Complications of Groin Hernia Repair: Their Prevention and Management

Ray D. Gaines, MD
Omaha, Nebraska

An estimated overall complication rate of approximately ten percent is found in the half million patients who annually undergo groin hernia repair in the United States. Certain features in the operative technique are emphasized which should prevent many of these complications. Intraoperative complications during the groin hernia repair are primarily hemorrhage and injury to the vas deferens, the three nerves in the area, the vascular supply of the testis, and the abdominal and pelvic viscera. Miscellaneous intraoperative complications relate to problems associated with the repair of massive hernias, missed hernia, and the loss of strangulated bowel into the abdominal cavity. Early postoperative complications may be either systemic or local with cardiac and respiratory conditions comprising the former group. The early local complications are primarily wound problems of infection, hematoma formation, and scrotal swelling involving the skin and testis. High ligation in excision of the sac in all hernias, repair of the defect in the plane of its occurrence, and suture of fascia to fascia in the same plane without tension are the basic tenets of inguinal hernia repair which should result in a low incidence of recurrence. The most effective prophylactic measures necessary for the prevention of complications considered are a thorough knowledge of inguinofemoral anatomy, mature surgical judgment, and meticulous surgical technique.
"You can judge the worth of a surgeon by the way he does a hernia." -Fairbank' Each year one half million Americans undergo groin hernia repair. It is one of the most common operations performed in US hospitals. There is an estimated ten percent complication rate associated with the procedure.2 Stated another way, approximately 50,000 paPresented to the 82nd Annual Convention of the National Medical Association, Los Angeles, California, August 4, 1977. Requests for reprints should be addressed to Dr. Ray D. Gaines, Department of Surgery, Creighton University, 601 North 30th Street, Omaha, NB 68131.

tients annually will experience some complication. Postoperative complications are always of concern to the surgeon. Some are of little consequence, others lead to prolonged disability, and some end in death. It is the surgeon's responsibility to ensure their prevention, recognition, and management.3 Four categories of complications exist. They are: (1) those arising from the disease for which the operation is performed, (2) those arising from associated conditions unrelated to the primary disorder, (3) those resulting directly from the operative procedure itself, and (4) those due in part to any of the preceding groups but not attribut-

able to any single one. It is the purpose of this discussion to emphasize some of the more common complications of groin hernia repair. Careful observation of certain features in operative technique will prevent many of the complications. These features include: (1) clean sharp dissection, (2) avoidance of rough dissection and trauma as from gauze or fingers, (3) use of minimal volumes of local anesthetic agents, (4) appropriate use of relaxing incisions to avoid tension, (5) utilization of nonabsorbable sutures, ie, monofilament type if the potential exists for contamination, and (6) irrigation of each wound layer.
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Intraoperative Complications
Intraoperative complications during groin hernia repair consist of hemorrhage, severance of the vas deferans, injury to the nerves in the area, injury to the vascular supply of the testes, injury to the abdominal viscera, and other miscellaneous problems. Meticulous hemostasis, achieved with fine ligatures, will help to prevent bleeding complications such as hematoma, seroma, or lymphocele formation. Significant hemorrhage during the operation is usually the result of injury to one of three vessels-the pubic branch of the obturator artery, often referred to as the corona mortis; the deep inferior epigastric vessels; and the external iliac artery and vein. Bleeding from the first two vessels can be troublesome but control can usually be achieved by extension of the exposure. Injury to the iliac (or femoral) vessels can be prevented by the accurate placement of the needle into the fascial structures bridging them. Injury can be further prevented by protecting the femoral vein with the index finger while placing the suture medially. If the suture should pass into the vein and result in bleeding, it must be immediately removed and direct pressure applied. Attempts to halt the bleeding by tying the suture only result in further injury to the vessel wall. If these measures are not effective in control of the hemorrhage, the femoral sheath must be opened widely so that more accurate local tamponade can be applied or repair of the defect can be accomplished with fine vascular suture. The placement of sutures too deeply into the iliopubic tract may injure the deep circumflex iliac vessels, but since the bleeding is almost always venous in origin, direct pressure will usually suffice. There have been reports of pulmonary embolism arising from a thrombus, confirmed by venography, in the femoral vein at the site of the transition suture.45 Although the incidence of this injury is not known, there is little margin for error in the placement of this suture. The decreased venous flow during operation together with the slight venous stasis caused by constriction at the suture site will probably permit formation of a thrombus. If the vas deferens is accidentally severed during the operation, it should be repaired. One method of repair con196

