Complications of Laparoscopic Inguinal Hernia Repair - Dr. R.K. Mishra

Complications of Laparoscopic Inguinal Hernia Repair

Like any other laparoscopic procedures, complications have been recorded during the learning curve. The major problems include:

•    Recurrence
•    Neurovascular injury
•    Urinary tract injury
•    Injury to the vas
•    Testicular complications
•    Problems are due to the mesh.

The mechanism of recurrence can be related to a lack of understanding of the difficult laparoscopic anatomy, wrong hernia repair technique, or the wrong prosthesis. These include incomplete dissection without proper pocket formation, missed sac, migration of mesh due to the small-sized mesh which may be prone to displaced once fixed, inadequate fixation with rolling up of the mesh, and hematoma formation leading to infection.

The complication of laparoscopic hernia repair can be summarized as follows:

•    Immediate: Visceral injury, vascular injury, injury to vas, spermatic vessels

•    Late: Bowel adhesions to mesh, intestinal obstruction, fistulization, orchitis, testicular atrophy, nerve entrapment, incisional hernia recurrence.

Perforation bowel during hernia surgery
 Perforation bowel during hernia surgery

Relative Contraindication for Laparoscopic Approach

A.    Obesity with BMI > 30
B.    Significant chest disease
C.    Patient on anticoagulants
D.    Adhesions
E.    Massive hernias
F.    Pregnancy
G.    Unfit for GA.

Inguinal Hernia Repair in Pediatric Patients

Small children gain little benefit from laparoscopic hernia repair as inguinal skin crease incision used in the herniotomy is one of the best incisions as far as cosmesis is concerned. It is hardly visible after a few months. Also, it is covered by underwear. Compared to these three stab incisions, however small, are in the visible area.

Inguinal Hernia Repair in Obese Patients

Operations in patients with BMI above 27 may be difficult for less experienced surgeons, particularly when trying to encircle an indirect sac. Patients with a BMI of above 30 should be encouraged to lose weight or should even be turned down for the laparoscopic approach. They are incidentally more likely to develop recurrence after an open hernia repair. It is also easy for the laparoscopic surgeon to become disoriented when the patient is very obese.

Inguinal Hernia Repair in Recurrence

Generally, the short-term recurrence rate of laparoscopic inguinal hernia repair is reported to be less than 5 percent. 
In both the open and laparoscopic repair procedures, the aim is to cover the whole inguinofemoral area by a preperitoneal prosthetic mesh, and recurrences should not occur. When they do occur, recurrences must be regarded as technical failures. Recurrences after laparoscopic repair most often result from using too small a mesh, or not using staples to fix the mesh. Most recurrences after laparoscopic hernia repair occurred medially, and the technique was adjusted. The mesh is now placed at least until the midline, and occasionally hernia staples are used when an adequate overlap (2 cm) cannot be achieved medially. The totally extraperitoneal technique is now used more often, allowing for better visual control in the medial part of the operating field.

Operating Time

Operating times of surgical techniques vary between surgeons and also vary considerably between centers. It reduces with experience and comparison between laparoscopic and open surgery is subject to bias due to pre-existing familiarity with open techniques. It is less important to the patient than a successful operation; the time taken to perform the surgery can have cost implications. The operative time to perform unilateral primary inguinal repair has frequently been reported as longer for laparoscopic compared to open repair, however, the mean difference in 36 of 37 randomized trials is 14.81 minutes. These differences disappear in bilateral and recurrent hernia repairs.

Postoperative Pain and Amount of Narcotics Used

The open tension-free mesh repair is found to cause less postoperative pain than open nonmesh repairs, however, most randomized trials assessing postoperative pain between open tension-free repairs and laparoscopic repairs, report less pain in the laparoscopic groups. In many cases, this also results in less analgesia being consumed by the patient.

Complication Rates

Complications in endoscopic inguinal hernia surgery are more dangerous and more frequent than those of open surgery, especially in inexperienced hands, and hence are best avoided. It is possible to avoid most of these complications if one follows a set of well-defined steps and principles of endoscopic inguinal hernia surgery.

Complications of laparoscopic repair of inguinal hernia can be divided into:

•    Intraoperative
•    Postoperative.

Intraoperative Complications and Precaution

During Creation of Preperitoneal Space

This is the most important step for beginners.

