Risks Associated With Laparoscopic Inguinal Hernia Surgery
“A must-read educational tool for all patients undergoing an inguinal hernia repair”
There are two types of laparoscopic inguinal hernia repairs – TEP (total extraperitoneal) and TAPP (transabdominal extraperitoneal). Both repairs, in general, consist of the 1) hernia dissection, 2) insertion of hernia mesh, and 3) mesh fixation (some surgeons do not use any additional mesh fixation). Both of these repairs carry similar risks, and these risks include, but are not limited to: incisional complications, infections, bleeding, bladder and urinary complications, acute and chronic pain complications, spermatic cord complications, seromas, recurrences, GI complications, and complications related to general anesthesia.
Fortunately, most of these risks are very uncommon, but patient education is very important to us.
Bleeding – Your TEP laparoscopic inguinal hernia surgery will be performed through three small incisions including a single ½-inch incision beneath the belly button, and two additional ¼-inch incisions below this along the lower midline. Likewise, a TAPP laparoscopic inguinal hernia surgery will also use a single ½ inch belly button incision, but the other two ¼-inch incisions will be on the sides of your abdomen. Always, hemostasis (assurance there is no bleeding) is assured at the end of each case, however mild bleeding can occur after the surgery is complete. This has the potential to result in a hematoma (collection of blood) in the space where the hernia was. While this is extremely rare, it is a known complication. Should it occur, applying warm compresses and time will usually allow full resolution. If any of these cuts bleed after surgery, this can cause the area to become black and blue. This may take up to 3-4 days to appear and a couple weeks to fade. In men, the black and blue skin (will look like a bruise) may also involve the penis and the scrotum (in women, the thigh or vulva). It is self-limiting, but should be brought to your surgeon’s attention.
Infections of the incisions or mesh after a laparoscopic inguinal hernia repair are almost non-existent (they are very rare). Despite its rarity, you will receive a single dose of antibiotics before the surgery begins. Incision infections are treated by opening the incisions and by sometimes providing you with an antibiotic. Mesh infections should be treated with mesh removal.
Bladder and Urine – Some patients (less than 5%) experience urinary retention (they have trouble initiating a urinary stream) after a laparoscopic inguinal hernia repair. If this occurs, the treatment may include a temporary insertion of a urinary catheter which is usually removed after one to three days. All patients eventually regain their baseline control of initiating a urinary stream. Bladder injury during the surgery is extremely rare. If you have had prostate surgery in the past, you should discuss this risk with your surgeon. Urinary infections are extremely rare, but have been reported.
Acute and Chronic Pain – It is very important to tell your surgeon if you have any groin pain or leg pain BEFORE the operation. The typical recovery after a laparoscopic inguinal hernia repair is associated with mild to moderate incisional pain and mild groin discomfort. This may last anywhere from 2 – 14 days, but is almost always gone by the 3rd or 4th week after surgery. The groin discomfort may be secondary to the gas used during surgery, the dissection, or rarely the mesh material or tacks (if used). There are a variety of mesh fixation materials that surgeons may choose to use, and all have a rare, but possible association with causing groin pain. These fixation options include (staples, permanent tacks, absorbable tacks, or glues). Some surgeons do repair without using mesh fixation materials at all.
Acute severe groin pain – Groin pain that is severe immediately after surgery should be brought to your surgeon’s attention, as this can be due to direct irritation from surgical material and could warrant return to the operating room to remove the foreign material or tack (if used). Fortunately, this risk is extremely rare. Should it occur, however, acute nerve injury could increase the risk of developing chronic pain.
Chronic groin pain (can be mild or severe) is defined as the presence of pain, discomfort, or hypersensitivity (not present before surgery) existing for more than 3 months after surgery. According to one national database, even a healthy male with no previous history of groin pain has as high as a 6% risk of developing chronic discomfort after undergoing any type of inguinal hernia repair. While the general risks of developing this chronic discomfort exist, our group’s experience has kept this complication at an absolute minimum.
There are 6 nerves in the groin that your surgeon is aware of and will avoid harm to.
