COMPLICATIONS OF LAP. INGUINAL HERNIA REPAIR

Laparoscopic groin hernia repair has 'Minimal Access but is not Minimally Invasive” overall complications are comparable if not lower than open hernia repairs. The recurrence rates in literature are - Open Hernia Repair 6.6 – 18%, Laparoscopic Hernia Repair 7.0 – 19%, Recent Reports - 0.6% with the potential for increased precision and effectiveness.

The majority of complications are related to the laparoscopic technique.

VISCERAL INJURIES

Testes
Testicular complications are far less common with laparoscopic hernia repair (0.3–5.0%). because the 'laparoscopic-posterior' repair does not involve that degree of dissection of cord structures as 'open' repairs do. Yet, testicular pain (most common), swelling, orchitis, epidydimitis and atrophy can complicate the situation. The aetiology of pain could be attributed to trauma to the genito-femoral nerve or the sympathetic testicular plexus during 'parietalsation' of the cord structures. Orchitis and epidydimitis are due to extensive dissection .

Prevention
Atraumatic parietalisation of the cord structures, avoiding complete removal of large indirect hernia sacs,careful tightening of the internalring in paediatric patients.

Management
Supporting the testis,limiting the activity of the patient, analgesics. Fortunately most of the complications resolve spontaneously without sequelae.

Vas Deferens
Again complications are few with lap. hernia repair. Transection injuries occur while transecting a redundant large indirect sac,obstruction can result from traumatic handling of the vas with instruments causing fibrosis.

BOWEL INJURIES
These occur in three situations:

The complications are Laceration of bowel, trocar site herniae (commonly the Richter type), adhesions resulting in acute obstruct-ion, Ileus and chronic pain syndromes, bowel erosion by prosthesis, entero-cutaneous fistulae, internal herniation of bowel because of the 'shower curtain' effect, secondary to failure of the peritoneum to remain anchored, leading to acute obstruction.

Urinary Bladder
The urinary bladder can be injured (1.5 5 %) as it forms the medial component of a sliding hernia. Types of bladder morbidity are Bladder laceration (laceration should be repaired in two layers), Retention, Infection and Haematuria.

Bone
The use of staples and tackers into the ligament of Cooper and underlying pubic ramus and tubercle may cause Osteitis pubis .

Skin
Severe Ecchymoses is due to inadvertent injury to the superficial vessels. Extensive subcutaneous emphysema is due to pneumoperitoneum or pneumo- extraperitoneum leaking into the subcutaneous plane at trocar sites.

Prevention
Avoiding repeated peritoneal perforations with trocars. Therefore, self-retaining trocars are preffered. Fortunately these complications are self-limiting and without serious morbidity.

VASCULAR INJURIES
Vascular morbidity could have different presentations:

Vascular injury can occur at the following sites:

LYMPHATIC MORBIDITY
The incidence of background Seromas (1.2 10%) is higher with laparoscopic than open repairs. These result from trauma of dissection around the hernial sac and by foreign bodies (eg. Prostheses)

Treatment
Most resolve spontaneously and need reassurance.
Aspiration is needed for those lasting more than 6-8 weeks and large seromas. Encysted seromas need excision.

HYDROCOELE (0.6%)
These usually resolve spontaneously, occasionally simple aspiration is necessary.

Nerve injury (12%)
TEP has been credited with having lower nerve injury rates because extra-peritoneal exposure is better with TEP. Causes are:
1. Failure to appreciate the anatomy
2. Difficulty in visualizing the nerves preperitoneally
3. Variable course of the nerves
4. Extensive preperitoneal dissection
5. Anchoring

The following three nerves are at risk - Lateral Femoral Cutaneous Nerve, Femoral Branch of the Genito-Femoral Nerve, Intermediate Cutaneous Br of the Femoral Nerve. Other three (Ilioinguinal, Iliohypogastric and Genital Br of Genito-femoral nerve) are usually not at risk but can be injured if excessive pressure is applied during mesh fixation, compressing the muscles enough to allow the staples to reach the nerve.

Prevention

Treatment
Rest, NSAIDS, Injections with local Anaesthetic or Corticosteroid.
Indications for operative treatment - neuralgia in the recovery room (Immediate re-exploration), debilitating and unremitting neuralgia.

INFECTIONS (1 - 2%)
Can be Superficial subcutaneous - do not affect recurrence rates or deep seated -associated with high recurrence rates.

Treatment
A broad spectrum antibiotic is started during an observation period of 48–72 hours.

Prostheses related Complications
Mesh - infection, adhesions with viscera , erosion, extrusion & migration, fibrosis causing nerve entrapment and Enteric fistula.

PORT SITE HERNIA
It is rare. Felix reported 0.63%. These are lower in the TEP procedure.

RECURRENCE
Technical factors
- Learning curve
- Inadequate dissection
- Inadequate mesh size (60%)
- Slitting the mesh
- Improper mesh placement
- Mesh twisting / folding
- Mesh migration
- Inadequate mesh overlap of hernia defect
- Inadequate or lack of fixation (32%)
- Lifting of the mesh by haematoma, peritoneal strand, etc.
- Missed herniae(15%)
- Missed lipoma
- Combination of the above( 30%)

Surgeon Factor
The problem is chiefly the lack of importance given to hernia repair! Despite a poor record, abdominal wall herniae continue to be repaired quite often by junior level staff.

Reference