immediately (i.e., in the recovery room). This patient may be best served by immediate re-exploration

before scar tissue develops. When groin exploration is required, triple neurectomy and neuroma

excision, adhesiolysis, and foreign body removal (i.e., mesh or suture) are options for treatment. The

patients reoperated for persistent pain after hernia surgery often experience a reduction in pain, but a

small percentage of patients experience no relief or even worsening of their symptoms.94 Given the

heterogeneity of the problem, further well designed studies are necessary to identify patient population

that may benefit the most from surgical intervention.

Cord and Testicles

Infertility. Infertility caused by inguinal hernia surgery is a recognized complication. The cause of

infertility can be related to either the vas deferens or the testicle. The incidence of injury to the vas

deferens during inguinal herniorrhaphy has been estimated at 0.3% for adults and between 0.8% and

2% for children.95 Injury to the testicle, which eventually leads to atrophy, is estimated to occur in

about 0.5% for primary hernia repairs but increases 10-fold to 5% for recurrent repairs. Injuries to the

vas deferens that may present as an obstruction include division, ligation, clipping, stapling,

electrocauterization, devascularization, and scarification. In addition, there is evidence that there is a

small subset of patients whose inflammatory response to mesh is so severe that vasal obstruction

results.96 In addition to obstruction, traction injuries during normal cord mobilization may damage the

muscular layer of the vas deferens, which then interferes with rapid sperm transfer during ejaculation.97

Sperm antibodies may develop as a result of extravasation of sperm at an injury site, which is why a

unilateral injury can also result in infertility. The role of mesh in the causation of infertility has been

implicated by some small case series and case reports. Ironically, one of the major arguments for the

routine use of mesh in inguinal hernia surgery is to preserve fertility. The theory is that by decreasing

the generally accepted recurrence rate in the general population from 10% to 15% seen with Bassini and

its variants to less than 5% with the mesh tension-free approach, reoperative surgery, with its heavy toll

of testicular loss, is avoided.98

Ischemic Orchitis. Damage to the blood supply of the testicle can cause ischemic orchitis and testicular

atrophy.97 Ischemic orchitis occurs in about 1% of primary hernioplasties but is much more common

with operations performed for recurrent hernias.99 It manifests as postoperative inflammation of the

testicle developing within 1 to 2 days after surgery. The patient has a painfully enlarged testicle that is

hard in consistency and associated with low-grade fever. Pain is severe and may last several weeks.

Ischemic orchitis is caused by thrombosis of the veins draining the testicle after extensive dissection of

the spermatic cord. It is generally accepted that the incidence can be decreased by division of large

inguinal–scrotal sacs leaving the distal sac open in situ rather than excising it.100 The majority of

patients with testicular swelling as an immediate complication of herniorrhaphy recover without

testicular atrophy. In one report, testicular atrophy developed in 19 patients among 52,583 primary

inguinal hernia repairs (0.036%) and 33 patients among 7,169 recurrent inguinal hernia repairs

(0.46%).101 A substantial number of patients who develop testicular atrophy after inguinal

herniorrhaphy have no history of a testicular problem at the time of the index operation. The

management of a patient with ischemic orchitis is usually conservative with elevation and antiinflammatory medication. Antibiotics and steroids have been used but their value is unproved.

Miscellaneous. Hydroceles occasionally develop after inguinal herniorrhaphy, but the cause is not

known and therefore a preventative measure is not possible. The urologic literature suggests that the

practice of leaving the distal aspect of an indirect inguinal sac in situ rather than removing it should be

incriminated, but this is not accepted by most experienced hernia surgeons. The treatment is the same as

for any other hydrocele. Testicular descent is a complication felt to be related to complete division of

the cremasteric muscle, but the occurrence is variable. The cord structures lose their tethering effect,

allowing the testicle to descend into the most dependent portion of the scrotum. Due to the elasticity of

the scrotum, with time, gravity causes the scrotum to elongate. Patients complain their testicle “drops

into the toilet” and can be quite unhappy. Few hernia surgeons now routinely completely divide the

cremasteric muscle, so it is hoped that this will become a rare phenomenon. The dysejaculation

syndrome is characterized by searing, burning, painful sensations throughout the groin around the time

of ejaculation. The incidence is approximately 0.04%.100

Wound Infection. This is a surprisingly rare complication of groin herniorrhaphy (<5%) and the

reason for the “protected” status, especially when compared to prosthetic ventral herniorrhaphy, is not

known.101 Most cases of necrotizing fascitis following inguinal hernia repair have been associated with

