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COMPLICATIONS OF HERNIA SURGERY

DR SRIRAM BHAT M MS PROFESSOR IN SURGERY KMC MANGALORE

Complications of open hernia surgery Complications of TEP / TAPP Complications of other hernia surgery ventral / femoral

Early Delayed Late Life threatening

Complications of open hernia surgery Infection Neural - Groin pain Ischaemic orchitis Injury to vas Injury to viscera Recurrence Hydrocele Seroma, haematoma Dysejaculation

Complications of TEP / TAPP / laparoscopic SC emphysema Pneumothorax, hypercarbia Vascular Neural Visceral Infection, ileus Conversion Recurrence

Immediate Vascular Visceral Vas Anaesthetic

Late / delayed Seroma / haematoma Neural Intestinal obstruction Bowel adhesion / fistula Testicular Mesh related Recurrence

Iliac vessels, IE vessels are important

INGUINODYNIA
Chronic inguinal pain in post hernia surgery patients whether tissue or mesh repair. Traction, cautery, transection, entrapment. It may be transient or persistent. Iliohypo gastric, ilio inguinal, genital branch of GF nerve.

Ilioinguinal N Iliohypogastric N

Features
Distressing pain in the Arch and twist groin mobility of pelvis reproduce the pain Radiates to thigh, scrotum, loin Bupivacaine injection relieves the pain Imaging / NCS is of no use

Open method has higher (32-38%) incidence of inguinodynia than TAPP / TEP. In open hernia surgery inguinodynia has replaced recurrence as a primary complication. It is distressing discomfort to both patient and surgeon. Treated with analgesics / nerve block / transcutaneous stimulation / neurectomy.

Mesh inguinodynia can occur.

Treatment
Drugs Reassurance Injection of steroid, LA agents, phemol, alcohol TC stimulation Cryo, RF Neurectomy Groin approach Suprainguinal Laparoscopic Neurolysis

PROBLEMS WITH TEP


Trocar injury, Bladder injury, bowel injury Vessel injury IEA / Ext iliac vessels , muscle branch, trocar site, spermatic vessels. Beware of triangle of doom. Injury to vas Difficulties in placing mesh and with instruments, peritoneum opening Conversion to TAPP / OPEN

TRIANGLE OF DOOM

Spreading and fixing the mesh is important to reduce recurrence

Seroma common 20-25%.


Nerve injury lateral cut nerve of thigh 2%. It may be temporary (hyperaesthesia) or permanent; latter causes life time numbness along upper aspect of thigh and hip. Femoral branch of genitofemoral nerve injury (1%) - hyperaesthesia of scrotum and femoral triangle; usually subsides.

Nerves TEP Haematoma Triangle of pain

Mesh related problems displacement, infection, rejection. Testicular complications Surgical site infection Recurrence missed indirect sac, folding or displacement of mesh, small mesh, haematoma, infection

MESH INFECTION
WOUND INFECTION

RECURRENT HERNIA
Technical causes Missed hernia Precipitating causes Infection

True recurrence / false recurrence Medial / lateral recurrence

Strangulation infection and recurrence rate is high Only tissue repair is done

Direct hernia when present, indirect may be missed.

Shouldice 1-2% Mesh repair 1-3% Other methods 5% TEP / TAPP 5-10% Bassinis 10-20%. Treat with a new approach Lap / open

RE RECURRENT HERNIA 1%

ISCHAEMIC ORCHITIS
Due to thrombosis of pampiniform plexus Can be arterial very rarely. Leads to testicular atrophy (0.5%). DYSEJACULATION Self limiting entity after hernia surgery distressing pain just before, during and after ejaculation RARE (0.25%).

INJURY TO VAS direct injury is rare; vas amalgamating in mesh can occur. Bilateral hernioplasty may rarely lead into infertility

Seroma / haematoma is aspirated. Bowel / bladder injury can occur in large irreducible hernia with adhesions. Urinary catheterization is better.

COMPLICATIONS OF OTHER HERNIA SURGERIES

COMPLICATIONS OF VENTRAL HERNIA


OPEN METHOD Ileus, infection, Bowel injury, Intraabdominal sepsis Difficulties in releasing adhesions. Difficulties in mesh placement in front of the peritoneum. Recurrence

COMPLICATIONS IN LAPAROSCOPIC VENTRAL HERNIA REPAIR


Intra operative Related to access, inability to reduce contents, bowel injury, mesh insertion, positioning, placing, fixing, bleeding. Early post operative Pain, seroma (20%), infection, ileus, retention of urine, delayed bowel injury

Late postoperative Post operative adhesions and fistula Port site hernia Recurrence Suture site pain.

TO BE REMEMBERED
CUTTING NERVE on EXACT ANATOMY table IS NOT AN vascular, neural, ANSWER fascial and muscular CREMASTER excision METICULOUS / retaining is DISSECTION controversial by SELECTION OF THE removal protection to PATIENT AND nerves is and PROCEDURE hanging testis like clapper bell can occur.

ALWAYS SEE AND CUT ALSO CUT AND SEE

Many patients feel after effect of hernia surgery is more distressing than hernia itself. Hernia surgery is a very common surgery BUT NOT a simple surgery.

THANK YOU