sists of approximation of the cut ends with fine catgut sutures after placement of an internal splint of fine steel wire which is then pulled out in seven to ten days. The utilization of an operating microscope will permit more accurate suture placement. Approximately 50 percent of those repaired secondarily by urologists are considered to be functional although it is difficult to evaluate the results with the presence of an intact contralateral vas. Certainly the attitude should not prevail that there is no necessity to attempt repair in the presence of an uninjured vas on the other side! There are three nerves in the groin region which are vulnerable to injury. Both the iliohypogastric and ilioinguinal nerves (branches of the first lumbar nerve) penetrate the internal oblique muscle in the lateral third of the groin and lie between it and the external oblique aponeurosis. The former is sensory to the suprapubic region while the latter innervates the base of the penis and upper scrotum (or their counterparts in the female) and the adjacent thigh. These nerves also give off motor branches to the adjacent muscles. The ilioinguinal nerve is at risk early in the dissection since it lies directly beneath the external oblique oponeurosis and overlies the spermatic cord passing with it through the external inguinal ring. It is also vulnerable to injury during closure of the aponeurosis. The nerve should be identified and isolated to prevent injury from stretching or actual division. Moosman and Oelrich6 recently demonstrated that the normal course of the ilioinguinal nerve prevailed in only 60 percent of their cadaver dissections whereas 35 percent exhibited an aberrant course, lying either behind or within the spermatic cord in males and behind the round ligament in females. The remaining five percent revealed both variations. Thus, the nerve may not be encountered early in the dissection but can be injured during either mobilization and retraction of the cord or exposure and isolation of the indirect
sac. The iliohypogastric nerve, located 1 to 2 cm above the inguinal canal, may be injured during creation of the relaxing incision in the rectus sheath or during medial exposure of the musculofascial layers in preperitoneal repairs.

into its terminal two branches just inside and lateral to the deep inguinal ring with the genital branch then perforating the internal oblique muscle at the origin of the cremasteric muscle supplying motor branches to it and sensory branches to the skin and scrotum. Injury to this nerve can occur when the cremaster muscle is divided or dissected near the internal ring. These nerves possess crossconnections and considerable sensory overlap so that prolonged anesthesia post-injury, if apparent at all, will regress by the sixth month. While nerve injury is neither life-threatening nor serious, the varying degree of hypesthesia, paresthesia, or anesthesia in the area can be most annoying and uncomfortable to the patient. There is a higher incidence of nerve injury associated with recurrent hernia repairs. If one of the nerves is inadvertently severed, the ends should be freshened and silver clips applied to prevent neuroma formation. No attempt should be made to repair these nerves. The nerves must be protected from entrapment by sutures during wound closure in order to prevent long-term discomfort. The late complication of ilioinguinal neuritis or neuroma formation may respond to local nerve blocks, but occasionally excision of a neuroma may be necessary after preoperative localization. Transcutaneous electrical stimulation of the symptomatic nerves has also been employed with variable success. Fortunately, most symptoms arising from nerve injury resolve without any treatment.

Testicular Injury
Injury to the testis during repair may result in actual infarction or, more commonly, testicular atrophy. The blood supply of the testis consists of: (1) The testicular artery (internal spermatic) from the abdominal aorta, (2) the external spermatic artery from the inferior epigastric artery, and (3) the artery to the vas deferens. Additionally, extensive collaterals exist at the upper end of the testes between these vessels and those branches from the vesical, prostatic, and pudendal arteries. Preoperatively, the testes should be

The genitofemoral nerve divides

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inspected and palpated to determine their size and consistency as a baseline as well as for the presence of atrophy, tumor, or hydrocele. During the operation, the testes should not be dissected from the scrotum, in order to protect the collateral circulation from injury. Dissection of the spermatic cord should be careful and nontraumatic, thereby preserving the venous and lymphatic drainage. Operations for hernia recurrence increase the risk of injury as do certain types of procedures. Bassini repair in children should be avoided due to the danger of cord compression. Transposition of the cord to the subcutaneous position should be avoided in young males because of the increased risk of injury with testicular atrophy as a possible consequence. Ljundahl7 recommends that young male patients not undergo bilateral repairs because of the risk of atrophy but rather allow an interval of six months between repairs. Postoperative testicular or scrotal swelling is probably a manifestation of impairment of venous flow and tissue edema although another cause may be hypoxic swelling secondary to arterial insufficiency particularly after resection of the spermatic cord. The exact mechanism may be related to too tight a closure of the internal ring. Treatment consists of bed rest, scrotal support, and ice compresses. There may be a role for decompression of the swollen testes by incision of the investing tunic if hypoxia is felt to be the etiology. Atrophy can be a late complication of either of these mechanisms. A final word regarding the testes is contained in Koontz' statement: ". . . atrophy of the testicle sometimes follows a simple primary operation for inguinal hernia repair, in which neither the collateral nor the primary circulation has been molested as far as the surgeon is aware."8 Postoperative cryptorchism is most frequently seen as the result of not replacing the dislocated testis into the proper scrotal tissue plane prior to completion of the operation. Twisting of the cord must be carefully avoided during replacement. In addition to this mechanism other presumed etiologies of the condition include excessive retractility or local infection creating irritation of the cremasteric muscle. Kaplan9 advocated anchoring the testis during a hernia or communicating hydrocele repair if preoperative examina-

tion demonstrates significant testicular retractility.