•    A wide linea alba may result in breaching the peritoneum; in such a situation, it is best to close the rectus and incise the sheath more laterally.
•    Improper placement of balloon trocar causing dissection of muscle fibers.
•    Entry into peritoneum causing pneumoperitoneum
•    Rupture of the balloon in preperitoneal space.
•    The Hassan’s trocar must snugly fit into the incision to avoid CO 2 leak.

To avoid these, one must ensure that the balloon is made properly and the correct space is entered by retracting the rectus muscle laterally to visualize the posterior rectus sheath. Also, the balloon trocar is inserted gently, parallel to the abdominal wall, to avoid puncturing the peritoneum. The balloon must be inflated slowly with saline to ensure smooth and even distention and prevent its rupture.

Precautions During Port Placement

The trocars should be short and threaded in proportion to less workspace and to ensure a snug fit respectively. The skin incisions should be just adequate to grip the trocar and prevent its slipping. The patient should empty their bladder before surgery as the suprapubic trocar could injure a filled bladder. The pressure in the preperitoneal space must be such as to offer sufficient resistance during trocar insertion to avoid puncturing the peritoneum.

Correct Identification of the Anatomical Landmarks

The next most important and crucial step in any hernia surgery is the correct identification of anatomical landmarks. This is difficult for beginners as the anatomy is different from that seen in open surgery. The first most important step is to identify the pubic bone. Once this is seen, the rest of the landmarks are traced keeping this as a reference point. One is advised to keep away from the triangle of doom, which contains the iliac vessels and to avoid placing tacks in the triangle of pain laterally.

Bladder Injuries

Bladder injury most commonly occurs during port placement, dissecting a large direct sac or in a sliding hernia. It is mandatory to empty the bladder prior to an inguinal hernia repair to avoid a trocar injury. It is advisable that beginners catheterize the bladder during the initial part of their learning curve. The diagnosis is evident when one sees urine in the extraperitoneal space. Repair is done with Vicryl in two layers and a urinary catheter inserted for 7 to 10 days.

Bowel Injuries

Bowel injury is rare during hernia surgery. It can occur when reducing large hernias, the inadvertent opening of peritoneum causing the bowel to come into the field of surgery, and in the reduction of sliding hernias. Injury is best avoided in such circumstances by opening the hernial sac as close as possible to the deep ring. The initial studies showed a higher incidence, especially with TAPP, but it decreased over time.

Vascular Injury

This is one of the most common injuries occurring in hernia repair and often a reason for conversion. The various sites where it can occur is rectus muscle vessel injury during trocar insertion; inferior epigastric vessel injury; bleeding from venous plexus on the pubic symphysis; aberrant obturator vein injury; testicular vessel injury; and the most disastrous of all, iliac vessels, which requires an emergency conversion to control the bleeding and the immediate services of a vascular surgeon to repair the same. Most of the other bleeding can be controlled with cautery or clips. Careful dissection and adherence to the principles of surgery will help in avoiding most of these injuries.

Injury to Vas Deferens

The injury occurs while dissecting the hernia sac from the cord structures. The injury causes an eventual fibrotic narrowing of the vas. A complete transaction of the vas needs to be repaired in a young patient. An injury to the vas is best avoided and this may be done by identifying before dividing any structure near the deep ring or floor of the extraperitoneal space. Also, the separation of cord structures from the hernial sac must be gentle and direct; grasping of vas deferens with forceps must be avoided.
Pneumoperitoneum

It is a common occurrence in TEP which every surgeon should be prepared to handle. Putting the patient in Trendelenburg’s position and increasing the insufflation pressures to 15 mm Hg helps. If the problem still persists, a Veress needle can be inserted at Palmer’s point.

Postoperative Complications

Seroma/Hematoma Formation

It is a common complication after laparoscopic hernia surgery, the incidence being in the range of 5 to 25 percent. They are especially seen after large indirect hernia repair. Most resolve spontaneously over 4 to 6 weeks. A seroma can be avoided by minimizing dissection of the hernia sac from the cord structures, fixing the direct sac to the pubic bone, and fenestration the transversalis fascia in a direct hernia. Some surgeons put in a drain if there is excessive bleeding or after extensive dissection.

Postoperative scrotal hematoma
 Postoperative scrotal hematoma

Urinary Retention

This complication after hernia repair has a reported incidence of 1.3 to 5.8 percent. It is usually precipitated in elderly patients, especially if symptoms of prostatism are present. These patients are best catheterized prior to surgery and catheter removed the next day morning.

Vascular Injury

The incidence of vascular injury has been documented to be about 0.5 to 1 percent and the inferior epigastric artery is the one most commonly traumatized.

