Complications associated with laparoscopic rgoin hernia repair

Complications associated with laparoscopic
groin hernia repair
Both open and laparoscopic hernia repairs can lead to
recurrence or complications. A new list. Of complication has
developed as different types of laparoscopic hernial repairs are
advocated. As with any new or evolving techniques, there is a
learning curve. Intra-operative complication rates of 0-3.6% and total
Complication rates of 5-13.6% are reported. Many potential intra-
operative complications are related to the laparoscopic approach.
Others are unique to the type of hernia repair. (Schultzet al, 1995)
I. Intraoperative complications:
A. General complications related to laparoscopic technique:
 complications related to needle and trocar insertion:
Insertion of the Veress needle or laparoscopic trocar and
cannula into the peritoneal cavity may result in injury to the intestine,
bladder, or major retro-peritoneal vessels. Injuries related to insertion
of a cannula are due to the sharp trocar that is used to penetrate the
abdominal wall, allowing for the introduction of the cannula into the
peritoneal cavity. The reported incidence of visceral injury from
insertion of the Veress needle or trocar varies from 0.05% to 0.2%.
Penetrating injuries are more likely to occur during placement of the
insufflation needle or with insertion of the initial cannula because
these are placed without the benefit of visual guidance. Insertion of
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Complications of Laparoscopic Groin Hernia Repair

other cannulas should be associated, with a much lower risk of injury,
as these are placed under laparoscopic guidance. In a recent report of
274 insufflation needle and trocar injuries, 109 were due to the
pneumo-peritoneum needle, 104 were due to the primary trocar, and
61 were due to the accessory trocar. (Fitzgibbons and Filipi, 2002)
Injury to the major retroperitoneal vessels is the most serious
complication of needle or trocar insertion. Serious vascular injury
may result from insertion of either the Veress needle or the trocar
during insertion of cannula. In a report of 31 major vascular injures,
20 were related to insertion of the Veress needle and 11 occurred
during trocar insertion. (Fitzgibbons and Filipi, 2002)
Early recognition that a vascular injury has occurred is
essential because a delay in the diagnosis is a major contributor to
postoperative morbidity and mortality. A vascular injury related to
the Veress needle is usually apparent by the saline injection-
aspiration test. Aspiration of blood through the Veress needle
indicates that it has entered a vascular structure. Injury to a major
retro-peritoneal vessel produced by a large diameter trocar and
cannula is usually associated with obvious signs of acute
Hemorrhage. Occasionally, bleeding from a vascular injury may be
temporally contained within the retro-peritoneal space, leading to a
delay in this diagnosis. The patient may then develop hemodynamic
instability during the early postoperative period. (Fitzgibbons and
Filipi, 2002)
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Immediate exploration is required for a vascular injury related
to insertion of a cannula. The trocar and cannula should be left in
place while the abdomen is opened to aid in identification of the site
of injury and to tamponade the injured vessel. Repair is accomplished
using standard vascular surgery techniques. In contrast, if the Veress
needle enters a vessel, the laparoscopic procedure may continue
provided there is no evidence of hemodynamic instability. After
insertion of the laparoscope into the peritoneal cavity, an attempt
should be made to identify the entry site of the needle, and to exclude
the presence of a retro-peritoneal hematoma. Indications for
immediate exploration include hemodynamic instability, an
expanding retroperitoneal hematoma, or active intra-abdominal
hemorrhage. Following completion of the laparoscopic procedure, the
patient should be closely monitored for evidence of continuing blood
loss or hemodynamic instability in an intensive care unit setting.
(Fitzgibbons and Filipi, 2002)
Blood vessels within the abdominal wall may also be injured
during insertion of the Veress needle or cannula. The trocar injury
typically occurs during placement of an accessory cannula and
usually involves the superior and inferior epigastric vessels. Injury to
these vessels is usually evident at the time of a laparoscopic
procedure by the appearance of blood dripping into the peritoneal
cavity along the cannula. The injured vessel may often be coagulated
or ligated from within the peritoneal cavity. Persistent bleeding may
be controlled by direct suture ligation through a small cut down over
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the cannula site or by placement of through and through suture on
either side of the cannula. Occasionally, the injury may not be
apparent at the time of Laparoscopy, resulting in the formation of an
abdominal wall or rectus sheath hematoma. Most abdominal wall
hematomas are small and require no specific treatment. Evidence of
continued bleeding or expansion of the hematoma is an indication for
wound exploration and ligation of the injured vessel. Injury to the
abdominal wall blood vessels may be avoided by trans-illumination
of the abdominal wall to identify the location of the epigastric vessels
before insertion of accessory cannula. At the completion of the
laparoscopic procedure, all cannula sites should be visualized from
within the peritoneal cavity to exclude the presence of active
bleeding. (Fitzgibbons and Filipi, 2002)
Intestinal injuries related to insertion of the Veress needle or
trocars are reported to occur in approximately one per 1000
laparoscopic procedures performed. These injuries are often
unrecognized at the time of the laparoscopic procedure, leading to the
development of sepsis and peritonitis in the postoperative period.
