Chapter 37: Inguinal Hernias

CHAPTER 37: INGUINAL HERNIA | Surgery Marcy, Kocher, and Lucas-Championnière

HERNIA
▪ Occurs when the contents of the body cavity bulge out of the area where they are normally contained
▪ Usually portions of the intestines or abdominal fatty tissue
▪ May be asymptomatic or cause slight to severe pain
▪ Improved understanding of the anatomy and pathophysiology of inguinal hernias, coupled with the
development of aseptic technique
▪ Perform sac dissection, high ligation, and closure of the internal ring
▪ Outcomes improved
▪ Recurrence rates remained high with prolonged follow-up

Inguinal Hernia Bassini (1844–1924)

▪ Contents bulge through a weak area in the lower abdomen
Inguinal Hernia Repair
▪ Most commonly performed operation in the US (significant lifetime incidence and variety of
successful treatment modalities)
▪ Year 2003, ~ 800,000 cases were performed
▪ Advancements in perioperative anesthesia and operative technique
o Outpatient ambulatory operation
o Low recurrence rates and morbidity
▪ Quality of life and the avoidance of chronic pain: most important considerations in hernia repair
▪ ~ 75% of abdominal wall hernias occur in the groin
▪ The lifetime risk: MEN (27%) > WOMEN (3%)
▪ Of inguinal hernia repair: 90% in men and 10% in women
▪ Incidence in males has a bimodal distribution
o Peaks before the first year of age and after age 40
▪ Abramson (1978) demonstrated the age dependence of inguinal hernias
▪ Era of tissue-based repairs
▪ transformed inguinal hernia repair into a successful venture with minimal morbidity
▪ Modifications were manifest in the McVay and Shouldice repairs.
o All three of these techniques, as well as modern variations such as the Desarda operation,
are currently practiced
In the Early 1980s
▪ Lichtenstein popularized the tension free repair
▪ Supplanting tissue-based repairs with the widespread acceptance of prosthetic materials for inguinal
floor reconstruction.
▪ Could restore the strength of the transversalis fascia, thereby avoiding tension in the defect closure
With the Advent of Minimally Invasive Surgery
▪ Laparoscopic inguinal hernia repair
o Offers an alternative approach
▪ Minimizes postoperative pain, and improves recovery
▪ Intraperitoneal onlay mesh, the transabdominal preperitoneal (TAPP) repair, and the
totally extraperitoneal (TEP) repair.
▪ Array of prosthetic materials has been introduced to minimize recurrence and improve quality of life

ANATOMY OF THE INGUINAL REGION

Inguinal Canal
▪ ~4- to 6 cm-long cone-shaped region situated in the anterior portion of the pelvic basin
▪ Begins on the posterior abdominal wall, where the spermatic cord passes through the deep (internal)
inguinal ring, a hiatus in the transversalis fascia.
▪ Concludes medially at the superficial (external) inguinal ring, the point at which the spermatic cord
crosses a defect in the external oblique aponeurosis

