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Management of Adult Inguinal Hernias: The Open Preperitoneal Approaches
111
Rives, J. (1967). Surgical treatment of the inguinal hernia with Dacron patch. Principles,
indications, technique and results. Int. Surg.,47, 360–361.
Sanjay, P., Watt, D. G., Ogston, S. A., Alijani, A. & Windsor, J. A. (2012). Meta-analysis of
Prolene Hernia System mesh versus Lichtenstein mesh in open inguinal hernia repair.
Surgeon, 10, 283-289.
Schroder, D. M., Lloyd, L. R., Boccaccio, J. E.&Wesen, C. A. (2004). Inguinal hernia
recurrence following preperitoneal Kugel patch repair. Am. Surg.,70, 132-136.
Stoppa, R. E. & Quintyn, M. (1969).Deficiencies of the abdominal wall in aged persons. Sem.
Hop.,45, 2182–2184.
Stoppa, R. E., Petit, J. & Henry, X. (1975). Unsutured Dacron prosthesis in groin hernias .Int.
Surg., 60,411-415.
Stoppa, R. E., Rives, J. L., Warlaumont, C. R., Palot, J. P., Verhaeghe, P.J.&Delattre, J. F.
(1984) .The use of Dacron in the repair of hernias of the groin. Surg. Clin. North Am.,64,
269–285.
Stoppa, R. E.&Warlaumont, C. R. (1989).The preperitoneal approach and prosthetic repair
of groin hernia. In “Hernia,” Nyhus, L. M. and Condon, R. E., (eds), 3
rd
Edition, 199-
225. Lippincott, Philadelphia.
Stoppa, R. E. (2003). Wrapping the visceral sac into a bilateral mesh prosthesis in groin
hernia repair. Hernia, 7, 2–12.
Usher, F. C., Ochsner, J. & Tuttle, L. L., Jr. (1958). Use of Marlex mesh in the repair of
incisional hernias. Am. Surg, 24, 969–974
Van Nieuwenhove, Y., Vansteenkiste, F., Vierendeels, T. & Coenye, K. (2007) Open,
preperitoneal hernia repair with the Kugel patch: a prospective, multicentre study of 450
repairs. Hernia,11, 9-13.
Wantz, G. E. (1989) Giant prosthetic reinforcement of the visceral sac. Surg. Gynecol.
Obstet.,169, 408–417.
Willaert, W., De Bacquer, D., Rogiers, X., Troisi. R. & Berrevoet, F. (2012). Open
Preperitoneal Techniques versus Lichtenstein Repair for elective Inguinal Hernias.
Cochrane Database Syst. Rev. CD008034.doi: 10.1002/14651858.CD008034.pub2.
In: Hernias ISBN: 978-1-62948-441-9
Editor: Mark A. Suckow © 2014 Nova Science Publishers, Inc.
Chapter 8
COMPLICATIONS OF INGUINAL HERNIA SURGERY
Manuel Hidalgo
1*
, Josè L. Porrero
2
, Manuel Ortiz
1
,
Belen Porrero
3
and Ana Hidalgo
4
1
Hospital Universitario 12 de Octubre Madrid, Spain
2
Hospital Universitario Santa Cristina Madrid, Spain
3
Hospital general de Asturias, Spain
4
Comunidad Autonoma de Madrid, Spain
ABSTRACT
Hernioplasty is the most frequently performed operation in general surgery
departments. The complication rate of these operations is between 2 and 15%, but due to
many of these operations being performed at ambulatory surgery settings, some of the
complications may go undiagnosed if patients are not very closely followed [Bay-Nielsen
et al., 2001]. Complications represent a problem for the patient due to lengthened
recovery time, for both patient and surgeon when facing more complex redo operations
with worse results, as in cases of recurrence or chronic groin pain, and for health systems
due to increasing expenditures (i.e., reoperations, lengthened hospital stay, time out of
work). Audit of complications following hernia surgery is difficult because patients and
surgeons define adverse events differently [Franneby et al., 2005]. Some complications,
like wound infection, are common with other types of operations, but others, like
testicular atrophy, are specific to hernia operations. Though it is impossible to completely
avoid complications they can be kept to a minimum with careful and precise surgical
technique.
