WeBSurg, the e-surgical reference of Laparoscopic surgery

INTRAOPERATIVE AND POSTOPERATIVE COMPLICATIONS OF INGUINAL HERNIA SURGERY

D Mutter, MD, PhD , Hôpitaux Universitaires de Strasbourg, Strasbourg, France

1. Introduction

2. Intraoperative complications

3. Postoperative period

4. Postoperative complications

5. Postoperative pain

6. General complications

7. References

1. Introduction

Complications and recurrence rate are the two criteria used to assess the success of an inguinal hernia repair.
A review of the literature reveals the heterogeneity of patient populations and the lack of standardization of the surgical techniques.
Often, the follow-up is short and surgeons lose track of many of their patients. Patients should be evaluated for hernia recurrence for a minimum of five years following hernioplasty.

1. Introduction

2. Intraoperative complications

3. Postoperative period

4. Postoperative complications

5. Postoperative pain

6. General complications

7. References

2. Intraoperative complications

Intraoperative complications are rare and do not correlate to a specific technique.

Complications are listed in large series (multicenter studies or meta-analyses), and rare complications are described in clinical cases. Below we list the frequency of specific complications given in large series in the literature.
Table 2: main intraoperative complications according to the technique ( Johansson et al. , 1999 : 613 patients, with 604 involved in a 1-year follow-up)

Complication	Conventional approach	Mesh repair by anterior approach	Laparoscopy
Hemorrhage(s)		0.5%	1%
Nerve damage	0.5%
Bladder injury			1%

2.1. Hemorrhage

Hemorrhage can be caused by injury to large vessels (vena cava injury [ Goodwin and Traverso, 1995 ]) or by venous or arterial vascular injuries of smaller vessels.

2.2. Obturator vessel injuries

2.2.1. Mechanism
Obturator vessel injuries occur during dissection of the internal part of the superior peripheral ligament, by laparoscopy or open surgery. During hernia repair, they may be divided using suture or staples.

2.2.2. Consequences
These injuries can result in intraoperative hemorrhaging as well as in large postoperative hematomas expanding into the scrotum and thigh.

2.2.3. Treatment
If this vascular pedicle is injured, it must be suture ligatured. This is often difficult due to its short course, starting at the epigastric vessels and in proximity to the femoral vessels. When performing laparoscopy, selective bipolar coagulation can sometimes control the hemorrhage.

2.3. Femoral vessel injuries

2.3.1. Mechanism
A femoral or iliac vascular injury can occur during a difficult dissection, especially in cases of a recurrent hernia. These injuries can be caused by a blind, traumatic insertion of a Veress needle or trocar while performing laparoscopy.

2.3.2. Consequences
A minimal vascular injury can heal spontaneously after compression.
It can, however, result in a serious intraoperative hemorrhage or a postoperative retroperitoneal hematoma.
A poorly controlled application of hemostatic stitches can lead to dramatic consequences, in cases of venous or arterial ligature, and cause acute ischemic syndromes.

2.3.3. Treatment
Vascular injuries may be tamponated by using compression. All vascular injuries must be repaired. If needed, a vascular control should be performed above and below the lesion. A patch or replacement of the injured segment of the vessel may be useful. With the laparoscopic approach, these injuries can be avoided by using an “open laparoscopic” technique.

2.4. Nerve injuries

2.4.1. Mechanisms
Nerve injuries may have 4 causes:

nerve damage caused by coagulation;
sectioning of a nerve during dissection;
a ligature during parietal suture or mesh fixation;
a puncture linked to staple application.

Complications affecting the nerves are slightly more frequent with traditional techniques as compared to tension-free techniques with mesh application: 4.4% versus 1.4% ( Collaboration EH, 2000 ).
Injuries of the nervous plexus lead to complications in 0.4% to 3.4% of hernia repairs by laparoscopic approach: TEP and TAPP ( Rosenberger et al. , 2000 ).

