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136
A.M. Lipskar and M.A. Reiner
uniting with the testicular artery. The cremasteric artery is a branch of
the inferior epigastric artery and runs with the spermatic cord but
super fi cial to the spermatic fascia. It supplies the connective tissue of
the cord structures and also eventually anastomoses with the testicular
artery.
Nerves
There are two nerves that course through the inguinal canal and run
super fi cial to the spermatic fascia. In addition, the sympathetic testicular
nerve plexus runs within the spermatic cord. All of these structures are
susceptible to injury during inguinal hernia repair. The ilioinguinal
nerve arises from the fi rst lumbar nerve and enters the inguinal canal
between the internal and external oblique muscles and exits through the
super fi cial inguinal ring, providing sensation to the skin of the upper
and medial thigh as well as the penis and upper scrotum. The genital
branch of the genitofemoral nerve arises from L1 to L2 and enters the
inguinal canal just lateral to the inferior epigastric vessels and enters the
inguinal canal either by piercing the transversalis fascia or passing
through the deep inguinal ring. It then descends behind the spermatic
cord, supplying both the scrotum and cremasteric muscle complex. The
sympathetic testicular nerve plexus runs with the spermatic cord
structures and innervates the testes.
The Posterior Perspective
Anatomy is most commonly reviewed from an anterior perspective,
although one of the unique challenges of laparoscopy is that the cord
structure is visualized from a posterior perspective. Whether an
intraperitoneal or preperitoneal approach is utilized, the cord structure
needs to be relearned from this point of view (Fig. 12.1 ). The spermatic
cord structures can be found superior to the iliopubic tract when looking at
the myopectineal ori fi ce de fi ned by the internal oblique muscle and
transversus abdominis muscle superiorly, the iliopsoas muscle laterally, and
the lateral edge of rectus abdominis and pubis pectin medially. Additionally,
from the posterior perspective, there is an anatomic area commonly known
as the triangle of doom that has been characterized in order to assist surgeons
in avoiding cord complication or major vascular bleeding during laparoscopic
inguinal hernia repair. The triangle of doom is formed by the vas deferens
137
12. Cord Structure Complications in Inguinal Hernia Surgery
medially and the vessels of cord laterally, with the apex pointing superiorly.
This space contains the external iliac vessels, deep circum fl ex iliac vein,
femoral nerve, and genital branch of the genitofemoral nerve.
Cord Complications
With a thorough understanding of the anatomy and physiology of the
spermatic cord structures, the mechanism and clinical signi fi cance of
cord structure injuries can be more easily appreciated. As aforementioned,
there is no clinically signi fi cant effect to injury of the cord structures in
a female patient other than nerve injuries, so this section will again focus
on primarily male patients.
Complications of Spermatic Cord Injury
Ischemic Orchitis
Ischemic orchitis is best de fi ned as postoperative in fl ammation of
the testicle after inguinal hernia repair. This complication is signi fi cantly
more common after open repairs. Clinically, ischemic orchitis usually
Normal anatomy of the inguinal region
as visualized laparoscopically
Transversalis
fascia
Pubic tubercle
Superior
pubic ramus
Vas deferens
External iliac artery
External iliac vein
Psoas muscle
Genital branch of
genitofemoral nerve
Testicular vessels
Iliopubic tract
Internal inguinal ring
Inferior epigastric vessels
Fig. 12.1. Normal anatomy of the inguinal region as seen at laparoscopy.
138
A.M. Lipskar and M.A. Reiner
presents 1–3 days following hernia repair as a painful, indurated, and
swollen testicle, and it is often associated with a low-grade fever. It
occurs in <1% of all hernia repairs, but the incidence increases to ~5%
in recurrent hernia repairs due to scar formation. The etiology of
ischemic orchitis is almost always due to injury of the pampiniform
venous plexus rather than the testicular artery itself. It is most commonly
caused by venous congestion of the testicle secondary to thrombosis of
veins within the venous plexus and likely occurs during dissection of
the hernia sac away from the cord structures. In addition, complete
stripping of the cremasteric muscle fi bers may cause injury to the
pampiniform plexus as well. Testicular sonography will demonstrate
decreased testicular blood fl ow and can aid in determining whether the
testicle is simply ischemic or if it is necrotic. In the case of straightforward
ischemia, treatment is nonoperative and involves reassurance and
analgesia, as this condition usually improves by six weeks postoperative.
