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)

156


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)

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complications associated with laparoscopic rgoin hernia repair

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