2.4.2. Consequences
Nerve injuries are characterized by disorders such as the appearance of zones of hypoesthesia or numbness. They are caused by the division of branches or trunks of the genito-femoral and femoro-cutaneous nerves. The disorders may be more serious if a motor nerve is affected (femoral nerve, for example)( Stoppa, 1997 ).

2.4.3. Prevention
These injuries may be avoided by:

dissecting under visual guidance;
applying staples only in the zones of safety (see techniques);
using acrylic-based glues to replace staples (see TEP technique) ( Jourdan and Bailey, 1998 ).

2.4.4. Treatment
It is not necessary to suture the divided sensory nerve branches. After a few weeks, sensitivity will be recuperated due to natural substitution.
A nerve caught in a suture can cause persistent, acute pain. NSAID therapy and analgesics may alleviate the pain. In the case of characteristically sharp pain due to nerve damage (e.g. electric discharge during mobilization), immediate reoperation to remove the responsible suture or staple will bring immediate relief to the patient.
In the case of a motor deficit, the surgeon should reoperate to free the nerve and replace the sutures if necessary.

2.5. Spermatic cord injuries

2.5.1. Mechanisms
Spermatic cord injuries involve the ductus deferens and genital vascular structures. They usually occur during dissection of recurrent hernias. Thrombosis of the venous plexus caused by the dissection of large hernia sacs or by stenosis of the external inguinal ring during suture leads to an orchitis which is primarily inflammatory and which may subsequently become atrophic.

2.5.2. Consequences
Genital vessel damage (particularly in their subpubic portion) leads to necrosis or testicular atrophy ( Marsden, 1988 ). In the case of suprapubic injuries, testicular necrosis, which can occur in 60% of cases, can be avoided by performing a genital vascular substitution.

2.5.3. Treatment
The treatment is preventative. It is crucial to avoid dissecting a recurrent hernia via an anterior approach. A posterior approach, by laparoscopy in particular, is preferable, especially in cases of recurrent hernias.

2.6. Injury to the ductus deferens

2.6.1. Mechanisms
The ductus deferens can be injured during dissection of the cord and peritoneal dissection via a laparoscopic approach.

2.6.2. Consequences
Ductus deferens injuries must be taken seriously in young adults. Damage to only one ductus deferens can decrease fertility for mechanical and immunological (increase in the anti-sperm antibody serum count) reasons. Seven per cent of adults who are a-zoospermic or hypo-zoospermic without testicular atrophy underwent hernia surgery during their childhood ( Friberg and Fritjofsson, 1979 ).

2.6.3. Treatment
In case of ductus deferens damage, a micro-surgical suture repair is indicated.

2.7. Bladder injuries

2.7.1. Mechanisms
A portion of the bladder slips into the hernia sac relatively frequently. It is possible to open the bladder to complete the dissection if necessary. A bladder injury can occur during open retromuscular dissection (Stoppa’s procedure) as well as laparoscopic dissections, including the totally extraperitoneal (TEP) and TAPP approaches ( Johansson et al. , 1999; Hernandez-Richter et al. , 2000 ).

2.7.2. Consequences
Generally, the injury is identified intraoperatively and the bladder is sutured immediately. If the injury is not observed intraoperatively, an intra-abdominal or inguinal urine effusion can cause complications.
When a laparoscopic procedure is performed for a hernia recurrence, the use of a urinary catheter is often indicated. The swelling of the hernia sac allows to identify the lesion.

2.7.3. Treatment
The treatment consists of suturing the bladder, combined with bladder drainage using a catheter for 5 to 8 days. If a catheter is placed before the operation, it should be left in place postoperatively.

2.8. Bowel injuries

2.8.1. Mechanisms
Bowel injuries are usually related to a dissection of the small intestine or colon which has migrated into the hernia sac. The structures which are the most at risk are the sigmoid colon on the left side, and the small intestine on the right side. To prevent these injuries, the digestive tract structures should be reintroduced with the peritoneum without dissecting the adhesions between the sac and the organs. Bowel injuries can complicate the laparoscopic procedure. They are most likely due to the technique rather than to the pathology ( Gillion et al. , 1996 ). Although they are presumed to be more frequent with the TAPP technique because of its intra-abdominal approach, they have also been reported for the TEP technique ( Ramshaw et al. , 1996 ). Other bowel injury mechanisms include direct trocar or Veress needle perforations and secondary necrosis caused by electrocoagulation.

