Complications of Groin Hernia Repair:Their Prevention and Management

Ray D. Gaines, MDOmaha, Nebraska

An estimated overall complication rate of approximately ten percentis found in the half million patients who annually undergo groinhernia repair in the United States. Certain features in the operativetechnique are emphasized which should prevent many of thesecomplications.

Intraoperative complications during the groin hernia repair areprimarily hemorrhage and injury to the vas deferens, the threenerves in the area, the vascular supply of the testis, and the abdomi-nal and pelvic viscera. Miscellaneous intraoperative complicationsrelate to problems associated with the repair of massive hernias,missed hernia, and the loss of strangulated bowel into the abdominalcavity.

Early postoperative complications may be either systemic or localwith cardiac and respiratory conditions comprising the formergroup. The early local complications are primarily wound problemsof infection, hematoma formation, and scrotal swelling involving theskin and testis. High ligation in excision of the sac in all hernias,repair of the defect in the plane of its occurrence, and suture offascia to fascia in the same plane without tension are the basic tenetsof inguinal hernia repair which should result in a low incidence ofrecurrence.The most effective prophylactic measures necessary for the

prevention of complications considered are a thorough knowledge ofinguinofemoral anatomy, mature surgical judgment, and meticuloussurgical technique.

"You can judge the worth of a surgeonby the way he does a hernia."

-Fairbank'

Each year one half million Ameri-cans undergo groin hernia repair. It isone of the most common operationsperformed in US hospitals. There is anestimated ten percent complication rateassociated with the procedure.2 Statedanother way, approximately 50,000 pa-

Presented to the 82nd Annual Convention of theNational Medical Association, Los Angeles,California, August 4, 1977. Requests for reprintsshould be addressed to Dr. Ray D. Gaines, De-partment of Surgery, Creighton University, 601North 30th Street, Omaha, NB 68131.

tients annually will experience somecomplication. Postoperative complica-tions are always of concern to the sur-geon. Some are of little consequence,others lead to prolonged disability, andsome end in death. It is the surgeon'sresponsibility to ensure their preven-tion, recognition, and management.3

Four categories of complicationsexist. They are: (1) those arising fromthe disease for which the operation isperformed, (2) those arising from asso-ciated conditions unrelated to the pri-mary disorder, (3) those resulting di-rectly from the operative procedure it-self, and (4) those due in part to any ofthe preceding groups but not attribut-

able to any single one. It is the purposeof this discussion to emphasize some ofthe more common complications ofgroin hernia repair.

Careful observation of certain fea-tures in operative technique willprevent many of the complications.These features include: (1) clean sharpdissection, (2) avoidance of rough dis-section and trauma as from gauze orfingers, (3) use of minimal volumes oflocal anesthetic agents, (4) appropriateuse of relaxing incisions to avoid ten-sion, (5) utilization of nonabsorbablesutures, ie, monofilament type if thepotential exists for contamination, and(6) irrigation of each wound layer.

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Intraoperative ComplicationsIntraoperative complications during

groin hernia repair consist of hemor-rhage, severance of the vas deferans,injury to the nerves in the area, injuryto the vascular supply of the testes, in-jury to the abdominal viscera, andother miscellaneous problems. Me-ticulous hemostasis, achieved withfine ligatures, will help to prevent bleed-ing complications such as hematoma,seroma, or lymphocele formation. Sig-nificant hemorrhage during the opera-tion is usually the result of injury to oneof three vessels-the pubic branch ofthe obturator artery, often referred toas the corona mortis; the deep inferiorepigastric vessels; and the external iliacartery and vein. Bleeding from the firsttwo vessels can be troublesome butcontrol can usually be achieved by ex-tension of the exposure.

Injury to the iliac (or femoral) ves-sels can be prevented by the accurateplacement of the needle into the fascialstructures bridging them. Injury can befurther prevented by protecting thefemoral vein with the index finger whileplacing the suture medially. If the su-ture should pass into the vein and resultin bleeding, it must be immediately re-moved and direct pressure applied. At-tempts to halt the bleeding by tying thesuture only result in further injury tothe vessel wall. If these measures arenot effective in control of the hemor-rhage, the femoral sheath must beopened widely so that more accuratelocal tamponade can be applied or re-pair of the defect can be accomplishedwith fine vascular suture. The place-ment of sutures too deeply into theiliopubic tract may injure the deep cir-cumflex iliac vessels, but since thebleeding is almost always venous inorigin, direct pressure will usually suf-fice.