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either strangulated bowel or appendicitis in the hernial sac. Necrotizing fasciitis has only previously

been reported in a few cases following elective hernia repair. Other factors leading to infection are preexisting infection or ulceration of the skin over the hernia, obesity, incarcerated or obstructed bowel

within the hernia, and perforation of the bowel at the time of hernia repair. Untreated seromas can

become secondarily infected. It is not always necessary to remove the mesh prosthesis in the presence

of infection. A trial of local wound care after opening of the incision and debridement is warranted.

Seromas. Seromas are common with extensive flap dissection in large hernias and with the use of

synthetic mesh in laparoscopic hernia repairs and are possibly related to the size of the mesh used. The

fluid eventually resorbs spontaneously. Aspiration is performed for symptomatic relief only. Strategies

to prevent and manage seromas are largely based on empiricism and personal opinion, as objective data

are nearly absent.

Bleeding. Hemorrhage can occur from the cremasteric, internal spermatic, or inferior epigastric vessels.

Conservative treatment with reassurance is preferred for a stable hematoma. Evacuation is rarely

required. Injuries to the deep circumflex artery, the corona mortis, or the external iliac vessels may

result in a large retroperitoneal hematoma.

Prosthetic Complications. Shrinkage of polypropylene and other meshes should be considered by

surgeons when performing prosthetic repairs. The decrease in size is felt to be due to scarification of the

recipient’s tissue. Intestinal obstruction or fistulization is possible by erosion, especially if there is

physical contact between intestine and the prosthesis. Rejection because of an allergic response is

possible but extremely rare. What patients cite as “rejection” of the mesh is usually the result of

infection. Local erosion into the cord structures has also been reported.102

Complications Related to Laparoscopy

Vascular Injury. These are for the most part related to access. The most serious injuries occur to

vessels that reside in the retroperitoneum. For all laparoscopic procedures, the risk for major vascular

injury that requires operative intervention is 0.9 per 1,000 cases.103 The vessels most at risk are the

distal aorta, common iliac arteries and veins, and inferior vena cava and the inferior epigastric vessels.

Injuries to the renal vessels have also been reported. These vessels are fixed and may be penetrated

even if the safety mechanisms of the needle or trocar are working properly. The mesenteric and

omental vessels are also at risk, especially in the presence of adhesions. The epigastric arteries may be

injured with secondary cannula placement.

The insufflation needle is the most common cause of vascular injury but may be self-limiting; on the

other hand, injuries caused by a trocar are usually more obvious and catastrophic. The mortality

associated with retroperitoneal injury secondary to trocar insertion ranges from 9% to 36%, even with

rapid identification and repair. When retroperitoneal trocar injury is suspected, immediate conventional

laparotomy is almost always indicated. Most abdominal wall vascular complications occur during the

placement of secondary cannulas. Usually, pressure can be applied to bleeding at the trocar site with the

cannula. Occasionally, suture ligation is required, which has been simplified by the development of

disposable “exit devices” designed to facilitate the placement of fascial sutures. Most of these

complications can be avoided by placing the secondary trocars under direct vision.

Gas Embolism. This is caused by intravascular insufflation.104 It is an uncommon complication, unique

to the needle insufflation technique. Careful attention to tests confirming proper peritoneal needle

placement will keep the incidence of this complication low.

Visceral Injury. Visceral injuries are uncommon, occurring in 1.8 per 1,000 cases of all laparoscopic

procedures, but they have a mortality rate of 5%.103 The most common means of injury is the

insufflation needle. Simple repair laparoscopically is usually possible as most are self-limiting. If the

injury is caused by a trocar, formal repair of the injury will be needed. The injury can be repaired

laparoscopically if the skill of the laparoscopic surgeon is sufficient. Otherwise, laparotomy is

mandatory. Quite often, these injuries go unnoticed at the time of insult, so that visceral injury is the

most common cause of late morbidity and mortality associated with laparoscopic access. Patients

typically present with peritonitis and sepsis 2 days to 1 week after surgery.