2.8.2. Consequences
If unidentified at the time of surgery, a bowel injury can cause complications leading to a postoperative peritonitis. The mortality rate can reach up to 50% of patients.
If identified, the bowel injury must be repaired immediately, with a conversion to laparotomy if necessary.

2.8.3. Treatment
An injury of the small intestine is repaired immediately, using a suture one or two layer sutured anastomosis.
An injury of the colon, occurring on an unprepared colon, is treated by suturing the injury and, in most cases, by establishing a protective colostomy. Synthetic, nonabsorbable material must not be used.

2.9. Conversions

The rate of conversion of laparoscopy to an open technique varies from 0 to 1.7% in most series. It is most frequently performed for the management of complications (hemorrhage, digestive tract injuries, etc.) and occasionally due to technical problems related to faulty surgical equipment ( Liem et al., 1997 ).

1. Introduction

2. Intraoperative complications

3. Postoperative period

4. Postoperative complications

5. Postoperative pain

6. General complications

7. References

3. Postoperative period

The hernia recurrence rate is the main criterion for assessing the quality of any surgical hernia repair.

Other criteria should be taken into consideration:

technical difficulty;
rate and severity of perioperative complications;
postoperative comfort;
return to normal activities;
socioeconomic factors.

1. Introduction

2. Intraoperative complications

3. Postoperative period

4. Postoperative complications

5. Postoperative pain

6. General complications

7. References

4. Postoperative complications

Postoperative complications are not specific to any particular technique.
Early complications are distinguished from late complications occurring over one year after an operation.

Table 4.a: Postoperative complications (0 to 8 weeks) according to the technique ( Liem et al., 1997; Johansson et al., 1999 ):

Complication	Conventional approach	Prosthesis via anterior approach	Laparoscopy
Hematoma	15%	15%	9.5%
Seroma/Hydrocele	0.5%	4.5%	6%
Urinary retention	1.5%	0.5%	2%
Urinary infection	0.5%	0.5%	0.2 to 0.6%
Superficial wound infection	3%	0.5%	0%
Deep infection	0.5%	*	*
Pain		0.5%	5%
Major edema	0.5%	*	2%
Hematuria	*	*	0.5%
Allergy	*	*	0.5%
Rupture by trocar	*	*	0.5%
Postoperative fever	*	0.5%	0.5%
Chronic effusions	*	0.5%	*
Phlebitis	*	0.5%	*

*no value is given if the frequency of complications is less than 0.5%

Table 4.b: Postoperative complications (after 1 year) according to the technique
( Cunningham et al. , 1996 : 315 patients, 276 of whom involved in 2-year follow-up)
( Johansson et al. , 1999 : 613 patients, 604 of whom involved in one-year follow-up)

Complication	Conventional approach	Prosthesis via anterior approach	Laparoscopy
Pain	10% ( Cunningham et al. , 1996 )	1%	2.5%
Seroma/hydrocele	2.8% ( Liem et al. , 1997 )	*	0.5 to 4.9%
Rupture by trocar	*	0.5%	0.5%
Superficial wound infection	*	0.5%	0.5%
Delayed healing	*	*	0.5%
Pulmonary embolism	0.5%	*	*

4.1. Postoperative bowel obstruction

4.1.1. Mechanism
Postoperative bowel obstruction resulting from the wedging of an intestinal loop in a peritoneal opening is a classical complication in hernia surgery (1/1,000 in conventional surgery). It is not related to any specific approach.
One mechanism is more frequently observed during laparoscopic surgery: early obstruction caused by the strangulation of the small intestine in a trocar site (complete strangulation or often lateral constriction) which should be suspected in the case of severe postoperative pain or vomiting.

