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40 Results andComplications ofInguinal Hernia Repair

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laparoscopic inguinal hernia to be as high as 22%, likely due to the need for general anesthesia with these cases [133]. Other potential causes include overhydration, bilateral repair, increased BMI, use of opioid analgesics, older age, prostatic hypertrophy, and longer operative time. Meta-analyses of laparoscopic and open inguinal hernia repairs have not found any signicant evidence of technique choice being related to POUR [133–137]. There is a tendency to place Foley catheters during laparoscopic repairs, which seems to be more a tradition than actually rooted in evidence-based medicine. Surgeons do this to decompress the bladder in an attempt to minimize potential injury. One study evaluated a preand post-intervention of no catheter use during laparoscopic repairs. This study found decreased incidence of cystitis, hematuria, and urinary retention once catheters were no longer routinely used [137].

40.2.3.6 Sexual Dysfunction

Sexual dysfunction after inguinal hernia repair is reported in the literature in one of several ways: the presence of pain affecting sexual function, effects of the operation on fertility and gonadal function, and complications stemming from dysejaculation and ischemic orchitis. The Danish Hernia Database surveyed patients after their operation and found that 28% of patients with open repairs had some pain with sexual activity and 11% of patients reported some pain in the laparoscopic group. Pain that moderately to severely impaired sexual activity was reported in

2.8% of open repairs and 2.4% of laparoscopic repairs. Dysejaculation related to trauma or mesh-associated inammation occurred in 7.6% of the open group and 3.1% in the laparoscopic group [107, 138, 139]. Ischemic orchitis is a complication associated with damage to the arterial and venous plexuses in the spermatic cord. This is often seen with large, adherent sacs and aggressive dissection causing venous thrombosis. Subsequently, the testicle becomes atrophic with absent seminiferous tubules. A meta-analysis of heavyweight versus lightweight mesh for Lichtenstein repairs did not show a signicant difference in rates of testicular atrophy [22].

Some clinical studies have provided evidence of mesh placement contributing to testicular hypoperfusion and sperm dysmotility in the short term [140–143]. Operative injury to the vas deferens, or inammation mediated by mesh, can cause vas deferens stricture, obstruction, or transection [140–143].

40.2.3.7 Hematoma andOther Vascular Injuries

Nine systematic reviews and meta-analyses have addressed in some form hematomas and other vascular injuries [69, 71, 79, 108, 144–147]. In one study, a signicant decrease in hematoma formation was noted with endoscopic compared to open repairs. However, in several other metaanalyses, there were no signicant differences between open suture-based and Lichtenstein repairs. Several studies did nd that cumulative experience and getting through the learning curve did reduce the incidence of complications in TEP repairs. However, no direct comparisons were made regarding hematomas and vascular injuries in these studies.

With regard to patients who are being anticoagulated and the risk of hematoma formation, most studies are dated with variable techniques studied that would not be applicable to presentday practice. However, laparoscopic repair opening the preperitoneal plane, especially with TEP repairs, should be performed in these patients with caution.

40.2.3.8 Seroma

Seromas are a known postoperative occurrence after laparoscopic and open inguinal hernia repairs, especially in patients with scrotal hernias or large direct defects in preperitoneal repairs without plication of the transversalis fascia. The incidence varies between 0.5 and 12%. Some risk factors for seroma formation include coagulopathy, liver disease, and congestive heart failure. Some meta-analyses found a higher incidence of seroma formation after endoscopic repairs, while others were unable to corroborate that nding [71, 146–151]. In the presence of a lax transversalis fascia present in a large direct defect, reduction and xation of the fascia to Cooper’s

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ligament or plication with an Endoloop suture can obliterate the dead space where seromas can form [71, 146–151]. Seromas tend to resolve spontaneously over the course of 1–2 months. They should not really be considered a postoperative complication unless an infection were to occur.

40.2.3.9 Late andSerious Postoperative Complications

Serious postoperative complications (bowel, bladder, vascular) occur between 0.1 and 1.4% in the largest reported series and meta-analyses [72, 146, 147]. One Cochrane review found more instances of serious complications with endoscopic versus open repairs and more with TAPP than with TEP repairs [147]. This likely has to do with intraperitoneal entry and working space used in the TAPP repair. Vascular injuries tend to occur with the dissection of the peritoneum off the spermatic cord near the triangle of doom or the corona mortis overlying Cooper’s ligament and during xation of the mesh. Other potential vascular injuries include lacerating the inferior epigastric vessels with preperitoneal dissection. Port-site hernias and small bowel obstructions can happen in up to 8% of patients after TAPP operations [151]. In the Swedish Hernia Register, only 0.3% of patients had intestinal obstruction related to the hernia repair, all of them with laparoscopic TAPP repairs.