Several deaths have resulted from delayed recognition of bowel
injuries following laparoscopic cholecystectomy. In the national
survey of laparoscopic cholecystectomies reported by Deziel and
associates, intestinal injury was a major cause of postoperative
deaths. Factors that increase the risk of penetrating intestinal injury
include previous abdominal operations, history of pancreatitis, and
bowel distension. (Fitzgibbons and Filipi, 2002)
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Perforation of the intestine by the Veress needle is usually
apparent by aspiration of enteric fluid during the saline injection-
aspiration test. If intestinal perforation due to the Veress needle is
suspected it should be removed and a new insufflation needle
reinserted. If underlying adhesions are suspected, an alternate site
for insertion should be selected. During the laparoscopic procedure,
an attempt should be made to visualize the site of the perforation
to assess the severity of the injury. In most instances, the needle
perforation has sealed, and no further therapy is required.
Occasionally, the Veress needle may result in a full thickness
laceration of the bowel wall, particularly if the needle is moved
side to side after it is inserted into the peritoneal cavity. Full
thickness laceration injuries should be managed by primary suture
repair.
Intestinal perforation with a trocar usually results in a
transmural intestinal injury and requires immediate laparotomy and
repair. The trocar should be left in place while the abdomen is opened
to minimize peritoneal contamination and to aid in identification of
the injured segment of the bowel. Occasionally, the injury may be
repaired during the laparoscopic procedure but this requires
considerable experience and skill with laparoscopic suture
techniques. (Fitzgibbons and Filipi, 2002)
Bladder perforation due to Veress needle or trocar insertion is
a rare complication of laparoscopy. These injuries usually occur as a
result of failure to decompress the bladder before insertion of the
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needle and trocar. Distortion of the normal anatomic relationships by
previous pelvic operations or congenital malformations may also
predispose to bladder injury. A bladder perforation due to the Veress
needle is usually discovered by aspiration of urine during the saline
injection test. The appearance of blood or gas in the urine also
indicates a bladder perforation: Occasionally, the bladder perforation
may be discovered when the bladder mucosa is visualized through
the laparoscope. Bladder perforation due to the Veress needle is
managed by post-operative catheter drainage. Bladder injury created
by a 5 or 10 mm tracer generally requires suture repair and
postoperative catheter drainage. (Fitzgibbons and Filipi, 2002)
The majority of needle and trocar injuries are avoidable by
strict adherence to the principles of laparoscopy. The bladder and
stomach should be decompressed with the use of a Foley catheter and
a nasogastric tube to reduce the risk of penetrating injury to these
structures. The patient should be placed in a reverse Trendelenburg
position to displace the stomach and transverse colon a way from the
umbilicus. The Veress insufflation needle is specially designed to
reduce the risk of visceral injury during its insertion. (Fitzgibbons
and Filipi, 2002)
The development of a hernia at the cannula insertion site is an
unusual complication of laparoscopy occurring in approximately 0.1
% to 0.3% of cases. Factors predisposing to the development of a
hernia include the use of a large diameter cannula and the presence of
a post operative wound infection. Fascial defects created by trocars
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10 mm or larger should be closed whenever possible to prevent
hernia formation. In general, fascial defects created by a 5.5 mm
cannula do not require closure. (Fitzgibbons and Filipi, 2002)
 complications related to pneumoperitoneum:
Creation of an adequate pneumo-peritoneum is essential for
visualization of the intra-abdominal organs and performance of
laparoscopic procedure. Insufflation of gas into the peritoneal cavity
to create the pneumo-peritoneum produces a variety of alterations in
cardiovascular and pulmonary functions. Although these alterations
are generally well tolerated by most individuals they may produce
significant adverse effects in elderly patients or patients with
preexisting cardiopulmonary disease. (Fitzgibbons and Filipi, 2002)
During the laparoscopic procedure, carbon dioxide, which is
the preferred insufflation gas for creation of pneumo-peritoneum, is
rapidly absorbed into the systemic circulation from the peritoneal
cavity. This rapid absorption may result in an increase in the arterial
PaC02 and a concomitant decrease in arterial pH. These changes in
the arterial PaC02 and pH may lead to the development of ventricular
dysrythmias. Frequent or continuous monitoring of carbon dioxide
homeostasis is particularly important in patients with preexisting
chronic lung disease or cardiac disease. Patients with sickle cell
disease also require careful monitoring and maintenance of the
arterial PaC02 and pH within the normal range to avoid precipitation
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of a sickle crisis. Because most laparoscopic procedures are
performed under general anesthesia, a normal PaC02 may be
effectively maintained with controlled mechanical ventilation in the
majority of patients.