4.1.2. Consequence
This obstruction can be functional.
An obstruction caused by early hernia strangulation can lead to necrosis of the small intestine with secondary peritonitis.

4.1.3. Treatment
If the patient has persistent postoperative pain or obstruction, a strangulated hernia should first be ruled out. It should be treated by immediate reoperation, debridement of the opening and closure.
Obstruction can be prevented by suturing the posterior aponeurosis of all trocar site openings measuring over 5mm. A functional obstruction, is treated symptomatically.

4.2. Hematomas

4.2.1. Mechanism
They are related to a vascular injury which was not identified during the operation. In certain cases, the hematoma may be due to the patient’s use of anticoagulants.
In laparoscopic surgery, postoperative bleeding may appear after the desufflation of the pneumoperitoneum, which was pressing on a small vein injury and temporarily stopping the bleeding.

4.2.2. Consequences
Large or encapsulated hematomas can evoke an early recurrence or lead to functional disturbance. Moderate hematomas or diffused ecchymoses do not modify the healing process. They do not require treatment.

4.2.3. Treatment
Large hematomas can be treated by repeated puncture, either externally or by local surgical or laparoscopic evacuation ( Hernandez-Richter et al. , 2000 ). Puncture involves a septic risk and exposes the patient to an early recurrence. It is therefore preferable to reoperate and evacuate the hematoma ( Leibl et al. , 2000 ). Preventative antibiotic therapy is required.

4.3. Postoperative infection

4.3.1. Mechanism
According to the series reporting the results of hernia repair via a conventional approach, its frequency varies from 0 to 6%. It can affect the superficial layers only, or can contaminate the entire rhaphy. Infectious complications are also reported by the laparoscopic series: prosthesis infections, or periostitis or osteitis resulting from stapling of the prosthesis ( Tetik et al. , 1994 ).

4.3.2. Diagnosis
Diagnosing an infection on a prosthesis is difficult. Symptoms include: an inflammatory edema, effusion from the incision site, atypical or prolonged postoperative pain, an increased sedimentation rate, an increase in the C-reactive protein, and/or hyperleukocytosis.
Complementary exams can help establish the diagnosis: ultrasonography, scintigraphy (bone lysis on contact), MRI, CT scan. There are no specific exams for this complication.

4.3.3. Consequences
A superficial wound infection can be adequately treated by local measures.
An infection exposes the patient to a greater risk of recurrence. The suture can be rejected after several years. The infection then can result in chronic effusions from the wound site.

4.3.4. Treatment
A superficial wound infection requires local debridement. An infected mesh can be treated by exposure, systemic antibiotic therapy and prolonged local treatment.
It is easier to remove the infected material. Microporous prostheses (type e-PTFE) must be removed.

4.4. Contraindications for prostheses

To avoid infection, prostheses should not be used in patients without proper preparation, in emergencies, or in cases of associated procedures involving potentially infectious contamination (opening of the bladder or digestive organs).

4.5. Migration of the prosthesis

4.5.1. Mechanism
Migration of the prosthesis is a rare complication, involving an estimated 0.1% to 1% of cases ( Begin, 1996; Johanet et al. , 1996; Tetik et al. , 1994 ).

4.5.2. Consequences
A prosthesis which has migrated is responsible for infectious complications or pain, depending on where it has migrated (bladder, intestine).

4.5.3. Treatment
A prosthesis which has migrated and become symptomatic must be removed. The procedure is difficult and may damage the tissues.

4.6. Testicular atrophy

4.6.1. Mechanism
A lesion of the spermatic vascular pedicle leads to testicular ischemia. It occurs in 1% to 10% of cases ( Schumpelick et al., 1994 ). Its pathognomonic signs, including pain, an increase in size and retraction of the testicle, appear between POD3 and POD5.

4.6.2. Consequences
Its evolution can be simple, with no notable consequences other than transient postoperative discomfort. The testicle becomes revascularized by genital anastomoses.
The most usual evolution is testicular atrophy. The testicle becomes hard, and its size decreases to between one third and one half of the remaining testicle. It sometimes develops into testicular necrosis within 10 to 15 days.