▪ The most common subtype of groin hernia in men and women is the indirect inguinal hernia Boundaries of the Inguinal Canal
▪ External oblique aponeurosis anteriorly
Femoral Hernia ▪ Internal oblique muscle laterally
▪ ~70% of femoral hernia repairs are performed in women ▪ Transversalis fascia
▪ Inguinal hernias are five times more common than femoral hernias ▪ Transversus abdominis muscle posteriorly
▪ Internal oblique muscle superiorly
HISTORY ▪ Inguinal (Poupart’s) ligament inferiorly
Ancient Civilizations of Egypt and Greece
Spermatic Cord
▪ Management involved a conservative approach with operative management reserved only for
▪ Traverses the inguinal canal
complications
▪ Contains three arteries, three veins, two nerves, the pampiniformvenous plexus, and the vas deferens
▪ Routine excision of the testicle, and wounds were closed with cauterization or left to granulate on
▪ Enveloped in three layers of spermatic fascia
their own
▪ Mortality was quite high
Ligaments and Tendons
▪ For those that survived the operation, recurrence of the hernia was common
Iliopubic Tract
▪ Aponeurotic band that begins at the anterior superior iliac spine and inserts into Cooper’s ligament
Late 1700s to the early 1800s
from above
▪ Physicians (Hesselbach, Cooper, Camper, Scarpa, Richter, and Gimbernat) identified vital components ▪ Forms on the deep inferior margin of the transversus abdominis and transversalis fascia
of the inguinal region, and their contributions are reflected in the current nomenclature.
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▪ The shelving edge of the inguinal ligament is a structure that connects the iliopubic tract to the inguinal GENERAL CATEGORIES OF INGUINAL HERNIA
ligament
1) Indirect Hernias
▪ Helps form the inferior margin of the internal inguinal ring as it courses medially, where it continues as o Protrude lateral to the inferior
the anteromedial border of the femoral canal epigastric vessels, through the
deep inguinal ring
The Lacunar Ligament, or Ligament of Gimbernat 2) Direct hernias
▪ Triangular fanning of the inguinal ligament as it joins the pubic tubercle o Protrude medial to the
inferior epigastric vessels,
Cooper’s (Pectineal) Ligament
within Hesselbach’s triangle.
▪ Lateral portion of the lacunar ligament that is fused to the periosteum of the pubic tubercle. The borders of the triangle are
the inguinal ligament inferiorly,
The Conjoined Tendon
the lateral edge of rectus
▪ Commonly described as the fusion of the inferior fibers of the internal oblique and transversus sheath medially, and the
abdominis aponeurosis at the point where they insert on the pubic tubercle inferior epigastric vessels
superolaterally
Major Vessels Found in the Inguinal Region 3) Femoral hernias
Inferior Epigastric Artery o Protrude through the small
▪ Supplies the rectus abdominis
and inflexible femoral ring.
▪ Derived from the external iliac artery, and it anastomoses with the superior epigastric, a continuation The borders of the femoral
of the internal thoracic artery ring include the iliopubic tract
and inguinal ligament
Epigastric Veins anteriorly, Cooper’s ligament
▪ Course parallel to the arteries within the rectus sheath, posterior to the rectus muscles. Inspection of posteriorly, the lacunar
the internal inguinal ring will reveal the deep location of the inferior epigastric vessels. ligament medially, and the
femoral vein laterally.
Nerves Found in the Inguinal Region
Ilioinguinal Nerve
▪ Emerges from the lateral border of the psoas major and passes obliquely across the quadratus
lumborum FOR LAPAROSCOPIC HERNIA REPAIR, CONSIDER THE FOLLOWING:
▪ At a point just medial to the anterior superior iliac spine, it pierces the transversus and internal oblique Intraperitoneal Points of Reference during Laparoscopic Approach to Hernia Repair
muscles to enter the inguinal canal and exits through the superficial inguinal ring ▪ Five peritoneal folds, bladder, inferior epigastric vessels, and psoas muscle
▪ It supplies somatic sensation to the skin of the upper and medial thigh ▪ Posterior approach
o In males, it also innervates the base of the penis and upper scrotum
o In females, it innervates the mons pubis and labium majus

Iliohypogastric Nerve
▪ Arises from T12–L1. After it pierces the deep abdominal wall, it courses between the internal oblique
and transversus abdominis, supplying both. It then divides into lateral and anterior cutaneous branches.
A common variant is for the iliohypogastric and ilioinguinal nerves to exit around the superficial inguinal
ring as a single entity

Genitofemoral Nerve
▪ Arises from L1–L2, courses along the retroperitoneum, and emerges on the anterior aspect of the
psoas. It then divides into genital and femoral branches. The genital branch enters the inguinal canal
lateral to the inferior epigastric vessels, and it courses ventral to the iliac vessels and iliopubic tract. In
males, it travels throughthe superficial inguinal ring and supplies the ipsilateral scrotum and cremaster
muscle. In females, it supplies the ipsilateral mons pubis and labium majus

