Complications - Inguinal hernia repair using TEP technique with ENDOLAP 3D

Bleeding/Vascular Injury

In the event of bleeding, it is advisable to initially use suction and irrigation to maintain a clearer surgical field and to accurately identify the source of bleeding. If clips are necessary, a 5mm trocar can be replaced with a 10mm one. If visibility is poor, open conversion is required.

• No staples in the "triangle of doom" (vessels), an anatomical triangle defined by the vas deferens medially, the spermatic vessels laterally, and the peritoneal fold below.
• Bleeding from the femoral vessels leads to massive blood loss and clinical hypovolemic shock in a short time. The bleeding must be detected and the source oversewn, possibly requiring conversion and the involvement of a vascular surgeon.
• Injury to the epigastric vessels during balloon dissection, suturing of the peritoneum, or parietalization may require these vessels to be clipped.
• An iatrogenic venous injury and subsequent thrombosis of the femoral vein in the operative area constitutes a pelvic floor thrombosis.
  • Diagnosis: 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).

Pneumopneumoperitoneum

Gas insufflation of the peritoneal cavity often occurs, slightly constricting the preperitoneal working space. Generally, this does not significantly hinder further preparation. If necessary, sufficient surgical field can be ensured by venting the abdomen using an inserted Veress needle. If it is still not possible to obtain enough working space, conversion to TAPP can be easily performed.

Larger Defect of the Peritoneum

Large defects (> 1-2cm) in the peritoneum should be closed with sutures or clips to prevent the mesh from contacting intra-abdominal organs and to avoid internal hernias with possible bowel entrapment.

Irritation, Constriction, or Injury of Inguinal Nerves with Postoperative Persistent Pain

• Particularly at risk are the lateral femoral cutaneous nerve and the genitofemoral nerve in the "triangle of pain" (an inverted V, with the apex corresponding to the internal inguinal ring, the upper anterior limb formed by the iliopubic tract or inguinal ligament, and the medial posterior by the spermatic vessels).
• Significantly lower in minimally invasive procedures
• Traumatic nerve damage during preparation, suturing, or entrapment of nerves in staples during mesh fixation
• Fixation of the mesh with glue reduces the frequency of pain compared to fixation with staples.

Injury to the Ductus Deferens

If the ductus deferens is injured, the following aspects are crucial for further management: Was the ductus 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 ductus deferens may be transected if necessary. In any case, the patient must be informed postoperatively about what has happened and the implications for him.

Bladder Injury (< 1%)

Bleeding from the retropubic plexus increases the risk of bladder injury.

If the bladder is injured, the injured area must be oversewn. Postoperatively, the bladder is decompressed for 1 week using a suprapubic fistula catheter (SPFK) or Foley catheter.

Chronic postoperative pain (10-12%)

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

Risk factors for the development of chronic pain include open procedures, young patient age, small-pore meshes, mesh fixation with sutures or staples, pre-existing or poorly controlled early postoperative pain.

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

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 crucial for tissue integration and the avoidance of acute and chronic pain.

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 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 recurrent hernia

Definition: Newly developed inguinal hernia after previously surgically treated inguinal hernia.

Clinic and diagnostics correspond to the inguinal hernia. DD pseudo-recurrence: Certain protrusion of the mesh through a large defect without an actual 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 meshes are integrated, they seem to maintain their stability over time. In late recurrences, the distinction between complication and natural course is fluid. Recurrences after more than 5 years likely represent the natural course in the inguinal region.

Therapy: In recurrence surgeries, the same access route should not be chosen. Surgical treatment with anterior procedure (Lichtenstein).

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

• Hb drop, low blood pressure, larger bloody drainage volumes, visible hematomas
• Diagnostics: Ultrasound and exclusion of systemic causes (e.g., coagulation disorders)
• Depending on size, resorption can be awaited, otherwise early minimally invasive revision, aspiration of the hematoma, and possibly hemostasis.

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 on a case-by-case basis. Otherwise, monitoring and discussion of findings are sufficient. In recurrent seromas, multiple punctures should be avoided; instead, an ultrasound-guided drainage should be inserted and consistently drained for several days.

Tip: Since the defect is only covered and not closed in the true sense, a seroma/hematoma can appear like a recurrence to the inexperienced. An ultrasound examination helps distinguish the recurrence from the fluid collection!

Wound infection/Mesh infection (<1%)

Opening and spreading of the wound, extensive cleaning, and subsequent open wound treatment, systemic antibiotic therapy. Worst-case scenario mesh explantation.

Postoperative bladder leakage:

Small bladder injuries occasionally occur. This results in an unusually large, clear secretion volume over the placed drainage or a correspondingly large seroma. Determination of urea and creatinine in the secretion helps confirm the diagnosis. A bladder fistula can almost always be adequately treated by placing an indwelling catheter, which is then left in place for about 1 week.

Disorders 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 may result in damage to the testicle up to atrophy/loss of the testicle, and open revision may be necessary.

Unnoticed bowel lesion

• Clinic: Patient does not recover from surgery, abdominal pain, nausea, guarding, signs of peritonitis.

Therapy: Reoperation with detection of the bowel lesion and suturing, possibly resection and abdominal lavage, antibiotic treatment.

Postoperative ileus

Internal hernia due to a larger peritoneal defect.

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

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 for 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 surgery on a healthy side.

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

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