**11.1. Local complications**

dissected, as interference with the anatomical planes may result in attempts made for re-

• The dissection should be performed at an adequate width of the myopectinale opening, but should be avoided from the extreme dissection in front of the psoas site in the lateral direction. There is an anatomic area defined as triangular pain in this region and it should be especially noted that the cutaneous femoral lateralis and femoral branches of genitofemoral nerves are not damaged. Postoperative chronic pain syndromes can be encountered in the

• Death triangle is defined as the anastomotic area between the external iliac vein and the obturator vein and should be avoided from the extreme dissection. Because, in the event of a possible vascular injury in this region, catastrophic consequences may be encountered. • The staples used for patch detection due to the same reasons should never be used under

• Should be sure to place the staples on the medial side, especially on the Cooper ligament,

• It is generally advised to use the least amount of other materials that can be used for sta-

• Wide laying of the mesh will reduce the recurrence rate by covering the three hernia areas.

closing of the flap is important to prevent postoperative intestinal adhesions.

disturbing the dissection plans and preventing the vision.

which will be entered from the Palmer point.

defects should be closed with endoclips.

ing the patient's position will facilitate closure because it will reduce tension. The effective

• The infraumbilical incision should be made from slightly left or right lateral. What should be noted here is to be on the rectus front sheath. If the linea alba is opened by mistake, the gas will flow to the intraabdominal region and strengthen the technique at the start.

• It is important to notice the bright white color of the rectus posterior sheath, and it is important that the balloon is inflated by advancing the balloon trocar in this space. The balloon dissection between the fibers of the rectus will cause bleeding between the muscle fibers,

• If gas flows into the abdomen during possible peritoneal injuries in the TEP technique, as mentioned in the techniques section, the gas must be evacuated with the Veress needle,

• Large peritoneal defects may cause postoperative patchy contact with the intestines and lead to postoperative intestinal adhesion development. For this reason, large peritoneal

pressure during the peritoneal flap closure and correct-

• Should be very careful not to hold Vas Deferens by endo-devices so as to not disturb.

current hernia.

86 Hernia Surgery and Recent Developments

the iliopubic tract.

pling or patch fixation.

**10.2. TEP**

• Reducing the intraabdominal CO<sup>2</sup>

event of a possible nerve injury.

so that postoperative osteitis pubis is avoided.

The most common complications are serous fluid deposits (seroma) and bleeding(hematoma) which may develop during operation. Patients should be informed in the preoperative period about these complications. Postoperative seromas usually resorb spontaneously within 2 weeks and do not require treatment. Therapeutic drainage needs arise in the presence of seroma persistent for longer than 6–8 weeks or in the presence of seroma causing clinical symptoms. The use of peroperative aspirative drains in risky patients of who may be predicted seroma and hematoma development may prevent the development of these complications. Scrotal elevation is recommended in the postoperative period. If abdominal wall ecchymosis occur, mechanical compression, cold application and medical treatment can be tried. Subcutaneous emphysema is often untreated and spontaneous. In rare occasional hydrocele cases, it will be more appropriate to consult with a urologist.

### **11.2. Neurological complications**

The treatment of chronic pain syndromes after laparoscopic hernia surgery is often long and difficult. Chronic postoperative pain has been reported in up to 63% of all groin repairs and significantly affects clinical outcomes. The pain following laparoscopic surgery is usually neuropathic pain. The cause is usually the damage or trapping of the lateral femoral cutaneous or femoral branch of the genitofemoral nerve. Clinically it occurs as acute burning and/ or crushing pain in a particular dermatome. Mareljia parestetika is the name of a pain clinic that develops after a lateral femoral cutaneous nerve injury and persistent paresthesia lateral of the femoral area. It is recommended to apply corticosteroids or anesthetic injections which can be applied at rest, cold application, NSAIDs, physical therapy, locally. Osteitis pubis is; the name of the pain clinic that occurs due to public inflammation and arises especially on the middle of the groin or on the pubis, especially with femoral adduction. Diagnosis can be made by excluding recurrent hernia diagnosis radiographically and performing bone imaging. The treatment approach is the same as neuropathic pain. Often, 6 months are required to respond to treatment. However, if the cure is not available, the orthopedic consultation may be needed to consider possible bone resection or curettage options.