Bladder Injury
Bladder injury most commonly occurs in the repair of direct inguinal hernia where the bladder is frequently encountered as a medial sliding component of the hernial sac. The presence of prevesical fat should guide the surgeon in suture placement to avoid injury. If such an injury is recognized at the operation it can be repaired with two or three layers of chromic catgut supplemented by catheter drainage for three to five days. Immediate recognition and repair of a bladder injury should not be associated with an increase in morbidity whereas delayed recognition of such an injury is heralded by urinary extravasation and sepsis. Colodny'" reported six cases of bladder injury presenting with urinary ascites and azotemia in which the diagnosis was established by opacification of the ascitic fluid on delayed views of cystograms where the defect in the bladder could not be seen. The mechanism of injury is felt to be due to the occurrence of inguinal protrusions of the bladder (bladder ears) which present in the medial aspect of the indirect sac in infants. Savran and Brown'2 reported the unusual complication of a postoperative hematoma in the prevesical space of Retzius felt to be the result of injury to the anterior vesical veins on the distended bladder wall. This injury can be prevented by performing a full preoperative urologic evaluation if there are any signs of chronic obstruction with correction of any conditions noted. Having the patient void prior to the operation should also avoid this potential problem.

Abdominal and Pelvic Visceral In-

jury
Injuries to the abdominal and pelvic viscera comprise another category of intraoperative complications. The practice of high ligation of the hernial sac can result in bowel injury if blind suturing is employed. This injury can then result in the development of a fecal fistula, abscess of the intestinal wall, or intestinal obstruction. In order to prevent such an injury the sac must be opened and the internal purse-string suture placed and tied under direct vision. Two potential complications can result when a sliding hernia involving the cecum or sigmoid colon is encountered. The bowel may be entered accidentally before recognition of the sliding hernia or the bowel segment may become devascularized as a result of injury to its blood supply which enters at the posterior aspect of the hernia. If the hernial sac appears excessively thickened when initially encountered, it should be approached with caution until it can be safely ascertained that bowel wall will not be damaged upon entry into the sac. It should be noted that the sliding component always lies in the posterior and lateral part of the inguinal ring. The sac should, therefore, be opened on the anterior surface with caution that a true sacless hernia is encountered. The technical aspects of the operation for sliding hernias will not be considered in this discussion. Should the colon be entered accidentally, a careful two-layer closure should be carried out followed by copious irrigation of the wound. If there is any question of vascular compromise of the segment, one of the following procedures should be employed: (1) wedge resection, primary closure, and temporary proximal colostomy or ileostomy, (2) Mickulicz in-continuity exteriorization, or (3) colectomy and primary anastomosis with or without proximal decompressing colostomy.10 In the repair of an indirect hernia in a female infant, the surgeon must be alert to the presence of a sliding hernia containing the fallopian tube and ovary to prevent accidental injury to these structures.

Incarcerated Bowel Segments

Another factor concerning the intraabdominal viscera relates to the determination of viability of an incarcerated intestinal segment found in the sac. When operating for incarceration or suspected strangulation that the affected bowel segment must be visualized in its entirety for such a determination to be made. The return of normal color, the contractile response to pinching, the return of normal peristalsis and the pulsation of the mesenteric
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vessels are well-known signs of apparent viability in such a bowel segment. Any question concerning viability should be resolved by replacing the bowel into the warm, moist environment of the peritoneal cavity while the patient is given high concentrations of oxygen rather than the usual routine of employing warm towels. Intravascular injection of fluorescein dye has been employed to detect areas of poor to absent blood flow but the results have been variable. Any continuing doubts regarding viability are an indication for resection of the involved segment. Should the segment be allowed to escape back into the peritoneal cavity it must be retrieved even if a laparotomy is necessary. Laparotomiy becomes mandatory also if the patient develops evidence of obstruction and/or peritoneal irritation in the immediate postoperative period. Two conditions in the miscellaneous category of complications include the respiratory embarrassment associated with the repair of massive hernias and the problem of missed hernia. The utilization of preoperative progressive pneumoperitoneum originally proposed by Moreno should allow the surgeon to safely repair massive hernias not only in the groin but elsewhere in the abdominal wall. 13 Failure to carefully evaluate the posterior inguinal floor through internal abdominal ring in the preperitoneal space may result in missed hernia or what is erroneously felt to be a very prompt recurrence even before the patient leaves the hos-

pital.