There have been reports of pulmo-nary embolism arising from a thrombus,confirmed by venography, in thefemoral vein at the site of the transitionsuture.45 Although the incidence of thisinjury is not known, there is little mar-gin for error in the placement of thissuture. The decreased venous flow dur-ing operation together with the slightvenous stasis caused by constriction atthe suture site will probably permitformation of a thrombus.

If the vas deferens is accidentallysevered during the operation, it shouldbe repaired. One method of repair con-

sists of approximation of the cut endswith fine catgut sutures after placementof an internal splint of fine steel wirewhich is then pulled out in seven to tendays. The utilization of an operatingmicroscope will permit more accuratesuture placement. Approximately 50percent of those repaired secondarilyby urologists are considered to befunctional although it is difficult toevaluate the results with the presenceof an intact contralateral vas. Certainlythe attitude should not prevail thatthere is no necessity to attempt repairin the presence of an uninjured vas onthe other side!

There are three nerves in the groinregion which are vulnerable to injury.Both the iliohypogastric and ilioingui-nal nerves (branches of the first lumbarnerve) penetrate the internal obliquemuscle in the lateral third of the groinand lie between it and the external ob-lique aponeurosis. The former is sen-sory to the suprapubic region while thelatter innervates the base of the penisand upper scrotum (or their counter-parts in the female) and the adjacentthigh. These nerves also give off motorbranches to the adjacent muscles.

The ilioinguinal nerve is at risk earlyin the dissection since it lies directlybeneath the external oblique opo-neurosis and overlies the spermaticcord passing with it through the exter-nal inguinal ring. It is also vulnerableto injury during closure of theaponeurosis. The nerve should beidentified and isolated to prevent injuryfrom stretching or actual division.Moosman and Oelrich6 recently dem-onstrated that the normal course of theilioinguinal nerve prevailed in only 60percent of their cadaver dissectionswhereas 35 percent exhibited an aber-rant course, lying either behind orwithin the spermatic cord in males andbehind the round ligament in females.The remaining five percent revealedboth variations. Thus, the nerve maynot be encountered early in the dissec-tion but can be injured during eithermobilization and retraction of the cordor exposure and isolation of the indirectsac.

The iliohypogastric nerve, located 1to 2 cm above the inguinal canal, maybe injured during creation of the relax-ing incision in the rectus sheath or dur-ing medial exposure of the mus-culofascial layers in preperitoneal re-pairs.

The genitofemoral nerve divides

into its terminal two branches just in-side and lateral to the deep inguinal ringwith the genital branch then perforatingthe internal oblique muscle at the originof the cremasteric muscle supplyingmotor branches to it and sensorybranches to the skin and scrotum. In-jury to this nerve can occur when thecremaster muscle is divided or dissec-ted near the internal ring.

These nerves possess cross-connections and considerable sensoryoverlap so that prolonged anesthesiapost-injury, if apparent at all, will re-gress by the sixth month. While nerveinjury is neither life-threatening norserious, the varying degree of hypes-thesia, paresthesia, or anesthesia in thearea can be most annoying and uncom-fortable to the patient. There is a higherincidence of nerve injury associatedwith recurrent hernia repairs. If one ofthe nerves is inadvertently severed, theends should be freshened and silverclips applied to prevent neuroma for-mation. No attempt should be made torepair these nerves. The nerves mustbe protected from entrapment by su-tures during wound closure in order toprevent long-term discomfort. The latecomplication of ilioinguinal neuritis orneuroma formation may respond tolocal nerve blocks, but occasionallyexcision of a neuroma may be neces-sary after preoperative localization.Transcutaneous electrical stimulationof the symptomatic nerves has alsobeen employed with variable success.Fortunately, most symptoms arisingfrom nerve injury resolve without anytreatment.