Femoral Branch
▪ Courses along the femoral sheath, supplying the skin of the upper anterior thigh. The lateral femoral
cutaneous nerve arises from L2–L3, emerges lateral to the psoas muscle at the level of L4, and crosses
the iliacus muscle obliquely toward the anterior superior iliac spine. It then passes inferior to the
inguinal ligament where it divides to supply the lateral thigh

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Two Potential Spaces within the Preperitoneum:

(1) Bogros’s (Preperitoneal) Space
▪ Between the peritoneum and the posterior lamina of the transversalis fascia
▪ Contains preperitoneal fat and areolar tissue
▪ Most medial aspect of the preperitoneal space, that which lies superior to the bladder, is known as the
space of Retzius
▪ The posterior perspective also allows visualization of the myopectineal orifice of Fruchaud, a
relatively weak portion of the abdominal wall that is divided by the inguinal ligament

(2) Vascular Space

▪ Situated between the posterior and anterior laminae of the transversalis fascia, and it houses the inferior
epigastric vessels

Important Anatomic Areas of Interest

The Triangle of Doom
▪ Bordered medially by the vas deferens and laterally by the vessels of the spermatic cord. The contents
of the space include the external iliac vessels, deep circumflex iliac vein, femoral nerve, and genital
branch of the genitofemoral nerve

The Triangle of Pain

▪ A region bordered by the iliopubic tract and gonadal vessels, and it encompasses the lateral femoral
cutaneous, femoral branch of the genitofemoral, and femoral nerves.

The Circle of Death

▪ A vascular continuation formed by the common iliac, internal iliac, obturator, inferior epigastric, and
external iliac vessels

PATHOPHYSIOLOGY
▪ Congenital or acquired
▪ Most adult inguinal hernias: acquired defects in the abdominal wall although collagen studies have
demonstrated a heritable predisposition
o The best-characterized risk factor is weakness in the abdominal wall musculature
▪ Pediatric hernias: congenital hernias
o Impedance of normal development, rather than an acquired weakness
▪ During the normal course of development, the testes descend from the intra-
abdominal space into the scrotum in the third trimester. Their descent is
preceded by the gubernaculum and a diverticulum of peritoneum, which
protrudes through the inguinal canal and becomes the processus vaginalis.
Between 36 and 40 weeks of gestation, the processus vaginalis closes and
eliminates the peritoneal opening at the internal inguinal ring.Most adult inguinal
hernias: acquired defects in the abdominal wall although collagen studies have DIAGNOSIS
demonstrated a heritable predisposition History
o Failure of the peritoneum to close results in a patent processus vaginalis (PPV), hence the ▪ Groin Pain
high incidence of indirect inguinal hernias in preterm babies. Children with congenital o Patients who present with symptomatic groin hernia
indirect inguinal hernias will present with a PPV; however, a patent processus does not ▪ Extrainguinal hernias (less common)
necessarily indicate an inguinal hernia. o e.g. change in bowel habits, urinary symptoms
▪ Inguinal hernias can compress adjacent nerves which can lead to:
o Generalized Pressure
o Localized Sharp Pain
o Referred Pain
▪ Pressure or heaviness in the groin (common)

Important considerations of the patient’s history:

▪ Duration
▪ Timing
▪
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▪ Hernias increase in size and content over a protracted time. Techniques of PE to differentiate between direct and indirect hernias:
o Ask questions that characterize whether hernia is reducible. ▪ Inguinal Occlusion Test
▪ Patients reduce hernia by pushing the contents back into the abdomen, providing o Examiner blocks the internal inguinal ring with a finger as the patient is instructed to cough.
temporary relief. ▪ Controlled impulse – indirect hernia
o As defect size increases and more intra-abdominal contents fill the hernia sac, the hernia ▪ Persistent herniation – direct hernia
become harder to reduce. ▪ These tests should be used to detect hernias, but NOT to diagnose hernia types.
▪ Ideally, patient should be examined in a standing position, with the groin and
scrotum fully exposed. Imaging
▪ Common radiologic modalities:
Physical Exam o Ultrasonography (US)
Inspection o Computed Tomography (CT)
▪ Identify an abnormal bulge along the groin or within the scrotum. o Magnetic Resonance Imaging (MRI)
▪ Ultrasonography (US)
Palpation o Least invasive technique
▪ Confirm the presence of hernia o Does not impart radiation to patient
▪ Performed by advancing the index finger through o Anatomic structures can be more easily identified by the presence of bony landmarks
the scrotum toward the external inguinal ring ▪ CT and MRI
o Provide static images that are able to:
Patient is asked to perform Valsalva’s maneuver ▪ Delineate groin anatomy
▪ To protrude hernia contents ▪ Detect groin hernias
▪ These maneuvers will reveal an abnormal bulge and ▪ Exclude potentially confounding anatomy
allow the clinician to determine whether hernia is
reducible or not. TREATMENT
▪ Surgical Repair
Examination of the contralateral side
o The definitive treatment of inguinal hernias
▪ To compare the presence and extent of herniation o However, operation is not necessary when patient’s medical condition confers an
between sides unacceptable level of operative risk. Elective surgery should be deferred until the condition
resolves.
▪ Nonoperative management
o Considered in minimally symptomatic patients

Open Approach
▪ Exposure of the anterior inguinal region is common to open approaches.
▪ An oblique or horizontal incision is performed over the groin.
▪ Open inguinal hernia repairs are subdivided into techniques that:
o Employ prostheses to create a tension-free repair
o Reconstruct the inguinal floor using native tissue

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Tissue Repairs (2) Plug and Patch Technique

▪ Suitable alternatives when prosthetic materials cannot be used safely (operative field contamination, ▪ A modification of the Lichtenstein repair.
emergency surgery, when viability of hernia contents is uncertain) ▪ Prior to placing the prosthetic mesh over the inguinal floor, a 3-dimentional prosthetic plug is placed in
the place previously occupied by the hernia sac.
(1) Bassini Repair
▪ Dissection of the spermatic cord
▪ Dissection of the hernia sac with high ligation
▪ Extensive reconstruction of the floor of the inguinal canal

(2) Shouldice Repair

▪ Recapitulates principles of the Bassini repair, and its distribution of tension over several tissue layers
results in lower recurrence rates.

(3) McVay Repair

▪ This technique is indicated for femoral hernias and in cases where the use of prosthetic material is
contraindicated

Prosthetic Repairs
▪ Mesh-based hernioplasty is the most commonly performed general surgical procedure.

(1) Lichtenstein Tension-Free Repair

▪ Expands the domain of the inguinal canal by reinforcing the inguinal floor with a prosthetic mesh,
thereby minimizing tension in the repair.
▪ The mesh is a 7x1.5 cm rectangle with a rounded medial edge, and it must be large enough to extend
2 to 3 cm superior to Hesselbach’s triangle.
(3) Prolene Hernia System
▪ Provides reinforcement to the anterior and posterior aspects of the abdominal wall.
▪ The mesh has an underlay flap and an onlay flap, joined by a short cylindrical connector.
▪ The underlay portion of the mesh is then placed through the hernia defect into the preperitoneal space.
▪ The overlay flap reinforces the inguinal floor similar to a tension-free repair.

Wound Closure
▪ Once the reconstruction of the inguinal canal is complete, the cord contents are returned to their
anatomic position

Giant Prosthetic Reinforcement of the Visceral Sac

▪ Also known as the Stoppa repair
▪ A broad prosthetic mesh is placed in the preperitoneal space from an anterior approach.