Carbon dioxide embolisation is a rare but potentially fatal
complication of laparoscopy. Carbon dioxide may enter the
circulatory system by inadvertent insufflation of the gas directly into
a vessel or indirectly through open venous channels. Because carbon
dioxide is rapidly absorbed from the blood, small amounts may be
injected intra-vascular without producing significant adverse effects.
If large amount of carbon dioxide enters the venous circulation, a
clinically significant gas embolism may occur. The embolus may
lodge in the right atrium or ventricle to from a gas lock. This gas lock
may impair venous return and obstruct right ventricular outflow,
resulting in (Fitzgibbons and Filipi, 2002)
Sudden cardio-vascular collapse. Alternatively, the embolus
may disperse and enter the pulmonary circulation, resulting in acute
pulmonary hypertension and right heart failure. The presenting signs
of gas embolus include hypotension, jugular venous distension, and
tachycardia. Other findings may include hypoxemia, cyanosis and a
rapid but transient increase in end-tidal carbon dioxide. The latter
may be one of the earliest clues to the diagnosis of a gas embolism.
The treatment of a gas embolism consists of immediate cessation of
carbon dioxide insufflation, and release of the pneumo-peritoneum.
The patient should be placed in Trendelenburg position and left
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lateral decubitus position to prevent the embolus from entering the
right ventricular outflow tract. Hyperventilation should be instituted
to increase carbon dioxide excretion. Finally, a central venous
catheter should be inserted to aspirate the carbon dioxide.
Insufflations of carbon dioxide into areas other than the
peritoneal cavity may lead to the development of subcutaneous
emphysema or pre-peritoneal insufflation. Subcutaneous emphysema
occurs when carbon dioxide is insufflated through the Veress needle
that is positioned anterior to the rectus fascia. This is usually
immediately recognized by the high insufflation pressure and the
appearance of subcutaneous crepitus. If subcutaneous emphysema
occurs, the needle should be withdrawn and correctly repositioned
within the peritoneal cavity. Pre-peritoneal insufflation occurs when
the needle is placed below the rectus fascia but anterior to the parietal
peritoneum. The insufflation of carbon dioxide may appear to
proceed normally with low insufflation pressures, asymmetrical
abdominal distension, and the loss of liver dullness. Pre-peritoneal
insufflation is usually discovered when the laparoscope is introduced
into the gas-filled pre-peritoneal space to reveal an intact peritoneum
overlying the intra-abdominal viscera. If pre-peritoneal insufflation
occurs, the peritoneum should be carefully incised and the
laparoscope placed through the opening in the peritoneum. The
carbon dioxide within the pre-peritoneal space is then evacuated.
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Total lung compliance and functional residual capacity may be
reduced during the laparoscopic procedure owing to the cephalic
displacement of the diaphragm by the increased intra-abdominal
pressure. Compression of the lung bases by the elevated diaphragm
may also compromise respiratory function by creating areas of
ventilation perfusion inequality. These alterations in pulmonary
function may be further exacerbated by placing the patient in the
Trendelenburg position for performance of pelvic and lower
abdominal procedures. The use of positive pressure ventilation
overcomes many of the adverse respiratory effects produced by the
increased intra-abdorninal pressure. In addition, maintenance of the
intra-abdominal pressure below 14 mmHg further reduces the
pneumo-peritoneum related ventilator abnormalities. (Fitzgibbons
and Filipi, 2002)
A number of cardiovascular changes occur during laparoscopy.