Keywords: Inguinal hernia, hernioplasty, complications, pain, infection, lesion, mesh
migration
*
Corresponding author: Instituto Dirugia Colorectal, Hospital Universitario 12 de Octubre Madrid, Spain.
'manuel.hidalgo@salud.madrid.org'.
Manuel Hidalgo, Josè L. Porrero, Manuel Ortiz et al.
114
SYSTEMIC COMPLICATIONS
Systemic complications appear with frequency equal to other, similar surgical
procedures. Mostly, complications are related to general anesthesia and to patients’ age and
comorbidities. Respiratory complications, hemorrhage or intestinal obstruction are included
in these complications. Pulmonary embolism occurs with a low incidence after these
operations but early ambulation and venous thrombosis prophylaxis may mitigate risk.
Complications of general anesthesia can be avoided by conducting these operations under
local anesthesia and sedation. The most common complication after general or spinal
anesthesia is urinary retention, its incidence being higher in patients with benign prostatic
hypertrophy. The rate of this complication is between 10 and 20 % after spinal anesthesia, but
below 5% in operations using local anesthesia. Apart from local anesthesia and sedation,
careful management of intravenous fluids during surgery, early ambulation, and adequate
pain control are the most important measures to avoid this complication [Goldman et al.,
1988].
Postoperative headache can occur after spinal anesthesia. In most cases it subsides after a
few days and only very rarely is a epidural blood patch necessary to control this problem.
LOCAL COMPLICATIONS
Seroma and Hydrocele
Seroma is an exudate caused by surgical trauma and foreign bodies. The risk of seroma
formation is proportional to the extent of dissection and the difficulty of the repair; it is higher
in large scrotal hernias and in recurrent hernias [Gilbert, 1994]. The global incidence of
seroma formation is between 2 and 10%. In most cases, seromas are resorbed spontaneously,
but at times needle aspiration or surgical drainage is needed.
In patients with large scrotal hernias in which the bottom of the sac is left in situ, fluid
can accumulate, causing it to resemble a hydrocele. If they are large, needle aspiration or –
very rarely- surgical drainage, may be needed.
Vascular Complications
Hemorrhagic complications are the most frequent complications after inguinal hernia
surgery. They occur in a wide range of presentations, from simple ecchymosis around the
incision to severe bleeding due to vascular lesions.
Intraoperative bleeding can arise from the pubic branch of the obturator artery (corona
mortis), external spermatic vessels, marginal vein, epigastric vessels or external iliac vessels.
The external iliac vessels can be injured in the Lotheissen-McVay repair method and in
preperitoneal repair. Minor hemorrhage can be controlled by compression alone, but in more
serious hemorrhage the inguinal canal should be exposed to allow for adequate vessel
exposure and suturing. Femoral vein compression by the lateral sutures in the McVay repair
can cause thrombosis with the attending risk of pulmonary embolism.
Complications of Inguinal Hernia Surgery
115
Surgeons performing the Shouldice repair or placing prostheses in the preperitoneal space
should be very careful when dissecting this space (Bogros’ space) that contains many venous
vessels which should be coagulated as dissection proceeds. Similarly, trauma to the external
epigastric vessels should be avoided when dissecting the transversalis facia close to the deep
inguinal ring [Bendavid, 1998].
Inguinal ecchymosis occurs frequently in patients treated with aspirin or non-steroidal
anti-inflammatory drugs (NSAIDs) and when local anesthesia is employed. Tissue infiltration
with anesthetic containing added epinephrine can cause minor hemorrhage from the
subcutaneous vessels, resulting in small contusions around the incision, base of the penis or
scrotum. Such bruises are of no clinical importance as they resolve readily without any sequel
but the patient should be warned beforehand that they can appear.
Hematomas arise most frequently from superficial vessels (i.e., superficial epigastric,
iliac circumflex vessels). Also, external spermatic vessels can be injured in the course of
cremasteric dissection leading to hematoma formation. Small hematomas disapear
spontaneously in the first postoperative weeks.
