Complications - Inguinal hernia repair, Lichtenstein

Irritation, constriction, or injury of inguinal nerves with postoperatively persistent pain

The inguinal nerves should be preserved as much as possible.

During preparation and suturing at the inguinal ligament, there may be injury or transection of the nerves. Particularly at risk are:

• Lateral femoral cutaneous nerve, 
• Ilioinguinal nerve, 
• Iliohypogastric nerve, 
• Genital branch and femoral branch of the genitofemoral nerve.

In case of nerve damage or obstruction of the mesh repair, neurectomy is preferred in case of doubt. Nerve mobilization for preservation represents a highly significant risk factor for chronic pain. Nerves damaged by the operation and dislodged from their natural embedding should be removed by proximal neurectomy. The nerve stump is infiltrated with a long-acting local anesthetic and embedded in the abdominal muscles to prevent scar adhesion with the mesh.

Injury to the vas deferens

If there is an injury to the vas deferens, the following aspects are crucial for further action: Was the vas deferens completely or only partially transected? How old is the patient? Does the patient have a desire for fertility?

In sexually inactive older patients, the vas deferens may be transected if necessary. In any case, the patient must be informed postoperatively about what happened and the implications for him.

Bowel injury

An intraoperative iatrogenic bowel lesion should be sutured immediately.

Vascular injury

Bleeding during suturing at the inguinal ligament (beware of the femoral vein). Locate the source of bleeding, possibly suture the femoral vein, and consider consulting a vascular surgery colleague.

In the case of iatrogenic venous injury with subsequent thrombosis of the femoral vein in the operative area, it is a thrombosis of the pelvic floor.

• Diagnostics: Duplex and Doppler sonography or phlebography
• Treatment of deep vein thrombosis: Compression, mobilization, full heparinization (beware of the risk of rebleeding!).
• For further information, please follow the link to the current guideline: Prophylaxis of venous thromboembolism (VTE).

Bladder injury

In the event of bladder injury, the injured area must be sutured. Postoperatively, the bladder is decompressed for 7-10 days using a suprapubic fistula catheter (SPFC) or indwelling catheter.

Chronic postoperative pain (10-12%)

Definition: Chronic postoperative pain was defined as pain persisting for more than three months despite optimal conservative therapy by the "International Association for the Study of Pain" in 1986.

The extent of preoperative and early postoperative pain is the decisive risk factor for postoperative pain. Open inguinal hernia surgery leads significantly more often to chronic pain than laparoscopic/endoscopic repair.

In the Lichtenstein operation, chronic pain is the most common complication. Nerve damage due to injury or contact with alloplastic material are possible triggers. Scar formation with mesh shrinkage are further potential causes.

According to international guidelines, large-pore meshes made of monofilament non-resorbable plastic (polypropylene, polyvinylidene fluoride, or polyester) are recommended today. The pore size seems to be crucial for tissue integration and the avoidance of acute and chronic pain.

Indicators for a high risk of chronic postoperative pain after inguinal hernia surgery:

• young age,
• preoperative pain,
• open procedure.

Therapy: Blockade of the ilioinguinal and iliohypogastric nerves by infiltration with a long-acting local anesthetic 1-2 cm above and medial to the anterior superior iliac spine. The worst-case scenario is the retroperitoneoscopic neurectomy of all three inguinal nerves.

Mesh removal is always associated with a hernia recurrence and is therefore the last resort.

Recurrence (1-10%)

Risk factors:

• female gender
• direct hernia
• sliding hernia in men
• nicotine abuse
• presence of a recurrent hernia

Definition: newly developed inguinal hernia after previous surgically treated inguinal hernia. It can also be a femoral hernia overlooked during surgery.

Clinic and diagnostics correspond to the inguinal hernia.

In the absence of symptoms, only a relative indication for surgery.

Tendency for higher recurrence rates with TEP and TAPP compared to the Lichtenstein procedure.

In mesh-based surgical techniques, recurrences tend to occur at an early postoperative stage, once ingrown meshes seem to maintain their stability over time. In later recurrences, the distinction between complication and natural course is fluid. Recurrences after more than 5 years probably represent the natural course in the inguinal region.

Therapy: In reoperations, the same access route should not be chosen. Surgical repair with posterior approach (TAPP or TEP).

Hematoma/bleeding (requiring revision 1.1%; 3.9% in patients with anticoagulants)

• Bleeding or rebleeding in the wound area
• Clinic: pressure-sensitive and discolored swelling
• Diagnostics: sonography and exclusion of systemic causes (e.g., coagulation disorders)
• Therapy: Smaller hematomas should be observed and usually do not require further therapy.
• Larger hematomas should be punctured or evacuated. Severe rebleeding must be surgically revised.
• If the skin is under tension or causes neurological symptoms, the hematoma should be surgically removed.

Seroma

• Small postoperative seromas are absorbed by the tissue and only require monitoring. If the size of the seroma leads to clinical symptoms, puncture (absolutely sterile!) may be performed in individual cases. Otherwise, monitoring and discussion of findings are sufficient. In recurrent seromas, multiple punctures should be avoided, and if necessary, a sonographically controlled drainage should be inserted and consistently drained for several days.

Wound infection/mesh infection (< 1%)

Opening and spreading of the wound, extensive cleaning, and subsequent open wound treatment, systemic antibiotic therapy.

Disturbances of testicular perfusion/ischemic orchitis/testicular atrophy (very rare)

Constriction or transection of the spermatic vessels can lead to postoperative testicular swelling due to reduced perfusion. This can result in damage to the testis up to atrophy/loss of the testis, and if necessary, open revision must be performed.

Unnoticed bowel injury

• Clinic: Patient does not recover from surgery, abdominal pain, nausea, guarding, signs of peritonitis.
• Therapy: Reoperation with detection of bowel injury and suturing, if necessary, resection and abdominal lavage and antibiotic treatment for at least 1 week.