How are complications prevented in laparoscopic inguinal hernia repair?

Updated: Apr 16, 2020
  • Author: Danny A Sherwinter, MD; Chief Editor: Kurt E Roberts, MD  more...
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Answer

Accurate identification of the laparoscopic anatomy of the groin during laparoscopic inguinal hernia repair helps prevent complications. Careful attention to detail at several points during the surgical procedure can also be helpful. Appropriate positioning and padding can help prevent nerve palsy.

The inferior epigastric vessels may be dislodged by the dissecting balloon used in TEP repair, and this can either cause significant bleeding or impede the dissection. The inferior epigastric vessels can be clipped and divided without consequence. If the bleeding occurs with the vessels in situ, a transabdominal wall suture ligature may be used to control the bleeding. In TAPP repair, starting the peritoneal dissection in the right plane helps prevent injuries to the inferior epigastric vessels during the creation of the peritoneal flap.

Hematoma or seroma formation may occur but is usually self-limited because of the tamponade effect of the peritoneum. On rare occasions, surgical intervention may be necessary.

Small holes in the peritoneum can lead to encroachment of the peritoneum into the working space. This can be remedied in multiple ways, such as by enlarging the hole to equilibrate the intra-abdominal pressure with the preperitoneal pressure, by placing a Veress needle into the abdomen to evacuate the intra-abdominal gas, or by closing the hole securely to prevent passage of carbon dioxide into the peritoneal cavity.

All holes in the peritoneum should be repaired. Large holes do not lead to diminished working space but can lead to postoperative complications. Exposed mesh can lead to adhesions to the small bowel and, in rare cases, bowel injury and fistulization. [59, 60, 61] A peritoneal rent can also serve as a site for bowel to become incarcerated. [62] Peritoneal rents may be closed with sutures, clips, or preformed suture ligatures.

It is particularly important to try to avoid tearing of the peritoneal flap during TAPP; this can be difficult, because the peritoneum can be very flimsy. Tearing the peritoneum may not be a significant complication for this repair, but it will add extra time to the procedure and can complicate peritoneal closure and coverage of the mesh. When the peritoneum is torn and cannot be repaired, a barrier-type mesh or one suitable for intra-abdominal placement can be used. However, this is not ideal, because the peritoneum helps hold the mesh in place.

Intra-abdominal injury is uncommon with TEP repair but may occur if the peritoneum is torn and the abdominal cavity entered. Extra care should be taken with wide-neck hernia sacs that contain abdominal organs. A final intraperitoneal evaluation may be helpful at the completion of the case if an injury is suspected. The potential for intra-abdominal injury is one of the drawbacks of TAPP repair; thus, safe laparoscopic access is essential. Surgeons should employ the laparoscopic access techniques with which they feel most comfortable. [63, 64]

Obviously, cautious hernia reduction and careful identification of the vas deferens and cord structures are crucial for avoiding complications. Large indirect hernia sacs may be difficult to reduce; their chronicity often results in adherence of the sac to the cord. If, after a diligent effort, the sac cannot be reduced, it can be divided. The sac and cord structures should be clearly separated, and the sac should be free of contents. A cold scissors can be used to divide the sac. The proximal sac should be closed with a suture ligature and the distal sac left open.

Adhesion formation is very uncommon with TEP repair but has been reported with large peritoneal rents. Closure of the defect may be warranted and can be performed laparoscopically with endoscopic clips or an endoscopic loop ligature.

Pain (acute postoperative or chronic) is another potential complication. Injury to the nerves during dissection is a common cause of chronic pain. Such injury can be avoided by gentle dissection in the lateral space inferior to the iliopubic tract and lateral to the spermatic vessels. Great care must be exercised in securing the mesh with tacks. Awareness of the groin anatomy will help surgeons fix the mesh without injuring critical nerves. Nerve injury is usually self-limited but may have to be treated with steroid injections or, if persistent, neurectomy.

Ischemic orchitis leading to atrophic testicle or even necrosis is a catastrophic but known complication of inguinal herniorrhaphy. The exact cause of this vascular injury is unclear, but it is thought to be secondary to venous thrombosis rather than arterial injury. Although this complication is rare, a high index of suspicion should be maintained; this, in conjunction with emergency testicular ultrasonography, may help avoid orchiectomy. Symptoms of ischemic orchitis include painful testicular swelling and fever commencing 2-3 days after surgery. [65]

A study comparing heavyweight and lightweight meshes for laparoscopic inguinal hernia repair in men found that the use of lightweight mesh for bilateral repair negatively influenced sperm motility. [66] A prospective randomized study involving 59 male patients found that at 1-year follow-up, sperm motility had declined from preoperative levels in patients receiving lightweight mesh but had increased slightly in those receiving heavyweight mesh. No differences in quality of life were noted between recipients of different types of mesh. [67]


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