Large tension hematomas, that can extend to the scrotum, may at times require surgical
exploration. In these cases antibiotic prophylaxis is indicated. Postoperative hematomas can
be controlled by compression on the wound.
Less common complications include dorsal penis vein or inferior epigastric vein
thrombosis.
Complications Related to Inguinal Region Nerves
Paresthesia and Skin Numbness
Following inguinal hernia surgery, some patients complain of numbness and paresthesia
in the inguinal area most frequently located medially to the incision, at times following the
skin distribution of the ilioinguinal nerve. Such disorders are temporary and disappear with
time. However, a small percent of patients may still have these symptoms a year after the
operation. These symptoms are directly related to inguinal nerve damage, they do not
interfere with patients’ daily life and should not be mistaken for chronic inguinal pain.
Chronic Inguinal Pain
The term “chronic inguinal pain” has different meanings in the literature. The
International Association for the Study of Pain [1986] has defined it as pain persisting for
more than three months after hernia operation, and some authors suggest a visual analogue
scale (VAS) intensity higher than 4 should be used as a criteria for establishing the presence
of chronic inguinal pain [Aasvang and Kehlet, 2005].
The iliohypogastric and ilioinguinal nerves are the primary sensory nerves to the inguinal
region, pubic area, root of the penis, the anteroexternal part of the scrotum and the upper and
medial aspect of the thigh. The ilioinguinal nerve lies under the external oblique aponeurosis,
usually forming a single trunk over the spermatic cord. It passes through the superficial
inguinal ring and provides sensory innervation to the root of the penis, higher part of the
scrotum and medial aspect of the thigh. The iliohypogastric nerve lies over the internal
Manuel Hidalgo, Josè L. Porrero, Manuel Ortiz et al.
116
oblique muscle; it traverses the external oblique aponeurosis close to the rectus muscle and
reaches the subcutaneous fat and the skin, providing sensory innervation to the pubic area.
The genitofemoral nerve arises from the first and second lumbar nerves and courses over
the psoas muscle, branching into the genital and femoral nerves. The genital branch traverses
the internal oblique muscle at the cremaster origin and courses over the iliopubic tract. This
nerve provides motor innervation to the cremaster muscle and sensory innervation to the skin
of the penis and scrotum [Klaassen et al., 2011].
Chronic inguinal pain after hernia surgery is a complication that seriously undermines
patients’ quality of life. The incidence in published studies varies between 0 and 62.9%; in
10% of patients, pain is graded as moderate to severe and only in 2-4% does the pain interfere
with patients’ daily activities [Poobolan et al., 2001].
Three types of chronic inguinal pain have been described: somatic, neuropathic and
visceral. Cunningham et al [1996] found that somatic pain was the most frequent type of
chronic inguinal pain. This pain is typically located over the pubic tubercle and related to
suture or staple placement on the periosteum for mesh fixation.
Neuropathic pain is due to injury of the iliohypogastric or ilioinguinal nerves or to
damage of the genital branch of the genitofemoral nerve. Injury can be due to partial or
complete section, contusion, entrapment, or thermal injury with the electric scalpel.
Secondary injury can occur by irritation or compression by an adjacent inflammatory mass
(granuloma).
Visceral pain occurs during ejaculation and is caused by dysfunction of the periurethral
structures involved in ejaculation. It has been attributed to sympathetic or somatic sacral
nerve injury, resulting in ejaculator muscle dysfunction [ Aasvang et al., 2007].
The main cause of chronic inguinal pain are nerve injuries during surgery, postoperative
scarring, and entrapment by the mesh, sutures or staples of the iliohypogastric or ilioinguinal
nerves or the genital branch of the genitofemoral nerve.