A decrease in the central venous return and cardiac output may
occur with intra-abdominal pressure above 20 mmHg. By contrast,
maintenance of intra-abdominal pressure below 20 mmHg may
actually increase venous return. Also deep venous thrombosis and
pulmonary embolism are reported following laparoscopic procedures
but with low incidence and this due to the potential for lower
extremity venous stasis due to the reverse trendelenburg position and
increased intra-abdominal pressure. (Fitzgibbons and Filipi, 2002)
Cardiac dysrythmias are a common complication of
laparoscopy. In one study cardiac arrhythmia occurred in 17% of
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patients when carbon dioxide was used to produce the pneumo-
peritoneum. The majority of dysrythmias are ventricular extra-
systoles. Respiratory acidosis and the resultant sympathetic
stimulation may be an etiologic factor in many of these dysrythmias.
Vagal stimulation from peritoneal distension during insufflation of
CO2 may result in bradycardia or a systole. (Fitzgibbons and Filipi,
2002)
 complications related to laparoscopic instrumentation:
There are a number of potential complications related to the use
of the laparoscope, laparoscopic instrument and electrocautery or
laser.
The xenon light source produces considerable heat at the end of
the endoscope. Prolonged contact between the end of the endoscope
and visceral structures may result in thermal injury and should
therefore be avoided. Injuries to intra-abdominal structures may
occur during insertion and manipulation of laparoscopic instruments
in the peritoneal cavity. To minimize the risk, all instruments should
be introduced into the peritoneal cavity under direct laparoscopic
guidance. (Fitzgibbons and Filipi, 2002)
There are a number of reported cases of thermal bowel injures
and subsequent deaths related to the use of monopolar electrocautery
during laparoscopy. A major concern with the use of monopolar
cautery is the potential for thermal bowel injury to occur without
direct contact between the cautery probe and bowel wall.
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Electrocautery intestinal injuries may also occur if the cautery-probe
tip or poorly insulated shaft inadvertently comes into direct contact
with the bowel wall. These injuries may be more frequent with
insulated (Fiberglass) cannulas than with reusable metallic cannulas.
To reduce the risk of visceral injury from monopolar electrocautery,
the current should be at the lowest possible setting. Cautery probes
and other electrosurgical instruments should be inspected to ensure
that the insulation along the shaft is intact. When the cautery probe is
within the peritoneal cavity, the tip should be kept within clear view
of the video image at all times. The electrocautery unit should be
activated only when the tip of the cautery probe is in direct contact
with the desired tissue. Finally, care should be taken to avoid contact
between the cautery probe tip and shaft and adjacent bowel.
 Difficulties:
There are a number of technical factor limitations inherent to
laparoscopic surgery that may increase the risk of these procedures-
specific complications, particularly during the early phases of the.
Learning experience. Such factors include lack of three-dimensional,
depth perception, limited view of operative field, and indirect contact
with the tissues during dissection, and inability of the surgeon to
control the view of operative field. (Crist, and Gadacz, 1993)
B. Complications related to laparoscopic groin hernia repair:
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Bleeding during the dissection can obscure the anatomy.
Careful technique and meticulous hemostasis are of cardinal
importance. Previous surgery can cause difficulty with the
dissection. The most common vascular injuries during laparoscopic
herniorrhaphy are to the inferior epigastric and spermatic vessels.
External iliac, circumflex iliac and obturator vessels are also within
the field of laparoscopic dissection. Control and repair can be
difficult and may require urgent conversion to an open procedure.
(Schultz et al, 1995)
Intestinal injuries can occur when reducing incarcerated bowel.