There is some debate about the role of antibiotics in ischemic orchitis,
but we do not routinely treat with antibiotics. Interestingly, testicular
ultrasounds performed at 6 months postoperatively have been shown to
show resolution of the fl ow abnormality in the vast majority of cases.
Emergent orchiectomy is only necessary in the case of testicular
necrosis, which would only be caused by signi fi cant injury to the
venous plexus and/or the testicular artery.
Testicular Atrophy
Testicular atrophy can be best de fi ned as shrinking of the testicle and
associated dysfunction. The inciting injury is to the testicular artery rather
than to the pampiniform plexus in cases of testicular atrophy. Testicular
atrophy usually occurs over several months and is not always preceded by
an immediate postoperative episode of testicular swelling. Whether
ischemic orchitis will progress to testicular atrophy is impossible to
determine. Testicular atrophy does not require emergent orchiectomy, but
the consequences of an atrophic testicle are signi fi cant and irreversible,
often requiring elective orchiectomy. The Shouldice clinic reported an
incidence of testicular atrophy of 0.036% in primary open mesh-free repairs
and 0.46% in recurrent hernia repairs. The incidence of testicular atrophy
in laparoscopic repairs is quite small, although it has been reported.
Avoidance of these testicular complications is best accomplished
by careful and minimal handling of the spermatic cord structures
while dissecting the hernia sac. There does not appear to be a bene fi t
of stripping the spermatic cord structures in either open or laparoscopic
techniques, and leaving the cord intact should minimize the incidence
of these complications.
139
12. Cord Structure Complications in Inguinal Hernia Surgery
Ductus (Vas) Deferens Injury
The vas deferens can be inadvertently injured during inguinal
hernia repair by either transection or obstruction. Either of these
etiologies can ultimately lead to infertility.
Complete transection of the vas deferens is a complication seen
more often in open repairs as compared to laparoscopic repairs, as
isolation of the vas deferens by digital manipulation is a standard part
of the open procedure. This complication is far more common in
recurrent hernia repairs due to scar tissue. Complete transection of the
vas deferens remains rare, but when it does occur and if it is recognized,
the vas deferens should be reanastomosed using 6.0 Prolene suture
over a stent, preferably with a urology consult.
Obstruction of the vas deferens cannot only lead to infertility but
also result in dysejaculation, an entity de fi ned as pain or burning in
the groin just before, during, or immediately after ejaculation. The
incidence of dysejaculation syndrome has been quoted to be
approximately 0.4%. The symptoms are usually self-limited. The
etiology of the obstruction is thought to be crushing or scarring of the
vas deferens, which can occur in both the open and laparoscopic
approaches with rough instrumentation that causes fi brosis through
the muscular wall of the vas deferens. Gentle and minimal handling of
the cord structures in laparoscopic repairs and avoidance of using
forceps or other instruments to handle the structures in open repairs
can minimize the occurrence of this complication.
Testicular Ptosis
Testicular ptosis is a less signi fi cant complication de fi ned as
sagging of the testicle on the side of a previous inguinal hernia repair.
Ptosis will routinely occur if the cord structures are skeletonized, and
the cremasteric muscle fi bers are divided, either in the open or
laparoscopic approach. This complication can be avoided if the
cremaster muscle is left intact or by fi xing the medial stump of the
muscle to the pubic tubercle, as done in the Shouldice technique.
Scrotal Hematoma
Due to the abundant vascularity of the spermatic cord, scrotal
hematomas after inguinal hernia repairs are common due to excessive
handling of the cord structures and slow bleeding from the vascular
cord structures, with an overall incidence of ~5%. This complication
is minor and can occur in both open and laparoscopic approaches.
Patients present with scrotal swelling and ecchymotic discoloration.
140
A.M. Lipskar and M.A. Reiner
These hematomas are self-limiting and almost always resorb
spontaneously. Treatment is usually limited to elevation and tincture
of time. Similar to other cord structure complications, this can be
minimized with gentle handling of the spermatic cord.
Hydrocele Formation
Hydroceles have been reported to occur in 0.7% of patients after
inguinal hernia repair and are thought to be caused by excessive
skeletonization of the cord structures with a disruption of lymphatic
drainage. Another theory is that an open distal hernia sac causes
hydroceles. They are treated the same way primary hydroceles are
treated.
Nerves
While not truly cord complications, nerve injuries remain a
common problem following both open and laparoscopic hernia
repairs, with incidences approaching 15–20%. Nerves can be injured
by either transection, injury, or excess retraction. Complete nerve
transection generally causes numbness but does not lead to neuralgias.
