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Inguinal Hernia repair - Complications

Early
Haematoma

Urinary retention

Wound infection

Intermediate
Testicular atrophy

Late

Persistant Pain 20% mild 2% severe


Recurrance ( 1% with Mesh)
OMPLICATIONS OF HERNIOTOMY
The classical open approach with high ligation of hernia sac has stood the
test of time and is associated with a complication rate of less than 2% [52].
1. Bleeding
Bleeding due to severing of small veins in superficial fascia may be a minor
trouble and is generally easy to control. Bleeding may also occur secondary
to injury to one of the fragile veins in the pampiniform plexus and can be
easily controlled by pressure or bipolar diathermy. Bleeding from the edges
of distal sac may lead to post-operative haematocele; thus it is important to
achieve hemostasis by coagulating the edges of distal sac with bipolar
cautery. Only after an adequate hemostasis should the testis be replaced back
into the scrotum.

1. Wound infection
Occurs in less than 2 % of the cases and can be prevented by meticulous
asepsis and hemostasis in operation room [52].
1. Injury to Ilioinguinal nerve
Injury to Ilioinguinal nerve is a rare occurrence. This slender nerve runs
through the inguinal canal and upon opening the leaf of external oblique
aponeurosis just runs over the spermatic cord. Careful eversion of the edge
along with the nerve will prevent damage.
1. Injury to vas deferens
Prepubertal vas deferens is a very delicate structure and is susceptible to
injury during pediatric hernia repairs as it runs along the hernia sac often
invested in soft tissue of the wall of the sac [52-59]. Fortunately, incidence
is less than 2% [52, 53]. Vasal injury during pediatric hernia repairs though
rare, has been documented to be the most common etiology for obstructive
azoospermia later on in adulthood and also the most difficult to repair [56].
Open exploration is associated with an increased risk of infertility; as many
as 40% of infertile males who had bilateral hernia repairs as children have
bilateral obstruction of the vas deferens [58]. Two types of injuries may
occur- ischemic injury or sectioning of the vas. Ischemic injury results in a
long segment of vas becoming fibrosed and is difficult to recognise during
surgery itself. Classically, patients present with obstructive azoospermia
later on in life and may need repair. Second type of vasal injury - sectioning
of the vas is very uncommon in experienced hands, though the risk is higher
in giant hernias of infants. If such an injury is recognised, it should be
documented and surgical repair tried after mid-puberty as pre-pubertal
narrow vasal diameter does not permit successful repair till tanner stage 3
has passed [56]. Overall, vasal injuries during hernia repairs are associated
with longer vasal defects, impaired blood supply and longer obstructive
intervals frequently resulting in secondary epididymal obstruction [50]. Vas
deferens injury can also result in sperm-agglutinating antibodies which
influence fertility [53]. Even minor inadvertent pinching of the vas or
stretching of the cord can result in injury, which also increases the risk of
infertility [54, 55, 61]. This inadvertent injury may be more likely when
there is no true hernia sac present because the vas is more exposed making a
case against routine contralateral exploration in a unilateral hernia.
1. Testicular atrophy

Vascular compromise of testis leading to atrophy occurs in less than 0-3% 2% of all hernia repairs [52]. This mostly occurs due to injury/ spasm of
testicular vessels.
1. Iatrogenic ascended testis
After mobilisation of the testis and division of the processus vaginalis, there
is a raw area created which may entrap the testis. To prevent this from
happening it is vital to pull the testis down and reposition it into the scrotum.
1. Post operative Hydrocele
Post-operative hydrocele is a common occurrence and represents the
continuing secretion of fluid by the left over distal sac. Most of the times it
is a minor collection and gets resorbed spontaneously over a period of 2-3
weeks. In large hernias, the incidence may be higher. Therefore, during
herniotomy, it is important to lay the distal sac widely open [62]. This
maneuver widens the neck and thus provides more surface area for the fluid
to get resorbed and prevent hydrocele. Hemostasis should be achieved
adequately with preferably bipolar current after the sac edges have been laid
open.
1. Recurrence
Factors that may contribute to recurrence in open inguinal hernia repair in
children include failure to ligate the sac high enough, inadvertent tearing of
the sac (and its extension into the peritoneal cavity), an excessively dilated
internal ring, injury to the floor of the canal (with subsequent development
of a direct inguinal hernia), and the presence of co-morbid conditions (eg,
collagen disorders, malnutrition, or pulmonary disease). The recurrence rate
has been documented to be around 1-3% [52, 63, 64].
1. Metachronous contralateral hernia
In 1950s reports appeared about a high rate of contralateral hernias in
children presenting with unilateral hernias and Rothenberg recommended
prophylactic contralateral exploration in all children [65]. These reports
became the basis for the recommendation that all children undergo a
contralateral exploration when a unilateral hernia was diagnosed. It has
become clear now that these hernias were often the patent processus
vaginalis and that, had they been left alone, a majority of them may not have
become clinically significant hernias. The debate about contralateral
exploration involves a choice between treating only obvious hernias (and
dealing with a metachronous hernia later) versus preventing metachronous
hernias by closing any patent processus vaginalis that is found. Ein etal in

one of the largest series of pediatric hernias reported only a 5%


metachronous hernia rate in a follow-up as long as 35 years. Among the risk
factors for developing metachronous contralateral hernias, age less than 18
months, initial left side and large hernia seem to be significant [66-68]. Still
the risk is not high enough (less than 5% in most series) to mandate a
routine contralateral exploration. After weighing the risks such as real
possibility of vasal injury or testicular atrophy in the light of low risk of
contralateral hernia, most surgeons now believe that routine open
contralateral exploration is not indicated [66-70]. Even in preterm babies if
there is a unilateral clinically evident hernia at presentation, contralateral
exploration is no longer recommended. A close clinical follow-up is
advisable though [71].