4.6.3. Treatment
An analgesic and antipyretic treatment usually decreases the pain. The process may then spontaneously evolve towards a painless atrophy.
In case of necrosis, the testicle must be removed on approximately POD15.

4.7. Hydrocele/Seromas

4.7.1. Mechanism
A hydrocele usually occurs after surgery for a very large hernia, especially when the distal part of the sac is left in place. A hydrocele is occurs seemingly more frequently after a repair via the laparoscopic approach (4.9% versus 2.8% via open surgery [ Liem et al. , 1997 ]).

4.7.2. Consequences
The main consequence is a functional and aesthetic problem. The patient often consults his/her physician for an “early hernia recurrence”. This hydrocele can resolve spontaneously or after performing one or two percutaneous draining procedures.

4.7.3. Treatment
An early treatment is not necessary. Many hydroceles resolve spontaneously. One to three percutaneous draining procedures may be required in case of a functional problem or major effusion. Resection of a sac is rarely indicated.

4.8. Dysejaculation

4.8.1. Mechanism
The long dissection of the ductus deferens and the fibrosis linked to the fixation of a prosthesis laparoscopically can cause a stenosis of the ductus deferens or an angular deformation along its course. It also occurs after conventional surgery.

4.8.2. Consequences
The seminal fluid cannot flow normally in the ductus deferens. Its stasis or reflux cause intense pain during ejaculation, described as a burning sensation along the spermatic cord.

4.8.3. Treatment
No specific treatment has been reported to preserve the patency of the ductus deferens and avert the pain.

4.9. Trocar site infection

4.9.1. Mechanism
This complication ( Hernandez-Richter et al., 2000 ) remains rare in the context of non-emergent surgery: less than 0.1%.

4.9.2. Consequence
The main risk is an infection of the prosthesis. Apart from this complication, management involves the need for local treatment and a prolongation of the patient’s sick leave or absence from work.

4.9.3. Treatment
Simple local treatment is useful.
This complication may justify the routine use of preventative antibiotic therapy.

4.10. Trocar site herniation

4.10.1. Mechanism
This complication is rare. It may be the result of a postoperative infection or occur spontaneously. Its frequency has not been evaluated. A sharp pain on the trocar site may possibly be related to an early obstruction.

4.10.2. Consequence
An obstruction caused by the strangulation of an intestinal loop or, more frequently, by lateral constriction. A bowel necrosis without obstruction can be observed.

4.10.3. Treatment
This complication justifies an early re-operation, by laparoscopy or by laparotomy. It sometimes requires a bowel resection. This risk can be decreased by using trocars measuring 5 mm or less in diameter.

4.11. Postoperative ileus

4.11.1. Mechanism
This rare complication is most commonly related to the laparoscopic transabdominal approach. It is caused by an adherence of the prosthesis onto a part of the prosthesis which is not covered by the peritoneum ( Hernandez-Richter et al., 2000 ).

4.11.2. Consequence
These adherences can result in a symptomatic obstruction.

4.11.3. Treatment
If it persists, an obstruction can require a reoperation for adhesiolysis.
An intestinal resection is sometimes indicated ( Hernandez-Richter et al., 2000 ).

1. Introduction

2. Intraoperative complications

3. Postoperative period

4. Postoperative complications

5. Postoperative pain

6. General complications

7. References

5. Postoperative pain

5.1. Early

5.1.1. Mechanism
Early postoperative pain can have several causes. Nerve damage can result in early or delayed pain. Other causes of postoperative pain have been elicited such as: ligature of the peritoneal sac ( Lichtenstein, 1989 ), or the reapproximation of the musculo-aponeurotic layers under tension (open techniques of MacVay, Shouldice). A controlled randomized study has failed to demonstrate that tension-free hernia repair results in less postoperative pain ( Schrenk et al. , 1996 ).

