Abdominal Wall: Complications of Inguinal Hernia Repair
Hernia Recurrence
Definitions
- Primary Hernia – The Initial Hernia, Not Previously Repaired
- Recurrent Hernia – Hernia that Develops After it was Initially Repair
- Re-recurrent Hernia – Hernia that Develops After At Least Two Prior Repairs
- Neglected Hernia – Hernia That was Missed During Repair of Another Hernia
Rates
- Tissue Repair: 30%
- Mesh Repair: 4%
- No Difference in Type of Mesh Used
Timing vs Cause
- Early (3-6 Months) – Generally the Result of Technical Error
- Late (> 6-12 Months) – Generally from Patient Factors
Risk Factors
- Technical Factors:
- Violent Extubation
- Coughing Attack in the First Few Weeks of Repair
- Incomplete Dissection of the Myopectineal Orifice
- Incomplete Reduction of Hernia Sac
- Mesh of Insufficient Size
- Mesh Migration
- Mesh Shrinking
- Mesh Folding/“Clam-Shelling”
- Unresected Cord Lipoma Can Cause a “Pseudo-Recurrence”
- Patient Factors:
- Immunosuppression
- Smoking
- Diabetes
- Obesity
- Female – Possibly Due to Neglected Femoral Hernias
- Direct Hernia – Inherent Tissue Weakness
Most Common Site
- Open – Direct
- Laparoscopic – Indirect
Treatment
- Approach Definitions:
- Anterior – Open
- Posterior – Laparoscopic or Robotic
- Asymptomatic: Observation
- Symptomatic:
- Previous Tissue Repair – Any Approach
- Previous Mesh Repair – Through Unviolated Tissue Planes
- Prior Anterior: Posterior
- Prior Posterior: Anterior (May Consider Repeat Posterior)
- Leave New Mesh, Even if Already Have Old Mesh
- Do Not Remove Old Mesh
Other Complications
Bleeding & Infection
- Bleeding
- External Iliac Vein Injury – Dark Blood While Suturing Inferior Edge of Mesh
- Infection (1%)
- Tx: Remove Mesh
Postoperative Urinary Retention (POUR)
- Most Common Early Complication (0.4-2.2%)
- *See Surgical Principles: General Postoperative Complications
Ischemic Orchitis
- Cause: Vessel Injury & Vein Thrombosis
- Most Common Risk Factor: Extensive Dissection of a Large Distal Hernia Sac
- Most Common After Indirect Repair
- Prevention:
- Divide Large Sacs & Leave In-Situ
- Do Not Dissect Cord Past Pubic Tubercle
- Sx: Pain & Testicle Atrophy
- Tx: NSAIDs
Neuralgia/Pain
- Most Common Complication in Open Mesh-Based Repairs
- If Nerve Injury Suspected Intraoperatively: Preform Neurectomy Proximal to Injury
- Immediate Severe Pain
- Cause: Compression/Tacking of Nerves
- Most Common Nerve:
- Open – Ilioinguinal Nerve
- Laparoscopic – Lateral Femoral Cutaneous Nerve or Genitofemoral Nerve
- Tx: Return to OR
- Late/Chronic Pain (10-15%)
- Most is Self-Limiting & Resolves within 6 Months
- Primary Tx: NSAIDs
- Secondary Treatments: Consider Steroid Injections or Nerve Blocks
- Last Resort: Triple Neurectomy & Mesh Removal
- Surgery Through Unviolated Tissue Plane