Testicular InjuryInjury to the testis during repair may

result in actual infarction or, morecommonly, testicular atrophy. Theblood supply of the testis consists of:(1) The testicular artery (internal sper-matic) from the abdominal aorta, (2) theexternal spermatic artery from the in-ferior epigastric artery, and (3) the ar-tery to the vas deferens. Additionally,extensive collaterals exist at the upperend of the testes between these vesselsand those branches from the vesical,prostatic, and pudendal arteries.

Preoperatively, the testes should be

196 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 70, NO. 3, 1978

inspected and palpated to determinetheir size and consistency as a baselineas well as for the presence of atrophy,tumor, or hydrocele. During the opera-tion, the testes should not be dissectedfrom the scrotum, in order to protectthe collateral circulation from injury.Dissection of the spermatic cord shouldbe careful and nontraumatic, therebypreserving the venous and lymphaticdrainage. Operations for hernia recur-rence increase the risk of injury as docertain types of procedures. Bassini re-pair in children should be avoided dueto the danger of cord compression.Transposition of the cord to the sub-cutaneous position should be avoidedin young males because of the in-creased risk of injury with testicular at-rophy as a possible consequence.Ljundahl7 recommends that youngmale patients not undergo bilateral re-pairs because of the risk of atrophy butrather allow an interval of six monthsbetween repairs.

Postoperative testicular or scrotalswelling is probably a manifestation ofimpairment of venous flow and tissueedema although another cause may behypoxic swelling secondary to arterialinsufficiency particularly after resec-tion of the spermatic cord. The exactmechanism may be related to too tight aclosure of the internal ring. Treatmentconsists of bed rest, scrotal support,and ice compresses. There may be arole for decompression of the swollentestes by incision of the investing tunicif hypoxia is felt to be the etiology. At-rophy can be a late complication ofeither of these mechanisms. A finalword regarding the testes is containedin Koontz' statement: ". . . atrophyof the testicle sometimes follows asimple primary operation for inguinalhernia repair, in which neither the col-lateral nor the primary circulation hasbeen molested as far as the surgeon isaware."8

Postoperative cryptorchism is mostfrequently seen as the result of not re-placing the dislocated testis into theproper scrotal tissue plane prior tocompletion of the operation. Twistingof the cord must be carefully avoidedduring replacement. In addition to thismechanism other presumed etiologiesof the condition include excessive re-tractility or local infection creating irri-tation of the cremasteric muscle. Kap-lan9 advocated anchoring the testis dur-ing a hernia or communicating hy-drocele repair if preoperative examina-

tion demonstrates significant testicularretractility.

Abdominal and Pelvic Visceral In-jury

Injuries to the abdominal and pel-vic viscera comprise another categoryof intraoperative complications. Thepractice of high ligation of the hernialsac can result in bowel injury if blindsuturing is employed. This injury canthen result in the development of afecal fistula, abscess of the intestinalwall, or intestinal obstruction. In orderto prevent such an injury the sac mustbe opened and the internal purse-stringsuture placed and tied under direct vi-sion.Two potential complications can re-

sult when a sliding hernia involving thececum or sigmoid colon is encountered.The bowel may be entered accidentallybefore recognition of the sliding herniaor the bowel segment may become de-vascularized as a result of injury to itsblood supply which enters at the pos-terior aspect of the hernia. If the hernialsac appears excessively thickenedwhen initially encountered, it should beapproached with caution until it can besafely ascertained that bowel wall willnot be damaged upon entry into thesac. It should be noted that the slidingcomponent always lies in the posteriorand lateral part of the inguinal ring. Thesac should, therefore, be opened on theanterior surface with caution that a truesacless hernia is encountered. Thetechnical aspects of the operation forsliding hernias will not be considered inthis discussion.

Should the colon be entered acci-dentally, a careful two-layer closureshould be carried out followed by copi-ous irrigation of the wound. If there isany question of vascular compromiseof the segment, one of the followingprocedures should be employed: (1)wedge resection, primary closure, andtemporary proximal colostomy or ileos-tomy, (2) Mickulicz in-continuity ex-teriorization, or (3) colectomy and pri-mary anastomosis with or withoutproximal decompressing colostomy.10

In the repair of an indirect hernia ina female infant, the surgeon must bealert to the presence of a sliding herniacontaining the fallopian tube and ovaryto prevent accidental injury to thesestructures.