Lateral femoral cutaneous nerve – This nerve is the most lateral nerve in the groin, innervates the upper lateral thigh skin, and in the past was the most common nerve irritated during a laparoscopic repair. If irritated, there may be pain or hypersensitivity experienced along the lateral thigh.
Genitofemoral (GF) nerve (both the femoral branch and the genital branch) – This nerve and its terminal branches are not routinely dissected out during a routine laparoscopic repair, but are well known to exist in the region just medial to the psoas muscle and lateral to the external iliac vein. The location of the two terminal branches varies. The trunk or either branch, however, can be potentially irritated or injured by the dissection, a tack, or by the mesh material. By limiting the use of tacks near its known location, injury to it can be minimized. The genital branch runs in the inguinal canal, under the spermatic cord in men and round ligament in women, and innervates the inner thigh and the lateral scrotal skin in men, and the labia majora in women. Its irritation is usually perceived by a hypersensitive scrotum in males and hypersensitive labia majora in females. The femoral branch innervates the anterior thigh, and irritation can lead to pain or hypersensitivity of the upper anterior thigh.
Femoral nerve (and its anterior cutaneous branches) – Like the GF nerve above, this nerve is not routinely identified during routine laparoscopic hernia dissection, but it does exist just lateral to the psoas muscle and entering the leg lateral to the femoral artery. Rather rarely, it at risk to be irritated or injured by use of a tack below the ileopubic tract. Even rarer, mesh can irritate this nerve. By limiting the use of tacks near its known location, injury to it can be minimized. If irritated or injured, leg muscles may feel heavy or weak, or pain along the leg may result.
Iliohypogastric nerve – This nerve may only be injured during a laparoscopic repair if a tack were to penetrate through the muscle and into the nerve. The incidence of irritation during a laparoscopic repair is extremely rare. Pain or hypersensitivity to the suprapubic region or groin may occur.
Ilioinguinal nerve – this nerve may be injured during a laparoscopic inguinal hernia repair only if your surgeon uses tacks and these tacks penetrate through muscle into this nerve. Its injury during a laparoscopic repair is extraordinarily rare. Irritation causes pain or hypersensitivity to the medial thigh, shaft of the penis, or groin.
Paravasal nerve fibers (tiny nerves along the vas deferens in a male) – irritation of these may cause temporary testicular discomfort.
Spermatic Cord Vas Deferens – very rarely, the vas deferens (tube that carries sperm from the testicle to the penis) in men may be irritated or even traumatized. This can cause testicular discomfort, infertility, or be completely asymptomatic. Women do not have a vas deferens, and instead have a round ligament that can be divided without consequence.
Spermatic Cord Artery and Vein – If the arterial supply to the testicle is divided, the testicle may become ischemic. This can be a serious complication, but is fortunately extremely rare. If the venous blood supply from the testicle is potentially compromised, this can lead to vague testicular discomfort or a varicocele.
Seroma – one of the more common side effects of a laparoscopic inguinal hernia repair (up to 12%). After the repair, patients can develop a temporary fluid collection in the same space where the hernia used to be. If it develops, it occurs about one week after surgery, and can last for months. They can become as large as the hernia. Some may mistake it for a recurrent hernia. Almost all reabsorb with time. Very rarely, persistent large seromas lasting beyond 4-6 months will require an operation as management. Percutaneous drains can be attempted with caution as they do risk converting a sterile seroma into an abscess.
Recurrence – All hernia repairs are subject to a very low, but definite, recurrence rate. Most recurrences will occur in the first 3 years, and the average rate is about 2-4% in most surgeon’s experience.
Gastrointestinal complications – Some patients develop nausea or vomiting the first 24 hours after general anesthesia. This will be self-limiting. If it continues beyond 24 hours, it could represent an extremely rare complication of an ileus or small bowel obstruction (<0.05%), and your surgeon should be alerted as soon as possible.
Constipation is common with the use of narcotic pain medication, and can be managed with a stool softener or laxative. Your surgeon can help recommend management if you experience constipation.
Shoulder Pain – this is a referred pain commonly experienced after laparoscopy, and is self limited within the first 3 days.