5.1.2. Treatment
Analgesics decrease the postoperative pain.
An acute pain of nerve origin can require a reoperation to remove a stitch or staple compressing a nerve. This is not a general rule, however. Analgesics and a neurolysis, if necessary, can efficiently relieve the pain.
Postoperative pain can be decreased by the intraoperative administration of local analgesics or by performing a spinal anesthesia ( Rutkow and Robbins, 1993 ).

5.2. After treatment by the laparoscopic approach

Laparoscopic techniques in the management of inguinal hernias should decrease postoperative pain. It is not possible to specify whether this decrease is linked to the technique itself or to the tension-free principle of the repair.

Prospective randomized studies measuring postoperative pain by use of an analogical visual scale or by the analgesic intake after hernia repair surgery, have always compared a laparoscopic technique to an open technique. The choice of the conventional technique used in these studies was arbitrary. These studies could be criticized for the lack of inclusion of other techniques.
Certain uncontrolled studies are in favor of the laparoscopic technique ( Barkun et al. , 1995; Champault et al. , 1994; Champault et al. , 1997; Lawrence et al. , 1995; Stoker et al. , 1994; Wright et al. , 1996 ).
The controlled study of Kozol et al. (1997) showed a significant advantage in favor of the laparoscopic approach as compared to the open techniques, with less postoperative pain. The tension-free techniques of the Lichtenstein type are seemingly less painful than techniques with tension of the Shouldice type ( Kux et al., 1994 ).
The laparoscopic approach may have an advantage over open techniques in terms of pain, but only for a very short period (1 or 2 postoperative days) ( Tschudi et al. , 1996; Schrenk et al. , 1996 ). The benefit related to pain disappears in 8 to 10 days ( Liem et al. , 1997 ).

5.3. Delayed

5.3.1. Mechanisms
15% to 20% of patients who undergo inguinal hernia repair have postoperative pain including neuralgia, paresthesia, neuropraxis, hypoesthesia, dysesthesia and burning. The cause of the pain, other than in cases where the nerve lesions are evident, is unknown. The laparoscopic technique is considered to give significantly less chronic postoperative pain than the anterior approaches (2.1% versus 13.8%; p<0.001) ( Liem et al. , 1997 ).

5.3.2. Consequence
This pain is not well accepted and results in substantial requests from the patients for pain management. The physical exam should also include a neurological exam and psychological care.

5.3.3. Treatment
Besides symptomatic treatment, the surgeon can consider performing a neurolysis to destroy the sensitive nerve branches responsible for the pain. The patient must accept the risk of postoperative dysesthesia or hypoesthesia.

1. Introduction

2. Intraoperative complications

3. Postoperative period

4. Postoperative complications

5. Postoperative pain

6. General complications

7. References

6. General complications

The complications related to hernia surgery are the same as those for other surgical procedures of similar complexity. The morbidity for hernia surgery involves 6.3% of patients ( Stoppa, 1997 ). Pulmonary complications (atelectasis), thrombophlebitis and pulmonary embolism, mortal myocardial infarction ( Fitzgibbons et al. , 1995 ) or arterial embolism ( Tschudi et al. , 1996 ) have all been observed.

6.1. Death

The mortality following inguinal hernia surgery is very low.
It was 0% for the 4005 patients involved in a multicenter study ( Collaboration EH, 2000 ), 0.19% over a 23-year period in the series of Shouldice Hospital ( Glassow, 1973 ), for “non complicated” hernias. The mortality is higher if all patients undergoing emergency surgery are included (strangulated hernias, bowel necrosis in elderly patients [ Stoppa, 1997 ]).
Death linked to a specific surgical (especially laparoscopic) technique has not been observed in any study.

6.2. Return to activities

An analysis of the time needed before resuming personal and professional activities after hernia repair must take into account the postoperative surgical evolution and the socio-economic background of the country in which the study is carried out. For these reasons, the results of different studies are not comparable.

