**4. Hernia surgery complications**

#### **4.1. Recurrence**

Recurrence of hernia is usually seen as a late complication of hernia surgery. When it occurs, it is generally due to deep infection or due to the excessive tension of the repaired tissues and tissue ischemia. Early over-activity is a principal causative agent of recurrent hernia, as it results in inadequate fibrous tissue formation around the mesh or suture used to approximate the hernia sac. O'Reilly et al. [29] found that patients who underwent a laparoscopic repair for an inguinal hernia had a higher chance of having a recurrence in comparison to those who underwent open repair. Recurrence should be differentiated from other etiologies that could have similar clinical presentations such as seromas in the obliterated hernia sac [30]. Seroma can be defined as fluid-filled dead space in the distal remnants of hernial sac, seromas are usually seen after laparoscopic repair and are sometimes termed as a pseudo-hernia. Other etiologies include hematomas that could be seen in anti-coagulated patients. They could be of a concern if they were of large volume, as they could provide an optimal environment for bacterial growth and infection. Overall hematomas are far more common than seromas and both could be prevented with a careful hemostasis during surgery [31]. One of the primary causes of hernia recurrence is wound tension; excessive tension could lead to tissues pulling apart thus recurrence at an early stage post-operatively. Excessive tension can also lead to tissue ischemia leading to sutures pulling apart or even falling off. Henceforth new modalities of tension free and suture-free hernia repairs are being promoted by experts such as Lichtenstein [7, 32].

Another factor to consider is the size of the initial hernia defect which is proposed proportional to the risk of developing recurrence in the aftermath of hernia repair. This fact might be explained by the quality of the tissue and fascia surrounding the defect area. As the defect grows bigger it affects the surrounding fascial plans making them weaker and relatively more ischemic in comparison to smaller sized defects. Isik et al. [33] found that higher levels of matrix metalloproteinase s-1-2-9-13, in addition to decreased levels of tissue inhibitors of metalloproteinases-1-2-3 played an integral role in the formation of inguinal hernia, leading to dysfunction of collagen fibers, which will result in weakening of fascia, indicating that a hernia is not only a local issue, but rather a reflection of systemic disease [33]. Other etiologies for hernia recurrence include complicated hernia at presentation such as incarceration or strangulation, in which the tissue will be inflamed and edematous providing a good medium for recurrence as the tissue is unhealthy, to begin with. Another causative agent for recurrence is smoking which is said to increase proteolytic enzymes and decrease protective factors involved in tissue healing [11].

### **4.2. Neuralgia**

**4. Hernia surgery complications**

Recurrence of hernia is usually seen as a late complication of hernia surgery. When it occurs, it is generally due to deep infection or due to the excessive tension of the repaired tissues and tissue ischemia. Early over-activity is a principal causative agent of recurrent hernia, as it results in inadequate fibrous tissue formation around the mesh or suture used to approximate the hernia sac. O'Reilly et al. [29] found that patients who underwent a laparoscopic repair for an inguinal hernia had a higher chance of having a recurrence in comparison to those who underwent open repair. Recurrence should be differentiated from other etiologies that could have similar clinical presentations such as seromas in the obliterated hernia sac [30]. Seroma can be defined as fluid-filled dead space in the distal remnants of hernial sac, seromas are usually seen after laparoscopic repair and are sometimes termed as a pseudo-hernia. Other etiologies include hematomas that could be seen in anti-coagulated patients. They could be of a concern if they were of large volume, as they could provide an optimal environment for bacterial

Infection occurs within 30 days after the surgery and involves skin and subcutaneous tissue

of the incision and encompasses the following criteria:

• Purulent discharge from deep tissue layer • Deep incisional spontaneous dehiscence

• Diagnosis made by an experienced surgeon

• Diagnosis made by an experienced surgeon

**Table 1.** Types and criteria for the diagnosis of surgical wound infection [22].

encompass the following criteria: • Purulent discharge from a drain • Organisms isolated from suspected area

• Acute inflammatory reaction with pain, swelling, redness, and heat

Deep incisional Infection occurs within 30 days after the operation if there are no implants or within 1 year

• Deep tissue infection or abscess found by direct examination

• Deep tissue infection or abscess found by direct examination

Organ space Infection occurs within 30 days after the operation if there are no implants or within 1 year

from the surgery if there are implants. Infections are related to implanted prosthetic material and involves deep fascial layers and muscle tissue, and encompass the following

from the surgery if there are implants. Infections are related to implanted prosthetic and involve organs or anatomical spaces that were manipulated during surgery, and

**4.1. Recurrence**

**Depth of infection**

Superficial incisional

**Comments**

96 Hernia Surgery and Recent Developments

criteria:

• Purulent discharge • Isolated organism

> Nerve injury could be a terrible consequence of an otherwise successful surgery presenting with pain, loss of sensation or muscular weakness. Neuralgia, commonly known as postoperative pain, is a rather common complication with varying degrees of pain after herniorrhaphy and follows nerve distribution. While some degree of post-operative pain is expected after surgery, for the diagnosis of post-herniorrhaphy neuralgia to be made, pain should persist for more than 3 months, not to be attributed to any other cause and interfere with patient social and/or sexual life [34, 35]. The differential diagnosis for post-herniorrhaphy neuralgia includes hernia recurrence, mesh infection or displacement, osteitis pubis, and fluid collection. Open approach injuries usually affects the ilioinguinal nerve, iliohypogastric nerve, genital branch of the genitofemoral nerve, while injuries to the lateral femorocutaneous nerve is more common with laparoscopic approach, see **Table 2** [1, 36].Most of the time, the mechanism of injury is attributed to nerve entrapment within the mesh or the suture line. This can be prevented with careful handling of the tissue and preventing over manipulation of the nerves. In laparoscopic approach staple placement below the iliopubic tract decreases the risk of nerve entrapment [37].

