5/18/2013
What can the surgeon do to minimize
these complications?
Complications of
Inguinal Hernia Repair
University of California, San Francisco
Department of General Surgery
Jonathan Carter, M.D.
1.Recurrent hernia
2.Chronic pain
3.Ischemic orchitis
4.Infection
UCSF Postgraduate Course in General Surgery
March 2013
What can the surgeon do to minimize
these complications?
Recurrence: Lap or Open?
1.Recurrent hernia
2.Chronic pain
3.Ischemic orchitis
4.Infection
Randomized 2,164 patients with inguinal hernia to open Lichtenstein
vs. laparoscopic (mostly TEP) repairs.
Primary outcome = recurrence at 2 years
Secondary outcomes = complications, death, pain
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Recurrence: Lap or Open?
open
Laparoscopic or Open?
laparoscopic
2003
Meta-analysis of over 6,000 patients enrolled in
randomized trials up to 2003
RECURRENCE: OR 0.81 p=0.16
Twice as many recurrences at 2 years with laparoscopic
10x as many life-threatening complications
Laparoscopic or Open?
NO DIFFERENCE!!
Laparoscopic or Open?
SUMMARY
Randomized 1512 patients to TEP vs. Lichtenstein with 5 year FU
1/3 of TEP recurrences
were from 1 surgeon
After exclusion,
TEP recurrence
was 2.4%
(vs 1.2% open)
In centers of excellence, laparoscopic
inguinal hernia repairs have about the
same recurrence risk as open repairs.
In the real-world, there may be twice as
many recurrences with laparoscopy. But
the absolute magnitude of the recurrence
risk is small for both techniques.
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What mesh technique for open
inguinal hernia repair has the
lowest recurrence?
Lichtenstein = Prolene Hernia System > mesh plug repair
What can the surgeon do to minimize
these complications?
Fix or don’t fix?
1.Recurrent hernia
2.Chronic pain
3.Ischemic orchitis
4.Infection
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Laparoscopic or Open?
Laparoscopic or Open?
2003
Persistent pain
OR 0.54 p=0.001 in favor of laparoscopy
Persistent numbness
OR 0.38 p=0.01 in favor of laparoscopy
PAIN
What mesh technique for open
inguinal hernia repair has the
lowest pain?
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My choice: Lichtenstein
Chronic pain
Why?
1. Teach residents
2. No posterior mesh
Makes redos easier!
Lichtenstein = Prolene Hernia System > Mesh plug
What can I do to reduce
the risk of pain after
open inguinal hernia repair?
Identify all nerves
POSSIBLE STRATEGIES
Strategy 1: identify all 3 nerves
Strategy 2: divide ilioinguinal nerve routinely
Strategy 3: use lightweight mesh
Strategy 4: use self adhesive mesh (minimal sutures)
Strategy 5: use local nerve block
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Divide ilioinguinal nerve routinely?
retrospective review of 90 patients, of whom
66 had routine nerve excision
Dittrick 2004
Am J Surg
pain
Divide ilioinguinal nerve routinely?
paresthesia
Malekour 2008
Am J Surg
Blinded randomized controlled trial
121 patients: 61 nerve excised, 60 nerve preserved
Outcome = pain in first year (VAS)
nerve excision
nerve preservation
p-value
Pain POD1
2.2 ± 0.8
2.8 ± 0.7
<0.001
Pain POD30 0.7 ± 0.7
1.5 ± 0.7
<0.001
chronic pain 6%
21%
0.033
preserved
excised
preserved
excised
Mui 2006
Use lightweight mesh?
Self-adhesive mesh?
n=30
n=30
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Other pain reduction strategies
Other pain reduction strategies
More urinary retention with spinal anesthesia….
What can I do to reduce
the risk of pain after
open inguinal hernia repair?
Strategy 1: identify all 3 nerves (recommended)
What can the surgeon do to minimize
these complications?
1.Recurrent hernia
2.Chronic pain
Strategy 2: divide ilioinguinal nerve routinely (controversial)
Strategy 3: use lightweight mesh (recommended)
3.Ischemic orchitis
Strategy 4: use self adhesive mesh (controversial)
Strategy 5: use local nerve block (recommended)
4.Infection
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open
laparoscopic
What can the surgeon do to minimize
these complications?
1.Recurrent hernia
2.Chronic pain
3.Ischemic orchitis
Advice:
1. Don’t dig a hernia sac out of the scrotum. Divide it.
4.Infection
2. For recurrent hernia, approach it from the opposite side. Otherwise
risk of ischemic orchitis is 3-5%
Infection risk
Use of mesh increases infection risk slightly. Here
antibiotics help:
2007 meta-analysis of six randomized trials
2507 patients
Results
prophylactic antibiotics
controls
Infections
1.38% OR 0.48 (0.27-0.85)
2.89%
Most patients who develop a wound infection, even if
polypropylene mesh is present, can be successfully treated
by aggressive antibiotic treatment without the need to
remove the prosthetic material.
Ann Surg. 2007;245(3):392
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