Smeds et al. [2010] suggest that nerve injury is due to inadequate nerve exposure during
dissection, coupled with ignorance of their locations and anatomic variants. This results in
partial or complete transection, neuroma formation and chronic pain. Nevertheless, in the
most widely performed anatomical repair technique, Shouldice’s, the genitofemoral nerve is
systematically sectioned, without development of chronic pain, albeit patients may sense that
the testis lies lower in the scrotal sac or experience loss of cremasteric reflex due to cremaster
muscle division. Suturing the distal cremaster section line to the superficial ring prevents this
nuisance. The anatomic dissections on 100 cadavers by Klaassen et al. [2011] showed the
many variations in the origin and course of these nerves. The ilioinguinal nerve was found to
arise from the L1 nerve in 62% of cases; from T12 and L1 in 14%; from L1 and L2 in 11%;
and from L2 and L3 in 10% of individuals. This nerve enters the anterior abdominal wall at a
point 2.8 cm medial, and 4 cm below, the anterior superior iliac spine, and ends 3 cm lateral
to the midline. The iliohypogastric nerve arises from the T12 nerve in 7% of cases; from T12
and L1 in 14%; from L1 in 10%; and from T11 and T12 in 6% of individuals. It enters the
anterior abdominal wall at a point 2.8 cm medial and 1.4 cm below the iliac spine and ends 4
cm lateral to the midline.
Surgeons have often been taught to protect the nerves as a way to minimize pain, but
there is another school of thought based on “no nerve-no pain.” Nerve preservation has been
Complications of Inguinal Hernia Surgery
117
compared to neurectomy in several studies with mixed results. Karakayali et al. [2010] found
a significantly lower incidence of pain after systematic neurectomy of iliohypogastric and
ilioinguinal nerves compared with their preservation. It should be kept in mind that surgical
treatment of chronic inguinal pain is triple neurectomy: this underlies the statement that nerve
section causes sensory disturbances that improve with time and only rarely result in chronic
inguinal pain. Similarly, in Shouldice’s anatomic repair the genitofemoral nerve is routinely
divided without development of chronic pain.
Franneby et al. [2006] identified several factors predictive of development of inguinal
pain: young age, the absence of inguinal tumor, recurrent hernia, and the presence of
moderate to severe pain before operation.
The type and composition of the mesh used for repair may also influence the occurrence
of chronic pain; presumably, low density meshes should result in less pain due to less scarring
and better integration. There are few prospective randomized studies to answer this question,
however. Bringmann et al. [2006] found no difference in the incidence of chronic pain,
hyposthesia or hyperesthesia between high or low-density meshes.
Pain related to surgery has led to proposals to fix the mesh with glue or human fibrin. Use
of such adhesives has shown to result in lower incidence of chronic pain, foreign body
sensation, and sensory inguinal disturbances both in observational and randomized studies
[Testini et al., 2010].
Inguinal or genital pain during sexual intercourse or ejaculation is not well known as
patients are not likely to be questioned about this complication. Its incidence is said to be 0.04
% but some studies have found a much higher figure of 2.5%. In these cases, treatment must
be as for chronic pain: triple neurectomy and freeing of the vas deferens.
Infection
Infection is not a frequent complication but it is an untoward event in the postoperative
recovery period. The frequency of wound and prosthesis infection, emergency and elective
cases grouped, is estimated between 3% and 4%. This complication is particularly relevant
because it can result in repair failure and hernia recurrence [Deysine, 1998].
Infection rates are influenced by duration of operation, hernia size, mesh type, and patient
comorbidities (e.g., obesity, COPD, smoking, diabetes, steroid therapy).
The first thing to consider when facing an infection after hernia repair is whether it is
superficial or deep. Superficial infections are located in the skin and subcutaneous fat; the
deep ones in fascia and muscle planes.
Superficial infections are more common and occur early in the postoperative course.
Though they usually resolve easily, superficial infections should never be taken lightly
because they can evolve into deep infections affecting the prosthesis. Superficial infections
should be treated promptly. Antibiotics may be curative for early superficial infections, but in
more advanced cases drainage and debridement are required along with bacterial culture,
antibiotic coverage and control of dressing changes until healing takes place.
Deep infections usually appear late, even months or years after the operation. They can
be due to inadequate treatment of a superficial infection, but can occur also after uneventful
Manuel Hidalgo, Josè L. Porrero, Manuel Ortiz et al.
118
postoperative courses. They can present as an abscess or insidiously as a chronic, persistent
drainage from a sinus tract on the scar, extending down to the mesh.