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Laparoscopic Approach ▪ Incision is made in the peritoneum at the medial umbilical ligament 3 to 4 cm superior to the hernia
▪ Laparoscopic inguinal hernia repairs reinforce the abdominal wall via a posterior approach defect, and it is carried laterally to the anterior superior iliac spine.
▪ Indications are similar to those for open repair ▪ The inferior edge of incised peritoneum is retracted, and the preperitoneum is dissected to expose the
▪ Any patient with a contraindication to the use of general anesthesia should not undergo laparoscopic spermatic cord.
hernia repair. o If a direct hernia is encountered,
▪ The patient is placed in the Trendelenburg position, and video screens are placed at the foot of the the sac is inverted and fixed to
bed. Cooper’s ligaments to prevent
▪ Surgeon stands contralateral to the hernia, and the assistant stands opposite the surgeon. The patient’s development of hematoma or
arms are tucked to the sides. seroma.
o For indirect hernia, the sac is
grasped and elevated superiorly
from the cord and the space
below is developed bluntly to
allow for mesh placement.
▪ The mesh usually measure 10 x 15cm to
completely cover the myopectineal orifice. It
is rolled lengthwise and placed through the
12-mm trocar. It is unrolled in the
preperitoneal space and secured medially to
Cooper’s ligament using a spiral tacker.
▪ The peritoneum should be closed completely
to avoid contact between the mesh and the
intestine. The abdomen is desufflated and the
trocars are removed.

(2) Totally Extraperitoneal (TEP)

Principal Laparoscopic Methods
(1) Transabdominal Preperitoneal Procedure (TAPP)
▪ Confers the advantage of an intraperitoneal perspective
▪ Useful for bilateral hernias, large hernia defects, and scarring from previous lower abdominal surgery
▪ Abdominal cavity is accessed using a dissecting trocar or open Hasson technique.
▪ Pneumoperitoneum is instilled to a level of 15mmHg and two 5-mm trocars are placed lateral and
slightly inferior to the umbilical trocar, avoiding injury to the inferior epigastric vessels.
▪ Confers the advantage of access to the preperitoneal space without intraperitoneal infiltration
▪ Minimizes the risk of injury to intra-abdominal organs and port site herniation through an iatrogenic
defect in the abdominal wall
▪ Indicated for repair of bilateral inguinal hernias or for unilateral hernias when scarring makes the
anterior approach challenging
▪ A small horizontal incision is made inferior to the umbilicus. Subcutaneous tissue is dissected to the
level of the anterior rectus sheath, which is then incised lateral to the linea alba. The rectus muscle is
retracted superolaterally, and a dissecting balloon is advanced through the incision toward the pubic
symphysis.

