**5. Post-operative hernia**

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

• Anterior thigh area

• Mons pubis and Labia majora

• Skin of the gluteal area

• Anterior lateral thigh area

• The root of the penis and upper scrotum

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].

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

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

inverted back into the peritoneal cavity to avoid unnecessary dissection [42, 43].

compared with open approach [28].

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

**Nerve Area affected**

98 Hernia Surgery and Recent Developments

Ilioinguinal nerve • Proximal and medial thigh

Iliohypogastric nerve • Skin of the hypogastric area

Genitofemoral nerve • Mons pubis and scrotum/labia

Femoral nerve • Motor nerve to quadriceps femoris

Later femoral cutaneous nerve Anterior lateral thigh area

**4.3. Visceral injury**

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 behind post reduction of hernia sac, such as hematomas and seromas. Henceforth, experts recommend placement of closed suction drainage; which by itself along with mesh will increase the risk of infection post-operatively [57, 58].

before surgery, and fluids should be managed judiciously along with continuous monitoring of the patient vital status [65–67]. While post-operative period is mainly concerned with pain management, fluid and diet, avoidance of nasogastric tube and early urinary catheter removal,

Worst Case Scenarios! Complications Related to Hernial Disease

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

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An umbilical hernia is usually seen in the pediatric population with an incidence of 10–30% at birth in infants of Caucasian ethnicity and higher in those of African-American ethnicity, for unknown reasons [1]. It is also more common in premature infants of all races, and some report a tendency for familial inheritance. While the cause is yet to be identified in most of the cases, an umbilical hernia usually will regress and close on its own by 2–3 years of age with

Meanwhile, umbilical hernias in adults have a different clinical presentation, most being acquired not congenital with a male to female ratio of 3:1. The adult-type umbilical hernia usually will need surgical intervention for it to close and usually are symptomatic at time of presentation. A typical presentation will be of an exquisitely tender peri-umbilical mass overlying the skin; long-standing untreated umbilical hernia might result in thinning of covering skin and ulceration due to pressure necrosis of the adjacent skin. While small umbilical hernias could pass unnoticed and discovered incidentally. This type of hernia is associated usually with recurrence in the setting of high intra-abdominal pressure. For this reason, surgical repair is offered for incarcerated hernia or a progressively symptomatic

Although the overall incidence of inguinal hernia in the pediatric population is low when compared with adults, the complication that might arise is almost the same. In the age group, bowel incarceration is incidence is low, but should this be the case, bowel infarction would happen within 2–3 hours. With bowel infarction, it is not uncommon to get testicular blood supply compromise leading to ischemic necrosis and testicular atrophy with an incidence around 9% according to some studies [71–73]. While in girls, ovarian torsion is reported to happen with inguinal hernia strangulation in about third of patients with incarcerated hernia that contain an irreducible ovary. For this reason, some experts recommend not to delay sur-

The congenital diaphragmatic hernia is caused by a diaphragmatic defect resulting abdominal viscera herniating to the chest. It usually presents in the first few hours of life with respiratory distress so severe that it could be incompatible with life [75]. In many cases, this condition

early mobilization, and finally early discharge [68, 69].

**7. Hernia and the pediatric population**

less than 10% needing surgical intervention.

gical intervention in this population [74].

**7.3. Congenital diaphragmatic hernia**

**7.1. Umbilical hernia**

type [3, 11, 70].

**7.2. Inguinal hernias**

### **6. Enhanced recovery after hernia surgery**

The aim of enhanced recovery after surgery protocols is to improve outcomes, lower health cost, while harnessing the benefits by standardizing the medical care [59, 60]. Such protocols are evidence-based guidelines that include minimizing surgical trauma, post-operative pain, reduce complications, and improve outcomes by decreasing the expected length of hospital stay and fasten the patient recovery [61]. Such approach to patient care should be a multidisciplinary approach including surgeon, anesthesiologists or pain specialists, nursing staff, physical rehabilitation service, and most importantly patient cooperation [62, 63]. Patients who are followed with an enhanced recovery protocol will have the same discharge criteria but will reach these milestones sooner. This approach will usually contain 15–20 elements and will span through the full patient hospital stay; preoperatively, intra-operatively, and postoperatively (**Table 3**) [64]. Before surgery, patient education and counseling about current treatment options and best approach should be discussed. After that, a meticulous overview of the patient general health condition and management of any comorbidities such as renal, cardiac, or respiratory should be done. Intra-operatively prophylactic antibiotics are recommended


**Table 3.** Main criteria for enhanced recovery after surgery protocol [66].

before surgery, and fluids should be managed judiciously along with continuous monitoring of the patient vital status [65–67]. While post-operative period is mainly concerned with pain management, fluid and diet, avoidance of nasogastric tube and early urinary catheter removal, early mobilization, and finally early discharge [68, 69].