Abscess treatment involves drainage and debridement with resection of all necrotic tissue
and lavaging the wound with povidone-iodine diluted in saline, followed by antibiotic
coverage. Patients should be followed closely, and dressing changes carried out by trained
staff. There is some debate about the need to remove the mesh. Macroporous meshes can be
salvaged in up to 70% of cases. In cases of healing by secondary intention the use of vacuum-
assisted therapy (VAC) can speed the healing process [Mann et al., 1998].
It is unclear if it is best to entirely or partly remove meshes in cases of chronic sinus
tracts which extend to the mesh. It seems more rational to remove only the contaminated,
non-integrated parts of the mesh. Aggressive removal of integrated mesh can only result in
damage and risks recurrence [Guillion and Palot, 2012]. Pore size and design are also relevant
to mesh salvage. Macroporous, low-weight meshes of monofilament material are more likely
to be successfully salvaged [Arnaud et al., 1977].
Mesh infection can occur by several mechanisms:
1) The most common mode is contamination at the moment of mesh placement with
bacteria from the patient’s skin, from health care personnel who might be either
asymptomatic or symptomatic carriers of bacteria, or from the hospital flora
(nosocomial infection);
2) Less frequently by faulty sterilization of the mesh (when mesh remnants are
sterilized for re-use);
3) Mesh contamination by the hematogenous route; and
4) Direct extension from a close infection site or by erosion and migration of the mesh.
The best treatment for prosthetic material infection is prevention: aseptic technique
should be strictly followed throughout the procedure to keep bacterial contamination at a
minimum, all non-viable tissue and hematoma should be removed from the field, and dead
space obliterated [Tolino et al., 2009].
Mesh Migration and Displacement
Displacement of the prosthesis from the structures to which it was sutured is very rare.
The most widely used prostheses (i.e., polyester, polypropylene) are integrated into the
abdominal wall by ingrowth of fibroblasts through prosthesis pores with the attending
formation of collagen fibers, resulting in an area of fibrosis. This fibrotic reaction is
proportional to pore size of the mesh, more intense in the macroporous materials. The
integration process takes some time to develop and during this time the mesh can displace
from its initial position due to movements of the abdominal wall. Mesh integration is better
when it is placed between two muscular planes. If it is placed between fascia and
subcutaneous fat, integration develops more slowly and incompletely. For this reason, and
because musculoaponeurotic planes restrict prosthesis movements, placement in this plane is
recommended, along with mesh fixation with non-absorbable sutures to keep the mesh in
place while integration develops [ Amid, 1997].
Complications of Inguinal Hernia Surgery
119
Adhesions and Fistula Formation
All the prosthetic materials commonly employed in abdominal wall surgery may form
adhesions to abdominal viscera, though adhesiogenesis is less with e-PTFE. This material is
promptly covered by a layer of mesothelial cells, isolating the mesh from abdominal viscera.
Both braided polyester and polypropylene induce intense inflammation in the abdominal
viscera, leading to development of dense adhesions and even erosions of the intestinal wall.
This is a very unlikely occurrence in anterior hernia repairs with onlay prosthesis placement.
This process can manifest as intestinal obstruction, as abscess formation, or as
enterocutaneous fistula. Such complications can occur late in the postoperative course, and
treatment is quite complex because removal of the mesh is mandatory, along with the
adherent intestinal segment, followed by debridement and lavage of the abscess cavity and
any infected tissue. The frequency of this complication depends on the proximity of the mesh
to the abdominal cavity: it occurs with preperitoneal placement of the mesh, be it
laparoscopic or open [Trunzo et al., 2009].
Mesh Rejection and Intolerance
Mesh rejection is exceptionally rare because most prosthetic materials are generally inert,
not inducing any significant inflammatory response. It has been observed, however, that in
some patients polypropylene prostheses induce a very intense fibrotic reaction that the patient
feels as an annoying rigidity that can be incapacitating in some cases. It has been found from
experimental studies that prostheses reduce flexibility and compliance of the abdominal wall.
This effect depends on the type (e.g., polyester, polypropylene) and amount of material in the
mesh. In almost all cases mesh rejection is related to infection.