Postoperative Complications
Early postoperative complications include systemic complications, major wound infections, wound hematoma, and swelling of the testis and scrotum. Systemic complications will not be considered in this except to state that they are comparable to those occurring after other operations of the same
magnitude. Rydell's figures indicating a seven percent incidence of systemic complications with the majority being
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cardiorespiratory (4.1 percent) are fairly typical for inguinal hernia repair in the United States.'4 There are statistics available which suggest that the use of local anesthesia can reduce further the incidence of systemic complications particularly in the aged and poor risk patient. Major wound infection is fortunately an infrequent occurrence and when seen is usually secondary to treatment of associated intestinal strangulation. The incidence of wound infection can be increased by obesity, the use of local anesthesia, and prolonged duration of operation. Minor wound infections, characterized by mild erythema, tenderness and fever, should be managed with warm, moist compresses and antibiotics. If suppuration occurs, the wound margins should be opened down to the fascia to establish drainage. A Gram stain and bacteriological culture should be obtained to determine the appropriate antibiotic regimen to be employed. In addition to collections of pus or serum in the wound, single or multiple suture sinuses may occur as may partial or complete extrusion of a prosthetic mesh implant. Although hernial recurrence can result from some of these situations, the presence of wound infection is usually not synonymous with its occurrence. Most of the wound infections are minor and should create no risk to the hernia repair. The of wound occurrence hematoma or seroma should be minimized by the achievement of meticulous hemostasis with fine ligatures. Local measures such as application of pressure and/or an icebag may prove effective for small wound hematomas. If the hematoma continues to enlarge in spite of the measures, reoperation may be necessary. Chronic hematomas may be left alone to spontaneously resorb or they may be carefully aspirated under strict asepsis. Postoperative hydrocele consisting of a collection of fluid either in the scrotum or along the spermatic cord, may occur when a part of the sac is left in place, if there is impairment of the lymphatic or venous drainage. The majority of these collections tend to resolve spontaneously while needle aspirations under strict asepsis may be necessary occasionally to completely eliminate the problem. Secondary operative correction is practically never necessary.
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A consideration of recurrent hernias is beyond the scope of this discussion. Generally, however, adherence to the basic tenets of inguinal hernia repair should result in a low incidence of this complication. These include: (1) high ligation of the sac in the case of indirect and excision of the sac in all groin hernias; (2) repair of the defect in the plane of its occurrence (the posterior inguinal floor); and (3) suture of fascia to fascia in the same tissue plane without tension.

Conclusion
A thorough knowledge of inguinofemoral anatomy, mature surgical judgment and meticulous surgical technique are the most effective prophylactic measures for the prevention of complications considered.

Literature Cited
1. Edwards H: Inguinal hernia. Br J Surg 31:172-185, 1943 2. Nyhus LM: Complications of hernial repair. In Artz CP, Hardy JD (eds): Management of Surgical Complications. Philadelphia, WB Saunders, 1972, pp 659-671 3. Weinstein M, Roberts M: Recurrent inguinal hernia-follow-up study of 100 postoperative patients. Am J Surg 129:564-569,1975 4. Lankau CA Jr, Beachley MC: McVay herniorrhaphy. The transition suture and femoral vein injury: Case report. Milit Med 140:641-642, 1975 5. Nissen HM: Constriction of the femoral vein following inguinal hernia repair. Acta Chir Scand 141:279-281, 1975 6. Moosman DA, Oelrich TM: Prevention of accidental trauma to the ilioinguinal nerve during inguinal herniorrhaphy. Am J Surg 133:146-148, 1977 7. Ljungdahl I: Inguinal and femoral hernia-an investigation of 502 own operated cases. Acta Chir Scand Suppl 139:1-81, 1973 8. Koontz AR: Atrophy of the testicle as a surgical risk. Surg Gynecol Obstet 120:511-513, 1965 9. Kaplan GW: latrogenic cryptorchidism resulting from hernia repair. Surg Gynecol Obstet 142:671-672, 1976 10. Condon RE, Nyhus LM: Complications of groin hernia and of hernial repair. Surg Clin N Am 51:1325-1336, 1971 11. Colodny AH: Bladder injury during herniorrhaphy manifested by ascites and azotemia. Urology 3:89-90, 1974 12. Savran J, Brown SA: An unusual complication of inguinal herniorrhaphy. Int Surg 57:583-584, 1972 13. Moreno IG: The rational treatment of hernias and voluminous chronic eventration. In Nyhus LM, Harkins HN (eds): Hernia. Philadelphia, JB Lippincott, 1964 14. Rydell WB Jr: Inguinal and femoral hernias. Arch Surg 87:493, 1963

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