A study carried out in France showed that more than 10% of patients refused the idea of leaving the hospital before POD2. After the operation, 20% of patients prolonged their hospital stay for personal and non medical reasons ( Millat et al., 1993 ).
In several Western countries, however, outpatient surgery is widespread. Several studies have shown a quicker return to activities after laparoscopic treatment of hernias ( Stoker et al., 1994; Champault et al. , 1994; Payne et al. , 1994 ).

6.3. Hernia recurrence

Hernia recurrence after inguinal hernioplasty is multifactorial. We have presented results of recurrences with minimal and maximal values (min/max%), reported by studies with a satisfactory methodology. We have presented the results by operative technique and by type of hernia.

The evaluation of the recurrence rate depends on the quality of the postoperative follow-up (50% of patients do not realize that they have a recurrence), accounting for the inaccuracy of telephone studies ( Kux et al., 1994 ) and of the period reported (5 or even 10 years for Lichtenstein et al. , 1989 ). We have not retained the values measured according to the principle of “maximal bias” ( Hay et al., 1995 ): a patient who could not be seen for a follow-up checkup is considered as having a recurrence.

The best results are those reported by specialized centers or by surgeons specialized in a technique ( Amid et al. , 1993 : 1% of recurrences). These results are regarded as exceptional, considering the recruitment of these centers and their “exclusiveness”. Certain studies report 0% recurrence! ( Payne et al., 1994; Stoker et al., 1994; Zieren et al., 1998 ).

6.4. Recurrence factors

They are rarely assessed in a methodological way.
Several factors are often implicated:

the surgeon’s inexperience ( Begin, 1996; Johanet et al., 1996 );
a mistake during dissection ( Liem et al., 1997 );
obesity ( Leroy, 1994 );
coughing and carrying heavy loads ( Tschudi et al., 1996 );
previous abdominal surgery ( Ramshaw et al., 1996 );
insufficient fixation of the prosthesis ( Gillion et al., 1996; Tetik et al., 1994 );
underestimation of size of the prosthesis ( Ferzli et al., 1998; Brooks, 1994 );
shrinkage of the prosthesis.

6.4.1. Rate of hernia recurrences observed with traditional techniques without prosthesis
Many studies are impossible to interpret due to the fact that they compare one technique (laparoscopic) to all the types of open surgery combined. In this case, the recurrence rate for open surgery is higher than for laparoscopy ( Liem et al., 1997 ). Most controlled studies report fewer recurrences for the Shouldice technique ( Tran et al., 1992; Hay et al., 1995; Kingsnorth et al., 1992; Panos et al., 1992; Paul et al., 1994; Kux et al., 1994; Beets et al., 1997 ).

Table 6.4.1: Studies: Paul et al. , 1994 : n = 265; Hay et al. , 1995 : n = 1247; Collaboration EH, 2000 : n = 1634; Panos et al. , 1992 : n = 308

Bassini	8.6% to 9.6%
MacVay	8.8% to 11.5%
Shouldice	2.7% to 6.6%
All non specified techniques without prosthesis (n = 1634)	2.9% to 4.4% ( Collaboration EH, 2000 )

6.4.2. Recurrence rates for mesh tension-free techniques
Few studies involving a large number of patients or randomized prospective studies have been carried out. One example is the analysis of the “mesh plug” technique with a 2% recurrence rate for primary surgery and a 9% recurrence rate in cases of re-operations for recurrences ( Rutkow and Robbins, 1998 ). No prospective studies have compared this technique to the Shouldice technique. This observation does not concern the Lichtenstein technique ( Amid et al., 1996 ), which has only been compared to the MacVay ( Friis and Lindahl , 1996 ). It seems to have a lower recurrence rate than the techniques with tension (5% versus 15%) ( Friis and Lindahl, 1996 ). Compared to the Shouldice technique, the recurrence rates are not significantly different (0 versus 1%) ( Kux et al. , 1994 ).

