Complications
Seroma is a collection of serous fluid in the operative field due to transudate from raw tissue surfaces. Usually occurs within 1 week. The fluid is usually reabsorbed over time. Routine drainage of seroma should not be performed as it may introduce infection. Seroma is common after all types of repair.
Reported incidence rate varies depending on the surgical procedure, but in clinical trials it has been reported to occur in up to 12% of patients following laparoscopic repair, and around 8% following open repair.[119][120]
Usually presents within 1 week of operation. Occurs most often in patients on chronic anticoagulation, in particular those requiring enoxaparin bridging while off warfarin.
Reported to occur in 5.6% to 16% of patients following open repair, and in 4.2% to 13.1% following laparoscopic repair.[2]
Usually resolves spontaneously, but a very large hematoma can sometimes begin to drain spontaneously through the incision and require evacuation of clot and discontinuation of anticoagulant therapy.
Usually presents within 1 week of surgery. It is more common after surgery for recurrent hernia. Reabsorbs slowly over time in most cases. Rarely requires evacuation.
Is uncommon (<1%) and usually occurs within 2 weeks when it does occur.[72] Infection is usually superficial and responds to local wound drainage and antibiotics, but may lead to infection of mesh prosthesis (if one is present).
A rare complication that mainly occurs during open repair of recurrent hernia. Microsurgical repair by a urologist is required if preservation of fertility is important.
Risk of serious injury to bowel, bladder, and vascular structure is high with laparoscopic procedures.[81] Preperitoneal mesh can also erode into adjacent bowel, requiring excision and repair.[121] Injury to bowel or bladder can also occur in open repair if the bowel or bladder is incarcerated, or if a sliding hernia is not recognized and the bowel wall is incised or sutured due to it being misinterpreted as a hernia sac. Mesh plugs, which extend into preperitoneal space, can also erode into bladder or bowel, requiring removal and repair.[67]
Minor laparoscopic bladder injury occurring during laparoscopic instrument (e.g., trocar) insertion may be treated conservatively by indwelling catheter. Large injury to bladder or bowel requires surgical intervention. Surgical repair of bladder injury may be further complicated by mesh erosion/migration following laparoscopic mesh repair. Injury to the aorta or iliac vessels from trocar insertion during laparoscopic repair is associated with high mortality. It requires urgent laparotomy and repair.
Usually presents within 1 to 5 days of the repair and is characterized by testicular pain, firmness, and inflammation of the testis. Following this, testicular atrophy occurs in 0.34% of patients. Commonly occurs after repair of recurrent hernia (0.5% to 5%) and is associated with low sperm count and poor libido.[122]
There is no effective treatment. Symptoms are managed by scrotal support and nonsteroidal anti-inflammatory drugs (NSAIDs). Corticosteroids and antibiotics are of unconfirmed benefit.[40]
Usually presents within 6 to 9 months of surgery. Occurs in up to 1% of cases.[123][124]
A large diameter port is probably the most common cause.[125]
Transmuscular placement of port, small trocars with conical obturators and the evacuation of air from the peritoneal cavity before the removal of the port decreases the incidence of incisional hernia.[123][126]
Requires immediate surgical intervention if strangulated; otherwise elective repair.
Usually associated with transabdominal preperitoneal (TAPP) surgery (incidence ranges from 0.07% to 0.4%), but may occur as a result of adhesions to preperitoneal mesh or mesh plug, or port-site hernia.[2] Not seen after open anterior repair.
Requires surgical intervention.
Characterized by a burning sensation that occurs just before, during, and after ejaculation.
Exact cause is unknown. Treatment is mainly supportive as almost all cases resolve with time.
Mesh insertion in the preperitoneal space may make radical prostatectomy more difficult and prevent iliac node dissection.[73]
Pain and numbness in the groin following inguinal hernia repair are common, but usually dissipate over time. Some patients may have chronic groin pain (inguinodynia) following inguinal repair, which can be disabling. The reported incidence of chronic groin pain varies considerably.[54][78][112] In the author's experience, the number of patients with chronic groin pain is small. The pain is often neuropathic in character, but its etiology is unclear and is likely multifactorial, with both physical and psychological components. Moderate to severe chronic groin pain is reported to occur in 10% to 12% of patients after inguinal repair.[2][111][112] It is more likely to occur in patients who present with groin pain preoperatively as their primary symptom, and incidence is reported to be higher after open repair than laparoscopic repair.[78][110][113][114]
Historically, postoperative groin pain has been attributed to nerve injury or entrapment, but awareness of nerve anatomy and procedures to divide or excise nerves in the inguinal canal, which are recommended to reduce the incidence of chronic post-herniorrhaphy pain, have shown inconsistent results.[25] Pain has also been attributed to the use of mesh (e.g., the type of mesh used [lightweight vs. heavyweight] and the type of mesh fixation [glue vs. suture vs. staple]). However, initial concerns regarding postoperative pain attributed to mesh prostheses have been shown to be unwarranted.[95]
The incidence of groin pain may be reduced by pre-emptive, multimodal postoperative pain management strategies that include regional nerve blocks and nonsteroidal anti-inflammatory medications. It does not respond to opioids and may gradually subside over time, often taking years. The incidence of numbness is lower when the ilioinguinal nerve has been preserved at the time of operation.[129]
Infected mesh after open-mesh repair is uncommon but can occur in patients with postoperative wound infection. It may present months or years later as a draining sinus tract.
Infected mesh can also occur after laparoscopic repair, but is often not recognized until months after surgery when fluid is seen around the mesh on a computed tomography (CT) scan done for abdominal pain.
Infected mesh should be removed.[127][128] Incidence of recurrent hernia after mesh removal is low.[92]
May be the result of a suture or staple placed into the pubic tubercle.
Treatment includes physical therapy to strengthen the lower abdominal muscles, and anti-inflammatory agents.
Intralesional injection of corticosteroid with local anesthesia is sometimes indicated, but its value remains unconfirmed.[40]
Surgical exploration and wedge resection of the pubic symphysis may be required if the cause is not identified.
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