Carcinogenesis
The oldest prosthetic materials like polyester and polypropylene have been in use since
the 1960s, and e-PTFE since 1982. There is no clinical nor experimental evidence that these
materials induce neoplasm formation as they are employed in clinical practice.
Ischemic Orchitis and Testicular Atrophy
The most common complications related to the testicles are ischemic orchitis and
testicular atrophy, occurring with a low frequency of 0.5% following primary repairs, and
reaching 5% in recurrent hernias. In one large retrospective study of Shouldice repairs
[Wantz, 1982] incidence was 0.36% with only 0.09% of patients developing testicular
atrophy. Recurrent and scrotal hernias were at the highest risk for this complication.
The etiologic mechanism of this complication is poorly understood. It appears that
collateral blood supply is sufficient for testicular viability; and complete section of the
spermatic cord does not systematically result in this complication.
Manuel Hidalgo, Josè L. Porrero, Manuel Ortiz et al.
120
Koontz [1965] has pointed out that it is possible to operate on a bilateral hernia patient,
with the same type of hernia, and the same repair performed bilaterally, with orchitis
developing only unilaterally.
Because this complication is more common in scrotal hernias it has been postulated that
lesions of the pampiniform plexus vein made during distal sac dissection lead to thrombosis
and injuries to collateral blood flow to the testis, thus causing congestion. Too tight a closure
of the deep inguinal ring, with constriction of the spermatic blood flow, has been proposed as
leading to ischemic orchitis. This mechanism seems unlikely because the deep inguinal ring is
an elastic, deformable, muscular structure and not a rigid, strangulating ring.
Clinical manifestations include orchitis, severe local pain, fever, and -frequently- malaise.
Symptoms appear between 24 to 48 hours after operation. Duration of symptoms is variable;
pain subsides in 4 to 6 weeks with treatment, but edema and swelling can persist for several
months. Treatment is with anti-inflammatory drugs, antibiotics, and a suspensory to keep the
testis elevated and at rest, but evolution to testicular atrophy is unpredictable. When atrophy
occurs, testicular size diminishes for a variable period that can last for a year, with the testis
transforming into a small, fibrotic, painless structure. Testicular gangrene is exceedingly rare.
An important point to keep in mind when this complication arises in patients wanting to
procreate is not to carry on with contralateral hernioplasty before a year has elapsed and the
final result of the ischemic orchitis process can be evaluated.
To avoid this complication, the spermatic cord should not be dissected below the pubic
tubercle, and dissection of the distal part of large, scrotal indirect sacs should be avoided, thus
keeping trauma to spermatic vessels at a minimum without compromising the quality of the
repair [Fong and Wantz, 1992]. A posterior preperitoneal approach can be a good alternative
to avoid this complication when operating on recurrent hernias, because the inguinal region is
approached through “virgin” territory. This can be a good approach, too, in patients with
previous operations on the scrotum (e.g., hydrocele, vasectomy) where blood flow to the
testis can be already compromised, thus making the testis prone to ischemia. Some
techniques, like Shouldice’s, require systematic division of the external spermatic vessels;
this maneuver, representing no risk in normal subjects, can result in ischemic orchitis in
patients with compromised testicular blood flow.
Lesions to the vas Deferens
The vas deferens can be cut or injured in the course of dissection of the inguinal canal,
more frequently in operations for recurrent hernia due to difficulties with identification of the
relevant structures. When detected in the operation, vas deferens repair should be carried out
with direct suture of the severed ends over a stent (monofilament polypropylene 0 suture, for
instance), with the suture end brought out through the skin for removal after 5 or 6 days.
Disejaculation is a very rare complication (0.04%) presenting as a painful and burning
sensation in the groin during ejaculation. It is due to adhesions between the vas deferens and
the posterior wall of the inguinal canal resulting in disturbed deferential flow.
A poorly defined complication is male infertility resulting from obstruction of the vas
deferens associated with mesh placement. Shin et al. [2005] were unable to determine
whether obstructive azoospermia was the direct result of mesh fibrosis over the vas deferens
or to other operative events. They recommended use of pre-formed meshes with a wide, deep