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▪ Under direct visualization with a 30° laparoscope, the balloon is inflated slowly to bluntly dissect the
preperitoneal space.
▪ The dissecting balloon is replaced with a 12-mm balloon trocar, and pneumopreperitoneum is achieved
by insufflation to 15 mmHg
▪ A 5-mm trocar is placed suprapubically in the midline, and another is placed inferior to the insufflation
port
▪ The patient is placed in the Trendelenburg position, and the operation proceeds in an identical fashion
to TAPP.
(3) Performed Intraperitoneal Onlay Mesh (IPOM)
▪ Permits the posterior approach without preperitoneal dissection.
▪ An attractive procedure in cases where the anterior approach is unfeasible, in recurrent hernias that
are refractory to other approaches, or where extensive preperitoneal scarring would make TEP or
TAPP challenging.
▪ Hernia sac contents are reduced; however, the sac itself is not inverted from the preperitoneal space.
Instead, mesh is placed directly over the defect and fixed in place with sutures or spiral tacks
Prosthesis Considerations
Most common types of mesh and fixatives:
▪ Synthetic Mesh Material
o Polypropylene and polyester are the most common synthetic prosthetic materials used
in hernia repair.
▪ Materials are permanent and hydrophobic; and promote a local inflammatory
response that results in cellular infiltration and scarring with slight contraction in
size.
o In selecting mesh material, considerations include mesh absorbability, thickness, weight,
porosity, and strength.
o Commonly used lightweight mesh materials include β-d-glucan, titanium-coated
polypropylene, and polypropylenepoliglecaprone.
▪ Biologic Mesh
o Commonly reserved for contaminated cases or when domain expansion is necessary in the
face of high infection risk.
o In general, they have lower tensile strength and subsequent higher rates of rupture than
synthetic prostheses
o Have varying degrees of tensile strength and tissue biocompatibility between them
▪ Fixation Technique
o Mesh may be fixed with fibrin-derived glue, and self-gripping mesh has been developed to
minimize trauma to surrounding tissues and to reduce the risk for entrapment neuropathy
o For hernias repaired via a strictly preperitoneal approach, prosthesis fixation may not be
necessary at all.
o In TEP repairs, fixation of mesh may not be compulsory.
o Anterior or transperitoneal repair without fixation is not recommended.
o Fibrin glue fixation is a successful alternative to tack fixation in hernia repair with a synthetic
prosthesis
COMPLICATIONS
Hernia Recurrence
▪ When a patient develops pain, bulging, or a mass at the site of an inguinal hernia repair, clinical entities
such as seroma, persistent cord lipoma, and hernia recurrence should be considered.
▪ Common medical issues associated with recurrence include malnutrition, immunosuppression, diabetes,
steroid use, and smoking.
▪ Technical causes of recurrence include improper mesh size, tissue ischemia, infection, and tension in
the reconstruction
▪ A focused physical examination should be performed.
▪ Recurrent hernia may warrant re-operation.
Chapter 37: Inguinal Hernias
Pain
▪ Pain after inguinal hernia repair is classified into acute or chronic manifestations of three mechanisms:
Nociceptive (somatic)
• Most common; usually a result of ligamentous or muscular trauma and inflammation
• Pain is reproduced with abdominal muscle contraction
• Treatment consists of rest, nonsteroidal anti-inflammatory drugs (NSAIDs), and reassurance, as it
resolves spontaneously
Neuropathic
▪ Result of direct nerve damage or entrapment
▪ May present early or late, and manifests as a localized, sharp, burning or tearing sensation
▪ May respond to pharmacologic therapy and to local steroid or anesthetic injections when indicated
Visceral
▪ Pain conveyed through afferent autonomic pain fibers
▪ Usually poorly localized and may occur during ejaculation as a result of sympathetic plexus injury
▪ Chronic postoperative pain syndromes:
o Post-herniorrhaphy inguinodynia
▪ A debilitating chronic complication caused by a combination of nociceptive,
neuropathic, and visceral elements.
▪ Incidence is independent of the method of hernia repair; however, the original
operative technique determines options for intervention and remedial surgery.
▪ Treatment is based on repair technique, subsequent re-operations, pain
character, and the presence of recurrence, meshoma, and fixation material.
▪ If it is refractory to pharmacologic and interventional measures, triple
neurectomy with removal of meshoma is the most effective option
o Local nerve entrapment
▪ Ilioinguinal and iliohypogastric nerves in anterior repairs and genitofemoral and
lateral femoral cutaneous nerves in laparoscopic repairs are at greatest risk of
entrapment
▪ Mimic acute neuropathic pain and occur with a dermatomal distribution
▪ Initial treatment consists of rest, ice, NSAIDs, physical therapy, and possible local
corticosteroid and anesthetic injection.
o Meralgia paresthetica
▪ Results from injury to the lateral femoral cutaneous nerve.
▪ Condition characterized by persistent paresthesias of the lateral thigh.
o Osteitis pubis.
▪ Characterized by inflammation of the pubic symphysis and usually presents as
medial groin or symphyseal pain that is reproduced by thigh adduction.
▪ Avoiding the pubic periosteum when placing sutures and tacks reduces the risk
of developing osteitis pubis
▪ if pain remains intractable, orthopedic surgery consultation should be sought for
possible bone resection and curettage.
Cord and Testes Injury
▪ Injury to spermatic cord structures may result in ischemic orchitis or testicular atrophy.
▪ Ischemic orchitis is likely caused by injury to the pampiniform plexus.
o Usually manifests within 1 week of inguinal hernia repair as an enlarged, indurated, and
painful testis, and it is almost certainly self-limited
o Emergent orchiectomy is only necessary in the case of necrosis
o Treatment for ischemic orchitis most frequently consists of reassurance, NSAIDs, and
comfort measures
▪ Injury to the testicular artery also may lead to testicular atrophy, which is manifested over a protracted
period.
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▪ Injury to the vas deferens within the cord may lead to infertility.
o Transections of the vas deferens should be addressed with a urologic consult and early
anastomosis, if possible.
LAPAROSCOPIC COMPLICATIONS
Urinary Retention
▪ Most common cause is general anesthesia, which is routine in laparoscopic hernia repairs
▪ Other risk factors for postoperative urinary retention include pain, narcotic analgesia, and perioperative
bladder distention.
▪ Initial treatment of urinary retention requires decompression of the bladder with short-term
catheterization.
▪ Patients will generally require an overnight admission and trial of normal voiding before discharge.
▪ Failure to void normally requires reinsertion of the catheter for up to a week.
OUTCOMES
▪ Incidence of recurrence is the most-cited measure of postoperative outcome following inguinal hernia
repair.
▪ Other salient signifiers of outcome include complication rates, operative duration, hospital stay, and
quality of life
▪ Among tissue repairs, the shouldice operation is the most commonly performed technique, and it is
most frequently executed at specialized centers
▪ Compared with open elective tissue-based repairs, mesh repair is associated with fewer recurrences
and with shorter hospital stay and faster return to usual activities
▪ Compared to open approaches, laparoscopic primary inguinal hernia repair produces equivalent
recurrence rates and improved recovery time, pain prevention, and return to normal activities
▪ In TAPP repair, the risk of intra-abdominal injury is higher than in TEP repair thus TAPP should only
be attempted by surgeons with sufficient experience