### **11.3. Cord and testicular injury**

Ischemic orchitis should be considered in the complaints of hardened, enlarged and painful testicles that appear about 10 days after the repair of the inguinal hernia. It is often self-limiting. It is usually the result of a possible damage to the pampiniform plexus, not the testicular artery. Ultrasound can distinguish necrosis or ischemia. If testicular necrosis is detected, urgent orchiectomy may be necessary. Treatment includes IV hydration and NSAIDs. If testicular artery is damaged, it can be caused testicular atrophy after long periods of operation. Vas deferens may not be manipulated during surgery and maximum effort to avoid disturbing their nutrition may help to avoid these complications.

100 cases. A meta-analysis by Köckerling et al. [13] evaluating the relationship between patch fixation and recurrence, cases that patch fixation was performed and in cases not performed, there was no difference in the duration of operation, patch-related complications, recurrence

Laparoscopic Inguinal Hernia Repair: Technical Details, Pitfalls and Current Results

http://dx.doi.org/10.5772/intechopen.76942

89

In a randomized controlled meta-analysis in which Wei and colleagues evaluated the outcomes of 1000 patients published in 2015, there was no difference between the two surgeries, pain score, operation time, return to daily activity, hospitalization time, complication and cost between the two surgeries. In conclusion, TEP was found to be more complicated than TAPP and advised to start laparoscopic surgery with TAPP to inexperienced surgeons [14]. In a study published by Köckerling et al. [15] there was no difference between two surgeries in terms of intraoperative complications and reoperation rates. However, after TAPP surgery, complication rates were found to be higher due to possible large complications, more scrotal

In a study conducted by Payne et al. [16] to measure postoperative quality of life, it has been shown that patients' compliance with straight leg exercises is better after laparoscopic surgery. Designed in the same way and studied by Lawrence et al. [17], this difference was more

The problem of cost is still an important problem, with the fact that it has been removed from the big picture compared to the past. In the study conducted by Stylopoulos et al. [18] in 2003 and the results of 1.5 million patients evaluated, laparoscopic operations have been claimed to reduce costs compared to long-term open surgery when salary, health insurance costs, reduced job quality, delayed work shifts and the salary of the worker looking after the patient are taken into consideration. Farinas et al. [19] showed that 60% reduction in indirect costs could be achieved despite the 40% increase in the direct costs of using non-disposable devices

When TEP and TAPP were compared, there was no difference between the two techniques in terms of hospitalization time, recovery time and short term recurrence rates. The duration of the TEP technique is shorter than that of the TAPP technique [20]. However, according to the International Endohernia Association, it has been suggested that surgeons should apply the TEP technique after learning the TAPP technique and acquiring a certain experience in

In our study, we have found that there is only a minimal difference between TAPP and TEP techniques, in terms of operative time. There was no difference in both techniques when recurrence, return to work, pain score, duration of hospitalization and complications were evaluated. Particularly, we observed that bilateral and recurrent hernia had high patient satisfaction. Also we observed that TAPP surgery in the early stages of surgery, shortened the

In conclusion, laparoscopic inguinal hernia surgery takes place in daily practice as an increasingly widespread up-to-date treatment method in which training and experience gained over

time and patient satisfaction of clinical outcomes are very good.

and duration of hospital stay.

hernia, elderly patient selection.

evident in bilateral hernia repair.

and shortening of the operation time.

the learning curve [21].

learning curve.

#### **11.4. Recurrents**

Postoperative pain, swelling and the presence of a mass in the inguinal region should be considered. Diagnosis can be made by radiological examinations. Technical factors that play a role in the development of recurrence include inappropriate patch size, inadequate patch, stress or inaccurate detection, lack of experience, tissue ischemia and infections. Factors related to the patient include malnutrition, obesity, wound healing disorders and uncontrolled diabetes mellitus. Surgical intervention should be considered in the treatment.

Other complications include urinary retention, which can be prevented by the patient's urination before surgery or by peroperative urinary catheterization. Paralytic ileus, visceral injuries, vascular injuries, intestinal obstruction, hypercapnia, pneumothorax and gas embolism are also uncommon complications.