Postoperative neuralgias can be grouped into those that cause
symptoms within hours of awakening from anesthesia and those that
cause chronic pain symptoms. Patients with acute neuropathic pain
immediately after herniorrhaphy will often bene fi t from immediate
reexploration. The mechanism of nerve injury is different depending
on operative approach. Injury to the genital branch of the genitofemoral
nerve and ilioinguinal nerve can occur during dissection of the cord in
open hernia repairs, as these structures run external to the spermatic
fascia but alongside the spermatic cord. Some authors therefore
advocate the identi fi cation and ligation of these nerves with minimal
residual effect in order to minimize these complications. In
laparoscopic repairs, injury to the genitofemoral nerve usually occurs
due to tacking the mesh improperly. A complete discussion of nerve
injuries during herniorrhaphy is beyond the scope of this chapter.
Conclusions
Injury to the components of the spermatic cord structures remains
one of the more common complications of hernia repair in male patients,
sometimes causing severe long-term sequelae. Almost all of the
141
12. Cord Structure Complications in Inguinal Hernia Surgery
complications can occur during either the open or laparoscopic approach,
although most of the cord-speci fi c complications are more common in
open repairs and especially in open repairs of recurrent hernias. The best
method of avoiding these injuries is obtaining a thorough knowledge of
the embryology and anatomy of the inguinal canal and the spermatic
cord, handling the tissues gently during the repair and avoiding
overskeletonization of the cord.
Suggested Reading
1. Bendavid R. Complications of groin hernia surgery. Surg Clin North Am.
1998;78(6):1089–103.
2. Schoenwolf GC, Larsen WJ. Larsen’s human embryology. 4th ed. Philadelphia, PA:
Elsevier Livingstone; 2009. p. 525–30.
3. Sherman V, Macho JR, Brunicardi FC. Inguinal hernias, chapter 37. In: Brunicardi FC,
Andersen DK, Billiar TR, Dunn DL, Hunter JG, Matthews JB, Pollock RE, editors.
Schwartz’s principles of surgery. 9th ed. New York: McGraw-Hill; 2010.
4. Shouldice EB. The Shouldice repair for groin hernias. Surg Clin North Am.
2003;83:1163–87.
5. Tetik C, Arregui ME, Dulucq JL, et al. Complications and recurrences associated with
laparoscopic repair of groin hernias. Surg Endosc. 1994;8(11):1316–23.
143
B.P. Jacob and B. Ramshaw (eds.), The SAGES Manual of Hernia Repair,
DOI 10.1007/978-1-4614-4824-2_13,
© Springer Science+Business Media New York 2013
13. Intraoperative Complications
During Laparoscopic Hernia Repair
Davide Lomanto and Rajat Goel
Laparoscopic repair for inguinal hernia was fi rst reported in the early
1990s by Ger, Schultz, Corbitt, and Filipi [ 1– 4 ] . Today, the two most common
laparoscopic hernia repairs are transabdominal preperitoneal repair (TAPP)
and the total extraperitoneal repair (TEP). Both involve placement of a
prosthetic mesh in the preperitoneal space to cover all potential hernia sites
in the myopectineal ori fi ce within the inguinal region. TAPP requires an
incision in the peritoneum to access the preperitoneal space, where as in
TEP, the dissection is done in the preperitoneal space itself. Both laparoscopic
hernia techniques require full exposure of the myopectineal ori fi ce, removal
of excess preperitoneal fat and cord lipomas, complete assessment of all
potential hernia sites, full reduction of direct hernia contents, evaluation to
assess a femoral hernia component, complete dissection of the proximal
indirect sac from the cord structures, and fi nally appropriate placement and
judicious fi xation of mesh in preperitoneal space.
The laparoscopic inguinal hernia repairs (TAPP and TEP) are looked
upon as technically demanding procedures. They have a “learning curve,”
and complication rates have been shown to drop with increased surgical
experience [ 5– 7 ] . Proper training and supervision can shorten the
learning curve and reduce the complications and recurrences [ 8 ] . The
high-volume centers have reported comparable result outcomes, if not
better, in terms of recurrence, chronic residual pain, and quality of life
[ 8– 10 ] . This de fi nitely suggests that surgeons who complete the learning
curve can deliver results that are not only acceptable but also impressive
and signi fi cantly better than open repair in bilateral and recurrent inguinal
hernias [ 9– 12 ] . The improved outcomes can be attributed to assimilation
of results of published literature and identifying factors that contribute to
complications and failure of repair. It is important to critically analyze
each of these factors and help postulate surgical techniques that would
reap good surgical outcomes.
