Complications - Inguinal hernia repair, Shouldice

Evidence-based risk factors for complications and reoperations in inguinal hernia surgery have been defined as:

1. Age >80 years: high mortality risk with existing comorbidities; more seromas, urinary retention, and readmissions. Even at age > 60 years, more urinary retention and complications.

2. ASA III and higher: more complications and reoperations, increased mortality risk.

3. Female gender: increased risk for pain

4. Obesity: tendency towards more complications

5. COPD: more complications, increased mortality in outpatient surgery.

6. Diabetes mellitus: independent risk factor for postoperative complications

7. Anticoagulation/antiplatelet agents: 4-fold increased risk of postoperative bleeding. Even after discontinuation of anticoagulant medication, the risk of rebleeding is significantly increased.

8. Immunosuppression/corticosteroid medication: increased risk of recurrence

9. Liver cirrhosis: significant increase in complication rates

10. Nicotine abuse: significant increase in general and surgical complication risk.

11. Bilateral inguinal hernia: increased perioperative risk, therefore no prophylactic operation on a healthy side.

12. Increased complication rate in recurrent procedures and femoral hernias.

13. Preoperative pain often leads to acute and then chronic groin pain postoperatively.

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 the femoral branch of the genitofemoral nerve.

In case of nerve damage, 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 should be embedded in the abdominal muscles after infiltration with a long-acting local anesthetic to prevent scar adhesion with the mesh.

Injury of the vas deferens

If the vas deferens is injured, 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 procreation?

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 immediately sutured.

Vascular injury

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

In the case of iatrogenic venous injury and subsequent thrombosis of the femoral vein in the surgical area, it is a thrombosis of the pelvic level.

• 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 a bladder injury, the injured area must be sutured. Postoperatively, the bladder is relieved for 7-10 days by a suprapubic fistula catheter (SPFK) 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.

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 retroperitoneoscopic neurectomy of all three groin nerves.

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 previously surgically treated inguinal hernia.

Clinic and diagnostics correspond to the inguinal hernia.

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

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

Hematoma/bleeding (1.1%; 3.9% in patients with anticoagulant therapy)

• Bleeding or rebleeding in the wound area
• Clinic: tender 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 becomes tense or causes neurological symptoms, the hematoma should be surgically relieved.

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!) can be performed in individual cases. Otherwise, monitoring and discussion of findings are sufficient. In the case of recurrent seromas, repeated puncture should be avoided, and if necessary, an ultrasound-guided drainage should be inserted and consistently drained for several days.

Wound 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)

Narrowing or transection of the spermatic vessels can lead to postoperative testicular swelling due to reduced perfusion. This may result in testicular damage up to atrophy/loss of the testicle, and if necessary, open revision is required.