•    Injury to iliac vessels: Chances of mortality
•    Inferior epigastric vessel: Hematoma
•    Iliopubic vein and artery which traverse the lacunar ligament: Hematoma
•    Injury to spermatic vessels: Postoperative scrotal hematoma.

Nerve Entrapment and Injury

The lateral cutaneous nerve of the thigh and the femoral branch of genitofemoral nerve are the two nerves vulnerable to trauma due to indiscriminate placement of staplers lateral to the spermatic cord on the iliopubic tract.

•    Injury of lateral cutaneous nerve injury.

•    Most common nerve injured is a lateral femoral cutaneous nerve (2%): Hyperesthesia or paresthesia of upper aspect of thigh and hip.

•    If pain starts days after surgery, it will recover within 2 to 4 weeks (or percutaneous steroid).

•    If pain starts within 24 hours of surgery there is permanent nerve damage.

•    Cryotherapy with the destruction of the sensory branch is indicated.

•    Lifelong numbness.
Nerve entrapment should be avoided in laparoscopic repair of hernia:

•    Genitofemoral nerve injury.

•    Genitofemoral nerve injury (1%): Hyperesthesia or paresthesia of scrotum.

•    Not significant.

•    With time it will subside.

Other Complications

•    Migration of mesh
•    Rejection of mesh (Rare)
•    Bowel adhesion.

The complete transaction of vas requires immediate anastomosis. Other complications include testicular pain, orchitis, epididymitis, swelling due to seromas or hematoma. The treatment is supportive and the incidence of all these complications is similar to that in conventional surgery.

After some experience, most cases of inguinal hernia can be treated laparoscopically. Several prospective randomized trials comparing open versus laparoscopic repair have reported. Reduced postoperative pain, earlier returns to work and fewer complications and less chance of recurrences for the laparoscopic approach are some of the crucial advantages. Although the procedural cost for laparoscopic hernia repair is more compared to conventional repair but the overall expense for open repair is high if we calculate a number of working days lost and medication is taken into consideration. Data is now available which documents the totally extraperitoneal repair to have a distinct advantage over the transabdominal preperitoneal repair in terms of lesser postoperative complications and lower recurrence rate. TAPP has been stated to violate the peritoneal cavity with all its known possible complication of pneumoperitoneum, vessel, or bowel injury. There is no doubt that the laparoscopic hernia repair is a proven technique and will become more popular over a period of time.

Neuralgias

The incidence of this complication is reported to be between 0.5 and 4.6 percent depending on the technique of repair.

The intraperitoneal Onlay mesh method had the highest incidence of neuralgias in one study and was hence abandoned as a form of viable repair. The commonly involved nerves are the lateral cutaneous nerve of thigh, genitofemoral nerve, and intermediate cutaneous nerve of the thigh. They are usually involved by mesh-induced fibrosis or entrapment by a tack. The complication is prevented by avoiding fixing the mesh lateral to the deep inguinal ring in the region of the triangle of pain, safe dissection of a large hernial sac, and no dissection of fascia over the psoas.

Anatomical landmarks, TV–Testicular vessel, GFN–Genitofemoral nerve, LCN–Lateral cutaneous nerve of high
 Anatomical landmarks, TV–Testicular vessel, GFN–Genitofemoral nerve, LCN–Lateral cutaneous nerve of thigh

Testicular Pain and Swelling

It occurs due to excessive dissection of a sac from the cord structures, especially a complete sac. The reported incidence is 0.9 to 1.5 percent, most are transient. Orchitis was found in a small number of patients but did not lead to testicular atrophy.

Mesh Infection and Wound Infection

Wound infection rates are very low. Mesh infection is a very serious complication and care must be taken to maintain strict aseptic precautions during the entire procedure. Any endogenous infection must be treated with an adequate course of antibiotics prior to surgery.

Recurrence

It is the most important endpoint of any hernia surgery. It requires proper and thorough knowledge of anatomy and a thorough technique of repair to help keep the recurrence in endoscopic repair to a minimum.

Postoperative Recovery

Marked variations are seen in postoperative recovery due to patient motivation, postoperative advice, and definition of “normal activity”, existing co-morbidity and local “culture”. Nevertheless, all trials reporting this as an endpoint of the study show a significant improvement in the laparoscopic group, with no real difference between the TAPP and TEP groups. This is estimated to equate to an absolute difference of about 7 days in terms of time off work.

Recurrence

Recurrence rates are low with the use of mesh and not significantly different between open or laparoscopic techniques.
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