Ileus and Bowel Obstruction

▪ Transabdominal approach is associated with a higher incidence of ileus than other modes of repair
▪ Complication is self-limited; however, it necessitates sustained inpatient observation, intravenous fluid
maintenance, and possibly nasogastric decompression.

Visceral Injury
▪ Small bowel, colon, and bladder are at risk for injury in laparoscopic hernia repair
▪ Direct bowel injuries may also result from trocar placement
▪ In reoperative abdominal surgery, open Hasson technique and direct visualization of trocars are
recommended to reduce the likelihood of visceral injury
▪ If injury to the bowel is suspected, its entire length should be examined, and conversion to open repair
may be necessary.
▪ Bladder injuries are less common but if encountered, cystotomies must be repaired in several layers
with 1 to 2 weeks of Foley catheter decompression.

Vascular Injury
▪ The most severe vascular injuries usually occur in iliac or femoral vessels, either by misplaced sutures
in anterior repairs, or by trocar injury or direct dissection in laparoscopic repairs
▪ Conversion to an open approach may be necessary, and bleeding should be temporarily controlled with
mechanical compression until vascular control is obtained
▪ most commonly injured vessels in laparoscopic hernia repair include the inferior epigastrics and
external iliacs.
▪ If injured, the inferior epigastrics may be ligated with a percutaneous suture passer or endoscopic
hemoclips.

Hematomas and Seromas

▪ Hematomas
o Present as localized collections or as diffuse bruising over the operative site
o Injury to spermatic cord vessels may result in a scrotal hematoma
o Self-limited; Intermittent warm and cold compression aids in resolution
▪ Seromas
o Loculated fluid collections that most commonly develop within 1 week of synthetic mesh
repairs.
o Treatment consists of reassurance and warm compression to accelerate resolution.
o To avoid secondary infection, seromas should not be aspirated unless they cause
discomfortor they restrict activity for a prolonged time

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