Conclusion

Non-surgeons and lay people often view the repair of an inguinal hernia as “just another small hernia operation.” However, serious and life-altering complications, such as CPIP, can happen to patients. The risk of recurrence, chronic postoperative inguinal pain, meshrelated complications, fertility issues, and serious vascular injuries should always be discussed with patients (See Table40.1). All general surgeons must have a solid grasp of the risks, benets, and alternative operations and management associated with repairing a hernia. This information must be disclosed in

Table 40.1 Complications of inguinal hernia repair

Complication Incidence Comment Recurrence

(overall) – Open 2.4% – Laparoscopic 3.3% Chronic pain (CPIP) – Clinically

signicant – Debilitating pain 0.5–6% – Preperitoneal 7.5% – Endoscopic 12.5% TEP – Open 12.3–

Orchialgia 0.5–1% Mesh shrinkage – Flat ~20% – Three

dimensional Infection Low-risk patients,

– Endoscopic 0.3% – Open 0.6% Urinary retention 1–20% Range – Local anesthetic 0.37%

Regional

–

anesthetic – General

anesthetic Sexual dysfunction – Open 28%/2.8% Any complaint/

– Endoscopic 11%/2.4% Any complaint/

Dysejaculation – Open 7.6% – Endoscopic 3.1% Seroma 0.5–12% Port-site hernia Up to 8% TAPP Bowel obstruction 0.3% TAPP Serious complication

1–15%

0.7–75% Range, any reported pain

10–12%

Anterior Lichtenstein

16.8%

~50% Plug

low-risk setting

2.42%

moderate to severe

0.1–1.4% Visceral/vascular (>endoscopic)

a way that is easy to understand in order to facilitate informed, shared decision-making between patient and their surgeon. For the patients who return with recurrence, CPIP, or other unforeseen issues, the surgeon must know the diagnostic work-up and, more importantly, when to operate versus when to refer the patient to dedicated herniologists.

40 Results andComplications ofInguinal Hernia Repair

391

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103. Aleri S, Amid PK, Campanelli G, etal. International guidelines for prevention and management of postoperative chronic pain following inguinal hernia surgery. Hernia. 2011;15(3):239–49.

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105. Cunningham J, Temple WJ, Mitchell P, Nixon JA, Preshaw RM, Hagen NA. Cooperative hernia study. Pain in the postrepair patient. Ann Surg. 1996;224:598–602.

106. Bay-Nielsen M, Perkins FM, Kehlet H. Pain and functional impairment 1 year after inguinal herniorrhaphy: a nationwide questionnaire study. Ann Surg. 2001;233:1):1–7.

107. Aasvang EK, Bay-Nielsen M, Kehlet H. Pain and functional impairment 6 years after inguinal herniorrhaphy. Hernia. 2006;10(4):316–21.

108. Koning GG, Wetterslev J, van Laarhoven CJ, Keus F. The totally extraperitoneal method versus Lichtenstein’s technique for inguinal hernia repair: a systematic review with meta-analyses and trial sequential analyses of randomized clinical trials. PLoS One. 2013;8:e52599. https://doi.org/10.1371/

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109. Poobalan AS, Bruce J, Smith WC, King PM, Krukowski ZH, Chambers WA.A review of chronic pain after inguinal herniorrhaphy. Clin J Pain. 2003;19:48–54.

110. Loos MJA, Roumen RMH, Scheltinga MRM. Classifying post-herniorrhaphy pain syndromes following elective inguinal hernia repair. World J Surg. 2007;31(9):1760–7.

111. Hakeem A, Shanmugam V. Current trends in the diagnosis and management of postherniorrhaphy chronic groin pain. World J Gastrointest Surg. 2011;3(6):73–81.

112. Magnusson N, Gunnarsson U, Nordin P, Smedberg S, Hedberg M, Sandblom G. Reoperation for persistent pain after groin hernia surgery: a populationbased study. Hernia. 2015;19(1):45–51.

113. Kennedy EM, Harms BA, Starling JR.Absence of maladaptive neuronal plasticity after genitofemoralilioinguinal neurectomy. Surgery. 1994;116(4):665–

70. discussion 670–671.

114. Klinge U, Klosterhalfen B. Modied classication of surgical meshes for hernia repair based on the analyses of 1,000 explanted meshes. Hernia. 2012;16(3):251–8. https://doi.org/10.1007/

s10029-012-0913-6.

115. Costello CR, Bachman SL, Ramshaw BJ, Grant SA. Materials characterization of 127 explanted polypropylene hernia meshes. J Biomed Mater Res B Appl Biomater. 2007;83((1):44–9.

116. Nelson EC, Vidovszky TJ.Composite mesh migration into the sigmoid colon following ventral hernia repair. Hernia. 2011;15(1):101–3.

117. Moorman M, Price P.Migrating mesh plug complication of a well-established hernia repair technique. Am Surg. 2004;70(4):298–9.

118. Murphy JW, Misra DC, Silverglide B. Sigmoid colonic stula secondary to perx-plug, 130 left inguinal hernia repair. Hernia. 2006;10(5):436–8.