These must be identified and repaired. Ischemic intestine should be
inspected carefully. If there is any doubt about viability, it should be
resected. (Schultz et al, 1995)
Bladder, cord, or Vas deferens injuries usually occur when
dissecting a large sac. It is crucial to carefully identify the anatomy
and separate the layers meticulously. With laparoscopic hernia repair,
intentional-division of the cord is not necessary to fashion a good
repair, as is often recommended for recurrent hernias repaired
anteriorly. (Schultz et al, 1995)
II. Postoperative Complications :
A. Local complications :
Postoperative complications are more common than intra-
operative complications. The rate of postoperative complications is 5-
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12.4%. This includes both minor and major complications: (Schultz
et al, 1995)
Most post operative complications are of a local nature. These
include: trocar site, inguinal canal, and scrotal hematomas or
seromas, subcutaneous emphysema, wound infection, trocar site
hernia, hydrocele, and groin pain. They occur least commonly with
simple ring closure, and most commonly with the total extra-
peritoneal mesh repair. Seromas or hematomas occasionally need to
be aspirated. Large direct sacs can be inverted and anchored to
cooper's ligament. Large indirect hernia sacs may require a temporary
drain. Subcutaneous emphysema is common but not of great clinical
significance because it subsides quickly on its own. Because
laparoscopic repairs do not cut through muscles and fascia nor
require forceful retraction, post-operative pain should be less severe.
(Shultz et al 2005)
Wound infection of the cannula insertion site is also an unusual
complication following laparoscopy. The reported incidence of this
complication is approximately 0.1% following diagnostic
laparoscopic procedures, 0.25% to 1% following laparoscopic
cholecystectomy. Wound infections usually occur at the umbilical
cannula site and are often related to wound contamination during
removal of the gall bladder or appendix. Most wound infections are
superficial and respond well to antibiotics and local wound care.
(Fitzglbbons and Filipi, 2002)
B. Neurological complications:
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Nerves are not usually seen during laparoscopic herniorrhaphy.
They may be injured during dissection or fixation of the mesh with
sutures or staples. The most common injuries are to the femoral
branch of the genitofemoral nerve, and the lateral femoral cutaneous
nerve. Ilioinguinal nerve injuries can occur from pushing too hard on
the abdominal wall when applying staples. The rates vary by
technique; intra-peritoneal onlay 0.5-4.6%, trans-abdominal pre-
peritoneal 1.2-2.2%, and total extra-peritoneal mesh repair 0-0.6%.
Symptoms of nerve injury include numbness and a burning
pain. Initial treatment is non-steroidal anti-inflammatory agents and
observation. Nerve irritation usually resolves within 2-4 weeks after
surgery. If the complaints persist, removal of staples or sutures may
be required. (Fitzgibbons and Filipi, 2002)
C. Testicular complications:
The most common testicular complication is pain, which is
usually transient lasting 1 -3 weeks. It may be due to trauma to the
genitofemoral nerve or sympathetic plexus to the testes. These nerves
can be damaged by dissecting a sac from the cord structures. The pre-
peritoneal approach to laparoscopic hernia avoids much of this
dissection and minimizes the risk of swelling, orchitis, epididymitis,
or atrophy compared to the open herniorrhaphy. Testicular pain is
present in 0-2% of patients, and the total testicular complication rate
is 0.3-5%. (Schultz et al, 1995)
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Both open and laparoscopic groin hernia repair have the
potential male infertility problem. Classically this is blamed on
testicular artery injury or manipulation of the vas deferens. Careful
dissection near the vas deferens and cord structures is very important.
Studies have shown that even unilateral injuries can result in
azospermia and high levels of antibodies to spermatozoa. Placement
of prosthesis raises the question of whether chronic (partial)
obstruction or immunologic interference could result. Both
techniques also can cause testicular pain, hematoma or seroma,
epididymitis, and atrophy. (Schultzet al, 1995)
• Ischemic orchitis:
There is a much lower rate of ischemic orchitis following
laparoscopic hernioplasty (0.07%) when compared with anterior
reconstruction methods (0.5-5%) (Skamtalakis et al, 1996). The
preperitonal dissection allows easy identification of the testicular
vessels and avoids injury of the collateral circulation. Progression to
testicular atrophy occurs in 20% of patients who develop ischemic
orchitis following a primary hernia repair and more than 70%
following repair of recurrence. The complication is prevented by
minimizing dissection of the spermatic cord, leaving the distal
segment of an indirect sac in situ and avoiding concurrent operations
upon the testicle during the hernioplasty. (Fong and Wantz, 1992)
The clinical manifestations of ischemic orchitis develops
insidiously, become apparent 2 to 5 days after the hernioplasty, and
are frequently misinterpreted initially, the testicle and spermatic cord
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become swollen, hard, tender, painful and retracted. The process lasts
6 to 12 weeks and may resolve completely or end in testicular
atrophy. The return of the testicle to normal size and shape does not
mean that the process is complete, and atrophy of the testicle may not
become apparent for as long as a year. The etiology of ischemic
orchitis is thrombosis of the spermatic cord, and the testicular
pathology is intense venous congestion. The thrombosis is induced
by surgical trauma in the cord especially that associated with the
dissection to completely remove a large indirect hernial sac.