Bladder InjuryBladder injury most commonly oc-

curs in the repair of direct inguinalhernia where the bladder is frequentlyencountered as a medial sliding com-ponent of the hernial sac. The presenceof prevesical fat should guide the sur-geon in suture placement to avoid in-jury. If such an injury is recognized atthe operation it can be repaired withtwo or three layers of chromic catgutsupplemented by catheter drainage forthree to five days. Immediate recogni-tion and repair of a bladder injuryshould not be associated with an in-crease in morbidity whereas delayedrecognition of such an injury isheralded by urinary extravasation andsepsis. Colodny'" reported six cases ofbladder injury presenting with urinaryascites and azotemia in which the diag-nosis was established by opacificationof the ascitic fluid on delayed views ofcystograms where the defect in thebladder could not be seen. The mecha-nism of injury is felt to be due to theoccurrence of inguinal protrusions ofthe bladder (bladder ears) which pre-sent in the medial aspect of the indirectsac in infants. Savran and Brown'2 re-ported the unusual complication of apostoperative hematoma in the pre-vesical space of Retzius felt to be theresult of injury to the anterior vesicalveins on the distended bladder wall.

This injury can be prevented by per-forming a full preoperative urologicevaluation if there are any signs ofchronic obstruction with correction ofany conditions noted. Having the pa-tient void prior to the operation shouldalso avoid this potential problem.

Incarcerated Bowel SegmentsAnother factor concerning the in-

traabdominal viscera relates to the de-termination of viability of an incarcer-ated intestinal segment found in thesac. When operating for incarcerationor suspected strangulation that the af-fected bowel segment must be visual-ized in its entirety for such a determi-nation to be made. The return of nor-mal color, the contractile response topinching, the return of normal peristal-sis and the pulsation of the mesenteric

JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 70, NO. 3, 1978 197

vessels are well-known signs of appar-ent viability in such a bowel segment.Any question concerning viabilityshould be resolved by replacing thebowel into the warm, moist environ-ment of the peritoneal cavity while thepatient is given high concentrations ofoxygen rather than the usual routine ofemploying warm towels.

Intravascular injection of fluores-cein dye has been employed to detectareas of poor to absent blood flow butthe results have been variable. Anycontinuing doubts regarding viabilityare an indication for resection of theinvolved segment. Should the segmentbe allowed to escape back into theperitoneal cavity it must be retrievedeven if a laparotomy is necessary.Laparotomiy becomes mandatory alsoif the patient develops evidence ofobstruction and/or peritoneal irritationin the immediate postoperative period.Two conditions in the miscellaneous

category of complications include therespiratory embarrassment associatedwith the repair of massive hernias andthe problem of missed hernia. The utili-zation of preoperative progressivepneumoperitoneum originally proposedby Moreno should allow the surgeon tosafely repair massive hernias not onlyin the groin but elsewhere in the ab-dominal wall. 13 Failure to carefullyevaluate the posterior inguinal floorthrough internal abdominal ring in thepreperitoneal space may result inmissed hernia or what is erroneouslyfelt to be a very prompt recurrenceeven before the patient leaves the hos-pital.

Postoperative ComplicationsEarly postoperative complications

include systemic complications, majorwound infections, wound hematoma,and swelling of the testis and scrotum.Systemic complications will not beconsidered in this except to state thatthey are comparable to those occurringafter other operations of the samemagnitude. Rydell's figures indicating aseven percent incidence of systemiccomplications with the majority being

cardiorespiratory (4.1 percent) arefairly typical for inguinal hernia repairin the United States.'4 There are statis-tics available which suggest that the useof local anesthesia can reduce furtherthe incidence of systemic complica-tions particularly in the aged and poorrisk patient.