> Ilioinguinal and iliohypogastric nerves are mostly injured during elevation of the external oblique fascia. The genitofemoral nerve is thought to be injured following cord isolation for cremasteric muscle fibers stripping. As soon as the nerves are identified, they are retracted out of the field by encircling them with a vessel loop and retraction. While injury happens with


population cord traction might cause testicular migration into the inguinal canal. Therefore,

Worst Case Scenarios! Complications Related to Hernial Disease

http://dx.doi.org/10.5772/intechopen.76079

99

Vas Deferens injury is considered a rare complication yet the most feared. However, if such an injury was to happen, it requires an urgent urological consultation; injuries range from as severe as transection to a mild laceration. Untreated injuries can result in the formation of anti-sperm antibodies and infertility. Avoiding such dreaded complications is possible by

Mesh migration or erosion may occur after femoral or inguinal hernias and depends on the extent of the symptoms; hence mesh removal might be advised. Mesh migration can be categorized into primary and secondary. Primary, also known as mechanical, is when the mesh dislodges along the path with least resistance as a result of inadequate fixation or external forces. While secondary, is the slow movement of the mesh through nearby anatomical structures due to body response to a foreign body. The result is an erosion of adjacent structures such as the urinary bladder leading to urinary tract infections or hematuria, bowel injury and subsequent fistula formation, and spermatic cord erosion causing vessel obstruction [45, 46].

Ott et al. [47] reported a case of late intestinal fistula formation as a consequence of an incisional hernia repair using an inter-peritoneal mesh. Animal studies showed that micro-erosions and mesh migration and consequent fistulae formation is decreased when mesh covered with biological material such as collagen [48]. In addition, Leber [49] reported a higher incidence

Also known as an incisional hernia, post-operative hernias occur as a direct result of fascial tissue failure to heal post laparotomy. Although incisional hernias are frequently seen either post mid line and/or transverse incisions, it can, in theory, happen after any surgical incisions like paramedian and McBurney incisions, and are also seen post laparoscopic surgeries [50]. Such hernias can grow to huge sizes and contain a significant amount of small and large bowel. Previously, the incidence was believed to be around 20%, but recent epidemiological studies estimate the number to be 11%. Around two-thirds of cases may present within the first 12 months after the operation, while the other -third present as a late complication after 5–10 years [51–53]. Risk factors of incisional hernias are increased with advanced patient age, malnutrition, immune-compromised state, smoking, and obesity [12, 15, 54, 55]. Other factors that play an important role include emergency surgery and post-operative wound infection. One major complication of incisional hernia repair surgery is a high recurrence rate, which might reach up to 50%. In some cases this risk is related to the type of surgical approach, whether suture repair or mesh supported repair, and also to the amount of tension applied on the wound edges. Recurrence in this type of hernia is also related to the appearance of unrecognized hernia sites [56]. Another set of complications is related to the empty hernia cavity that is left

entero-cutaneous fistula formation with the use of Mersilene mesh.

before the end of the surgery testes are palpated to ensure the right placement [1, 44].

gentle traction of the vas and avoiding grasping or squeezing the Vas Deferens [21].

**4.4. Mesh erosion\migration**

**5. Post-operative hernia**

**Table 2.** Commonly injured nerves post-herniorrhaphy [1].

mesh tacking in the laparoscopic approach, which can be side stepped by avoiding tacking in known areas of nerves distribution [1]. O'Reilly et al. [29] found that the risk for post-herniorrhaphy neuralgia and/or numbness was significantly lower with laparoscopic approach when compared with open approach [28].

The first line in the management of neuralgia is usually conservative, mainly by local anesthesia injections in the affected groin. When this modality fails, surgical re-exploration is advocated to identify the affected nerve and excise it. On rare cases of patients presenting with pain not matching the distribution of a single nerve, surgical re-exploration is not advised as it usually will fail improving the pain and may result in damaging more structures [15, 38].

### **4.3. Visceral injury**

Bladder, testicular, and vas deferens injuries are among the commonly injured visceral organs with groin herniorrhaphy procedures Among the least injured structures are the ureters which are more often seen with the laparoscopic approach- the most common type of injury is incomplete transection of the ureter and ureteral perforation [39–41]. Bladder injuries are frequently reported with direct inguinal hernias, and in rare cases could result in a sliding hernia, in which part of the bladder adheres to the hernia sac. Thus, direct sacs are usually inverted back into the peritoneal cavity to avoid unnecessary dissection [42, 43].

Testicular swelling and atrophy could develop after inguinal hernia repair. Swelling and edema of the scrotum are due to hematoma or edema of the inguinal canal that progress inferiorly to the scrotum with gravity. On one hand, testicular atrophy is associated with blood supply injury during the process of dissection and isolation of the cord and usually is a painless complication. On the other hand, testicular pain post-operatively could be a result of torsion or abscess and ruling out such suspicion is done by ultrasound imaging. In the pediatric population cord traction might cause testicular migration into the inguinal canal. Therefore, before the end of the surgery testes are palpated to ensure the right placement [1, 44].

Vas Deferens injury is considered a rare complication yet the most feared. However, if such an injury was to happen, it requires an urgent urological consultation; injuries range from as severe as transection to a mild laceration. Untreated injuries can result in the formation of anti-sperm antibodies and infertility. Avoiding such dreaded complications is possible by gentle traction of the vas and avoiding grasping or squeezing the Vas Deferens [21].