Dissection of a scrotal indirect hernial sac damages the delicate veins
of the pampiniform plexus, initiates the thrombosis, and
coincidentally disrupts collateral circulation. (Wantz, 1999)
D. Urinary complications:
Urinary tract complications include retention, infection, and
hematuria. They are usually related to urinary catheter trauma,
dissection, general anesthesia, or large volume of intravenous fluids
during the operation. Retention is the most common, but does not
occur appreciably more often than with open repair. The general
anesthesia effect is possibly offset by less postoperative pain and
reflex spasm. The rate of urinary complications after all laparoscopic
technique is 1.5-3.7%. With pre-peritoneal techniques it is 2-5%.
Using routine bladder catheterization will decrease the complication
rate. (Fitzgibbons and Filipi, 2002)
E. Mesh complications:
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Implanting a foreign body (prosthesis) raises concern about
many potential complications. This needs to be weighed against the
advantages of tension free repair and possible lower recurrence rate.
Palpable mesh, migration of mesh, infection, adhesions or erosion
into bowel all are possibilities. With the plug and patch technique
complication rates were reported at 4.5-7.3% compared to large mesh
without a plug at 0-0.3%, so the plug has largely been abandoned.
Mesh fixation may prevent migration but can cause
neurovascular complications. Non-fixation of the mesh has been
introduced, depending on the intra-peritoneal pressure which will
sandwich the mesh between the abdominal wall and the peritoneum
to hold it in place. (Schultz at al, 1995)
Prosthetic infection is uncommon with reported rates of 0-
0.6%. Monofilament biomaterials have a theoretical advantage.
Intravenous antibiotics or antibiotic irrigation have been used but
unproven. The total extra-peritoneal mesh repair should cause fewer
adhesions by minimizing dissection and disruption of the peritoneal
surface. It is important to stay extra-peritoneal during the dissection
required, which allows for the large mesh insertion to cover all hernia
orifices. The pre-peritoneal dissection balloon is not used since it
only does the easy part and adds expense. (Schultz et al, 1995)
Open or laparoscopic placement of prosthesis seems to give a
higher rate of seroma. Fortunately a chronic hydrocele is uncommon.
Hematomas cause more concern about development of infection
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when there is prosthesis. An infected prosthesis may require removal.
However, if the infection can be eradicated with antibiotics, re-
operation for recurrence may be less likely than with pure tissue
repairs. (Schultz et al, 1995)
Miscellaneous complications:
Small bowel obstruction from adhesions can be related to
sutures, staples, or gaps in peritoneal closure. Although we think of
staples as being inert, they can cause bowel problems by simple
mechanical erosion or adhesion. The trans-abdominal pre-peritoneal
approach requires careful peritoneal closure since staples themselves
or gaps can lead to adhesions. Richter's hernias can occur at trocar
sites. All trocars sites larger than 10 mm should be closed.
Osteitis pubis can occur with open or laparoscopic repairs.
Placement of sutures or staples near the pubic tubercle should be
avoided. Sutureless herinorrhaphy (with large mesh) also avoids this
complication. (Fitzgibbons and Filipi, 2002)
• Recurrence Rates:
Early reports showed recurrence rates of 6% for trans-
peritoneal suture repair and 22% for plug and patch. Recurrence is
less common with the large mesh methods. Rates of 2.2-3.2% for
intra-peritoneal onlay, 0.7-0.8% for trans-abdominal pre-peritoneal,
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and 0.1-0.4% for extra-peritoneal repairs were reported. This
compares to 0.1% reported for Lichtenstein tension-free repair. These
recurrence rates don't depend on the patient's tissue integrity.
Recurrences have been due to technical factors. The most common is
an undersized mesh. Staple misplacement or disruption, poorly
placed mesh, rolling of mesh, and missed hernias are other reasons
for recurrence. (Davis and Arregui, 2003)
In Fitzgibbons study, the recurrences were lowest with total
extra-peritoneal repair. Trans-peritoneal suture repair and plug and
patch techniques have been unsatisfactory and largely abandoned.
Although the extra-peritoneal mesh repair has a higher complication
rate, it has the lowest recurrence rate (0-0.4%). Most of the
complications are minor and the potential for adhesions is reduced.
