemorrhage

    • Arterial hemorrhage from the femoral artery will result in rapid massive blood loss with the clinical sequela of hypovolemic shock. If the hemorrhage cannot be controlled laparoscopically, immediately convert to open procedure and suture the injured vessel under direct visual control.