Page 69 - International guidelines for groin hernia management

Hernia

One study has shown that patients with a history of adhesions resulting in bowel obstruction. 132 Adhesions and
lower abdominal surgery are at increased risk for visceral obstruction caused by tacks have been reported. 133
injury during laparoscopic hernia operation. 122 In a register study of postoperative complications and
Vascular injuries at dissection and mesh fixation or recurrence risks spanning 150,514 operations, those with
suturing in the preperitoneal space typically involve the complications such as hematoma and severe pain docu-
epigastric vessels or the aberrant obturator vessels crossing mented in the medical record at 30-day follow-up had a
the Cooper ligament, the so-called corona mortis. 123 significantly increased relative risk (RR 1.23 and RR 1.84,
134
Subcutaneous carbon dioxide emphysema can occur respectively) of reoperation for recurrent hernia.
during TEP repair. This rare but serious condition affects
124, 125
the respiratory and/or cardiovascular system. Discussion
Infrequent serious late complications related to mesh,
mesh fixation, port-site hernia formation, and intra-ab- Serious complications related to hernia operations are rare.
dominal adhesions have all been reported. 12, 118, 126, 127 When they do occur, their details and descriptions are often
Port-site hernias occur mostly after TAPP operations published as secondary outcomes. Reviews of complica-
with a frequency of 0–3.7% according to a Cochrane tions are often based on collections of individual cases in
review 118 and up to 8% after TAPP operations of recur- RCTs, retrospective follow-up cohorts, and case reports.
rences after previous preperitoneal—mainly TAPP—re- Prospective registration of specific complications in a
pairs of primary hernias. 126 Closure of port sites C 1cm is national registry is difficult, hampered by practical limita-
12
recommended. tions on reporting of details and by compliance issues when
The risk of intestinal obstruction after hernia surgery reported. Secondary outcomes are frequently ill defined
was calculated in a study based on data from the Swedish making comparisons difficult and potentially unreliable.
Hernia Register. Ninety patients—representing 0.3% of These confounders should be considered when interpreting
33,275 operations on primary hernias—had intestinal reviews on severe and/or rare complications.
obstruction considered to be related to the hernia operation.
TAPP was the only operative technique associated with an Mortality
increased relative risk of obstruction. 127
Mesh complications (see chapter 10 on meshes)—ex- The mortality rate associated with elective hernia surgery is
cluding pain and problems related to the mesh itself or its no higher than the mortality rate in the general population
fixation—are rare and can take years to develop. These when compared to Cause-of-Death registers calculating
generally are not mentioned in RCTs and only occasionally expected deaths considering age and gender of the popu-
in meta-analyses. Clinical observations of these compli- lation, and often somewhat lower given patient selection
cations are most often published as case reports. Late criteria for operation, 135 with high-risk patients being
mesh-related complications are associated most often with excluded from elective hernia repairs. This is not the case
polypropylene meshes. Sometimes deep infections, for emergent hernia repair. It is important to know the risk
including abscesses, develop around mesh. Erosion into factors for incarceration and strangulation and patient
hollow organs including the bowel or bladder and ingrowth characteristics such as medical history, age, and physical
and obstruction of the spermatic duct has been reported. 128 condition that place patients at increased risk of death.
Mesh migration into the abdominal cavity, the bowel or
bladder or into the scrotum and mainly associated with Key question
mesh plugs in open techniques and preperitoneal meshes
129–131
placed laparoscopically. Mesh exposed to the KQ18.z What is the 30-day mortality rate following groin
abdominal cavity through peritoneal defects (e.g., after hernia repair? What are the causes of this mortality?
hernia sac resections and peritoneal tears) may cause bowel

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