However, it is more difficult to perform. (Fitzgibbons and Filipi,
2002)
The mechanisms of recurrence are summarized in the following
Table. They are almost all technical problems. As techniques have
evolved and improved, recurrence rates have fallen. Likewise, as the
surgeon has improved, so have his results. (Davis and Arregui,
2003)
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157

158
Table (3): Causes of recurrence after laparoscopic inguinal
hernia repair.

Management of acceptable complications:
♦ Closing the peritoneal defects in TEP repair:
Peritoneal defects generated during a TEP repair must be
repaired. These defects can generate delayed small bowel
obstructions and other significant complications. For these reasons
they need to be clearly identified and immediately repaired.
These defects can be repaired using SURGICON 5mm Clips,
an ENDOLOOP or a 5 mm USSC ENDOCLIP. The edges of the
defects are approximated with one grasper and clipped closed with
clip applier. This repair is safe and has been proven to hold well.
If the operator is not certain all defects have been appropriately
closed, a completion laparoscopy can be easily performed at the end
of the TEP repair. (QuILici et al, 2000)
♦ Injuries to the Epigastric Vessels:
The epigastric vessels are dangerous vascular structures. The
laparoscopic surgeon should at all time know their location. All
bleeding complications with or without re-exploration have been
secondary to an intra-operative injury to the Epigastric vessels.
For these reasons, rigid operative guidelines were applied with
which one should always comply. They are as follows:
1. Whenever feasible, always insert the lateral trocars using
trans-illumination.
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2. Always locate the Epigastric vessels before making the
peritoneal incision.
3. Always know the position of the Epigastric vessels during
the entire hernia repair.
4. When anchoring the Mesh, always staple or place tacks on
each side of the Epigastric vessels.
5. When closing the peritoneum (TAPP Repairs), always staple
or place tacks on each side of the epigastric vessels.
6. When an injury to the Epigastric vein or artery is
suspected, ligation of the epigastric vessels should be performed.
7. During a TEP repair, if the dilating balloon has migrated the
Epigastric vessels inferiorly (on the inferior aspect of the repair or the
peritoneum), they should be ligated and cut immediately.
8. If a patient, become hypotensivc or tachycardic during his
immediate recovery, always suspect an Epigastric vessels injury.
(Quilici et al, 2000)
Immediate Post-operative Bleeding:
Immediate, minimal post-operative bleeding (without
hypotension or tachycardia) should prompt the surgeon to admit the
patient to the surgical service. A stable hematoma restricted to the
inguinal region and scrotum does not require re-exploration. Serial
CBC and observation should be obtained.
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Immediate, severe post-operative bleeding (with hypotension
and/or tachycardia) requires an aggressive management. The patient
will be immediately transferred to a monitored unit. Serial (every 3
hours) CBC will be ordered as well as a Type and Hold for 4 Packed
Red Blood Units. If the hypotension does not respond to intra-
venous fluid, reexploration should be done. An injury to the
Epigastric vessels is almost always the etiology. If the hemodynamic
indices of the patient respond to intravenous fluid hydration,
observation is warranted with transfusion if the Hemoglabin level
drops below 8mg/ml. continuously dropping hemoglobin level will
require re-exploration. (Quilici et al, 2000)
Hernias without a peritoneal Sac:
The classical concept that all inguinal hernias must be
accompanied with a hernia sac has been questioned since the
introduction of the laparoscopic inguinal hernia repair. In a series of
2300 laparoscopic inguinal hernia repairs, eleven patients undergoing
a TAPP repairs, where found to have a direct inguinal hernia without
a peritoneal sac. All observed defects should be repaired. (Quilici et
al, 2000)
♦ Post-operative Neuropathies
Injuries to the neural structure in the inguino-femoral area are
reported to happen during a laparoscopic repair. Some authors claim
that using a Mesh without any means of fixation (tacks) eliminates
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this complication. However, there are no long term studies available
with this technical variation.
However, in a latest analysis of 2500 repairs, the occurrence of
permanent, post-operative neuralgia was negligible even when
placing tacks lateral to the spermatic cord or inguinal rings.
Temporary, short term neuropathy do commonly occur, but do not
impair the recovery of the patient but subside within a few days.
(QuiUci et at, 2000)
162

Complications associated with laparoscopic rgoin hernia repair

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