Bladder Injury. Bladder injury can be the result of a laparoscopic misadventure or can be directly

related to the herniorrhaphy. Laparoscopic peritoneal access can result in a bladder perforation, usually

the result of failure to decompress a distended bladder. Less commonly, injury is associated with a

congenital bladder abnormality. Bladder injury has not been reported with the open access technique.

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Injury to the bladder can also occur during secondary suprapubic trocar placement during the course of

an operation. When bladder injury occurs, it is usually obvious. After Veress needle insertion, urine is

withdrawn into the syringe, or blood and gas are noticed in the urine if the patient is catheterized. In

questionable cases, methylene blue dye may be instilled into the bladder to look for leakage. Bladder

injury recognized during laparoscopy should be repaired laparoscopically provided the experience of the

surgeon is sufficient. This should be followed by bladder drainage for 7 to 10 days.

Bladder injury may present in a delayed fashion with hematuria and lower abdominal discomfort. A

retrograde cystogram usually confirms the diagnosis. Small defects may be managed with postoperative

decompression via an indwelling catheter for urinary drainage, while larger defects necessitate repair.

The bladder is especially prone to injury during preperitoneal herniorrhaphies or when the

preperitoneal space has previously been dissected (e.g., previous preperitoneal hernia repair or

prostatectomy).105

Bowel Obstruction. This problem plagued the developmental stages of laparoscopic inguinal

herniorrhaphy for two reasons. First, the importance of closing trocar sites at the fascial level if greater

than 5 mm was not appreciated, resulting in the occasional patient with an incarcerated or strangulated

ventral hernia at the trocar site, leading to the clinical presentation of a bowel obstruction. There are

now several different types of reusable and disposable appliances designed to facilitate trocar site fascial

closure, which should minimize the incidence of these hernias. The second is inadequate peritoneal

closure over the prosthesis, which allows bowel to migrate into the preperitoneal space, also resulting

in intestinal obstruction. Steps taken to avoid tension at the peritoneal closure site (see TAPP technique

section) have decreased this problem. Theoretically, the TEP procedure eliminates the possibility of this

complication because the abdomen is not entered. However, inadvertent breaches of the peritoneum

during a TEP herniorrhaphy are common, especially in patients with thin peritoneum or those who have

scar tissue associated with previous lower abdominal surgery. These peritoneal lacerations can be

difficult to recognize because they are not in the visual field of the limited working space, and indeed,

intestinal obstruction has been reported.106

Diaphragmatic Dysfunction. Phrenic nerve palsy has been reported with a variety of laparoscopic

procedures; it is usually transient but has been known to require a short period of mechanical

ventilation. Stretching during the pneumoperitoneum probably causes this complication.

Hypercapnia. This is the result of inadequate compensatory ventilation given the fact that, in the vast

majority of laparoscopic procedures, carbon dioxide is used as the insufflating agent.

Table 72-9 Classification of Ventral Abdominal Wall Hernias

VENTRAL ABDOMINAL WALL HERNIAS

Repair of ventral abdominal wall hernia is one of the most common procedures performed by a general

surgeon. Ventral hernias comprise a diverse group of hernias and are best divided into their various

subtypes when discussing surgical management because the natural history as well as results of

operations varies depending on the specific hernia. Table 72-9 uses the common terminology familiar to

all surgeons for classifying abdominal wall hernias. Table 72-10 is a classification system published by

Zollinger that expands upon Table 72-9 by further subdividing ventral hernias based on etiology.107 An

expert panel of European Hernia Society proposed a grid classification system of incisional hernias in

based on localization, size, recurrences, and symptoms (Table 72-11)108,109 and the Ventral Hernia

Working Group (VHWG)110 (Table 72-12) has proposed a grading system for ventral hernias based on

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risk of post-operative surgical site occurrences.

Table 72-10 Zollinger Classification of Ventral Abdominal Wall Hernias

Table 72-11 European Hernia Society (EHS) Classification of Incisional Hernia

UMBILICAL AND PERIUMBILICAL HERNIAS

Umbilical and periumbilical hernias are usually congenital, caused by arrest of the normal spontaneous

closure of the umbilical ring through which umbilical blood vessels pass in the developing fetus, which

results in a defect in the fascia covered by skin. In infants, the fascial defect varies in size but is most

commonly 1 to 2 cm. A large proportion of pediatric umbilical hernias heal spontaneously, and 80% of

them close by the time the patient is 2 years old. This is the only abdominal wall defect genetically

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