144
D. Lomanto and R. Goel
The complication rates for laparoscopic repair of inguinal hernia
ranges from less than 3% to as high as 20%. [ 6, 13– 15 ] . A summary of
the complications speci fi cally related to TAPP and TEP can be found in
Table 13.1 .
Laparoscopic Inguinal Complications
Noteworthy intraoperative complications speci fi c to laparoscopic
inguinal repair are:
Vascular Injury
This can involve the iliac vessels, femoral vessels, inferior •
epigastric vessels, gonadal vessels, muscular branches, vessels
over the pubic arch (including “corona mortis” vein), or other
vessels in the region.
Visceral Injury
• Bowel injuries can occur with trocar entry, or during the course
of dissection in large irreducible hernias, sliding hernias, or
with the use of electrodiathermy. The incidence of bowel
injuries is greatly reduced, but not completely eliminated, with
TEP as compared to TAPP repair.
• Urinary tract injuries are reported in laparoscopic inguinal
hernia repair. These include bladder injuries and rarely even
urethral rupture.
Table 13.1. Summary of intraoperative complications.
Related to laparoscopic technique Related to laparoscopic hernia repair
Trocar injury to bowel and bladder
a
Vascular injury: Femoral, epigastric,
gonadal, iliac, and others
Subcutaneous emphysema Nerve injury: Lateral femoral
cutaneous, genitofemoral,
ilioinguinal, iliohypogastric, and
femoral
Cardiopulmonary complications
related to hypercapnia
Visceral injury: Bladder and bowel
Injury to cord structures: Vas deferens
and gonadal vessels
a
More common in TAPP
145
13. Intraoperative Complications During Laparoscopic Hernia Repair
Nerve Injuries.
The myopectineal ori fi ce of Fruchaud has several nerves coursing
in it, viz., ilioinguinal nerve, iliohypogastric nerve, genitofemoral
nerve with its medial genital (external spermatic nerve) and lateral
femoral (lumboinguinal nerve) branches, femoral nerve, and lateral
femoral cutaneous nerve. All these are prone to injury, either during
lateral dissection or during mesh fi xation. It can result in long-term
pain and discomfort [ 16 ] .
Injury to Cord Structures.
The vas deferens can be damaged or transected, as can the gonadal
vessels during the course of dissection.
Complications can occur at every step of the operation even though
some of them are occasionally reported. However, it is important to
analyze all of them chronologically, so that we can de fi ne methods to
prevent them, or tackle them once they occur.
Risk Reduction Strategy
A risk reduction strategy is required to improve the clinical outcome
of laparoscopic hernia repair, and this must be adopted during the
following surgical steps:
1. Placement of the fi rst trocar
2. Placement of the working port
3. Dissection of the preperitoneal space
4. Dissection of the hernia sac
5. Mesh placement and fi xation
6. Closure of the port
Placement of the First Trocar
Since the TEP repair involves a preperitoneal placement of a trocar,
injuries that can be avoided during the fi rst trocar placement during a
laparoscopic inguinal hernia repair are limited to those found during a
TAPP inguinal hernia repair. Most, if not all, of these injuries that are
expected from the fi rst trocar entry can be attributed to a sharp instrument
like a Veress needle or sharp trocar entering the peritoneal cavity and
causing potentially vascular or visceral injury [ 13, 14 ] . This type of injury
146
D. Lomanto and R. Goel
is not common in a TEP repair in which the preperitoneal space is entered
under direct vision and a preperitoneal domain is maintained during the
procedure. The surgeon stands on the opposite side of hernia, and the
camera setup is on the same side of the hernia on the foot end of the
patient (Fig. 13.1 ). Few authors [ 17 ] advocate the use of Veress needle or
blind trocar entry in the suprapubic area to create the space, as this
maneuver can lead to an inadvertent injury of the bladder or bowel and is
simply avoidable with other techniques. Veress needle is also
contraindicated when the patient has had a previous laparotomy (especially
with an infraumbilical midline incision) as previous incisions often result
in scarring with distortion of tissue planes and visceral adhesions to the
anterior abdominal wall. Consequently, injury can be minimized by
judiciously using an open-entry technique in an area distant from the
previous incision. Open entry under direct vision certainly does not
eliminate visceral or vascular injury, but its use is certainly more logical
in those situations and has been shown to minimize risks.
Fig. 13.1. OT setup for right-sided hernia repair.