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122. Amid PK.The Lichtenstein repair in 2002: an overview of causes of recurrence after Lichtenstein tension-free hernioplasty. Hernia. 2003;7(1):13–6.

123. Schoenmaeckers EJP, Van Der Valk SBA, Van Den Hout HW, Raymakers JFTJ, Rakic S. Computed tomographic measurements of mesh shrinkage after laparoscopic ventral incisional hernia repair with an expanded polytetrauoroethylene mesh. Surg Endosc. 2009;23(7):1620–3.

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Aetiology, Pathogenesis andAssessment ofChronic Pain After Inguinal Hernia Repair

W.A.R.Zwaans, M.R.M.Scheltinga, andR.M.H.Roumen

41.1 Denition

Chronic postoperative inguinal pain, abbreviated as CPIP, is currently the most invalidating complication of inguinal hernia repair and often leads to an inability to normally participate in society. It is the most costly adverse event of inguinal hernia surgery and poses a major health issue [1, 2]. CPIP is dened by the International Association for the Study of Pain (IASP) as ‘pain beyond three months after inguinal hernia surgery’ [3]. Others have suggested to extend this period to 6 months, allowing inammatory mesh-based responses to decrease [4].

41.2 Epidemiology

Inguinal hernia repair is one of the most frequently performed procedures in general surgery, with approximately 20million repairs every year worldwide [5]. Pooled incidences of CPIP following open mesh-based repairs such as the Lichtenstein technique may vary between 11 and 17% [6–9]. It is estimated that some 2–6% of inguinal hernia repairs result in signicant restrictions in social and daily activities leading

to an impairment of health status and marked lower quality of life [10–14]. Laparo-endoscopic techniques for inguinal hernia repair including TAPP and TEP may result in lower CPIP incidences, varying from 6 to 12.4% [9, 14].

CPIP is generally classied as neuropathic or as non-neuropathic (inammatory or nociceptive) pain (Fig.41.1). Neuropathic CPIP covers approximately 50–70% of CPIP, whereas the rest may be thought of as nociceptive or inammatory pain syndromes [15]. Proles of both neuropathic and non-neuropathic CPIP following laparo-endoscopic hernia repair are different compared to CPIP after open hernia repair. It must be appreciated that distinction between the two types is often difcult. Moreover, patients may present with a combination of pain characteristics, as CPIP can be considered as a spectrum (Fig. 41.1). To improve our understanding, the various CPIP syndromes are classied into three different entities (neuropathic, nociceptive or combined), and their associated aetiology and pathogenesis are discussed separately. Finally, pain can either be of central origin or more peripherally located. The clinical distinction of these classications is often very difcult, if not impossible.

W. A. R. Zwaans · M. R. M. Scheltinga R. M. H. Roumen (*) Department of General Surgery, Máxima Medical Center, Veldhoven, The Netherlands e-mail: R.Roumen@mmc.nl, solvimax.resurqe@mmc.nl

397

398

Centralization of pain

ipheral neuropathic pain

Dysejaculation, orchialgia,

Local tissue reactions

Mesh-related pain

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W. A. R. Zwaans et al.

Iliohypogastric nerve

Genitofemoral nerve

Th12 intercostal nerve

Ilioinguinal nerve

Centralized pain

Mesh-related pain

Orchialgia

CombinedNeuropathic Nociceptive

Dysejaculation

Periostitis

Recurrences

Other causes Iliopectineal bursitis Endometriosis

Adductor tendinopathy

Neuropathic pain Nociceptive pain

Fig. 41.1 Classication (a) and spectrum (b) of chronic inguinal postoperative pain following groin hernia repair

41.3 Aetiology andPathogenesis

41.3.1 Neuropathic Pain Syndromes

41.3.1.1 Inguinal Nerve Involvement

The majority of neuropathic CPIP is due to the involvement of one or more of the inguinal nerves (ilioinguinal nerve, iliohypogastric nerve, genitofemoral nerve or lateral femoral cutaneous nerve, Fig.41.2). If pain occurs in the early postoperative phase, immediate mechanical effects of the inserted mesh, sutures, staples or other prosthetic materials or direct damage to inguinal nerves during surgery is most likely [6, 15, 16]. Injury to the nerves can vary from complete transections (a so-called neurectomy) to smaller, partial nerve

Autonomic nerve involvement

Per

funiculodynia

lesions [17]. Partial lesions can vary from neurapraxis (in which the axons and myelin sheath are both intact) to axonotmesis (interruption of the axons but intact myelin sheath) or neurotmesis (interruption of both axons and the myelin sheath) [17]. The consequences of these grades of damage on pain perception are unclear. In case of pain due to surgical disruption of these nerves, one might in fact refer to this situation as postdissection or deafferentation pain (Sect. 41.3.1.4).

mines which nerves are at risk. Although the inguinal nerves are less frequently affected after laparo-endoscopic hernia repair as they course in another plane between the transverse and oblique muscles, the genital branch of the genitofemoral

Hernia recurrences

Meshoma

The technique of inguinal hernia repair deter-

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