Major wound infection is fortunatelyan infrequent occurrence and whenseen is usually secondary to treatmentof associated intestinal strangulation.The incidence of wound infection canbe increased by obesity, the use of localanesthesia, and prolonged duration ofoperation. Minor wound infections,characterized by mild erythema, ten-derness and fever, should be managedwith warm, moist compresses and an-tibiotics. If suppuration occurs, thewound margins should be opened downto the fascia to establish drainage. AGram stain and bacteriological cultureshould be obtained to determine theappropriate antibiotic regimen to beemployed. In addition to collections ofpus or serum in the wound, single ormultiple suture sinuses may occur asmay partial or complete extrusion of aprosthetic mesh implant. Althoughhernial recurrence can result fromsome of these situations, the presenceof wound infection is usually notsynonymous with its occurrence. Mostof the wound infections are minor andshould create no risk to the hernia re-pair.

The occurrence of woundhematoma or seroma should beminimized by the achievement ofmeticulous hemostasis with fine liga-tures. Local measures such as applica-tion of pressure and/or an icebag mayprove effective for small woundhematomas. If the hematoma continuesto enlarge in spite of the measures, re-operation may be necessary. Chronichematomas may be left alone to spon-taneously resorb or they may be care-fully aspirated under strict asepsis.

Postoperative hydrocele consistingof a collection of fluid either in thescrotum or along the spermatic cord,may occur when a part of the sac is leftin place, if there is impairment of thelymphatic or venous drainage. Themajority of these collections tend to re-solve spontaneously while needle aspi-rations under strict asepsis may be nec-essary occasionally to completely elim-inate the problem. Secondary operativecorrection is practically never neces-sary.

A consideration of recurrent herniasis beyond the scope of this discussion.Generally, however, adherence to thebasic tenets of inguinal hernia repairshould result in a low incidence of thiscomplication. These include: (1) highligation of the sac in the case of indirectand excision of the sac in all groin her-nias; (2) repair of the defect in the planeof its occurrence (the posterior inguinalfloor); and (3) suture of fascia to fasciain the same tissue plane without ten-sion.

ConclusionA thorough knowledge of in-

guinofemoral anatomy, mature surgicaljudgment and meticulous surgical tech-nique are the most effective pro-phylactic measures for the preventionof complications considered.

Literature Cited1. Edwards H: Inguinal hernia. Br J Surg

31:172-185, 19432. Nyhus LM: Complications of hernial re-

pair. In Artz CP, Hardy JD (eds): Management ofSurgical Complications. Philadelphia, WBSaunders, 1972, pp 659-671

3. Weinstein M, Roberts M: Recurrent in-guinal hernia-follow-up study of 100 post-operative patients. Am J Surg 129:564-569,1975

4. Lankau CA Jr, Beachley MC: McVayherniorrhaphy. The transition suture andfemoral vein injury: Case report. Milit Med140:641-642, 1975

5. Nissen HM: Constriction of the femoralvein following inguinal hernia repair. Acta ChirScand 141:279-281, 1975

6. Moosman DA, Oelrich TM: Preventionof accidental trauma to the ilioinguinal nerveduring inguinal herniorrhaphy. Am J Surg133:146-148, 1977

7. Ljungdahl I: Inguinal and femoralhernia-an investigation of 502 own operatedcases. Acta Chir Scand Suppl 139:1-81, 1973

8. Koontz AR: Atrophy of the testicle as asurgical risk. Surg Gynecol Obstet 120:511-513,1965

9. Kaplan GW: latrogenic cryptorchidismresulting from hernia repair. Surg GynecolObstet 142:671-672, 1976

10. Condon RE, Nyhus LM: Complicationsof groin hernia and of hernial repair. Surg Clin NAm 51:1325-1336, 1971

11. Colodny AH: Bladder injury during her-niorrhaphy manifested by ascites and azotemia.Urology 3:89-90, 1974

12. Savran J, Brown SA: An unusual com-plication of inguinal herniorrhaphy. Int Surg57:583-584, 1972

13. Moreno IG: The rational treatment ofhernias and voluminous chronic eventration. InNyhus LM, Harkins HN (eds): Hernia. Philadel-phia, JB Lippincott, 1964

14. Rydell WB Jr: Inguinal and femoral her-nias. Arch Surg 87:493, 1963

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