There are no controlled studies in the literature comparing these techniques to the methods considered as gold standards. A few rare studies report the advantages of these techniques ( Beets et al. , 1996 ). Two studies compare Stoppa’s approach to the laparoscopic techniques. The laparoscopic approach decreases pain, the length of hospital stay and postoperative recovery time, but significantly increases the complications ( Champault et al. , 1997; Velasco et al. , 1996 ).

Table 6.4.2: Studies: Collaboration EH, 2000 : n = 1513; Rutkow et Robbins, 1998 ; Amid et al., 1996

Stoppa	1%
Rives	10%
Lichtenstein	0.1% to 0.6%
Plug	2%
All non specified tension-free techniques (n = 1513)	1.38% ( Collaboration EH, 2000 )

6.4.3. Rate of hernia recurrence observed with videoscopic techniques
A single randomized prospective study ( Sarli et al. , 1997 ) compared the IPOM (Intra Peritoneal Onlay Mesh technique) and the TAPP technique (Trans Abdominal Pre Peritoneal). Although the IPOM technique is performed more quickly, it leads to more complications, especially neuralgia. It is also associated with a higher number of recurrences and has been practically abandoned.
The TEP technique (Totally Extra Peritoneal) seemingly has a longer hospitalization and more pain than the TAPP technique, while the rates of recurrence and complications are similar ( Khoury, 1995; Felix et al., 1995; Ramshaw et al. , 1996 ). The studies are biased, particularly in the choice of the techniques used for the comparison with laparoscopy. The criteria used to evaluate these techniques are imprecise. Most of these studies show a postoperative rate of complications and recurrence which are comparable to the open techniques ( Brooks, 1994; Wilson et al., 1995; Massaad et al. , 1996; Filipi et al. , 1996; Liem et al. , 1996; Heikkinen et al. , 1997 ).
Neither of the 2 laparoscopic techniques has been shown to be superior compared to the other in the controlled studies.

Table 6.4.3: Studies: Wright et al. , 1996 ; Collaboration EH, 2000 ; Sarli et al. , 1997 ; Schrenk et al. , 1996 ; Vogt et al. , 1995

IPOM	6%
TAPP (n = 1896)	2%
TEP (n = 911)	2.6%

6.5. Results according to the type of hernia

The variability of the recurrence rates according to the type of hernia demonstrates how difficult it is to homogenize the results according to the patients and the techniques. 7% ( Hay et al. , 1995 ) to 25% ( Amid et al. , 1993 ) of all hernia operations are for recurrent hernias. It is impossible to evaluate which types of hernias recur the most often. Patients often change surgical teams between their first and second operations. Moreover, not all patients who have a recurrence want to undergo surgery again!

The surgical treatment for a hernia recurrence is in itself a factor for recurrence ( Kald et al. , 1995 )! These factors are rarely specified in all of the studies, however ( Fitzgibbons et al. , 1995 ).

Table 6.5: Recurrence rate according to the type of hernia ( Nyhus, 1989; Nyhus et al. , 1991; Leroy, 1994 ):

External oblique hernias	1.1% to 20.7%
Direct hernias	3.5% to 20.9%
Femoral hernias	0 to 31.3%
Recurrent hernias	0 to 33.1%

6.6. European Institute of Tele-Surgery (EITS) recommendations

The “gold standard” techniques are:

Open conventional technique: Shouldice
Open tension-free technique: Lichtenstein
Laparoscopic technique: TAPP or TEP

A surgeon should be familiar with all of these techniques in order to choose which is best suited for each patient.

6.7. Indications

Table 6.7

Patient groups	Open technique	Videoscopic technique
Female Thin patient Young patient Unilateral hernia	Shouldice technique	TAPP or TEP
Obese patient Bilateral hernia		TEP or TAPP
Large hernia Recurrent hernia		TAPP
Very elderly patient Patient: - immunosuppressive; - diabetic; - with multiple defects; - with a contraindication for anesthesia.	Plug Shouldice Lichtenstein

1. Introduction

2. Intraoperative complications

3. Postoperative period

4. Postoperative complications

5. Postoperative pain

6. General complications

7. References

7. References

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